Hepatorenal syndrome
Cirrhosis - hepatorenal; Liver failure - hepatorenal; HRSHepatorenal syndrome is a condition in which there is progressive kidney failure that occurs in a person with cirrhosis of the liver. It is a serious complication that can lead to death.
Cirrhosis
Cirrhosis is scarring of the liver and poor liver function. It is the last stage of chronic liver disease.
Read Article Now Book Mark ArticleCauses
Hepatorenal syndrome occurs when the kidneys stop working well in people with serious liver problems. Less urine is produced by the body, so waste products that contain nitrogen build up in the bloodstream (azotemia).
Azotemia
Prerenal azotemia is an abnormally high level of nitrogen waste products in the blood.
Read Article Now Book Mark ArticleThe disorder occurs in up to 1 in 10 people who are in the hospital with liver failure. It leads to kidney failure in people with:
Kidney failure
Acute kidney failure is the rapid (less than 2 days) loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in your b...
Read Article Now Book Mark Article- Acute liver failure
- Alcoholic hepatitis
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Cirrhosis
Cirrhosis
Cirrhosis is scarring of the liver and poor liver function. It is the last stage of chronic liver disease.
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Infected abdominal fluid (peritonitis)
Infected abdominal fluid
The peritoneum is the thin tissue that lines the inner wall of the abdomen and covers most of the organs in the abdomen. Peritonitis is present when...
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Risk factors include:
- Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
- Use of medicines called diuretics ("water pills")
- Gastrointestinal bleeding
- Infection
- Recent abdominal fluid removal (paracentesis)
Abdominal fluid removal
An abdominal tap is used to remove fluid from the area between the belly wall and the spine. This space is called the abdominal cavity or peritoneal...
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Symptoms
Symptoms include:
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Abdominal swelling due to fluid (called ascites, a symptom of liver disease)
Abdominal swelling due to fluid
Ascites is the build-up of fluid in the space between the lining of the abdomen and abdominal organs.
Read Article Now Book Mark Article - Mental confusion
Confusion
Confusion is the inability to think as clearly or quickly as you normally do. You may feel disoriented and have difficulty paying attention, remembe...
Read Article Now Book Mark Article - Muscle jerks
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Dark-colored urine (a symptom of liver disease)
Dark-colored urine
The usual color of urine is straw-yellow. Abnormally-colored urine may be cloudy, dark, or blood-colored.
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Decreased urine output
Decreased urine output
Decreased urine output means that you produce less urine than normal. Most adults make at least 500 milliliters of urine in 24 hours (a little over ...
Read Article Now Book Mark Article - Nausea and vomiting
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Weight gain
Weight gain
Unintentional weight gain is when you gain weight without trying to do so and you are not eating or drinking more.
Read Article Now Book Mark Article - Yellow skin (jaundice, a symptom of liver disease)
Exams and Tests
This condition is diagnosed after testing to check for other causes of kidney failure.
A physical exam does not detect kidney failure directly. However, the exam will very often show signs of chronic liver disease, such as:
- Confusion (often due to hepatic encephalopathy)
Hepatic encephalopathy
Loss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem ma...
Read Article Now Book Mark Article - Excess fluid in the abdomen (ascites)
- Jaundice
- Other signs of liver failure
Other signs include:
- Abnormal reflexes
- Smaller testicles
- Dull sound in the belly area when tapped with the tips of the fingers
- Increased breast tissue in men (gynecomastia)
- Sores (lesions) on the skin
The following may be signs of kidney failure:
- Very little or no urine output
- Fluid retention in the abdomen or extremities
- Increased BUN and creatinine blood levels
BUN
BUN stands for blood urea nitrogen. Urea nitrogen is what forms when protein breaks down. A test can be done to measure the amount of urea nitrogen ...
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The creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys are working. Creatinine in t...
Read Article Now Book Mark Article - Increased urine specific gravity and osmolality
Urine specific gravity
Urine specific gravity is a laboratory test that shows the total concentration of all chemical particles in the urine.
Read Article Now Book Mark ArticleOsmolality
Osmolality blood test is a test that measures the concentration of all chemical particles found in the fluid part of blood. Osmolality in the urine c...
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Blood sodium
The sodium blood test measures the concentration of sodium in the blood. Sodium can also be measured using a urine test.
Read Article Now Book Mark Article - Very low urine sodium concentration
Urine sodium
The sodium urine test measures the amount of sodium the urine. Sodium can also be measured in a blood sample.
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The following may be signs of liver failure:
- Abnormal prothrombin time (PT)
Prothrombin time
Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot. It measures the functio...
Read Article Now Book Mark Article - Increased blood ammonia level
Ammonia
Ammonia is a strong, colorless gas. If the gas is dissolved in water, it is called liquid ammonia. Poisoning may occur if you breathe in ammonia. ...
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Blood albumin
Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood. Albumin c...
Read Article Now Book Mark Article - Abdominal ultrasound shows ascites
- Signs of hepatic encephalopathy (an EEG may be done to diagnose this condition)
Hepatic encephalopathy
Loss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem ma...
Read Article Now Book Mark ArticleEEG
An electroencephalogram (EEG) is a test to measure the electrical activity of the brain.
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Treatment
The goal of treatment is to help the liver work better and to make sure the heart is able to pump enough blood to the body.
Treatment is about the same as for kidney failure from any cause. It includes:
- Stopping all unnecessary medicines, especially ibuprofen and other NSAIDs, certain antibiotics, and diuretics ("water pills")
- Having dialysis to improve symptoms
- Taking medicines to improve blood pressure and help your kidneys work better; infusion of albumin may also be helpful
- Placing a shunt known as transjugular intrahepatic portosystemic shunt (TIPS) to relieve the symptoms of ascites (This may also help kidney function, but the procedure can be risky.)
- Surgery to place a shunt from the abdominal space to the jugular vein to relieve some symptoms of kidney failure (This procedure is risky and is rarely done.)
Outlook (Prognosis)
The outcome is often poor. Death often occurs due to an infection or severe bleeding (hemorrhage).
Possible Complications
Complications may include:
- Bleeding
- Damage to, and failure of, many organ systems
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End-stage kidney disease
End-stage kidney disease
End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's...
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Heart failure
Heart failure is a condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptom...
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Coma caused by liver failure
Coma caused by liver failure
Loss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem ma...
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When to Contact a Medical Professional
This disorder most often is diagnosed in the hospital during treatment for a liver disorder.
References
Fernandez J, Arroyo V. Hepatorenal syndrome. In: Johnson RJ, Floege J, Tonelli M, eds. Comprehensive Clinical Nephrology. 7th ed. Philadelphia, PA: Elsevier; 2024:chap 76.
Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Cooney KA, eds. Goldman-Cecil Medicine. 27th ed. Philadelphia, PA: Elsevier; 2024:chap 139.
Mehta SS, Fallon MB. Hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, and other systemic complications of liver disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 94.
Review Date: 6/11/2024
Reviewed By: Jenifer K. Lehrer, MD, Department of Gastroenterology, Aria - Jefferson Health Torresdale, Jefferson Digestive Diseases Network, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.