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Recent advances in our understanding of hepatorenal syndrome

Nature Reviews Gastroenterology & Hepatology volume 9, pages 382–391 (2012)Cite this article

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Abstract

Hepatorenal syndrome (HRS) is a serious complication of advanced cirrhosis with ascites. HRS develops as a result of abnormal haemodynamics, leading to splanchnic and systemic vasodilatation, but renal vasoconstriction. Increased bacterial translocation, various cytokines and mesenteric angiogenesis also contribute to splanchnic vasodilatation, and altered renal autoregulation is involved in the renal vasoconstriction. Type 1 HRS is usually initiated by a precipitating event associated with an exaggerated systemic inflammatory response that perturbs haemodynamics, resulting in multiorgan failure. An inadequate cardiac output with systolic incompetence increases the risk of renal failure. Vasoconstrictors are the main treatment in patients with type 1 HRS; terlipressin is the superior agent. Norepinephrine is similar to terlipressin in efficacy and can be used as an alternative. Transjugular intrahepatic portosystemic stent shunt might be applicable in a small number of patients with type 1 HRS and in most patients with type 2 HRS. Liver transplantation is the definitive treatment for HRS, and should be performed after reversal of HRS. In nonresponders to vasoconstrictor therapy, much controversy still exists as to whether to do simultaneous or sequential liver and kidney transplant. In general, patients who have had >8–12 weeks of pretransplant dialysis should be considered for combined liver–kidney transplantation.

Key Points

  • Hepatorenal syndrome (HRS) in patients with cirrhosis is the result of haemodynamic derangement, which is initiated by portal hypertension and ultimately leads to renal vasoconstriction

  • The diagnosis of HRS has been simplified to enable earlier and easier diagnosis, so that treatment can be started early in the course of the illness

  • Vasoconstrictors are the primary treatment to improve systemic and splanchnic haemodynamics in HRS; terlipressin is superior to midodrine, but norepinephrine is also efficacious and is cheaper than terlipressin

  • Patients with cirrhosis, ascites and HRS who do not respond to vasoconstrictor therapy should be offered liver transplantation early; bridging dialysis is often required until liver transplantation

  • Patients who have had >8–12 weeks of pretransplant dialysis should be considered for combined liver–kidney transplantation to improve patient outcomes

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Figure 1: The pathophysiology of hepatorenal syndrome.
Figure 2: The natural history of cirrhosis from compensated to decompensated cirrhosis.
Figure 3: Precipitating factors for type 1 hepatorenal syndrome as observed in the author's own cohort of patients with cirrhosis and type 1 hepatorenal syndrome in the past 10 years.39
Figure 4: Treatment of hepatorenal syndrome with vasoconstrictor therapy.

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Wong, F. Recent advances in our understanding of hepatorenal syndrome. Nat Rev Gastroenterol Hepatol 9, 382–391 (2012). https://doi.org/10.1038/nrgastro.2012.96

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