An Update on Hepatorenal Syndrome

Samuel Chan,Ross Francis,Kenneth Au,David W Johnson,Tony Rahman,David W Mudge

doi:10.15586/jrenhep.2017.12

Abstract

Hepatorenal syndrome (HRS) is one of the many potential causes of acute kidney injury (AKI) in patients with decompensated liver disease. HRS is associated with poor prognosis and represents the end-stage of a sequence of reductions in renal perfusion induced by progressively severe hepatic injury. The pathophysiology of HRS is complex with multiple mechanisms interacting simultaneously, although HRS is primarily characterised by renal vasoconstriction. A recently revised diagnostic criteria and management algorithm for AKI has been developed for patients with cirrhosis, allowing physicians to commence treatment promptly. Vasopressor therapy and other general management, such as antibiotic prophylaxis, need to be initiated whilst patients are assessed for eligibility for transplantation. Liver transplantation remains the treatment of choice for HRS but is limited by organ shortage. Other management options, such as transjugular intrahepatic portosystemic shunt, renal replacement therapy and molecular absorbent recirculating system, may provide short-term benefit for patients not responding to medical therapy whilst awaiting transplantation. Clinicians need to be aware of the pathophysiology and management principles of HRS to provide quality care for patients with multi-organ failure.

Highlights

Renal failure is common amongst patients with decompensated cirrhosis and is associated with a poor prognosis, with life expectancy ranging from weeks to months
This review article will provide an update on the pathophysiology, diagnostic criteria and treatment options, including prophylaxis, in patients with Hepatorenal syndrome (HRS)
Another randomised controlled trial reported that primary prophylaxis with norfloxacin reduced the incidence of spontaneous bacterial peritonitis (SBP), delayed the development of HRS and improved survival in patients with cirrhosis, ascites and either advanced liver failure or impaired renal function [13]

Summary

Introduction

Renal failure is common amongst patients with decompensated cirrhosis and is associated with a poor prognosis, with life expectancy ranging from weeks to months. In patients with SBP, a meta-analysis of four randomised trials demonstrated that treatment with antibiotics and albumin was associated with a significant reduction in renal impairment (8% vs 31%) and mortality (16% vs 35%) compared with controls [12] Another randomised controlled trial reported that primary prophylaxis with norfloxacin reduced the incidence of SBP, delayed the development of HRS and improved survival in patients with cirrhosis, ascites and either advanced liver failure or impaired renal function [13]. In 2015, a randomised controlled trial of 49 patients comparing terlipressin with octreotide/midodrine illustrated a significantly higher rate of improvement in renal function with terlipressin (≥50% serum creatinine decrease, 70.4% vs 28.6%, P = 0.01), there was no significant difference in survival between the two groups [18]. Simultaneous liver–kidney transplantation is not necessary for patients with isolated HRS and should only be considered in selected patients at high risk for non-recovery of renal function, such as patients with heavy proteinuria and other evidence of advanced primary renal disease

Conclusion

Findings

Conflict of interest