Abstract

Hepatorenal syndrome (HRS) is a form of kidney dysfunction that characteristically occurs in liver cirrhosis. It is characterized by a marked impairment of kidney function in response to circulatory and hemodynamic alterations that occur in advanced stages of liver cirrhosis, aggravated by systemic inflammation and bacterial translocation. The classical definitions of the types of HRS have been recently revisited and two forms of HRS have been re-defined: the acute form, referred to as acute kidney injury, HRS-AKI, and the chronic form, referred to as chronic kidney disease, HRS-CKD. HRS-AKI is one of the most severe forms of AKI in patients with cirrhosis and it consists of an abrupt impairment of kidney function, frequently triggered by an infection, appearing in the setting of advanced decompensated cirrhosis. Differential diagnosis with other causes of AKI is crucial, as HRS-AKI requires a specific treatment. Differential diagnosis with AKI-acute tubular necrosis (ATN) may be challenging and kidney biomarkers may be useful in this setting. Treatment of HRS-AKI is based on the administration of vasoconstrictor drugs in combination with volume expansion with albumin. Prognosis of HRS-AKI is poor, and the ideal definitive treatment consists of liver transplantation or simultaneous liver-kidney transplant. HRS-AKI has a big impact on patients' quality of life. Management of HRS-AKI remains challenging in specific situations such as Alcohol-associated hepatitis (AH) or Metabolic-associated steatotic liver disease (MASLD) cirrhosis. Developing preventive measures for HRS-AKI, improving its early identification, discovering new biomarkers for differential diagnosis, and improving the response to therapy are some of the unmet needs in the field of HRS-AKI.