What is the initial treatment for hepatorenal syndrome?

Initial Treatment 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

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis of hepatorenal syndrome using the following criteria:

• Cirrhosis with ascites
• Acute kidney injury (AKI)
• No response to diuretic withdrawal and plasma volume expansion with albumin
• Absence of shock
• No current/recent use of nephrotoxic drugs 1

First-Line Treatment Protocol

1. Terlipressin plus Albumin

   • Terlipressin: 0.85 mg IV every 6 hours, can be increased progressively if no response
   • Albumin: 1.5 g/kg on day 1, followed by 1 g/kg on day 3 (or 20-40 g/day) 1
   • Continue treatment for up to 14 days or until serum creatinine improves

2. Patient Assessment Before Treatment

   • Evaluate Acute-on-Chronic Liver Failure (ACLF) Grade
   • Assess oxygenation status (do not start treatment if SpO2 <90%)
   • Evaluate volume status
   • Note: Patients with serum creatinine >5 mg/dL are unlikely to benefit 1

Alternative Treatment Options

If terlipressin is unavailable (as in the United States), the following alternatives can be used, though they are less effective:

1. Midodrine + Octreotide + Albumin 1, 2

   • Midodrine: Start at 7.5 mg orally three times daily, titrate up to 12.5 mg three times daily
   • Octreotide: Start at 100 μg subcutaneously three times daily, titrate up to 200 μg three times daily
   • Albumin: 10-20 g/day IV for up to 20 days
   • Note: This regimen has shown significantly lower response rates (28.6%) compared to terlipressin plus albumin (70.4%) 2

2. Norepinephrine + Albumin (requires ICU setting) 1, 3

   • Norepinephrine: Start at 0.5 mg/h, maximum 3 mg/h
   • Albumin: 20-40 g/day
   • Note: More effective than midodrine/octreotide (57.6% vs 20% response rate) 3

Monitoring During Treatment

• Serum creatinine (to assess treatment response)
• Blood pressure and heart rate
• Urine output
• Adverse effects of vasoconstrictors (ischemic complications)
• Serum sodium (stop diuretics and give volume expansion if 121-125 mmol/L with elevated creatinine) 1

Treatment Response and Duration

• Continue treatment until serum creatinine improves or for a maximum of 14 days
• Early treatment initiation is associated with better outcomes
• Higher baseline serum creatinine predicts poorer response to vasoconstrictors 1

Important Considerations

• Liver transplantation is the only curative treatment for hepatorenal syndrome
• Expedited referral for transplantation should be considered for all patients 1
• Hemodialysis or continuous venovenous hemofiltration may be used as a bridge to liver transplantation
• Despite treatment, prognosis remains poor with median survival of approximately 3 months without transplantation 1

Prevention Strategies

• Treatment or prevention of precipitating factors (gastrointestinal bleeding, bacterial infections)
• IV albumin with antibiotics in patients with spontaneous bacterial peritonitis
• Avoid nephrotoxic medications
• Avoid large volume paracentesis without albumin administration
• Use non-selective beta-blockers with caution in patients with refractory ascites 1

Common Pitfalls to Avoid

1. Delaying treatment initiation (worsens outcomes)
2. Failing to differentiate hepatorenal syndrome from acute tubular necrosis 4
3. Not monitoring for adverse effects of vasoconstrictors
4. Overlooking the need for liver transplantation evaluation
5. Using terlipressin in patients with SpO2 <90% or volume overload (risk of respiratory failure) 1