History

Most individuals with cirrhosis who develop hepatorenal syndrome (HRS) have nonspecific symptoms, such as fatigue, malaise, or dysgeusia (altered sense of taste). Development of HRS is usually noticed when patients observe decreased urine output and when blood test results show a decline in renal function. Although type 2 HRS is typically spontaneous, type 1 (now known as HRS-acute kidney injury [AKI]) may be precipitated by infection (such as bacterial or viral hepatitis), excessive response to diuretics, use of alcohol and drugs, or large-volume paracentesis without administration of albumin.

Physical Examination

Hepatorenal syndrome (HRS) has no specific signs. However, detecting the stigmata of chronic liver disease is important, because most patients at risk for HRS have cirrhosis. The following list of physical findings is not all-inclusive, and these findings are not present in all patients with chronic liver disease.

The hands may exhibit the following:

Palmar erythema
Leuconychia (white nails)
Muscle wasting
Asterixis (flapping tremors)
Clubbing

Head, ears, nose, throat examination may reveal the following:

Scleral icterus
Spider nevi (usually confined to the drainage area of the superior vena cava)
Fetor hepaticus (strong musty smell)
Xanthelasma

Chest findings may include gynecomastia.

Abdominal findings may include the following:

Caput medusae
Hepatosplenomegaly
Ascites
Paraumbilical hernia
Bruits

The genitalia may show loss of pubic hair/secondary sexual characteristics in men and/or atrophic testes.

The extremities may exhibit muscle wasting, peripheral edema, and/or clubbing.

