[Hepatorenal syndrome]

Hepatorenal syndrome (HRS) is a particular form of functional renal failure which may develop in patients with liver cirrhosis. Recent advances in the understanding of the biology of vasoactive mediators and the physiology of microcirculation have allowed to better anticipate its pathophysiological mechanisms.

To review new advances in the knowledge of epidemiology, diagnosis criteria, pathophysiological mechanisms and treatment of HRS.

Review of literature using medical data bases (Medline) with the following key words: hepatorenal syndrome, pathophysiology, medical treatment, MARS, liver transplantation.

During the course of cirrhosis, portal hypertension leads to splanchnic and systemic vasodilation, responsible for a reduction of effective arteriel blood volume. As a result, a state of intense renal vasoconstriction develops, leading to renal failure in the absence of any organic renal disease. At this stage, liver transplantation is the only definitive therapy able to reverse renal dysfunction. Pharmacologic and radiologic therapy is aimed at improving renal function to enable patients to survive until transplantation is possible. These therapies are based on vasoconstrictor drugs associated with intravenous albumin infusion and transjugular intrahepatic portosystemic shunt (TIPS). They improve circulatory function, normalize serum creatinine and may improve survival.

Simple measures have been shown to reduce the risk of HRS in cirrhotic patients including the plasma volume expansion with albumin in patients with spontaneous bacterial peritonitis and optimal fluid management in patients undergoing large volume paracentesis.