title: Pathophysiology, diagnosis and clinical management of hepatorenal syndrome: from classic to new drugs.
abstract: Advanced cirrhosis is frequently associated with renal dysfunction. Hepatorenal syndrome (HRS) is characterized by the occurrence of kidney injury in cirrhotic patients in the absence of other identifiable causes. HRS is classified in 2 different types. Type 1 is characterized by acute renal failure and rapid functional deterioration of other organs, usually related to a precipitating event. Type 2 is characterized by slowly progressive renal failure and refractory ascites. Advanced liver disease induces the progression of hemodynamic alterations such as arterial vasodilation of splanchnic circulation and impairment of cardiac function. The resulting ineffective circulating blood volume promotes the activation of both the renin-angiotensin-aldosterone and sympathetic nervous system, by an increase of antidiuretic hormone activity, in an attempt to restore volemia. Despite fluid retention, ascites and dilutional hyponatremia, renal function is often initially preserved by renal production of vasodilators. However, further insults can lead to an imbalance between systemic vasoconstriction and local renal vasodilation, resulting in progressive renal failure. Over the last decade, clinical strategies to prevent HRS have been improved by a better understanding of the natural history of renal failure in cirrhosis, resulting in a reduction of HRS prevalence in cirrhotic patients. Vasoconstrictor drugs may improve renal function, but the effect on mortality has not yet been established. Vaptans, nonpeptide vasopressin receptor antagonists, may also reduce hyponatraemia and ascites, even if the clinical effects in HRS remain unknown. This review updates the pathophysiology, diagnosis and management of HRS.
authors.forename: Biagio
authors.initials: B
authors.lastname: Barbano
authors.forename: Liborio
authors.initials: L
authors.lastname: Sardo
authors.forename: Antonietta
authors.initials: A
authors.lastname: Gigante
authors.forename: Maria Ludovica
authors.initials: ML
authors.lastname: Gasperini
authors.forename: Marta
authors.initials: M
authors.lastname: Liberatori
authors.forename: Gianluca Di Lazzaro
authors.initials: GD
authors.lastname: Giraldi
authors.forename: Antonio
authors.initials: A
authors.lastname: Lacanna
authors.forename: Antonio
authors.initials: A
authors.lastname: Amoroso
authors.affiliation: Department of Nephrology, "Sapienza", University of Rome, Viale dell'Universita, 37, 00185, Rome, Italy. biagionet@hotmail.com.
authors.forename: Rosario
authors.initials: R
authors.lastname: Cianci
mesh_terms: D065092:Antidiuretic Hormone Receptor Antagonists; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D006530:Hepatorenal Syndrome / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications / Q000503:physiopathology; D016031:Liver Transplantation; D019152:Paracentesis; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D012079:Renal Circulation / Q000187:drug effects / Q000502:physiology; D017582:Renal Replacement Therapy; D013152:Splanchnic Circulation / Q000187:drug effects / Q000502:physiology; D013564:Sympathetic Nervous System / Q000187:drug effects / Q000503:physiopathology; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D014664:Vasodilation / Q000187:drug effects
chemical_list: D065092:Antidiuretic Hormone Receptor Antagonists; D004232:Diuretics; D014662:Vasoconstrictor Agents; D003404:Creatinine