Hepatorenal syndrome

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 16 Aug 2024

Last updated: 20 Jun 2023

Hepatorenal syndrome (HRS) is associated with acute liver failure including cirrhosis.

HRS is diagnosed by excluding other causes of renal failure.

Liver transplantation is the only definitive treatment.

Dialysis and transjugular intrahepatic portosystemic shunts are temporizing measures while awaiting liver transplantation.

The vasopressin analog terlipressin is very effective at reversing the condition in some patients, but its benefits need to be weighed against the risk of respiratory failure and sepsis.

General prognosis is poor.

Definition

Hepatorenal syndrome (HRS) is a type of acute kidney injury in patients with acute or chronic liver disease. HRS occurs in the absence of hypovolemia or significant abnormalities in kidney histology.[1][2]

History and exam

Key diagnostic factors

advanced cirrhosis
jaundice
ascites

Full details

Other diagnostic factors

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

Full details

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

Full details

Diagnostic tests

1st tests to order

creatinine
BUN
electrolytes
CBC
LFTs
coagulation study
diagnostic paracentesis and culture of ascitic fluid
blood culture
urinalysis and culture
Chest x-ray

Full details

Tests to consider

renal ultrasound

Full details

Treatment algorithm

INITIAL

spontaneous bacterial peritonitis (SBP): prevention of HRS

alcoholic hepatitis: prevention of HRS

suspected HRS

ACUTE

confirmed HRS-AKI

Contributors

Authors

John Kepros, MD

Trauma Medical Director

HonorHealth Osborn Hospital

Scottsdale

Disclosures

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

Disclosures

HJW declares that he has no competing interests.

George Y. Wu, MD, PhD

Professor of Medicine

University of Connecticut Health Center

Farmington

Disclosures

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 information
Hepatitis C: what is it?
Hepatitis C: what treatments work?
More Patient information
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Hepatorenal syndrome

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

spontaneous bacterial peritonitis (SBP): prevention of HRS

alcoholic hepatitis: prevention of HRS

suspected HRS

confirmed HRS-AKI

Contributors

Authors

John Kepros, MD

Disclosures

Peer reviewers

Howard J. Worman, MD

Disclosures

George Y. Wu, MD, PhD

Disclosures

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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