Acute renal dysfunction in liver diseases

Table 1 Intrinsic kidney involvement in liver diseases

Tubulo-interstitial involvement
1 Drugs[7] (paracetamol, aspirin, carbon tetrachloride, halogenated hydrocarbons, immunosuppressant agents)
2 Toxins[28-35] (Galerina family of mushrooms, hemoglobin, myoglobin, bilirubin, contrast agents)
3 Infections (leptospirosis, malaria, hepatitis)
4 Hypersensitivity reactions (sulphonamides, salicylates, etc.)
Glomerular involvement
1 Drugs[7] (carbon tetrachloride)
2 Hepatitis[28-35] A, B, C
3 Type II mixed cryoglobulinemia[28-35]
4 IgA nephropathy[28-35] (alcoholic cirrhosis, HCV cirrhosis)
5 Others (sickle cell disease, hemochromatosis, acute fatty liver and toxemia of pregnancy)
Vascular
1 Vasculitis
2 Toxemia of pregnancy and HELLP syndrome

Table 2 Diagnostic criteria of HRS

Major criteria
1 Chronic or acute liver disease with advanced liver failure and portal hypertension
2 Low GFR, as indicated by a serum creatinine of > 1.5 mg/dL or a 24-h creatinine clearance < 40 mL/min
3 Exclusion of shock, ongoing bacterial infection, volume depletion, and the use of nephrotoxic drugs
4 No improvement in renal function despite stopping diuretics and volume repletion with 1.5 L of saline
5 No proteinuria or ultrasonographic evidence of obstructive uropathy or parenchymal renal disease
Minor criteria1
1 Urine volume lower than 500 mg/day
2. Urine sodium lower than 10 mEq/L
3 Urine osmolality > plasma osmolality
4 Urine blood cells < 50 per high-power field
5 Serum sodium concentration lower than 130 mEq/L

¹Only major criteria are necessary for the diagnosis of hepatorenal syndrome.

Table 3 Differential diagnosis of ARF in advanced liver disease

	Prerenal failure	Intrinsic renal failure	HRS
Urine sodium	< 10	> 30	< 10
U/Pcreat	> 30:1	< 20:1	> 30:1
U/Posm	UO > PO	UO = PO	UO > PO
Urine sediment	Normal	Casts, cellular debris	Unremarkable
History disease	Profound volume	Volume contraction	Advanced liver disease
Clinical course (renal response)	Contraction	Nephrotoxic agent sepsis	Tence ascites
Fluid challenge	+	-	-
Vasoconstriction	±	-	+
Ultrasound	Elevated resitive index	Elevated resitive index	Elevated resitive index