Hepatorenal syndrome is when the kidneys stop working properly due to liver failure. It is a life threatening condition. In most cases, a person will not survive without a liver transplant.

There are two types of hepatorenal syndromes. The outlook is better with type 2 hepatorenal syndrome because it allows more time for a liver transplant. However, type 1 can cause the kidneys to deteriorate rapidly and has a poor outlook.

People who have liver disease experience problems with blood circulation. This may damage the kidneys over time.

However, researchers do not understand the exact mechanism through which liver disease damages the kidneys, nor why some people with liver failure develop hepatorenal syndrome and others do not.

Read on to learn more about hepatorenal syndrome, including what causes it and how doctors treat this condition.

Share on Pinterest
dtimiraos/Getty Images

Hepatorenal syndrome is kidney damage due to severe liver disease. A person does not typically have symptoms of primary kidney disease, such as protein or blood in the urine, and scans of the kidneys may appear normal.

Instead, a person rapidly experiences kidney disease symptoms and may even experience kidney failure. Kidney failure is a life threatening medical emergency.

People with hepatorenal syndrome typically also have portal hypertension, which is high blood pressure in the vein that carries blood to the liver.

People without liver disease may develop other forms of kidney disease. And not every case of kidney disease in people with liver disease is hepatorenal syndrome.

Doctors divide hepatorenal syndrome into two main types:

Type 1

This is the most serious type and the most immediately life threatening. Without treatment, people with type one hepatorenal syndrome typically survive less than 2 weeks.

People with this form develop rapidly deteriorating kidney function and quickly progress to kidney failure. They may experience symptoms such as:

  • fluid buildup and swelling
  • low urine output
  • creatinine and other nitrogen-rich waste products in the blood
  • hepatic encephalopathy

Hepatic encephalopathy can lead to confusion, drowsiness, and other psychological changes.

Type 2

This type can also be life threatening. However, it progresses more slowly — usually over several months. People may present with swelling in the abdomen from fluid retention, or ascites.

It usually takes 6 to 12 months for them to develop kidney failure.

Without treatment, type 2 can also be fatal.

Cirrhosis is a chronic liver condition that affects people with viral hepatitis or alcohol use disorder.

Decompensated liver disease occurs when there is a dramatic deterioration in liver function in a person with conditions such as cirrhosis. In this case, a person may begin to experience symptoms.

A 2022 StatPearls article estimates that 4% of people with decompensated liver disease develop hepatorenal syndrome. The cumulative probability of having hepatorenal syndrome during decompensated liver disease is 18% after 1 year and 39% after 5 years.

A third of patients with bacterial peritonitis — an infection that affects the stomach’s lining — may develop hepatorenal syndrome. This condition is thought to be a trigger for hepatorenal syndrome.

People with hepatorenal syndrome may experience symptoms of their liver disease worsening. Symptoms can include:

They may also develop symptoms such as:

Narrowing of blood vessels that supply the kidney can lead to decreased blood flow to the organ, impairing its function.

Although the exact cause of the condition is unknown, hepatorenal syndrome occurs in people with chronic and severe decompensated liver disease. This means that anyone with liver disease is at risk. However, people with severe unmanaged liver disease face a higher risk.

In developing countries, viral hepatitis is the most common cause.

Some other causes of this condition include:

  • chronic alcohol use disorder, often leading to cirrhosis
  • drug-induced liver injuries
  • nonalcoholic fatty liver disease
  • portal vein thrombosis, a blood clot in the vein that leads to the liver

Doctors will perform a physical examination and order some laboratory tests to help them diagnose hepatorenal syndrome. They will look for signs of liver disease specifically.

Also, the following tests may be beneficial:

  • Creatinine testing: Creatinine is usually high in people with hepatorenal disease.
  • Tests to identify liver disease with portal hypertension: These tests will determine if there is high blood pressure in the portal vein that leads to the liver.
  • Tests to rule out other kidney diseases: This might include assessing kidney function using tests, such as blood tests and ultrasounds.
  • Tests to rule out other diseases: This may include urinary diseases.

The only treatment that will cure hepatorenal syndrome is a liver transplant. This greatly increases the chances of long-term survival and can significantly reduce or even eliminate symptoms.

However, not all people are good candidates for liver transplants, and the transplant waiting list is long. Some people may never receive a transplant.

If a person is not a candidate for a transplant, or if they are waiting for a transplant, a doctor may try a number of treatments to improve symptoms and prolong their life:

  • stopping any drugs that may damage the kidneys
  • paracentesis, a surgery to remove excess abdominal fluid
  • placing a transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal hypertension and stress on the kidneys
  • molecular adsorbent recirculating system, a type of experimental dialysis
  • the drug terlipressin, which the Food and Drug Administration approved in 2022, to improve kidney function in people with hepatorenal syndrome

In some cases, kidney failure will require a person to have a kidney transplant along with a liver transplant.

Hepatorenal syndrome is a very serious diagnosis that can be fatal.

The only cure is a liver transplant, which is a risky procedure for which not all people will be eligible. People who have a liver transplant after hepatorenal failure may still have kidney disease. Hepatorenal syndrome also predicts a lower liver transplant success rate.

The type of hepatorenal syndrome a person has can also affect their outlook. With type 1, the outlook is typically poor. Even with treatment, without a liver transplant, 2-year survival is less than 50%.

Doctors do not have a good understanding of why some people with liver disease develop hepatorenal syndrome while others do not.

Preventing liver disease is, therefore, the most important strategy to reduce the risk of hepatorenal syndrome.

The following strategies may prevent liver disease and reduce the risk of liver disease worsening:

  • reduce alcohol intake, or stop drinking completely
  • maintain a moderate body weight
  • manage chronic medical conditions such as diabetes
  • avoid nonsteroidal anti-inflammatory drugs if a person has liver cirrhosis (talk with a doctor before using any other medication)
  • eat a balanced diet and minimize trans fats

People with liver disease can talk with a doctor about their diagnosis and ask about additional strategies for managing their condition.

Hepatorenal syndrome is a life threatening medical condition that occurs in people who have serious liver disease. It usually requires a hospital stay and rapid intervention to save the person’s life.

Though some treatments may prolong a person’s life, the only treatment that will cure hepatorenal syndrome is a liver transplant.

People with liver disease should talk with their doctor about options for improving liver function to reduce the risk of hepatorenal syndrome.

Managing liver disease risk factors, such as reducing alcohol intake, can minimize a person’s lifetime risk of both liver disease and hepatorenal syndrome.