Should fluid administration be withheld in Hepatorenal Syndrome (HRS)?

From the Guidelines

No, you should not withhold fluids in hepatorenal syndrome (HRS), and instead, patients with HRS should receive appropriate volume expansion, particularly if there are signs of hypovolemia, with albumin infusion being the preferred choice. The standard approach includes albumin infusion (typically 1 g/kg on day 1, followed by 20-40 g/day) alongside vasoconstrictors like terlipressin (0.5-2 mg IV every 4-6 hours) or norepinephrine (0.5-3 mg/hour) for 2-14 days, as recommended by the most recent guidelines 1.

Key Considerations

• Fluid management should be carefully monitored with regular assessment of vital signs, urine output, and electrolytes to avoid overly aggressive fluid administration, which may worsen ascites and edema 1.
• The rationale behind fluid administration in HRS is that the condition involves intense renal vasoconstriction with reduced renal blood flow despite overall arterial vasodilation in the splanchnic circulation, and albumin helps expand plasma volume and improves cardiac output, while vasoconstrictors help redistribute blood flow to the kidneys 1.
• The ultimate goal is to improve renal perfusion while working toward definitive management, which may include liver transplantation in appropriate candidates.

Treatment Approach

• Albumin infusion is the preferred choice for volume expansion in HRS, given its effectiveness in restoring effective arterial blood volume compared to saline solution 1.
• Vasoconstrictors like terlipressin or norepinephrine should be used in combination with albumin to help redistribute blood flow to the kidneys and improve renal perfusion 1.
• The treatment approach should be tailored to the individual patient's needs, with careful monitoring of response to therapy and adjustment of the treatment plan as needed.

From the Research

Treatment of Hepatorenal Syndrome

• The treatment of hepatorenal syndrome (HRS) typically involves the use of vasoconstrictor agents and intravenous albumin 2.
• Terlipressin, an analog of vasopressin, has been shown to be effective in improving renal function in patients with HRS 3, 4.
• The combination of midodrine and octreotide with albumin is also used as an alternative treatment for HRS, particularly in the United States where terlipressin is not available 3, 5.
• A standardized approach to treatment with albumin, midodrine, and octreotide may improve treatment response rates and reduce the need for renal replacement therapy and liver transplantation 6.

Fluid Management in Hepatorenal Syndrome

• There is no clear evidence to suggest that withholding fluids is a recommended treatment strategy for HRS.
• In fact, the use of intravenous albumin is a key component of HRS treatment, suggesting that fluid management is an important aspect of care 3, 5, 6.
• The goal of fluid management in HRS is to improve renal function and prevent further complications, rather than to restrict fluid intake 2, 4.

Key Findings

• Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 3.
• The combination of octreotide, midodrine, and albumin improves survival and renal function in patients with HRS type 1 and type 2 5.
• A standardized approach to treatment with albumin, midodrine, and octreotide may improve treatment response rates and reduce the need for renal replacement therapy and liver transplantation 6.