Current Approaches to the Treatment of Hepatorenal Syndrome

This is the authors' abstract. We don't add key points for this paper.

Hepatorenal syndrome (HRS) is a life-threatening complication of advanced cirrhosis that requires early recognition, treatment of precipitating factors, and coordinated transplant assessment. This narrative review examines pharmacological treatment, fluid management, kidney replacement therapy (KRT), transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation in adults, with emphasis on HRS with acute kidney injury (AKI). Contemporary diagnostic criteria recognize that hepatorenal physiology can coexist with tubular injury or chronic kidney disease (CKD) and discourage a routine 48-hour albumin challenge. Clinical assessment should integrate perfusion, oxygenation, and congestion, with ultrasound used as an adjunct when available. Terlipressin with individualized albumin improves renal reversal in suitable patients, but a consistent overall survival benefit has not been established, and respiratory failure remains a major safety concern. Norepinephrine is an important alternative where appropriate monitoring is available; midodrine with octreotide has a limited fallback role. Albumin dosing should reflect serial volume assessment rather than a serum albumin target. Kidney replacement therapy supports patients with metabolic or volume complications, while evidence for routine shunt placement in acute HRS remains insufficient. Liver transplantation addresses the underlying disease, although kidney recovery is variable. Biomarkers may assist clinical phenotyping, but their use to guide treatment requires prospective validation. The review emphasizes timely diagnosis, individualized treatment, and distinguishing renal recovery from survival.