Management of hepatorenal syndrome
Hepatorenal syndrome–acute kidney injury (HRS-AKI) causes a rapid deterioration in kidney function. It can also be superimposed on hepatorenal syndrome–no acute kidney injury (HRS-NAKI).
Initial management of HRS-AKI is to correct precipitants and remove risk factors:
- correct hypovolaemia
- treat infection if present
- stop contributory drugs (eg nephrotoxins, vasodilators, beta blockers, diuretics).
If kidney function continues to deteriorate, stop diuretics (if not already stopped) and use albumin to expand plasma volume for 2 days. A typical albumin regimen is:
albumin 20%, 1 g/kg (5 mL/kg) (up to a maximum of 100 g [500 mL]) intravenously, daily for 2 days. hepatorenal syndrome
If kidney function does not improve, discuss use of terlipressin with a specialist. If appropriate, use:
terlipressin (base) 0.85 mg intravenously, 6-hourly. If response is insufficient (ie decrease in serum creatinine is less than 25% from peak value), increase the dose gradually up to a maximum of 1.7 mg intravenously, 4-hourly. Treat for 7 to 14 days12 hepatorenal syndrome terlipressin
PLUS
albumin 20%, 20 g (100 mL) intravenously, twice daily for 7 to 14 days.
Continue treatment with terlipressin and albumin until serum creatinine returns to baseline value, then taper terlipressin dosage. Treatment is usually required for at least 7 days, and should not extend beyond 14 days unless it is being used as a bridge to liver transplantation.
Patients receiving terlipressin do not need cardiac monitoring. However, terlipressin can cause systemic ischaemic adverse effects, and it should not be used in patients with diagnosed or suspected ischaemic heart disease.
Terlipressin plus albumin may lead to reversal of HRS–AKI and improvement in short-term survival. Improvement of long-term survival in the absence of liver transplantation has not been established.
Liver transplantation should be considered for patients who have had hepatorenal syndrome. It is the only definitive treatment for HRS-NAKI. Dialysis is not usually indicated for hepatorenal syndrome, other than as a bridge to liver transplantation. The role of transjugular intrahepatic portosystemic shunt (TIPS) is not established in HRS-NAKI.
In patients who have had hepatorenal syndrome but who are not eligible for liver transplantation, establish whether an advance care plan is in place, and consider referral for palliative care.