Kidney Week Educational Symposia-Hepatorenal Syndrome Type 1: Diagnosis Methods and Management

Video Transcription

Video Summary

This Simulife session reviews diagnosis and management of hepatorenal syndrome (HRS) type 1 (now often termed HRS-AKI) in patients with cirrhosis and acute kidney injury (AKI). AKI in cirrhosis is increasingly common, and HRS remains a diagnosis of exclusion with major prognostic and treatment implications. Diagnostic criteria (ICA 2015) align AKI with KDIGO thresholds and remove creatinine cutoffs for HRS, emphasizing lack of response to diuretic withdrawal plus albumin and absence of shock, nephrotoxins, and overt structural kidney disease. Speakers highlight that distinguishing HRS from acute tubular necrosis (ATN) is difficult because triggers and clinical features overlap and conditions exist on a spectrum. A more practical approach is identifying “perfusion-responsive” vs “non–perfusion-responsive” AKI.<br /><br />Emerging diagnostic tools include point-of-care ultrasound to reassess true volume status (some presumed HRS improves with additional albumin, paracentesis for abdominal hypertension, or even diuresis), cardiac stress testing to evaluate limited cardiac reserve, and urine tests to assess tubular injury and function. Urinary NGAL helps separate ATN from HRS, while very low FENa/FEurea supports preserved tubular integrity.<br /><br />Therapy centers on treating liver insults, infection control, albumin, and vasoconstrictors. Terlipressin is most effective in trials but not FDA-approved due to safety concerns (notably respiratory failure). Norepinephrine is effective but ICU-based; midodrine/octreotide is widely used but likely less effective. Liver transplant is the only definitive cure; dialysis decisions depend heavily on transplant candidacy, with palliative care often appropriate when transplant is not possible.

Asset Subtitle

Chirag Parikh, Justin Belcher, Andrew Allegretti
Support is provided by an educational grant from Mallinckrodt LLC.

Keywords

hepatorenal syndrome

HRS-AKI

cirrhosis

acute kidney injury

ICA 2015 diagnostic criteria

acute tubular necrosis

urinary NGAL

albumin and vasoconstrictor therapy

liver transplantation