Snapshot A 55-year-old man is admitted to the hospital due to fatigue, malaise, and weakness in the setting of poorly controlled cirrhosis. His symptoms began approximately one week prior to presentation, where he began to increase his alcohol intake after receiving news of the passing of his brother. Medical history is significant for cirrhosis due to chronic alcohol use disorder and hepatitis C infection. On hospital day 7, he was found to have a creatinine of 3.7 mg/dL (his creatinine was 1.2 mg/dL upon admission) and has significantly decreased urine output. He was not started on any nephrotoxic medications and post-renal obstruction has been ruled out. On physical exam, he is confused, has ascites, palmar erythema, jaundice, and gynecomastia. He is admitted into the intensive care unit to receive intravenous epinephrine and albumin. Introduction Clinical definition kidney failure in the setting of liver disease 2 types of hepatorenal syndrome (HPS) login to view 4 more bullets Associated conditions portal hypertension secondary to cirrhosis severe alcoholic hepatitis fulminant hepatic failure Epidemiology Risk factors acute or chronic liver disease low mean arterial blood pressure dilutional hyponatremia urinary sodium retention (severe) Etiology Can occur spontaneously Can be precipitated by spontaneous bacterial peritonitis (SBP) Pathogenesis portal hypertension triggers splanchnic arterial vasodilatation this in turn decreases systemic vascular resistance which decreases renal perfusion login to view 1 more bullet Presentation Symptoms fatigue malaise dysgeusia Physical exam stigmata of chronic liver disease such as palmar erythema spider nevi scleral icterus gynecomastia hepatosplenomegaly ascites caput medusae atrophic testes oliguria may be seen Studies Labs - abnormalities secondary to pre-renal pathology progressive rise in serum creatinine type 1 hepatorenal syndrome login to view 1 more bullet type 2 hepatorenal syndrome login to view 1 more bullet low sodium excretion rate Differential Glomerulonephritis Vasculitis Diabetic nephropathy Drug-induced nephrotoxicity e.g., from aminoglycosides, diuretics, and contrast agents DIAGNOSIS Making the diagnosis a diagnosis of exclusion Treatment Medical norepinephrine with albumin indication login to view 1 more bullet terlipressin with albumin or midodrine with octreotide and albumin indication login to view 2 more bullets Operative dialysis indication login to view 1 more bullet liver transplantation indication login to view 1 more bullet Complications Worsening liver failure that can result in hepatic encephalopathy jaundice coagulopathy Prognosis Depends on the type of hepatorenal syndrome however, prognosis is typically poor without treatment