Hepatorenal syndrome, MELD score and liver transplantation: an evolving issue with relevant implications for clinical practice.

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis that is associated with poor survival. A rapid diagnosis of HRS and a prompt initiation of the treatment with terlipressin and albumin are mandatory because this leads to an improvement of prognosis. This review covers the predictive value of HRS on 3-month mortality beyond the MELD score and its consequential impact on the prioritization policy to liver transplantation (LT). Moreover, it analyzes the impact of the response to pharmacological treatment on the MELD score, its possible delaying effect on the timing of LT, and suggests a way of overcoming the paradoxical effect of terlipressin and albumin on the priority to LT in responders. Finally, the review discusses the appropriate use of combined liver-kidney transplantation (CLKT) in patients with HRS who do not respond to treatment with terlipressin and albumin.