Summary
Definition
History and exam
Key diagnostic factors
- advanced cirrhosis
- jaundice
- ascites
Other diagnostic factors
- moderate lowering of BP
- peripheral edema
- splenomegaly
- spider angioma
- oliguria
- bruising
- petechiae
- palmar erythema
- scratch marks
- gynecomastia
- encephalopathy
- pruritus
- confusion
- drowsiness
Risk factors
- advanced cirrhosis
- ascites
- alcohol-related hepatitis
- hyponatremia
- high plasma renin activity (PRA)
- spontaneous bacterial peritonitis
- large volume paracentesis
- gastrointestinal (GI) bleeding
Diagnostic tests
1st tests to order
- serum creatinine
- BUN
- electrolytes
- CBC
- liver tests
- coagulation study
- diagnostic paracentesis and culture of ascitic fluid
- blood culture
- urinalysis and culture
- Chest x-ray
Tests to consider
- renal ultrasound
Treatment algorithm
spontaneous bacterial peritonitis (SBP): prevention of HRS
suspected HRS-AKI
confirmed HRS-AKI
Contributors
Authors
Douglas A. Simonetto, MD
Associate Professor of Medicine
Division of Gastroenterology and Hepatology, Department of Medicine
Mayo Clinic
Rochester
MN
Disclosures
DAS has done consultancy work for Mallinckrodt, Evive, Resolution Therapeutics, and BioVie. DAS is an author of a reference cited in the topic.
Kathryn A. Schmidt, MD
Division of Gastroenterology and Hepatology, Department of Medicine
Mayo Clinic
Rochester
MN
Disclosures
KAS declares that she has no competing interests.
Acknowledgements
Dr Douglas A. Simonetto and Dr Kathryn A. Schmidt would like to gratefully acknowledge Dr John Kepros, the previous contributor to this topic.
Disclosures
JK declares that he has no competing interests.
Peer reviewers
William Carey, MD, MACG, FAASLD
Hepatology Section Head
Cleveland Clinic
Cleveland
OH
Disclosures
WC declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74(2):1014-48.Full text Abstract
Simonetto DA, Gines P, Kamath PS. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ. 2020 Sep 14;370:m2687.Full text Abstract
European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69(2):406-60.Full text Abstract
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010 Sep;53(3):397-417.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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