What are the guideline sources, guidelines and references for Hepatorenal syndrome ?
Guideline sources The following summarized guidelines for the evaluation and management of hepatorenal syndrome (HRS) are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2022), the American Association for the Study of Liver Diseases (AASLD 2021; 2017; 2014), the Society of Critical Care Medicine (SCCM 2020), and the European Association for the Study of the Liver (EASL 2018; 2010). 1 2 3 4 5 6 7 CalculatorDiagnostic criteria for hepatoren Guidelines 1. Screening and diagnosis https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 1/6 6/24/23, 12:41 PM Hepatorenal syndrome Pathway Differential diagnosis: As per AASLD 2021 guidelines: Evaluate and treat precipitating factors of AKI, such as fluid loss, bacterial infections, hemodynamic instability, potentially nephrotoxic agents (particularly NSAIDs). E Use the consensus criteria for the differential diagnosis of AKI, HRS and acute tubular necrosis. E As per EASL 2018 guidelines: Differentiate between pre-renal AKI, HRS, intrinsic, particularly acute tubular necrosis, and post-renal AKI. B Consider obtaining urinary neutrophil gelatinase-associated lipocalin to distinguish between acute tubular necrosis and HRS as kidney biopsy is rarely performed in the setting of AKI. C As per EASL 2010 guidelines: Exclude other common causes of renal failure (including hypovolemia, shock, parenchymal renal diseases, and use of nephrotoxic drugs) in patients with cirrhosis before a diagnosis of HRS is made. B Suspect parenchymal renal diseases in patients with significant proteinuria or microhematuria, or if renal ultrasound demonstrates abnormalities in kidney size. B Diagnostic criteria: as per EASL 2018 guidelines, diagnose HRS-AKI based on the revised ICA criteria. B 2. Classification and risk stratification Classification: Classify HRS into two types: type 1 HRS: characterized by a rapid and progressive impairment in renal function (increase in serum creatinine 100% compared to baseline, to a level > 2.5 mg/dL, within 2 weeks) type 2 HRS: characterized by a stable or less progressive impairment in renal function. A 3. Diagnostic procedures Kidney biopsy: consider performing kidney biopsy in patients with suspected parenchymal renal disease in order to orient further management, including the potential need for combined liver and kidney transplantation. B 4. Medical management General principles: decide on the management (including initiation of vasoconstrictor therapy and RRT) by a multidisciplinary team including specialists in hepatology, nephrology, critical care, and transplant surgery, if possible, given the complexity of patients with suspected HRS-AKI. E Vasoactive agents: https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 2/6 6/24/23, 12:41 PM Hepatorenal syndrome Pathway As per ACG 2022 guidelines, consider initiating terlipressin C or norepinephrine to improve renal function in hospitalized patients with cirrhosis and HRS-AKI without high-grade acute-on- chronic liver failure or major cardiopulmonary or vascular disease. C Landmark trials: CONFIRM In adult patients with type 1 hepatorenal syndrome, terlipressin was superior to placebo with respect to verified reversal of hepatorenal syndrome. Florence Wong et al. N Engl J Med. 2021 Mar 4. As per AASLD 2021 guidelines: Initiate vasoconstrictor drugs in combination with albumin as the treatment of choice in patients with HRS-AKI. Administer terlipressin either as IV bolus or continuous IV infusion as the preferred drug. E Administer norepinephrine if terlipressin is not available. Consider initiating a trial of oral midodrine (5-15 mg per os every 8 hours) in combination with octreotide (100-200 g every 8 hours or 50 g/hour IV) if neither terlipressin nor norepinephrine can be used. E As per SCCM 2020 guidelines, initiate vasopressors in critically ill patients with acute-on-chronic liver failure developing HRS. B As per EASL 2018 guidelines, initiate vasoconstrictors and albumin expeditiously in all patients meeting the current definition of AKI-HRS stage > 1A. B Show 3 more Albumin: administer albumin solution (20%) at the dose 20-40 g/day. Consider obtaining serial measurements of central venous pressure or other measures of assessing central blood volume, apart from routine monitoring, to prevent circulatory overload by optimizing the fluid balance and titrating the albumin dose. B Antibiotic therapy: Identify bacterial infection promptly by blood, urine, and ascitic fluid cultures, and administer antibiotics as appropriate. Continue prophylactic antibiotics, if previously prescribed, in patients without signs of infection. B Insufficient evidence to support the use of antibiotics as empirical treatment for unproven infection in patients presenting with type 1 HRS. I Management of beta-blockers: decrease or temporarily hold nonselective -blockers in patients with refractory ascites and HRS. Consider re-introducing if clinical status improves. E Management of diuretics: Discontinue all diuretics at the initial evaluation and diagnosis of HRS. A Consider administering furosemide to maintain urine output and treat central volume overload if present. Do not use spironolactone because of