Hepatorenal Syndrome - Causes, Symptoms, and Treatment

Introduction:

Hepatorenal syndrome is a hepatic (liver) and renal (kidney) system dysfunction. The kidney does not function properly due to underlying liver diseases like cirrhosis (scarring of healthy liver tissues), alcoholic hepatitis (inflammation and damage to the liver due to alcohol consumption), or acute liver failure (liver fails to function properly quickly within a few days to weeks).

What Is Hepatorenal Syndrome?

The hepatorenal syndrome does not damage the kidney structurally. It damages the functioning of the kidney. A reduced amount of urine is excreted from the body, and the waste products that contain nitrogen get accumulated in the blood leading to azotemia.

What Causes Hepatorenal Syndrome?

The exact reasons for the hepatorenal syndrome are unknown. The blood circulation is abnormal in patients with hepatorenal syndrome. The blood vessels that supply oxygenated blood from the lungs to other parts of the body widen, and vessels that supply kidneys are narrowed. Though vasoconstriction (narrowing of blood vessels) of the blood vessels that supply the kidney results in the dysfunction and the exact reasons are also not clear. Some researchers believe certain factors like the interaction between high blood pressure in the portal vein (the main blood vessel of the liver), abnormality in channelizing the blood flow by some physical factors, and activation of substances (endothelin) that cause the blood vessels to constrict, and inactivation or suppressing the factors (adenosine) that cause widening of blood vessels (vasodilator) may cause renal function impairment.

Some research also suggests cirrhotic cardiomyopathy (a heart problem in cirrhotic patients) contributes to renal impairment. Cirrhotic cardiomyopathy causes reduced cardiac outflow (heart failure) and abnormal widening of other arteries. Some triggering factors are called precipitating factors like low blood pressure, infections, spontaneous bacterial peritonitis, and gastrointestinal bleeding also play a role in kidney function failure. Spontaneous bacterial peritonitis is the infection of the peritoneum (a thin membrane that lines the abdominal cavity) and also is a result of hepatorenal syndrome.

What Are the Types of Hepatorenal Syndrome?

• Type I - Type I progresses quickly and results in renal failure.

• Type II - Type II is slower than type I and progresses gradually over weeks to months.

What Are the Symptoms of Hepatorenal Syndrome?

• Ascites (enlargement of the abdomen due to abnormal fluid accumulation).

• Abdominal pain (pain in the stomach region).

• Feeling weak and tired.

• Reduced urine output.

• Gynecomastia (enlarged chest muscles in males that resemble breasts).

• Jaundice (yellowish discoloration of the skin and eyes).

• Dark-colored urine.

• Skin lesions.

• Nausea and vomiting.

• Weight gain.

• Slow and sudden muscle movements.

• Dementia (loss of cognitive functions like remembering, thinking, and reasoning).

• Confusion.

What Are the Tests to Find Hepatorenal Syndrome?

• Physical Examination: A physical examination is performed by the physician to look for ascites, signs of jaundice, swelling in the legs, and abnormal reflexes.

• Complete Blood Cell Count: This blood test screens the components of blood like red blood cells, white blood cells, platelets, and hemoglobin. This test shows if there are any infections like spontaneous bacterial peritonitis.

• Serum Electrolyte test: This test is used to screen the electrolytes like sodium and chloride in the blood. Sodium keeps a check on the amount of the fluid, and chloride helps to control the fluid volume. Low serum electrolyte levels are suggestive of kidney problems.

• Renal Function Tests: Renal function tests are used to screen the kidney for the glomerular filtration rate (GFR). They are tested with urine samples or blood samples. This test reveals the effective functions of the kidney (removal of waste from the body). The lower GFR levels indicate kidney failure.

• Urinalysis: It is done to test urine's appearance, concentration, and composition. It is used to check for urinary tract infections, kidney disease, and diabetes.

• Ultrasound Abdomen: A high-frequency sound wave is used to capture images of structures or organs inside the body. An ultrasound scan of the abdomen helps to find the liver disease.

• Echocardiogram: Echocardiogram uses high-frequency sound waves to capture images of the heart and blood vessels surrounding it.

How Is Hepatorenal Syndrome Treated?

• Liver Transplant: A liver transplant is replacing the diseased liver with a whole healthy liver, or a part of the liver from a healthy donor.

