Hepatorenal syndrome is a serious life threatening complication in end stage liver disease. A recent consensus conference has agreed definitions for hepatorenal syndrome and divided the syndrome into types I and II.1 Type I is characterised by rapidly progressive renal failure with a doubling of serum creatinine to a level greater than 2.5 mg/dl or a halving of creatinine clearance to less than 20 ml/min in less than two weeks. In type II, serum creatinine must be greater than 1.5 mg/dl or creatinine clearance <40 ml/min but is more slowly progressive with a correspondingly better prognosis. Most patients pass through a sequence of ascites, followed by refractory ascites, and then hepatorenal syndrome. A large prospective study including patients with ascites demonstrated that hepatorenal syndrome developed in 18% at one year and in 39% at five years.2 Prognosis was poor with median survival of 1.7 weeks and 90% mortality at 10 weeks. The pathogenesis of hepatorenal syndrome is believed to involve splanchnic vascular dilatation with resultant vasoconstriction in other vascular beds particularly affecting the kidney.1 Therapies such as head out water immersion …