Medical TopicsPathology

Hepatorenal Syndrome : Diagnostic Criteria With Mnemonics


Renal complications are common in patients with Chronic Liver Disease. The relationship between the liver and kidney diseases has been the object of a considerable research since history. Frerichs and Flint’s description of  development of oliguria in CLD patients dates back to early 20th century.

International Ascites Club defines Hepatorenal syndrome as a clinical condition that occurs in patients with advanced chronic liver disease, liver failure, and portal hypertension characterized by impaired renal function and marked abnormalities in the arterial circulation and activity of the endogenous vasoactive systems.

The functional renal failure with reduced GFR in severe liver disease is pathologically attributed to vasoconstriction of renal circulation. Histologically the kidneys are normal and recover function after successful liver transplantation. The diagnosis of HRS is  based on several diagnostic criteria which are given below:

Major Criteria

All of the following major criteria must be present for the diagnosis of Hepatorenal Syndrome. These can be remembered using the memory aid – PLAN.

  • P – Proteinuria < 500 mg/day and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease
  • L – Low glomerular filtration rate, as indicated by serum creatinine > 1.5 mg/dl or 24-h creatinine clearance < 40 ml/min
  • A – Absence of shock, ongoing bacterial infection, fluid losses and current treatment with nephrotoxic drugs
  • N–  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/min or more) following diuretic withdrawal and expansion of plasma volume with 1.5 l of a plasma expander

Additional  Criteria

These are not necessary for diagnosis of HRS but provide supportive evidence.

  • Urine volume < 500 ml/day
  • Urine sodium < 10 mEq/l
  • Urine osmolality greater than plasma osmolality
  • Urine red blood cells less than 50 per high-power field
  • Serum sodium concentration < 130 mEq/l


We hope the mnemonics mentioned above will help you recall the diagnostic criteria of Hepatorenal Syndrome whenever you need. If you have any other useful tips or clinical pearls on Liver Diseases, please share it on our comment section below.



Zakim and Boyer’s Hepatology -5th Edition

Walker’s Pediatric Gastrointestinal Disease – 5th Edition





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