2. • Progressive weakness for
5 months
• Productive cough , low
grade fever X 20 days
• Progressive ascites with
decreasing urine output x
15 days
Altered sensorium x 2 days
No GI Bleed/Jaundice
• H/o Treatment with
multiple i.v. antimicrobials
prior to admission for LRTI
• No H/O:
• Prior surgery
• Skin rash
• Blood transfusion
• Unknown drugs
O/E : afebrile, BMI- 24
Pallor +, Icterus +
Edema
Tense ascites
April 2016
78/F,
HTN X 17y
controlled
Dec 2015
5 months
3. Parameters Values
HbsAg/Anti HCV Negative
ANA,ASMA,ALKM1 Negative
S. Ferritin/B12 Normal
Anti Tissue
Tranglutaminase
Antibody
<3.0 au/ml
S . ceruloplasmin 20 mg/dl(N<20-40)
Ascitic fluid analysis High SAAG ascites,
no SBP
Chest X ray Resolving right side
pneumonia
Parameters Values
Hemoglobin 9.8 g/dl
TLC 8.4 x 1000/ul
Platelets 80 x 1000/ul
Total bilirubin 1.2 mg/dl
AST/ALT 74/60
ALP 128
Total s. protein 5.7 g/dl
Albumin 2.7 g/dl
INR 19.2/12.9 (1.6)
Na/K/Cr 108/3.8/2.1
Ig G 1630 mg/dl (N)
TSH 1.84 miu/ ml (N)
HbA1C 5.4 %
Investigations
UGIE – Normal
USG- CLD , PHT, Gross ascites
4. Diagnosis
• Cryptogenic cirrhosis (CTP C , MELD- 20)
• Tense ascites
• HE II (possible precipitants : LRTI, constipation,
hyponatremia)
• AKI with oliguria
? Cause of Renal failure ? AKI ? Underlying CKD
(Hypertension related)
9. What percent of AKI in cirrhosis are due to
HRS?
1. <25%
2. 25-50%
3. 50-75%
4. >75%
10. Causes of AKI in pts with cirrhosis
Martín-LlahíM et al, Gastroenterology. 2011;140(2):488.
11. Diagnostic criteia of renal dysfunction in
cirrhosis
• Acute renal failure : Rise in s.creatinine ≥ 50% from
baseline or rise by ≥ 0.3 mg/dL in < 48h
• Chronic kidney disease :GFR < 60ml/min for >3mo
• Acute on chronic renal dysfunction: Rise in
s.creatinine ≥ 50% from baseline or rise by ≥0.3
mg/dl in < 48h in cirrhosis whose GFR < 60ml/min for
>3mo
12. Actuarial probability to survive in cirrhotic
patients with different renal impairments
Adapted from Alessandria et al
13. How to investigate AKI ?
• Urine r/m
• Urine spot sodium
• 24 hour urine protein
• USG abdomen
15. Patient’s Reports
S. Na 109
S. Potassium 3.6
S. Creatinine 2.1
24 Hr Na 5.7
24 Hr K 8.6
24 Hr Cr 2.1
24 Hr Albumin 360 mg
Fe Na < 1%
URINE r/m WNL, No casts, RBC- 0-2/hpf, protein -
trace
Urine C/S sterile
Central venous pressure 14 cm
Chest X RAY Right sided pneumonia (RESOLVING)
USG Abdomen/KUB CLD, PHT, Gross ascites, Kidneys- Normal
16. Final diagnosis
• Cryptogenic cirrhosis , CTP B , MELD- 20
• Tense ascites, HRS 2, AKI cause HRS
• No SBP/HE/Bleed
• Hypertension, Concentric LVH, NYHA II
17. HRS
• Volume-unresponsive, refractory prerenal azotemia in
patients with chronic liver disease, characterized by
systemic and splanchnic vasodilatation but profound
renal vasoconstriction, without parenchymal kidney
injury
21. Issues with s.creatinine
• Affected by age, gender, race, body weight
• Malnutrition,muscle wasting,advanced liver disease
• High bilirubin values.
