Causes

Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a 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 10% of patients hospitalized with liver failure. It is caused by the mounting effects of liver damage and 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)
• Diuretic use
• Gastrointestinal bleeding
• Infection
• Recent abdominal fluid tap (paracentesis)

Symptoms

• Abdominal swelling due to fluid (called ascites, a symptom of the underlying liver disease)
• Change in mental status
  • Confusion
  • Delirium
  • Dementia
• Coarse muscle movements or mucle jerks
• Dark-colored urine (a symptom of the underlying liver disease)
• Decreased urine production
• Nausea and vomiting
• Weight gain
• Yellow skin (jaundice, a symptom of the underlying liver disease)

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:

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

Other signs include:

• Abnormal reflexes
• Decreased testicle size
• Dull sound in the abdomen when tapped with the tips of the fingers, and visible fluid wave when examined by feel
• 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 serum creatinine levels
• Increased urine specific gravity and osmolality
• Low serum sodium
• Very low urine sodium concentration

The following may be signs of liver failure:

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

Treatment

Treatment aims to improve liver function and ensure that there is enough blood volume in the body and that the heart is pumping it adequately.

The disorder is generally treated in the same way as kidney failure from any other cause.

• All unnecessary medicines should be stopped, especially the antibiotic neomycin, ibuprofen and other NSAIDs, and diuretics ("water pills").
• Dialysis may improve symptoms.
• Medications such as octreotide plus midodrine, albumin, or dopamine may be used temporarily to improve kidney function.
• 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 usually occurs as a result of secondary infections or hemorrhage.

Possible Complications

• Bleeding
• Damage to, and failure of, many organ systems
• End-stage kidney disease
• Fluid overload with congestive heart failure or pulmonary edema
• Hepatic coma
• Secondary infections

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 sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007: chap 157.

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

Update Date: 5/4/2012

Reviewed by: 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, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.