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Hepatorenal Syndrome (HRS): Types, Causes, Symptoms & Diagnosis | Max Hospital

Understanding Hepatorenal Syndrome: A Severe Liver Complication

By Dr. Piyush Gupta in Gastroenterology, Hepatology & Endoscopy

Dec 19 , 2023 | 7 min read

What is Hepatorenal Disease or HRS? 

Hepatorenal syndrome (HRS) is a life-threatening complication of advanced liver disease that affects kidney function. It causes sudden, without prior kidney disease or visible kidney changes. HRS is most commonly associated with severe liver damage, often due to cirrhosis. As kidney function declines, toxins accumulate, leading to eventual liver failure.

Hepatorenal Syndrome Types 

There are two main types of hepatorenal disease:

Type 1 HRS (HRS-1)

Type 1 HRS is the more severe and acute form of hepatorenal syndrome, characterised by a rapid and significant decline in kidney function, often resulting in acute kidney injury (AKI). Serum creatinine levels increase rapidly, typically doubling within a short period, usually less than two weeks.

HRS-1 typically occurs in the setting of a precipitating event, such as an infection, gastrointestinal bleeding, or other factors that worsen liver function, and is associated with a poor prognosis and a high mortality rate if not promptly treated. 

Type 2 HRS (HRS-2)

Type 2 HRS is considered a more indolent or slowly progressive form of hepatorenal syndrome, characterised by a gradual decline in kidney function, with a more modest increase in serum creatinine levels over time.

Unlike HRS-1, HRS-2 does not typically have a rapid onset or a clear precipitating event and often occurs in patients with more stable cirrhosis. While HRS-2 may have a somewhat better prognosis compared to HRS-1, it can still lead to significant kidney dysfunction and complications if left untreated.

Both types of hepatorenal syndrome are associated with significant morbidity and mortality. Early diagnosis and intervention are crucial for improved outcomes.

Hepatorenal Syndrome Causes and Risk Factors

The exact cause of Hepatorenal Syndrome (HRS) remains somewhat elusive, but it is believed to arise from a combination of factors associated with liver dysfunction and circulatory changes. Let's delve into the fundamental causes and contributing factors:

Cirrhosis

Cirrhosis stands out as the primary underlying cause of HRS. This condition is characterised by the progressive scarring of liver tissue, often arising from chronic liver diseases like hepatitis and alcohol-related liver disease. As cirrhosis advances, it can lead to significant liver dysfunction, subsequently affecting kidney function.

Portal Hypertension

Cirrhosis results in elevated pressure within the portal vein, a critical blood vessel for transporting blood from the intestines and spleen to the liver. This high pressure, known as portal hypertension, disrupts normal blood flow within the liver and impacts kidney function.

Systemic Vasodilation

Advanced liver disease can trigger widespread vasodilation, causing blood vessels throughout the body to expand. This leads to decreased effective circulating blood volume and reduced blood flow to the kidneys.

Activation of Vasoconstrictor Systems

In response to the circulatory changes brought about by liver disease, the body often activates vasoconstrictor systems, such as the renin-angiotensin-aldosterone system, to maintain blood pressure. However, these compensatory mechanisms can have detrimental effects on kidney function.

Bacterial Infections

In some cases, bacterial infections, particularly spontaneous bacterial peritonitis (SBP), can trigger HRS.  SBP refers to an infection of the fluid present within the abdominal cavity, a condition often observed in individuals with cirrhosis. These infections can result in additional stress on the kidneys.

Other Factors

Additional factors that may contribute to HRS include electrolyte imbalances, such as hyponatremia (low sodium levels), and the use of certain medications.

Read more - 10 Habits That Indicate Future Liver Damage

Hepatorenal Failure Symptoms 

The symptoms of hepatorenal syndrome can vary in severity and may include:

Changes in Urination

  • Decreased urine output: Individuals with HRS may produce significantly reduced amounts of urine, often less than 500 millilitres per day.
  • Dark urine: Urine may appear darker than usual due to concentrated waste products.

Fluid Retention

  • Ascites: Accumulation of fluid in the abdominal cavity, leading to abdominal swelling and discomfort.
  • Peripheral oedema: Swelling of the legs and ankles due to fluid retention.

Nausea and Vomiting

Gastrointestinal symptoms, including nausea and vomiting, can occur.

Fatigue and Weakness

General fatigue and weakness may be present, often due to the build-up of toxins in the body.

Confusion and Altered Mental Status

Accumulation of toxins in the bloodstream can affect brain function, leading to confusion, difficulty concentrating, and altered mental status. This condition is often referred to as hepatic encephalopathy.

Jaundice

Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction and may be present in individuals with HRS.

Abdominal Pain

Some individuals may experience abdominal pain, particularly if they have underlying abdominal conditions, such as ascites.

Hypotension

Low blood pressure is a common feature of HRS and may result in dizziness and fainting.

Difficulty Breathing

In severe cases, fluid build-up in the chest cavity (pleural effusion) can lead to difficulty breathing.

