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Copyright ©The Author(s) 2015.
World J Nephrol. Nov 6, 2015; 4(5): 511-520
Published online Nov 6, 2015. doi: 10.5527/wjn.v4.i5.511
Table 1 Diagnostic criteria for hepatorenal syndrome
Cirrhosis with ascites
Serum Creatinine > 1.5 mg/dL
Absence of shock
No improvement of serum creatinine (decrease to a level of 1.5 mg/dL or less) after at least 2 d of diuretic withdraw and volume expansion with albumin (The recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/d)
No current o recent exposure to nephrotoxic drugs
Absence of parenchymal disease as indicated by proteinuria > 500 mg/d, microscopic hematuria (50 red blood cells per high power field) and abnormal renal ultrasonography
Table 2 Characteristics of type I and type II hepatorenal syndrome
HRS IDoubling of serum creatinine in < 2 wkA precipitating event is present in the most of caseNo history of diuretic resistant ascites10% survival in 90 d without treatment
HRS IIRenal impairment gradually progressiveNo precipitating eventsAlways ascites diuretic resistanceMedian survival 6 mo
Table 3 Risk factors for the onset of hepatorenal syndrome
Spontaneous bacterial peritonitis
Large volume paracentesis (> 5 L) with inadequate albumin substitution
NSAID and other nephrotoxic drugs, iv contrast
Bleeding from esophageal varices
Post TIPS syndrome
Diuretic treatment
Table 4 Differential diagnosis of renal failure in cirrhosis
Pre-renalHistory of fluid loss, gastrointestinal bleeding, treatment with diuretics or non-steroidal anti-inflammatory drugs
OrganicMedical history, laboratory tests (cryoglobulinemia, complementemia, etc.)
ObstructiveUltrasound imaging
Chronic kidney diseaseAnemia, proteinuria, secondary hyperparathyroidism, ultrasound evidence of renal cortical thinning
Table 5 Prevention of hepatorenal syndrome and general patient management strategies
Avoid drugs that reduce renal perfusion or nephrotoxic substances
Minimize exposure to organ-iodated contrast agents
Intravenous albumin is recommended for volemic filling after large volume paracentesis (8 g of albumin for each liter of ascites removed)
Diuretic therapy should be suspended
Pentoxifylline as drug’s anti-TNFa activity
Antibiotic prophylaxis to prevent infections reducing intestinal bacterial translocation (norfloxacin 400 mg/d)
Intravenous albumin administered in association with ceftriaxone in SPB
Adrenal insufficiency should be identified and treated
Drug dosages must be adjusted according to renal function