Hepatorenal

H e p a t o ren a l S y n d ro m e
Saro Khemichian, MDa, Claire Francoz, MD, PhDb,

Francois Durand, MDc, Constantine J. Karvellas, d
MD, SM, FRCPC ,
Mitra K. Nadim, MDe,*
KEYWORDS
Acute on chronic liver failure Acute kidney injury Cirrhosis
Hepatorenal syndrome Biomarkers Liver transplantation
Simultaneous liver kidney transplantation Model end-stage liver disease
KEY POINTS
Assessment and evaluation of renal function and identifying cause of acute kidney injury
(AKI) remain difficult in patients with liver cirrhosis.
Various novel biomarkers have been developed that may be helpful in the diagnosis of AKI
in patients with chronic liver disease and liver cirrhosis.
Vasoconstrictor therapies, such as noradrenalin and terlipressin, along with albumin
remain the main treatment for hepatorenal syndrome-AKI.
Most recent Organ Procurement and Transplantation Network/United Network for Organ
Sharing criteria for consideration of simultaneous liver and kidney transplantation have
streamlined the decision-making process.
Development of post–liver transplant AKI is multifactorial, relating to the recipient’s pre-
transplant course, the donor, surgical events, and the use of immunosuppression.
INTRODUCTION
Acute kidney injury (AKI) is a frequent complication of end-stage liver disease and oc-
curs in as high as 50% of shospitalized patients.1 The development of AKI impacts
short- and long-term mortality and reduces kidney function following liver transplanta-
tion (LT).2,3 Circulatory changes observed in end-stage cirrhosis, namely, hyperkinetic
state, with renal vasoconstriction leading to decreased kidney blood flow are central in
a
Division of Gastroenterology/Liver, Keck School of Medicine, University of Southern Califor-
nia, 1510 San Pablo Street, Los Angeles, CA 90033, USA; b Hepatology and Liver Intensive Care,
Hospital Beaujon, 100 Boulevard Du General Leclerc, Clichy 92110, France; c Hepatology and
Liver Intensive Care, Hospital Beaujon, University of Paris, 100 Boulevard Du General Leclerc,
Clichy 92110, France; d Division of Gastroenterology (Liver Unit), Department of Critical Care
Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G 2X8,
Canada; e Division of Nephrology and Hypertension, Keck School of Medicine, University of
Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033, USA
* Corresponding author.
E-mail address: mitra.nadim@med.usc.edu
Crit Care Clin 37 (2021) 321–334

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322 Khemichian et al
the development of AKI.4 Traditional diagnostic criteria focused on these changes,

along with an increase in serum creatinine (sCr) >50% over baseline with
value greater than 1.5 mg/dL as diagnostic for hepatorenal syndrome (HRS). Other
studies, however, have shown that these criteria may be too narrow5 and certainly
may not encompass the spectrum of kidney injury in patients with end-stage liver dis-
ease. There are also no specific urine biomarkers that can reliably identify the cause of
AKI in these patients.
ASSESSMENT OF KIDNEY FUNCTION IN CIRRHOSIS
Assessment of kidney function in patients with cirrhosis remains a challenging issue.