Read more - Awareness About Liver Disease

Hepatorenal Syndrome Diagnosis

The diagnosis of hepatorenal syndrome (HRS) involves a combination of clinical assessment, laboratory tests, and imaging studies to confirm the presence of kidney dysfunction in individuals with advanced liver disease, typically cirrhosis. Here are the key steps involved in the diagnosis of HRS:

Clinical Evaluation

A thorough medical history and physical examination are conducted to assess the patient's overall health and any signs or symptoms of liver disease and kidney dysfunction.

Laboratory Tests

  • Serum Creatinine: Measurement of serum creatinine levels in the blood is essential. In HRS, serum creatinine levels are typically elevated, indicating impaired kidney function.
  • Blood Urea Nitrogen (BUN): BUN levels may also be elevated in HRS.
  • Urinalysis: A urinalysis may be performed to assess the presence of protein and other abnormalities in the urine.

Ultrasonography or Imaging

Abdominal ultrasonography or other imaging studies may be used to assess the liver and detect any structural abnormalities or signs of advanced liver disease, such as cirrhosis, portal hypertension, and ascites.

Assessment of Circulatory Function

Hemodynamic parameters, such as blood pressure, heart rate, and central venous pressure, may be monitored to evaluate a patient's circulatory status.

Consideration of Clinical Criteria

The diagnosis of HRS may be based on clinical criteria established by medical societies, such as the International Ascites Club. These criteria typically include elements related to the severity of liver disease and kidney dysfunction.

Liver Disease Severity Assessment

The severity of liver disease is often assessed using scoring systems such as the Child-Pugh score or Model for End-Stage Liver Disease (MELD) score.

Exclusion of Infection and Other Complications

Infections, particularly spontaneous bacterial peritonitis (SBP), can worsen kidney function in individuals with advanced liver disease. It is, therefore, important to assess for signs of infection and treat promptly if present. 

Hepatorenal Syndrome Treatment 

As per the reports of the diagnosis, doctors may recommend any of the below-listed treatment options:

Medication

Doctors may recommend various medications that can help control low blood pressure caused by HRS. In some cases, dialysis is also performed to improve kidney symptoms by filtering harmful waste from the blood. Medication serves only as a bridge towards liver transplantations.

Liver Transplantation

Remain the treatment of choice for hepatorenal syndrome. A liver transplant treats liver disease as well as impaired renal function. The patient must get their names listed on the waiting list for a liver transplant in India under Max Healthcare.

Patients looking for a liver transplant hospital in Delhi can seek medical guidance from a renowned liver transplant specialist. We at Max Healthcare offer dedicated services to our patients to help them attain a healthy and disease-free life.

Can Hepatorenal Syndrome be Prevented?

Hepatorenal syndrome (HRS) is a severe complication that often arises in individuals grappling with advanced liver disease, particularly cirrhosis. While it might not always be possible to prevent HRS completely, there are steps one can take to mitigate the risk and minimise its impact:

  • Managing Underlying Liver Disease: The most effective means of preventing HRS is to actively manage and treat the underlying liver disease, such as cirrhosis. This entails adhering to prescribed medical treatment plans, avoiding alcohol and other substances harmful to the liver, and adopting a healthy lifestyle.
  • Regular Medical Follow-up: Individuals with liver disease, notably cirrhosis, should undergo regular medical check-ups and maintain follow-up appointments with their healthcare provider. Consistent monitoring of liver function and any indications of kidney dysfunction is crucial.
  • Avoiding Precipitating Factors: HRS is often triggered or exacerbated by specific events or conditions, such as infections, gastrointestinal bleeding, and large-volume paracentesis (fluid drainage from the abdomen). To reduce the risk of HRS, avoiding or addressing these precipitating factors is vital.
  • Maintaining Adequate Blood Volume: Ensuring a sufficient blood volume and maintaining appropriate blood pressure is vital for supporting kidney function. In cases of dehydration or significant blood loss, prompt replenishment of fluids is essential.
  • Limiting the Use of Nephrotoxic Medications: Some medications, notably nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics, can be nephrotoxic, posing a risk to the kidneys. Patients with liver disease should either avoid or limit the use of such medications and consult their healthcare provider for safer alternatives.
  • Embracing Balanced Nutrition: Proper nutrition plays a pivotal role for individuals with liver disease. Malnutrition can exacerbate liver function and elevate the risk of complications. A balanced diet, often supervised by a registered dietitian, can contribute significantly to maintaining overall health.
  • Abstinence from Alcohol: If alcohol is a contributing factor to liver disease, complete abstinence is imperative to prevent further liver damage and complications.
  • Vaccination and Infection Control: Vaccinations, such as those for hepatitis A and B, can effectively prevent certain infections that may worsen liver disease. Practising good hygiene and adhering to infection control measures can further reduce the risk of infections affecting the liver and kidneys.
  • Considering Liver Transplantation: For individuals grappling with advanced cirrhosis or liver failure, liver transplantation emerges as a life-saving option. It not only halts the progression of liver disease but also significantly reduces the risk of HRS. Eligible candidates should undergo evaluation for transplant candidacy at a reputable transplant centre.