A systematic review of all articles published in English was done with the help of PubMed Services with the keywords “cirrhosis”, “liver failure”, “renal failure”, and “hepatorenal syndrome” for the period 1960–2002. Priority was given to prospective clinical studies published in journals with high impact factors. For topics on which there was not enough published information to provide evidence-based criteria, we used our own clinical judgment and experience to fill the gaps.
SeminarHepatorenal syndrome
Section snippets
Definition
HRS generally occurs in patients with advanced liver disease and portal hypertension. It is characterised by a combination of disturbances in circulatory and kidney function.6 The principal abnormality in the systemic circulation is low arterial pressure due to greatly reduced total systemic vascular resistance. Kidney function is much impaired because of severe reduction of renal blood flow. The reduction in renal blood flow is pathogenetically related to the impairment in the systemic
Pathogenesis
The pathophysiological hallmark of HRS is vasoconstriction of the renal circulation.1, 2, 3, 4, 6, 10, 11, 12, 13 The mechanism of the vasoconstriction is incompletely understood; it may be multifactorial, involving disturbances in the circulatory function and activity of systemic and renal vasoactive mechanisms. There is severe arterial underfilling in the systemic circulation due to pronounced arterial vasodilatation in the splanchnic circulation, which is related to the presence of portal
Clinical and laboratory findings
In the setting of cirrhosis, HRS generally occurs in late stages of the disease when patients have already had several episodes of some of the major complications of cirrhosis, especially ascites. Patients with ascites showing renal sodium retention together with dilutional hyponatraemia are at high risk of developing HRS.27
The dominant finding of HRS is renal failure, although many patients have other manifestations such as electrolyte disorders, cardiovascular and infectious complications,
Precipitating factors
In some patients, HRS develops spontaneously without any apparent triggering event, whereas in others it occurs in close chronological relation to some precipitating factors that can cause circulatory dysfunction and subsequent renal hypoperfusion.1, 3, 15, 24, 36 Well-known precipitating factors include bacterial infections, large-volume paracentesis without plasma expansion, and gastrointestinal bleeding. Among the different types of bacterial infections that occur in cirrhosis, a clear
Prognosis
Of all the complications of cirrhosis, HRS has the worst prognosis. The survival expectancy is very low1, 2, 6, 27 and spontaneous recovery very rare. The main determinant of survival is the type of HRS. In type 1, hospital survival is less than 10% and the expected median survival time only 2 weeks.26, 27 By contrast, patients with type 2 have a much longer median survival time (about 6 months; figure 2). The second determinant of survival is the severity of liver disease.34, 35 Patients with
Diagnostic approach
The initial step in the diagnosis of HRS is to demonstrate the existence of renal failure (ie, low GFR). The serum creatinine concentration is generally deemed a better marker of GFR than the blood urea nitrogen concentration, because the latter can vary in the absence of changes of GFR (eg, gastrointestinal bleeding, diets high or low in protein). However, serum creatinine concentration is not an ideal marker of GFR in cirrhosis because it is generally lower than expected for any given GFR
Management of type 1 HRS
Patients with suspected type 1 HRS should be managed as inpatients for diagnostic investigation and treatment. Vital signs, urine output, and blood chemistry should be closely monitored. Because most patients have dilutional hyponatraemia (serum sodium below 130 mmol/L), total fluid intake (both oral and intravenous fluids) should be restricted to avoid a positive fluid balance, which would lead to a further reduction in serum sodium concentration. In most cases, total fluid intake should be
Management of type 2 HRS
Unlike patients with type 1 HRS, those with type 2 HRS can be managed as outpatients unless they develop complications of cirrhosis that necessitate hospital admission. The commonest clinical finding in these patients is refractory ascites. Diuretics should be given only if they cause a significant natriuresis (ie, urine sodium excretion of more than 30 mmoles daily). Care should be taken with the use of spironolactone in these patients because of the risk of hyperkalaemia. Dietary sodium
Prevention
Until very recently, no effective methods for prevention of HRS existed. However, two recent studies have shown that the syndrome can be prevented effectively in two specific clinical settings: spontaneous bacterial peritonitis and alcoholic hepatitis. In spontaneous bacterial peritonitis, the intravenous administration of albumin (1·5g/kg at the diagnosis of the infection and 1 g/kg 48 h later) together with antibiotics greatly decreases the risk of HRS compared with the standard treatment of
Search strategy and selection criteria
References (93)
- et al.
Electrolyte and circulatory changes in terminal liver failure
Lancet
(1956) - et al.
Renal failure in the patient with cirrhosis: the role of active vasoconstriction
Am J Med
(1970) Milestones in liver disease. Hecker R, Sherlock S. Electrolyte and circulatory changes in terminal liver failure [Lancet 1956; 2: 1221–25]
J Hepatol
(2002)- et al.
Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis
Hepatology
(1996) - et al.
Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial
Gastroenterology
(2000) - et al.
Renal failure in patients with cirrhosis of the liver: evaluation of intrarenal blood flow by para-aminohippurate extraction and response to angiotensin
Am J Med
(1967) - et al.
Renal and intrarenal blood flow in cirrhosis of the liver
Lancet
(1971) - et al.
Hepatorenal syndrome in cirrhosis: pathogenesis and treatment
Gastroenterology
(2002) - et al.
Systemic and regional hemodynamics in patients with liver cirrhosis and ascites with and without functional renal failure
Gastroenterology
(1989) - et al.
Postprandial middle cerebral arterial vasoconstriction in cirrhotic patients: a placebo, controlled evaluation
J Hepatol
(2001)
Incidence, predictive factors, and prognosis of hepatorenal syndrome in cirrhosis
Gastroenterology
Terlipressin in patients with cirrhosis and type 1 hepatorenal syndrome: a retrospective multicenter study
Gastroenterology
Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study
Hepatology
Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document
J Hepatol
Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis
Gastroenterology
Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors and short-term prognosis
Hepatology
Effect of indomethacin and prostaglandin AI in renal function and plasma renin activity in alcoholic liver disease
Gastroenterology
Beyond hepatorenal syndrome: glomerulonephritis in patients with liver disease
Serum Nephrol
Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure
Kidney Int
The kidney in liver transplantation
Clin Liver Dis
A model to predict survival in patients with end-stage liver disease
Hepatology
MELD and PELD: Application of survival models to liver allocation
Liver Transpl
Model for end-stage liver disease (MELD) and allocation of donor livers
Gastroenterology
Effects of renal impairment on liver transplantation
Gastroenterology
Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation
Hepatology
Live donor liver transplantation
J Hepatol
Adult-adult right hepatic lobe living donor liver transplantation for status 2a patients: too little, too late
Liver Transpl
Beneficial effects of the 2-day administration of terlipressin in patients with cirrhosis and hepatorenal syndrome
J Hepatol
Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome
J Hepatol
Effects of noradrenalin and albumin in patients with type I hepatorrenal syndrome: a pilot study
Hepatology
Octreotide in hepatorenal syndrome: a randomized, double-blind, placebo-controlled, crossover study
Hepatology
Salvage transjugular intrahepatic portosystemic shunt: is it really life-saving?
J Hepatol
Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial
Liver Transpl
Improvement in renal function in hepatorenal syndrome with N-acetylcysteine
Lancet
Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis
Gastroeterology
The North American Study of Treatment for Refractory Ascites (NASTRA)
Gastroenterology
Hepatorenal syndrome
Clinical disorders of renal function in cirrhosis with ascites
Frequency and type of renal and electrolyte disorders in fulminant hepatic failure
BMJ
Clinical disorders of renal function in acute liver failure
Renal blood flow in cirrhosis: relation to systemic and portal hemodynamics and liver function
Scand J Clin Lab Invest
Renal dysfunction in hepatic disease: early identification with renal duplex doppler US in patients who undergo liver transplantation
Radiology
The hepatorenal syndrome
Gut
Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis
Hepatology
Peripheral arterial vasodilation: determinant of functional spectrum of cirrhosis
Semin Liver Dis
Role of nitric oxide as mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis
N Engl J Med
Cited by (532)
Hepatorenal Syndrome in Cirrhosis
2024, GastroenterologyOutcomes of Living Donor Liver Transplantation Compared with Deceased Donor Liver Transplantation
2024, Surgical Clinics of North AmericaAnalysis of outcomes and renal recovery after adult living-donor liver transplantation among recipients with hepatorenal syndrome
2022, American Journal of TransplantationMortality, disease progression, and disease burden of acute kidney injury in alcohol use disorder subpopulation
2022, American Journal of the Medical SciencesCitation Excerpt :Although the mechanisms through which AUD might directly lead to AKI are not clearly defined,15 AUD may result in alcohol-related cirrhosis 16 and alcoholic hepatitis,17,18 conditions that leave patients particularly vulnerable to AKI.1,19 Hepatorenal syndrome (HRS) is a common complication of cirrhosis and alcoholic hepatitis.20,21 Approximately 75% of patients with cirrhosis develop renal dysfunction,22,23 and approximately 20% of patients hospitalized with cirrhosis develop AKI.1
Update on hepatorenal Syndrome: Definition, Pathogenesis, and management
2022, Arab Journal of GastroenterologyThe Kidney and Friends: The Heart, Liver, and Gut
2022, Physician Assistant Clinics