Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:12

Hepatorenal Syndrome 695

Minor Criteria

■Urine volume <500 mL/day

■Urine sodium <10 mmol/day

■Urine osmolality < plasma osmolality

■Urine RBC <50 per high power field

■Serum sodium <130 mmol/L

Potential Precipitating Factors

■Infection, particularly spontaneous bacterial peritonitis

■Rapid diuresis, particularly large volume paracentesis without vol-

ume expansion

■Excessive gastrointestinal fluid loss due to vomiting or diarrhea (lac-

tulose)

■GI bleeding

■NSAID use

tests

■To establish the diagnosis (i.e., major criteria):

➣Serum electrolytes and creatinine

➣Creatinine clearance and 24 hour urine protein excretion

➣Abdominal ultrasound

➣Routine urinalysis and microscopic exam

➣Spot urine sodium and osmolality

■Additional tests to look for potential precipitants

➣Diagnostic paracentesis with WBC count and bedside culture

➣Blood cultures

differential diagnosis

■Acute tubular necrosis (ATN)

■Intrinsic kidney disease

■Obstructed urinary tract

■Recent treatment with nephrotoxic drugs

■Volume depletion from excessive fluid losses, e.g., vomiting, diar-

rhea, diuretics

management

What to Do First

■Confirm diagnosis, using major criteria

■Look for precipitating factors in type 1 HRS

General Measures

■Expand the plasma volume, ideally in an ICU with a pulmonary artery

catheter in place to guide the volume therapy.