Management of hepatorenal syndrome in patients with cirrhosis

Patients with liver cirrhosis develop progressive circulatory dysfunction, which induces activation of the renin-angiotensin-aldosterone system (RAAS), activation of the sympathetic nervous system and increased activity of antidiuretic hormone. Such activation results in renal fluid retention, ascites and dilutional hyponatremia. In patients with advanced cirrhosis, these processes culminate in renal vasoconstriction and type 2 hepatorenal syndrome (HRS), which is characterized by slowly progressive renal failure and refractory ascites. Type 1 HRS is characterized by acute renal failure and rapid deterioration in the function of other organs in the setting of a precipitating event. Prognosis for both types of HRS is notably poor and orthotopic liver transplantation is the only definitive treatment; however, various therapies that restore renal function can provide a bridge to transplantation. Vasoconstrictors plus albumin improve renal function in 40-60% of patients with type 1 HRS. Transjugular intrahepatic portosystemic shunt (TIPS) placement is also effective in type 1 HRS, but its applicability is low (as it is not suitable for all patients), and it increases the risk of encephalopathy. Albumin dialysis is a potentially effective treatment for type 1 HRS still under investigation. Patients with type 2 HRS are treated with repeated large-volume paracentesis or TIPS.