The Intern At Work: Internal Medicine 239. A Liver-Kidney Conundrum - Hepatorenal Syndrome
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Jun 2, 2024 Dr. Cynthia Tsien, a Transplant Hepatologist, discusses the acute presentation of hepatorenal syndrome, including nomenclature, epidemiology, clinical presentation, investigations, and management. The episode also reviews the utility of terlipressin in treating HRS in patients with decompensated cirrhosis.
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Physiology behind HRS AKI
- Cirrhosis leads to portal hypertension causing systemic vasodilation and decreased effective circulating volume.
- Kidney compensatory vasoconstriction and fluid retention maintain function but are fragile and easily tipped into AKI.
Systematic evaluation of HRS patient
- Evaluate vitals carefully to distinguish baseline hypotension from life-threatening causes like sepsis or bleeding.
- Identify precipitating factors and assess for underlying kidney disease, nephrotoxic medications, and recent paracentesis.
Diagnostic workup in AKI due to HRS
- Perform broad renal workup including urine studies and microscopy to differentiate HRS from other AKI causes like ATN.
- Consider urine output monitoring and imaging to rule out obstruction in suspected postrenal AKI.