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Management

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Consult expert advice

The most important part of management is prevention:

avoidance of hypotension, nephrotoxic drugs, excessive diuretic therapy or paracentesis (1,2,3)
promptly treatment of sepsis
maintenance of diuresis before and after any surgery

Once established measures include:

fluid and salt restriction
vasoconstrictors and albumin are recommended in all patients meeting the current definition of AKI-HRS stage
- such patients should be expeditiously treated with vasoconstrictors and albumin
terlipressin
- in patients with type 1 hepatorenal syndrome terlipressin may cause serious or fatal respiratory failure at a frequency higher than previously known, and that terlipressin increases the risk of sepsis and septic shock (4)
  - consider the individual benefits and risks for patients with type 1 hepatorenal syndrome when initiating terlipressin treatment, especially for those with severe renal or hepatic impairment and monitor all patients closely during terlipressin treatment
albumin solution (20%) should be used at a dose of 20-40 g/day
noradrenaline can be an alternative to terlipressin. However, limited information is available (3)
- in contrast to terlipressin, the use of noradrenaline always requires a central venous line and, in several countries, the transfer of the patient to an ICU. Midodrine plus ctreotide can be an option only when terlipressin and noradrenaline are unavailable, but its efficacy is much lower than that of terlipressin
- adverse events related to terlipressin or noradrenaline include ischemic and cardiovascular events. Thus, a careful clinical screening including electrocardiography is recommended before starting the treatment. Patients can be treated on a regular ward, but the decision to transfer to higher dependency care should be case based. For the duration of treatment, close monitoring of patients is important. According to the type and severity of side effects, treatment should be modified or discontinued
norfloxacin (400 mg/day) should be given as prophylaxis of SBP to prevent HRS-AKI
treatment of underlying disease
liver transplantation

Both haemofiltration and dialysis are options for patients with alcoholic hepatitis plus hepatorenal syndrome if other organs are functioning well - however these measures are controversial because the chances of survival are low (1).

the in-hospital survival of patients with alcoholic hepatitis undergoing renal support is approximately 14% - this is similar to survival rates for patients receiving renal support in an ITU setting - the mortality rate is even higher for those patients also requiring ventilation

Reference:

1. Drug and Therapeutics Bulletin (2003), 41 (7), 49-52.
2. Sanyal AJ et al. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology. 2008 May;134(5):1360-8.
3. Angeli P, Garcia-Tsao G, Nadim MK, Parikh CR. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document. J Hepatol 2019;71:811-22. doi:10.1016/j. jhep.2019.07.002.
4. Terlipressin: new recommendations to reduce risks of respiratory failure and septic shock in patients with type 1 hepatorenal syndrome Drug Safety Update volume 16, issue 8: March 2023: 2.

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