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Hepatorenal syndrome

What's new

The European Association for the Study of the Liver (EASL) has published a focused update on transjugular intrahepatic portosystemic shunt (TIPS). For hepatorenal syndrome, current evidence does not support the use of TIPS to reduce morbidity or mortality in patients with hepatorenal synreome (HRS)-acute kidney injury (AKI). However, TIPS may be considered in patients with cirrhosis, ascites, and HRS-non-AKI, where it may help improve clinical outcomes. .

Background

Overview

Definition
HRS is a severe complication of advanced liver disease, characterized by progressive renal failure in response to circulatory and hemodynamic alterations.
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Pathophysiology
The pathophysiology of HRS involves intense renal vasoconstriction, systemic and splanchnic arterial vasodilation, and reduced cardiac output, leading to renal dysfunction.
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Epidemiology
The prevalence of HRS-AKI in hospitalized patients with cirrhosis and refractory ascites is about 11%.
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Risk factors
HRS develops in patients with advanced liver disease, with risk factors including advanced liver cirrhosis with ascites, marked circulatory dysfunction, portal hypertension, SBP, severe alcoholic hepatitis, and specific triggers such as bacterial infections, nephrotoxic drugs, fluid loss, and large-volume paracentesis.
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Disease course
HRS is classified into two types: type 1 HRS is characterized by a rapid and progressive impairment in renal function, while type 2 HRS is characterized by a stable or less progressive impairment in renal function. The decline in renal function seen in HRS is consistent with AKI.
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Prognosis and risk of recurrence
The prognosis of HRS is extremely poor, especially for those with a rapidly progressive course. The median survival of patients with HRS without liver transplantation is < 6 months.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hepatorenal syndrome are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2025,2018), the American Gastroenterological Association (AGA 2023), the American College of Gastroenterology (ACG 2022), the American Association for the Study of Liver Diseases (AASLD 2021,2017,2014), and the Society ...
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Screening and diagnosis

Differential diagnosis
As per AASLD 2021 guidelines:
Evaluate and treat precipitating factors of AKI, such as fluid loss, bacterial infections, hemodynamic instability, potentially nephrotoxic agents (particularly NSAIDs).
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Use the consensus criteria for the differential diagnosis of AKI, HRS and acute tubular necrosis.
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  • Diagnostic criteria

Medical management

General principles: as per AASLD 2021 guidelines, decide on the management (including initiation of vasoconstrictor therapy and RRT) by a multidisciplinary team including specialists in hepatology, nephrology, critical care, and transplant surgery, if possible, given the complexity of patients with suspected HRS-AKI.
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  • Vasoactive agents

  • Intravenous albumin

  • Management of beta-blockers

Therapeutic procedures

RRT
As per AASLD 2021 guidelines:
Initiate RRT in candidates for liver transplantation with worsening renal function or electrolyte disturbances or increasing volume overload unresponsive to vasoconstrictor therapy.
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Initiate RRT with a clear endpoint in mind in patients not being candidates for liver transplantation.
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  • TIPS

Surgical interventions

Liver transplantation
As per AASLD 2021 guidelines:
Consider obtaining urgent evaluation for liver transplantation in all patients with cirrhosis and AKI because of the high short-term mortality even in responders to vasoconstrictors.
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Consider performing simultaneous liver-kidney transplantation in patients not expected to recover kidney function post-transplantation.
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Preventative measures

Norfloxacin: as per EASL 2018 guidelines, initiate norfloxacin 400 mg/day as SBP prophylaxis to prevent HRS-AKI.
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  • Albumin

Follow-up and surveillance

Clinical follow-up: as per AASLD 2021 guidelines, obtain close monitoring for side effects of vasoconstrictors and albumin, including ischemic complications and pulmonary edema.
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  • Assessment of treatment response