Differential Diagnoses

Betrosian AP, Agarwal B, Douzinas EE. Acute renal dysfunction in liver diseases. World J Gastroenterol. 2007 Nov 14. 13(42):5552-9. [QxMD MEDLINE Link]. [Full Text].
Arroyo V. The liver and the kidney: mutual clearance or mixed intoxication. Contrib Nephrol. 2007. 156:17-23. [QxMD MEDLINE Link].
Lau C, Martin P, Bunnapradist S. Management of renal dysfunction in patients receiving a liver transplant. Clin Liver Dis. 2011 Nov. 15(4):807-20. [QxMD MEDLINE Link].
Zusman RM, Axelrod L, Tolkoff-Rubin N. The treatment of the hepatorenal syndrome with intra-renal administration of prostaglandin E1. Prostaglandins. 1977 May. 13(5):819-30. [QxMD MEDLINE Link].
Fernandez J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007 Sep. 133(3):818-24. [QxMD MEDLINE Link].
Moreau R, Lebrec D. Diagnosis and treatment of acute renal failure in patients with cirrhosis. Best Pract Res Clin Gastroenterol. 2007. 21(1):111-23. [QxMD MEDLINE Link].
Portal AJ, Austin M, Heneghan MA. Novel approaches to assessing renal function in cirrhotic liver disease. Hepatol Res. 2007 Sep. 37(9):667-72. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wong F, Raina N, Richardson R. Molecular adsorbent recirculating system is ineffective in the management of type 1 hepatorenal syndrome in patients with cirrhosis with ascites who have failed vasoconstrictor treatment. Gut. 2010 Mar. 59(3):381-6. [QxMD MEDLINE Link].
Wong F. The evolving concept of acute kidney injury in patients with cirrhosis. Nat Rev Gastroenterol Hepatol. 2015 Dec. 12(12):711-9. [QxMD MEDLINE Link].
Arroyo V, Terra C, Gines P. Advances in the pathogenesis and treatment of type-1 and type-2 hepatorenal syndrome. J Hepatol. 2007 May. 46(5):935-46. [QxMD MEDLINE Link].
Turban S, Thuluvath PJ, Atta MG. Hepatorenal syndrome. World J Gastroenterol. 2007 Aug 14. 13(30):4046-55. [QxMD MEDLINE Link].
Al-Khafaji A, Nadim MK, Kellum JA. Hepatorenal Disorders. Chest. 2015 Aug. 148(2):550-8. [QxMD MEDLINE Link].
Wong F, Moore K, Dingemanse J, Jalan R. Lack of renal improvement with nonselective endothelin antagonism with tezosentan in type 2 hepatorenal syndrome. Hepatology. 2008 Jan. 47(1):160-8. [QxMD MEDLINE Link].
Amin AA, Alabsawy EI, Jalan R, Davenport A. Epidemiology, pathophysiology, and management of hepatorenal syndrome. Semin Nephrol. 2019 Jan. 39(1):17-30. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Bittencourt PL, de Carvalho GC, de Andrade Regis C, et al. Causes of renal failure in patients with decompensated cirrhosis and its impact in hospital mortality. Ann Hepatol. 2012 Jan. 11(1):90-5. [QxMD MEDLINE Link].
Appenrodt B, Zielinski J, Brensing KA, Heller J, Sauerbruch T, Schepke M. Degree of hepatic dysfunction and improvement of renal function predict survival in patients with HRS type I: a retrospective analysis. Eur J Gastroenterol Hepatol. 2009 Dec. 21(12):1428-32. [QxMD MEDLINE Link].
Jamil K, Huang X, Lovelace B, Pham AT, Lodaya K, Wan G. The burden of illness of hepatorenal syndrome (HRS) in the United States: a retrospective analysis of electronic health records. J Med Econ. 2019 May. 22(5):421-9. [QxMD MEDLINE Link]. [Full Text].
Angeli P, Morando F, Cavallin M, Piano S. Hepatorenal syndrome. Contrib Nephrol. 2011. 174:46-55. [QxMD MEDLINE Link].
Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar. 28(3):e10-8. [QxMD MEDLINE Link].
Schepke M. Hepatorenal syndrome: current diagnostic and therapeutic concepts. Nephrol Dial Transplant. 2007 Sep. 22 Suppl 8:viii2-viii4. [QxMD MEDLINE Link].
Angeli P, Gines P, Wong F, et al, for the International Club of Ascites. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015 Apr. 64(4):531-7. [QxMD MEDLINE Link]. [Full Text].
Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004 Mar. 32(3):691-9. [QxMD MEDLINE Link].
