What is the management of hepatorenal syndrome?

Management of Hepatorenal Syndrome

The definitive treatment for hepatorenal syndrome is liver transplantation, while vasoconstrictor therapy with terlipressin plus albumin is the first-line pharmacological treatment for type 1 HRS to bridge patients to transplantation or treat those who are not transplant candidates. 1

Diagnostic Approach

• Diagnose HRS by excluding other causes of acute kidney injury in cirrhotic patients with advanced cirrhosis with ascites, serum creatinine >1.5 mg/dL, no improvement after at least 2 days of diuretic withdrawal and volume expansion with albumin, absence of shock, no current/recent nephrotoxic drug exposure, and absence of parenchymal kidney disease 1
• Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis, which can precipitate HRS 2

Pharmacological Management Algorithm

First-Line Treatment

• Terlipressin plus albumin is the first-line pharmacological treatment for type 1 HRS (HRS-AKI) 1
  • Initial dose: 1 mg IV every 4-6 hours
  • Increase dose stepwise to maximum of 2 mg every 4 hours if serum creatinine doesn't decrease by at least 25% after 3 days 1
  • Continue treatment until 24 hours after creatinine returns to within 0.3 mg/dL of baseline for 2 consecutive days, or for a maximum of 14 days 3
  • Contraindicated in patients with creatinine ≥5 mg/dL or oxygen saturation <90% 3

Alternative Treatments (Where Terlipressin is Unavailable)

• Midodrine plus octreotide plus albumin 1

  • Midodrine: Titrate up to 12.5 mg orally three times daily
  • Octreotide: 200 μg subcutaneously three times daily
  • Albumin: 10-20 g IV daily for up to 20 days 2
  • This regimen can be administered outside of an intensive care unit and even at home 2

• Norepinephrine plus albumin (requires ICU setting) 1

  • Goal: Increase mean arterial pressure by 15 mmHg
  • Success rate of 83% (10 of 12 patients) in reversing type 1 HRS in pilot studies 2

Albumin Administration

• Initial dose: 1 g/kg on first day
• Maintenance: 20-40 g daily throughout treatment 3
• Helps expand plasma volume and improve response to vasoconstrictors 4

Definitive Treatment

• Liver transplantation is the definitive treatment for both type 1 and type 2 HRS 1
• Patients with cirrhosis, ascites, and type 1 HRS should have expedited referral for liver transplantation 2
• Post-transplant survival rates are approximately 65% in type 1 HRS 1

Renal Replacement Therapy

• Should not be used as first-line therapy 5
• Consider as a bridge to liver transplantation in selected patients 2
• Continuous venovenous hemofiltration/hemodialysis causes less hypotension but requires continuous involvement of a dialysis nurse 2

Prevention Strategies

• Norfloxacin (400 mg/day) to reduce the incidence of HRS in advanced cirrhosis 1
• Pentoxifylline (400 mg three times daily) to prevent HRS development in patients with severe alcoholic hepatitis 1
• Intravenous albumin infusion in patients with spontaneous bacterial peritonitis can prevent HRS 6

Important Considerations and Pitfalls

• Differentiating HRS from acute tubular necrosis is crucial as vasoconstrictors are not indicated for ATN 4
• Mortality rate approaches 90% three months after diagnosis without appropriate treatment 7
• No FDA-approved treatments exist for HRS despite liver society recommendations 8
• Monitor for complications of vasoconstrictor therapy including ischemic events, arrhythmias, and respiratory effects 3
• TIPS has been reported to be effective in type 1 HRS in an uncontrolled study of 7 patients, but more evidence is needed 2