Hepatorenal Syndrome/Bile Nephrosis

Hepatorenal Syndrome/Bile Nephrosis

Anthony Chang, MD

Gross photograph shows the capsular surface of an autopsy kidney from a 32-year-old man with cirrhosis. The green discoloration of the kidney is accentuated after formalin fixation.

Gross photograph of a cross section of renal medulla shows plugging of nephrons by bile casts image and vasa recta congestion image in a patient with end-stage liver disease. (Courtesy C. Abrahams, MD.)



  • Hepatorenal syndrome (HRS)

  • Bile nephrosis (BN)


  • Cholemic nephrosis

  • Jaundice-associated acute kidney injury

  • Jaundice-related renal insufficiency


  • HRS: Renal failure with cirrhosis

    • Type 1: Rapid reduction of renal function

    • Type 2: Slowly progressive loss of renal function

    • Lack of benefit from volume expansion

    • Absence of other causes

  • BN: Acute renal failure with bile-containing casts in distal nephron


Hepatorenal Syndrome

  • Circulatory disturbance causing decreased perfusion of kidney

    • Decreased glomerular filtration rate

    • Acute ischemia of tubules

    • Reversible when transplanted into noncirrhotic recipient

Bile Nephrosis

  • Distal nephron casts containing bilirubin and bile salts

    • Direct toxicity to tubular epithelium by bile salts

    • Obstruction in distal nephron

      • Propensity of distal nephron due to admixture of Tamm-Horsfall protein with bile components



  • Hepatic failure

    • Total bilirubin levels often > 20 mg/dL

    • Jaundice

  • Acute renal failure

    • Concentrated urine, low Na

  • Chronic renal failure


  • Surgical approaches

    • Liver transplantation if cause of liver failure is irreversible

  • Drugs

    • Vasopressors for type 1 HRS

  • Supportive therapy

    • Renal replacement therapy


  • Poor; dependent on reversibility of liver failure

  • Reduction of bilirubin can lead to recovery of renal function


General Features

Jul 7, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Hepatorenal Syndrome/Bile Nephrosis

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