Hepatorenal syndrome: pathophysiology, diagnosis, and managementBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2687 (Published 14 September 2020) Cite this as: BMJ 2020;370:m2687
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We read with great interest the article on the hepatorenal syndrome (HRS) by Simonetto DA, et al . We commend the authors for their well-balanced and meticulous discussion of this topic. However, we would like to point out that the blanket recommendation of fluid challenge in anyone suspected to have HRS without objectively assessing the volume status puts the patients at risk of iatrogenic volume overload. This is particularly important, as we now know that fluid overload is associated with worse outcomes in various clinical settings .
Point of care ultrasonography (POCUS) of the lung, inferior vena cava (IVC), heart and venous Doppler (in varying combinations as needed) provides helpful insights into hemodynamics that can be integrated with conventional assessment to guide management in such patients. As an example, in a cohort of 53 patients with ‘clinical’ diagnosis of hepatorenal syndrome type 1, 64% were found to have alternative diagnoses such as intravascular volume overload and intra-abdominal hypertension using IVC ultrasonography . Similarly, in another study, approximately two-thirds of ‘apparently’ euvolemic patients with acute kidney had moderate to severe lung congestion (defined as more than 15 B lines) on POCUS . More recently, venous excess ultrasound grading (VExUS), a novel protocol using portal, hepatic and intra-renal venous Doppler waveforms has shown promising results in classifying the severity of hypervolemia when used in combination with IVC ultrasound .
Once confined to specialties such as obstetrics and emergency medicine, the scope of diagnostic POCUS is rapidly expanding in the fields of internal medicine and nephrology. In fact, POCUS is considered as an upgrade to the traditional physical examination and we believe no patient deserves ‘empiric’ intravenous fluid therapy without bedside sonographic assessment.
1. Simonetto DA, Gines P, Kamath PS. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ. 2020 Sep 14;370:m2687. doi: 10.1136/bmj.m2687. PMID: 32928750.
2. Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014;46(5):361-80. doi: 10.5603/AIT.2014.0060.
3. Velez JCQ, Petkovich B, Karakala N, Huggins JT. Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome. Am J Nephrol. 2019;50(3):204‐211. doi:10.1159/000501299
4. Panuccio V, Tripepi R, Parlongo G, et al. Lung ultrasound to detect and monitor pulmonary congestion in patients with acute kidney injury in nephrology wards: a pilot study. J Nephrol. 2020;33(2):335‐341. doi:10.1007/s40620-019-00666-3
5. Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, Denault AY. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16. doi: 10.1186/s13089-020-00163-w.
Competing interests: No competing interests
The authors state that "albumin infusion is essential for effective management of AKI-HRS". This seems like a strong recommendation, and should be backed by high quality evidence. But the authors do not cite a single high-quality RCT to back their opinion. Instead, we are fed a litany of circumstantial evidence and one referenced non-randomised trial of 21 vs 13 pts (Terlipressin +/- albumin). Another study compares albumin to starches, which are now widely recognised to be nephrotoxic. This is hardly supportive of strong claims.
Competing interests: No competing interests