What is Hepatorenal Syndrome (HRS), a type of progressive kidney dysfunction (Impaired Renal Function) in individuals with advanced liver disease?

From the Guidelines

Hepatorenal syndrome (HRS) is a serious complication of advanced liver disease where kidney function deteriorates despite the kidneys themselves being structurally normal, and the primary treatment approach involves addressing the underlying liver disease while supporting kidney function with vasoconstrictors like terlipressin or norepinephrine combined with albumin. The diagnosis of HRS is based on the presence of advanced liver disease, serum creatinine >1.5 mg/dl, absence of shock, absence of hypovolemia, no current or recent treatment with nephrotoxic drugs, and absence of parenchymal renal disease as defined by proteinuria <0.5 g/day, no microhaematuria, and normal renal ultrasonography 1. There are two types of HRS: Type 1 HRS, characterized by a rapid and progressive impairment in renal function, and Type 2 HRS, characterized by a stable or less progressive impairment in renal function 1. The treatment of HRS involves the use of vasoconstrictors like terlipressin (1 mg/4–6 h intravenous bolus) in combination with albumin, with the aim of improving renal function sufficiently to decrease serum creatinine to less than 133 lmol/L (1.5 mg/dl) 1. In severe cases, dialysis may be needed as a bridge to liver transplantation, which is the definitive treatment for eligible patients 1. The prognosis for HRS is generally poor without liver transplantation, with Type 1 having a worse outlook than Type 2, and early recognition and prompt treatment are crucial to improve outcomes 1. Some key points to consider in the management of HRS include:

• The use of vasoconstrictors and albumin as first-line therapy for HRS 1
• The importance of close monitoring of fluid status, electrolytes, and kidney function during treatment 1
• The potential need for dialysis as a bridge to liver transplantation 1
• The consideration of liver transplantation as the definitive treatment for eligible patients 1
• The importance of early recognition and prompt treatment to improve outcomes 1

From the Research

Definition and Pathophysiology of Hepatorenal Syndrome

• Hepatorenal syndrome (HRS) is a critical and potentially life-threatening complication of advanced liver disease, including cirrhosis 2.
• It is characterized by the development of renal dysfunction in the absence of underlying structural kidney pathology 2, 3.
• The pathophysiology of HRS involves complex interactions between systemic and renal hemodynamics, neurohormonal imbalances, and the intricate role of vasoconstrictor substances 2.

Diagnostic Criteria for Hepatorenal Syndrome

• The diagnosis of HRS is primarily clinical and relies on specific criteria that consider the exclusion of other causes of renal dysfunction 2, 4.
• HRS is diagnosed when kidney function is reduced but evidence of intrinsic kidney disease, such as hematuria, proteinuria, or abnormal kidney ultrasonography, is absent 4.

Management Strategies for Hepatorenal Syndrome

• The management of HRS comprises two main approaches: vasoconstrictor therapy and albumin infusion, which aim to improve renal perfusion and mitigate the hyperdynamic circulation often seen in advanced liver disease 2.
• Combination treatment with octreotide, midodrine, and albumin has shown possible benefit in improving renal function and short-term survival in patients with HRS type 1 and type 2 5.
• Transjugular intrahepatic portosystemic stent shunt (TIPS) is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites, following the improvement of renal function with combination therapy of midodrine, octreotide, and albumin 6.
• Liver transplantation is the best option in suitable candidates, but it is not always applicable due to the short survival expectancy and donor shortage 3.