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Hepatorenal syndrome

Hepatorenal syndrome is a condition in which there is progressive kidney failure in a person with cirrhosis of the liver. It is a serious and often life-threatening complication of cirrhosis.

Causes, incidence, and risk factors

Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a severe 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 1 in 10 patients who are in the hospital due to liver failure. It leads to kidney failure in people with:

Risk factors include:

  • Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
  • Use of medicines called diuretics ("water pill")
  • Gastrointestinal bleeding
  • Infection
  • Recent abdominal fluid tap (paracentesis)

Symptoms

Signs and tests

This condition is diagnosed when other causes of kidney failure are ruled out by the appropriate tests.

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

Other signs include:

  • Abnormal reflexes
  • Smaller testicle
  • Dull sound in the belly area when tapped with the tips of the fingers
  • Increased breast tissue (gynecomastia)
  • Sores (lesions) on the skin

The following may be signs of kidney failure:

The following may be signs of liver failure:

Treatment

The goal of treatment is to help your liver work better and to make sure your heart is pumping enough blood to your body.

Treatment is generally the same as kidney failure due to any cause.

  • All unnecessary medicines should be stopped, especially ibuprofen and other NSAIDs, the antibiotic neomycin, and diuretics ("water pills").
  • Dialysis may improve symptoms.
  • Medications such as octreotide plus midodrine, albumin, or dopamine may be used to improve blood pressure and temporarily to help your kidneys work better.
  • A nonsurgical shunt (known as TIPS) is used to relieve the symptoms of ascites and may help kidney function.
  • Surgery to place a shunt (called a Levine shunt) from the abdominal space (peritoneum) to the jugular vein may also relieve some of the symptoms of kidney failure. Both procedures are risky and proper selection of patients is very important.

Expectations (prognosis)

The predicted outcome is poor. Death is usually the result of a secondary infection or severe bleeding (hemorrhage).

Complications

Calling your health care provider

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

References

Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L,Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 156.

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

Updated: 5/1/2012

David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


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