What is the treatment for Hepatorenal Syndrome (HRS)?

Treatment of Hepatorenal Syndrome (HRS)

Terlipressin plus albumin is the first-line treatment for hepatorenal syndrome, with liver transplantation being the definitive curative treatment. 1

Pharmacological Management

First-Line Therapy

• Terlipressin plus albumin:
  • Initial dose: 1 mg IV every 4-6 hours 2
  • Albumin: 1.5 g/kg on day 1, followed by 1 g/kg on day 3 1
  • If serum creatinine doesn't decrease by at least 25% after 3 days, increase terlipressin dose stepwise to maximum 2 mg/4 hours 2
  • Treatment goal: Decrease serum creatinine to <133 μmol/L (1.5 mg/dL) 2
  • Maximum treatment duration: 14 days if no response 2

Alternative Vasoconstrictors (if terlipressin unavailable)

• Midodrine + Octreotide + Albumin:

  • Midodrine: Start at 2.5 mg orally TID, titrate up to 12.5 mg TID 1
  • Octreotide: 100 μg SC TID, increase to 200 μg TID 1
  • Albumin: 10-20 g/day IV for up to 20 days 1
  • Advantage: Can be administered outside ICU or even at home 1

• Norepinephrine + Albumin:

  • Requires ICU setting 1
  • Dose: 0.5-3 mg/hour as continuous infusion 2

Non-Pharmacological Management

Liver Transplantation

• Definitive treatment for both type 1 and type 2 HRS 2, 3
• Survival rates approximately 65% in type 1 HRS 2
• Patients with HRS should receive priority for transplantation due to high mortality while on waiting list 2
• Combined liver-kidney transplantation should be considered for patients who have been on prolonged renal support therapy (>12 weeks) 2

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• May improve renal function in selected patients 2
• Limited applicability due to contraindications in many patients 2
• Insufficient data to support routine use for type 1 HRS 2

Renal Replacement Therapy

• Useful in patients who don't respond to vasoconstrictor therapy and fulfill criteria for renal support 2
• Can serve as bridge to liver transplantation 1
• Options include hemodialysis or continuous venous hemofiltration 2

Monitoring During Treatment

• Serum creatinine to assess treatment response 1
• Blood pressure and heart rate 1
• Urine output 1
• Monitor for adverse effects of vasoconstrictors, particularly ischemic complications 1
• Assess oxygenation status (don't start treatment if SpO2 <90%) 1
• Monitor for hyponatremia (stop diuretics and give volume expansion if serum sodium 121-125 mmol/L) 1

Preventive Measures

• Avoid nephrotoxic medications 1
• Avoid large volume paracentesis without albumin administration 1
• Use non-selective beta-blockers with caution in patients with refractory ascites 1
• Consider pentoxifylline (400 mg three times daily) in patients with severe alcoholic hepatitis 2
• Norfloxacin (400 mg/day) can reduce HRS incidence in advanced cirrhosis 2

Important Clinical Considerations

• Early diagnosis and treatment are critical for improving outcomes 1
• Higher baseline serum creatinine predicts poorer response to vasoconstrictors 1
• Despite treatment, prognosis remains poor with median survival of approximately 3 months without transplantation 1, 4
• Treatment with vasoconstrictors before transplantation may improve post-transplant outcomes 2
• Reduction in serum creatinine after treatment should not change the decision to perform liver transplantation, as prognosis after recovering from type 1 HRS remains poor 2

Treatment Algorithm

1. Diagnose HRS (cirrhosis with ascites, acute kidney injury, no response to diuretic withdrawal and volume expansion)
2. Start terlipressin + albumin as first-line therapy
3. Monitor response (target: decrease in serum creatinine)
4. If no response after 3 days, increase terlipressin dose
5. If no response after 14 days, discontinue treatment
6. Consider renal replacement therapy for non-responders
7. Refer for liver transplantation evaluation (definitive treatment)