When Liver Disease Silently Pulls the Kidneys Into Trouble

One of the most heartbreaking moments for families dealing with advanced liver disease is hearing the words:

“The kidneys have started failing.”

It often creates panic and confusion:

“Doctor, the problem is in the liver… why are the kidneys shutting down?”
“Will dialysis fix this?”
“Can medicines reverse it?”
“Does this mean the liver is failing faster than we expected?”

The answer lies in a condition called Hepatorenal Syndrome (HRS) — a unique and serious type of kidney failure that occurs because of advanced liver disease and portal hypertension.
HRS is not a kidney disease. The kidneys themselves are usually healthy.

It is the liver that pulls them into trouble through complex circulatory and hormonal changes.

In this article, I will break down HRS in the clearest possible way — what it is, why it happens, how it is diagnosed, what treatment options exist, and most importantly, when it becomes a signal for urgent liver transplant.

1. What Is Hepatorenal Syndrome?

Hepatorenal Syndrome is kidney failure caused by advanced liver disease, especially cirrhosis with severe portal hypertension.

To understand it:

The kidneys stop working
Not because they are damaged
But because they stop receiving blood
And without blood, they cannot filter toxins or create urine

It is a functional failure — meaning if we restore liver function or perform a liver transplant, the kidneys often recover completely.

HRS is NOT caused by:

Diabetes
High blood pressure
Kidney stone disease
Chronic kidney disease
Medication-induced kidney injury

This is what makes HRS different from all other forms of kidney failure.

2. Why Do Kidneys Fail When the Liver Fails?

The concept can feel confusing. The organs are in different locations.
However, inside the body, the liver and kidneys work in tandem, constantly communicating through blood flow and hormones.

When the liver becomes scarred and portal hypertension develops, several things begin to happen:

2.1 Blood gets trapped in the abdomen

In portal hypertension:

The blood vessels in the abdominal organs dilate
A large amount of blood collects in these vessels
The effective blood reaching other organs decreases

This is called splanchnic vasodilation.

Even though the patient may have swollen veins or fluid in the abdomen, the rest of the body feels dehydrated.

2.2 The kidneys interpret this as “low blood volume.”

Kidneys do not know the liver is failing.
They simply detect low blood pressure and assume:

The body is severely dehydrated
More water and salt must be retained
Urine output must decrease

This triggers powerful hormonal systems:

Renin–angiotensin system
Sympathetic nervous system
ADH (anti-diuretic hormone) release

These make the kidneys “tighten” their blood vessels to preserve water.

2.3 The tightening reduces blood flow further

These responses worsen the situation:

Kidney blood vessels constrict dramatically
Blood supply reduces
Urine output begins falling
Toxins like creatinine rise in the blood

Eventually, the kidneys stop filtering altogether.

This is Hepatorenal Syndrome.

3. The Two Types of HRS: Different Speeds, Same Threat

HRS is broadly classified into two types:

3.1 HRS Type-A (formerly Type 1)

The aggressive form.

Kidney function declines rapidly — within days
Creatinine may rise from 1.5 to 3, 4, or even 6 mg/dL in a week
Urine output drops sharply
Patients may become drowsy or confused
Often triggered by:
- Infection (especially SBP)
- Severe dehydration
- GI bleeding
- Major surgery

This form requires urgent hospitalisation and is often a sign the patient needs immediate transplant evaluation.

3.2 HRS Type-B (formerly Type 2)

The slower form.

Kidney function declines gradually
Ascites becomes severe and difficult to control
Responds partially to medications
Seen in chronic, long-standing portal hypertension

This form indicates the liver is “exhausting” slowly and may need a transplant soon.

4. Early Warning Signs Families Should Watch For

HRS doesn’t always announce itself loudly.
In many patients, it starts with subtle signs such as:

Gradually decreasing urine output
Dark, concentrated urine
Swelling of the feet
Tiredness and weakness
Nausea or reduced appetite
Confusion or irritability
Worsening jaundice
Rapidly increasing abdominal fluid
Low blood pressure
Rising creatinine on blood tests
Sodium levels dropping

If a cirrhosis patient shows these symptoms, it is important to get medical attention immediately.

5. What Triggers Hepatorenal Syndrome?

HRS rarely happens “out of the blue.”
Most patients develop it due to one or more triggers:

5.1 Infections

Especially spontaneous bacterial peritonitis (SBP).
This is the most common trigger.

5.2 Severe dehydration

From vomiting, high fever, or overuse of diuretics.

5.3 Gastrointestinal bleeding

5.4 Aggressive paracentesis without albumin

Removing too much fluid without replacing albumin can reduce blood volume.

5.5 Certain medications

NSAIDs (painkillers like ibuprofen)
Some antibiotics
Contrast injection during scans

5.6 Severe worsening of liver disease

5.7 Alcohol binge

Triggers a sudden decline in liver function.

When the liver destabilises, the kidneys follow — often within days.

6. How Doctors Diagnose HRS: A Step-by-Step Process

HRS diagnosis requires precision because we must rule out other causes of kidney failure.

6.1 Basic blood tests

Creatinine
Urea
Sodium
Potassium
Liver function tests

6.2 Urine examination

HRS shows:

Very low sodium
Almost no protein
No blood cells

This helps rule out kidney diseases like glomerulonephritis.

6.3 Ultrasound

To ensure:

No obstruction
No structural kidney disease
Adequate blood flow

6.4 Rule out dehydration

Doctors give albumin challenge tests.

If the kidneys improve with albumin, it is not HRS.

