The Curbsiders Internal Medicine Podcast

#145 NephMadness: Hepatorenal Syndrome vs AKI

Mar 25, 2019
Juan Carlos Velez, nephrology chair and hepatorenal physiology expert; Bill Whittier, academic nephrologist and educator; Joel Topf, clinical nephrologist and co-founder of NephMadness. They discuss diagnosing hepatorenal syndrome in cirrhosis. Topics include albumin challenges, volume assessment, when to start vasoconstrictors and MAP-targeted therapy, dialysis as a bridge to transplant, and debates over bile-acid casts.
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ADVICE

Get A Renal Ultrasound To Rule Out Obstruction

  • Order a renal ultrasound liberally because obstruction is reversible and easy to miss.
  • Joel Topf and Juan Carlos Velez both argue ultrasound has low risk and missing obstruction is unacceptable.
ADVICE

Pick One Strategy And Go All In

  • When you choose between volume resuscitation and diuresis, pick one and go all in.
  • Bill Whittier warns doing both confounds assessment; give a decisive fluid challenge or aggressive diuresis to know if it worked.
ADVICE

Do The Standard Albumin Challenge Early

  • Use the standard albumin challenge for suspected HRS: 1 g/kg (25 g IV q6h) and reassess.
  • Juan Carlos Velez endorses albumin as the default volume expander despite imperfect evidence.
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