the high risk of life-threatening hyperkalemia. B https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 3/6 6/24/23, 12:41 PM Hepatorenal syndrome Pathway 5. Therapeutic procedures Renal replacement therapy: As per AASLD 2021 guidelines: Initiate RRT in candidates for liver transplantation with worsening renal function or electrolyte disturbances or increasing volume overload unresponsive to vasoconstrictor therapy. E Initiate RRT with a clear endpoint in mind in patients not being candidates for liver transplantation. E As per EASL 2018 guidelines, decide on initiating RRT based on the individual severity of illness. B Therapeutic paracentesis: consider performing large-volume paracentesis with albumin in patients with tense ascites, despite the paucity of data on the use of paracentesis in patients with HRS. B Transjugular intrahepatic portosystemic shunt: Insufficient evidence to recommend TIPS placement in patients with HRS-AKI. I Consider placing a TIPS in selected patients with HRS outside the criteria of AKI. C 6. Surgical interventions Liver transplantation: As per AASLD 2021 guidelines: Consider obtaining urgent evaluation for liver transplantation in all patients with cirrhosis and AKI because of the high short-term mortality even in responders to vasoconstrictors. E Consider performing simultaneous liver-kidney transplantation in patients not expected to recover kidney function post-transplantation. E As per EASL 2018 guidelines: Perform liver transplantation as the best therapeutic option in patients with HRS regardless of the response to medical therapy. A Consider performing liver-kidney transplantation in patients with significant CKD or with sustained AKI including HRS-AKI with no response to medical therapy. B As per AASLD 2014 guidelines, obtain prompt evaluation for liver transplantation in potential liver transplant candidates with worsening renal dysfunction or other evidence of rapid hepatic decompensation. B 7. Preventative measures Norfloxacin: initiate norfloxacin 400 mg/day as SBP prophylaxis to prevent HRS-AKI. A Albumin: administer albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) in patients with SBP to prevent AKI. A https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 4/6 6/24/23, 12:41 PM Hepatorenal syndrome Pathway 8. Follow-up and surveillance Serial clinical assessment: As per AASLD 2021 guidelines, obtain close monitoring for side effects of vasoconstrictors and albumin, including ischemic complications and pulmonary edema. E As per EASL 2018 guidelines, recognize that adverse events related to terlipressin and norepinephrine include ischemic and cardiovascular events. Obtain a careful clinical screening including an ECG before treatment initiation. A Show 2 more Assessment of treatment response: As per AASLD 2021 guidelines: Define response to terlipressin or norepinephrine as creatinine decrease to < 1.5 mg/dL or return to within 0.3 mg/dL of baseline over a maximum of 14 days. Discontinue therapy if creatinine remains at or above the pretreatment level over 4 days with the maximum tolerated doses of the vasoconstrictor. E Retreat recurrence as it may occur after treatment discontinuation. E As per EASL 2018 guidelines, define complete response to treatment as a final serum creatinine level within 0.3 mg/dL (26.5 mcmol/L) from the baseline value and partial response as the regression of AKI stage to a final serum creatinine level 0.3 mg/dL (26.5 mcmol/L) from the baseline value. B Show 2 more References 1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 2. Scott W Biggins, Paulo Angeli, Guadalupe Garcia-Tsao et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74 2 1014 1048. Open 3. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010 Sep;53 3 397 417. Open 4. Paul Martin, Andrea DiMartini, Sandy Feng et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014 Mar;59 3 1144 65. Open 5. Rahul Nanchal, Ram Subramanian, Constantine J Karvellas et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations: Executive Summary. Crit Care Med. 2020 Mar;48 3 415 419. Open 6. Jasmohan S Bajaj, Jacqueline G O'Leary, Jennifer C Lai et al. Acute-on-Chronic Liver Failure Clinical Guidelines. Am J Gastroenterol. 2022 Jan 10. Open https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 5/6 6/24/23, 12:41 PM Hepatorenal syndrome Pathway 7. Garcia-Tsao G, Abraldes JG, Berzigotti A et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan;65 1 310 335. Open 8. Khurram Jamil, Xingyue Huang, Belinda Lovelace et al. The burden of illness of hepatorenal syndrome HRS in the United States: a retrospective analysis of electronic health records. J Med Econ. 2019 May;22 5 421 429. Open 9. G Low, G J M Alexander, D J Lomas. Hepatorenal syndrome: aetiology, diagnosis, and treatment. Gastroenterol Res Pract. 2015;2015 207012. Open 10. J Bradford Rice, Alan G White, Philip Galebach et al. The burden of hepatorenal syndrome among commercially insured and Medicare patients in the United States. Curr Med Res Opin. 2017 Aug;33 8 1473 1480. Open 11. Florence Wong, S Chris Pappas, Michael P Curry et al. Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome. N Engl J Med. 2021 Mar 4;384 9 818 828. Open https://web.pathway.md/diseases/recEXDsu3o2GGbP4N 6/6