Hepatorenal Syndrome: Causes, Symptoms, Treatment and Cost

Hepatorenal Syndrome (HRS) is a rare syndrome characterized by renal failure in individuals with liver cirrhosis.

• Type 1 Hepatorenal Syndrome (HRS-1): This is a rapidly progressive form of renal failure, which occurs in patients with advanced liver cirrhosis and generally occurs within two weeks of the onset of symptoms.
• Type 2 Hepatorenal Syndrome (HRS-2): This is a less severe form of HRS, which develops more slowly over several months. It is usually not associated with advanced liver cirrhosis and may be reversible with treatment.
• Acute-on-Chronic Liver Failure Associated Hepatorenal Syndrome (ACLF-HRS): This type of HRS can occur in patients with acute exacerbations of chronic liver disease, such as hepatitis B or C infection. It is characterized by fast development to end-stage renal failure and has a high mortality rate.
• Drug Induced Hepatorenal Syndrome (DIHRS): This type of HRS is caused by certain medications or toxins that can lead to acute kidney injury in patients with underlying liver disease.

• Hepatorenal syndrome (HRS) is a rare condition caused by severe liver damage.
• It takes place when the kidneys cease functioning and are unable to remove toxins from the blood.
• The most common cause of HRS is cirrhosis, a chronic disease caused by scarring of the liver due to long-term alcohol abuse or hepatitis infection.
• Other causes of HRS include sepsis, heart failure, and acute liver failure due to drug overdose or viral hepatitis.
• There is no recognised reason for the development of HRS in certain situations.

• Abdominal pain and swelling.
• Angular stomatitis (cracking of the corners of the mouth).
• Weakness
• Diarrhea or constipation
• Dark urine
• Generalized malaise
• Weight loss
• Nausea and vomiting
• Jaundice.

• Exercise regularly, eat healthy, avoid smoking and drinking alcohol.
• Take proper medication for liver and kidney related diseases.
• Manage cirrhosis symptoms and complications to delay the progression of the disease.
• Have your blood tested regularly to check ammonia levels and other signs of how well your liver is working.
• Avoid taking medicines that can hurt the kidneys or make other health problems worse.

• Serum Creatinine Test: This test measures the blood's level of creatinine, which may be used to identify kidney issues and evaluate how effectively the kidneys are functioning.
• Bilirubin Test: This test measures the level of bilirubin in the blood which can help identify liver problems such as hepatitis and cirrhosis.
• Albumin Test: This test measures albumin in the urine or blood, which can indicate liver damage or kidney malfunction.
• Urine Protein Test: This test is used to measure protein in the urine, which can indicate a possible kidney disease or disorder.
• Prothrombin Time Test: This test assesses the amount of time it takes for a clotting factor to develop, which may point to possible liver damage.
• Liver Function Tests: These tests evaluate liver-produced proteins and enzymes in the blood and may be used to identify liver conditions including cirrhosis and hepatitis.

• Anemia: Reduced red blood cell count due to decreased liver production of clotting factors.
• Ascites: Fluid buildup in the abdominal cavity due to impaired ability of the kidneys to balance salt and fluid levels in the body.
• Neurological complications: Including confusion, headache, and coma due to low blood pressure, electrolyte imbalances, or toxins building up in the bloodstream.
• Cardiovascular complications: Such as hypotension (low blood pressure) or heart failure due to fluid loss from ascites or an enlarged spleen causing reduced oxygen delivery to the heart muscle.
• Electrolyte imbalances: Such as hyponatremia (low sodium levels) and hyperkalemia (high potassium levels).
• Infection risk: Impaired ability of liver to produce antibiotics such as penicillins or cephalosporins leaves patient vulnerable to infections.

• Taking the herbal mixture of Guduchi (Tinospora Cordifolia), Neem (Azadirachta indica), and Manjistha (Rubia cordifolia) with lukewarm water twice daily.
• Consuming a decoction made with Kutki (Picrorhiza kurroa) and Punarnava (Boerhavia diffusa) roots daily.
• Drinking an infusion made with the herbs Amalaki (Emblica officinalis), Bhumyamalaki (Phyllanthus niruri), and Gokshura (Tribulus terrestris).

• To maintain nutritional balance in Hepatorenal Syndrome, focus on high-protein, low-sodium, low-fat foods.
• Include small portions of lean meat and fish, whole-grain pasta and breads, healthy fats such as olive oil and nuts.
• Eat plenty of fruits and vegetables for their antioxidants and fibre content.
• In order to maintain proper nutrition, talk with your physician about adding supplements to your diet.

