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Therapy Insight: management of hepatorenal syndrome

Nature Clinical Practice Gastroenterology & Hepatology volume 3, pages 338–348 (2006)Cite this article

Abstract

Hepatorenal syndrome (HRS), a feared complication of advanced cirrhosis, is characterized by functional renal failure, secondary to renal vasoconstriction in the absence of underlying kidney pathology. Extreme underfilling of the arterial circulation, caused by arterial vasodilation of the splanchnic circulation, activates vasoconstrictor systems, which lead to intense renal vasoconstriction and HRS. Factors predictive for the development of HRS include intense urinary sodium retention, dilutional hyponatremia, low blood pressure, decreased cardiac output, and increased activity of systemic vasoconstrictors. The prognosis for patients with HRS is extremely poor, especially for those with the acute, progressive (type 1) form. Liver transplantation is the best treatment for suitable candidates and should always be the management option considered first. Pharmacologic therapies are aimed at improving renal function to enable patients to survive until transplantation is possible. These therapies are based on plasma expansion with albumin, combined with the use of either vasopressin analogs or α-adrenergic agonists. Other nonpharmacologic therapies, such as transjugular intrahepatic portosystemic shunts and albumin dialysis show promise, but experience with these treatments is limited. For prevention of HRS, albumin infusion is recommended in patients with spontaneous bacterial peritonitis, and pentoxifylline treatment is recommended in patients with acute alcoholic hepatitis.

Key Points

  • Hepatorenal syndrome (HRS) is at the end of a spectrum of functional renal abnormalities caused by a severe vasoconstriction of the renal circulation

  • Splanchnic vasodilation causing arterial underfilling, a compensatory neurohormonal response that leads to renal vasoconstriction, and a reduction in cardiac output seem to be the main factors responsible for the development of HRS

  • Type 1 HRS is an acute and rapidly progressive form with a very poor prognosis; type 2 HRS is a more stable form with a slightly better prognosis

  • HRS that develops in patients with cirrhosis after spontaneous bacterial peritonitis can be prevented by intravenous albumin and antibiotic therapy

  • Patients with HRS who are transplant candidates should be given high priority for liver transplantation

  • Therapy of HRS should be aimed at reversing the intense splanchnic arteriolar vasodilation with splanchnic vasoconstrictors and plasma expansion as a bridge to liver transplantation; the use of transjugular intrahepatic portosystemic shunt also seems to be effective in selected cases of HRS

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Figure 1: The pathogenesis of hepatorenal syndrome and its precipitating factors.
Figure 2: Probability of survival of patients with cirrhosis according to the type of hepatorenal syndrome.
Figure 3: Therapeutic options and the aim of therapy for hepatorenal syndrome.

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Authors and Affiliations

  1. Associate Researcher,

    Andrés Cárdenas & Pere Ginès

  2. Associate Professor of Medicine and Chief of the Liver Unit at the Institut de Malalties Digestives, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain

    Andrés Cárdenas & Pere Ginès

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Correspondence to Pere Ginès.

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Cárdenas, A., Ginès, P. Therapy Insight: management of hepatorenal syndrome. Nat Rev Gastroenterol Hepatol 3, 338–348 (2006). https://doi.org/10.1038/ncpgasthep0517

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