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Hepatorenal Syndrome

Hepatorenal Syndrome. Andrew P. Keaveny, M.D., F.R.C.P.I. Chair, Division of Transplant Medicine Medical Director of Liver Transplantation Mayo Clinic Florida. Disclosures. No disclosures relevant to this talk Off label use: Midodrine, octroetide Not FDA approved: terlipressin.

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Hepatorenal Syndrome

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  1. Hepatorenal Syndrome Andrew P. Keaveny, M.D., F.R.C.P.I. Chair, Division of Transplant Medicine Medical Director of Liver Transplantation Mayo Clinic Florida

  2. Disclosures • No disclosures relevant to this talk • Off label use: Midodrine, octroetide • Not FDA approved: terlipressin

  3. Grass snake swimming in duckweed in Britain

  4. “Snakeless in Ireland: Blame Ice Age, Not St. Patrick” National Geographic News 10/28/2010

  5. Outline • Case • Complications of cirrhosis • Acute kidney injury • Hepatorenal syndrome • Management • Combined liver-kidney transplant

  6. Case 59 year old female Decompensated cirrhosis due to HCV Ascites Hepatic encephalopathy (HE) Bleeding varices Initial presentation MELD = 13, CR = 1.1 CR Clearance = 98 mls/min

  7. Listed for liver transplant Within 7 months, patient had developed refractory ascites MELD = 24 [CR 1.8, INR = 1.9, TBIL 4.4] Paracentesis at another hospital complicated by ascites leaking from site Admitted 6 days later with abdominal wall cellulitis Oliguric, BP 102/54, abdominal wall erythema, moderately tense ascites Serum Na 131, UA: Na <10, no protein, no RBCs MELD = 29 [CR 2.6, INR 2.0, TBIL 4.5]

  8. Diuretics stopped Blood, urine, ascitic cultures sent – all negative Doppler US: Minimal ascites, no hydronephrosis, patent PV IV antibiotics: Vancomycin + Ampicillin/Sulbactam 100 gm IV albumin Subsequent course Generalized anasarca

  9. MELD = 35 Serum Creatinine mg/dL Time (Days)

  10. Intake and Output Chart Time (Days)

  11. Cardiovascular Data Time (Days)

  12. Midodrine/octreotide started Time (Days)

  13. Octreotide S/C, midodrine added to IV albumin Increasing UO ( 500 mls/day), systolic BP CR = 2.2 MELD = 31 Case continued

  14. Intake and Output Chart Midodrine/octreotide started Time (Days)

  15. Cardiovascular Data Midodrine/octreotide started Time (Days)

  16. Renal Function Midodrine/octreotide started Serum Creatinine mg/dL Time (Weeks)

  17. Renal Function Liver Transplant Serum Creatinine mg/dL Time (Weeks)

  18. Case continued • Octreotide S/C, midodrine added to IV albumin • Increasing UO ( 500 mls/day), systolic BP • CR = 2.2 • MELD = 31 • Liver transplant 15 days after admitted to hospital • Continuous renal replacement therapy for 36 hrs (intra-op & immediately post-op)

  19. Liver Transplant Serum Creatinine mg/dL Time (months)

  20. Listed for liver transplant Within 7 months, patient had developed refractory ascites MELD = 24 [CR 1.8, INR = 1.9, TBIL 4.4] Paracentesis at another hospital complicated by ascites leaking from site Admitted 6 days later with abdominal wall cellulitis Oliguric, BP 102/54, abdominal wall erythema, moderately tense ascites Serum Na 131, UA: Na <10, no protein, no RBCs MELD = 29 [CR 2.6, INR 2.0, TBIL 4.5]

  21. Listed for liver transplant Within 7 months, patient had developed refractory ascites MELD = 24 [CR 1.8, INR = 1.9, TBIL 4.4] Paracentesis at another hospital complicated by ascites leaking from site Admitted 6 days later with abdominal wall cellulitis Oliguric, BP 102/54, abdominal wall erythema, moderately tense ascites Serum Na 131, UA: Na <10, no protein, no RBCs MELD = 29 [CR 2.6, INR 2.0, TBIL 4.5] Type 2 HRS

  22. MELD = 35 Serum Creatinine mg/dL Time (Days)

  23. MELD = 35 Type 1 HRS Serum Creatinine mg/dL Time (Days)

  24. Cirrhosis

  25. Cirrhosis – 12th leading cause of death in US in 2000: >25,000 deaths • 9th leading cause by 2015 • 1999-2004: Rate of hospitalization with diagnosis of liver disease  by >30% • Survival determined by presence of compensation Median survival >12 years for compensated vs. approximately 2 years for decompensated cirrhosis

  26. About 26,000 patients with cirrhosis require ICU care each year • In-hospital mortality >50% • Mean length of hospitalization 14 days • Total charges with ICU admission $3 billion Olson JC et al. Hepatology 2011

  27. Compensated cirrhosis Portal pressure <10 mmHg Decompensated cirrhosis Portal pressure Liver function Ascites Jaundice Encephalopathy Portal hypertensive gastrointestinal bleeding

