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Published on: July 3, 2013
End-stage liver disease: Management of hepatorenal syndrome
Ezequiel Mauro1, Lucrecia Garcia-Olveira1, Adrián Gadano1
1Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
Insights
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a severe cirrhosis complication. Updated definitions and biomarkers aid early diagnosis, while terlipressin offers effective treatment, improving liver transplant eligibility assessments.
Area of Science:
- Hepatology
- Nephrology
- Critical Care Medicine
Background:
- Hepatorenal syndrome (HRS) is a severe complication of cirrhosis, characterized by high morbidity and mortality.
- Recent updates define HRS type 1 as HRS-acute kidney injury (HRS-AKI), simplifying diagnosis and reducing treatment delays.
- Inflammatory responses and extrahepatic organ dysfunction are key pathophysiological mechanisms in cirrhosis-related kidney injury.
Purpose of the Study:
- To review the updated definition and diagnostic challenges of HRS-AKI.
- To discuss current and emerging biomarkers for early and differential diagnosis of kidney injury in cirrhosis.
- To evaluate the efficacy and safety of terlipressin in HRS-AKI treatment and its impact on liver transplant waiting lists.
Main Methods:
- Review of recent literature on HRS-AKI definition, pathophysiology, diagnosis, and treatment.
- Analysis of the role of biomarkers in differentiating HRS-AKI from other causes of acute kidney injury (e.g., acute tubular necrosis).
- Evaluation of terlipressin efficacy, administration routes (bolus vs. continuous infusion), and safety profile.
Main Results:
- The updated HRS-AKI definition streamlines diagnosis by removing creatinine cut-offs.
- New biomarkers are crucial for early and accurate diagnosis of kidney injury in cirrhosis.
- Terlipressin, combined with albumin, demonstrates high response rates; continuous infusion may reduce adverse events.
- MELD/MELD-Na scores, crucial for liver transplant prioritization, may decrease post-treatment, potentially lengthening wait times for responders.
Conclusions:
- Early diagnosis and treatment of HRS-AKI are critical, facilitated by updated definitions and potential new biomarkers.
- Terlipressin is a key therapeutic agent for HRS-AKI, with continuous infusion offering a potentially safer alternative.
- Initial MELD/MELD-Na scores should be used for liver transplant waiting list prioritization to ensure equitable access for responders.
Abstract:
Hepatorenal syndrome (HRS) is a serious complication of cirrhosis with high morbidity and mortality rates. Recently, the definition of HRS type 1 has been updated and is now called HRS-AKI. This new definition reduces the risk of delaying HRS treatment and eliminates the need to establish a minimum creatinine cut-off for the diagnosis of HRS-AKI. From a pathophysiological point of view, newly identified mechanisms involved in the development of HRS are related to the inflammatory response, conditioning the development of extrahepatic organ dysfunction in patients with cirrhosis. One of the main challenges for the diagnosis of HRS is the validation of new biomarkers to obtain an early and differential diagnosis of kidney injury (eg HRS vs. ATN). Treatment of HRS is based on the use of vasoconstrictive agents in combination with albumin and terlipressin is the most widely used vasoconstrictor drug, with a high response rate. The effects of a continuous infusion of terlipressin at a dose of 2-12 mg/day was similar to bolus administration, but with lower rates of adverse events. Finally, MELD/MELD-Na which includes creatinine as one of its main determinants gives AKI-HRS patients priority on the waiting list (WL) for liver transplant (LT). However, the MELD and MELD-Na scores are reduced in responding patients, resulting a longer waiting time in these patients than in non-responders. Thus, the initial MELD/MELD-Na score (pre-treatment value) should be used to prioritize patients on the WL for LT in these cases.
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