Board Review: Internal Medicine
You’re working in a rural community Emergency Department when a 52 year old male presents with lethargy and decreased urine output for the past three days. Patient denies any fevers, chills, abdominal pain, nausea, vomiting, diarrhea, dysuria. He has a past medical history of autoimmune hepatitis and diabetes. Vital signs are: Temp 98.3F, HR 80, BP 70/40, RR 18, Sp02 98% on room air. Labs demonstrate a creatinine of 3.5, which is elevated from outpatient labs drawn one week prior with a creatinine of .8 at that time. Which type of hepatorenal syndrome does this patient qualify for with these lab results?
Answer: A. Type 1
Hepatorenal syndrome occurs in patients with acute or chronic liver disease causing portal hypertension. Increased portal hypertension leads to increased nitric oxide production. This causes decreased systemic arterial peripheral vascular resistance, in particular in the splanchnic arterial system. Due to decreased blood flow to the kidneys there is an increase in the renin-angiotensin system, which leads to increased local renal vasoconstriction. Ultimately, this leads to decreased glomerular filtration rate. There are two categories of hepatorenal syndrome:
Type 1- doubling of serum creatinine to a level greater than 2.5 in less than two weeks
Type 2- gradual increase in serum creatinine, typically over weeks to months. This type is also associated with diuretic resistant ascites.
To make the diagnosis all potentially inciting medications must be discontinued and the patient must not improve with two days of albumin 1g/kg (max of 100g) per day.
Ginès, P., Guevara, M., Arroyo, V., & Rodés, J. (2003). Hepatorenal syndrome. Lancet (London, England), 362(9398), 1819–1827. https://doi.org/10.1016/S0140-6736(03)14903-3
O’Mara S.R., & Wiesner L (2020). Hepatic disorders. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill. https://accessemergencymedicine-mhmedical-com.ezproxy.rowan.edu/content.aspx?bookid=2353§ionid=189593407
Wadei, H. M., Mai, M. L., Ahsan, N., & Gonwa, T. A. (2006). Hepatorenal syndrome: pathophysiology and management. Clinical journal of the American Society of Nephrology : CJASN, 1(5), 1066–1079. https://doi.org/10.2215/CJN.01340406