From the Guidelines
Hepatorenal syndrome (HRS) management should prioritize vasoconstrictors, specifically terlipressin, in combination with albumin, as the first-line therapeutic approach, with transjugular intrahepatic portosystemic shunt (TIPS) considered in select patients who have failed medical therapy. The primary management approach for HRS involves vasoconstrictors combined with albumin, typically terlipressin 1-2 mg IV every 4-6 hours or norepinephrine 0.5-3 mg/hour, along with albumin 20-40g/day 1.
Key Considerations
- Terlipressin is the preferred vasoconstrictor due to its efficacy in improving renal function and short-term survival in patients with HRS 1.
- Albumin is administered in combination with terlipressin to enhance the efficacy of treatment on circulatory function and to provide antioxidant and anti-inflammatory properties 1.
- TIPS may be considered for suitable candidates with MELD scores <18-20, no severe liver failure, no hepatic encephalopathy, and no significant cardiac dysfunction, as it can improve renal function in 60-70% of appropriate candidates 1.
- Liver transplantation remains the definitive treatment for patients with HRS and end-stage liver disease, with TIPS serving as a bridge to transplantation in many cases 1.
Treatment Approach
- Terlipressin should be started at a dose of 1 mg/4–6 h and increased to a maximum of 2 mg/4–6 h if there is no reduction in serum creatinine of at least 25% compared to the baseline value at day 3 of therapy 1.
- Albumin should be administered at a dose of 20-40g/day, with the dose adapted according to the level of central venous pressure (CVP) to prevent circulatory overload 1.
- Treatment should be maintained until a complete response (serum creatinine below 1.5 mg/dl) or for a maximum of 14 days, either in case of partial response or in case of non-response 1.
Monitoring and Complications
- Patients on terlipressin need to be monitored for the development of ischemic complications, such as arrhythmia, angina, and splanchnic and digital ischemia 1.
- TIPS is contraindicated in patients with severe liver failure, recurrent hepatic encephalopathy, heart failure, pulmonary hypertension, or active infection, and requires close monitoring for complications including encephalopathy, shunt thrombosis, and heart failure 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).
- Hepatorenal Syndrome Management: Terlipressin may be used to manage hepatorenal syndrome by increasing renal blood flow.
- Key Mechanism: Reducing portal hypertension and increasing mean arterial pressure (MAP) to improve renal function.
- Administration: Terlipressin is administered intravenously, with a dose of 0.85 mg shown to increase MAP and decrease heart rate in patients with hepatorenal syndrome type 1 (HRS-1) 2.
- Tips for Management:
- Monitor blood pressure and heart rate closely after administration.
- Be aware of the potential for increased renal blood flow and improved renal function.
- Consider the pharmacokinetics and pharmacodynamics of terlipressin when managing patients with hepatorenal syndrome.
From the Research
Hepatorenal Syndrome Management
Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis, characterized by oliguria, severe urinary sodium retention, and elevated serum creatinine levels 3. The management of HRS involves a combination of pharmacological therapies and supportive care.
Pharmacological Therapies
The current mainstay pharmacological therapies for HRS are vasoconstrictors, such as terlipressin, noradrenaline, and dopamine, in combination with albumin 3. Terlipressin plus albumin has been shown to be effective in the reversal of HRS, with a significantly higher rate of recovery of renal function compared to midodrine and octreotide plus albumin 4.
Alternative Treatments
Midodrine and octreotide with albumin are used as an alternative treatment for HRS, particularly in cases where terlipressin is not available 4. The combination of octreotide, midodrine, and albumin has been shown to improve survival and renal function in patients with HRS type 1 and type 2 5.
Transjugular Intrahepatic Portosystemic Stent Shunt (TIPS)
TIPS is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites, following the improvement of renal function with combination therapy of midodrine, octreotide, and albumin 6.
Standardized Approach
A standardized approach to HRS treatment using albumin, midodrine, and octreotide has been shown to improve treatment response rates and reduce the need for renal replacement therapy and liver transplantation 7. Key points to consider in HRS management include:
- Liver transplantation is the best choice of treatment for HRS, but it is rarely available 3
- Vasoconstrictors, such as terlipressin, noradrenaline, and dopamine, in combination with albumin, are the current mainstay pharmacological therapies for HRS 3
- Midodrine and octreotide with albumin are used as an alternative treatment for HRS 4
- TIPS is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites 6
- A standardized approach to HRS treatment using albumin, midodrine, and octreotide can improve treatment response rates and reduce the need for renal replacement therapy and liver transplantation 7