From the Guidelines
The treatment for hepatorenal syndrome (HRS) should prioritize terlipressin (1 mg/4–6 h intravenous bolus) in combination with albumin as the first-line therapeutic agent, aiming to improve renal function and decrease serum creatinine to less than 133 lmol/L (1.5 mg/dl). This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of vasoconstrictors and albumin in managing HRS [ 1 ].
Key Considerations in Treatment
- Terlipressin Dosage and Administration: The dose of terlipressin should be increased in a stepwise manner up to a maximum of 2 mg/4 h if serum creatinine does not decrease at least 25% after 3 days [ 1 ].
- Albumin Infusion: Albumin infusion is essential alongside vasoconstrictors to expand plasma volume, with a recommended dose of 1 g/kg on day 1, followed by 20-40 g/day [ 1 ].
- Monitoring and Treatment Duration: Patients should be monitored for response within 3-5 days, with treatment continuing until serum creatinine improves significantly or for up to 14 days [ 1 ].
- Alternative Therapies: Norepinephrine or midodrine plus octreotide can be considered as alternatives when terlipressin is unavailable [ 1 ].
- Liver Transplantation: Liver transplantation remains the definitive treatment for eligible patients, addressing the underlying liver disease [ 1 ].
- Renal Replacement Therapy: Renal replacement therapy may be necessary as a bridge to transplantation in severe cases [ 1 ].
Predictors of Response to Treatment
Predictors of response to terlipressin include a baseline bilirubin of <10 mg/dL, a baseline serum creatinine of <5 mg/dL, and lower stage of acute-on-chronic liver failure [ 1 ]. A sustained increase in mean arterial pressure by 5–10 mm Hg with treatment is also associated with response to terlipressin [ 1 ].
Importance of Addressing Precipitating Factors
Identifying and treating precipitating factors such as infections, gastrointestinal bleeding, or nephrotoxic medications is crucial for successful management of HRS [ 1 ]. This comprehensive approach prioritizes morbidity, mortality, and quality of life outcomes in the treatment of hepatorenal syndrome.
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. The treatment for hepatorenal syndrome is terlipressin (IV), a vasopressin receptor agonist, which is indicated to improve kidney function in adults with hepatorenal syndrome with rapid reduction in kidney function 2. Key points:
- 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) 2.
- Patients with a serum creatinine >5 mg/dL are unlikely to experience benefit from terlipressin 2.
From the Research
Treatment Options for Hepatorenal Syndrome
The treatment for hepatorenal syndrome (HRS) includes several options, with liver transplantation being the best treatment option for suitable candidates 3, 4, 5.
- Vasoconstrictor drugs: Terlipressin is effective for the management of HRS, and noradrenaline is a good choice if terlipressin is not available 3.
- Albumin: The combination of terlipressin and albumin is efficacious in the reversal of HRS and is used worldwide 6, 7, 5.
- Midodrine and octreotide: Where terlipressin is not available, midodrine and octreotide with albumin are used as an alternative treatment of HRS 6.
- Transjugular intrahepatic portosystemic shunt (TIPS): TIPS is effective in improving renal function in patients with HRS 4.
Effectiveness of Treatment Options
Studies have shown that terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 6.
- The recovery rate of renal function was 70.4% in the terlipressin group compared to 28.6% in the midodrine and octreotide group 6.
- Long-term treatment of HRS with vasoconstrictors until liver transplantation is beneficial as a bridge to liver transplantation 3.
- Liver transplantation offers a clear survival benefit to patients with HRS regardless of prior therapy with vasoconstrictors 3.
Patient Outcome
Patient outcome is improved further if the renal function is normalized prior to liver transplantation 4.