Hepatorenal syndrome

Last updated: September 20, 2022

Summarytoggle arrow icon

Hepatorenal syndrome (HRS) refers to a unique type of kidney injury that occurs in patients with cirrhosis and ascites. The pathophysiology is not well understood but is likely due to splanchnic vasodilation in the setting of portal hypertension. HRS may develop rapidly in the case of HRS acute kidney injury (HRS-AKI) or gradually in the case of HRS non-acute kidney injury (HRS-NAKI). It is a diagnosis of exclusion and requires the elimination of other potential etiologies, including hypovolemia. A liver transplant is the only curative treatment, but it may be mitigated pharmacologically with vasoconstrictors and albumin.

Epidemiological data refers to the US, unless otherwise specified.

Hepatorenal syndrome (HRS) is a diagnosis of exclusion. It is diagnosed based on the presence of renal impairment in patients with cirrhosis after other potential causes of renal impairment have been ruled out. [1][3]

Treatment for HRS-AKI should always be combined with adequate management for cirrhosis, and a multidisciplinary team should be involved as soon as possible. Data on effective treatments for HRS-NAKI is lacking. [1]

Pharmacotherapy for HRS-AKI [1]

Surgical or interventional options [1]


Rule out other causes of AKI and ensure the diagnostic criteria for HRS-AKI are fulfilled before initiating vasoconstrictor therapy.

Vasoconstrictor therapy is challenging and has potentially severe adverse effects (e.g., ischemia); involve specialists early.

Patients with cirrhosis and HRS can develop significant fluid retention and pulmonary edema. Therefore, administer IV fluids with caution. [2]

  1. Francoz C, Durand F, Kahn JA, Genyk YS, Nadim MK. Hepatorenal Syndrome. Clinical Journal of the American Society of Nephrology. 2019; 14 (5): p.774-781. doi: 10.2215/cjn.12451018 . | Open in Read by QxMD
  2. Simonetto DA, Gines P, Kamath PS. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ. 2020 : p.m2687. doi: 10.1136/bmj.m2687 . | Open in Read by QxMD
  3. Biggins SW, Angeli P, Garcia‐Tsao G, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021; 74 (2): p.1014-1048. doi: 10.1002/hep.31884 . | Open in Read by QxMD
  4. Angeli P, Garcia-Tsao G, Nadim MK, Parikh CR. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document. J Hepatol. 2019; 71 (4): p.811-822. doi: 10.1016/j.jhep.2019.07.002 . | Open in Read by QxMD
  5. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015; 64 (4): p.531-7. doi: 10.1136/gutjnl-2014-308874 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer