Hepatorenal Syndrome in Focus: Emerging Diagnostic Criteria and Current Therapeutic Approaches

Hepatorenal syndrome (HRS) is a phenotype of kidney injury specific to patients with liver cirrhosis and ascites, characterized by impaired kidney function due to reduced blood flow and reduced glomerular filtration rate. HRS can occur quickly with acute kidney injury (HRS-AKI). In those not meeting HRS-AKI criteria, this can develop as HRS-acute kidney disease (HRS-AKD) or HRS-chronic kidney disease (HRS-CKD). This pathophysiology occurs along a continuum, dependent on timing of the disease course, and the presence of functional and structural abnormalities. Traditionally, pharmacologic treatment for HRS has relied on midodrine, octreotide, and albumin. Norepinephrine and albumin use have been limited by the need for continuous monitoring and intensive care unit (ICU). The development and expanded availability of the synthetic vasopressin analog terlipressin offers promise for effective therapy to reverse HRS and decrease the need for renal replacement therapy (RRT). While norepinephrine and terlipressin have similar efficacy, terlipressin has more supportive data, is not restricted to the ICU, and is considered the preferred therapy in combination with albumin. The objective of this literature review is to summarize and critically appraise published models of current medical therapies used to treat HRS, along with their history and mechanisms of action, and to provide a review of HRS, including emerging concepts in diagnosis and treatment.