How to manage a patient with hepatorenal syndrome and anasarca?

Management of Hepatorenal Syndrome with Anasarca

In patients with hepatorenal syndrome and anasarca, the recommended approach is terlipressin plus albumin as first-line pharmacological treatment, with careful monitoring of fluid status using point-of-care ultrasonography to guide therapy and avoid pulmonary complications, while pursuing liver transplantation as the definitive treatment. 1, 2

Diagnostic Considerations

• Confirm hepatorenal syndrome diagnosis by excluding other causes of acute kidney injury in cirrhotic patients with ascites, serum creatinine >1.5 mg/dL, no improvement after diuretic withdrawal and albumin administration, absence of shock, no nephrotoxic drug exposure, and no parenchymal kidney disease 1, 3
• Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis, which can precipitate hepatorenal syndrome 1, 2
• Consider using inferior vena cava ultrasound to assess intravascular volume status, as this can help distinguish true hepatorenal syndrome from pre-renal causes that may respond to additional volume management 4

Management of Anasarca in Hepatorenal Syndrome

• In patients with anasarca, carefully assess volume status before administering additional albumin to avoid worsening fluid overload and pulmonary complications 5
• Use point-of-care ultrasonography (POCUS) to objectively evaluate hemodynamics and guide fluid management decisions, as conventional physical examination has poor sensitivity 5, 4
• Monitor for signs of pulmonary edema before and during albumin administration, as patients with anasarca are at high risk for respiratory complications 5

Pharmacological Treatment

• Administer terlipressin plus albumin as first-line treatment for hepatorenal syndrome, 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, 2
• In regions where terlipressin is unavailable, use midodrine plus octreotide plus albumin as 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, 6
• Consider norepinephrine plus albumin as another treatment option, requiring ICU setting, with a goal to increase mean arterial pressure by 15 mmHg 1, 2

Albumin Administration

• Administer albumin at 1 g/kg before initiating vasoconstrictor treatment, followed by 20-40 g/day 2
• In patients with anasarca, carefully titrate albumin administration based on hemodynamic response and signs of fluid overload 7, 5
• Albumin helps support blood volume after removal of ascitic fluid and may prevent cardiovascular dysfunction 7

Diuretic Management

• Discontinue diuretics initially as part of the diagnostic criteria for hepatorenal syndrome 1, 3
• In patients with anasarca who have evidence of hypervolemia on IVC ultrasound, cautious reintroduction of diuretics may be considered after vasoconstrictor therapy has improved renal function 4
• Use furosemide with caution in hepatic cirrhosis, as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 8

Monitoring and Response Assessment

• Monitor serum creatinine, mean arterial pressure, urine output, and serum sodium concentration to assess response to therapy 2
• Carefully monitor fluid balance, especially in patients with anasarca, to avoid worsening pulmonary edema 5
• Consider central venous pressure monitoring to help manage fluid balance in patients with severe anasarca 3

Definitive Treatment

• Pursue liver transplantation as the definitive treatment for both type 1 and type 2 hepatorenal syndrome 1, 3, 2
• Expedite referral for transplantation in patients with type 1 hepatorenal syndrome 1, 3
• Continue vasoconstrictor therapy as a bridge to transplantation, as treatment of hepatorenal syndrome before transplantation may improve post-transplant outcomes 1

Important Considerations and Pitfalls

• Avoid nephrotoxic drugs in patients with advanced cirrhosis to prevent worsening of hepatorenal syndrome 2
• Be vigilant for adverse effects of vasoconstrictors including cardiac or intestinal ischemia, pulmonary edema, and distal necrosis 2
• Consider transjugular intrahepatic portosystemic shunt (TIPS) in selected patients, although evidence is limited 1, 9
• Provide adequate nutritional support with daily energy intake of 35-40 kcal/kg and protein intake of 1.2-1.5 g/kg through small frequent meals 3