From the Guidelines
The management of hepatorenal syndrome (HRS) should involve the use of vasoconstrictors, specifically terlipressin, in combination with albumin as the first-line treatment, as it has been shown to improve renal function and short-term mortality in patients with HRS-AKI 1. The goal of treatment is to improve renal function, and the combination of terlipressin and albumin has been demonstrated to be effective in achieving this goal.
- The recommended dose of terlipressin is 1-2 mg IV every 4-6 hours, with the option to increase the dose up to a maximum of 2 mg every 4-6 hours if the serum creatinine level does not decrease by at least 25% 1.
- Albumin should be administered at a dose of 20-40g/day, as it helps to expand plasma volume and has anti-inflammatory and antioxidant properties that can help preserve kidney function 1.
- Treatment should be continued for 5-14 days, or until serum creatinine improves or liver transplantation occurs.
- Supportive care, including careful fluid management, avoiding nephrotoxic medications, treating infections promptly, and discontinuing diuretics, is also crucial in the management of HRS.
- Renal replacement therapy may be needed as a bridge to liver transplantation, which is the definitive treatment for HRS.
- Norepinephrine can be considered as an alternative to terlipressin, especially in patients with a central venous catheter, as it has been shown to be effective in reversing HRS 1.
- The combination of midodrine and octreotide is less effective and should not be used as a first-line treatment for HRS 1.
From the FDA Drug Label
TERLIVAZ is a vasopressin receptor agonist indicated to improve kidney function in adults with hepatorenal syndrome with rapid reduction in kidney function. Terlipressin is thought to increase renal blood flow in patients with hepatorenal syndrome by reducing portal hypertension and blood circulation in portal vessels and increasing effective arterial volume and mean arterial pressure (MAP).
The management of hepatorenal syndrome involves the use of terlipressin (IV), a vasopressin receptor agonist, to improve kidney function in adults with rapid reduction in kidney function.
- The drug works by reducing portal hypertension and increasing effective arterial volume and mean arterial pressure (MAP).
- Key considerations:
- Patients with a serum creatinine >5 mg/dL are unlikely to experience benefit.
- The drug should be used with caution in patients with certain medical conditions, such as hepatic impairment. 2
From the Research
Management of Hepatorenal Syndrome
The management of hepatorenal syndrome (HRS) involves a combination of pharmacological and non-pharmacological interventions, aiming to improve renal function and reduce the risk of mortality 3.
Pharmacological Interventions
- Vasoconstrictors, such as terlipressin and midodrine, have been shown to improve renal function and reduce mortality in HRS patients 3, 4.
- Albumin infusion is also used in combination with vasoconstrictors to improve renal function 4, 5.
- α-Adrenergic drugs, such as intravenous norepinephrine or oral midodrine plus subcutaneous octreotide, administered with albumin have also been used in the treatment of HRS, with promising results 5, 6.
Non-Pharmacological Interventions
- Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to be effective in improving renal function in HRS patients 3, 7.
- Plasma exchange, liver transplantation, and renal replacement therapy may also be considered in the management of HRS 3.
- Liver transplantation remains the top consideration for the treatment of end-stage liver disease and HRS 3.
Comparison of Treatment Options
- Terlipressin plus albumin has been shown to be more effective than midodrine and octreotide plus albumin in improving renal function in HRS patients 4.
- Norepinephrine plus albumin has been shown to be more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 6.
Importance of Early Recognition and Prompt Intervention
- Early recognition and prompt intervention in HRS patients are crucial, as delaying treatment can result in poorer outcomes 3.