Hepatorenal syndrome

Definition

Hepatorenal syndrome is a condition in which the kidneys fail suddenly in a person with cirrhosis of the liver. It is a serious complication of cirrhosis.

Causes, incidence, and risk factors

Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a liver disorder. Because less urine is removed from the body, nitrogen-containing waste products build up in the bloodstream (azotemia).

The disorder occurs in up to 10% of patients hospitalized with liver failure. It is caused by the built-up effects of liver damage and kidney failure in people with:

• Acute liver failure
• Alcoholic hepatitis
• Cirrhosis

Other risk factors include:

• Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
• Diuretic use
• Gastrointestinal bleeding
• Infection
• Recent abdominal paracentesis

Symptoms

• Abdominal swelling
• Change in mental status
  • Confusion
  • Delirium
  • Dementia
• Coarse muscle movements, jerking
• Dark-colored urine
• Decreased urine production
• Nausea and vomiting
• Weight gain
• Yellow skin

Signs and tests

This condition is diagnosed when other causes of kidney failure are ruled out.

A physical examination will not directly reveal kidney failure. However, the exam will usually show signs of chronic liver disease:

• Excess fluid in the abdomen (ascites)
• Hepatic encephalopathy
• Jaundice
• Other signs of liver failure

Other signs include:

• Abnormal reflexes
• Decreased testicle size
• Dull sound in the abdomen when tapped with the tips of the fingers, and visible fluid wave when examined by feel
• Increased breast tissue
• Sores (lesions) on the skin

The following may be signs of kidney failure:

• Absent or low urine production, less than 400 cc/day
• Fluid retention in the abdomen or extremities
• Increased BUN and creatinine levels
• Increased urine specific gravity and osmolality
• Low serum sodium
• Very low urine sodium concentration

The following may be signs of liver failure:

• Abnormal PT
• Increased ammonia levels
• Low serum albumin
• Paracentesis with ascites
• Signs of hepatic encephalopathy (an EEG may be performed if such signs are present)

Treatment

Treatment aims to improve liver function and ensure that there is enough blood in the body and the heart is pumping adequately.

The disorder is generally treated in the same way as kidney failure from any other cause.

• All unnecessary medicines are stopped, especially the antibiotic neomycin, ibuprofen and other NSAIDs, and diuretics ("water pills").
• Dialysis may improve symptoms.
• Medications such as octreotide, albumin, and dopamine may be used temporarily to improve kidney function.
• Surgery to place a shunt (called a Levine shunt) from the abdominal space (peritoneum) to the jugular vein may relieve some of the symptoms of kidney failure. However, surgical shunts are rarely placed, because severe liver disease makes surgery very risky. A nonsurgical shunt (known as TIPS) may be tried in some patients.

Expectations (prognosis)

The predicted outcome is poor. Death usually occurs as a result of secondary infections or hemorrhage.

Complications

• Bleeding
• Damage to, and failure of, many organ systems
• End-stage kidney disease
• Fluid overload with congestive heart failure or pulmonary edema
• Hepatic coma
• Secondary infections

Calling your health care provider

This disorder most often is diagnosed in the hospital during treatment for a liver disorder.

References

Cárdenas A, Gines P. Hepatorenal syndrome. Clin Liver Dis. 2006;10:371-385.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851.