• Rukmani Birla Hospital,Gopalpura Bypass Road, Near Triveni Bridge,Gopalpura,Jaipur – 302018.

HEPATORENAL SYNDROME: DIAGNOSIS AND TREATMENT

The Hepatorenal Syndrome (HRS) is characterized by functional failure of kidney in patients that have end-stage liver disease. Patients with the end-stage liver disease usually develop acute kidney injury (AKI) complications, which in turn leads to hepatorenal syndrome in patients. Even though HRS is reversible, it is very critical to be diagnosed early and given adequate medical attention, to avoid the complexity arising from its severe forms. That said, HRS usually has a very poor prognosis and hence, it becomes very critical to reverse the damage caused at early stages to avoid fatal consequences. Moreover, the pathophysiological base of this disease is complex and not completely known. This condition tends to decrease the blood flow in the kidneys, which is caused because of a deteriorating liver function in patients that suffer from cirrhosis or other such issues.

Types of Hepatorenal Syndrome

  • Type 1: This type of HRS is characterized by acute and severely progressing kidney failure in a short period of 2 weeks. This type of HRS can cause multi-organ failure and has a very poor prognosis.
  • Type 2: This type of HRS is known to develop spontaneously but often has evident symptoms such as bacterial infections, pneumonia, urinary tract infection, cellulitis, etc. This type is less severe and causes a gradual decline in the renal function.

Signs and Symptoms of Hepatorenal Syndrome

Most severe symptoms include:

  • Advanced cirrhosis
  • Jaundice
  • Ascites – fluid build-up in the abdomen

Some other signs and symptoms of the hepatorenal syndrome include:

  • Water intoxication also medically called dilutional hyponatremia
  • Lower urine output than usual
  • Azotemia characterized by high-level of urea, creatinine, and other waste products in blood
  • Low blood pressure or hypotension
  • Peripheral edema – a condition that causes swollen legs or hands due to fluid accumulation
  • Swelling in liver and spleen
  • Swollen blood vessels appearing like spider’s web (medically called spider angioma)

Risk Factors of Hepatorenal Syndrome

People who suffer from any of the below-mentioned problems or health conditions are more likely to develop hepatorenal syndrome.

  • Viral
  • Excessive alcohol consumption
  • Toxic or ischemic hepatitis
  • Gastrointestinal bleeding

Diagnosis of Hepatorenal Syndrome

Currently, there are no definitive diagnostic tests or exams to detect hepatorenal syndrome. The doctors rely on symptoms and exclusion of any other cause of kidney failure to arrive at the diagnosis conclusion.

That said, to assess the kidney functioning, a few diagnostic tests might be recommended, such as:

  • Creatinine level
  • BUN (Blood Urea Nitrogen)
  • Electrolytes
  • CBC (Complete Blood Count)
  • Renal Ultrasound (this is done at a later stage)

Treatment of Hepatorenal Syndrome

Despite such medical advancement, there is no direct treatment available for the hepatorenal syndrome. There is no absolute cure for this syndrome but to treat the underlying condition – the damaged liver; however, it can be prevented in the first place by some strict lifestyle modifications and diet changes. Moreover, in severe cases, liver transplantation (artificial or natural) is the only definitive treatment; whereas in other cases, dialysis and shunts can provide temporary relief, while awaiting liver transplantation. Liver transplant as an HRS treatment is limited by high mortality rate and also the limited availability of organs. The mortality rate is typically very high for a patient suffering from Type 1 hepatorenal syndrome since their survival rate is too poor and hence, multiple deaths occur while awaiting the liver transplant.

That said, in some patients, the early stage impacts can be reversed with certain targeted medications such as vasopressin analogue terlipressin, gradually titrated up to a maximum dosage of 12 mg/day; this medicine is given to the patient for a maximum of 14 days and is discontinued if there has been no response from the patient.

However, the response to each type of treatment should be extensively monitored. In many cases, the hepatorenal syndrome can recur and can predispose the patient to other major health problems. This is one reason, patient with the hepatorenal syndrome are considered on priority in the waiting list for a liver transplant. Moreover, all forms of treatment of the hepatorenal syndrome only offer short-term survival but not much long-term benefit.

Prevention of Hepatorenal Syndrome

To prevent the hepatorenal syndrome, a patient should keep the liver and kidney healthy by making a few lifestyle modifications, such as:

  • Maintaining normal blood pressure
  • Maintaining a healthy weight
  • Controlling blood glucose levels
  • Quitting smoking
  • Avoiding or limiting alcohol intake
  • Regularly exercising
  • Eating a nutritional and healthy diet

Overall, it is important to understand that hepatorenal syndrome is a critical and life-threatening condition which arises in patients suffering from liver cirrhosis. This condition has a very poor prognosis and no definitive treatment apart from a liver transplant which has a high mortality rate and shortage of organs. Though with medical advancements, there have been more improvements in this area which has significantly increased patient survival rate.

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