Hepatorenal syndrome: MedlinePlus Mobile Medical Encyclopedia

Images

Causes
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:

Acute liver failure
Alcoholic hepatitis
Cirrhosis

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)

Exams 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:

Confusion (often due to hepatic encephalopathy)
Excess fluid in the abdomen (ascites)
Jaundice
Other signs of liver failure

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:

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

The following may be signs of liver failure:

Abnormal prothrombin time (PT)
Increased blood ammonia levels
Low blood albumin
Paracentesis shows ascites
Signs of hepatic encephalopathy (an EEG may be performed if such signs are present)

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.

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

When to Contact a Medical Professional
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.

Update Date: 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.