Although sCr is the most commonly used clinical index of kidney function, it overesti-
mates glomerular filtration rate (GFR) in patients with advanced cirrhosis because of
the combination of decreased creatine production by the liver, muscle wasting, and
large volume of distribution in the setting of fluid overload. In patients with AKI, sCr
can lag by days despite a significant decrease in GFR especially in patients with fluid
overload.6,7 In addition, in patients with high serum bilirubin, sCr can be inaccurate if
colorimetric-based Jaffe assays are used, as bilirubin interferes with the color reac-
tion. There is no evidence that other serum markers of kidney function, such as cys-
tatin C, are superior to sCr in patients with cirrhosis even though cystatin C is less
influenced by confounding factors, such as age and muscle mass.8
The clearance of exogenous markers, such as radiocontrast media, inulin, or radio-
isotopes, is considered the gold standard for GFR assessment; however, they are not
routinely used in clinical practice, because of cost, convenience, and availability, and
have not been rigorously studied in patients with advanced cirrhosis and ascites.
When properly performed, timed urinary collection of creatinine and urea overcomes
some of these limitations. These limitations are, however, subject to errors because of
inaccurate or incomplete collection and because of increased tubular secretion of
creatinine as GFR declines.9,10
Estimation of GFR using mathematical equations based on sCr and/or cystatin-C is
a simple method in the general population with stable sCr; however, in patients with
cirrhosis, the precision of all estimated GFR (eGFR) equations is poor and tends to
overestimate true GFR, especially in patients with GFR <40 mL/min and should be
used with caution. The Modified Diet in Renal Disease-6 (MDRD-6) equation
has been shown to be the most accurate creatinine-based equation in cirrhosis.11
Equations based on cystatin C, with or without sCr (ie, Chronic Kidney Disease Epide-
miology Collaboration creatinine-cystatin C equation), may be superior to creatinine-
based equations.12,13 More recently, in a single-center study of more than 10,000
iothalamate samples, GRAIL equation (Glomerular filtration rate in liver disease;
http://www.bswh.md/grail) demonstrated more precision and less bias compared
with MDRD-6 equation in patients with low GFR and correctly classified 75% of the
cohort as having a measured GFR <30 mL/min/1.73 m2 versus 52.8% in MDRD-6
(P<.01).14,15
DEFINITIONS
Historically, AKI in cirrhosis was defined by a fixed value of sCr >1.5 mg/dL (133 mmol/
L).16 However, this definition had limitations because patients with advanced cirrhosis
and sCr values within the normal range may have a significant decrease in GFR
because of reduced muscle mass and decreased creatine production.11 In 2010,
the Acute Disease Quality Initiative (ADQI) proposed a novel classification system of
AKI in cirrhosis based on sCr changes and qualifying type 1 HRS as only one of the

Hepatorenal Syndrome 323
possible causes of AKI in end-stage liver disease.17 In 2015, the International Club of
Ascites (ICA) proposed revised definitions of AKI in cirrhosis based on the Kidney Dis-
ease Improving Global Outcomes Guidelines (KDIGO) (Table 1).18 In line with the
KDIGO criteria, AKI is defined by a change in sCr only and categorized into 3 stages
of increasing severity. Baseline sCr is defined by a value of sCr obtained in the previ-
ous 3 months when available. Type 1 HRS is now considered one of the different phe-
notypes of AKI in cirrhosis termed AKI-HRS (see Table 1).18 The prognostic relevance
of these new definitions has been validated in several studies.1,19
Although oliguria was not included in the current definition of AKI in patients with
liver disease, urine output (UO) has been found to be a sensitive and early marker
for AKI and to be associated with adverse outcomes with more than 50% increase
(14.6% vs 9%; P<.001) in mortality among critically ill patients with chronic liver dis-
ease and stage 1 AKI when defined by oliguria instead of sCr alone.20 Furthermore,
61% of stage 2 to 3 AKI patients classified by oliguria were misclassified as non-
AKI or stage 1 AKI based on sCr criteria. An international consensus meeting on
management of critically ill cirrhotic patients has recommended that regardless of
any increase in sCr, worsening oliguria or development of anuria should be considered
AKI in patients with cirrhosis until proven otherwise.21
Recently, a group of experts proposed further changes in the definitions of HRS and
other phenotypes of AKI in cirrhosis.22 According to these changes, UO was reintro-
duced as one of the criteria defining HRS-AKI (UO 0.5 mL/kg for 6 hours). Type
2 HRS, which is a more chronic presentation of HRS, is termed HRS-NAKI (for non-
AKI) and defined by eGFR 60 mL/min/1.73 m2 for more than 3 months with initial
fulfillment of ICA criteria for the diagnosis of HRS-AKI.18,22,23 Whether these changes
help better categorize cirrhotic patients with AKI or chronic kidney disease (CKD)
needs further validation.
A major limitation of the HRS criteria is that they do not allow for the coexistence of
other forms of acute or CKD, such as underlying diabetic nephropathy or other
Table 1
International club of ascites definition of acute kidney injury and hepatorenal syndrome in
cirrhosis
Purpose Definition
Definition of AKI Increase in sCr 0.3 mg/dL (26 mmol/L) within 48 h, or
A percentage increase in sCr 50% from baseline, which is known
or presumed to have occurred within the previous 7 d
Staging of AKI Stage 1: increase in sCr 0.3 mg/dL (26 mmol/L) or increase in
sCr 1.5 to 2-fold from baseline
Stage 2: increase in sCr >2- to 3-fold from baseline
Stage 3: increase in sCr >3-fold from baseline or sCr >4 mg/dL
(353 mmol/L) with an acute increase 0.3 mg/dL (26 mmol/L) or
initiation of renal replacement therapy
AKI-HRS AKI stage 2
No improvement in sCr after 48 h of diuretic withdrawal and
volume expansion with albumin at a dose of 1 g/kg up to a
maximum of 100 g daily
Absence of hypovolemic shock or infection requiring vasoactive
drugs to support blood pressure
No current or recent use of nephrotoxic drugs
Proteinuria <500 mg/d and hematuria <50 red blood cells per
high-power field

