COVID-19 and hepatorenal syndrome

Table 1 Key components of clinical assessment and management in COVID-19 induced hepatorenal syndrome

Clinical Assessment of HRS	Management of HRS
Medical history: (1) Identify likely course of disease progression; and (2) rule out other causes of acute liver injury/fulminant liver failure	Minimize potential drug-induced hepato- and nephron-toxicities: (1) Monitor response to immunosuppressive treatments; (2) monitor response to antivirals and other COVID-19 treatment regimes; and (3) aim to prescribe these medications through a dose-dependent approach
Clinical examination: (1) Identify signs of systemic and/or respiratory decompensation; (2) identify evidence of cirrhosis/decompensated liver disease; and (3) monitor for oliguria	Medical management strategies in COVID-19 induced HRS: (1) Extracorporeal membrane support therapy & dialysis; (2) potential utilization of MARS or other liver support devices; (3) TIPSS to reduce portal vein pressure (if renal function allows and known CLD); (4) adding intravenous albumin to other procedural/medical therapies to expand plasma volume; and (5) combined use of Midodrine (α-agonist) and Octreotide (somatostatin analogue) to regulate blood vessel tone in the gastrointestinal tract and act as systemic vasoconstrictors to inhibit splanchnic vasodilation. Terlipressin may be used as an alternative
Laboratory and imaging tests: (1) Confirm positive COVID-19 status; (2) assess systemic hemodynamic stability through basic observations; (3) chest imaging to assess degree of COVID-19 severity for the respiratory system; (4) serum tests to evaluate the degree of inflammation; (5) liver pathology could be evaluated via serum markers (e.g., increased ALT, AST, total bilirubin, GGT and ALP, reduction in albumin) and liver ultrasound; (6) urinalysis to identify low urine sodium i.e., < 10 mmol/L, proteinuria, hematuria and urinary casts seen in ATN; (7) serum eGFR reductions, low serum sodium (dilutional hyponatremia) and elevated plasma renin would be classically observed in HRS; and (8) kidney ultrasound should be performed to rule out obstruction of the kidney outflow tract	Consider liver transplantation if kidney function and hepatic recovery is unlikely with medical management

AKI: Acute kidney injury; ALP: Alkaline phosphatase; ALT: Alanine transaminase; AST: Aspartate transaminase; ATN: Acute tubular necrosis; COVID-19: Coronavirus disease 2019; eGFR: Estimated glomerular filtration rate; GGT: Gamma-glutamyl transferase; HRS: Hepatorenal syndrome; MARS: Molecular adsorbents recirculation systems; TIPS: Transjugular intrahepatic portosystemic shunt.