Hepatorenal syndrome misdiagnosis may be reduced using inferior vena cava ultrasound to assess intravascular volume and guide management

Abstract

Hepatorenal syndrome (HRS) is a diagnosis of exclusion defined as acute kidney injury (AKI) with cirrhosis and ascites, with serum creatinine unresponsive to standardized volume administration and diuretic withdrawal. Persistent intravascular hypovolemia or hypervolemia may contribute to AKI and be revealed by inferior vena cava ultrasound (IVC US), which may guide additional volume management. Twenty hospitalized adult patients meeting HRS-AKI criteria had IVC US to assess intravascular volume after receiving standardized albumin administration and diuretic withdrawal. Six had IVC collapsibility index (IVC-CI) ≥50% and IVCmax ≤0.7 cm suggesting intravascular hypovolemia, 9 had IVC-CI <20% and IVCmax >0.7 cm suggesting intravascular hypervolemia, and 5 had IVC-CI ≥20% to <50% and IVCmax >0.7 cm. Additional volume management was prescribed in the 15 patients with either hypovolemia or hypervolemia. After 4–5 days, serum creatinine levels decreased ≥ 20% without hemodialysis in 6 of 20 patients – 3 with hypovolemia received additional volume, and 2 with hypervolemia plus one with ‘euvolemia’ and dyspnea were volume restricted and received diuretics. In the other 14 patients, serum creatinine failed to persistently decrease ≥20% or hemodialysis was required indicating that AKI did not improve. In summary, fifteen of 20 patients (75%) were presumed to have intravascular hypovolemia or hypervolemia by IVC ultrasound. Six of the 20 patients (40%) improved AKI by 4-5 days of follow-up with additional IVC US-guided volume management, and thus had been misdiagnosed as HRS-AKI. IVC US may more accurately define HRS-AKI as being neither hypovolemic nor hypervolemic, and guide volume management, decreasing the frequency of HRS-AKI misdiagnosis.

Seeing and Sensing the Hepatorenal Syndrome (HRS): The Growing Role of Ultrasound-Based Techniques as Non-Invasive Tools for the Diagnosis of HRS

“…The data showed a great variability of IVCD and IVCCI in patients with an AKI that was suspected of being HRS; according to these data, the reclassification of the subjects in terms of depleted volume, expanded volume, and increased intraabdominal pressure requires a different approach. These results were confirmed by other studies which concluded that 40% of the patients were misdiagnosed as HRS-AKI and treated according to the measurements of IVCD and IVCCI that suggested hipo-or hypervolemia; their renal function was improved with supplementary hydration or an increase in diuretics [58].…”

Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

“…[46] A recent study on pulmonary artery catheterization in cirrhosis-AKI showed that 62% of patients diagnosed with HRS by clinical criteria have elevated pulmonary capillary wedged pressure and were counterintuitively started on diuretics. [47] Patients can be better assessed for volume resuscitation in AKI using IVC dynamics, [48] and incorporation of POCUS is recommended in an updated HRS-AKI management algorithm. [16] While our institutional protocol for the management of HRS-AKI entails treating these patients in the liver ICU, we recognize that many other institutions' HRS-AKI protocol entails treating them in step-down units on the medical ward while they are on terlipressin.…”

“…The use of POCUS in classifying the type of AKI in cirrhosis is an important evolving domain in HRS-AKI management 46 . A recent study on pulmonary artery catheterization in cirrhosis-AKI showed that 62% of patients diagnosed with HRS by clinical criteria have elevated pulmonary capillary wedged pressure and were counterintuitively started on diuretics 47 . Patients can be better assessed for volume resuscitation in AKI using IVC dynamics, 48 and incorporation of POCUS is recommended in an updated HRS-AKI management algorithm 16 .…”

Inferior vena cava ultrasound and other techniques for assessment of intravascular and extravascular volume: an update

“…[ 82 ] reported 64% of 53 patients initially presumed to have HRS-AKI had intravascular hypovolemia or hypervolemia, or intra-abdominal hypertension by IVC ultrasound assessment, and 35% improved AKI following IVC ultrasound-guided volume management, making the diagnosis of HRS-AKI unlikely. In our study of 20 patients presumed to have HRS-AKI, 75% had intravascular hypovolemia or hypervolemia by IVC ultrasound [ 83 ]. Forty percent improved AKI with additional IVC ultrasound-guided volume management and had been misdiagnosed as HRS-AKI.…”