They may have struggled to get girlfriends in college, but members of the International Ascites Club do call the shots when it comes to defining hepato-renal syndrome (HRS). As they were published in Gut, their revised criteria for the diagnosis of HRS may have escaped the attention of some Nephrologists, so I thought I might present them for you here:- Cirrhosis with ascites.
- Serum creatinine > 1.5 mg/dl (133 mmol/l).
- No improvement of serum creatinine (decrease to a level of 1.5 mg/dl) after at least 2 days with diuretic withdrawal 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/day.
- Absence of shock.
- No current or recent treatment with nephrotoxic drugs.
- Absence of parenchymal kidney disease as indicated by proteinuria .500 mg/day, microhaematuria (.50 red blood cells per high power field) and/or abnormal renal ultrasonography.
There are several important differences from the original diagnostic criteria that most of you would be familiar with:
- Creatinine clearance has been dropped; the diagnosis is now purely based on serum creatinine
- Controversially, renal failure during bacterial infection, but in the absence of septic shock, is now considered HRS. This implies treatment of HRS should be started before complete recovery from sepsis.
- Plasma volume expansion should be performed with albumin rather than the original 1.5L of saline.
- Minor diagnostic criteria have been removed, most notably the need for a salt-avid urine (low urine sodium).
- Acute liver injury is not included as a cause.
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