Treatment of Hepatorenal Syndrome
Terlipressin plus albumin is the first-line treatment for hepatorenal syndrome to improve kidney function and reduce mortality. 1, 2
Diagnosis Confirmation
Before initiating treatment, confirm the diagnosis of hepatorenal syndrome:
- Elevated serum creatinine (>133 μmol/L or 1.5 mg/dL)
- Exclude other causes of renal failure:
- Hypovolemia
- Shock
- Parenchymal renal diseases
- Nephrotoxic drugs
- Perform diagnostic paracentesis with SAAG calculation
- Obtain abdominal and renal ultrasound with Doppler
Initial Management
- Stop diuretics immediately
- Consider withholding non-selective beta-blockers (particularly in hypotensive patients)
Treatment Algorithm
First-Line Treatment
- Terlipressin plus albumin:
- Terlipressin: Start at 1 mg IV every 4-6 hours
- Increase dose stepwise to maximum 2 mg every 4-6 hours if serum creatinine does not decrease by at least 25% after 3 days
- Albumin: 1 g/kg on day 1, followed by 20-40 g/day
- Continue until serum creatinine decreases below 1.5 mg/dL or maximum 14 days
Important limitation: Patients with serum creatinine >5 mg/dL are unlikely to benefit from terlipressin therapy 2
Alternative Treatments (if terlipressin unavailable or contraindicated)
Norepinephrine plus albumin (requires ICU setting)
Midodrine + octreotide + albumin:
- Midodrine: Titrate up to 12.5 mg orally three times daily
- Octreotide: 200 μg subcutaneously three times daily
- Albumin: 10-20 g/day IV for up to 20 days
- This regimen can be administered outside the ICU or even at home 1
Monitoring During Treatment
- Check serum creatinine daily
- Monitor for cardiovascular complications
- Assess response to treatment (target: decrease in serum creatinine)
Refractory Cases
For patients not responding to vasoconstrictors:
- Continuous renal replacement therapy (CRRT) as a bridge to liver transplantation (preferred over intermittent hemodialysis due to less hemodynamic instability)
- Transjugular Intrahepatic Portosystemic Shunt (TIPS) may be considered in selected patients with partial response to medical therapy
- Contraindicated in severe liver failure or significant encephalopathy
Definitive Treatment
- Liver transplantation is the only curative treatment for hepatorenal syndrome
- Expedited referral for transplantation should be considered for all patients with cirrhosis, ascites, and hepatorenal syndrome
- Consider simultaneous liver-kidney transplantation for patients with significant kidney damage
Prevention
- Treatment of spontaneous bacterial peritonitis (SBP) with albumin plus antibiotics reduces the risk of HRS development
Prognosis
- Despite treatment, prognosis remains poor (median survival ~3 months)
- Untreated Type 1 HRS has a median survival of approximately 1 month
- Early diagnosis and treatment are critical for improving outcomes
- Higher baseline serum creatinine predicts poorer response to vasoconstrictors