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Management of hepatorenal syndrome in patients with cirrhosis

Nature Reviews Nephrology volume 7, pages 517–526 (2011)Cite this article

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Abstract

Patients with liver cirrhosis develop progressive circulatory dysfunction, which induces activation of the renin–angiotensin–aldosterone system (RAAS), activation of the sympathetic nervous system and increased activity of antidiuretic hormone. Such activation results in renal fluid retention, ascites and dilutional hyponatremia. In patients with advanced cirrhosis, these processes culminate in renal vasoconstriction and type 2 hepatorenal syndrome (HRS), which is characterized by slowly progressive renal failure and refractory ascites. Type 1 HRS is characterized by acute renal failure and rapid deterioration in the function of other organs in the setting of a precipitating event. Prognosis for both types of HRS is notably poor and orthotopic liver transplantation is the only definitive treatment; however, various therapies that restore renal function can provide a bridge to transplantation. Vasoconstrictors plus albumin improve renal function in 40–60% of patients with type 1 HRS. Transjugular intrahepatic portosystemic shunt (TIPS) placement is also effective in type 1 HRS, but its applicability is low (as it is not suitable for all patients), and it increases the risk of encephalopathy. Albumin dialysis is a potentially effective treatment for type 1 HRS still under investigation. Patients with type 2 HRS are treated with repeated large-volume paracentesis or TIPS.

Key Points

  • Patients with cirrhosis develop progressive impairment in circulatory function owing to splanchnic arterial vasodilatation and deterioration in cardiac function

  • Type 2 hepatorenal syndrome (HRS) is the extreme expression of this circulatory dysfunction, which manifests as slowly progressive functional renal failure associated with refractory ascites

  • Type 1 HRS is an acute functional renal failure accompanied by multiorgan failure that develops in close temporal relationship to a precipitating event, commonly an infection

  • Patients with type 2 HRS and refractory ascites are treated by repeated large volume paracentesis, or by transjugular intrahepatic portosystemic shunt insertion

  • The treatment of choice for patients with type 1 HRS is intravenous administration of vasoconstrictors (terlipressin or norepinephrine) in addition to intravascular volume expansion with albumin

  • Primary prophylaxis for type 1 HRS comprises oral norfloxacin (prophylaxis for bacterial infection) oral pentoxifylline (in acute alcoholic hepatitis), and intravenous albumin (in spontaneous bacterial peritonitis)

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Figure 1: Mechanisms leading to type 1 HRS and multiorgan failure in patients with SBP.
Figure 2: Mechanisms leading to circulatory and renal dysfunction in cirrhosis.
Figure 3: Changes in serum creatinine levels and vasoconstrictor systems activity over time in nine patients with hepatorenal syndrome (six patients with type 1 HRS and three patients with type 2 HRS) who were treated with terlipressin and intravenous albumin.

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Acknowledgements

V. Arroyo and J. Fernández are both supported by the Centro de Investigación Biomédica en Red en el Área temática de enfermedades hepáticas y digestivas (CIBERehd). C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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  1. Liver Unit, Hospital Clinic Barcelona, University of Barcelona, Villarroel 170, Barcelona, 08036, Catalonia, Spain

    Vicente Arroyo & Javier Fernández

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  1. Vicente Arroyo
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  2. Javier Fernández
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V. Arroyo and J. Fernández contributed equally to researching data, discussion of content, writing and review/editing of the manuscript before submission.

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Correspondence to Vicente Arroyo.

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Arroyo, V., Fernández, J. Management of hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol 7, 517–526 (2011). https://doi.org/10.1038/nrneph.2011.96

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