Medscape is available in 5 Language Editions – Choose your Edition here.


Pediatric Hepatorenal Syndrome Workup

  • Author: Rajendra Bhimma, MB, MD, ChB, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal); Chief Editor: Timothy E Corden, MD  more...
Updated: Mar 19, 2015

Laboratory Studies

No specific tests help in definitively diagnosing hepatorenal syndrome (HRS). HRS is a diagnosis of exclusion.

Serum creatinine measurement usually has good specificity for low glomerular filtration rate (GFR). However, it is least useful in patients with hepatic failure and ascites because their creatinine levels may be in the reference range or only slightly elevated despite a severely decreased GFR secondary to low endogenous production of creatinine, poor nutrition, and decreased muscle mass. A creatinine level of more than 1.5 mg/mL and a creatinine clearance of less than 40 mL/min are criteria the 1996 International Ascites Club used to define hepatorenal syndrome. A 24-hour urine collection or a specific measure of the GFR may be required for accurate measurement.

The BUN level is not reliable for assessing for low GFR in the clinical settings of hepatorenal syndrome. The level may be abnormally low because of reduced hepatic synthesis or low protein intake. Causes other than a low GFR, such as GI bleeding, may contribute to an elevated BUN level.

Dilutional hyponatremia may be seen in patients with hepatorenal syndrome. This condition is secondary to impaired renal capacity to excrete solute-free water, as well as increased vasopressin release in response to the severe arterial underfilling.

No urinary findings are consistently associated with the diagnosis of hepatorenal syndrome. Clinically significant proteinuria (>500 mg/dL) usually indicates renal failure secondary to tubular or glomerular damage and not hepatorenal syndrome. Microscopic hematuria makes the diagnosis of hepatorenal syndrome unlikely and suggests a glomerular pathology. Tubular cells or muddy, brown casts suggest that acute tubular necrosis as the etiology of renal failure.

The concentrating capacity of the kidney is preserved in hepatorenal syndrome, and urine osmolality is typically higher than the plasma osmolality. In some patients, osmolality may decrease as renal failure progresses.

The reabsorption capacity of the tubule is maintained in patients with hepatorenal syndrome because it is only functional renal failure. Therefore, the urinary sodium concentration is usually less than 10 mEq/L. However, some patients have high urinary sodium excretion. Therefore, this marker is not reliable in the diagnosis of hepatorenal syndrome.


Imaging Studies

Renal ultrasonography is useful in eliminating structural causes of renal failure, such as obstructive uropathy and intrinsic parenchymal renal disease, especially in the setting of an abnormal urinary sediment.

Doppler sonography is performed to determine the intrarenal arteriolar vascular resistance, defined as the resistive index (RI). The reference range for RI is 0.7 or lower. The RI can be a more sensitive parameter than the creatinine clearance.



Renal biopsy is indicated for patients with abnormal urinary sediment, proteinuria or hematuria, or renal ultrasonographic findings suggestive of organic causes of renal failure.

Patients with hepatorenal syndrome are usually too ill to tolerate renal biopsy. However, if performed, biopsy reveals normal histology because hepatorenal syndrome is only functional renal failure.


Histologic Findings

In patients with hepatorenal syndrome, renal histology is preserved.

After the patient undergoes liver transplantation, renal recovery is usually good.

Contributor Information and Disclosures

Rajendra Bhimma, MB, MD, ChB, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal) Associate Professor of Pediatrics, Principal Specialist, Department of Pediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa

Rajendra Bhimma, MB, MD, ChB, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal) is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, South African Medical Association, South African Paediatric Association, South African Transplant Society, International Pediatric Transplant Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.


The author would like to thank Mr. Duran Ramsuran and the staff of Medscape Drugs & Diseases for the help in reviewing this article.

  1. Kastelan S, Ljubicic N, Kastelan Z, Ostojic R, Uravic M. The role of duplex-doppler ultrasonography in the diagnosis of renal dysfunction and hepatorenal syndrome in patients with liver cirrhosis. Hepatogastroenterology. 2004 Sep-Oct. 51(59):1408-12. [Medline].

