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Hepatorenal syndrome

Last reviewed: 10 Nov 2023
Last updated: 20 Jun 2023



History and exam

Key diagnostic factors

  • advanced cirrhosis
  • jaundice
  • ascites
More key diagnostic factors

Other diagnostic factors

  • moderate lowering of BP
  • peripheral edema
  • hepatosplenomegaly
  • spider angioma
  • oliguria
  • bruising
  • petechiae
  • palmar erythema
  • scratch marks
  • gynecomastia
  • encephalopathy
  • pruritus
  • confusion
  • drowsiness
Other diagnostic factors

Risk factors

  • advanced cirrhosis
  • ascites
  • alcoholic hepatitis
  • acute liver failure
  • hyponatremia
  • high plasma renin activity (PRA)
  • spontaneous bacterial peritonitis
  • large volume paracentesis
  • gastrointestinal (GI) bleeding
  • salt restriction
More risk factors

Diagnostic investigations

1st investigations to order

  • creatinine
  • BUN
  • electrolytes
  • CBC
  • LFTs
  • coagulation study
  • diagnostic paracentesis and culture of ascitic fluid
  • blood culture
  • urinalysis and culture
  • Chest x-ray
More 1st investigations to order

Investigations to consider

  • renal ultrasound
More investigations to consider

Treatment algorithm


spontaneous bacterial peritonitis (SBP): prevention of HRS

alcoholic hepatitis: prevention of HRS

suspected HRS


confirmed HRS-AKI



John Kepros, MD
John Kepros

Trauma Medical Director

HonorHealth Osborn Hospital




JK declares that he has no competing interests.

Peer reviewers

Howard J. Worman, MD

Professor of Medicine and Cell Biology

Columbia University College of Physicians and Surgeons

New York



HJW declares that he has no competing interests.

George Y. Wu, MD, PhD

Professor of Medicine

University of Connecticut Health Center




GYW is on the medical advisory boards of the following: Gilead Sciences, Bristol-Myers Squibb, AbbVie, and Intercept.

  • Differentials

    • Prerenal azotemia
    • Acute tubular necrosis - ischemic
    • Acute tubular necrosis - nephrotoxic
    More Differentials
  • Guidelines

    • Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome
    • EASL clinical practice guidelines for the management of patients with decompensated cirrhosis
    More Guidelines
  • Patient leaflets

    Hepatitis C: what is it?

    Hepatitis C: what treatments work?

    More Patient leaflets
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