Noradrenaline Plus Albumin in Hepatorenal Syndrome Management
Noradrenaline plus albumin is an effective alternative to terlipressin plus albumin for treating hepatorenal syndrome, particularly in patients with central venous access in ICU settings. 1
Diagnostic Criteria for Hepatorenal Syndrome
- Diagnosis requires all of the following criteria 1:
- Cirrhosis with ascites
- Acute kidney injury stage 2 or 3 according to KDIGO criteria
- No response after 2 consecutive days of diuretic withdrawal and plasma volume expansion with albumin (1 g/kg)
- Absence of shock
- No recent use of nephrotoxic drugs
- No macroscopic signs of structural kidney injury
First-Line Treatment
- Terlipressin plus albumin is the reference treatment for hepatorenal syndrome 1
- Terlipressin is administered at an initial dose of 0.5-1 mg IV every 4-6 hours, with gradual increase to maximum 2 mg every 4-6 hours if serum creatinine doesn't decrease by >25% 1
- Treatment should continue until complete response or maximum 14 days for partial response 1
- Continuous administration of terlipressin (2-12 mg/24h) is an effective alternative to bolus dosing with fewer adverse events 1
Role of Noradrenaline Plus Albumin
- Noradrenaline is a reliable alternative to terlipressin in patients with central venous access 1
- Meta-analyses show no significant difference between terlipressin+albumin and noradrenaline+albumin in HRS reversal or relapse rates 1, 2
- Noradrenaline is administered as continuous infusion (0.5-3 mg/h) with dose increased to achieve increased arterial pressure 1, 3
- Noradrenaline plus albumin has shown 83% success rate in reversing type 1 HRS in pilot studies 3
- Recent research shows noradrenaline is significantly more effective than midodrine/octreotide combination, with 57.6% vs 20% full response rates (p=0.006) 4
Albumin Administration
- Albumin is administered at 1 g/kg before initiating vasoconstrictor treatment, followed by 20-40 g/day 1
- Albumin improves systemic hemodynamics by increasing cardiac output and through its antioxidant and anti-inflammatory properties 1
- No studies have compared vasoconstrictors alone versus vasoconstrictors plus albumin, so combination therapy remains standard 1
Alternative Treatments
- Midodrine plus octreotide plus albumin is less effective than noradrenaline and should not be the first choice when noradrenaline is available 1, 4
- TIPS (transjugular intrahepatic portosystemic shunts) may improve renal function in some patients but has limited applicability due to contraindications 1
- Renal replacement therapy may be considered as a bridge to liver transplantation in selected patients 1
Monitoring and Response Assessment
- Monitor serum creatinine, mean arterial pressure, urine output, and serum sodium concentration 1
- Response is characterized by progressive reduction in serum creatinine, increase in arterial pressure, urine volume, and serum sodium 1
- Baseline creatinine clearance, mean arterial pressure, and plasma renin activity are independent predictors of response to therapy 5
- A decrease in creatinine of ≥0.15 mg/dL/day by day 4 of therapy predicts favorable response (sensitivity 90%, specificity 75%) 5
Important Considerations and Pitfalls
- Patients with cirrhosis and ascites should undergo diagnostic paracentesis to rule out spontaneous bacterial peritonitis, which can precipitate HRS 1
- Liver transplantation remains the definitive treatment for hepatorenal syndrome 6
- Avoid nephrotoxic drugs in patients with advanced cirrhosis to prevent HRS 7
- Noradrenaline requires ICU monitoring but is significantly less expensive than terlipressin 5
- Adverse effects of vasoconstrictors include cardiac or intestinal ischemia, pulmonary edema, and distal necrosis 1