What is the general management of Hepatorenal Syndrome (HRS)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
DS

Dainyal Siddiqui, MD

Internal Medicine

MJ

Manuel Jimenez, MD

Cardiology

FP

Franz Pierre-Louis, MD

Infectious Disease

Article Review Status
Submitted
Under Review
Approved

Last updated: April 25, 2025 • View editorial policy

From the Guidelines

The general management of hepatorenal syndrome (HRS) should prioritize the use of terlipressin as the first-line vasoconstrictor, administered as an intravenous bolus of 1-2 mg every 6 hours for up to 14 days, in combination with albumin infusion, to improve renal function and reduce mortality. This approach is supported by the most recent and highest quality study, which demonstrated that terlipressin, when used in combination with albumin, can improve renal function and short-term survival in patients with HRS 1. The use of terlipressin should be initiated as soon as possible, as higher pretreatment serum creatinine is associated with treatment failure.

Key Components of HRS Management

  • Discontinuing nephrotoxic medications, diuretics, and beta-blockers to prevent further renal injury
  • Ensuring adequate volume status with albumin infusion, typically 1g/kg on day 1, followed by 20-40g/day
  • Monitoring patients for response to terlipressin, typically defined as a decrease in serum creatinine by at least 25% from baseline
  • Considering alternative vasoconstrictors, such as norepinephrine or midodrine plus octreotide, if terlipressin is unavailable

Important Considerations

  • Patients on terlipressin should be monitored for the development of ischemic complications, such as arrhythmia, angina, and splanchnic and digital ischemia
  • Terlipressin should not be resumed in patients who experience cardiac or ischemic symptoms, even if the symptoms have subsided following discontinuation of treatment
  • The dose of albumin in HRS treatment has not been well established, but studies have suggested adapting the dose according to the level of central venous pressure (CVP) to prevent circulatory overload 2

Prognosis and Definitive Treatment

  • Prognosis remains poor without liver transplantation, with mortality rates exceeding 50% at one month in untreated HRS type 1
  • Liver transplantation remains the definitive treatment for HRS, and patients who respond to terlipressin and albumin may be bridged to transplantation with improved outcomes 1

From the FDA Drug Label

Terlipressin is thought to increase renal blood flow in patients with hepatorenal syndrome by reducing portal hypertension and blood circulation in portal vessels and increasing effective arterial volume and mean arterial pressure (MAP). The general management of hepatorenal syndrome with terlipressin involves increasing renal blood flow by reducing portal hypertension and increasing mean arterial pressure (MAP).

  • The mechanism of action of terlipressin is as a synthetic vasopressin analogue with selectivity for vasopressin V1 receptors.
  • The goal of treatment is to increase effective arterial volume and mean arterial pressure (MAP), which can help to improve renal function in patients with hepatorenal syndrome 3.

From the Research

General Management of Hepatorenal Syndrome

The general management of hepatorenal syndrome (HRS) involves the use of vasoconstrictors, such as terlipressin, in combination with albumin infusion.

  • Terlipressin plus albumin has been shown to be effective in improving renal function in patients with HRS, with a significantly higher rate of recovery of renal function compared to midodrine and octreotide plus albumin 4.
  • The use of terlipressin has been associated with improved survival, particularly in patients who show an improvement in renal function 5.
  • Combination treatment with octreotide, midodrine, and albumin has also been shown to improve survival and renal function in patients with HRS type 1 and type 2 6.

Treatment Options

Treatment options for HRS include:

  • Terlipressin, which has been shown to be effective in improving renal function and survival 4, 5, 7.
  • Midodrine and octreotide, which can be used in combination with albumin as an alternative treatment for HRS, particularly in patients who do not respond to terlipressin 4, 6, 8.
  • Transjugular intrahepatic portosystemic stent shunt (TIPS), which can be effective in improving renal function and sodium excretion in selected patients with cirrhosis and type 1 HRS, following improvement in systemic hemodynamics with medical treatment 8.

Key Considerations

Key considerations in the management of HRS include:

  • The importance of early recognition and treatment of HRS, as delayed treatment can lead to poor outcomes 5, 7.
  • The need for individualized treatment approaches, taking into account the patient's underlying liver disease, renal function, and other comorbidities 4, 6, 8.
  • The potential benefits and limitations of different treatment options, including terlipressin, midodrine and octreotide, and TIPS 4, 5, 6, 7, 8.

References

5
Research

Terlipressin in hepatorenal syndrome: Evidence for present indications.

Journal of gastroenterology and hepatology, 2011

Related Questions

What are the management strategies for Hepatorenal Syndrome (HRS)?
What is Hepatorenal Syndrome (HRS), a type of progressive kidney dysfunction (Impaired Renal Function) seen in individuals with severe liver disease?
What is the recommended albumin dosage for hepatorenal syndrome (HRS)?
Is it appropriate to use midodrine (midodrine) and octreotide (octreotide) with albumin instead of terlipressin (terlipressin) and albumin for a patient with hypotension requiring minimal noradrenaline (noradrenaline) support?
What are the typical urine study changes in patients with Hepatorenal Syndrome (HRS)?
Does Vyvanse (lisdexamfetamine) or Prozac (fluoxetine) cause tinnitus?
What anxiety medications, including those prescribed as needed (PRN), are suitable for someone diagnosed with Supraventricular Tachycardia (SVT) syndrome?
What is the management of a patient on chlorthalidone (a diuretic) for hypertension (HTN) with hypokalemia (low potassium level of 3.1) who is hemodynamically stable?
What is the management of a new diagnosis of migraine with aura?
What is the diagnosis and treatment for septic bursitis (infection of the bursae)?
What is the recommended dosage of clindamycin (Clindamycin) for the treatment of septic bursitis?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Ask a new Question. Chat with the Guidelines