What is the management of type II hepatorenal syndrome?

Management of Type II Hepatorenal Syndrome

The management of type II hepatorenal syndrome should include liver transplantation as the definitive treatment, with vasoconstrictor therapy plus albumin as a bridge to transplantation or for patients who are not transplant candidates. 1, 2

Diagnostic Criteria

• Diagnosis requires 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
• Type II HRS is characterized by a more stable kidney failure compared to the rapidly progressive Type I HRS, with its main clinical manifestation being refractory ascites 3
• Diagnostic paracentesis should be performed to rule out spontaneous bacterial peritonitis, which can precipitate HRS 4

Pharmacological Management

• Terlipressin plus albumin is the first-line pharmacological treatment for HRS, with an initial dose of 1 mg IV every 4-6 hours, increasing stepwise to a maximum of 2 mg every 4 hours if serum creatinine doesn't decrease by at least 25% after 3 days 1
• In regions where terlipressin is unavailable, midodrine plus octreotide plus albumin is an alternative treatment, with midodrine titrated up to 12.5 mg orally three times daily, octreotide 200 μg subcutaneously three times daily, and albumin 10-20 g IV daily for up to 20 days 1
• Norepinephrine plus albumin is another treatment option, requiring an ICU setting, with a goal to increase mean arterial pressure by 15 mmHg 1, 4
• The combination of octreotide, midodrine, and albumin has shown benefit in improving renal function and short-term survival in both type 1 and type 2 HRS 5

Non-Pharmacological Management

• Transjugular intrahepatic portosystemic shunts (TIPS) has been shown to improve renal function and the control of ascites in patients with type 2 HRS 6
• TIPS may be useful in maintaining patients who have initially responded to pharmacological therapy, though its applicability is limited due to contraindications in many patients 7
• Renal replacement therapy may be useful in patients who do not respond to vasoconstrictor therapy and who fulfill criteria for renal support, but there are very limited data on artificial liver support systems 6

Definitive Treatment

• Liver transplantation is the treatment of choice for both type 1 and type 2 HRS, with survival rates of approximately 65% in type 1 HRS 6, 1
• Patients with type 2 HRS should be referred for liver transplantation evaluation, as this represents the definitive treatment 1, 2
• Treatment of HRS before transplantation (with vasoconstrictors) may improve outcome after transplantation 6

Prevention of HRS

• Norfloxacin (400 mg/day) can reduce the incidence of HRS in advanced cirrhosis 6, 1
• Pentoxifylline (400 mg three times a day) has been shown to prevent the development of HRS in patients with severe alcoholic hepatitis 6, 1
• Albumin infusion with antibiotics when treating spontaneous bacterial peritonitis can help prevent HRS development 8

Important Considerations and Pitfalls

• Careful monitoring of urine output, fluid balance, arterial pressure, and standard vital signs is essential during treatment 2
• Patients with type 2 HRS may progress to type 1 HRS if left untreated 5
• Avoid nephrotoxic drugs in patients with advanced cirrhosis to prevent hepatorenal syndrome 4
• Despite improvements in survival with current treatments, long-term prognosis remains poor without liver transplantation 7
• The reduction in serum creatinine levels after treatment and the related decrease in the MELD score should not change the decision to perform liver transplantation since the prognosis after recovering from HRS is still poor 6