Unifying Concepts

Diagnostic Criteria of Hepatorenal Syndrome (HRS)

Acute kidney injury (AKI) is a common complication in patients with end-stage liver disease and advanced cirrhosis regardless of the underlying cause. Hepatorenal syndrome (HRS), a functional form of kidney failure, is one of the many possible causes of AKI.

Diagnostic Criteria of Hepatorenal Syndrome (HRS)

Major criteria

  1. Low glomerular filtration rate, as indicated by serum creatinine greater than 1.5 mg/dl or 24-hour creatinine clearance lower than 40 ml/minute

  2. Absence of shock, ongoing bacterial infection, fluid losses and current treatment with nephrotoxic drugs

  3. No sustained improvement in renal function (decrease in serum creatinine to 1.5 mg/dl or less or increase in creatinine clearance to 40 ml/minute or more) following diuretic withdrawal and expansion of plasma volume with 1.5 l of a plasma expander

  4. Proteinuria lower than 500 mg/day and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease

Additional criteria

  1. Urine volume lower than 500 ml/day

  2. Urine sodium lower than 10 mEq/l

  3. Urine osmolality greater than plasma osmolality

  4. Urine red blood cells less than 50 per high-power field

  5. Serum sodium concentration lower than 130 mEq/l

All major criteria must be present for the diagnosis of hepatorenal syndrome. Additional criteria are not necessary for the diagnosis, but provide supportive evidence.


Clinical types of hepatorenal syndrome


  • Type I: Rapid and progressive impairment of renal function as defined by a doubling of the initial serum creatinine to a level higher than 2.5 mg/dl or a 50% reduction of the initial 24-hour creatinina clearance to a level lower than 20 ml/minute in less than 2 weeks
  • Type II: Impairment in renal function (serum creatinine 41.5 mg/dl) that does not meet the criteria of type I



  1. Gines P. Diagnosis and treatment of hepatorenal syndrome. Baillieres Best Pract Res Clin Gastroenterol. 2000 Dec;14(6):945-57. [Medline]


Created: Apr 12, 2007

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