Diagnosis, Prevention, and Treatment of Hepatorenal Syndrome in Cirrhosis

Introduction:

Cirrhosis of the liver is considered to be a developing ailment with the formation of a scar in the liver (hepatic) tissue for a chronic period. As this progression occurs over a long period of time, several complications can arise. One such major complication is hepatorenal syndrome. It is a condition where there is advanced liver failure accompanied by kidney dysfunction.

How Does Liver Cirrhosis Cause Hepatorenal Syndrome?

There can be various mechanisms that comprehensively play a role in the causation or incidence of hepatorenal syndrome in people with liver cirrhosis.

• Due to extensive fibrosis and scarring in cirrhosis, the vascular supply collapses, and there can be excessive resistance to the flow of blood. This leads to increased splanchnic (intestinal) arterial vasodilation, causing reduced effective arterial blood volume. The body's compensatory mechanisms will try to maintain blood pressure by activating various neurohormonal systems. One such activation system is the renin-angiotensin-aldosterone system.

• Activating this renin-angiotensin-aldosterone system will release substances like angiotensin II and aldosterone into the circulating blood. Being vasoconstrictive substances, they try to reduce the blood pressure in the arteries by constricting them. Constriction of blood vessels will, in turn, lead to constricted renal blood vessels. Thus, renal perfusion or renal blood flow becomes reduced.

• The sympathetic nervous system is also activated due to decreased effective circulating volume. This heightens norepinephrine release, thus inducing constriction in peripheral vessels, including the kidneys. As a consequence, renal blood flow is further reduced.

• The combined effects of splanchnic vasodilation, activation of renin-angiotensin-aldosterone, and sympathetic nervous system decrease effective arterial blood volume and reduce renal perfusion pressure. In cirrhosis, this compromised renal perfusion can lead to renal hypoperfusion, impairing the kidneys' ability to filter and excrete waste products.

Further, the production and removal of vasodilators like nitric oxide and prostaglandins become compromised and imbalanced. This imbalance further exacerbates the reduction of renal blood perfusion. As renal blood flow decreases, the kidneys activate mechanisms to retain sodium and water to increase intravascular volume. However, this contributes to the incidence of ascites and edema while further compromising renal function.

How to Diagnose Hepatorenal Syndrome in Cirrhosis?

• Eliciting a history of cirrhosis and relevant symptoms is necessary. Physical examination shows renal and liver dysfunction signs like ascites, edema, jaundice, spider nevi, and other skin changes. It is also important to grade the severity and level of liver cirrhosis because it can provide insight into the level of complication arising due to cirrhosis.

• Kidney function tests should be done. Serum creatinine levels will be elevated. The glomerular filtration rate will be greatly reduced.

• Urine analysis may reveal concentrated urine with a low sodium concentration, reflecting the kidneys' impaired ability to concentrate urine in response to reduced renal blood flow.

• Through other radiographic and hematological investigations, the cause of changes and defects in the urine analysis tests should be detected. This helps rule out other causes of kidney disease like urinary tract obstruction, urinary tract infection, or use of nephrotoxic medications.

• Being a condition that originates as a result or complication of liver cirrhosis, looking into the functional status of the liver through liver function tests becomes obvious. They help in knowing the severity of the progression of cirrhosis.

• Any radiographic investigations taken will not be done to diagnose hepatorenal syndrome. In turn, they will be done to assess the level and extent of damage that occurred to the liver and kidney as a result of cirrhosis.

• In some cases, a renal biopsy will be done to differentiate between hepatorenal syndrome and other causes of kidney dysfunction, like obstruction.

Thus, the diagnostic criteria are the presence of cirrhosis with signs of advanced liver disease (jaundice, ascites, edema), decreased kidney function elicited by reduced urine output and increased creatinine levels, and excluding other causes of liver and kidney dysfunction like shock, infections, or toxicity arising from the use of nephrotoxic drugs.

What Are the Treatment Options for Hepatorenal Syndrome?

• The primary motto of treating this condition is to increase renal blood flow and perfusion. Vasoconstrictors will be used for this purpose. Commonly used vasoconstrictors for this condition are Terlipressin or Medodrine.

• The next step will be focussed on improving the plasma concentration, thereby increasing the renal perfusion. Albumin infusion will be done to achieve this. This will expand the volume and help in stabilizing the blood circulation.

• The liver is the organ where the purification of toxins occurs. When the liver is damaged, this process is affected. Thus, techniques like molecular adsorbent recirculating systems (MARS) or other extracorporeal liver support systems might be employed to aid in the removal of toxins and metabolic byproducts. This transiently improves the condition of the kidney.

• As it is a disease occurring in the late stages of liver cirrhosis, it requires a complete substitution of the affected liver with a healthier one. For this, liver transplantation will be advocated.

• Any other factors that could worsen the kidney function should be checked and removed immediately.

How to Prevent Hepatorenal Syndrome in Cirrhosis?

• When any sign of fluid accumulates in the abdomen (ascites), it should be looked at and treated promptly. Aggressive treatment of ascites with dietary sodium restriction, diuretic therapy, or large-volume paracentesis with albumin infusion can help prevent hepatorenal syndrome.

• Doctors and patients should be cautious and make sure that cirrhosis patients are not administered with any kind of nephrotoxic medicines.

• Any infection in the body, especially the kidney, like spontaneous bacterial peritonitis or urinary tract infections, should be treated as early as possible.

• The correct balance of fluid intake should be maintained to prevent fluid retention or dehydration.

• Several complications arising from cirrhosis of the liver, like gastrointestinal bleeding and hepatic encephalopathy, should be addressed promptly.

• The functions of the liver and kidney should be monitored regularly through kidney and liver function tests.

• Liver transplantation should certainly be considered as an option to prevent any further adverse events occurring due to advanced liver disease, thereby preventing hepatorenal syndrome.

• Above all, balanced nutrition is a major part of preventing the deterioration of any vital organ in the body.

Conclusion:

Hepatorenal syndrome in cirrhosis represents an important complication requiring prompt diagnosis and management. Early recognition of clinical signs, diligent monitoring of renal function, and proactive measures to prevent its occurrence play pivotal roles in mitigating the impact caused by hepatorenal syndrome. While various therapeutic strategies exist, liver transplantation remains the most definitive treatment option, and opting for such an option in the earlier stages itself can prevent the incidence of hepatorenal syndrome.