Hepatorenal syndrome is characterized by acute kidney injury that occurs in patients with acute or chronic liver disease. Ten percent of hospitalized patients with cirrhosis and ascites were reported to have hepatorenal syndrome as well as forty percent of patients with end-stage liver disease and ascites. There are two types of hepatorenal syndrome: Type 1 is defined by rapidly progressing, severe renal failure and is often precipitated by a specific event such as spontaneous bacterial peritonitis; type 2 is defined by slowly progressive renal failure consisting of serum creatinine greater than 1.5 mg/dL and less than 2.5 mg/dL and a glomerular filtration rate below 20 mL/min. The general disease process involves renal vasoconstriction and peripheral arterial vasodilation. The histological appearance of the kidneys is unchanged and the kidneys often resume normal function following liver transplantation; therefore, a liver transplant is the curative treatment for hepatorenal syndrome. For patients that aren't liver transplant candidates, alternative treatment options exist, but are less effective; vasopressin analogs (ornipression, terlipressin), alpha-adrenergic agonists (midodrine), somatostatin analogs (octreotide), and albumin. Type 1 hepatorenal syndrome has the worst prognosis with a 90% mortality rate in three months, while Type 2 hepatorenal syndrome has a 30% mortality rate in three months and a 60% mortality rate in one year. This case study thoroughly reviews the pathogenesis, diagnosis, and treatment of hepatorenal syndrome. Because the prognosis is poor and the mortality rate is high, it is of great importance that clinicians promptly recognize and treat hepatorenal syndrome. This should be considered a differential diagnosis in any patient that has co-existing liver and renal impairment. In this case, a 44-year-old African American female presented to the emergency department with worsening ascites, dyspnea on exertion, fatigue, and generalized weakness for one week. Other associated symptoms include diffuse pruritus, bilateral leg pain, and altered mental status. The patient has a past medical history of depression, cirrhosis, hallucinations, B12, folate, and thiamine deficiency, peripheral neuropathy, gastroesophageal reflux disease, asthma, hiatal hernia, congestive heart failure, chronic ascites, portal hypertension, esophagitis, chronic pancreatitis, hyperbilirubinemia, and bipolar disorder. Her home medications prior to this hospi...