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Clinical Review State of the Art Review

Hepatorenal syndrome: pathophysiology, diagnosis, and management

BMJ 2020; 370 doi: (Published 14 September 2020) Cite this as: BMJ 2020;370:m2687
  1. Douglas A Simonetto, assistant professor of medicine and consultant in gastroenterology and hepatology1,
  2. Pere Gines, professor of medicine2,
  3. Patrick S Kamath, professor of medicine and consultant in gastroenterology and hepatology1
  1. 1Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
  2. 2Liver Unit, Hospital Clinic, University of Barcelona IDIBAPS – CIBEReHD, Barcelona, Spain
  1. Correspondence to: P S Kamath Kamath.patrick{at}


Hepatorenal syndrome (HRS), the extreme manifestation of renal impairment in patients with cirrhosis, is characterized by reduction in renal blood flow and glomerular filtration rate. Hepatorenal syndrome is diagnosed when kidney function is reduced but evidence of intrinsic kidney disease, such as hematuria, proteinuria, or abnormal kidney ultrasonography, is absent. Unlike other causes of acute kidney injury (AKI), hepatorenal syndrome results from functional changes in the renal circulation and is potentially reversible with liver transplantation or vasoconstrictor drugs. Two forms of hepatorenal syndrome are recognized depending on the acuity and progression of kidney injury. The first represents an acute impairment of kidney function, HRS-AKI, whereas the second represents a more chronic kidney dysfunction, HRS-CKD (chronic kidney disease). In this review, we provide critical insight into the definition, pathophysiology, diagnosis, and management of hepatorenal syndrome.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All authors were involved in the conception, writing and revision of the manuscript.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: PG has received research funding from Mallinckrodt, USA, Grifols, SA, and Gilead, USA, and has worked on advisory boards for Intercept, Gilead, Grifols, Mallinckrodt, and Martin Pharmaceuticals. DAS is a co-investigator of the CONFIRM trial sponsored by Mallinckrodt.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: No patients were asked for input in the creation of this article.

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