Treatment for Hepatorenal Syndrome
Terlipressin plus albumin is the first-line treatment for hepatorenal syndrome, with terlipressin started at 1 mg IV every 4-6 hours (maximum 2 mg every 4-6 hours) and albumin at 1 g/kg on day 1, followed by 20-40 g/day. 1
First-Line Treatment Options
Terlipressin Plus Albumin
- Recommended by the European Association for the Study of the Liver as first-line therapy 1
- Dosing regimen:
- Terlipressin: Start at 1 mg IV every 4-6 hours
- Increase to maximum 2 mg every 4-6 hours if serum creatinine doesn't decrease by at least 25% after 3 days
- Albumin: 1 g/kg on day 1, followed by 20-40 g/day
- Response rate: 40-50% of patients 1
- Important limitation: Patients with serum creatinine >5 mg/dL are unlikely to benefit from terlipressin 2
Alternative Treatment Options
Norepinephrine Plus Albumin
- Can be used in ICU setting 1
- Effective alternative when terlipressin is unavailable or contraindicated
Midodrine + Octreotide + Albumin
- Recommended by the American Association for the Study of Liver Diseases 1
- Dosing:
- 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
- Advantage: Can be administered outside ICU and even at home 1
Predictors of Treatment Response
- Serum bilirubin <10 mg/dL before treatment 1
- Increase in mean arterial pressure >5 mm Hg at day 3 of treatment 1
- Lower baseline serum creatinine, especially <5.0 mg/dL 1, 2
Definitive Treatment
- Liver transplantation is the only curative treatment for HRS 1
- Expedited referral for transplantation should be considered for all patients with cirrhosis, ascites, and HRS 1
- Simultaneous liver-kidney transplantation may be considered for patients with significant kidney damage 1
Bridge Therapies
- Continuous renal replacement therapy (RRT) may be used as a bridge to liver transplantation in non-responders to vasoconstrictors 1
- Transjugular Intrahepatic Portosystemic Shunt (TIPS) may be considered in selected patients with partial response to medical therapy 1
- Contraindicated in severe liver failure or significant encephalopathy
Prevention Strategies
- Norfloxacin (400 mg/day) reduces HRS incidence in advanced cirrhosis 1
- Pentoxifylline (400 mg three times daily) may prevent HRS in severe alcoholic hepatitis 1
- Treatment of spontaneous bacterial peritonitis with albumin plus antibiotics reduces risk of HRS development 1
Monitoring and Complications
- Monitor for cardiovascular complications, which occur in approximately 12% of patients treated with terlipressin 1
- Terlipressin is contraindicated in patients with known severe cardiovascular conditions 1
- Early diagnosis and treatment are critical for improving outcomes 1
- Recurrence after withdrawal of terlipressin therapy is uncommon, and retreatment is generally effective 1