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Hepatorenal syndrome

Key sources
The following summarized guidelines for the evaluation and management of hepatorenal syndrome are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2023), the American College of Gastroenterology (ACG 2022), the American Association for the Study of Liver Diseases (AASLD 2021; 2017; 2014), the Society of Critical Care Medicine (SCCM 2020), and the European Association for the Study of the Liver (EASL 2018; 2010).
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Guidelines

1.Screening and diagnosis

Differential diagnosis
As per AASLD 2021 guidelines:
Evaluate and treat precipitating factors of AKI, such as fluid loss, bacterial infections, hemodynamic instability, potentially nephrotoxic agents (particularly NSAIDs).
E
Use the consensus criteria for the differential diagnosis of AKI, HRS and acute tubular necrosis.
E
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  • Diagnostic criteria

2.Classification and risk stratification

Classification: classify HRS into two types:
type 1 HRS: characterized by a rapid and progressive impairment in renal function (increase in serum creatinine ≥ 100% compared to baseline, to a level > 2.5 mg/dL, within 2 weeks)
type 2 HRS: characterized by a stable or less progressive impairment in renal function
A

3.Diagnostic procedures

Kidney biopsy: consider performing kidney biopsy in patients with suspected parenchymal renal disease in order to orient further management, including the potential need for combined liver and kidney transplantation.
B

4.Medical management

General principles: decide on the management (including initiation of vasoconstrictor therapy and RRT) by a multidisciplinary team including specialists in hepatology, nephrology, critical care, and transplant surgery, if possible, given the complexity of patients with suspected HRS-AKI.
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  • Vasoactive agents

  • Intravenous albumin

  • Antibiotic therapy

  • Management of beta-blockers

  • Management of diuretics

5.Therapeutic procedures

Renal replacement therapy
As per AASLD 2021 guidelines:
Initiate RRT in candidates for liver transplantation with worsening renal function or electrolyte disturbances or increasing volume overload unresponsive to vasoconstrictor therapy.
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Initiate RRT with a clear endpoint in mind in patients not being candidates for liver transplantation.
E

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  • Therapeutic paracentesis

  • TIPS

6.Surgical interventions

Liver transplantation
As per AASLD 2021 guidelines:
Consider obtaining urgent evaluation for liver transplantation in all patients with cirrhosis and AKI because of the high short-term mortality even in responders to vasoconstrictors.
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Consider performing simultaneous liver-kidney transplantation in patients not expected to recover kidney function post-transplantation.
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7.Preventative measures

Norfloxacin: initiate norfloxacin 400 mg/day as SBP prophylaxis to prevent HRS-AKI.
A

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  • Albumin

8.Follow-up and surveillance

Serial clinical assessment: as per AASLD 2021 guidelines, obtain close monitoring for side effects of vasoconstrictors and albumin, including ischemic complications and pulmonary edema.
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  • Assessment of treatment response