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Hepatorenal syndrome

Definition

Hepatorenal syndrome is a condition in which there is progressive kidney failure. It occurs in a person with cirrhosis of the liver. It is a serious complication that can lead to death.

Causes

Hepatorenal syndrome occurs when the kidneys stop working well in people with serious liver problems. Less urine is removed from the body, so waste products that contain nitrogen build up in the bloodstream (azotemia).

The disorder occurs in up to 1 in 10 patients who are in the hospital with 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 pills")
  • Gastrointestinal bleeding
  • Infection
  • Recent abdominal fluid tap (paracentesis)

Symptoms

Exams and Tests

This condition is diagnosed after testing to rule out other causes of kidney failure.

A physical exam does not detect kidney failure directly. However, the exam will very often show signs of chronic liver disease, such as:

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 the liver work better and to make sure the heart is able to pump enough blood to the body.

Treatment is about the same as for kidney failure from any cause. It includes:

  • Stopping all unnecessary medicines, especially ibuprofen and other NSAIDs, the antibiotic neomycin or gentamicin, and diuretics ("water pills")
  • Having dialysis to improve symptoms
  • Taking medicines such as octreotide plus midodrine, albumin, norepinephrine, or dopamine to improve blood pressure and help your kidneys work better
  • Placing a nonsurgical shunt (known as TIPS) to relieve the symptoms of ascites (this may also help kidney function, but the procedure can be risky)
  • Surgery to place a shunt (called a peritoneovenous shunt) from the abdominal space (peritoneum) to the jugular vein to relieve some symptoms of kidney failure (this procedure is risky and is rarely done)

Outlook (Prognosis)

The outcome is often poor. Death often occurs due to an infection or severe bleeding (hemorrhage).

Possible Complications

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. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 156.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851. PMID: 18328931 www.ncbi.nlm.nih.gov/pubmed/18328931.

Review Date:5/15/2014
Reviewed By:Jenifer K. Lehrer, MD, Department of Gastroenterology, Frankford-Torresdale Hospital, Aria Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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