In liver cirrhosis complicated by hepatorenal syndrome with acute kidney injury (HRS-AKI) at stage greater than 1A, first-line treatment with terlipressin plus albumin is the established approach. When this fails to produce a complete serum creatinine response, a clearly defined next-line regimen applies.
Hepatorenal syndrome with acute kidney injury (HRS-AKI) at stage greater than 1A, complicating liver cirrhosis. Current evidence supports expeditious treatment with vasoconstrictors and albumin in all patients meeting this definition.
First-line therapy — terlipressin plus albumin — is considered to have failed when a complete response has not been achieved: serum creatinine has not returned to within 0.3 mg/dl of the baseline value, or has not fallen below 1.5 mg/dl, within the allowed treatment period. This protocol is the next step in that scenario.
An alternative vasoconstrictor agent administered by continuous intravenous infusion, used in combination with albumin, is the cornerstone of this protocol. A separate fallback combination is specified for situations where the primary alternative is not available. The full regimen — including agent selection, dose titration, and sequencing — is in the complete protocol.
DOI: 10.1016/j.jhep.2018.03.024
Vasoconstrictors and albumin are recommended in all patients meeting the current definition of AKI-HRS stage >1A, should be expeditiously treated with vasoconstrictors and albumin (III;1).
Noradrenaline can be an alternative to terlipressin. However, limited information is available (I;2).
Noradrenaline, given by continuous i.v. infusion at the dose of 0.5–3 mg/h, has been proven to be as effective as terlipressin regarding the increase in mean arterial pressure, the reversal of renal impairment and one-month survival.
Midodrine plus octreotide can be an option only when terlipressin or noradrenaline are unavailable, but its efficacy is much lower than that of terlipressin (I;1).
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