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Oct 7, 2018 13 tweets 10 min read Twitter logo Read on Twitter
What is hepatorenal syndrome?
A #Livertwitter #tweetorial

Hepatology is awesome, exciting, but also humbling.
Nowhere is that clearer than HRS, a true unmet need for patients with ascites

1. What
2. Why
3. How to prevent/treat
4. ❤️ #cirrhosis physiology
1. Ascites trashes QOL & is deadly enough to merit mention in the bible(Fig1)
2. Ascites physiology damages other organs; Austin Flint said it 1st (Fig2)
3. HRS is the knockout punch of portal hypertension. What begins as elevated portal mmHg and ascites ends as HRS(Fig3)
1. HRS is not rare in pts w/ascites (Fig1)
2. HRS is deadly (Fig2)
3. For a definition of terms, check out the Ascites Club (that's a thing!)
ref: gut.bmj.com/content/gutjnl…
or see my review: amjmed.com/article/S0002-… (Fig3)
This is where HRS gets wild

1. The kidneys are (mostly) normal(Fig1)
2. Take the kidneys of someone who died from HRS, transplant them into someone without cirrhosis and they work just fine (Fig2)
3. Replace the liver of someone with HRS & the kidneys may wake back up(Fig3)
What's going on in HRS?

1. #Cirrhosis is a traffic jam 4 portal inflow (Fig 1)
2. Splanchnic (gut) vascular bed vasodilates 🔼 pooling of blood (Fig2)
3. This means🔽return to the ❤️
4. Carotid baroreceptors, ADH, and RAAS to the "rescue" (Fig3)
HRS is: compensatory mechanisms gone awry
To maintain ❤️ output:
Baroreceptors ▶️catecholamines, ADH
The kidney 🔼🔼 RAAS
The result?
1. Hyperdynamic circ (F1) (or just look @ a TTE)
2. Salt avidity (F3)
3. 🔼Circulatory volume (F2)

but this results in a very tenuous situation
HRS: All about glomerular perfusion pressure

1. Cirrhosis🔽arterial BP, RAAS/catecholes squeezw the efferent arteriole 2 maintain renal perfusion(Fig1)
2. To keep the afferent open, need prostaglandins(Fig2)
3. If thromboxane>PG🔽renal blood flow(Fig3)
Then comes calamity(Fig4)
Precarious cirrhotic hemodynamics: Like driving w/one🦶on the gas, one on the breaks
1. The gas pedal: Splanch pooling 🔽SV; ❤️🔼HR & contractility
2. The tank: To🔼SV we🔼ADH,Aldo
3. The breaks: RAAS/catechole r good, till they aint
Empty tank▶️all breaks▶️HRS
What can you do to prevent HRS?

1. If severe infection (e.g.SBP)🔼vasodilation▶️empty tank: Give albumin!(Fig1)
2. If lrg volume para▶️6-8g/L removed albumin!
3. NO NSAIDS in patients w/ascites!!!(Fig3)
4. Don't miss SBP, temporarily hold anti-HTN meds if at risk for HRS(Fig3)
How to treat HRS?

1. Like most things in #hepatology, Sheila Sherlock did it first. (obit: aasldpubs.onlinelibrary.wiley.com/doi/abs/10.105…)
2. In 1956, she was first to note arterial vasodilation and first to use Norepi to treat HRS (Fig2)
3. Today: Albumin + Terli>/=Norepi>Midodrine/Octreo
This concludes a HRS #tweetorial.

