Hepatorenal Syndrome: Management

Key points

• Hepatorenal syndrome (HRS) is functional renal failure in advanced liver disease from splanchnic vasodilatation and renal vasoconstriction; the definitive treatment is liver transplantation, but many patients are too unwell.
• First-line medical therapy for HRS-AKI: terlipressin (a vasopressin analogue causing splanchnic vasoconstriction) WITH IV albumin; noradrenaline is an alternative in the ICU.
• Volume expansion with 20% human albumin supports circulating volume and is combined with the vasoconstrictor.
• Transjugular intrahepatic portosystemic shunt (TIPS) in selected patients; renal replacement therapy as a bridge to transplant. Treat precipitants (SBP/sepsis, GI bleeding) and stop diuretics/nephrotoxins.