Management of Hepatorenal Syndrome: A Review

Abstract

Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negatively impacts pre- and post-transplant patient survival and healthcare burden. Reduced effective blood volume with consequent reduced renal blood flow, along with systemic inflammation in patients with decompensated cirrhosis, result in susceptibility to HRS. In this article, we will review updates over the last 5 years on the changing definition with diagnostic criteria and nomenclature of AKI and HRS, data on medical treatment with vasoconstrictors, and urinary biomarkers in diagnosis of etiology of AKI. We will also discuss the significance of liver transplantation evaluation once the diagnosis of HRS is established and the post-transplant immunosuppression management. We will also review one of the challenging issues that remains among transplant-eligible patients, that of allocation of simultaneous liver kidney transplant. Finally, we will review the new implemented policy from the Organ Procurement Transplant Network on simultaneous liver kidney allocation.

Keywords: HRS; Liver transplant for HRS; Management.

Fig. 1.. Pathophysiology of renal dysfunction and HRS in cirrhosis.

Abbreviations: AKI, acute kidney injury; BT, bacterial translocation; ECBV, effective circulating blood volume; GFR, glomerular filtration rate; HRS, hepatorenal syndrome; NSAID, non-steroidal anti-inflammatory drug; RAS, renin-angiotensin system; SIRS, systemic inflammatory response syndrome; SNS, sympathetic nervous system.

Fig. 2.. Management approach and algorithm for AKI in patients with cirrhosis.

Abbreviations: AKI, acute kidney injury; ESLD, end-stage liver disease; LTA, liver transplant alone; LVP, large volume paracentesis; RRT, renal replacement therapy; SLK, simultaneous liver kidney; TIPS, transjugular intrahepatic portosystemic shunt. Reproduced with permission from Russ K et al.