Towards goal-directed therapy of hepatorenal syndrome: we have the tools but we need the trials

Patients with cirrhosis who develop tense ascites and hepatorenal syndrome have a very high mortality and present a management challenge. Current debate stems from a lack of studies evaluating changes in effective arterial blood volume following paracentesis or targeting fluid replacement with appropriate vascular physiological measures to ensure no paracentesis-related circulatory dysfunction. The study by Umgelter and colleagues addresses a goal-directed approach to fluid management in hepatorenal syndrome and raises several mechanistic questions, the answers to which are likely to improve our understanding of the pathophysiology in hepatorenal syndrome and to guide future management.