What are the blood pressure goals in patients at risk for Hepatorenal Syndrome (HRS)?

Blood Pressure Management in Patients at Risk for Hepatorenal Syndrome

For patients at risk for hepatorenal syndrome (HRS), a mean arterial pressure (MAP) increase of 10-15 mmHg from baseline is the optimal blood pressure target to improve outcomes and reduce mortality. 1

Understanding HRS and Blood Pressure Targets

• HRS is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and carries a high mortality rate approaching 90% within three months of diagnosis if untreated 2
• The pathophysiologic cascade of HRS begins with splanchnic vasodilation and pooling of blood, resulting in decreased effective circulating arterial volume 3
• Maintaining adequate blood pressure is critical as studies show that improvement in kidney function during vasoconstrictor therapy directly correlates with increases in mean arterial pressure (MAP) 4
• A change in MAP during treatment is the sole independent predictor for patient survival in HRS patients 1

Specific Blood Pressure Goals

• For patients with cirrhosis at risk for HRS, aim for a MAP increase of at least 10 mmHg from baseline during treatment 1
• Increasing MAP beyond 15 mmHg does not result in further improvement in clinical outcomes 1
• For patients with diabetes and chronic kidney disease (CKD), a blood pressure goal of less than 130/80 mmHg is recommended 5
• For elderly patients (≥65 years) with cirrhosis, a systolic blood pressure (SBP) goal of 130-139 mmHg is appropriate to balance cardiovascular protection while avoiding hypotension 6

Treatment Approach for HRS Prevention

• For patients with spontaneous bacterial peritonitis (SBP), which is the most important risk factor for HRS, treatment with albumin infusion plus antibiotics significantly reduces the risk of developing HRS 6
• Vasoconstrictors combined with albumin are the cornerstone of HRS treatment, with the goal of increasing MAP 7
• For type 1 HRS, treatment options include:
  • Terlipressin plus albumin (now FDA-approved in the US) 7
  • Midodrine and octreotide plus albumin (10-20g IV daily for 20 days) 6
  • Norepinephrine plus albumin (in ICU setting) 6

Medication Selection and Monitoring

• RAAS blockers (ACE inhibitors or ARBs) are recommended as first-line agents for patients with diabetes, hypertension, and albuminuria 5
• For patients with cirrhosis at risk for HRS, careful monitoring of blood pressure response to vasoconstrictor therapy is essential 4
• Monitor the following parameters closely in patients at risk for HRS:
  • Urine output
  • Fluid balance
  • Arterial pressure
  • Central venous pressure (ideally) 6
• Patients with type 1 HRS should be managed in an intensive care or semi-intensive care setting 6

Special Considerations and Precautions

• Avoid excessive blood pressure lowering in patients with cirrhosis as this may precipitate HRS 6
• Patients with standing SBP <110 mmHg should be treated with extreme caution due to increased risk of hypotension and syncope 6
• For elderly patients with cirrhosis, use a stepped-care approach rather than starting with 2-drug therapy 6
• Close monitoring for adverse effects including acute kidney injury, electrolyte abnormalities, and hypotension is essential 6
• Patients with HRS should be expedited for liver transplantation evaluation, as this remains the definitive treatment 6, 7

Treatment Response Assessment

• Response to vasoconstrictor therapy is generally characterized by:
  • Progressive reduction in serum creatinine
  • Increase in arterial pressure
  • Increase in urine volume
  • Increase in serum sodium concentration 6
• Median time to response is approximately 14 days, with shorter response times in patients with lower baseline serum creatinine 6
• Predictors of positive response include serum bilirubin less than 10 mg/dl before treatment and an increase in MAP of >5 mmHg at day 3 of treatment 6