glomerular diseases often associated with patients with liver disease (eg, immuno-
globulin A, membranous or membranoproliferative disease). However, patients with
underlying kidney disease can still develop “hepatorenal physiology.” As a result,
ADQI proposed that the term “hepatorenal disorders” be used to describe all patients
with advanced cirrhosis and concurrent kidney dysfunction.17 Such a definition would
allow patients with cirrhosis and renal dysfunction to be properly classified and treated
while maintaining the term HRS.
PATHOPHYSIOLOGY
Splanchnic and Systemic Circulatory Changes
Portal hypertension and splanchnic vasodilatation are characteristic features of
cirrhosis that play a central role in HRS-AKI (Fig. 1).4,24,25 In early stages of cirrhosis
(compensated cirrhosis), mild reduction in arterial blood pressure is compensated
for by an increase in cardiac output (CO) that preserves kidney perfusion. As portal hy-
pertension increases and liver function deteriorates, systemic circulatory changes are
more pronounced with a further decrease in systemic vascular resistance (SVR) and
increase in CO. Splanchnic arterial vasodilatation increases as a result of increased
synthesis of nitric oxide and other vasodilatory mediators. The state of central hypo-
volemia results in activation of systemic vasoconstrictors, including the renin angio-
tensin aldosterone system, the sympathetic system, and release of arginine
vasopressin (AVP), which all contribute to maintain arterial pressure and kidney perfu-
sion.24 Although activation of RASS with elevated plasma renin activity and increased
circulating levels of norepinephrine has a positive impact on arterial pressure, this
response has a negative impact with retention of sodium and water, resulting in asci-
tes, edema, and impaired free water excretion. Intense renal vasoconstriction also re-
sults in decreased kidney perfusion and decreased GFR, a central mechanism of
HRS-AKI.26 In recent years, it has been suggested that impaired cardiac function
could also be one of the mechanisms leading to HRS-AKI.27 Evidence suggests that
cardiac work decreases in the most advanced stages of cirrhosis and that impaired
cardiac work is more pronounced in patients receiving b-blockers.28
Kidney Factors
The main renal prostaglandins (prostaglandin I2 and prostaglandin E2) have vasodi-
lator effects in the kidney and are increased in patients with cirrhosis and ascites.29
Fig. 1. Mechanisms involved in HRS-AKI.

