Hepatorenal syndrome: Current concepts and future perspectives

Abstract

Hepatorenal syndrome (HRS), a progressive but potentially reversible deterioration of kidney function, remains a major complication in patients with advanced cirrhosis, often leading to death before liver transplantation (LT). Recent updates in the pathophysiology, definition, and classification of HRS have led to a complete revision of the nomenclature and diagnostic criteria for HRS type 1, which was renamed HRS-acute kidney injury (AKI). HRS is characterized by severe impairment of kidney function due to increased splanchnic blood flow, activation of several vasoconstriction factors, severe vasoconstriction of the renal arteries in the absence of kidney histologic abnormalities, nitric oxide dysfunction, and systemic inflammation. Diagnosis of HRS remains a challenge because of the lack of specific diagnostic biomarkers that accurately distinguishes structural from functional AKI, and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The optimal treatment of HRS is LT. While awaiting LT, treatment options include vasoconstrictor drugs to counteract splanchnic arterial vasodilation and plasma volume expansion by intravenous albumin infusion. In patients with HRS unresponsive to pharmacological treatment and with conventional indications for kidney replacement therapy (KRT), such as volume overload, uremia, or electrolyte imbalances, KRT may be applied as a bridging therapy to transplantation. Other interventions, such as transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Although recently developed novel therapies have potential to improve outcomes of patients with HRS, further studies are warranted to validate the efficacy of these novel agents.

Keywords: Acute kidney injury; Biomarkers; Hepatorenal syndrome; Liver cirrhosis; Terlipressin.

Figure 1.

Pathophysiology of hepatorenal syndrome. PAMPs, pathogen-associated molecular patterns; DAMPs, damage-associated molecular patterns; RAAS, renin-angiotensin-aldosterone system; SNS, sympathetic nervous system; AVP, arginine vasopressin.

Figure 2.

Algorithm for the management of acute kidney injury in patients with cirrhosis. AKI stages 1A and 1B are adaptations of the International Club of Ascites definitions of AKI stages by the European Association for the Study of the Liver [101]. NSAIDs, non-steroidal anti-inflammatory drugs; AKI, acute kidney injury; HRS-AKI, hepatorenal syndrome-acute kidney injury.