• Avoid processed and fatty foods like fried, sugary, and high-fat dairy products.
• Eliminate excess sodium, which aggravates kidney function, by avoiding canned soups, processed meats or snacks/sauces that contain a lot of added salt.
• Be aware of food substances containing high amounts of phosphorus like milk and milk products (chocolate milk, ice cream) as these may increase the risk of renal failure.
• Avoid foods high in potassium such as bananas and potatoes as they can interfere with medication absorption and worsen kidney damage.
• Limit alcohol consumption to reduce stress on the liver and kidneys.

• Supportive care: Patients may need supportive care to help manage symptoms and complications of hepato-renal syndrome, such as nutrition support, dialysis, and other treatments.
• Transplant: Liver transplantation may be recommended for some patients with hepato-renal syndrome. This procedure carries risks but can potentially reverse the condition in some cases.
• Plasma exchange: This procedure involves removing the patient’s blood and replacing it with a plasma substitute or donor plasma, in order to reduce urea and creatinine levels.
• Surgery: Surgical procedures such as hepatic venous thrombectomy and transjugular intrahepatic portosystemic stent can be performed to treat obstructed circulation in the liver and remove toxins from the blood.
• Dialysis: Dialysis can be used to maintain well-being when hepatorenal syndrome is accompanied by kidney failure.

• The best type of doctor to consult for this condition would be a Nephrologist, who specializes in diagnosing and treating conditions related to the kidneys.
• Gastroenterologists, who specialise in digestive illnesses, may also be visited for HRS because it is often linked with cirrhosis of the liver.
• Dietitians or nutritionists can also be consulted for advice on how to adequately nourish someone with this condition.

• Diuretics: These drugs help to reduce the amount of fluid in the body, which can help to reduce the pressure on the kidneys and liver, thus improving their function.
• Angiotensin-Converting Enzyme (ACE) Inhibitors: These medications help to widen blood vessels, which lowers blood pressure and improves kidney function.
• Angiotensin II Receptor Blockers (ARBs): These drugs work like ACE inhibitors but are less likely to cause side effects such as a dry cough. They also help to reduce blood pressure and improve kidney function.
• Vasopressin Antagonists: These drugs can help to reduce levels of vasopressin, a hormone that increases water reabsorption in the kidneys, which can lead to fluid retention and worsen liver and kidney function in people with hepatorenal syndrome.
• Laxatives: Laxatives may be prescribed for people with hepatorenal syndrome who are having difficulty passing stool due to reduced bowel motility caused by liver failure.
• Intravenous Albumin: Albumin is a protein found naturally in the blood that helps protect against fluid loss from the body’s cells into the bloodstream, reducing swelling and helping maintain healthy levels of proteins in the body. Intravenous albumin may be used to replace lost albumin in people with severe liver failure or hepatorenal syndrome.

Generally, those with milder cases of HRS can expect to recover within 6 to 8 weeks if they receive the proper treatment and care.

However, patients who display more severe symptoms of HRS may take up to 12 weeks or longer to completely recover.

No, the effects of treatment for Hepatorenal Syndrome are not lifelong.

While treatment can improve symptoms and reduce the severity of the condition, it does not cure it entirely.

In some cases, the condition can worsen over time if not managed correctly.

The following post-treatment guidelines are recommended for HRS:

• Liver transplantation: If a person’s condition does not improve with medical therapy, a liver transplant should be considered as a possible option in order to reverse HRS.
• Lifestyle modifications: Adherence to recommended lifestyle modifications can help improve the prognosis of people with HRS and slow the progression of the disease. These include abstaining from alcohol use and avoiding foods that could worsen hepatic encephalopathy.
• Regular monitoring: People with HRS should be monitored closely by their provider on an ongoing basis in order to monitor for signs of deterioration or improvement in their condition. Such monitoring may involve blood tests, urine tests, imaging studies, or other testing as appropriate for each individual case.

Generally, treatments for HRS involve medications, fluid replacement, and dialysis which may range from Rs 30,000-Rs 90,000 (~$400-$1,200).

More complex interventions such as liver transplant surgeries or liver support systems may cost significantly more with prices ranging from Rs 5-10 lakhs (~$7000-$13,500).

Common side effects include:

• Nausea
• Vomiting
• Diarrhea
• Headache
• Dizziness
• Rash
• Itching
• Abdominal pain
• Low blood pressure
• Fatigue.
• Certain drugs may result in liver or kidney damage if used for an extended period of time.

If you are experiencing any of the symptoms that are associated with Hepatorenal Syndrome, you should make an appointment with a physician as soon as possible. These symptoms, if left untreated, can lead to complications such as 'ascites, neurological complications, and cardiovascular complications,' the treatment for which can take anywhere from a few months to several years based on the severity of the ailment.