Hepato–Cardio–Renal Interactions and Transplant Implications

ABSTRACT: Acute kidney injury is a common and prognostically significant complication of cirrhosis, with hepatorenal syndrome (HRS) representing its most severe clinical manifestation. Traditionally viewed as a functional renal disorder driven by splanchnic vasodilation and neurohormonal activation, HRS has been increasingly recognized as part of a more complex, multisystem circulatory disturbance. Growing evidence implicates impaired cardiac reserve, hemodynamic derangements, and systemic inflammation as key contributors to renal dysfunction in advanced liver disease, supporting a unified hepato-cardio-renal syndrome framework. Herein, we synthesize emerging mechanistic insights linking hepatic, cardiac, and renal dysfunction in cirrhosis, with particular emphasis on circulatory derangements, cirrhotic cardiomyopathy, congestive nephropathy, and inflammatory mediators. We discuss evolving diagnostic paradigms, highlighting the role of point-of-care ultrasonography for bedside hemodynamic phenotyping beyond traditional clinical assessment. Therapeutic implications are reviewed through a cardiorenal lens, including the nuanced use of albumin, vasoconstrictors, and transjugular intrahepatic portosystemic shunting. Finally, we explore the impact of hepato-cardio-renal syndrome on liver transplant evaluation, perioperative management, and decisions regarding combined organ transplantation.