When should I consider referring a patient with hepatorenal syndrome for liver transplantation?

Consider referring a patient with hepatorenal syndrome for liver transplantation when they have end-stage liver disease with decompensated cirrhosis and renal failure that is not reversible by medical management. This includes patients with signs of decompensated liver disease and hepatorenal syndrome who are at high risk of serious complications and poor prognosis, as assessed by specialist hepatology teams using prognostic scores such as the Model for End-stage Liver Disease (MELD).

Early referral to a hepatologist or gastroenterologist with an interest in hepatology is recommended for patients with decompensated cirrhosis and hepatorenal syndrome to assess transplant eligibility and arrange specialist management.

Referral should be considered urgently if the patient has acute kidney injury stage 3 or complications such as fluid overload, metabolic acidosis, or uraemic symptoms not responding to medical treatment, as these may indicate the need for renal replacement therapy and evaluation for transplantation.

In summary, referral for liver transplantation in hepatorenal syndrome is appropriate when there is irreversible decompensated liver disease with renal failure, poor response to medical therapy, and a high risk of mortality, as determined by specialist assessment.

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