What is the treatment for hepatorenal syndrome?

Treatment of Hepatorenal Syndrome

Terlipressin plus albumin is the most effective first-line treatment for hepatorenal syndrome, with significantly higher rates of renal function recovery compared to alternative regimens. 1

First-Line Treatment Options

Vasoconstrictor Therapy + Albumin

1. Terlipressin + Albumin (First Choice)

   • Dosage: Start at 0.85 mg IV every 6 hours
   • Albumin: 1.5 g/kg on day 1, followed by 20-40 g/day thereafter
   • Can be titrated up to 12 mg/24 hours if no response 1
   • Significantly more effective than midodrine/octreotide (70.4% vs 28.6% recovery rate) 2

2. Alternative Vasoconstrictors (If Terlipressin Unavailable)

   • Norepinephrine + Albumin

     • Dosage: 0.5-3 mg/h continuous infusion
     • Requires ICU setting
     • More effective than midodrine/octreotide (57.6% vs 20% response rate) 3

   • Midodrine + Octreotide + Albumin

     • Midodrine: Start at 7.5 mg orally TID, titrate up to 12.5 mg TID
     • Octreotide: Start at 100 μg SC TID, titrate up to 200 μg TID
     • Albumin: 20-40 g/day IV
     • Can be administered outside ICU setting 1

Patient Selection and Monitoring

Before Starting Treatment

• Confirm HRS diagnosis using International Ascites Club criteria:

  • Cirrhosis with ascites
  • Acute kidney injury
  • No response to diuretic withdrawal and albumin
  • Absence of shock
  • No current/recent nephrotoxic drugs 1

• Important Considerations:

  • Patients with serum creatinine >5 mg/dL are unlikely to benefit
  • Assess oxygenation status (do not start if SpO2 <90%)
  • Evaluate volume status and ACLF grade (higher grades have increased risk of respiratory failure) 1

During Treatment

• Monitor:
  • Serum creatinine (response marker)
  • Blood pressure and heart rate
  • Urine output
  • Signs of ischemic complications (particularly with vasoconstrictors) 1
  • Serum sodium (stop diuretics if 121-125 mmol/L with elevated creatinine) 1

Definitive Treatment

Liver Transplantation

• Liver transplantation is the only curative treatment for HRS 1, 4
• Expedited referral should be considered for all patients
• Treatment with vasoconstrictors before transplantation may improve outcomes 5
• Combined liver-kidney transplantation may be considered for patients with prolonged renal support (>12 weeks) 5

Bridge Therapies

1. Transjugular Intrahepatic Portosystemic Shunt (TIPS)

   • May improve renal function in selected patients
   • Limited applicability due to contraindications in many HRS patients 5
   • Can be considered in combination with vasoconstrictor therapy 4

2. Renal Replacement Therapy

   • Hemodialysis or continuous venovenous hemofiltration
   • Useful as bridge to transplantation in non-responders to vasoconstrictors 5, 1

Prevention Strategies

• Treat or prevent precipitating factors (especially GI bleeding and bacterial infections)
• Avoid nephrotoxic medications
• Avoid large volume paracentesis without albumin administration
• Administer IV albumin with antibiotics in patients with spontaneous bacterial peritonitis
• Use non-selective beta-blockers with caution in patients with refractory ascites 1

Prognosis and Pitfalls

Prognosis

• Despite treatment, prognosis remains poor (median survival ~3 months without transplantation)
• Relapse is common without liver transplantation
• Higher baseline serum creatinine predicts poorer response to vasoconstrictors 1

Common Pitfalls

1. Delayed Treatment

   • Early diagnosis and treatment are critical for improving outcomes
   • Delaying treatment significantly worsens prognosis 1

2. Inadequate Monitoring

   • Patients on vasoconstrictors require close monitoring for adverse effects
   • Ischemic complications can occur with vasoconstrictor therapy 1

3. Misdiagnosis

   • Differentiating HRS from acute tubular necrosis is challenging but crucial
   • Vasoconstrictors are not indicated for ATN 6

4. Inadequate Albumin Administration

   • Albumin plays a crucial role beyond volume expansion
   • Proper dosing is essential for treatment success 1