Hepatorenal syndrome (HRS)


Acute kidney Injury (AKI) and hepatorenal syndrome (HRS) in patients with liver cirrhosis; diagnostic criteria, classification and management.

Acute kidney injury stages in cirrhotic patients

diagnostic criteria hepatorenal syndrome in cirrhosis

Hepato-renal classification:
HRS type 1: characterized by a rapid and progressive impairment in renal function (increase in serum creatinine of equal to or greater than 100% compared to baseline to a level higher than 2.5 mg/dl in less than 2
HRS type 2 characterized by a stable or less progressive impairment in renal function

Diagnostische criteria (LUMC):
– chronisch of acute nierinsufficientie met ernstige leverfunctiestoornis en portale hypertensie
– serum kreat >133
– geen verbetering in nierfunctie (kreat <133) 2 dagen na staken diuretica en met plasma volume expansie met albumine infusie (1g/kg lichaamsgewicht, max 100g/dag)
– afwezigheid van shock en huidig of recent gebruik van nefrotoxische middelen
– geen aanw voor parenchymateuze nierziekte, zich uitend als proteinurie >500mg/dag, microscopische hematurie, of afwijkende bevindingen aan nieren bij echo

Management of type 1 hepatorenal syndrome
Terlipressin (1 mg/4–6 h intravenous bolus) in combination with albumin should be considered the first line therapeutic agent for type 1 HRS.
The aim of therapy is to improve renal function sufficiently to decrease serum creatinine to less than 133 umol/L (1.5 mg/dl) (complete response).
If serum creatinine does not decrease at least 25% after 3 days, the dose of terlipressin should be increased in a stepwise manner up to a maximum of 2 mg/4 h.

Management of type 2 hepatorenal syndrome
Terlipressin plus albumin is effective in 60–70% of patients with type 2 HRS. There are insufficient data on the impact of this treatment on clinical outcomes .

Contra-indications Terlipressin
Ischemic cardiovascular diseases. Patients on terlipressin should be carefully monitored for development of cardiac arrhythmias or signs of splanchnic or digital ischemia, and fluid overload, and treatment modified or stopped accordingly. Recurrence of type 1 HRS after discontinuation of terlipressin therapy is relatively uncommon. Treatment with terlipressin should be repeated and is frequently successful

Behandeling (LUMC protocol):
– maak voor start terli een ECG (terlipressine is vaso-actieve stof)
– start terlipressine 6dd 0.5 ampul en 2 dd 20 gram albumine
– op dag 3: als baseline kreat niet met 25% is gedaald: verhoog terli naar 6 dd 1 ampul
– herhaal zn tot max 6 dd 2 ampullen
– minimale behandelduur 3 dagen, max 14 dagen (indien geen respons)