Changes in renal blood flow autoregulation also exist in cirrhosis with a shift in the
autoregulation curve, at least in part related to the activation of the sympathetic ner-
vous system. As a result, for a given level of kidney perfusion pressure, kidney perfu-
sion is lower in patients with cirrhosis as compared with patients without cirrhosis.
Systemic Inflammatory Response
There is now general agreement that cirrhosis is characterized by systemic inflamma-
tory state and that inflammation contributes to complications, such as HRS-AKI. Even
in the absence of documented infection, patients with cirrhosis have increased circu-
lating levels of C-reactive proteins and proinflammatory cytokines, and this increase is
correlated with disease severity, portal pressure, and hyperkinetic syndrome.30 Bac-
terial translocation is one of the mechanisms involved in chronic systemic inflamma-
tory response. Patients with bacterial translocation from gut lumen to mesenteric
lymph nodes were shown to have increased levels of proinflammatory cytokines (tu-
mor necrosis factor-a [TNF-a] and interleukin-6 [IL-6]), and vasoactive factors,
including NO, in the splanchnic area.31 In patients with spontaneous bacterial perito-
nitis (SBP) and HRS-AKI, TNF-a and IL-6 levels in ascitic fluid and blood are signifi-
cantly higher than in patients with SBP and no HRS-AKI. This increased cytokine
level is associated with increased NO levels also.32 These findings suggest that sys-
temic inflammatory response may trigger HRS-AKI by worsening circulatory dysfunc-
tion and further decreasing kidney perfusion.
CAUSE OF KIDNEY DYSFUNCTION
The most common causes of AKI in hospitalized patients are prerenal azotemia (most
due to hypovolemia-induced AKI and only one-third due to HRS), followed by ATN.
The cause of AKI should be determined promptly in order to prevent further worsening
of AKI as progression to advanced stage AKI has been associated with a higher mor-
tality. The cause of AKI is generally distinguished by the preceding history as well as
urinalysis and response to diuretic withdrawal and volume challenge. However, these
criteria may be misleading in certain circumstances, such as presence of CKD or
recent diuretic use. Prompt diagnosis and identification of AKI phenotype in patients
with cirrhosis allow for appropriate and timely intervention, whereby progression of
AKI stage confers increasing mortality, particularly with HRS.33 Given that sCr often
lags in highlighting the timing and severity of renal injury, several urine biomarkers in
addition to urine microalbuminuria or fractional excretion of sodium have been evalu-
ated to allow earlier diagnosis and identification of the cause of AKI (ie, HRS vs ATN).
This can potentially help identify patients who are less likely to benefit from volume
resuscitation and vasopressor therapy.34–36
Urinary NGAL has emerged as the most sensitive marker to detect ATN or persistent
AKI.36 However, even though urinary NGAL level is higher in ATN when compared with
HRS and other causes of AKI, there is a significant overlap between the groups.34,36–38
Accurate biomarkers of underlying CKD are still lacking, and kidney biopsy is often
contraindicated in this population. In most studies, the diagnosis of ATN was based
on nonspecific criteria without a gold standard (biopsy) and therefore should be inter-
preted with caution.
PREVENTION AND TREATMENT OF HEPATORENAL SYNDROME
It is important to identify and remove potential precipitating agents in the development

of AKI/HRS and to prevent factors that further impair circulatory status and reduce
renal perfusion. It is also important to monitor the volume status closely in cirrhotic

patients and to avoid hypovolemia. Early administration of broad-spectrum antibiotics

