What is hepatorenal syndrome and how is it managed?

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Hepatorenal syndrome is a functional decline in kidney function that occurs in people with advanced liver disease, especially cirrhosis with portal hypertension. The problem isn’t a primary kidney disease; it stems from severe circulatory dysregulation: widespread splanchnic vasodilation lowers effective arterial blood volume, prompting the kidneys to constrict to preserve perfusion, which reduces kidney function despite relatively normal kidney tissue. Management focuses on reversing this circulatory imbalance and restoring renal blood flow. The main approach is vasoconstrictor therapy combined with volume expansion using albumin to improve effective circulating volume. Regimens include terlipressin with albumin, or alternatives such as midodrine plus octreotide with albumin; norepinephrine in intensive care can also be used. If renal function improves, liver transplantation offers definitive treatment. In select patients, a TIPS procedure may help by reducing portal hypertension and improving circulation. Nephrotoxic drugs should be stopped and the patient’s overall hemodynamic status optimized; diuretics are usually held initially. Dialysis may serve as a bridge in severe cases but does not address the underlying liver-driven hemodynamics.