For personal use. Only reproduce with permission from The Lancet publishing Group. SEMINAR

Renal failure is a common complication of patients with advanced cirrhosis.1,2 It generally indicates a poor prognosis because of the combined detrimental effect of renal and liver failure. In some cases, renal failure in cirrhosis is due to aetiological factors that also lead to renal failure in patients without liver disease, such as severe dehydration, shock (haemorrhagic or septic), or nephrotoxic drugs, or is the consequence of an intrinsic renal parenchymal disease, such as glomerulonephritis. However, in other cases renal failure in cirrhosis occurs in the absence of these factors and with normal renal histology. This disorder is known as hepatorenal syndrome (HRS). It is caused by intense vasoconstriction of the renal circulation, which leads to a pronounced reduction in glomerular filtration rate (GFR).1–5 Although HRS was described more than 50 years ago, many features of its pathogenesis and natural history remained unknown for many years. No effective treatment existed until very recently. The aim of this seminar is to provide an up to date revision of HRS, with special emphasis on its diagnosis and management. Definition HRS generally occurs in patients with advanced liver disease and portal hypertension. It is characterised by a combination of disturbances in circulatory and kidney function.6 The principal abnormality in the systemic circulation is low arterial pressure due to greatly reduced total systemic vascular resistance. Kidney function is much impaired because of severe reduction of renal blood flow. The reduction in renal blood flow is pathogeneticall