Pediatric Hepatorenal Syndrome Workup
- Author: Rajendra Bhimma, MB, MD, ChB, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal); Chief Editor: Timothy E Corden, MD more...
No specific tests help in definitively diagnosing hepatorenal syndrome (HRS). HRS is a diagnosis of exclusion.
Serum creatinine measurement usually has good specificity for low glomerular filtration rate (GFR). However, it is least useful in patients with hepatic failure and ascites because their creatinine levels may be in the reference range or only slightly elevated despite a severely decreased GFR secondary to low endogenous production of creatinine, poor nutrition, and decreased muscle mass. A creatinine level of more than 1.5 mg/mL and a creatinine clearance of less than 40 mL/min are criteria the 1996 International Ascites Club used to define hepatorenal syndrome. A 24-hour urine collection or a specific measure of the GFR may be required for accurate measurement.
The BUN level is not reliable for assessing for low GFR in the clinical settings of hepatorenal syndrome. The level may be abnormally low because of reduced hepatic synthesis or low protein intake. Causes other than a low GFR, such as GI bleeding, may contribute to an elevated BUN level.
Dilutional hyponatremia may be seen in patients with hepatorenal syndrome. This condition is secondary to impaired renal capacity to excrete solute-free water, as well as increased vasopressin release in response to the severe arterial underfilling.
No urinary findings are consistently associated with the diagnosis of hepatorenal syndrome. Clinically significant proteinuria (>500 mg/dL) usually indicates renal failure secondary to tubular or glomerular damage and not hepatorenal syndrome. Microscopic hematuria makes the diagnosis of hepatorenal syndrome unlikely and suggests a glomerular pathology. Tubular cells or muddy, brown casts suggest that acute tubular necrosis as the etiology of renal failure.
The concentrating capacity of the kidney is preserved in hepatorenal syndrome, and urine osmolality is typically higher than the plasma osmolality. In some patients, osmolality may decrease as renal failure progresses.
The reabsorption capacity of the tubule is maintained in patients with hepatorenal syndrome because it is only functional renal failure. Therefore, the urinary sodium concentration is usually less than 10 mEq/L. However, some patients have high urinary sodium excretion. Therefore, this marker is not reliable in the diagnosis of hepatorenal syndrome.
Renal ultrasonography is useful in eliminating structural causes of renal failure, such as obstructive uropathy and intrinsic parenchymal renal disease, especially in the setting of an abnormal urinary sediment.
Doppler sonography is performed to determine the intrarenal arteriolar vascular resistance, defined as the resistive index (RI). The reference range for RI is 0.7 or lower. The RI can be a more sensitive parameter than the creatinine clearance.
Renal biopsy is indicated for patients with abnormal urinary sediment, proteinuria or hematuria, or renal ultrasonographic findings suggestive of organic causes of renal failure.
Patients with hepatorenal syndrome are usually too ill to tolerate renal biopsy. However, if performed, biopsy reveals normal histology because hepatorenal syndrome is only functional renal failure.
In patients with hepatorenal syndrome, renal histology is preserved.
After the patient undergoes liver transplantation, renal recovery is usually good.
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