Treatment for Hepatorenal Syndrome
The first-line treatment for hepatorenal syndrome is vasoconstrictor therapy combined with albumin, with liver transplantation being the definitive treatment for suitable candidates. 1
Types of Hepatorenal Syndrome
Hepatorenal syndrome is classified into two types:
- HRS-AKI (formerly Type 1): Rapidly progressive renal impairment with median survival of approximately 1 month without treatment
- HRS-CKD (formerly Type 2): Stable or slowly progressive renal impairment
Diagnostic Criteria
Diagnosis requires all of the following:
- Advanced chronic or acute liver failure with portal hypertension
- Serum creatinine >1.5 mg/dL
- No improvement in renal function after diuretic withdrawal and plasma volume expansion with 1.5 L of isotonic saline
- Absence of shock, ongoing bacterial infection, recent nephrotoxic drug use, or massive fluid losses
- <500 mg/dL proteinuria and no ultrasonographic evidence of obstructive uropathy or parenchymal kidney disease 2, 1
Treatment Algorithm
1. First-Line Pharmacological Treatment
- Vasoconstrictor therapy plus albumin:
- Terlipressin + albumin: Most effective option where available 1
- Midodrine + octreotide + albumin: Alternative when terlipressin unavailable
- Midodrine: Titrate up to 12.5 mg orally three times daily
- Octreotide: Target dose 200 μg subcutaneously three times daily
- Albumin: 10-20 g intravenously daily for 20 days 2
- Norepinephrine + albumin: Alternative requiring intensive care unit monitoring 2
2. Renal Replacement Therapy
- Hemodialysis or continuous venovenous hemofiltration/hemodialysis for:
- Control of azotemia
- Maintenance of electrolyte balance
- Bridge to liver transplantation 2
3. Definitive Treatment
- Liver transplantation: The only curative treatment for hepatorenal syndrome 2, 1
- Simultaneous liver-kidney transplantation: Consider for patients with significant kidney damage 1
Monitoring During Treatment
- Urine output
- Fluid balance
- Arterial pressure
- Central venous pressure
- Serum creatinine
- Adverse effects of vasoconstrictors 1
Treatment Efficacy and Considerations
- Combination of midodrine, octreotide, and albumin has shown superior results compared to dopamine and albumin alone 2
- A retrospective study showed reduced mortality (43% vs 71%) with octreotide/midodrine/albumin compared to albumin alone 2
- Norepinephrine plus albumin has shown 83% success in reversing type I hepatorenal syndrome in a pilot study 2
- TIPS (transjugular intrahepatic portosystemic shunt) may be considered in selected patients 2
Important Caveats
- Early diagnosis and treatment are critical for improving outcomes
- Higher baseline serum creatinine predicts poorer response to vasoconstrictors
- Differentiating hepatorenal syndrome from acute tubular necrosis is challenging but essential as treatment approaches differ
- Non-selective beta-blockers should be used with caution in patients with refractory ascites
- Without liver transplantation, even with vasoconstrictor therapy, mortality remains high 1, 3
Prevention Strategies
- Intravenous albumin infusion in patients with spontaneous bacterial peritonitis
- Oral pentoxifylline in patients with acute alcoholic hepatitis 4
Hepatorenal syndrome represents a severe complication of end-stage liver disease with poor prognosis, making prompt recognition and appropriate management essential to improve patient outcomes.