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  • Type 1 hepatorenal syndrome—rapid and progressive impairment of renal function defined by doubling of the initial serum creatinine level to >2.5 mg/dL or 50% reduction of the initial 24-hour creatinine clearance to <20 mL/min in less than 2 weeks.
  • Type 2 hepatorenal syndrome—impairment in renal function leading to serum creatinine level >1.5 mg/dL that does not meet the criteria for type 1.
  • Frequent precipitants include gastrointestinal bleeding, sepsis, spontaneous bacterial peritonitis, aggressive diuresis and paracentesis, nonsteroidal anti-inflammatory drugs (NSAIDs), and intravenous contrast agents.
  • Intravenous albumin, 1.0 g/kg, should be administered on the first day of diagnosis of hepatorenal syndrome, Type 1 followed by 20–40 g/day.

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Hepatorenal syndrome is characterized by functional kidney failure in patients with end-stage liver disease. It results in intense renal vasoconstriction without any other identifiable kidney pathology. Clinical features of hepatorenal syndrome include oliguria, dilutional hyponatremia, progressive azotemia, and hypotension. Frequent precipitants include gastrointestinal bleeding, sepsis, aggressive diuresis, and paracentesis. However, many patients develop hepatorenal syndrome as a consequence of chronic end-stage liver disease without any identifiable precipitating factors.

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Incidence

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Hepatorenal syndrome develops in 5% of patients with chronic liver disease who present with upper gastrointestinal bleeding, 30% of patients admitted with spontaneous bacterial peritonitis, 10% of patients with ascites treated with total paracentesis, and 25% of patients with severe alcoholic hepatitis. The probability of hepatorenal syndrome developing in a patient with cirrhosis and new onset of ascites is 7–10%. The 5-year probability of hepatorenal syndrome developing in a patient with cirrhosis and recurrent ascites is 40%.

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Definition

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Type 1 Hepatorenal Syndrome

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Type 1 is characterized by rapid and progressive impairment of renal function defined by a doubling of the initial serum creatinine to a level higher than 2.5 mg/dL or a 50% reduction of the initial 24-hour creatinine clearance to a level lower than 20 mL/min in less than 2 weeks.

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Type 2 Hepatorenal Syndrome

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Type 2 is defined as impairment in renal function (serum creatinine >1.5 mg/dL) that does not meet the criteria for type 1. Prerenal failure is a preischemic state and may lead to ischemic tubular necrosis.

Salerno F, Gerbes A, Ginés P, et al. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56:1310–1318.   [PubMed: 17389705]

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In patients with cirrhosis and ascites there is activation of the renin-angiotensin and sympathetic nervous systems, resulting in elevated levels of renin, aldosterone, and norepinephrine. If cirrhotic patients undergo diuresis successfully, the levels of renin, aldosterone, norepinephrine, and antidiuretic hormone all decrease. However, in patients with end-stage liver disease complicated by hepatorenal syndrome, levels of renin, aldosterone, antidiuretic hormone, and norepinephrine are raised and remain persistently elevated despite vigorous attempts at volume expansion. This consequence occurs in part because of decreased systemic vascular resistance and splanchnic arteriolar vasodilation. The splanchnic vasodilation results from increased nitric oxide synthesis. The combination of decreased ...

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