Dr. Sruti Brahmandam & Dr. Sravya Brahmandam

Introduction:

We all know decompensated cirrhotic patients can be critically ill, with a myriad of associated syndromes. Despite this, only on two occasions were syndromes defined by a consensus. In 1978, a conference organized in Sassari, Italy was convened to define and propose diagnostic criteria for hepatorenal syndrome (HRS). After another decade, the 13th International Conference of Gastroenterology in Rome, Italy called for modification of the original criteria in Table 1 below.

HRS can be classified into two different clinical types: type I is with rapid reduction in renal function, defined by a doubling of the initial serum creatinine (SCr) to a level greater than 2.5 mg/dl or a 50% reduction of the initial 24-hour creatinine clearance to a level lower than 20 ml/min in less than 2 weeks. Whereas type 2 is with renal dysfunction that does not progress rapidly and is associated with refractory ascites, which represents the main clinical problem. With the old classification system, the International Club of Ascites (IAC), a fixed SCr was used; however, in clinical practice, SCr is influenced by body weight, race, age, and gender. It is also affected by muscle wasting and increased volume of distribution which is seen in cirrhotics and decreases SCr. As a result, SCr is overestimate in cirrhotic patients.

It is time for a new way to classify?

The new diagnostic criteria for HRS according to ICA in 2019 proposed HRS-1 to be renamed as HRS-AKI and be defined based on changes in serum creatinine and/or changes in urinary output. This new definition removes the rigid cut off value of SCr (2.5 mg/dL or 220 μmol/L) to start pharmacologic treatment.

Updated Criteria:

Highlighted Difference:

The old criteria for HRS-1 required the diagnosis to be established at an advanced stage of AKI (minimum CKD II) which limited the efficacy of vasoconstrictor therapy. This new definition aims to push clinicians to start treatment earlier even with small increases in SCr., to be specific: an absolute increase in SCr ≥0.3 mg/dl within 48 h or an increase in SCr ≥50% from an SCr obtained within the prior 3 months.

Conclusion:

This new nomenclature should help clinicians define HRS-AKI superimposed on CKD. This is imperative with the increasing rate of cirrhosis due to non-alcoholic steatohepatitis. The new HRS definitions and classifications still need to be validated in future prospective studies. I hope an update on these new guidelines will help guide you for your next cirrhotic!

Sruti Brahmandam, M.D.

*Second Year Fellow*
**Medical school**: Northeast Ohio Medical School, Rootstown, OH
**Residency**: University of Louisville Hospital
**About Sruti**: Originally from Ohio and came to Louisville for residency. I have been enjoying the vibrant culture of Louisville, and I am excited to continue my training here. I love experimenting in the kitchen and hope to create new recipes. I also enjoy watching movies and spending time with my family.
**Research interests**: COPD, Ultrasound, Sleep, Lung Cancer, Health Disparities

References:

Arroyo V, Gines P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–176.
Salerno F, Gerbes A, Gines P, et al. Diagnosis, prevention and treatment of the hepatorenal syndrome in cirrhosis a consensus workshop of the International Ascites Club. Gut 2007;56:1310–1318.
Piano S, Schmidt HH, Ariza X, Amoros A, Romano A, Hüsing-Kabar A, et al. Association between grade of acute on chronic liver failure and response to terlipressin and albumin in patients with hepatorenal syndrome. Clin Gastroenterol Hepatol 2018;16:1792–1800.
Boyer TD, Sanyal AJ, Garcia-Tsao G, Blei A, Carl D, Bexon AS, Teuber P, et al. Predictors of response to terlipressin plus albumin in hepatorenal syndrome (HRS) type 1: relationship of serum creatinine to hemodynamics. J Hepatol 2011;55:315–321.

HRS: Out with the Old & In with the New