From the Guidelines
Hepatorenal syndrome (HRS) is classified into two main types: Type 1 and Type 2, as defined by the most recent and highest quality study 1.
Classification of HRS
The classification of HRS into two types is based on the rate of progression of renal dysfunction.
- Type 1 HRS is characterized by a rapid and progressive impairment in renal function, with an increase in serum creatinine of equal to or greater than 100% compared to baseline to a level higher than 2.5 mg/dl in less than 2 weeks 1.
- Type 2 HRS is characterized by a stable or less progressive impairment in renal function, often associated with refractory ascites 1.
Diagnostic Criteria
The diagnostic criteria for HRS include serum creatinine >1.5 mg/dl, absence of shock, absence of hypovolemia, no current or recent treatment with nephrotoxic drugs, and absence of parenchymal renal disease as defined by proteinuria <0.5 g/day, no microhaematuria (<50 red cells/high powered field), and normal renal ultrasonography 1.
Management
Management of HRS typically includes vasoconstrictors like terlipressin or norepinephrine combined with albumin to improve effective arterial blood volume, as recommended by the most recent guidelines 1.
- Terlipressin is given as a continuous IV infusion, starting at 2 mg/day, increased every 24-48 hours up to 12 mg/day until creatinine decreases, in combination with albumin infused at a dose of 1 g/kg on day 1 of therapy followed by 40-50 g/day 1.
- Norepinephrine is given as a continuous IV infusion, typically in an intensive care unit setting, starting at 0.5 mg/hour to achieve an increase in mean arterial pressure of at least 10 mm Hg or an increase in urine output of >200 mL/4 hours, in combination with albumin to maintain a central venous pressure between 4 and 10 mm Hg 1.
Prognosis
The prognosis of HRS is poor, with a median survival of approximately two weeks without treatment for Type 1 HRS, and about six months for Type 2 HRS 1. Liver transplantation remains the definitive treatment for eligible patients, as it addresses the underlying liver dysfunction that drives the pathophysiological changes in renal function 1.
From the Research
Types of Hepatorenal Syndrome (HRS)
Characteristics of Type 1 HRS
- Type 1 HRS is characterized by a rapid deterioration in kidney function in patients with cirrhosis 2
- It shows a rapid and progressive decline in renal function with a very poor prognosis (median survival of about 2 weeks) 3
- It is diagnosed when the serum creatinine level increases by more than 50% of the baseline value to above 133 micromol/L 5
Characteristics of Type 2 HRS
- Type 2 HRS has a more stable kidney failure, with a median survival of 6 months 3
- Its main clinical manifestation is refractory ascites 3
- It is characterized by a stable or slowly progressive renal failure 6