6.5 Rule out drug-induced kidney injury

6.6 Rule out infections

Since infections are the biggest trigger.

Diagnosis is confirmed when:

Kidneys are anatomically normal
No improvement with fluids/albumin
Creatinine keeps rising
Urine output remains low
No other cause explains kidney failure

7. How HRS Affects the Body: The Domino Effect

Hepatorenal Syndrome does not affect only the kidneys.
It accelerates the decline of the entire body.

7.1 Toxin buildup

Ammonia increases
Urea increases
Creatinine increases

7.2 Brain function worsens

Encephalopathy becomes more frequent
Confusion increases
A coma may develop

7.3 Fluid retention becomes severe

Ascites increases
Leg swelling becomes pronounced

7.4 Hyponatremia

Sodium levels fall dangerously.

7.5 Blood pressure drops

The body cannot maintain circulation.
Without treatment or transplant, HRS rapidly leads to multi-organ failure.

8. Treatment: What Can Be Done?

The treatment of HRS has two goals:

Stabilise kidney function
Prepare for a liver transplant

Because only a liver transplant offers a permanent cure.
But several treatments help improve kidney function while preparing for a transplant.

8.1 Albumin Infusions

Albumin expands blood volume and helps restore kidney blood flow.
It also improves blood pressure, reduces inflammation, and prevents complications.

8.2 Vasoconstrictor Medications

These medicines tighten blood vessels in the abdomen so that more blood returns to the kidneys.

Common options include:

Terlipressin
Norepinephrine
Midodrine + Octreotide

These drugs can significantly improve kidney function in many patients.

8.3 Treating the Trigger

If infection causes HRS, antibiotics are started immediately.
If bleeding was the cause, it must be controlled.
Addressing the trigger is critical to stopping the spiral.

8.4 Avoiding Kidney-Harming Medications

NSAIDs
Some antibiotics
Certain contrast dyes

These are strictly avoided.

8.5 Dialysis (Temporarily)

Dialysis is not a cure, but it helps:

Remove toxins
Manage fluid overload
Stabilise electrolytes

It is usually used as a bridge to transplant, not as long-term therapy.

8.6 TIPS Procedure

Transjugular Intrahepatic Portosystemic Shunt (TIPS) reduces portal pressure.
In selected patients, it can improve kidney function temporarily.

However, TIPS is not suitable for all, especially those with severe encephalopathy.

9. Why Liver Transplant Is the Only Cure

Because in HRS:

Kidneys stop functioning due to a lack of blood flow
Blood flow is reduced because of portal hypertension
Portal hypertension is caused by cirrhosis
Cirrhosis is irreversible

Therefore:

Unless the damaged liver is replaced, the cycle cannot be broken.

Liver transplant restores:

Normal blood circulation
Kidney blood flow
Hormonal balance
Toxin clearance
Fluid regulation

Many patients experience dramatic improvement in kidney function within days of transplant.

Those who had severe HRS may need temporary dialysis after transplant but often recover over weeks.

10. When HRS Means It’s Time to Consider Transplant

HRS is one of the strongest medical indications for urgent liver transplant.

Doctors evaluate a transplant when HRS:

Develops suddenly
Keeps worsening despite medication
Causes creatinine to rise above 1.5–2 mg/dL
Reduces urine output significantly
Occurs after an infection or bleeding episode
Causes severe hyponatremia
Increases encephalopathy
Indicates the liver is entering the final decompensated stage

HRS dramatically increases the 3-month mortality risk, which is why a timely transplant is essential.

11. What Happens If HRS Is Not Treated?

Without treatment, HRS progresses rapidly.

Multi-organ failure develops
Blood pressure collapses
Brain function deteriorates
Fluid accumulates in the lungs
Severe encephalopathy develops
Toxins build up to dangerous levels

In untreated HRS Type-A, survival can be less than 2 weeks.
With Type-B, it may be a few months.

This is why early detection is vital.

12. Can HRS Be Prevented?

Not completely, but risks can be lowered.

Patients with cirrhosis should:

Avoid alcohol completely
Take diuretics only as prescribed
Avoid NSAIDs
Get regular screening for SBP
Treat infections early
Avoid dehydration
Ensure albumin replacement during large-volume paracentesis
Monitor kidney function regularly
Follow a low-salt diet
Be under the care of a hepatologist

Early transplant referral is important before the body becomes too weak.

13. Life After Recovery or Transplant

With successful treatment

Kidney function improves
Ascites reduces
Muscle mass increases
Mental clarity returns
Appetite improves
Quality of life becomes stable

After a liver transplant

Many patients regain completely normal kidney function
Survival improves dramatically
Long-term outcomes are excellent
Patients return to normal routines, work, and family life

Transplant is often life-changing — especially for patients who have developed HRS.

14. Summary: HRS Is the Body’s Final Signal That the Liver Needs Urgent Help

Hepatorenal Syndrome is the body’s way of saying the liver can no longer cope.

It means:

The liver is severely damaged
Portal hypertension is extreme
Blood cannot reach the kidneys
Body systems are collapsing

And most importantly:

It signals that medical treatment is reaching its limit and a transplant may be necessary.

Understanding HRS helps families recognise urgency, seek timely medical care, and make informed decisions that can dramatically improve survival.

Final Message for Patients and Families

If your loved one with cirrhosis is showing signs of kidney dysfunction, do not assume it is “just dehydration” or “too many medicines.”
Get evaluated immediately.

With timely treatment — and when needed, timely transplant — patients with HRS can recover, regain their health, and return to a normal, fulfilling life.