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Hepatorenal Syndrome — Detailed Review

Functional Renal Failure in Advanced Cirrhosis

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dahiliye (İç Hastalıkları) department. Book Appointment →

What is Hepatorenal Syndrome — Detailed Review?

Hepatorenal syndrome (HRS) is a unique form of functional acute kidney injury in patients with cirrhosis and portal hypertension, defined by progressive renal failure without intrinsic renal pathology.

Pathophysiology involves splanchnic arterial vasodilation (mediated by nitric oxide, endocannabinoids), effective arterial underfilling, and compensatory activation of renin-angiotensin-aldosterone and sympathetic systems causing severe renal vasoconstriction.

Reclassified by ICA-AKI 2015 criteria into HRS-AKI (rapidly progressive, formerly type 1) and HRS-NAKI (slowly progressive, formerly type 2 or HRS-CKD).

Diagnosis requires cirrhosis with ascites, AKI per ICA criteria, no improvement after 48 hours of diuretic withdrawal and albumin challenge (1 g/kg/day, max 100 g), absence of shock, no nephrotoxic drugs, and no structural kidney disease.

Symptoms

Progressive oliguria or anuria with rising serum creatinine (HRS-AKI: doubling within 2 weeks)
Tense ascites refractory to diuretics, often with spontaneous bacterial peritonitis as precipitant
Hyponatremia, jaundice, hepatic encephalopathy, and stigmata of chronic liver disease
Low urinary sodium (<10 mmol/L), unremarkable urinary sediment without proteinuria or hematuria
Hypotension, mean arterial pressure typically below 80 mmHg with hyperdynamic circulation
Variceal bleeding, sepsis, or large-volume paracentesis without albumin replacement as common triggers

Risk Factors

Advanced cirrhosis with portal hypertension and refractory ascites
Spontaneous bacterial peritonitis (precipitant in 30–40% of HRS-AKI)
Gastrointestinal bleeding, especially variceal hemorrhage
Large-volume paracentesis without albumin (>5 L without 8 g/L removed)
Hyponatremia (<130 mmol/L) and elevated MELD score
Use of nephrotoxic drugs (NSAIDs, aminoglycosides, IV contrast)
Severe alcoholic hepatitis

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Patient with cirrhosis and ascites developing rising creatinine or oliguria
  • Cirrhosis patient with abdominal pain, fever, or worsening ascites (suspect SBP)
  • Refractory ascites requiring frequent large-volume paracenteses
  • Variceal bleeding or hepatic encephalopathy with renal dysfunction
  • MELD score escalation in known cirrhosis

Treatment Methods

01
Albumin infusion: 1 g/kg/day on day 1 (max 100 g), then 20–40 g/day combined with vasoconstrictor therapy throughout treatment
02
Terlipressin 0.5–2 mg IV every 4–6 hours (or continuous infusion 2–12 mg/24 h) for 7–14 days — first-line vasoconstrictor; preferred where available
03
Norepinephrine continuous infusion 0.5–3 mg/h titrated to MAP increase ≥10 mmHg with albumin in ICU setting when terlipressin unavailable
04
Midodrine (7.5–12.5 mg PO TID) plus octreotide (100–200 mcg SC TID) plus albumin as alternative oral regimen with lower efficacy
05
Antibiotic prophylaxis (norfloxacin 400 mg/day) for SBP prevention; treat active infections promptly with cefotaxime
06
Avoid nephrotoxins: NSAIDs, aminoglycosides, IV contrast; suspend non-essential diuretics and beta-blockers if hypotensive
07
Renal replacement therapy as bridge to liver transplantation; TIPS in selected non-transplant candidates with HRS-NAKI
08
Liver transplantation is the only definitive curative treatment — early MELD-based listing for all eligible patients

Which Department to Visit?

You can visit our Dahiliye (İç Hastalıkları) department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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