From the Guidelines
The primary treatment target for Hepatorenal Syndrome (HRS) is to improve renal perfusion by addressing splanchnic vasodilation and the resulting renal vasoconstriction, with the goal of reducing serum creatinine levels and improving patient outcomes, as supported by the most recent study 1.
Treatment Approach
The treatment approach for HRS typically involves the use of vasoconstrictors combined with albumin.
- The first-line regimen is terlipressin, which is administered as an intravenous bolus dose of 1-2 mg every 6 hours for up to 14 days, as recommended in the study 1.
- Albumin is also administered at a dose of 1 g/kg on day 1 of therapy, followed by 40-50 g/day, continued for the duration of therapy, as suggested in the study 1.
Alternative Treatments
If terlipressin is unavailable, norepinephrine can be used as an alternative, administered as a continuous IV infusion starting at 0.5 mg/hour, with the goal of achieving an increase in mean arterial pressure of at least 10 mm Hg or an increase in urine output of >200 mL/4 hours, as recommended in the study 1.
- For patients who cannot access these medications, the combination of midodrine and octreotide with albumin can be used, although this approach is of much lower efficacy than terlipressin, as noted in the study 1.
Concurrent Management
Concurrent management should include discontinuing diuretics, nephrotoxic drugs, and beta-blockers while maintaining adequate intravascular volume, as supported by the study 1.
- Liver transplantation remains the definitive treatment for eligible patients with HRS, as it addresses the underlying liver dysfunction that triggers the pathophysiological cascade, as recommended in the study 1.
Monitoring and Side Effects
Patients on terlipressin need to be monitored for the development of ischemic complications, such as arrhythmia, angina, and splanchnic and digital ischemia, as noted in the study 1.
- The risk of ischemic side effects related to terlipressin may be reduced by administration of the drug in a continuous IV infusion, as suggested in the study 1.
From the FDA Drug Label
Terlipressin is thought to increase renal blood flow in patients with hepatorenal syndrome by reducing portal hypertension and blood circulation in portal vessels and increasing effective arterial volume and mean arterial pressure (MAP). The treatment target for Hepatorenal Syndrome (HRS) is to increase renal blood flow by:
- Reducing portal hypertension
- Reducing blood circulation in portal vessels
- Increasing effective arterial volume
- Increasing mean arterial pressure (MAP) 2, 2, 2
From the Research
Treatment Target for Hepatorenal Syndrome (HRS)
The primary treatment target for HRS is to reverse the underlying mechanisms of the syndrome, including portal hypertension, splanchnic vasodilation, and renal vasoconstriction 3. The main goals of treatment are to:
- Improve renal function
- Increase survival rates
- Bridge patients to liver transplantation, which is the preferred definitive treatment option 3, 4, 5
Treatment Options
The treatment options for HRS can be categorized into pharmacologic and non-pharmacologic therapies.
- Pharmacologic therapies:
- Terlipressin with albumin volume expansion is the preferred pharmacologic therapy for the treatment of patients with HRS 3, 4, 6, 7
- Norepinephrine and vasopressin are acceptable alternatives in countries where terlipressin is not available 3
- Midodrine plus octreotide is an effective pharmacologic regimen for patients with Type II HRS 3, 6
- Non-pharmacologic options:
- Artificial hepatic support devices
- Renal replacement therapy
- Transjugular intrahepatic portosystemic shunt (TIPS) 3
Key Considerations
When treating HRS, it is essential to:
- Carefully monitor patients to prevent tissue ischemia and severe adverse effects 3
- Consider the classification of HRS (Type I or Type II) when selecting a treatment regimen 3, 4
- Recognize that liver transplantation is the most successful therapeutic option for patients with HRS, and that other treatments are primarily used as a bridge to transplantation 3, 4, 5