What is the management of hepatorenal syndrome?

From the Guidelines

The management of hepatorenal syndrome (HRS) should prioritize the use of terlipressin (0.5-2 mg IV every 4-6 hours for up to 14 days) in combination with albumin as the first-line therapeutic agent, as recommended by the most recent guidelines. This approach is supported by the latest evidence, including a study published in 2021 1, which highlights the importance of early treatment and the revised classification of HRS. The use of terlipressin and albumin has been shown to significantly improve renal function in HRS and improve short-term mortality.

Key Interventions

• Terlipressin and albumin: The combination of terlipressin and albumin is the mainstay of treatment for HRS, with terlipressin being the preferred vasoconstrictor due to its effectiveness in improving renal function and short-term mortality 1.
• Volume status optimization: Careful assessment and management of ascites through paracentesis and diuretic adjustment are crucial to optimize volume status and improve renal function.
• Discontinuation of nephrotoxic medications: All nephrotoxic medications, including NSAIDs and ACE inhibitors, should be discontinued to prevent further renal injury.
• Infection screening and treatment: Infections often trigger HRS, and therefore, infection screening and treatment are essential components of management.

Alternative Treatments

• Norepinephrine: Norepinephrine (0.5-3 mg/hour as continuous infusion) may be considered as an alternative to terlipressin, particularly in patients with a central venous catheter 1.
• Midodrine and octreotide: The combination of midodrine and octreotide is less effective and should not be used as a first-line treatment for HRS 1.

Definitive Treatment

• Liver transplantation: For eligible patients with end-stage liver disease, liver transplantation represents the definitive treatment, potentially resolving both liver failure and renal dysfunction. Renal replacement therapy may be necessary as a bridge to transplantation in severe cases.

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. Limitation of Use Patients with a serum creatinine >5 mg/dL are unlikely to experience benefit.

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. However, it is essential to note that patients with a serum creatinine >5 mg/dL are unlikely to experience benefit from this treatment 2.

• Key points:
  • Terlipressin is indicated for hepatorenal syndrome with rapid reduction in kidney function
  • Patients with serum creatinine >5 mg/dL may not benefit from terlipressin treatment
  • The mechanism of action of terlipressin involves reducing portal hypertension and increasing effective arterial volume and mean arterial pressure (MAP) 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 Treatments:
  • 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.
  • Terlipressin plus albumin has been found to be more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 4.
• Non-Pharmacological Interventions:
  • Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to be effective in improving renal function in HRS patients, especially in those with type 1 HRS 6.
  • Liver transplantation remains the most effective treatment for end-stage liver disease and HRS, and is considered the top option for patients with HRS 3.
  • Renal replacement therapy and plasma exchange may also be considered in certain cases 3.
• 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, 7.
  • Recent studies have emphasized the importance of early diagnosis and treatment of HRS to improve patient outcomes 7.