What is the treatment regimen for Hepatorenal Syndrome?

Treatment Regimen for Hepatorenal Syndrome

Terlipressin plus albumin is the most effective first-line treatment for hepatorenal syndrome, with a recommended dosage of 0.85 mg IV every 6 hours plus albumin 20-40 g/day. 1, 2

First-Line Treatment Options

Terlipressin + Albumin (Preferred)

• Dosing: 0.85 mg IV every 6 hours by slow intravenous bolus injection (over 2 minutes) 2
• Albumin: 20-40 g/day IV 1
• Duration: Continue for up to 14 days, adjusting dose on Day 4 based on changes in serum creatinine 2
• Monitoring:
  • Continuous pulse oximetry (discontinue if SpO2 <90%)
  • Blood pressure, heart rate, serum creatinine, urine output
  • Watch for ischemic complications 1, 2

Alternative Regimens (If Terlipressin Unavailable)

Midodrine + Octreotide + Albumin

• Midodrine: Titrate up to 12.5 mg orally three times daily 1
• Octreotide: Target dose of 200 μg subcutaneously three times daily 1
• Albumin: 10-20 g/day IV for up to 20 days 1
• This regimen can be administered outside an ICU setting and even at home 3
• Studies show improved survival compared to controls (median survival 101 days vs. 18 days) 4

Norepinephrine + Albumin

• Requires ICU setting 1
• 83% success rate in reversing type I hepatorenal syndrome in pilot studies 3

Albumin Administration Protocol

• Initial dose: 1.5 g/kg on day 1
• Follow-up: 1 g/kg on day 3 1
• Albumin plays a crucial role beyond volume expansion by preventing progression of acute kidney injury 1

Important Considerations and Contraindications

Patient Selection

• Patients with serum creatinine >5 mg/dL are unlikely to experience benefit 2
• Assess oxygenation status before initiating therapy - do not start in patients with SpO2 <90% 2
• Evaluate volume status and Acute-on-Chronic Liver Failure (ACLF) Grade 2

Contraindications for Terlipressin

• Hypoxia or worsening respiratory symptoms
• Ongoing coronary, peripheral, or mesenteric ischemia 2
• Patients with volume overload or ACLF Grade 3 are at increased risk for respiratory failure 2

Definitive Treatment

• Liver transplantation is the only curative treatment for hepatorenal syndrome 1
• Expedited referral for transplantation should be considered for all patients with cirrhosis, ascites, and hepatorenal syndrome 3, 1
• Simultaneous liver-kidney transplantation should be considered for patients with significant kidney damage 1

Adjunctive Measures

• Salt restriction to 90 mmol/day (5.2 g salt/day) 1
• Avoid nephrotoxic medications
• Avoid large volume paracentesis without albumin administration
• Use non-selective beta-blockers with caution in patients with refractory ascites 1

Monitoring Response

• Monitor serum creatinine to assess treatment response
• For patients on vasoconstrictors, monitor for adverse effects including ischemic complications 1
• Consider TIPS (transjugular intrahepatic portosystemic shunt) in selected patients 1
• Hemodialysis or continuous venovenous hemofiltration may be used as a bridge to liver transplantation 1

Pitfalls and Caveats

1. Respiratory failure risk: Terlipressin may cause serious or fatal respiratory failure, particularly in patients with volume overload or ACLF Grade 3 2

2. Delayed treatment worsens outcomes: Higher baseline serum creatinine predicts poorer response to vasoconstrictors 1

3. Octreotide alone is ineffective: Studies show octreotide must be combined with midodrine to be effective 3

4. Relapse is common: Treatment provides acute reversal of renal failure, but relapse frequently occurs without liver transplantation 5

5. Mortality remains high: Despite treatment, the prognosis for HRS patients remains poor, with a median survival of approximately 3 months 1