Recent Advances in the Treatment of Renal Dysfunction in Liver Disease (Hepatorenal Syndrome)

  • Carlos A. Vaamonde
Part of the International Yearbooks of Nephrology book series (IYNE, volume 2)


A large body of information is available concerning the effects on the kidney of a diseased liver. The most grave expression of this interrelationship is the hepatorenal syndrome (HRS) (1, 2). The HRS is a form of unexplained acute renal failure occurring in patients with parenchymal end-stage or acute liver disease of diverse etiology in the absence of clinical, laboratory, or anatomic evidence of other known causes of renal failure. The relative frequency of different types of liver disease causing HRS, depends on geographic and other unknown factors. In the U.S.A. the most common cause of HRS is alcoholic liver disease (Laennec’s cirrhosis), whereas in other countries in addition to an alcoholic etiology, postnecrotic, cryptogenic cirrhosis or fulminant acute hepatic failure are also frequently reported. The occurrence of the HRS is distinctly rare in children (3). Terms such as “renal failure of cirrhosis”, “functional renal failure”, “cirrhotic nephropathy”, and others, have been used from time to time to identify this specific renal dysfunction of liver disease. Not having any desire to add to the controversy related to terminology, I will use in this review the more appealing and common term HRS. A comprehensive review of the clinical aspects and pathogenesis of the HRS can be found elsewhere (1, 2, 4). In this review, the emphasis will be on the treatment of this serious condition.