• Dialysis: Dialysis is a method where the waste products and fluid build-up in the blood are removed when there is kidney dysfunction.

• Kidney Transplant: Kidney transplant will be considered when the patient has advanced kidney damage 6-8 weeks before liver transplant.

• Transjugular Intrahepatic Portosystemic Shunts: Transjugular intrahepatic portosystemic shunt provides an artificial passage between the portal vein (a blood vessel that carries blood from the gallbladder, pancreas, gastrointestinal tract, and the liver) and hepatic artery (a blood vessel that supplies oxygenated and nutrients to the liver, duodenum, and pancreas) and eases the blood flow.

• Antibiotic Medications: Antibiotic medications like Cephalosporin are prescribed to avoid infections.

• Vasoconstrictors: Vasoconstrictors are medications that narrow the blood vessels. Vasoconstrictors are used along with albumin (medication used in the treatments of low blood volume, which is injected through veins) in hepatorenal syndrome. Terlipressin, Noradrenalin, and a combination of Midodrine and Octreotide (vasoconstrictors) are used to treat hepatorenal syndrome. The first effect of hepatorenal syndrome is vasodilation (widening of the blood vessels) of the vessels that supply the liver, pancreas, stomach, small intestine, and large intestine. To maintain the normal environment inside the body, vasoconstrictors are administered to constrict the vasodilate vessels.

• Paracentesis: It is a surgical procedure that removes the fluid build-up in the stomach.

• Stop Diuretics: Diuretic is a medication used to lower high blood pressure. This acts by removing salts and water from the body. Diuretics will further reduce the fluids in the circulation.

What Are the Complications of Hepatorenal Syndrome?

• Secondary infections (an infection that occurs while treating another infection).

• Organ damage (when an important internal organ like the kidney or liver loses its function).

• Coma (a state of being unconscious for a long time).

What Is the Prognosis of Hepatorenal Syndrome?

• Type I hepatorenal syndrome has a poor prognosis with a survival of 2 weeks.

• Type II hepatorenal syndrome has a poor to moderate prognosis with a survival rate of about 3 to 6 months.

What Is the Recovery Status of Patients From Hepatorenal Syndrome After Liver Transplant?

• Patients who had hepatorenal syndrome before liver transplant may not completely recover their kidney function and may need to go for dialysis.

• Patients with hepatorenal syndrome with acute liver failure but no cirrhosis recover once the liver heals after transplantation.

• Patients with severe kidney damage may require liver transplantation and kidney transplant.

Is Patient Education Needed in People With Hepatorenal Syndrome?

• Yes, patients with cirrhosis developing ascites should be warned that they are at high risk of developing hepatorenal syndrome.

• They should also be informed that the patient should consult a doctor before taking any new medications.

• They should also be aware to avoid pain killer medications like NSAIDs (non-steroidal anti-inflammatory drugs) causing nephrotoxicity (causing damage to the kidney cells).

• They should visit the doctor immediately if their condition worsens.

• They should inform the doctor about their condition if the doctor is unaware of their health status or if he/she is prescribing any new medications.

Can Hepatorenal Syndrome Be Prevented?

• A healthy liver can be obtained by avoiding alcohol consumption. This prevents the risk of developing cirrhosis (scarring of liver tissues) which in turn reduces the risk of getting hepatorenal syndrome.

• Avoid contracting Hepatitis A, B, or C viral infections. Vaccinations are available for hepatitis A and B.

• Since there are no vaccinations for hepatitis C, the following precautions can be taken:

  • Wash your hands with soap and water after shaking hands.

  • Practice safe sex.

  • Avoid sharing needles; use a sterile needle.

  • Have your sexual partner test for hepatitis C.

Conclusion:

Hepatorenal syndrome is a serious condition and is fatal sometimes. The hepatorenal syndrome usually happens in patients with an underlying liver disease like cirrhosis. The condition may happen within a few weeks to months. The treatment involves liver transplant, dialysis, and medications for bacterial infections. The damage to the kidney does not involve the kidney cells but it causes functional damage. Though a liver transplant reverses kidney disease, the waiting period for a liver donor is not predictable. Most of the patients die due to complications without getting any donors. Though this is a serious condition, a regular check-up with the doctor may keep the condition at bay. If the patient has cirrhosis, regular liver function tests can help detect the disease at the earliest, and necessary steps can be planned to extend the lifespan of the patient.