All right, so welcome back to the Internet Book of Critical Care podcast. I'm here with Adam

Thomas and we're going to talk about hepatorenal syndrome. Josh, we got into some spicy fun ones

and then this is bringing us back to the core of intensive care. I think it's hard to be in the

unit and not have someone with

Apatoreno syndrome, correct? You know, with COVID, we've been seeing just a ton of liver

disease. And yeah, I agree with you. I think at all points in time, there's been usually someone

with a patel renal syndrome or some variant thereof. Some great tweets over the years about how

in ICU our jobs are just shifting fluids, right? And this is a big part of that.

Compartment syndromes and fluid shifts are huge in ICU. So we'll talk about what

Apatoreno physiology is, how to name it so you understand it, how you work it up and how you treat it.

And it's all about the tinctures on this one, isn't it, Josh?

Yep. So, hepatorino physiology. What is this thing and why can it contribute to badness?

In cirrhosis, basically there are various systemic vasodilatory substances like nitric oxide

that the liver does not adequately metabolize and they spill out into the systemic

circulation and they cause systemic vasodilation. And I think we've all seen this. These are these

patients who show up in clinic and their blood pressures like ADE systolic and that's just like

how they live. Now the problem is beyond a certain point, what ends up happening is you get progressive

vasodilation of this systemic

circulature. And then like the sympathetic nervous system and the renan angiotensin

aldosterone system are like desperately trying to cause vasoconstriction. And somehow they like

succeed in the kidney. So the kidney ends up like vasoconstricting, but the rest of the body

is vasodilated. So it's this like really horrific situation where like all the blood is essentially going to the wrong place. Just calling your friends to doing the work and nobody else

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