Hepatorenal Syndrome Medication

Updated: Oct 16, 2017
  • Author: Deepika Devuni, MBBS; Chief Editor: BS Anand, MD  more...
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Medication

Medication Summary

The pharmacological approach to the treatment of HRS continues to evolve, with several possible effective treatments. However, readers should be aware that none of these medications (including the addition of albumin) has been validated in randomized controlled trials. A brief review of only the most promising (but yet unproven) medications will be described because not only is this historical list extensive, but most of the trials for the medications were conducted outside the United States.

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Vasopressin analogues

Class Summary

Improve circulatory dysfunction secondary to splanchnic vasodilatation. Also improve RPF, the GFR, and urine output.

Ornipressin (POR-8)

Not available in the United States. Synthetic vasopressin analogue with a short half-life that requires continuous IV administration. V1 vasopressin receptors are abundantly expressed in the mesenteric arteries as compared with other vascular areas. Has been used in conjunction with albumin to treat HRS but is associated with ischemic complications.

Terlipressin

Not available in United States. Nonselective V1 vasopressin agonist that has similar vasoconstrictor potency to ornipressin but a lower incidence of ischemic complications. Inactive by itself but is transformed into a biologically active form (lysine-vasopressin) by the action of tissue endopeptidases and exopeptidases. Due to its longer half-life (2-10 h) compared to ornipressin, terlipressin may be administered as a bolus. It has lower incidence of adverse ischemic effects, with < 5% of cases reported in a series of 1258 patients receiving it for variceal bleeding.

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Sympathomimetic agents

Class Summary

Improve renal artery perfusion.

Dopamine (Intropin)

Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on dose. Lower doses predominantly stimulate dopaminergic receptors, which, in turn, produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation are produced by higher doses. Described for its historical interest because it has no role in monotherapy for HRS. However, reversal of HRS has been described when used at low doses in conjunction with ornipressin.

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Somatostatin analogs

Class Summary

Improvement in splanchnic circulation may improve renal hemodynamics.

Octreotide (Sandostatin)

Synthetic derivative of somatostatin. Potent physiological inhibitor of several gastrointestinal functions, one of which is a reduction in intestinal blood flow by splanchnic vasoconstriction.

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Antioxidants

Class Summary

Experimental evidence demonstrates improvement of renal function in acute cholestasis and renal failure.

N-acetylcysteine (Mucomyst)

Traditionally used to treat acetaminophen overdose. Replenishes low hepatic glutathione stores to prevent synthesis of toxic epoxide intermediates. Does not have a role in the treatment of non–acetaminophen-related liver failure. Exact mechanism of action in HRS remains unclear.

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Antibiotics

Class Summary

Are only indicated in the treatment of HRS if renal dysfunction is precipitated by an infection. Prophylactic antibiotics may play a role in preventing spontaneous bacterial peritonitis (SBP), which, in turn, is also a risk factor for the development of type 1 HRS in patients with type 2 HRS. The efficacy and safety of prophylactic antibiotics remains to be established because of reports of emergent resistant bacteria. May play an important role in selected patients, such as those awaiting liver transplantation, although the duration (long-term vs cyclic) remains to be determined.

Cefotaxime (Claforan)

Because the most common cause of type 1 HRS is SBP, IV cefotaxime is the drug of choice (DOC).

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Norfloxacin (Noroxin, Chibroxin)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

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Plasma volume expanders

Class Summary

Indicated for the correction of abnormal hemodynamic parameters.

Albumin (Albunex, Albuminar, Albumisol)

Useful for plasma volume expansion and maintenance of cardiac output.

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