An Update on Hepatorenal Syndrome

Main Article Content

Samuel Chan
Kenneth Au
Ross Francis
David W. Mudge
David W. Johnson
Tony Rahman


acute kidney injury, hepatorenal syndrome, molecular absorbent recirculating system, renal replacement therapy, ransjugular intrahepatic portosystemic shunt


Hepatorenal syndrome (HRS) is one of the many potential causes of acute kidney injury (AKI) in patients with decompensated liver disease. HRS is associated with poor prognosis and represents the end-stage of a sequence of reductions in renal perfusion induced by progressively severe hepatic injury. The pathophysiology of HRS is complex with multiple mechanisms interacting simultaneously, although HRS is primarily characterised by renal vasoconstriction. A recently revised diagnostic criteria and management algorithm for AKI has been developed for patients with cirrhosis, allowing physicians to commence treatment promptly. Vasopressor therapy and other general management, such as antibiotic prophylaxis, need to be initiated whilst patients are assessed for eligibility for transplantation. Liver transplantation remains the treatment of choice for HRS but is limited by organ shortage. Other management options, such as transjugular intrahepatic portosystemic shunt, renal replacement therapy and molecular absorbent recirculating system, may provide short-term benefit for patients not responding to medical therapy whilst awaiting transplantation. Clinicians need to be aware of the pathophysiology and management principles of HRS to provide quality care for patients with multi-organ failure.


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1. Boyer TD, Sanyal AJ, Garcia-Tsao G, Regenstein F, Rossaro L, Appenrodt B, et al. Impact of liver transplantation on the survival of patients treated for hepatorenal syndrome type 1. Liver Transpl. 2011;17(11):1328–32.
2. Angeli P, Ginès P, Wong F, Bernardi M, Boyer TD, Gerbes A, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: Revised consensus recommendations of the International Club of Ascites. J Hepatol. 2015;62(4):968–74.
3. Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008;48(6):2064–77.
4. Wong F. The evolving concept of acute kidney injury in patients with cirrhosis. Nat Rev Gastroenterol Hepatol. 2015;12(12):711–19.
5. Chayanupatkul M, Liangpunsakul S. Cirrhotic cardiomyopathy: Review of pathophysiology and treatment. Hepatol Int. 2014;8(3):308–15.
6. Elia C, Graupera I, Barreto R, Solà E, Moreira R, Huelin P, et al. Severe acute kidney injury associated with non-steroidal anti-inflammatory drugs in cirrhosis: A case-control study. J Hepatol. 2015;63(3):593–600.
7. Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol. 2014;60(1):197–209.
8. Oliver JA, Verna EC. Afferent mechanisms of sodium retention in cirrhosis and hepatorenal syndrome. Kidney Int. 2010;77(8):669–80.
9. Arroyo V, Ginès P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996;23(1):164–76.
10. Martín-Llahí M, Guevara M, Torre A, Fagundes C, Restuccia T, Gilabert R, et al. Prognostic importance of the cause of renal failure in patients with cirrhosis. Gastroenterology. 2011;140(2):488–96.
11. Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jiménez W, Arroyo V, et al. MELD score and clinical type predict prognosis in hepatorenal syndrome: Relevance to liver transplantation. Hepatology. 2005;41(6):1282–9.
12. Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: A meta-analysis of randomized trials. Clin Gastroenterol Hepatol. 2013;11(2):123–30.e1.
13. Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133(3):818–24.
14. Park SH, Kim DJ, Kim YS, Yim HJ, Tak WY, Lee HJ, et al. Pentoxifylline vs. corticosteroid to treat severe alcoholic hepatitis: A randomised, non-inferiority, open trial. J Hepatol. 2014;61(4):792–8.
15. Velez JC, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: A pooled analysis of clinical trials. Am J Kidney Dis. 2011;58(6):928–38.
16. Nassar Junior AP, Farias AQ, D’ Albuquerque LA, Carrilho FJ, Malbouisson LM. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: A systematic review and meta-analysis. PLoS One. 2014;9;9(9):e107466.
17. Velez JC, Kadian M, Taburyanskaya M, Bohm NM, Delay TA, Karakala N, et al. Hepatorenal acute kidney injury and the importance of raising mean arterial pressure. Nephron. 2015;131(3):191–201.
18. Cavallin M, Kamath PS, Merli M, Fasolato S, Toniutto P, Salerno F, et al. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: A randomized trial. Hepatology. 2015;62(2):567–74.
19. Brensing KA, Textor J, Perz J, Schiedermaier P, Raab P, Strunk H, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: A phase II study. Gut. 2000;47(2):288–95.
20. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864–71.
21. Rossle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: A critical update. Gut. 2010;59(7):988–1000.
22. Nadim MK, Kellum JA, Davenport A, Wong F, Davis C, Pannu N, et al. Hepatorenal syndrome: The 8th International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2012;9;16(1): R23.
23. Bañares R, Nevens F, Larsen FS, Jalan R, Albillos A, Dollinger M, et al. Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: The RELIEF trial. Hepatology. 2013;57(3):1153–62.
24. Restuccia T, Ortega R, Guevara M, Ginès P, Alessandria C, Ozdogan O, et al. Effects of treatment of hepatorenal syndrome before transplantation on posttransplantation outcome. A case-control study. J Hepatol. 2004;40(1):140–6.
25. Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl. 2015;21(3):300–7.