Renal Syndrome

HEPATORENAL SYNDROME 1. CHIEF COMPLAINT •Hepatorenal syndrome 2. HPI 3. ROS 4. SYMPTOMS •Fatigue •Malaise •Dysgeusia •Decreased urine output 5. HISTORY •FAMILY HISTORY •SOCIAL HISTORY •PAST MEDICAL HISTORY o Low urinary sodium excretion o Low serum sodium (dilutional hyponatremia) o Reduced free-water excretion after water load o Low mean arterial pressure o High plasma renin activity o Increased plasma norepinephrine o Low plasma osmolality o High urine osmolality o High serum potassium o Previous episodes of ascites o Absence of hepatomegaly o Esophageal varices o Poor nutritional status o Moderately increased serum urea o Moderately increased serum creatinine o Moderately reduced GFR •SURGICAL HISTORY •CHRONIC CONDITIONS 6. ALLERGIES 7. PHYSICAL EXAMINATION

•Palmar erythema •Leuconychia •Asterixis •Muscle wasting •Clubbing •Scleral icterus •Muscle wasting •Spider nevi •Fetor hepaticus •Xanthelasma •Gynecomastia •Caput medusae •Hepatosplenomegaly •Ascites •Paraumbilical hernia •Bruits •Loss of pubic hair/secondary sexual characteristics in men •Atrophic testes •Peripheral edema •Clubbing 8. SPECIFIC DATA LIKE GRADING ETC 9. TESTS TO BE ORDERED •Serum creatinine level •Urine red blood cell count •Serum sodium concentration •Complete blood cell count with differential •Serum electrolytes •Renal function tests •Liver function tests •Prothrombin time •Alpha-fetoprotein •Blood cultures •Cryoglobulins •Urinalysis •Urine electrolytes •Abdominal ultrasound •Echocardiogram •Paracentesis •Bladder catheterization

•Central line and Swan-Ganz line placement 10.ASSESSMENT /PLAN Surgical Care •Peritoneovenous shunting •Liver transplantation 11.EDUCATION •Institute a low-salt (2 g) diet. •Do not restrict protein intake unless patient has severe encephalopathy. •Patients who have cirrhosis with ascites must be informed that they are at risk of developing HRS and they must be informed about the dismal prognosis this carries in the absence of liver transplantation. •They should be very cautious when new medications are prescribed by physicians not familiar with their care and must avoid known nephrotoxic agents such as nonsteroidals and aminoglycosides. 12.MEDICATION •Octreotide •N-acetylcysteine •Cefotaxime •Ciprofloxacin •Norfloxacin •Sulfamethoxazole •Trimethoprim •Albumin •Dopamine •Misoprostol •Saralasin •Ornipressin •Terlipressin •Midodrine •Norepinephrine •Octapressin •N-acetylcysteine (NAC) 13.FOLLOW-UP