How is hepatorenal syndrome (HRS) diagnosed?

Updated: Oct 16, 2017
  • Author: Deepika Devuni, MD; Chief Editor: BS Anand, MD  more...
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The diagnosis of HRS is one of exclusion [13] and depends mainly on serum creatinine level, as no specific tests establish the diagnosis of HRS. Although serum creatinine level is a poor marker of renal function in patients with cirrhosis, no other validated and reliable noninvasive markers exist for monitoring renal function in these patients. [19]

Diagnosis of HRS is based on the presence of a reduced glomerular filtration rate (GFR) in the absence of other causes of renal failure in patients with chronic liver disease. The following criteria, as proposed by the International Ascites Club in 1996, help diagnose HRS:

Major criteria include the following (All major criteria are required to diagnose HRS.):

  • Low GFR, indicated by a serum creatinine level higher than 1.5 mg/dL or 24-hour creatinine clearance lower than 40 mL/min

  • Absence of shock, ongoing bacterial infection and fluid losses, and current treatment with nephrotoxic medications

  • No sustained improvement in renal function (decrease in serum creatinine to <1.5 mg/dL or increase in creatinine clearance to >40 mL/min) after diuretic withdrawal and expansion of plasma volume with 1.5 L of plasma expander

  • Proteinuria less than 500 mg/d and no ultrasonographic evidence of obstructive uropathy or intrinsic parenchymal disease

Additional criteria include the following (Additional criteria are not necessary for the diagnosis but provide supportive evidence.):

  • Urine volume less than 500 mL/d

  • Urine sodium level less than 10 mEq/L

  • Urine osmolality greater than plasma osmolality

  • Urine red blood cell count of less than 50 per high-power field

  • Serum sodium concentration less than 130 mEq/L

Urinary indices are not considered major criteria because a subset of patients with HRS may have high urine sodium levels and low urine osmolality (similar to acute tubular necrosis [ATN]), while other patients with cirrhosis and ATN may have low urine sodium levels and high urine osmolality.

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