The #cirrhosis #QI takeaways
1. Dont miss SBP (early dx para when admitted)
2. 🚫NSAIDs if ascites
3. Albumin w/therapeutic paras

Please @ me if u have anything to add!
If U want more #cirrhosis physiology, the refs are embedded in the figs
See below for this post without spelling errors
Precarious cirrhotic hemodynamics: Like driving w/one🦶on the gas, one on the brakes
1. The gas pedal: Splanch pooling 🔽SV; ❤️🔼HR & contractility
2. The tank: To🔼SV we🔼ADH,Aldo
3. The brakes: RAAS/catechole r good, till they aint
Empty tank▶️all brakes▶️HRS

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More from @ebtapper

Sep 27, 2018
Hepatic encephalopathy in the hospital (An ode to #lactulose):
A brief #livertwitter #tweetorial
1. Share the greatest t-shirt ever made
2. Rule out infection!
3. Laxation now! But how?

keywords: #cirrhosis, paracentesis, stool pH
1. This shirt, made by a patient, reminds us:
▶️HE is horrible, unpredictable
▶️Preventing HE is hard
▶️Dont be quick 2 label pts as 'noncompliant' - there's more to the story
▶️Our patients are awesome. Hepatology is the best

2. Think of hepatic encephalopathy as a biomarker.

For what? The answers form a mandatory checklist of sorts

1. Para to r/o SBP. Delay @ your patient's peril. (Fig1)
2. GI Bleeding?
3. UA/Blood Cultures/CXR
3. What's the Cr? Na? K?
review: nature.com/articles/s4139…
Read 14 tweets
Aug 20, 2018
Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial

1. Top 3 causes of acute liver injury
2. I always say it's ischemic hepatitis; 50% of the time, I'm right every time

Brought to u by:
@tonybreu et al. What causes severe ALI?
The liver is awesome.

Yet its vocabulary is ... limited.

We can all tell when it is upset - high ALT, AST.

But that could mean anything!

So what's your specific patient's specific reason for high ALT?
First - a poll:
What's the most common cause of severe acute liver injury
(ALT or AST > 10xULN)?
Read 11 tweets
Jul 25, 2018
Introducing the “The Hepatologist’s CBC”

A #cirrhosis #tweetorial all about the platelet

- Identify cirrhosis based on blood tests-
- Understand why platelets are low in #cirrhosis
- Describe the plt’s role in the #cirrhotic #coagulopathy

The hepatologist's dream:
identify patients with cirrhosis before complications like HCC and variceal bleeding.

Enter the platelet count
Shout out to JAMA's Rational Clin Exam Series & Udell et al's big beautiful systematic review ncbi.nlm.nih.gov/pubmed/22357834
Platelets are low in #cirrhosis.
We can use this to our advantage - even sparing biopsies.

Easy to do. E.g. Google: FIB-4
(ref aasldpubs.onlinelibrary.wiley.com/doi/abs/10.100…)

There are many platelet-based scores to help ID cirrhosis.
(review: ncbi.nlm.nih.gov/pubmed/2883446
Read 14 tweets
Jul 16, 2018
What's the deal with Ammonia in hepatic encephalopathy?
A #cirrhosis QI #tweetorial

Try to answer this question while also showing
1) Ammonia levels dont matter
2) U should not restrict protein in patients with HE

Keywords: "ammonia hypothesis", sarcopenia
First, a poll:
Does Ammonia cause hepatic encephalopathy?
How did NH3 get involved with #HE in the first place?

Step 1: In 1877 Eck develops the first successful vascular anastamosis, a portocaval shunt. ncbi.nlm.nih.gov/pubmed/9186464
Step2: Pavlov improves it
Step3: Dogs get goofy after eating meat:"Meat stupor"
Step4: What's up with meat!?
Read 26 tweets
Jul 10, 2018
A celebration of paracentesis: a QI #Tweetorial

For all my twitter friends who care for inpatients with #cirrhosis

Take home messages: paras for all, FFP for none
Keywords: #SBP and the #cirrhotic #coagulopathy
First - which hospitalized patient needs a diagnostic para?

Patients with ascites and:
Spontaneous bacterial peritonitis (SBP) is a deadly condition. Appropriate tx can prevent hepatorenal syndrome and death.

How many patients are asymptomatic?


In this study from Pinzello et al, 1 in 3 patients with SBP were "silent"
Read 19 tweets

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