Hepatorenal Syndrome

Hepatorenal syndrome (HRS) is a serious form of kidney dysfunction that develops in people with advanced liver disease, most often cirrhosis. The kidneys themselves are not structurally damaged at first, but changes in blood flow caused by liver failure reduce their function. Early recognition and joint care by a hepatologist and nephrologist are important.

What Is Hepatorenal Syndrome?

In advanced liver disease, blood vessels in the abdomen widen, and the body responds by tightening the blood vessels that supply the kidneys. As a result, the kidneys receive less blood and filter less, even though they may look normal on imaging.

HRS can develop rapidly over days, often after a trigger, or more gradually in people with long-standing fluid accumulation in the abdomen (ascites).

Risk Factors and Triggers

HRS usually occurs in people with advanced cirrhosis, often from alcohol, hepatitis B or C, or fatty liver disease. Certain events may trigger it.

• Infection of the abdominal fluid (spontaneous bacterial peritonitis) or other infections
• Bleeding from the stomach or food pipe
• Removal of large volumes of abdominal fluid without adequate support
• Excessive use of diuretics, or dehydration from vomiting or diarrhoea
• Alcoholic hepatitis
• Use of NSAID painkillers

Symptoms

Symptoms often overlap with those of liver disease itself.

• Reduced urine output
• Increasing abdominal swelling from fluid
• Yellowing of the skin and eyes
• Confusion, drowsiness or altered behaviour
• Nausea, weakness and tiredness
• Swelling of the legs

Diagnosis

HRS is a diagnosis made after other causes of kidney injury have been considered. Doctors monitor creatinine, urine output and electrolytes, and may check urine tests and a kidney ultrasound. Diuretics may be stopped and fluids or albumin given to see whether kidney function improves. Infection and other causes such as medicines or kidney damage from other conditions are carefully looked for.

Because kidney function can change quickly in advanced liver disease, these tests are often repeated daily in hospital so that treatment can be adjusted promptly.

Treatment

HRS is generally treated in hospital through close coordination between the hepatologist, nephrologist and critical care team.

Because HRS is closely linked to the severity of liver disease, prevention and early action are important. People with cirrhosis are often advised to avoid alcohol completely, report fever, abdominal pain, black stools or reduced urine without delay, take diuretics only as prescribed and avoid over-the-counter painkillers. Regular blood tests help detect a rise in creatinine early, when treatment may be more effective.

• Identifying and treating triggers such as infection or bleeding
• Stopping diuretics and medicines that may harm the kidneys
• Albumin infusion and medicines that improve blood flow to the kidneys, as decided by the treating team
• Careful monitoring of fluid balance and electrolytes
• Dialysis support in selected patients, often as a bridge to further treatment
• Evaluation for liver transplantation, which may offer the best long-term outcome in suitable patients

When to See a Nephrologist

Anyone with cirrhosis whose urine output falls or whose creatinine rises should seek medical attention promptly. A nephrologist is usually involved in hospital to help distinguish HRS from other causes of kidney injury and to guide supportive treatment, including decisions about dialysis.

This page is for general information only and is not a substitute for a medical consultation. Please consult a qualified doctor for diagnosis and treatment.