Hepatorenal syndrome: Update on diagnosis and therapy

Abstract

Hepatorenal syndrome (HRS) is a manifestation of extreme circulatory dysfunction and entails high morbidity and mortality. A new definition has been recently recommended by the International Club of Ascites, according to which HRS diagnosis relies in serum creatinine changes instead that on a fixed high value. Moreover, new data on urinary biomarkers has been recently published. In this sense, the use of urinary neutrophil gelatinase-associated lipocalin seems useful to identify patients with acute tubular necrosis and should be employed in the diagnostic algorithm. Treatment with terlipressin and albumin is the current standard of care. Recent data show that terlipressin in intravenous continuous infusion is better tolerated than intravenous boluses and has the same efficacy. Terlipressin is effective in reversing HRS in only 40%-50% of patients. Serum bilirubin and creatinine levels along with the increase in blood pressure and the presence of systemic inflammatory response syndrome have been identified as predictors of response. Clearly, there is a need for further research in novel treatments. Other treatments have been assessed such as noradrenaline, dopamine, transjugular intrahepatic portosystemic shunt, renal and liver replacement therapy, etc. Among all of them, liver transplant is the only curative option and should be considered in all patients. HRS can be prevented with volume expansion with albumin during spontaneous bacterial peritonitis and after post large volume paracentesis, and with antibiotic prophylaxis in patients with advanced cirrhosis and low proteins in the ascitic fluid. This manuscript reviews the recent advances in the diagnosis and management of this life-threatening condition.

Keywords: Hepatorenal syndrome; Acute-on-chronic liver failure; Liver cirrhosis; Terlipressin; Acute kidney injury

Core tip: Hepatorenal syndrome (HRS) is a life-threatening complication present in very advanced liver cirrhosis. This manuscript addresses many recent advances in this field, including the recent change in the definition of HRS according to acute kidney injury criteria, the potential consequences of the adoption of this new definition, and the use of biomarkers to help in the diagnostic algorithm. Moreover, it reviews the recent advances in treatment of HRS such as the use of continuous infusion of terlipressin instead of bolus and the low efficacy of midodrine plus octreotide. Potential areas of research are identified as well.