Treating Hepatorenal Syndrome in the Current Era

Area of Science:

• Gastroenterology and Hepatology
• Nephrology
• Critical Care Medicine

Background:

• Hepatorenal syndrome type 1 (HRS-1) is a critical complication of advanced cirrhosis and ascites.
• Pathogenesis involves significant renal vasoconstriction.
• Diagnosis is challenging due to the absence of a gold standard and need to exclude other acute kidney injury (AKI) causes.

Purpose of the Study:

• To review the assessment, diagnosis, and medical treatment of HRS-1.
• To highlight challenges in managing AKI in decompensated cirrhosis.
• To discuss recent findings on terlipressin and albumin in HRS-1 management.

Main Methods:

• Literature review focusing on HRS-1 pathogenesis, diagnosis, and treatment.
• Analysis of current therapeutic strategies, including vasoconstrictors (terlipressin, norepinephrine) and albumin.
• Emphasis on clinical decision-making for treatment eligibility and agent selection.

Main Results:

• Terlipressin and norepinephrine are effective vasoconstrictor therapies for HRS-1.
• Treatment goals include sustained increase in mean arterial pressure for renal perfusion.
• Albumin's role is re-evaluated; it may increase fluid overload risk, while diuretics can be safely used.

Conclusions:

• Accurate diagnosis of HRS-1 is crucial for initiating specific pharmacotherapy.
• Terlipressin is a key agent, with careful consideration of safety and logistics.
• Management paradigms are shifting, particularly concerning albumin's coadjuvant role.