Highlights & Basics
- 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.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Citations
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.[Abstract][Full Text]
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.[Abstract][Full Text]
Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993;105:229-236.[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.[Abstract][Full Text]
1. Dagher L, Moore K. The hepatorenal syndrome. Gut. 2001 Nov;49(5):729-37.[Abstract][Full Text]
2. 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.[Abstract][Full Text]
3. Salerno F, Gerbes A, Gines P, et al. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007 Sep;56(9):1310-8.[Abstract][Full Text]
4. Angeli P, Ginès P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol. 2015 Apr;62(4):968-74.[Abstract][Full Text]
5. 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.[Abstract][Full Text]
6. Simonetto DA, Gines P, Kamath PS. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ. 2020 Sep 14;370:m2687.[Abstract][Full Text]
7. Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993 Jul;105(1):229-36.[Abstract][Full Text]
8. Salerno F, Cazzaniga M, Merli M, et al. Diagnosis, treatment and survival of patients with hepatorenal syndrome: a survey on daily medical practice. J Hepatol. 2011 Dec;55(6):1241-8.[Abstract]
9. Rey R M, Delgado AF, De Zubiria A, et al. Prevalence and short-term outcome of hepatorenal syndrome: A 9-year experience in a high-complexity hospital in Colombia. PLoS One. 2020;15(10):e0239834.[Abstract][Full Text]
10. Gines P, Arroyo V. Hepatorenal syndrome. J Am Soc Nephrol. 1999 Aug;10(8):1833-9.[Abstract][Full Text]
11. Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993;105:229-236.[Abstract]
12. Angeli P, Garcia-Tsao G, Nadim MK, et al. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document. J Hepatol. 2019 Oct;71(4):811-822.[Abstract][Full Text]
13. 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.[Abstract][Full Text]
14. Gines P, Guevara M, Arroyo V, et al. Hepatorenal syndrome. Lancet. 2003 Nov 29;362(9398):1819-27.[Abstract]
15. Aithal GP, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021 Jan;70(1):9-29.[Abstract][Full Text]
16. Sorrentino P, Castaldo G, Tarantino L, et al. Preservation of nutritional-status in patients with refractory ascites due to hepatic cirrhosis who are undergoing repeated paracentesis. J Gastroenterol Hepatol. 2012 Apr;27(4):813-22.[Abstract]
17. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5;341(6):403-9.[Abstract][Full Text]
18. Wong F, Blendis L. New challenge of hepatorenal syndrome: prevention and treatment. Hepatology. 2001 Dec;34(6):1242-51.[Abstract][Full Text]
19. Singal AK, Bataller R, Ahn J, et al. ACG clinical guideline: alcoholic Liver Disease. Am J Gastroenterol. 2018 Feb;113(2):175-94.[Abstract]
20. Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med. 2015 Apr 23;372(17):1619-28.[Abstract][Full Text]
21. Pavlov CS, Varganova DL, Casazza G, et al. Glucocorticosteroids for people with alcoholic hepatitis. Cochrane Database Syst Rev. 2019 Apr 9;(4):CD001511.[Abstract][Full Text]
22. Arroyo V, Gines P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996 Jan;23(1):164-76.[Abstract][Full Text]
23. Fabrizi F, Dixit V, Messa P, et al. Terlipressin for hepatorenal syndrome: a meta-analysis of randomized trials. Int J Artif Organs. 2009;32:133-140.[Abstract]
24. Fabrizi F, Dixit V, Martin P. Meta-analysis: terlipressin therapy for the hepatorenal syndrome. Aliment Pharmacol Ther. 2006;24:935-944.[Abstract][Full Text]
25. Sridharan K, Sivaramakrishnan G. Vasoactive agents for hepatorenal syndrome: a mixed treatment comparison network meta-analysis and trial sequential analysis of randomized clinical trials. J Gen Intern Med. 2018 Jan;33(1):97-102.[Abstract][Full Text]
26. Best LM, Freeman SC, Sutton AJ, et al. Treatment for hepatorenal syndrome in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2019 Sep 12;(9):CD013103.[Abstract][Full Text]
27. Israelsen M, Krag A, Allegretti AS, et al. Terlipressin versus other vasoactive drugs for hepatorenal syndrome. Cochrane Database Syst Rev. 2017 Sep 27;(9):CD011532.[Abstract][Full Text]
28. Wong F, Pappas SC, Curry MP, et al. Terlipressin plus albumin for the treatment of type 1 hepatorenal syndrome. N Engl J Med. 2021 Mar 4;384(9):818-28.[Abstract][Full Text]
29. Hiremath SB, Srinivas LD. Survival benefits of terlipressin and non-responder state in hepatorenal syndrome: a meta-analysis. Indian J Pharmacol. 2013 Jan-Feb;45(1):54-60.[Abstract][Full Text]
30. US Food and Drug Administration. FDA approves treatment to improve kidney function in adults with hepatorenal syndrome. Sep 2022 [internet publication].[Full Text]
31. European Medicines Agency. Terlipressin-containing medicinal products indicated in the treatment of hepatorenal syndrome. Sep 2022 [internet publication].[Full Text]
32. Medicines and Healthcare products Regulatory Agency. Terlipressin: new recommendations to reduce risks of respiratory failure and septic shock in patients with type 1 hepatorenal syndrome. Mar 2023 [internet publication].[Full Text]
33. Stutchfield BM, Simpson K, Wigmore SJ. Systematic review and meta-analysis of survival following extracorporeal liver support. Br J Surg. 2011 May;98(5):623-31.[Abstract]
34. Karwa R, Woodis CB. Midodrine and octreotide in treatment of cirrhosis-related hemodynamic complications. Ann Pharmacother. 2009 Apr;43(4):692-9.[Abstract]
35. Guevara M, Ginès P. Hepatorenal syndrome. Dig Dis. 2005;23(1):47-55.[Abstract][Full Text]
36. Thomson MJ, Taylor A, Sharma P, et al. Limited progress in hepatorenal syndrome (HRS) reversal and survival 2002-2018: a systematic review and meta-analysis. Dig Dis Sci. 2020 May;65(5):1539-48.[Abstract][Full Text]
37. Planas R, Montoliu S, Balleste B, et al. Natural history of patients hospitalized for management of cirrhotic ascites. Clin Gastroenterol Hepatol. 2006;4:1385-1394.[Abstract]
38. Gonwa TA, Klintmalm GB, Levy M, et al. Impact of pretransplant renal function on survival after liver transplantation. Transplantation. 1995;59:361-365.[Abstract]
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