Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2024; 30(2): 128-136
Published online Jan 14, 2024. doi: 10.3748/wjg.v30.i2.128
Hepatocardiorenal syndrome in liver cirrhosis: Recognition of a new entity?
Henry H L Wu, Amina Rakisheva, Arvind Ponnusamy, Rajkumar Chinnadurai
Henry H L Wu, Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital & The University of Sydney, St. Leonards (Sydney) 2065, New South Wales, Australia
Amina Rakisheva, Department of Cardiology, City Cardiological Center, Almaty 050000, Kazakhstan
Arvind Ponnusamy, Department of Renal Medicine, Royal Preston Hospital, Preston PR2 9HT, United Kingdom
Rajkumar Chinnadurai, Donal O’Donoghue Renal Research Centre & Department of Renal Medicine, Northern Care Alliance National Health Service Foundation Trust, Salford M6 8HD, United Kingdom
Author contributions: Wu HHL and Chinnadurai R designed the outline and coordinated the writing of the paper; Wu HHL performed majority of the writing; Chinnadurai R prepared the figures and tables; Rakisheva A and Ponnusamy A provided review of the draft versions of the paper prior to submission of the final version; and all authors read and approved the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Henry H L Wu, MBChB, Academic Editor, Academic Fellow, Doctor, Honorary Research Fellow, Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital & The University of Sydney, Reserve Road, St. Leonards (Sydney) 2065, New South Wales, Australia.
Received: November 6, 2023
Peer-review started: November 6, 2023
First decision: November 30, 2023
Revised: December 5, 2023
Accepted: December 28, 2023
Article in press: December 28, 2023
Published online: January 14, 2024

Emerging evidence and perspectives have pointed towards the heart playing an important role in hepatorenal syndrome (HRS), outside of conventional understanding that liver cirrhosis is traditionally considered the sole origin of a cascade of pathophysiological mechanisms directly affecting the kidneys in this context. In the absence of established heart disease, cirrhotic cardiomyopathy may occur more frequently in those with liver cirrhosis and kidney disease. It is a specific form of cardiac dysfunction characterized by blunted contractile responsiveness to stress stimuli and altered diastolic relaxation with electrophysiological abnormalities. Despite the clinical description of these potential cardiac-related complications of the liver, the role of the heart has traditionally been an overlooked aspect of circulatory dysfunction in HRS. Yet from a physiological sense, temporality (prior onset) of cardiorenal interactions in HRS and positive effects stemming from portosystemic shunting demonstrated an important role of the heart in the development and progression of kidney dysfunction in cirrhotic patients. In this review, we discuss current concepts surrounding how the heart may influence the development and progression of HRS, and the role of systemic inflammation and endothelial dysfunction causing circulatory dysfunction within this setting. The temporality of heart and kidney dysfunction in HRS will be discussed. For a subgroup of patients who receive portosystemic shunting, the dynamics of cardiorenal interactions following treatment is reviewed. Continued research to determine the unknowns in this topic is anticipated, hopefully to further clarify the intricacies surrounding the liver-heart-kidney connection and improve strategies for management.

Keywords: Hepatorenal syndrome, Cardiorenal syndrome, Cirrhosis, Cardiac dysfunction, Circulatory dysfunction

Core Tip: There is emerging evidence to suggest that the heart plays an important role in advanced liver disease and contributes significantly to hepatorenal syndrome (HRS) progression. It is now increasingly agreed upon that circulatory dysfunction in HRS is at least in part due to cardiac impairment, which can exist prior to kidney dysfunction in cirrhotic patients who develop HRS. There are numerous pathophysiological mechanisms which may co-exist in both hepatorenal and cardiorenal syndrome pathways, and treatments which ameliorate kidney dysfunction in HRS are likely to also address the mechanisms which lie within this intricate hepatocardiorenal syndrome entity that is being postulated.