Hepatorenal syndrome

AbstractHepatorenal syndrome is a functional renal disorder that occurs in patients with liver failure and portal hypertension. It is characterized by progressive renal impairment secondary to marked renal vasoconstriction that occurs in the presence of a predominance of vasodilatation in the extrarenal circulation. In liver failure and portal hypertension, homeostatic abnormalities secondary to disturbances of a multitude of neurohumoral factors are present. Hepatorenal syndrome likely represents one end of the spectrum of these homeostatic abnormalities. Hepatorenal syndrome is often precipitated by such events as volume contraction, sepsis (especially spontaneous bacterial peritonitis), or the administration of potential nephrotoxic agents. Therefore, the mainstay in the management of hepatorenal syndrome is to avoid the occurrence of such events, to have awareness of their existence, and to treat them promptly when they occur. In established hepatorenal syndrome, orthotopic liver transplantation is currently the treatment of choice. In patients waiting for a transplant, a number of treatments have been shown to act as an effective bridge to liver grafting. The same treatments have also been shown to prolong survival in patients who are not transplant candidates. These include pharmacotherapy with the combined use of intravenous vasopressin analogs and albumin infusion or oral midodrine and subcutaneous octreotide, intervention procedures such as transjugular intrahepatic portosystemic stent-shunt, extracorporeal liver support therapy such as the molecular absorbent recirculating system, and in patients with advancing uremia, renal replacement therapy such as continuous venovenous hemofiltration