What is the management of Hepatorenal Syndrome (HRS)?

From the Guidelines

The management of Hepatorenal Syndrome (HRS) should focus on improving renal perfusion through vasoconstrictors combined with albumin, with terlipressin being the preferred first-line treatment, as evidenced by the most recent and highest quality study 1.

Key Considerations

• Terlipressin should be administered at a dose of 1-2 mg IV every 4-6 hours for up to 14 days, with albumin infused at a dose of 1 g/kg on day 1 followed by 20-40 g/day, as recommended by recent guidelines 1.
• Norepinephrine (0.5-3 mg/hour continuous infusion) or midodrine (7.5-12.5mg orally three times daily) with octreotide (100-200mcg subcutaneously three times daily) can be used as alternative treatments in countries where terlipressin is unavailable, always in combination with albumin 1.
• Patients should be monitored for complications including ischemic events, arrhythmias, and pulmonary edema, and supportive care should include careful fluid management, avoiding nephrotoxic medications, treating infections promptly, and discontinuing diuretics 1.
• For eligible patients with end-stage liver disease, liver transplantation offers definitive treatment, and renal replacement therapy may be necessary as a bridge to transplantation in severe cases 1.

Treatment Approach

• The treatment approach should prioritize the use of vasoconstrictors, such as terlipressin, in combination with albumin to improve renal perfusion and address the underlying liver disease.
• The choice of vasoconstrictor and dosing regimen should be individualized based on patient factors, such as the presence of contraindications or intolerance to certain medications.
• Close monitoring of patients is essential to promptly identify and manage potential complications, and to adjust the treatment plan as needed to optimize outcomes.

From the Research

Management of Hepatorenal Syndrome (HRS)

The management of HRS involves the use of vasoconstrictor drugs, such as terlipressin, in combination with albumin infusion.

• Terlipressin has been shown to be effective in improving renal function and reducing mortality in patients with HRS 2, 3, 4.
• The combination of terlipressin and albumin has been demonstrated to be more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 3.
• Terlipressin works by increasing mean arterial pressure and systemic vascular resistance, while decreasing heart rate, cardiac output, and portal venous blood flow 2.
• The use of terlipressin has been shown to be safe, with minimal side effects, and can be used as a bridge to liver transplantation 2, 5.

Alternative Treatment Options

• Midodrine and octreotide plus albumin can be used as an alternative treatment for HRS, particularly in cases where terlipressin is not available 3, 6.
• The combination of octreotide, midodrine, and albumin has been shown to improve survival and renal function in patients with HRS type 1 and type 2 6.
• Liver transplantation is the most successful therapeutic option for patients with HRS, and the use of terlipressin and albumin can be used as a bridge to transplantation 5.

Key Considerations

• The prognosis for HRS remains poor, with an expected survival time of 2 weeks and 6 months for type 1 and type 2 HRS, respectively 2.
• Early recognition and treatment of HRS are crucial to improve outcomes 2, 3, 4, 5, 6.
• The choice of treatment should be individualized based on the patient's specific needs and circumstances 3, 6.