should be prompt upon diagnosis of any infection. The patient’s medication lists need
to be carefully monitored daily. Long-term administration of albumin in patients with
decompensated cirrhosis has been shown in a large randomized control trial to be
associated with reduced rates of SBP, bacterial infections other than SBP, HRS,
and improved survival.39
Volume expansion is not only important in the treatment of AKI but also in the differ-
ential diagnosis of cause of AKI. The type of fluid needed for resuscitation should be
tailored based on the cause of AKI and volume status of the patient. It is imperative to
exercise caution when administrating fluids in patients with AKI to avoid development
of fluid overload and pulmonary edema. Diuretics should be discontinued, and any
potentially nephrotoxic drug should also be stopped, whenever possible. Several
treatments and therapies have been demonstrated to be beneficial for HRS, whereas
LT remains the only definitive treatment. Other treatments have evolved to try to
reverse some of the pathophysiological conditions that were described earlier. These
are described in later discussion.
Albumin
Infusion of volume expanders, such as albumin, has been noted to be beneficial, and
its use has become very common in the diagnosis and treatment of patients with HRS-
AKI. Proposed mechanisms for this improvement include increased cardiac preload
and peripheral vascular resistance, which may be due to the ability of albumin to
bind vasodilators, such as nitric oxide, IL-6, and TNF-a.40 Reduced levels of inflamma-
tory markers have been noted in plasma and ascitic fluid of patients with SBP after al-
bumin infusion.41 In addition, albumin infusion has been shown in randomized trials to
prevent HRS and improve survival in patients diagnosed with SBP.42
Pharmacologic Therapy
Once a diagnosis of HRS is made, the goal of medical therapy is to improve systemic
hemodynamics with vasoconstrictors and restoring effective circulatory volume with
albumin (Table 2). It is recommend to use concentrated albumin 1 g/kg with a
maximum of 100 g initially followed by daily doses of 20 to 40 g/d. Choice of vasocon-
strictors is guided by location of hospitalized patients (intensive care unit [ICU] vs gen-
eral ward) and availability, as terlipressin is currently not available in several countries,
including North America. Several randomized controlled trials have shown the efficacy
of vasoconstrictors, particularly terlipressin and albumin, in treating HRS with a
response rate ranging from 45% to 75% in more recent studies (Table 3). Recently,
a large randomized controlled trial (n 5 300) in North America demonstrated a higher
rate of HRS reversal in patients who received terlipressin plus albumin versus albumin
alone (29.1% vs 15.8%) for treatment of patients with HRS type 1.43
Noradrenaline or norepinephrine is an a-adrenergic agonist that has shown efficacy
in treatment of HRS. A systematic review comparing terlipressin and noradrenaline
demonstrated equivalent efficacy in regard to HRS reversal, 30-day mortality, and
recurrence of HRS.44 Adverse events were less frequent in patients who received
noradrenaline.
Midodrine, which is an orally administered a-adrenergic agonist, in combination
with octreotide, a somatostatin analogue, along with albumin infusion has also been
used widely in management of type 1 HRS. Recently, a small randomized controlled
trial of 49 patients comparing midodrine/octreotide to terlipressin, both with albumin,
showed that the latter was more effective in reversing HRS (28.6% vs 70.4%;
P 5 .01).45

Table 2
Vasoconstrictors for the treatment of hepatorenal syndrome
Drug Mechanism of Action Dose Comments

Terlipressin Vasopressin analogue 1.0 mg every 4–6 h either as IV bolus or Not available in the United States
through continuous IV infusion. Dose In countries where terlipressin is not
can be increased to 2 mg IV every 4–6 h available, the combination of
after 48 h if sCr has not decreased octreotide/midodrine can be initiated,
by >25% from baseline up to a and if there is no decline in sCr within a
maximum of 12 mg/d as long as there maximum of 3 d, then the patient
are no side effects. Maximal treatment should be transferred to the ICU for a
14 d trial of noradrenaline
Contraindicated in patients with
preexisting ischemic heart disease,
cerebrovascular disease, peripheral
arterial, disease, hypertension, or
asthma
Noradrenaline a-Adrenergic agonist 0.5–3.0 mg/h (continuous infusion). Requires ICU
Titrate to achieve a 15 mm Hg increase
in MAP
Midodrine 1 Octreotide a-Adrenergic agonist (midodrine) 7.5 mg orally tid with an increase to 12.5–
Somatostatin analogue (octreotide) 15 mg tid as needed to increase MAP by
15 mm Hg
Hepatorenal Syndrome
Octreotide SQ 100 mg tid, titrated 200 mg
tid on day 2, if renal function has not
improved
Abbreviations: IV, intravenous; MAP, mean arterial pressure; SQ, subcutaneous; tid, 3 times a day.
Note: All vasoconstrictors should be given in combination with 25% IV albumin, initially 1 g of albumin/kg for 2 d, up to a maximum of 100 g/d, followed by 20 to
40 g/d.
327
328
Khemichian et al
Table 3
Randomized controlled trials of terlipressin for the treatment of hepatorenal syndrome
Intervention and Mortality

