The hepatorenal syndrome: recovery after portacaval shunt

Reversal of the morbid hepato-renal syndrome has been achieved in a cirrhotic patient with ascites following successful side-to-side portacaval shunt. The hepatorenal syndrome is defined as progressive unresponsive renal failure with previously normal kidneys in the presence of impaired hepatic function. Although the etiologic mechanism has not been defined, it is suggested the relationship of increased intrahepatic sinusoidal pressure on the thoracic duct and subsequent decreased lymph flow are interrelated to increased levels of aldosterone and manifested by (chylous) ascites. Laboratory and clinical evidence suggest that cirrhotics with ascites have remarkably high levels of aldosterone secretion via the rennin-angiotensin-adrenal cortex mechanism. This is the group that develops hepatorenal syndrome. Reduction of the intrahepatic pressure and decompression of the portal hypertension can be successfully achieved with a side-to-side shunt which should return the aldosterone-rennin-angiotensin axis to normal and subsequently reverse the hepatorenal syndrome.