Hepatorenal Syndrome - Diagnosis and Management Summary

Who gets HRS?

 • Decompensated cirrhosis

 • Typically with existing ascites

 • HypoNa+ Often present, higher risk

Often will have a precipitant: Medications, Alcohol abuse, Bacterial infection

Mainstay of treatment in HRS-AKI is vasoactive therapy + albumin

TERLIPRESSIN

Mechanism: 

 • Vasopressin agonist

 • Acts on V1 receptors

 • Splanchnic/extrarenal vasoconstriction

Dose: 2-12mg/24h (infusion)

Side effects: Diarrhea, circulatory overload, CV ischemia

NOREPINEPHRINE

Mechanism: 

 • agonist of a1 (↑ vasoconstriction), ß1 (↑ cardiac output)

Dose: 0.5-3mg/h (infusion)

Typically requires ICU

May be as effective as terlipressin though limited data

MIDODRINE+OCTREOTIDE

Mechanisms:

 • Midodrine - Selective a1 agonist, Splanchnic vasoconstriction

 • Octreotide - Inhibits release of glucagon, which is a splanchnic vasodilator

Dose:

 • Midodrine 5-15mg PO TID

 • Octreotide 50mcg/hr infusion (or 100-200mcg SQ TID)

ALBUMIN

Should be given regardless of vasoconstrictor used

Dose: 20-50 g/day of 25% albumin

Mechanism:

 • ↑ intravascular volume

 • Maintains cardiac output

 • Proposed anti-oxidant, anti-inflammatory effects



- Dr. Hersh Shroff @HershShroff



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