Liver Transplantation Peritoneal Dialysis Cirrhotic Patient Orthotopic Liver Transplantation Hepatorenal Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Vaamonde CA, Papper S: The kidney in liver disease, In: “Diseases of the Kidney”, Third edition, LE Earley and CW Gottschalk (Eds), Little, Brown & Co., Boston, 1979, pp 1289–1317.Google Scholar
  2. 2.
    Papper S: Hepatorenal syndrome, In: “Acute Renal Failure”, VE Andreucci (Ed), Martinus Nijhoff Publishing, Boston, 1984, pp 233–250.Google Scholar
  3. 3.
    Wood RP, Ellis D, Starzl TE: The reversal of the hepatorenal syndrome in four pediatric patients following successful orthotopic liver transplantation. Ann Surg, 205: 415–419, 1987.PubMedCrossRefGoogle Scholar
  4. 4.
    Epstein M: The Kidney in Liver Disease. Third edition, Williams & Wilkins, Baltimore, 1988.Google Scholar
  5. 5.
    Koppel MH, Coburn JW, Mims MM, Goldstein H, Boyle JD, Rubini ME: Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functional nature of renal failure in advanced liver disease. N Eng J Med, 280: 1367–1371, 1969.CrossRefGoogle Scholar
  6. 6.
    Iwatsuki S, Popovtzer MM, Corman JL, Ishikawa MM, Putnam CW, Katz F, Starzl T: Recovery from “hepatorenal syndrome” after orthotopic liver transplantation. N Eng J Med, 280: 1155–1159, 1973.CrossRefGoogle Scholar
  7. 7.
    Solez K, Racusen LC, Jewell LD: Pathology of acute renal failure occurring in liver disease. In: “The Kidney in Liver Disease”, Third edition, M Epstein (Ed), Williams & Wilkins, Baltimore, 1988, pp 182–206.Google Scholar
  8. 8.
    Papadakis MA, Arieff AI: Unpredictability of clinical evaluation of renal function in cirrhosis. Am J Med, 82: 945–952, 1987.PubMedCrossRefGoogle Scholar
  9. 9.
    Galambos JT, Wilkinson HA III: Reversible hyponatremia and azotemia in a patient with cirrhosis and ascites. Amer J Dig Dis, 7: 642–647,1962.PubMedCrossRefGoogle Scholar
  10. 10.
    Goldstein H, Boyle JD: Spontaneous recovery from the hepato-renal syndrome. Report of four cases. N Eng J Med, 272: 895–897,1965.CrossRefGoogle Scholar
  11. 11.
    Vaamonde CA: Renal water handling in liver disease. In “The Kidney in Liver Disease”, Third edition, M Epstein (Ed), Williams & Wilkins, Baltimore, 1988, pp 31–72.Google Scholar
  12. 11a.
    Arroyo V, Ginés P, Planas R, Panés J, Rodés J: Paracentesis in the management of cirrhotics with ascites. In: “The Kidney in Liver Disease”, Third edition, M Epstein (Ed), Williams & Wilkins, Baltimore, 1988, pp 578–592.Google Scholar
  13. 12.
    Boyer TD, Zia P, Reynolds TB: Effect of indomethacin and prostaglandin A1 on renal function and plasma renin activity in alcoholic liver disease. Gastroenterology, 77: 215–222, 1979.PubMedGoogle Scholar
  14. 13.
    Carriho F, Bosch J, Arroyo V, Mas A, Viver J, Rodes J: Renal failure associated with demeclocycline in cirrhosis. Ann Intern Med, 87: 195–197, 1977.Google Scholar
  15. 14.
    Cabrera J, Arroyo V, Ballesta AM, Rimola A, Gual J, Elena M, Rodes J: Aminoglycoside nephrotoxicity in cirrhosis. Value of urinary ß-microglobulin to discriminate functional renal failure from acute tubular damage. Gastroenterology, 82: 97–105, 1982.PubMedGoogle Scholar
  16. 15.
    Lietman PS: Liver disease, aminoglycoside antibiotics and renal dysfunction. Hepatology, 8: 966–968, 1988.PubMedCrossRefGoogle Scholar
  17. 16.
    Coratelli P, Passavanti G, Munno I, Fumarola D, Amerio A: New trends in hepatorenal syndrome. Kidney Int, 17: S143–S147, 1985.Google Scholar
  18. 17.
    Zager RA, Prior RB: Gentamicin and gram-negative bacteremia. A synergism for the development of experimental nephrotoxic acute renal failure. J Clin Invest, 78: 196–204, 1986.PubMedCrossRefGoogle Scholar
  19. 18.
    Bataille C, Bercoff E, Pariente EA, Valla D, Lebrec D: Effects of propranolol on renal blood flow and renal function in patients with cirrhosis. Gastroenterology, 86: 129–133, 1984.PubMedGoogle Scholar
  20. 19.
    Cade R, Wagemaker H, Vogel S, Mars D, Hood-Lewis D, Privette M, Peterson J, Schlein E, Hawkins R, Raulerson D, Campbell K: Hepato-renal syndrome. Studies of the effect of vascular volume and intra-peritoneal pressure on renal and hepatic function. Am J Med, 82:427–438, 1987.PubMedCrossRefGoogle Scholar
  21. 20.
    Bichet DG, Groves BG, Schrier RW: Effect of head-out water immersion on hepatorenal syndrome. Am J Kidney Dis, 3: 258–263, 1984.PubMedGoogle Scholar
  22. 21.
    Wilkinson SP, Davidson AR, Henderson J, Williams R: Ascites re-infusion using the Rhodiascit apparatus — clinical experience and coagulation abnormalities. Postgrad Med J, 51: 583–587, 1975.PubMedCrossRefGoogle Scholar
  23. 22.
    Perez GO, Epstein M, Oster JR: Role of dialysis and ultrafiltration in the treatment of the renal complications of liver disease. In: “The Kidney in Liver Disease”, Third edition, M Epstein (Ed), Williams & Wilkins, Baltimore, 1988, pp 613–624.Google Scholar
  24. 23.
    Landini S, Coli U, Fracasso A, Morachiello P, Righetto F, Scanferia F, Gallenda F, Bazzato O: Spontaneous ascites filtration and reinfusion (SAFR) as ambulatory chronic treatment for hepato-renal syndrome. Trans Am Soc Artif Intern Organs, 31: 439–443, 1985.PubMedGoogle Scholar