Alessandria C, Ottobrelli A, Debernardi-Venon W, et al. Noradrenalin vs terlipressin in patients with hepatorenal syndrome: a prospective, randomized, unblinded, pilot study. J Hepatol. 2007 Oct. 47(4):499-505. [QxMD MEDLINE Link].
Testro AG, Wongseelashote S, Angus PW, Gow PJ. Long-term outcome of patients treated with terlipressin for types 1 and 2 hepatorenal syndrome. J Gastroenterol Hepatol. 2008 Oct. 23(10):1535-40. [QxMD MEDLINE Link].
Kiser TH, Maclaren R, Fish DN. Treatment of hepatorenal syndrome. Pharmacotherapy. 2009 Oct. 29(10):1196-211. [QxMD MEDLINE Link].
Narahara Y, Kanazawa H, Taki Y, et al. Effects of terlipressin on systemic, hepatic and renal hemodynamics in patients with cirrhosis. J Gastroenterol Hepatol. 2009 Nov. 24(11):1791-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pitre T, Kiflen M, Helmeczi W, et al. The comparative effectiveness of vasoactive treatments for hepatorenal syndrome: a systematic review and network meta-analysis. Crit Care Med. 2022 Oct 1. 50 (10):1419-29. [QxMD MEDLINE Link].
Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet. 2000 Dec 23-30. 356(9248):2139-43. [QxMD MEDLINE Link].
Fevery J, Van Cutsem E, Nevens F, Van Steenbergen W, Verberckmoes R, De Groote J. Reversal of hepatorenal syndrome in four patients by peroral misoprostol (prostaglandin E1 analogue) and albumin administration. J Hepatol. 1990 Sep. 11(2):153-8. [QxMD MEDLINE Link].
Gines A, Salmeron JM, Gines P, et al. Oral misoprostol or intravenous prostaglandin E2 do not improve renal function in patients with cirrhosis and ascites with hyponatremia or renal failure. J Hepatol. 1993 Feb. 17(2):220-6. [QxMD MEDLINE Link].
Soper CP, Latif AB, Bending MR. Amelioration of hepatorenal syndrome with selective endothelin-A antagonist. Lancet. 1996 Jun 29. 347(9018):1842-3. [QxMD MEDLINE Link].
Esrailian E, Pantangco ER, Kyulo NL, Hu KQ, Runyon BA. Octreotide/midodrine therapy significantly improves renal function and 30-day survival in patients with type 1 hepatorenal syndrome. Dig Dis Sci. 2007 Mar. 52(3):742-8. [QxMD MEDLINE Link].
Wong F, Pappas SC, Curry MP, et al, for the CONFIRM Study Investigators. Terlipressin plus albumin for the treatment of type 1 hepatorenal syndrome. N Engl J Med. 2021 Mar 4. 384 (9):818-28. [QxMD MEDLINE Link]. [Full Text].
Lenz K, Druml W, Kleinberger G, et al. Enhancement of renal function with ornipressin in a patient with decompensated cirrhosis. Gut. 1985 Dec. 26(12):1385-6. [QxMD MEDLINE Link].
Lenz K, Hortnagl H, Druml W, et al. Beneficial effect of 8-ornithin vasopressin on renal dysfunction in decompensated cirrhosis. Gut. 1989 Jan. 30(1):90-6. [QxMD MEDLINE Link].
Lenz K, Hortnagl H, Druml W, et al. Ornipressin in the treatment of functional renal failure in decompensated liver cirrhosis. Effects on renal hemodynamics and atrial natriuretic factor. Gastroenterology. 1991 Oct. 101(4):1060-7. [QxMD MEDLINE Link].
Guevara M, Gines P. Hepatorenal syndrome. Dig Dis. 2005. 23(1):47-55. [QxMD MEDLINE Link].
Guevara M, Rodes J. Hepatorenal syndrome. Int J Biochem Cell Biol. 2005 Jan. 37(1):22-6. [QxMD MEDLINE Link].
Velez JCQ, Therapondos G, Juncos LA. Author correction: Reappraising the spectrum of AKI and hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol. 2020 Mar. 16(3):186. [QxMD MEDLINE Link]. [Full Text].
Narahara Y, Kanazawa H, Sakamoto C, et al. The efficacy and safety of terlipressin and albumin in patients with type 1 hepatorenal syndrome: a multicenter, open-label, explorative study. J Gastroenterol. 2012 Mar. 47(3):313-20. [QxMD MEDLINE Link].
Gluud LL, Christensen K, Christensen E, Krag A. Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome. Hepatology. 2010 Feb. 51(2):576-84. [QxMD MEDLINE Link].
