Revised diagnostic criteria of HRS

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:

1. Creatinine clearance has been dropped; the diagnosis is now purely based on serum creatinine
2. 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.
3. Plasma volume expansion should be performed with albumin rather than the original 1.5L of saline.
4. Minor diagnostic criteria have been removed, most notably the need for a salt-avid urine (low urine sodium).
   
5. Acute liver injury is not included as a cause.