The Diagnosis and Management of Hepatorenal Syndrome: A Comprehensive Update for the Intensivist.

Intensivists are being increasingly tasked with caring for critically ill patients with cirrhosis (ie, acute-on-chronic liver failure), many of whom develop acute kidney injury (AKI). Among the most morbid and complex causes of AKI in patients with cirrhosis is hepatorenal syndrome (HRS-AKI). Though HRS-AKI accounts for a fraction of AKI cases in the setting of cirrhosis, recent data suggest that effective pharmacologic treatment of HRS-AKI requires rapid diagnosis to allow for prompt intervention. Consequently, a firm understanding of the diagnosis and treatment of HRS-AKI is vital for all intensivists. In this review, we summarize recent developments in the diagnosis and treatment of HRS-AKI. Chief among these is the recent realization that HRS-AKI is not a diagnosis of exclusion, but instead may coexist with other forms of AKI, such as acute tubular injury, or may develop in the context of pre-existing chronic kidney disease. Moreover, with multiple recent trials suggesting that administration of fixed doses of intravenous albumin to unselected patients with cirrhosis and AKI may cause harm via volume overload and pulmonary edema, no longer is a 48-h trial of intravenous albumin recommended for all patients with AKI and cirrhosis. Instead, the newest guidelines recommend thoughtful assessment of volume status in all patients with AKI and cirrhosis and determination of an HRS-AKI diagnosis within 24 h to allow for prompt initiation of effective therapy. Short of liver transplantation, treatment of HRS-AKI is with vasoconstrictive agents. Though commonly used, midodrine/octreotide should largely be abandoned due to lack of efficacy. While recent trials have confirmed the effectiveness of terlipressin, its use is associated with a risk of potentially fatal respiratory failure and therefore requires careful patient selection and monitoring. As such, treatment of HRS-AKI with norepinephrine in the intensive care unit will remain the primary treatment option for many patients.