Hepatorenal syndrome: aetiology, diagnosis, and treatment

Abstract

Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

Figure 1

A flow diagram outlines the main pathophysiologic mechanisms involved in the development of HRS (reproduced with permission from “John Wiley and Sons,” Garcia-Tsao et al. [1]). RAAS—renin angiotensin aldosterone system; SNS—sympathetic nervous system; ADH—antidiuretic hormone; HRS—hepatorenal syndrome.

Figure 2

Probability of survival in cirrhotic patients with different types of renal impairment: nonazotemic patients (bold continuous line), type 2 HRS (dotted line), and type 1 HRS (continuous line) (reproduced with permission from “BMJ Publishing Group Limited,” Salerno et al. [16]).