Diagnosis and treatment of hepatorenal syndrome

Hepatorenal syndrome (HRS) is a common complication of advanced cirrhosis c haracterized not only by renal failure due to a marked vasoconstriction of the renal circulation but also by marked alterations in systemic haemodynam ics and activity of endogenous vasoactive systems. The pathogenesis of HRS is not completely known but it is probably the result of an extreme underfi lling of the arterial circulation secondary to an arterial vasodilation loc ated in the splanchnic circulation. Besides the renal circulation all other extrasplanchnic vascular beds appears to be vasoconstricted. The diagnosis of HRS is currently based on the exclusion of non-functional causes of ren al failure. Prognosis of patients with HRS is very poor. Liver transplantat ion is the best option in selected patients, but is seldom applicable due t o the short survival expectancy of most patients with HRS, particularly tho se with the progressive type (type I MRS). Therapies introduced during the last few years, such as transjugular intrahepatic portosystemic shunts or, particularly, vasoconstrictor drugs with preferential effect on the splanch nic circulation (VI receptor agonists) are very effective in improving rena l function and reverting HRS. However, the impact of the improvement of ren al function on the natural course of HRS is unknown. Finally, the developme nt of HRS after spontaneous bacterial peritonitis can be effectively preven ted by the administration of albumin together with antibiotic therapy.