Hepatorenal syndrome (HRS), a feared complication of advanced
cirrhosis, is characterized by functional
renal failure, secondary to renal vasoconstriction in the absence of underlying kidney pathology. Extreme underfilling of the arterial circulation, caused by arterial vasodilation of the splanchnic circulation, activates
vasoconstrictor systems, which lead to intense renal vasoconstriction and HRS. Factors predictive for the development of HRS include intense urinary
sodium retention, dilutional
hyponatremia,
low blood pressure, decreased cardiac output, and increased activity of systemic
vasoconstrictors. The prognosis for patients with HRS is extremely poor, especially for those with the acute, progressive (type 1) form.
Liver transplantation is the best treatment for suitable candidates and should always be the management option considered first. Pharmacologic
therapies are aimed at improving renal function to enable patients to survive until
transplantation is possible. These
therapies are based on plasma expansion with
albumin, combined with the use of either
vasopressin analogs or
alpha-adrenergic agonists. Other nonpharmacologic
therapies, such as transjugular intrahepatic
portosystemic shunts and
albumin dialysis show promise, but experience with these treatments is limited. For prevention of HRS,
albumin infusion is recommended in patients with spontaneous bacterial
peritonitis, and
pentoxifylline treatment is recommended in patients with acute
alcoholic hepatitis.