Definition of Complete HRS Comparator (Both Without

Author, y (Country) No. of Subjects Patient Population Reversal with Albumin) HRS Reversal, % Transplant, %
Alessandria et al, 60
2007 22 Type 1 HRS 30% decrease in sCr from Terlipressin 83 90
(Italy) Type 2 HRS baseline to a final Noradrenaline 70 100
value 1.5 mg/dL
Sharma et al,61 2008 (India) 40 Type 1 HRS sCr 1.5 mg/dL Terlipressin 50 45
Noradrenaline 50 45
Sanyal et al,62 2008 (USA, 112 (double-blind, Type 1 HRS sCr 1.5 mg/dL on 2 Terlipressin 34 87
Germany, Russia) multicenter) occasions at least 48 h Placebo 13 91
apart
Martin-Llahi et al,63 2008 46 (multicenter) Type 1 HRS sCr 1.5 mg/dL Terlipressin 44 73
(Spain) Type 2 HRS Albumin 9 81
Singh,64 2012 (India) 46 Type 1 HRS sCr 1.5 mg/dL Terlipressin 39 61
Noradrenaline 43 52
Cavallin et al,45 2015 (Italy) 49 (multicenter) Type 1 HRS sCr 1.5 mg/dL Terlipressin 70 41
Type 2 HRS Midodrine/ 29 57
Octreotide
Boyer et al,65 2016 (USA, 196 (double-blind, Type 1 HRS sCr 1.5 mg/dL on 2 Terlipressin 24 70
Canada) multicenter) occasions at least 48 h Albumin 15 86
apart
Arora,66 2020 (India) 120 Type 1 HRS (defined Return of sCr to a value Terlipressin 40 52
by new AKI-HRS within 0.3 mg/dL of Noradrenaline 17 80
criteria) baseline
Wong et al,43 2019 (North 300 Type 1 HRS sCr 1.5 mg/dL on 2 Terlipressin 29 63
America) occasions at least 2 h Placebo 16 61
apart with subjects alive
without RRT at least 10 d
after second sCr
Treatment with vasoconstrictors should be discontinued if there is no improvement

in sCr after 5 to 7 days, if the patient is initiated on renal replacement therapy (RRT), or
for those who exhibit side effects.
Renal Replacement Therapy

Initiation of RRT in patients who are not transplant candidates, especially those with
HRS, has been controversial. However, the severity of illness and number of organ fail-
ure in patients with acute on chronic liver failure have been shown to be more predic-
tive of mortality than cause of AKI.46,47 Initiation of RRT should be considered in the
broader clinical context, for therapeutic and/or supportive treatment of “nonkidney”
indications, before overt complications from AKI have developed and the threshold
for initiation should be lowered when AKI occurs as part of multiorgan failure. RRT
should also be considered in patients if the daily fluid balance cannot be maintained
as even or negative regardless of their UO in order to prevent fluid accumulation.48
Continuous RRT should be preferred over other modalities, as it provides better car-
diovascular stability. In patients undergoing LT, intraoperative RRT has the potential
benefit of mitigating metabolic complications associated with LT; however, larger pro-
spective studies are required to confirm benefit.49,50
Liver transplantation versus simultaneous liver-kidney transplantation
Prediction of recovery of kidney function following LT remains a challenge, as the rela-
tive contribution of preexisting comorbidities, such as diabetes and age, unrecognized
intrinsic renal disease, perioperative events, and posttransplant immunosuppression
on kidney dysfunction, following LT is difficult to delineate. Simultaneous liver-
kidney (SLK) transplantation is a potential therapeutic option for patients with sus-
tained kidney impairment before LT in whom renal recovery is less likely after LT.
Which patients should receive an SLK transplant versus liver alone had been a difficult
decision for LT programs with considerable regional variability in listing practices for
SLK transplant.51,52 In 2017, the US Organ Procurement and Transplantation Network
and United Network for Organ Sharing (UNOS) approved a new allocation policy for
these patients (Box 1).53 The new policies also included a safety-net criteria such
that patients that continued to have evidence of renal dysfunction in the form of either
dialysis dependency or creatinine clearance or GFR of 20 mL/min would be priori-
tized for kidney transplant if they were placed on the kidney transplant waiting list
Box 1
Medical eligibility criteria for simultaneous liver and kidney transplantation53
Patients with CKD with a measured GFR 60 mL/min for more than 90 consecutive days and
at least one of the following:
ESRD on dialysis
Measured/calculated creatinine clearance or GFR 30 mL/min, at the time of placement of
the patient on the LT waiting list
Diagnosis of sustained AKI for 6 weeks including either:
Dialysis at least once every 7 days, or
Measured/calculated creatinine clearance or GFR of 25 mL/min documented at least once
every 7 days
Diagnosis of metabolic disease with either:
Hyperoxaluria
Atypical hemolytic uremic syndrome from mutations in factor H or factor I
Familial nonneuropathic systemic amyloidosis
Methylmalonic aciduria

