In hepatorenal syndrome, first-line treatment centres on vasoconstrictor therapy combined with albumin. When this approach does not achieve the defined renal response within the treatment window, a structured next-line strategy is required — particularly for patients who are candidates for liver transplantation.
Vasoconstrictor therapy in combination with albumin is considered to have failed when serum creatinine has not decreased to <1.5 mg/dL, or has not returned to within 0.3 mg/dL of baseline, after up to 14 days of therapy.
Once vasoconstrictor therapy is no longer adequate — with worsening renal function, electrolyte disturbances, or increasing volume overload that does not respond — a renal replacement approach becomes relevant for eligible liver transplant candidates. The preferred modality in this setting depends on haemodynamic status.