• Increased secretion of creatinine by tubules
• Expanded volume of distribution
Risk of overestimating renal function
30. Ideal Treatment of HRS
Improvement of liver function
• Recovery of alcoholic hepatitis1
• Treatment of decompensated hepatitis B with
effective antiviral therapy2
• Recovery from acute hepatic failure
• Liver transplantation
1. Amini M et al. Alcoholic hepatitis 2010: a clinician's guide to diagnosis and therapy. World J Gastroenterol
2010; 16:4905
2, Garg H et al Tenofovir improves the outcome in patients with spontaneous reactivation of hepatitis B
presenting as acute onchronic liver failure. Hepatology 2011; 53:774
32. Improve intravascular volume
• Albumin
• 1 g/kg per day [100 g maximum] followed by
25 to 50 grams per day until therapy
continued
33. Vasoconstrictor drugs
Drug Dose
Noradrenaline Continuous infusion (0.5 to 3 mg/hr)
Vasopressin Starting at 0.01 units/min and titrating upward
Terlipressin Intravenous bolus (1 to 2 mg every four to six hours)
Midodrine
+ Octreotide
Orally (starting at 7.5 mg and increasing the dose at eight
hour intervals up to a maximum of 15 mg by mouth three
times daily)
35. Terlipressin in HRS
• Multicenter double blinded RCT
• HRS type 1 diagnosed by
ICA criteria (1996)
• Treatment discontinued if
– Treatment failure
– Liver transplantation
– Adverse effects
• If treatment success achieved,
discontinue or continue drug at
investigator discretion till
max. of 14 days
Placebo
Albumin 25g/d
N =56
180 d0 14 d3 d
Terlipressin 1mg q6h
Albumin 25g/d
N =56
Dose increased to 2mg q6h if
Cr decrease <30%
Albumin 100g on day 1
Sanyal A J et al. Gastroenterology 2008; 134(5): 1360
37. Terlipressin in HRS – Survival benefit
No difference in survival at 180 d
Sanyal A J et al. Gastroenterology 2008; 134(5): 1360
38. Noradrenaline vs Terlipressin
Equally efficacious
Adverse events (mostly abdominal pain, chest pain,
or arrhythmia) were significantly more common with
Terlipressin (28 versus 8%)
Cost of Terlipressin 3X of NE
NE in ICU
39. Midodrine, octreotide in HRS
• Retrospective study of 60 patients with type 1 HRS treated
with midodrine/octreotide compared with 21 untreated
controls
• Dose of drugs titrated to achieve MAP increase of 15 mmHg
– Octreotide 100 to 200 µg TID subcutaneous
– Midodrine 5, 7.5, 10, 12.5 & 15 mg TID oral
• Outcome measured - HRS reversal & survival at 30 days
Treatment group
n=60
Control group
n=21
P value
Sustained reduction of Cr 24 (40%) 2 (10%) 0.01
Death at 30 days 26 (43%) 15 (71%) 0.03
Esrailian E et al. Dig Dis Sci (2007) 52:742
41. What treatment is most appropriate for her ?
• Terlipressin
• Effective but high risk- old age, concentric LVH
• Noradrenaline
• Equally effective, similar safety profile
• TIPS
• H/O HE II +, invasive, require expertise
• Liver transplant
• Curative but MELD 20, old age, low patient
acceptability
43. Discharged in June 2016
• Lasix – 40 mg OD
• Aldactone – 50 mg OD
• Remained well till September 2016
• Readmitted 2 days back with ascites & creatinine of
4.2 mg%
44. Case 2
• 52/M, HCV cirrhosis
• HRS-2, Creatinine – 3.2 mg%
• No response to Terlipressin & albumin
46. TIPSS in HRS
1. Is it useful?
2. Does it improve survival?
3. Problems?
47. Transjugular intrahepatic portosystemic shunt
TIPS
• Used in the treatment of refractory ascites
• Provide short-term benefit
• Considered only as a last resort in selected patients
49. Liver transplantation
• Retrospective analysis of 726 LT patients
• 71 patients fulfilled HRS criteria (ICA 1996) pre transplant
Survival at 1 y Survival at 3 y
With HRS 80.3% 76.6%
Without HRS 90.7% 85.3%
Improvement in renal
function over first month
Lee J P et al. Liver Transplant 2012;18:1237
51. Prevention of HRS
1. Salerno F et al. Clin Gastroenterol Hepatol. 2013;11(2):123
2. Fernández J et al. Gastroenterology. 2007;133(3):818.
52. Take home messages…..
• HRS is second most common form of AKI in cirrhosis
• HRS has a very poor prognosis and high resource
utilization
• Vasoconstrictors & albumin are effective in less than
50% of HRS patients
• TIPSS can be used as a stop gap treatment in
selected group of patients
• Liver transplantation is the only effective treatment
• Prevention of HRS possible in few cases