Hepatorenal Syndrome: Causes, Symptoms, and Treatment
Medically reviewed by Achuta Uppu, MD, Internal Medicine. Last reviewed: October 23, 2026.
What kind of doctor treats Hepatorenal Syndrome?
A hepatologist (a liver doctor) and a nephrologist (a kidney doctor) usually care for hepatorenal syndrome. It is most often found in the hospital, while a person is being treated for a liver problem. A direct primary care or concierge doctor can be a first stop for an evaluation and can refer you to a specialist when needed.
What is hepatorenal syndrome?
Hepatorenal syndrome (HRS) is a condition in which kidney failure gets worse over time in a person with cirrhosis of the liver. Cirrhosis is scarring of the liver. HRS is a serious complication that can lead to death.
Doctors divide HRS into two types. One is a sudden injury to the kidneys, called HRS-AKI. The other is a slower, longer-lasting kidney problem, called HRS-CKD. HRS-AKI is the more severe type, and it gets worse quickly.
Symptoms
Symptoms include:
- Abdominal swelling from fluid, called ascites.
- Mental confusion.
- Muscle jerks.
- Dark-colored urine.
- Decreased urine output.
- Nausea and vomiting.
- Weight gain.
- Yellow skin, called jaundice.
Confusion that comes on suddenly is an emergency. See the section on when to see a doctor.
Causes and who gets it
HRS happens when the kidneys stop working well in people with serious liver problems. The body makes less urine.
It can lead to kidney failure in people with acute liver failure, cirrhosis, or peritonitis. Peritonitis is an infection of the fluid in the belly. HRS occurs in up to 1 in 10 people who are in the hospital with liver failure.
Portal hypertension is the main underlying cause. This is high blood pressure in the vein that carries blood into the liver.
Risk factors include:
- Blood pressure that drops when a person stands up or changes position suddenly.
- Use of diuretics, also called water pills.
- Bleeding in the digestive tract, infection, or recent removal of fluid from the belly.
How doctors diagnose it
Doctors diagnose HRS after tests to check for other causes of kidney failure. It is called a diagnosis of exclusion. This means other causes must be ruled out first. Doctors look for causes that can be reversed. Examples are low body fluid, medicines that harm the kidneys, or a blockage in the urinary tract.
Blood tests may show signs of kidney failure. These include higher BUN and creatinine levels and low blood sodium. They may also show signs of liver failure, such as low albumin, a blood protein.
Treatment
The goal is to help the liver work better. Doctors also make sure the heart pumps enough blood. Treatment is about the same as for kidney failure from any cause. It is usually given in the hospital and may include:
- Stopping all unnecessary medicines, especially ibuprofen and other NSAIDs, certain antibiotics, and diuretics. Never stop a medicine on your own. Follow your doctor's instructions.
- Medicines that raise blood pressure and help the kidneys work, such as norepinephrine. This usually needs an intensive care unit.
- Albumin, a blood protein, given through a vein.
- Terlipressin, which works best when given with albumin. Common side effects include diarrhea and belly pain. Others are circulatory overload, which is too much fluid in the blood vessels, and heart or blood vessel problems from poor blood flow. It can also cause serious or even deadly breathing failure, so the care team checks your oxygen level.
- Dialysis, which cleans the blood with a machine, to improve symptoms.
- A shunt called TIPS, placed to relieve ascites. It may also help kidney function, but the procedure can be risky.
A liver transplant is the best treatment for HRS-AKI, the sudden type. It treats the underlying causes, which are mostly portal hypertension and poor liver function. Doctors advise a referral for a transplant evaluation as soon as possible.
When to see a doctor
HRS is a serious complication that can lead to death. People with cirrhosis or liver failure should tell their care team about less urine, swelling, weight gain, confusion, or yellow skin.
Call 911 or go to the emergency room if you vomit blood, have bleeding that will not stop, have trouble breathing, or faint. Also call if your mental state suddenly changes, such as unusual behavior or trouble waking up.
How a direct primary care or concierge doctor fits in
A direct primary care doctor charges a flat monthly fee instead of billing insurance, while a concierge doctor usually charges more and often works alongside insurance. Such a doctor can help with the liver disease that often comes first. They can review medicines, such as NSAIDs, with you and coordinate care with liver and kidney specialists.
Common questions
Is hepatorenal syndrome serious?
Yes. HRS is a serious complication that can lead to death. The outcome is often poor, and death often occurs because of infection or severe bleeding.
What are the two types of hepatorenal syndrome?
There are two types of HRS. HRS-AKI is a sudden injury to the kidneys and is the more severe type. HRS-CKD is a slower, longer-lasting kidney problem.
Is a liver transplant the treatment for hepatorenal syndrome?
Yes, for the sudden type, HRS-AKI. A liver transplant is the best treatment because it cures the underlying causes, mostly portal hypertension and liver dysfunction.
Which medicines do doctors stop in hepatorenal syndrome?
Doctors stop all unnecessary medicines, especially ibuprofen and other NSAIDs, certain antibiotics, and diuretics. Never stop a medicine on your own. Follow your doctor's instructions.
Sources
- MedlinePlus - Hepatorenal syndrome
- National Library of Medicine (PubMed Central) - Hepatorenal Syndrome: Novel Insights into Diagnostics and Treatment
- U.S. Food and Drug Administration - FDA approves treatment to improve kidney function in adults with hepatorenal syndrome
Medical Disclaimer
This content is for general educational and informational purposes only and is not medical advice. It is not a substitute for professional medical advice, diagnosis, or treatment, and reading it does not create a doctor-patient relationship. Always seek the advice of your physician or another qualified health provider with any questions about a medical condition, and never disregard or delay seeking professional advice because of something you read here. If you think you may have a medical emergency, call 911 (or your local emergency number) immediately.
