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Presents as a patient with ascites with increased creatinine. This is an increase in serum creatinine in a patient with ascites. Because patients with cirrhosis have little muscle mass, a small increase in creatinemia is already significant, namely an increase in creatinine in 24 hours greater than or equal to 0.3 mg/dl or an increase greater than or equal to 50% of the basal value. This is a functional renal impairment due to the reduction in the effective arterial blood volume with reflex vasoconstriction in the cortex of the kidney. The fact that the hepatorenal syndrome disappears after liver transplantation is evidence of this.

Other causes of acute renal impairment must always be excluded, such as volume depletion due to diuretics, sepsis and renal insufficiency due to the use of nephrotoxic drugs. An important precipitating factor is spontaneous bacterial peritonitis.

Progressive increase over several weeks is also seen in patients with difficult to treat ascites due to decreased cardiac output (due to heart failure) that can no longer fully compensate for the hypovolemia.

These phenomena can also superimpose on an underlying renal disease and this is called acute on chronic renal failure, which will not improve renal function after a liver transplant.

Treatment consists mainly of prevention. If an increase in creatinine is found, all diuretics should be stopped and albumin should be administered at a dose of 1g/kg body weight albumin 20% for two days. If the patient does not respond to this, terlipressin should be started intravenously (bolus injections 0.5 mg every 4 to 6 hours). Untreated, this complication has a mortality of 100%.

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