Available online 1 October 2025, 101077

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Hepatorenal syndrome (HRS) is a severe complication of advanced liver disease, characterized by renal dysfunction in the absence of intrinsic kidney disease. It is associated with high mortality, necessitating early recognition and prompt treatment. In this review, we summarize the latest in pathophysiology, diagnosis, classification and treatment of hepatorenal syndrome relevant to a consulting interventional radiologist. The diagnosis and classification of HRS has recently been updated by the International Club of Ascites (ICA) and Kidney Disease Improving Global Outcomes (KDIGO) to include more subcategories that better reflect disease severity and prognosis. Greater insights have also been obtained into the pathophysiology of HRS, currently understood to be a complex manifestation of hemodynamic disturbances due to portal hypertension, systemic inflammation, oxidative stress, and biliary injury. We discuss the role of laboratory biomarkers in diagnosis and prognosis along with associated pitfalls. Treatment options are reviewed starting with first line medical management, adjunctive renal replacement therapy, and liver transplantation. Finally, we review the evidence to date investigating transjugular intrahepatic portosystemic shunt (TIPS) creation in this population, focusing on expected efficacy for specific subpopulations and current gaps in knowledge, all driving practical recommendations for when the procedure should be considered.

Section snippetsINTRODUCTION

Hepatorenal syndrome (HRS) is a multi-system disorder, marked by significant renal dysfunction in individuals with acute or chronic liver disease without evidence of intrinsic kidney disease. [1,2] HRS is associated with high mortality, which can be mitigated with prompt recognition and treatment. [2] However, diagnosing HRS is challenging as it requires the exclusion of numerous other more common entities. [3] Over the past few years, our understanding of the associated pathophysiology has

DEFINITION AND CLASSIFICATION

Historically, the International Club of Ascites (ICA) classified HRS into two forms: acute (type 1) and chronic (type 2). Type 1 HRS was characterized by a rapid decline in kidney function, typically related to an identifiable precipitating event. Type 2 HRS progresses more gradually and was primarily associated with refractory ascites. [5] In recent years, the Kidney Disease Improving Global Outcomes (KDIGO) group reclassified HRS into three forms: Acute Kidney Injury (HRS-AKI), Acute Kidney

DIAGNOSIS

Despite a clear definition and classification, HRS remains a diagnostic challenge. First, the differential diagnosis of renal dysfunction in cirrhotic patients is similar to that in the broader population. In addition to HRS, other forms of AKI in this population include volume-responsive pre-renal AKI caused by infection, hypovolemia, or vasodilators; obstructive post-renal AKI; and intra-renal AKI, which may result from toxin- or ischemia-induced acute tubular necrosis (ATN) or

PATHOPHYSIOLOGY

Liver cirrhosis leads to portal hypertension which causes splanchnic vasodilatation, decreased effective central blood volume and multiple downstream effects, summarized in Figure 1. Splanchnic vasodilation causes a redistribution of blood flow from the peripheral circulation, reducing effective arterial blood volume and subsequently arterial perfusion to multiple other organs. This in turn activates the sympathetic nervous system and renin-angiotensin-aldosterone system (RAAS) to maintain

Medical Management

Medical management in HRS has been consistently shown to improve short-term outcomes. The initial management of acute kidney injury should focus on hemodynamic and volume status. [28]. The choice of fluid for repletion depends on the underlying condition of the patient. For instance, blood products are administered in cases of active gastrointestinal bleeding, crystalloids are used for volume depletion, and 20–25% albumin is recommended for patients with spontaneous bacterial peritonitis (SBP)

CONCLUSION

Hepatorenal syndrome (HRS) is a complex and evolving clinical entity that presents significant challenges and high mortality rates in patients with advanced liver disease. Over the decades, there have been substantial improvements in our understanding of the pathophysiology and epidemiology of acute kidney injury (AKI) in cirrhosis. Accordingly, the 2023 ICA consensus guidelines redefined HRS classifications, into HRS-AKI, HRS-AKD, and HRS-CKD. This change acknowledges the contributions of

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