  2. Wadei HM. Hepatorenal syndrome: a critical update. Semin Respir Crit Care Med. 2012 Feb. 33(1):55-69. [Medline].

  3. Wong F. Treatment to improve acute kidney injury in cirrhosis. Curr Treat Options Gastroenterol. 2015 Mar 15. [Medline].

  4. Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993 Jul. 105(1):229-36. [Medline].

  5. Planas R, Montoliu S, Balleste B, et al. Natural history of patients hospitalized for management of cirrhotic ascites. Clin Gastroenterol Hepatol. 2006 Nov. 4(11):1385-94. [Medline].

  6. Wong LP, Blackley MP, Andreoni KA, Chin H, Falk RJ, Klemmer PJ. Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int. 2005 Jul. 68(1):362-70. [Medline].

  7. Salerno F, Cazzaniga M, Merli M, et al. Diagnosis, treatment and survival of patients with hepatorenal syndrome: a survey on daily medical practice. J Hepatol. 2011 Dec. 55(6):1241-8. [Medline].

  8. Stadlbauer V, Mookerjee RP, Hodges S, Wright GA, Davies NA, Jalan R. Effect of probiotic treatment on deranged neutrophil function and cytokine responses in patients with compensated alcoholic cirrhosis. J Hepatol. 2008 Jun. 48(6):945-51. [Medline].

  9. Arroyo V, Gines P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996 Jan. 23(1):164-76. [Medline].

  10. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007 Sep. 56(9):1310-8. [Medline]. [Full Text].

  11. Remer EM, Papanicolaou N, Casalino DD, et al, for the Expert Panel on Urologic Imaging. ACR appropriateness criteria renal failure [online publication]. Reston, Va: American College of Radiology (ACR); 2013. Available at Accessed: March 19, 2015.

  12. Nassar Junior AP, Farias AQ, D' Albuquerque LA, Carrilho FJ, Malbouisson LM. Terlipressin versus Norepinephrine in the Treatment of Hepatorenal Syndrome: A Systematic Review and Meta-Analysis. PLoS One. 2014. 9(9):e107466. [Medline]. [Full Text].

  13. Parson CE, Nelson R, Book L, Jensen MK. The use of renal replacement therapy in infants and children with hepatorenal syndrome awaiting liver transplantation: A case control study. Liver Transpl. 2014 Sep 1. [Medline].

  14. Guevara M, Gines P, Bandi JC, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998 Aug. 28(2):416-22. [Medline].

  15. Brensing KA, Textor J, Perz J, Schiedermaier P, Raab P, Strunk H. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut. 2000 Aug. 47(2):288-95. [Medline].

  16. Guerrini GP, Pleguezuelo M, Maimone S, et al. Impact of tips preliver transplantation for the outcome posttransplantation. Am J Transplant. 2009 Jan. 9(1):192-200. [Medline].

  17. Davenport A. Renal replacement therapy in the patient with acute brain injury. Am J Kidney Dis. 2001 Mar. 37(3):457-66. [Medline].

  18. Alessandria C, Debernardi-Venon W, Carello M, Ceretto S, Rizzetto M, Marzano A. Midodrine in the prevention of hepatorenal syndrome type 2 recurrence: a case-control study. Dig Liver Dis. 2009 Apr. 41(4):298-302. [Medline].

  19. Alessandria C, Ottobrelli A, Debernardi-Venon W, Todros L, Cerenzia MT, Martini S. Noradrenalin vs terlipressin in patients with hepatorenal syndrome: a prospective, randomized, unblinded, pilot study. J Hepatol. 2007 Oct. 47(4):499-505. [Medline].

  20. Barnardo DE, Baldus WP, Maher FT. Effects of dopamine on renal function in patients with cirrhosis. Gastroenterology. 1970 Apr. 58(4):524-31. [Medline].