between 60 and 365 days after LT. Currently, there is not a substantial number of
studies analyzing the outcomes associated with changes implemented by UNOS
with regards to SLK versus Liver-alone transplant. Emergence of these data will
help with future policy changes to allow the best possible outcome for patients and
utilization of scarce organs.
POST–LIVER TRANSPLANT ACUTE KIDNEY INJURY
AKI after LT is a common occurrence that can be seen in more than 50% of cases in
some recent series.54–57 Many patients undergoing LT have had some evidence of AKI
and may have been on RRT, both of which are predisposing factors for development
of CKD in the posttransplant setting.58,59 Typically, posttransplant AKI is multifactorial,
relating to the recipient’s pretransplant course, the donor, surgical events, and the use
of immunosuppression.
SUMMARY
Cirrhosis is a condition that predisposes to several phenotypes of AKI, and HRS-AKI is

a specific complication of end-stage cirrhosis. AKI is especially common in critically ill
cirrhotic patients, and it is associated with a worse outcome. Different phenotypes of
AKI are associated with different outcomes. Early diagnosis of AKI is an important step
in critically ill cirrhotic patients, and mild changes in sCr may a major decrease in GFR.
Use of biomarkers may be able to differentiate ATN from other phenotypes, Prediction
of reversibility after LT is an unresolved issue, and innovative biomarkers are needed.
In critically ill cirrhotic patients who are not candidates for transplantation, a trial of
RRT can be started for 48 to 72 hours with limitation in patients with multiple organ
failures who do not improve rapidly.
CLINIC CARE POINTS
Development of HRS portends a poor prognosis in patients with chronic liver disease.
Determining the cause of AKI in patients with chronic liver disease can be challenging.
HRS remains a diagnosis of exclusion and may coexist with patients with underlying CKD.
It is imperative to identify and remove any potential precipitating agents that may
predispose to development of HRS.
Once a diagnosis of HRS is made, the goal of medical therapy is to improve systemic
hemodynamics with vasoconstrictors and to restore effective circulatory volume with
albumin with the goal to increase the mean arterial pressure by approximately 15 mm Hg.
Patients with sustained kidney impairment who are eligible should be considered for SLK
transplantation.
DISCLOSURE
All authors: none.
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H e p a t o ren a l S y n d ro m e

Saro Khemichian, MDa, Claire Francoz, MD, PhDb,

Crit Care Clin 37 (2021) 321–334

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the development of AKI.4 Traditional diagnostic criteria focused on these changes,

ASSESSMENT OF KIDNEY FUNCTION IN CIRRHOSIS

Assessment of kidney function in patients with cirrhosis remains a challenging issue.

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Fig. 1. Mechanisms involved in HRS-AKI.

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CAUSE OF KIDNEY DYSFUNCTION

PREVENTION AND TREATMENT OF HEPATORENAL SYNDROME

It is important to identify and remove potential precipitating agents in the development

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patients and to avoid hypovolemia. Early administration of broad-spectrum antibiotics

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Drug Mechanism of Action Dose Comments

Intervention and Mortality

Definition of Complete HRS Comparator (Both Without

Treatment with vasoconstrictors should be discontinued if there is no improvement

Renal Replacement Therapy

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POST–LIVER TRANSPLANT ACUTE KIDNEY INJURY

Cirrhosis is a condition that predisposes to several phenotypes of AKI, and HRS-AKI is

CLINIC CARE POINTS

All authors: none.

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Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

39. Caraceni P, Riggio O, Angeli P, et al. Long-term albumin administration in decom-

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Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

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