Diagnostic Criteria for Hepatorenal Syndrome

Diagnostic Criteria

The International Club of Ascites requires all of the following elements for a diagnosis of hepatorenal syndrome: cirrhosis with ascites, acute kidney injury defined by ICA-AKI criteria, no response after 2 days of diuretic withdrawal and volume expansion with albumin, absence of shock, no current or recent use of nephrotoxic drugs, and absence of signs of structural kidney damage 1, 4.
The American Association for the Study of Liver Diseases recommends staging acute kidney injury as follows: Stage 1, increase in creatinine ≥0.3 mg/dL to 2 times the baseline value; Stage 2, increase in creatinine between 2 and 3 times the baseline value; Stage 3, increase in creatinine >3 times the baseline value or creatinine >4 mg/dL with an acute increase ≥0.3 mg/dL, or initiation of renal replacement therapy 2, 3.

Type 1 hepatorenal syndrome is characterized by rapidly progressive renal deterioration, with a doubling of the initial serum creatinine to a level >2.5 mg/dL or a 50% reduction in initial creatinine clearance to <20 mL/minute in less than 2 weeks, and has a poor prognosis with a median survival of approximately 1 month without treatment 1, 2, 5.
Type 2 hepatorenal syndrome has a more stable or slowly progressive course, with less severe renal dysfunction 1, 2, 5.

The European Association for the Study of the Liver recommends terlipressin plus albumin as first-line treatment for Type 1 hepatorenal syndrome, with a starting dose of 0.5-1 mg IV every 4-6 hours, increasing gradually to a maximum of 2 mg every 4 hours if serum creatinine does not decrease by at least 25% after 3 days 2, 4.
The American Association for the Study of Liver Diseases recommends norepinephrine plus albumin as an alternative to terlipressin in patients with central venous catheter placement 2, 4.

The administration of albumin with antibiotics when treating spontaneous bacterial peritonitis may help prevent hepatorenal syndrome 2, 3.
Norfloxacin (400 mg/day) may reduce the incidence of hepatorenal syndrome in advanced cirrhosis 2.
Pentoxifylline (400 mg three times a day) may prevent hepatorenal syndrome in severe alcoholic hepatitis 2.
Avoiding nephrotoxic drugs in patients with advanced cirrhosis is also recommended 2.