OSCE — Hepatorenal Syndrome

Brief (to candidate)

You will assess a patient with a presentation consistent with Hepatorenal Syndrome.
You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.^[1]

Clinical context

Hepatorenal syndrome (HRS) is a functional, potentially reversible acute kidney injury that occurs in patients with ascites and advanced cirrhosis (or acute liver failure / acute-on-chronic liver failure), in the absence of any other identifiable renal injury. The kidneys are structurally normal and recover after liver transplantation. The dominant mechanism is splanchnic arterial vasodilation (nitric oxide, carbon monoxide, endocannabinoids) producing reduced effective arterial blood volume, with compensatory RAAS, sympathetic and vasopressin activation causing intense renal vasoconstriction. It is a diagnosis of exclusion after diuretic withdrawal and albumin 1 g/kg (maximum 100 g) for two consecutive days. First-line treatment is terlipressin plus albumin; liver transplantation is the only cure.^[1][3]

Candidate tasks

1. Clarify onset, severity, associated features, and red-flag symptoms.
2. State focused examination priorities.
3. List first-line investigations and any named score/criteria.
4. Give immediate resuscitation steps.
5. Outline definitive management with doses/routes where standard.
6. Name complications and disposition (ward / HDU / theatre / discharge safety-net).
7. Mention one special-population modifier (pregnancy, child, elderly, CKD).^[1]

Examiner checklist

Model outline

Lead with the working diagnosis and life threats. Stop NSAIDs and diuretics. Diagnostic ascitic tap in every cirrhotic with ascites and AKI. Albumin 1 g/kg (maximum 100 g) for two consecutive days. If HRS-AKI is confirmed: terlipressin 0.5 to 1 mg every 4 to 6 hours, maximum 2 mg every 4 hours, or infusion 2 to 12 mg/day, plus albumin 1 g/kg day 1 then 20 to 40 g/day, up to 14 days. Do not claim a mortality win from CONFIRM (verified reversal 32 vs 17 percent; 90-day death 51 vs 45 percent). Contraindicated in hypoxaemia and ongoing coronary, peripheral or mesenteric ischaemia. The only cure is liver transplantation. Document escalation and transplant referral.^[5][3][4]

References19ShowHide

1. [1]Girish V, Ranasinghe IR, Rout P Hepatorenal Syndrome StatPearls [Internet], 2026.PMID 28613606
2. [2]Angeli P, Garcia-Tsao G, Nadim MK, et al. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document J Hepatol, 2019.PMID 31302175
3. [3]Francoz C, Durand F, Kahn JA, Nadim MK Hepatorenal Syndrome Clin J Am Soc Nephrol, 2019.PMID 30996046
4. [4]Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis N Engl J Med, 1999.PMID 10432325
5. [5]Wong F, Pappas SC, Curry MP, et al. Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome N Engl J Med, 2021.PMID 33657294
6. [6]Cavallin M, Kamath PS, Merli M, et al. Terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of hepatorenal syndrome: A randomized trial Hepatology, 2015.PMID 25644760
7. [7]Cavallin M, Fasolato S, Marenco S, Piano S, Tonon M, Angeli P The Treatment of Hepatorenal Syndrome Dig Dis, 2015.PMID 26159272
8. [8]Sharma P, Kumar A, Sharma BC, Sarin SK An open label, pilot, randomized controlled trial of noradrenaline versus terlipressin in the treatment of type 1 hepatorenal syndrome and predictors of response Am J Gastroenterol, 2008.PMID 18557715
9. [9]Guevara M, Ginès P, Bandi JC, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems Hepatology, 1998.PMID 9696006
10. [10]Ginès A, Escorsell A, Ginès P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites Gastroenterology, 1993.PMID 8514039
11. [11]Ginès P, Titó L, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis Gastroenterology, 1988.PMID 3360270
12. [12]Fernández J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis Gastroenterology, 2007.PMID 17854593
13. [13]Caregaro L, Menon F, Angeli P, et al. Limitations of serum creatinine level and creatinine clearance as filtration markers in cirrhosis Arch Intern Med, 1994.PMID 8285815
14. [14]Khemichian S, Francoz C, Nadim MK Advances in management of hepatorenal syndrome Curr Opin Nephrol Hypertens, 2021.PMID 34397647
15. [15]Garcia-Tsao G, Abraldes JG, Rich NE, et al. AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review Gastroenterology, 2024.PMID 37978969
16. [16]Best LM, Freeman SC, Sutton AJ, et al. Treatment for hepatorenal syndrome in people with decompensated liver cirrhosis: a network meta-analysis Cochrane Database Syst Rev, 2019.PMID 31513287
17. [17]Weinberg EM, Wong F, Vargas HE, et al. Decreased need for RRT in liver transplant recipients after pretransplant treatment of hepatorenal syndrome-type 1 with terlipressin Liver Transpl, 2024.PMID 37801553
18. [18]European Association for the Study of the Liver EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis J Hepatol, 2018.PMID 29653741
19. [19]Belcher JM, Sanyal AJ, Peixoto AJ, et al. Kidney biomarkers and differential diagnosis of patients with cirrhosis and acute kidney injury Hepatology, 2014.PMID 24375576