Hepatorenal syndrome natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]

Overview

Hepatorenal syndrome progresses from pre-ascitic stage to frank ascites. Multiorgan system failure, infections and chronic renal failure are the most common complication of HPS. Type I HPS carries poorer prognosis compared to type II HPS.

Natural History

Pre-ascites Phase

Systemic vasodilatation causes kidneys to retain sodium and water, thereby overcoming the compensatory renal vasoconstriction. This prevents the drop in glomerular filtration rate and subsequent vasoconstriction of renal arterioles.

Ascitic Phase

As the systemic vasodilatation worsens further, the kidney's are unable to compensate and renal arterioles undergo vasoconstriction. As a result, there is sodium and water retention from the renal tubules resulting in ascites. This ascites is responsive to diuretics. Further increase in renal sodium retention causes the ascites to become resistant to treatment with diuretics.

Once the ascites progresses to a point where it is unresponsive to diuretics, even repeated paracentesis does not prevent progression to hepatorenal syndrome type I or II.

Complications

• Bleeding
• Multiorgan system failure
• End-stage kidney disease
• Fluid overload with congestive heart failure or pulmonary edema
• Hepatic coma
• Secondary infections
• Death

Prognosis

• Type I HRS carries a very poor prognosis, usually of less than 50% over one month. Patients with type I hepatorenal syndrome are usually ill, may have low blood pressures, and may require therapy with inotropes, or intravenous drugs to maintain blood pressure.

• It is typically associated with ascites that is unresponsive to diuretic medications, and also carries a poor, if somewhat longer (median survival ~6 months) outlook, unless the patient undergoes liver transplantation.