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Hrs management

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"Hepatorenal Syndrome"[MeSH Terms] AND treatment

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AASLD hepatorenal syndrome acute kidney injury management albumin terlipressin guidance

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https://pmc.ncbi.nlm.nih.gov/articles/PMC10524408

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PMID: 40207491

Assuming HRS means hepatorenal syndrome, now termed HRS-AKI.

Immediate management

This is a hospital-level emergency in decompensated cirrhosis.
  1. Confirm AKI and look for reversible causes
    • Stop diuretics, NSAIDs, ACE inhibitors/ARBs, nephrotoxic antibiotics, and recent contrast where possible.
    • Assess for hypovolemia, gastrointestinal bleeding, sepsis, spontaneous bacterial peritonitis, urinary obstruction, and acute tubular injury.
    • Obtain urinalysis, urine microscopy, renal ultrasound, cultures, and diagnostic ascitic tap if ascites is present.
    • Treat infection or bleeding promptly.
  2. Albumin volume challenge
    • Withdraw diuretics and give 25% albumin 1 g/kg/day, maximum 100 g/day, for 2 consecutive days, while reassessing volume status and respiratory status.
    • Avoid indiscriminate albumin in fluid-overloaded or hypoxic patients.
  3. Diagnose HRS-AKI only after non-response Typical criteria are: cirrhosis with ascites, AKI, no improvement after diuretic withdrawal plus albumin challenge, no shock, no nephrotoxin exposure, and no evidence of structural renal disease such as marked proteinuria, hematuria, or abnormal renal ultrasound. AASLD-based diagnostic criteria

Specific treatment

Use a vasoconstrictor plus albumin once HRS-AKI is established:
Preferred orderRegimenPractical point
1. Terlipressin + albuminFirst choice where availableMonitor closely for hypoxia, respiratory failure, ischemia, and volume overload. Avoid or use extreme caution with hypoxemia, pulmonary edema, or advanced ACLF.
2. Norepinephrine + albuminICU infusion, preferably central accessEffective alternative if terlipressin is unavailable or unsuitable. Titrate to improved MAP and creatinine.
3. Midodrine + octreotide + albuminWard-based fallbackLess effective than terlipressin or norepinephrine; use only when the above options cannot be given.
For terlipressin, use the local product label and hepatology protocol. US labeling commonly begins with IV dosing every 6 hours and reassesses serum creatinine after 3 days. Albumin during vasoconstrictor therapy is usually individualized by intravascular volume and pulmonary status, often 20-40 g/day. The AASLD treatment hierarchy favors terlipressin, then norepinephrine, with midodrine-octreotide as a lower-efficacy alternative. Management review

Monitoring and endpoints

  • Daily: serum creatinine, urine output, electrolytes, MAP, weight, fluid balance.
  • Frequent: oxygen saturation and signs of pulmonary edema, especially with albumin and terlipressin.
  • Stop vasoconstrictor therapy for:
    • HRS reversal or creatinine returning close to baseline
    • No renal response after an adequate protocol-defined trial
    • Serious ischemic or respiratory adverse effects
    • Need for renal replacement therapy or transplantation pathway

Definitive management

  • Urgently refer for liver transplantation assessment. Vasoconstrictors may reverse AKI or serve as a bridge, but transplant is the definitive therapy.
  • Renal replacement therapy is mainly a bridge for transplant candidates or for standard indications: refractory hyperkalemia, severe acidosis, pulmonary edema/volume overload, or uremic complications.
  • Consider ICU, hepatology, nephrology, and transplant-team involvement early.
Evidence update: a 2025 meta-analysis found terlipressin plus albumin improved HRS reversal versus albumin-based control, but did not show a clear 15- or 90-day mortality benefit. Braga et al., 2025, PMID 40207491
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