Date:
Patient:
MRN:
Clincian: (Nephrologist, Hepatologist)
Reason for Visit:
Evaluation for suspected or confirmed HRS
Review of laboratory results and clinical features
Discussion of management plan
History of Present Illness:
Briefly describe the onset and progression of symptoms:
Development of ascites (fluid accumulation in the abdomen) despite diuretic therapy
Decreasing urine output (oliguria)
Encephalopathy (confusion, altered mental status) – may occur in later stages
History of underlying liver disease (cirrhosis is the major risk factor)
Recent episodes of variceal bleeding or worsening liver function
Past Medical History:
Underlying liver disease (stage of cirrhosis)
Previous hospitalizations for complications of cirrhosis
Other relevant medical history (e.g., diabetes, heart disease)
Social History:
Alcohol and/or nephrotoxic medication use (contributing risk factors)
Physical Exam:
Vital Signs: May be normal or show signs of volume depletion (low blood pressure).
Evidence of ascites on abdominal exam.
Consider mentioning signs of encephalopathy (confusion, asterixis) if present.
Labs:
Renal function tests (RFTs):
Progressive rise in serum creatinine despite adequate hydration and diuretic use (characteristic feature).
Electrolyte imbalances (hyponatremia, hyperkalemia) may be present.
Liver function tests (LFTs):
Usually abnormal and reflect the underlying liver disease.
Consider mentioning other labs ordered as needed (urinalysis, complete blood count, coagulation studies).
Imaging:
Imaging studies are not diagnostic for HRS but may be helpful to rule out other causes of kidney dysfunction:
Abdominal ultrasound (assess ascites)
Doppler ultrasound of renal arteries (rule out renal artery stenosis)
Assessment:
Summarize the diagnosis of HRS based on clinical presentation (ascites, oliguria), underlying liver disease, and characteristic rise in serum creatinine despite diuretics.
Discuss the stage of HRS based on serum creatinine levels and presence of encephalopathy.
Consider mentioning the use of specific diagnostic criteria (e.g., International Ascites Club criteria) for HRS diagnosis if applicable.
Plan:
Outline the management plan which focuses on treating the underlying liver disease and improving renal function:
Liver-directed therapies:
Management of ascites and other complications of cirrhosis to improve liver function.
Consideration of liver transplantation in select cases, which is the only curative option.
Diuretics:
Optimization of diuretic therapy to manage ascites while avoiding excessive volume depletion.
Albumin replacement:
Intravenous albumin administration to improve circulatory volume and renal perfusion.
Vasodilators:
In some cases, medications to reduce systemic vascular resistance and improve renal blood flow may be considered.
Management of complications:
Treatment of infections (a common complication in HRS).
Management of encephalopathy if present.
Consider mentioning referral to a multidisciplinary team for comprehensive management.
Prognosis:
Briefly discuss the prognosis. Prognosis depends on the severity of HRS and the underlying liver disease.
Early diagnosis and treatment can improve outcomes.
Advanced HRS has a poor prognosis with high mortality rates.
Education:
Document any education provided to the patient regarding:
The nature of HRS and its link to liver disease
The importance of adhering to the treatment plan and medication use
Dietary modifications (may be needed to restrict sodium intake)
The importance of regular follow-up and monitoring
Liver transplantation as a potential curative option
Palliative care options for advanced disease
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about treatment side effects, prognosis, or end-of-life care decisions.
Address the potential emotional impact of a chronic illness and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a nephrologist, hepatologist, or other specialists involved in the patient’s care for diagnosis, treatment recommendations, and prognosis.