Hepatorenal Syndrome (HRS)

What is hepatorenal syndrome?

Hepatorenal syndrome (HRS) is a life-threatening complication of end-stage liver disease. HRS can cause kidney failure in people who don’t have a history of kidney issues and in people with chronic kidney disease. If you have HRS, you’ll need immediate medical care. In most cases, a liver transplant is the only cure.

If this is your situation, you’re already dealing with one serious illness. Learning you have hepatorenal syndrome may feel like a tough and final medical challenge for you to overcome. But there are treatments to ease kidney failure symptoms. And there’s the hope that you’ll receive a donated liver.

In hepatorenal syndrome, liver failure causes blood vessels in your kidneys to narrow or constrict so blood can’t move through them. Your kidneys stop working because they don’t get enough blood.

What are the symptoms of hepatorenal syndrome?

People with hepatorenal syndrome tend to have vague symptoms of general unwellness, such as:

• Bad taste in the mouth
• Fatigue
• Nausea
• Stomachache

They may also have symptoms of advanced liver disease or liver failure, like:

• Confusion, disorientation or drowsiness (hepatic encephalopathy)
• Easy bruising and bleeding
• Itchy skin
• Jaundice (yellowing of the whites of the eyes)
• Light-colored poop and dark-colored pee
• Swollen abdomen (due to ascites, enlarged liver or enlarged spleen)

When kidney failure becomes severe, you’ll notice you pee less than usual.

What causes hepatorenal syndrome?

Experts are still researching the exact cause. Researchers believe a combination of factors related to liver disease and liver failure is why the blood vessels in your kidneys become narrower.

The most common factor is portal hypertension. Portal hypertension is high blood pressure in the portal vein that runs through your liver. It causes the vein and its branches throughout your digestive system to widen.

There are other conditions that may increase your risk of developing HRS:

• Gastrointestinal bleeding
• Overusing diuretics
• Spontaneous bacterial peritonitis (SBP)

Who is most at risk for hepatorenal syndrome?

Hepatorenal syndrome typically affects people who’ve had chronic, progressive liver disease for some time and are on the threshold of liver failure. Chronic liver disease results in cirrhosis, which changes the liver’s blood supply and stops it from functioning over time. HRS can also occur with acute liver failure from a sudden cause.

Studies suggest that up to 40% of people with end-stage liver disease will develop HRS. These people represent all ages and sexes. They are more often in the second half of their lives. Up to 10% of people hospitalized with chronic or acute liver failure will develop it.

How do healthcare providers diagnose hepatorenal syndrome?

Healthcare providers diagnose hepatorenal syndrome by first confirming that you have liver disease and kidney failure. Then, they do tests to rule out other possible causes of kidney failure. They’ll order a variety of imaging tests, blood tests and urine tests to check your liver function and kidney function.

How is hepatorenal syndrome treated?

The ultimate treatment is a transplant to replace your damaged liver. But hepatorenal syndrome treatment starts with taking care of your kidneys. Treatments may include:

• IV fluids to treat electrolyte imbalances and support blood flow to your kidneys
• Discontinuing certain medications, such as diuretics
• Antibiotics to treat any related infections
• Paracentesis to remove excess fluid from ascites
• Vasoconstrictors to tighten blood vessels in other parts of your body (this increases blood flow to your kidneys)
• Hemodialysis to support your stressed kidneys

Treatment may help improve your overall health and make you more fit for a liver transplant. The treatment may improve your outcome if you do have a liver transplant.

Can hepatorenal syndrome be prevented?

Hepatorenal syndrome happens because you have end-stage liver disease. The best way to prevent HRS is to manage chronic liver disease before it can become cirrhosis. Chronic liver disease progresses slowly over many years. If you have it, you may be able to slow it down or reduce its symptoms by quitting alcohol, losing weight and making changes in what you eat.

If you already have cirrhosis, there’s no way to predict or prevent the onset of HRS. But you may be able to prevent spontaneous bacterial peritonitis (SBP), which is the most common trigger. About 25% of people with HRS have spontaneous bacterial peritonitis. A healthcare provider may prescribe antibiotics if they think you’re at particularly high risk for SBP.

What is the life expectancy for someone with hepatorenal syndrome?

That depends on whether you can have a liver transplant. Studies show 60% of people who have HRS and have a liver transplant are alive three years later. Most people’s kidneys start working again, but some may need ongoing dialysis.

Finding a donor liver is easier said than done, though. There are more people waiting for a liver transplant than there are available donor livers.

Your best chance may be finding a living liver donor. Living donors are healthy volunteers whose blood type and body size are like yours. A single piece of a liver from another living person can grow back into a full-sized liver in both you and your donor. Donated living livers are often in better condition than livers from a deceased donor.

Your life expectancy may also depend on your health. If you’re already very sick with HRS, you may not be well enough to have a liver transplant.

What happens if I can’t have a liver transplant?

Without a liver transplant, the outlook for most people is grim. The median survival rate for people with acute onset HRS and no transplant is two weeks. Acute onset means your symptoms come on very fast. With more chronic HRS, the median survival rate without a transplant is three to six months.