  21. Bataller R, Sort P, Gines P, Arroyo V. Hepatorenal syndrome: definition, pathophysiology, clinical features and management. Kidney Int Suppl. 1998 May. 66:S47-53. [Medline].

  22. [Guideline] Bush WH Jr, Choyke PL, Bluth RI, et al. Renal failure. ACR Appropriateness Criteria renal failure. 2005. [Full Text].

  23. Cardenas A. Hepatorenal syndrome: a dreaded complication of end-stage liver disease. Am J Gastroenterol. 2005 Feb. 100(2):460-7. [Medline].

  24. Carl DE, Sanyal A. The management of hepatorenal syndrome. Minerva Gastroenterol Dietol. 2009 Jun. 55(2):207-26. [Medline].

  25. Charlton MR, Wall WJ, Ojo AO, Gines P, Textor S, Shihab FS. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl. 2009 Nov. 15(11):S1-34. [Medline].

  26. Eason JD, Gonwa TA, Davis CL, Sung RS, Gerber D, Bloom RD. Proceedings of Consensus Conference on Simultaneous Liver Kidney Transplantation (SLK). Am J Transplant. 2008 Nov. 8(11):2243-51. [Medline].

  27. Epstein M. The hepatorenal syndrome--newer perspectives. N Engl J Med. 1992 Dec 17. 327(25):1810-1. [Medline].

  28. Fabrizi F, Dixit V, Messa P, Martin P. Terlipressin for hepatorenal syndrome: A meta-analysis of randomized trials. Int J Artif Organs. 2009 Mar. 32(3):133-40. [Medline].

  29. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology. 1994 Dec. 20(6):1495-501. [Medline].

  30. Fullen WD. Hepatorenal syndrome: reversal by peritoneovenous shunt. Surgery. 1977 Sep. 82(3):337-41. [Medline].

  31. Gines P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology. 1987 Aug. 93(2):234-41. [Medline].

  32. Gines P, Guevara M, Arroyo V, Rodes J. Hepatorenal syndrome. Lancet. 2003 Nov 29. 362(9398):1819-27. [Medline].

  33. Gonwa TA, Morris CA, Goldstein RM, et al. Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome--experience in 300 patients. Transplantation. 1991 Feb. 51(2):428-30. [Medline].

  34. Guevara M, Gines P, Fernandez-Esparrach G, et al. Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion. Hepatology. 1998 Jan. 27(1):35-41. [Medline].

  35. Guevara M, Rodes J. Hepatorenal syndrome. Int J Biochem Cell Biol. 2005 Jan. 37(1):22-6.

  36. Gulberg V, Bilzer M, Gerbes AL. Long-term therapy and retreatment of hepatorenal syndrome type 1 with ornipressin and dopamine. Hepatology. 1999 Oct. 30(4):870-5. [Medline].

  37. Henriksen JH. Cirrhosis: ascites and hepatorenal syndrome. Recent advances in pathogenesis. J Hepatol. 1995. 23 Suppl 1:25-30. [Medline].

  38. Kiser TH, Fish DN, Obritsch MD, et al. Vasopressin, not octreotide, may be beneficial in the treatment of hepatorenal syndrome: a retrospective study. Nephrol Dial Transplant. 2005 Sep. 20(9):1813-20. [Medline].

  39. Levy M. Hepatorenal syndrome. Kidney Int. 1993 Mar. 43(3):737-53. [Medline].

  40. Magan AA, Khalil AA, Ahmed MH. Terlipressin and hepatorenal syndrome: what is important for nephrologists and hepatologists. World J Gastroenterol. 2010 Nov 7. 16(41):5139-47. [Medline].

  41. Maroto A, Gines A, Salo J, et al. Diagnosis of functional kidney failure of cirrhosis with Doppler sonography: prognostic value of resistive index. Hepatology. 1994 Oct. 20(4 Pt 1):839-44. [Medline].

  42. Moller S, Henriksen JH, Bendtsen F. Pathogenetic background for treatment of ascites and hepatorenal syndrome. Hepatol Int. 2008 Dec. 2(4):416-28. [Medline].