  25. 24.
    Lai KN, Leung JWC, Vallance-Owen J: Dialytic ultrafiltration by hemofilter in treatment of patients with refractory ascites and renal insufficiency. Am J Gastroenterol, 82: 665–668, 1987.PubMedGoogle Scholar
  26. 25.
    Schroeder ET, Anderson GH Jr, Smulyan H: Effects of portacaval or peritoneovenous shunt on renin in the hepatorenal syndrome. Kidney Int, 15: 54–61, 1979.PubMedCrossRefGoogle Scholar
  27. 26.
    LeVeen HH, Christoudias G, Moon JP, Luft R, Falk G, Grossberg S: Peritoneovenous shunting for ascites. Ann Surg, 180: 580–591, 1974.PubMedCrossRefGoogle Scholar
  28. 27.
    Smith RE, Nostrant TT, Eckhauser FE, Wilson JP, Knol JA, Strodel WE: Patient selection and survival after peritoneovenous shunting for nonmalignant ascites. Am J Gastroenterol, 79: 659–662, 1984.PubMedGoogle Scholar
  29. 28.
    Linas SL, Schaefer JW, Moore EE, Good JT Jr, Giansiracusa R: Peritoneovenous shunt in the management of the hepatorenal syndrome. Kidney Int, 30: 736–740,1986.PubMedCrossRefGoogle Scholar
  30. 29.
    Stanley MM, and members of the VA Cooperative Study Group 142: Peritoneovenous shunting vs medical treatment of alcoholic cirrhotic ascites. Hepatology, 5: 980, 1985.Google Scholar
  31. 30.
    Nakamoto M, Shapiro JI, Shanley PF, Chan L, Schrier RW: In vitro and in vivo protective effect of atriopeptin III on ischemic acute renal failure. J Clin Invest, 80: 698–705, 1987.PubMedCrossRefGoogle Scholar
  32. 31.
    Edelson JT: Calcium-channel blockers and the hepatorenal syndrome. Med Hypothesis, 22: 335–340, 1987.CrossRefGoogle Scholar
  33. 32.
    Berkowitz HD, Miller LD, Rosato EF: Letter: Renin substrate depletion in hepatorenal syndrome. N Eng J Med, 290: 461, 1974.Google Scholar
  34. 33.
    Solis-Herruza JA, Duran A, Favela V, Castellano G, Madrid JL, Muñoz–Yagüe MT, Morillas JD, Estenoz J: Effects of lumbar sympathetic block on kidney function in cirrhotic patients with hepatorenal syndrome. J Hepatology, 5: 167–173, 1987.CrossRefGoogle Scholar
  35. 34.
    Wilkinson SP, Weston MJ, Parsons V, Williams R: Dialysis in the treatment of renal failure in patients with liver disease. Clin Nephrol, 8: 287–292, 1977.PubMedGoogle Scholar
  36. 35.
    Mactier RA, Dobbie JW, Khanna R: Peritoneal dialysis in fulminant hepatic failure. Perit Dial Bull, 6: 199–202, 1986.Google Scholar
  37. 36.
    Ring-Larsen H, Clausen E, Ranek L: Peritoneal dialysis in hyponatremia due to liver failure. Scand J Gastroenterol, 8: 33–40, 1973.PubMedGoogle Scholar
  38. 37.
    Quellhorst EA: Hemofiltration. In: “Textbook of Nephrology”, Second edition, SG Massry and RJ Glassock (Eds), Williams & Wilkins, Baltimore, 1989, pp 1426–1433.Google Scholar
  39. 38.
    Epstein M, Perez GO, Bedoya LA, Molina R: Continuous arterio-venous ultrafiltration in cirrhotic patients with ascites or renal failure. Int J Artif Organs, 9: 253–256, 1986.PubMedGoogle Scholar
  40. 39.
    Kaplan AA: Clinical trials with predilution and vacuum suction: enhancing the efficiency of the CAVH treatment. Trans Am Soc Artif Intern Organs, 32:49–51, 1986.Google Scholar
  41. 40.
    Davenport A, Will EJ, Losowsky MS, Swindells S: Continuous arteriovenous haemofiltration in patients with hepatic encephalopathy and renal failure. Br Med J, 295: 1028, 1987.CrossRefGoogle Scholar
  42. 41.
    Rimola A, Gavaler JS, Schade RR, El–Lankany S, Starzl TE, Van Thiel DH: Effects of renal impairment on liver transplantation. Gastroenterology, 93: 148–156, 1987.PubMedGoogle Scholar
  43. 42.
    Gonwa TA, Poplawski S, Paulsen W, Brajtbord D, Goldstein R, Husberg B, Klintmalm GB: Pathogenesis and outcome of hepatorenal syndrome in patients undergoing orthotopic liver transplant. Transplantation, 47: 395–397, 1989.PubMedCrossRefGoogle Scholar
  44. 43.
    Busuttil RW, Colonna JO II, Hiatt JR, Brems JJ, El Khoury G, Goldstein LI, Quiñones-Baldrich WJ, Abdul-Rasool IH, Ramming KI: The first 100 liver transplants at UCLA. Ann Surg, 206: 387–399, 1987.PubMedCrossRefGoogle Scholar
  45. 44.
    Krom RA, Wiesner RH, Rettke SR, Ludwig J, Southorn PA, Hermans PE, Taswell HF. The first 100 liver transplantations at the Mayo Clinic. Mayo Clin Proc, 64: 84–94, 1989.PubMedGoogle Scholar
  46. 45.
    O’Grady JG, Alexander GJM, Thick M, Potter D, Calne RY, Williams R: Outcome of orthotopic liver transplantation in the aetiological and clinical variants of acute liver failure. Q J Med, 69: 817–824, 1988.Google Scholar
  47. 46.
    Flavin DK, Niven RG, Kelsey JE: Alcoholism and orthotopic liver transplantation. JAMA, 259: 1546–1547, 1988.PubMedCrossRefGoogle Scholar
  48. 47.
    Starzl TE, Van Thiel D, Tzakis AG, Iwatsuki S, Todo S, Marsh JW, Koneru B, Staschak S, Stieber A, Gordon RD: Orthotopic liver transplantation for alcoholic cirrhosis. JAMA, 260: 2542–2544, 1988PubMedCrossRefGoogle Scholar

Copyright information

© Kluwer Academic Publishers 1990

Authors and Affiliations

  • Carlos A. Vaamonde
    • 1
  1. 1.Nephrology Section, Veterans Administration Medical Center and Department of MedicineUniversity of Miami School of MedicineMiamiUSA

Personalised recommendations