What is the best medical management of hepatorenal syndrome?

The Bottom Line: Although the introduction of terlipressin and albumin has improved the outlook for patients with HRS, <50% of patients respond to therapy.

Reference: Davenport A, Ahmad J, Al-Khafaji A, Kellum JA, Genyk YS, Nadim MK.  Medical management of hepatorenal syndrome. Nephrol Dial Transplant. 2012 Jan;27(1):34-41.   

Summary: Excessive administration of fluids should be avoided to prevent volume overload due to the presence of kidney injury and development or progression of dilutional hyponatremia. Traditional methods based on clinical examination and static measurements of CVP and PCWP are of questionable accuracy in  predicting volume responsiveness and should not be relied on. Functional hemodynamic monitoring should be used where possible to assess the dynamic response to a fluid volume bolus. Patients with HRS should be optimally resuscitated, with intravenous administration of albumin (initially 1 g of albumin/kg of body weight, up to a maximum of 100 g, followed by 20–40 g/day) in combination with vasopressor therapy, for up to 14 days. Patients with Type 1 HRS should be optimally resuscitated with albumin (initially 1 g of albumin/kg of body weight for 2 days, up to a maximum of 100 g/day, followed by 20–40 g/day) in combination with a vasoconstrictor, preferentially terlipressin. If terlipressin is unavailable, alternative vasoconstrictors, such as norepinephrine or combination octreotide/midodrine, together with albumin should be considered. Therapy should be discontinued after 14 days in non-responders and only continued thereafter in partial responders while awaiting the outcome of salvage techniques.