  43. [Guideline] Murray KF, Carithers RL Jr. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology. 2005 Jun. 41(6):1407-32. [Medline].

  44. Neuschwander-Tetri BA. Organ interactions in the hepatorenal syndrome. New Horiz. 1994 Nov. 2(4):527-44. [Medline].

  45. O'Beirne JP, Heneghan MA. Current management of the hepatorenal syndrome. Hepatol Res. 2005 Aug. 32(4):243-9. [Medline].

  46. Ortega R, Gines P, Uriz J, et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study. Hepatology. 2002 Oct. 36(4 Pt 1):941-8. [Medline].

  47. Peron JM, Bureau C, Gonzalez L, et al. Treatment of hepatorenal syndrome as defined by the international ascites club by albumin and furosemide infusion according to the central venous pressure: a prospective pilot study. Am J Gastroenterol. 2005 Dec. 100(12):2702-7. [Medline].

  48. Roberts LR, Kamath PS. Ascites and hepatorenal syndrome: pathophysiology and management. Mayo Clin Proc. 1996 Sep. 71(9):874-81. [Medline].

  49. Ruiz-del-Arbol L, Monescillo A, Jimenez W, Garcia-Plaza A, Arroyo V, Rodes J. Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology. 1997 Aug. 113(2):579-86. [Medline].

  50. Ruiz-del-Arbol L, Urman J, Fernandez J, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology. 2003 Nov. 38(5):1210-8. [Medline].

  51. Sacerdoti D, Bolognesi M, Merkel C, et al. Renal vasoconstriction in cirrhosis evaluated by duplex Doppler ultrasonography. Hepatology. 1993 Feb. 17(2):219-24. [Medline].

  52. Salo J, Gines A, Quer JC, et al. Renal and neurohormonal changes following simultaneous administration of systemic vasoconstrictors and dopamine or prostacyclin in cirrhotic patients with hepatorenal syndrome. J Hepatol. 1996 Dec. 25(6):916-23. [Medline].

  53. Skagen C, Einstein M, Lucey MR, Said A. Combination treatment with octreotide, midodrine, and albumin improves survival in patients with type 1 and type 2 hepatorenal syndrome. J Clin Gastroenterol. 2009 Aug. 43(7):680-5. [Medline].

  54. Soper CP, Latif AB, Bending MR. Amelioration of hepatorenal syndrome with selective endothelin-A antagonist. Lancet. 1996 Jun 29. 347(9018):1842-3. [Medline].

  55. Strang J, Ramlow W, Mitzner S, et al. Dialysis against a recycled albumin solution enables the removal of albumin-bound toxins. Artificial Organs. 1993. 17:809-13.

  56. Testino G, Ferro C, Sumberaz A, Messa P, Morelli N, Guadagni B. Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology. 2003 Nov-Dec. 50(54):1753-5. [Medline].

  57. Umgelter A, Schmid RM. [Terlipressin for hepatorenal syndrome - what is the role of plasma expansion and hemodynamic monitoring?]. Z Gastroenterol. 2009 Mar. 47(3):307-8. [Medline].

  58. Van Roey G, Moore K. The hepatorenal syndrome. Pediatr Nephrol. 1996 Feb. 10(1):100-7. [Medline].

  59. Wadei HM, Mai ML, Ahsan N, Gonwa TA. Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol. 2006 Sep. 1(5):1066-79. [Medline].

  60. Witzke O, Baumann M, Patschan D, et al. Which patients benefit from hemodialysis therapy in hepatorenal syndrome?. J Gastroenterol Hepatol. 2004 Dec. 19(12):1369-73. [Medline].

  61. Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004 Jul. 40(1):55-64. [Medline].

  62. Xu X, Ling Q, Zhang M, et al. Outcome of patients with hepatorenal syndrome type 1 after liver transplantation: Hangzhou experience. Transplantation. 2009 May 27. 87(10):1514-9. [Medline].

Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A curved catheter is placed into the right hepatic vein.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.