T. Tomy Saputra, S.

Ked/I11108030
Kepaniteraan Klinik Ilmu Penyakit Dalam
RST. Kartika Husada FK Untan 2015

JOURNAL READING
Medical Management of Hepatorenal Syndrome
Andrew Davenport, Jawad Ahmad, Ali Al-Khafaji, John A. Kellum, Yuri S. Genyk and Mitra K. Nadim

Introduction
Hepatorenal syndrome (HRS) is defined as the occurrence of renal dysfunction (functional renal
failure) in a patient with end-stage liver cirrhosis in the absence of another identifiable cause of
renal failure (renal pathology). The International Ascites Club defined HRS in 1996, on the basis of
a series of major inclusion criteria which were later revised in 2007 and subdivided into Types 1 and
2. Type 1 HRS is characterized by a progressive impairment in renal function and a significant
reduction in creatinine clearance within 12 weeks of presentation. Type 2 HRS is characterized by
a reduction in glomerular filtration rate with an elevation of serum creatinine level, but it is fairly
stable and is associated with a better outcome than that of Type 1 HRS.
Results
General management strategies:
1. Prevention of HRS
Type 1 HRS patients should be closely monitored and precipitating factors including bacterial
infection should be actively sought and treated (not graded). Drugs reducing renal perfusion or
directly causing nephrotoxicity should be avoided when possible. Exposure to contrast should be
minimized.
2. Assesement of intravascular volume in patients with cirrhosis
Excessive administration of fluids should be avoided to prevent volume overload
3. Fluid resuscitation in HRS
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 2040
g/day) in combination with vasopressor therapy (1A), for up to 14 days.
4. Paracentesis
In cirrhotics, paracentesis is typically performed for symptomatic relief
5. Pharmacological treatment of HRS
Vasoconstrictors: vasopressin, terlipressin, norepinephrine (noradrenaline), octreotide and
midodrine, Other agents (Ornipressin). Albumin + terlipressin (vasopressin/
norepinephrine/octreotide and midodrine/Ornipressin) up to 14 days
Conclusions
1.
Although the introduction of terlipressin and albumin has improved the outlook for patients
with HRS, only ~50% of patients respond to therapy
2.
In addition, the effects of changes in IAP on renal function in patients with HRS have not
been explored and may need to be considered in terms of renal perfusion pressure, along with
MAP