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Hepatorenal syndrome
Other Resources UpToDate PubMed

Hepatorenal syndrome

Contributors: Michael W. Winter MD, Paritosh Prasad MD
Other Resources UpToDate PubMed


Hepatorenal syndrome (HRS) is a syndrome of progressive renal insufficiency without underlying renal parenchymal damage in a cirrhotic patient. In patients with decompensated cirrhosis, the risk of developing HRS is 8%-20% per year. In patients with HRS, renal vasoconstriction occurs in the absence of reduced cardiac output and blood volume with vasoconstriction secondary to the activation of the renin-angiotensin activating system and sympathetic nervous system. Patients with cirrhosis and portal hypertension also exhibit low arterial pressure and reduced systemic vascular resistance.

Risk factors for development of HRS include hyponatremia, low urine sodium, hyperkalemia, large volume paracentesis (> 5 L removal), drug-induced nephrotoxicity, acute liver failure, decompensated cirrhosis (spontaneous bacterial peritonitis, bleeding esophageal varices), or, as a complication, post-transjugular intrahepatic portosystemic shunts (TIPS).

Presentation varies between type 1 and type 2 HRS. In both types, patients present with low urine output and rising serum creatinine values:
  • Type 1 HRS – Progressive, acute renal failure (creatinine > 2.5 mg/dL or 50% reduction in glomerular filtration rate [GFR]) over a 2-week period. Often triggered by infection. Poor prognosis with a 10% 90-day survival rate.
  • Type 2 HRS – Moderate and stable reduction in GFR that occurs in patients with relatively preserved hepatic function and diuretic resistance. Can precipitate type 1 HRS. More favorable prognosis than type 1 HRS; median survival 6-8 months.
HRS is a diagnosis of exclusion. Diagnostic criteria:
  • Acute kidney injury with increase in serum creatinine of 0.3 mg/dL or more within 48 hrs or an increase of greater than 50% from baseline within 7 days.
    • Other definitions include a serum creatinine > 1.5 mg/dL or 24-hour creatinine clearance < 40 mL/min.
  • Absence of shock, fluid losses, ongoing bacterial infection, or use of nephrotoxic medications.
  • No improvement in renal function despite plasma expansion with intravenous (IV) albumin (1 g/kg of body weight up to 100 g/day for 2 days) and/or diuretic withdrawal.
  • Proteinuria < 500 mg/day and no ultrasonographic evidence of uropathy or intrinsic parenchymal disease.


K76.7 – Hepatorenal syndrome

51292008 – Hepatorenal syndrome

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Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:07/02/2018
Last Updated:03/14/2021
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Hepatorenal syndrome
A medical illustration showing key findings of Hepatorenal syndrome : Dark urine, Jaundice, Nausea/vomiting, Ascites, Delirium, Oliguria, Weight gain
Copyright © 2023 VisualDx®. All rights reserved.