Cavallin M, Kamath PS, Merli M, et al, for the Italian Association for the Study of the Liver Study Group on Hepatorenal Syndrome. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: A randomized trial. Hepatology. 2015 Aug. 62(2):567-74. [QxMD MEDLINE Link].
Wong F, Boyer TD, Sanyal AJ, Pappas SC, Escalante S, Jamil K. Reduction in acute kidney injury stage predicts survival in patients with type-1 hepatorenal syndrome. Nephrol Dial Transplant. 2019 Mar 18. [QxMD MEDLINE Link]. [Full Text].
Angeli P, Volpin R, Gerunda G, et al. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology. 1999 Jun. 29(6):1690-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mindikoglu AL, Pappas SC. New developments in hepatorenal syndrome. Clin Gastroenterol Hepatol. 2018 Feb. 16(2):162-177.e1. [QxMD MEDLINE Link]. [Full Text].
Marik PE, Wood K, Starzl TE. The course of type 1 hepato-renal syndrome post liver transplantation. Nephrol Dial Transplant. 2006 Feb. 21(2):478-82. [QxMD MEDLINE Link]. [Full Text].
Goldaracena N, Marquez M, Selzner N, et al. Living vs. deceased donor liver transplantation provides comparable recovery of renal function in patients with hepatorenal syndrome: a matched case-control study. Am J Transplant. 2014 Dec. 14(12):2788-95. [QxMD MEDLINE Link].
Gonwa TA, Morris CA, Goldstein RM, Husberg BS, Klintmalm GB. 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. [QxMD MEDLINE Link].
Organ Procurement and Transplantation Network. Policy 9.9: Liver-kidney allocation. United Network for Organ Sharing (UNOS). August 19, 2017. Available at https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf#nameddest=Policy_09. Accessed: July 14, 2020.
Cui J, Spann A, Schaefer H, et al. Predictors of renal recovery in recipients of liver transplant alone who met 2017 simultaneous liver-kidney transplant criteria. Clin Transplant. 2022 Sep 6. e14812. [QxMD MEDLINE Link].
Allegretti AS, Parada XV, Eneanya ND, et al. Prognosis of patients with cirrhosis and AKI who initiate RRT. Clin J Am Soc Nephrol. 2018 Jan 6. 13(1):16-25. [QxMD MEDLINE Link]. [Full Text].
Capling RK, Bastani B. The clinical course of patients with type 1 hepatorenal syndrome maintained on hemodialysis. Ren Fail. 2004 Sep. 26(5):563-8. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Keller F, Heinze H, Jochimsen F, Passfall J, Schuppan D, Buttner P. Risk factors and outcome of 107 patients with decompensated liver disease and acute renal failure (including 26 patients with hepatorenal syndrome): the role of hemodialysis. Ren Fail. 1995 Mar. 17(2):135-46. [QxMD MEDLINE Link].
Song T, Rossle M, He F, Liu F, Guo X, Qi X. Transjugular intrahepatic portosystemic shunt for hepatorenal syndrome: A systematic review and meta-analysis. Dig Liver Dis. 2018 Apr. 50(4):323-30. [QxMD MEDLINE Link].
Charilaou P, Devani K, Petrosyan R, Reddy C, Pyrsopoulos N. Inpatient mortality benefit with transjugular intrahepatic portosystemic shunt for hospitalized hepatorenal syndrome patients. Dig Dis Sci. 2020 Feb 15. [QxMD MEDLINE Link]. [Full Text].
Trivedi PS, Brown MA, Rochon PJ, Ryu RK, Johnson DT. Gender disparity in inpatient mortality after transjugular intrahepatic portosystemic shunt creation in patients admitted with hepatorenal syndrome: a nationwide study. J Am Coll Radiol. 2020 Feb. 17(2):231-7. [QxMD MEDLINE Link].
Chmielewski J, Lewandowski RJ, Maddur H. Hepatorenal syndrome: physiology, diagnosis and management. Semin Intervent Radiol. 2018 Aug. 35(3):194-7. [QxMD MEDLINE Link]. [Full Text].
Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5. 341(6):403-9. [QxMD MEDLINE Link].
Akriviadis E, Botla R, Briggs W, Han S, Reynolds T, Shakil O. Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial. Gastroenterology. 2000 Dec. 119(6):1637-48. [QxMD MEDLINE Link].
Salerno F, Cazzaniga M, Gobbo G. Pharmacological treatment of hepatorenal syndrome: a note of optimism. J Hepatol. 2007 Nov. 47(5):729-31. [QxMD MEDLINE Link].