  28. Compensated cirrhosis Portal pressure <10 mmHg Transition rate 5-7%/year Decompensated cirrhosis Portal pressure Liver function Ascites Jaundice Encephalopathy Portal hypertensive gastrointestinal bleeding D’Amico J Hepatol 2006

  29. Ascites EASL J Hepatol 2010 Ascites is most common complication of cirrhosis

  30. Assessment of Disease Severity:Model for End-Stage Liver Disease Score • MELD: INR, total bilirubin & serum creatinine • Calculator at the Mayo, UNOS websites • Good predictor of 3 month survival • Prioritizes patients awaiting liver transplantation Kamath P. Hepatology ’07

  31. Acute Kidney Injury in Cirrhosis • Nearly 50% of patients with cirrhosis develop AKI • Causes • Pre-renal • Renal • Post-renal

  32. Assessment of Kidney Function in Cirrhotics • In patients with cirrhosis, serum CR is unreliable due to low production rate of creatine by liver with reduced muscle mass • CR-based equations also unreliable (MDRD, CKD-EPI) • 24-hour CR clearance more accurate but cumbersome • Gold standard: Iohexol or iothalamate clearance study

  33. Hospitalized patients with cirrhosis Chronic renal failure 1% Acute Kidney Injury 19% (293/1544) Post-renal (obstructive) (<1%) Intra-renal (ATN, GMN)32% (224/712) Pre-renal 68% (437/639) • Volume-responsive* • 66% (288/437) • Infection • Hypovolemia • Vasodilators • Other Not volume-responsive HRS type 1 25% (108/437) HRS type 2 9% (41/437) Garcia-Tsao G et al. Hepatology 2008

  34. Wong F et al., Gut 2011

  35. Stages of AKI • Stage 1: ↑ SCR ≥0.3 mg/dl or ↑ in SCR ≥1.5 to 2-fold from baseline • Stage 2: ↑ in SCR ≥2 to 3-fold from baseline • Stage 3: ↑ SCR >3x from baseline or SCR ≥ 4.0 mg/dl with acute ↑ of at least 0.5 mg/dl Wong F et al., Gut 2011

  36. Causes & Outcomes of Renal Failure Martin-Llahi et al, Gastroenterology 2011

  37. Causes & Outcomes of Renal Failure Martin-Llahi et al, Gastroenterology 2011

  38. Progression of AKI Stage Piano et al, J Hepatol 2013

  39. Biomarkers For Early Detection of AKI Parikh & Devarajan, Crit Care Med 2008;36[Suppl]:S159-S165

  40. Urinary NGAL NGAL, neutrophil gelatinase-associated lipocalin Fagundes et al, J Hepatol 2012

  41. Hepatorenal Syndrome • A functional form of acute kidney injury (AKI) that results in severe renal vasoconstriction without evidence of structural kidney disease Arroyo V. J Hepatol ’13

  42. Hepatorenal Syndrome • A functional form of AKI that results in severe renal vasoconstriction without evidence of structural kidney disease • Type 2: Extreme expression of the spontaneous deterioration of circulatory function in cirrhosis, associated with refractory ascites & poor survival (months) Arroyo V. J Hepatol ’13

  43. Hepatorenal Syndrome • A functional form of AKI that results in severe renal vasoconstriction without evidence of structural kidney disease • Type 2: Extreme expression of the spontaneous deterioration of circulatory function in cirrhosis, associated with refractory ascites & poor survival (months) • Type 1: A form of acute renal failure that occurs secondary to a rapid deterioration of cardiocirculatory function closely associated in time with a precipitant & having an extremely poor survival (days or weeks) Arroyo V. J Hepatol ’13

  44. Hepatorenal Syndrome • A functional form of AKI that results in severe renal vasoconstriction without evidence of structural kidney disease • Type 2: Extreme expression of the spontaneous deterioration of circulatory function in cirrhosis, associated with refractory ascites & poor survival (months) • Type 1: A form of acute renal failure that occurs secondary to a rapid deterioration of cardiocirculatory function closely associated in time with a precipitant & having an extremely poor survival (days or weeks) Diagnosis of Exclusion Arroyo V. J Hepatol ’13

  45. Pathophysiology of HRS

  46. Intrahepatic resistance Effective arterial blood volume Cirrhosis Portal (sinusoidal) hypertension Splanchnic/systemic vasodilatation Activation of neurohumoral systems Renal vasoconstriction HEPATORENAL SYNDROME

  47. Wong F. Nat Rev. Gastoenterol 2012

  48. Mechanisms Leading to Circulatory & Renal Dysfunction in Cirrhosis Arroyo, V. & Fernández, J. Nat. Rev. Nephrol. 2011

  49. Precipitants of Type 1 HRS • Infection • Spontaneous bacterial peritonitis (SBP) • Urinary tract infection • Cellulitis • Gastrointestinal hemorrhage • NSAID use • Large volume paracentesis without albumin • Adrenal insufficiency

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