Treatment of Hepatorenal Syndrome
Terlipressin plus albumin is the first-line pharmacological treatment for type 1 hepatorenal syndrome (HRS-AKI), while liver transplantation is the definitive treatment for both type 1 and type 2 HRS. 1, 2
Diagnostic Criteria
- HRS diagnosis requires cirrhosis with ascites, serum creatinine >1.5 mg/dL, no improvement after diuretic withdrawal and albumin volume expansion, absence of shock, no recent nephrotoxic drugs, and absence of parenchymal kidney disease 3
- Diagnostic paracentesis should be performed to rule out spontaneous bacterial peritonitis, which can precipitate HRS 4, 1
- Two types are recognized: Type 1 HRS (rapidly progressive) and Type 2 HRS (more stable, chronic course) 3
First-Line Pharmacological Treatment
- Terlipressin plus albumin is the first-line treatment for type 1 HRS 1, 3, 2
- Initial dose: 1 mg IV every 4-6 hours
- Increase stepwise to maximum 2 mg every 4 hours if serum creatinine doesn't decrease by at least 25% after 3 days
- Continue until complete response or maximum 14 days for partial response
- Limitation: Patients with serum creatinine >5 mg/dL are unlikely to benefit 2
Alternative Pharmacological Options
In regions where terlipressin is unavailable, midodrine plus octreotide plus albumin is recommended 1, 3:
Norepinephrine plus albumin is another alternative but requires ICU setting 1, 3
- Goal: Increase mean arterial pressure by 15 mmHg
Definitive Treatment
- Liver transplantation is the definitive treatment for both type 1 and type 2 HRS 4, 1, 3
- Patients with type 1 HRS should have expedited referral for liver transplantation 4, 1
- Post-transplant survival rates are approximately 65% in type 1 HRS 1, 5
Bridging Therapies
- Continuous venovenous hemofiltration/hemodialysis may be considered as a bridge to liver transplantation in selected patients 1
- TIPS (transjugular intrahepatic portosystemic shunt) has been reported effective in type 1 HRS in a small uncontrolled study but requires more evidence 4, 1
Prevention of HRS
- Albumin infusion with antibiotics when treating spontaneous bacterial peritonitis 5, 3
- Norfloxacin (400 mg/day) to reduce HRS incidence in advanced cirrhosis 1, 5
- Pentoxifylline (400 mg three times daily) to prevent HRS in severe alcoholic hepatitis 1, 5
- Avoiding nephrotoxic drugs in patients with advanced cirrhosis 3
Important Considerations and Pitfalls
- Terlipressin increases renal blood flow by reducing portal hypertension and increasing mean arterial pressure 2
- Recovery of renal function can be achieved in less than 50% of patients with HRS after terlipressin use 6
- Untreated type 1 HRS has a poor prognosis with median survival of approximately 1 month 5, 7
- Differentiating HRS from acute tubular necrosis is challenging but important as vasoconstrictors are not indicated for ATN 8
- Careful monitoring of urine output, fluid balance, arterial pressure, and vital signs is essential during treatment 5