Tandon P, Bain VG, Tsuyuki RT, Klarenbach S. Systematic review: renal and other clinically relevant outcomes in hepatorenal syndrome trials. Aliment Pharmacol Ther. 2007 May 1. 25(9):1017-28. [QxMD MEDLINE Link].
Arieff AI, Chidsey CA. Renal function in cirrhosis and the effects of prostaglandin A. Am J Med. 1974 May. 56(5):695-703. [QxMD MEDLINE Link].
Arroyo V, Bosch J, Rivera F, et al. The renin angiotensin system in cirrhosis. Its relation to functional renal failure. Bartoli E, Chiandussi L, eds. Hepatorenal Syndrome. Padua, Italy: Piccin Medical Books; 1979. 201-29.
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. [QxMD MEDLINE Link].
Arroyo V, Terra C, Gines P. New treatments of hepatorenal syndrome. Semin Liver Dis. 2006 Aug. 26(3):254-64. [QxMD MEDLINE Link].
Arroyo V, Torre A, Guevara M. Recent advances in hepatorenal syndrome. Trop Gastroenterol. 2005 Jan-Mar. 26(1):13-20. [QxMD MEDLINE Link].
Bacq Y, Gaudin C, Hadengue A, et al. Systemic, splanchnic and renal hemodynamic effects of a dopaminergic dose of dopamine in patients with cirrhosis. Hepatology. 1991 Sep. 14(3):483-7. [QxMD MEDLINE Link].
Barnardo DE, Baldus WP, Maher FT. Effects of dopamine on renal function in patients with cirrhosis. Gastroenterology. 1970 Apr. 58(4):524-31. [QxMD MEDLINE Link].
Bennett WM, Keeffe E, Melnyk C, Mahler D, Rosch J, Porter GA. Response to dopamine hydrochloride in the hepatorenal syndrome. Arch Intern Med. 1975 Jul. 135(7):964-71. [QxMD MEDLINE Link].
Cardenas A. Hepatorenal syndrome: a dreaded complication of end-stage liver disease. Am J Gastroenterol. 2005 Feb. 100(2):460-7. [QxMD MEDLINE Link].
Cardenas A, Gines P. Hepatorenal syndrome. Clin Liver Dis. 2006 May. 10(2):371-85, ix-x. [QxMD MEDLINE Link].
Cardenas A, Gines P. Therapy insight: management of hepatorenal syndrome. Nat Clin Pract Gastroenterol Hepatol. 2006 Jun. 3(6):338-48. [QxMD MEDLINE Link].
D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006 Jan. 44(1):217-31. [QxMD MEDLINE Link].
Dagher L, Patch D, Marley R, Moore K, Burroughs A. Review article: pharmacological treatment of the hepatorenal syndrome in cirrhotic patients. Aliment Pharmacol Ther. 2000 May. 14(5):515-21. [QxMD MEDLINE Link].
Epstein M, Berk DP, Hollenberg NK, et al. Renal failure in the patient with cirrhosis. The role of active vasoconstriction. Am J Med. 1970 Aug. 49(2):175-85. [QxMD MEDLINE Link].
Esrailian E, Runyon BA. Alcoholic cirrhosis-associated hepatorenal syndrome treated with vasoactive agents. Nat Clin Pract Nephrol. 2006 Mar. 2(3):169-72. [QxMD MEDLINE Link].
Esrailian E, Runyon BA. Alcoholic cirrhosis-associated hepatorenal syndrome treated with vasoactive agents. Nat Clin Pract Nephrol. 2006 Mar. 2(3):169-72. [QxMD MEDLINE Link].
Esteva-Font C, Baccaro ME, Fernandez-Llama P, et al. Aquaporin-1 and aquaporin-2 urinary excretion in cirrhosis: Relationship with ascites and hepatorenal syndrome. Hepatology. 2006 Dec. 44(6):1555-63. [QxMD MEDLINE Link].
Fabrizi F, Dixit V, Martin P. Meta-analysis: terlipressin therapy for the hepatorenal syndrome. Aliment Pharmacol Ther. 2006 Sep 15. 24(6):935-44. [QxMD MEDLINE Link].
Flint A. Clinical report on hydro-peritoneum based on an analysis of forty-six cases. Am J Med Sci. 1863. 45:306-39.
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. [QxMD MEDLINE Link].
Ganne-Carrie N, Hadengue A, Mathurin P, Durand F, Erlinger S, Benhamou JP. Hepatorenal syndrome. Long-term treatment with terlipressin as a bridge to liver transplantation. Dig Dis Sci. 1996 Jun. 41(6):1054-6. [QxMD MEDLINE Link].
Gines P, Rimola A, Planas R, et al. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology. 1990 Oct. 12(4 Pt 1):716-24. [QxMD MEDLINE Link].
Gines P, Tito L, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology. 1988 Jun. 94(6):1493-502. [QxMD MEDLINE Link].
Gines P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002 Dec. 123(6):1839-47. [QxMD MEDLINE Link].
Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med. 2004 Apr 15. 350(16):1646-54. [QxMD MEDLINE Link].
Gines P, Guevara M, Arroyo V, Rodes J. Hepatorenal syndrome. Lancet. 2003 Nov 29. 362(9398):1819-27. [QxMD MEDLINE Link].
Gluud LL, Kjaer MS, Christensen E. Terlipressin for hepatorenal syndrome. Cochrane Database Syst Rev. 2006 Oct 18. CD005162. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hadengue A, Gadano A, Moreau R, et al. Beneficial effects of the 2-day administration of terlipressin in patients with cirrhosis and hepatorenal syndrome. J Hepatol. 1998 Oct. 29(4):565-70. [QxMD MEDLINE Link].
Hadengue A, Moreau R, Bacq Y, Gaudin C, Braillon A, Lebrec D. Selective dopamine DA1 stimulation with fenoldopam in cirrhotic patients with ascites: a systemic, splanchnic and renal hemodynamic study. Hepatology. 1991 Jan. 13(1):111-6. [QxMD MEDLINE Link].
Halimi C, Bonnard P, Bernard B, et al. Effect of terlipressin (Glypressin) on hepatorenal syndrome in cirrhotic patients: results of a multicentre pilot study. Eur J Gastroenterol Hepatol. 2002 Feb. 14(2):153-8. [QxMD MEDLINE Link].
Han MK, Hyzy R. Advances in critical care management of hepatic failure and insufficiency. Crit Care Med. 2006 Sep. 34(9 Suppl):S225-31. [QxMD MEDLINE Link].
Heidelbaugh JJ, Sherbondy M. Cirrhosis and chronic liver failure: part II. Complications and treatment. Am Fam Physician. 2006 Sep 1. 74(5):767-76. [QxMD MEDLINE Link].
Kaffy F, Borderie C, Chagneau C, et al. Octreotide in the treatment of the hepatorenal syndrome in cirrhotic patients. J Hepatol. 1999 Jan. 30(1):174. [QxMD MEDLINE Link].
Linas SL, Schaefer JW, Moore EE, Good JT Jr, Giansiracusa R. Peritoneovenous shunt in the management of the hepatorenal syndrome. Kidney Int. 1986 Nov. 30(5):736-40. [QxMD MEDLINE Link].
Martin PY, Gines P, Schrier RW. Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med. 1998 Aug 20. 339(8):533-41. [QxMD MEDLINE Link].
Mitzner SR, Stange J, Klammt S, et al. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transpl. 2000 May. 6(3):277-86. [QxMD MEDLINE Link].
Neri S, Pulvirenti D, Malaguarnera M, et al. Terlipressin and albumin in patients with cirrhosis and type I hepatorenal syndrome. Dig Dis Sci. 2008 Mar. 53(3):830-5. [QxMD MEDLINE Link].
Neri S, Pulvirenti D, Malaguarnera M, et al. Terlipressin and albumin in patients with cirrhosis and type I hepatorenal syndrome. Dig Dis Sci. 2008 Mar. 53(3):830-5. [QxMD MEDLINE Link].
O'Beirne JP, Heneghan MA. Current management of the hepatorenal syndrome. Hepatol Res. 2005 Aug. 32(4):243-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Papper S. The role of the kidney in Laennec's cirrhosis of the liver. Medicine (Baltimore). 1958 Dec. 37(4):299-316. [QxMD MEDLINE Link].
Perez GO, Golper TA, Epstein M. Dialysis, hemofiltration and other extracorporeal techniques in the treatment of renal complications of liver disease. Epstein M, ed. The Kidney in Liver Disease. 4th ed. Philadelphia, Pa: Hanley & Belfus; 1996. 517-28.
Restuccia T, Ortega R, Guevara M, et al. Effects of treatment of hepatorenal syndrome before transplantation on posttransplantation outcome. A case-control study. J Hepatol. 2004 Jan. 40(1):140-6. [QxMD MEDLINE Link].
Ruiz-del-Arbol L, Monescillo A, Arocena C, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005 Aug. 42(2):439-47. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sanyal AJ, Genning C, Reddy KR, et al. The North American study for the treatment of refractory ascites. Gastroenterology. 2003 Mar. 124(3):634-41. [QxMD MEDLINE Link].
Schepke M, Appenrodt B, Heller J, Zielinski J, Sauerbruch T. Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study. Liver Int. 2006 Sep. 26(7):834-9. [QxMD MEDLINE Link].
Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodes J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988 Sep-Oct. 8(5):1151-7. [QxMD MEDLINE Link].
Sen S, Williams R, Jalan R. Emerging indications for albumin dialysis. Am J Gastroenterol. 2005 Feb. 100(2):468-75. [QxMD MEDLINE Link].
Senzolo M, Cholongitas E, Tibballs J, Burroughs A, Patch D. Transjugular intrahepatic portosystemic shunt in the management of ascites and hepatorenal syndrome. Eur J Gastroenterol Hepatol. 2006 Nov. 18(11):1143-50. [QxMD MEDLINE Link].
Singh N, Gayowski T, Yu VL, Wagener MM. Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med. 1995 Apr 15. 122(8):595-8. [QxMD MEDLINE Link].
Solanki P, Chawla A, Garg R, Gupta R, Jain M, Sarin SK. Beneficial effects of terlipressin in hepatorenal syndrome: a prospective, randomized placebo-controlled clinical trial. J Gastroenterol Hepatol. 2003 Feb. 18(2):152-6. [QxMD MEDLINE Link].
Mattos AZ, Mattos AA, Ribeiro RA. Terlipressin versus noradrenaline in the treatment of hepatorenal syndrome: systematic review with meta-analysis and full economic evaluation. Eur J Gastroenterol Hepatol. 2016 Mar. 28(3):345-51. [QxMD MEDLINE Link].
Acevedo JG, Cramp ME. Hepatorenal syndrome: update on diagnosis and therapy. World J Hepatol. 2017 Feb 28. 9(6):293-9. [QxMD MEDLINE Link]. [Full Text].
Ahmed R, Haseeb A. Ischemic skin necrosis in hepatorenal syndrome patient secondary to terlipressin. J Coll Physicians Surg Pak. 2019 Jun. 29(6):S26-S28. [QxMD MEDLINE Link].
Nguyen-Tat M, Jager J, Wilhelm Rey J, et al. Terlipressin and albumin combination treatment in patients with hepatorenal syndrome type 2. United European Gastroenterol J. 2019 May. 7(4):529-37. [QxMD MEDLINE Link]. [Full Text].
Mattos AZ, Schacher FC, Mattos AA. Vasoconstrictors in hepatorenal syndrome - a critical review. Ann Hepatol. 2019 Mar - Apr. 18(2):287-90. [QxMD MEDLINE Link]. [Full Text].
Arora V, Maiwall R, Rajan V, et al. Terlipressin is superior to noradrenaline in the management of acute kidney injury in acute on chronic liver failure. Hepatology. 2020 Feb. 71(2):600-10. [QxMD MEDLINE Link].
Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol. 2015 Apr. 62(4):968-74. [QxMD MEDLINE Link]. [Full Text].
Angeli P, Garcia-Tsao G, Nadim MK, Parikh CR. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document. J Hepatol. 2019 Oct. 71(4):811-22. [QxMD MEDLINE Link]. [Full Text].

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Author

Deepika Devuni, MD Assistant Professor of Gastroenterology, University of Massachusetts Medical School

Deepika Devuni, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Association of Physicians of Indian Origin, American College of Gastroenterology, American Gastroenterological Association, American Society of Transplantation

Disclosure: SIte PI for: Sequana Medical .

Coauthor(s)

Emily Weng, DO Fellow, Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut School of Medicine

Emily Weng, DO is a member of the following medical societies: American Academy of Osteopathy, American College of Gastroenterology, American College of Physicians, Student Osteopathic Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Hemant K Roy, MD Associate Professor of Medicine, Section of Gastroenterology, Feinberg School of Medicine at Northwestern University, Evanston-Northwestern Healthcare

Disclosure: Nothing to disclose.

Rowen K Zetterman, MD Director, Faculty Mentoring Programs, University of Nebraska Medical Center; Dean Emeritus, Creighton University School of Medicine

Rowen K Zetterman, MD, is a member of the following medical societies: Alpha Omega Alpha, American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

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