1. Volume and Electrolyte Management

Effective volume optimization and electrolyte balance are foundational in Hepatorenal Syndrome (HRS) care to support renal perfusion and prevent arrhythmias.

Albumin Expansion Protocols

• Initial dose: 1 g/kg IV on day 1 (maximum 100 g)
• Maintenance: 20–40 g IV daily, guided by central venous pressure (CVP) target of 8–12 mm Hg or dynamic indices of fluid responsiveness.
• Mechanism: Restores intravascular oncotic pressure, mobilizes extravascular fluid from the interstitium, and attenuates systemic inflammatory mediators.

Electrolyte Monitoring and Targets

• Sodium: Limit the rate of correction to ≤6 mEq/L per 24-hour period to avoid osmotic demyelination syndrome.
• Potassium: Maintain serum levels >4.0 mEq/L, as hypokalemia can potentiate vasopressor-induced arrhythmias.
• Magnesium: Keep serum levels >2.0 mg/dL to stabilize cardiac membranes and reduce arrhythmia risk.
• Acid–Base: Monitor arterial pH. Consider cautious sodium bicarbonate infusion if severe acidemia (pH <7.2) persists after adequate volume resuscitation.

Nephrotoxin Avoidance

A systematic review of all medications is critical. Avoid common nephrotoxic agents, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Aminoglycoside antibiotics
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)
• If iodinated contrast is unavoidable, use pre- and post-procedure IV fluids and the lowest possible contrast dose.

2. Renal Replacement Therapy (RRT) Considerations

RRT is a supportive therapy, often serving as a bridge to liver transplantation, for HRS patients when medical management fails. The choice of modality and timing of initiation significantly influence outcomes.

Indications for RRT

• Refractory volume overload causing respiratory compromise (e.g., pulmonary edema)
• Severe hyperkalemia (>6.5 mEq/L or associated ECG changes)
• Severe metabolic acidosis (pH <7.2) unresponsive to medical therapy
• Uremic complications, such as pericarditis or encephalopathy

Modality Selection

3. ICU-Related Prophylaxis

Prophylactic measures are crucial to reduce the incidence of preventable ICU-acquired morbidity and mortality in vulnerable HRS patients.

Venous Thromboembolism (VTE) Prophylaxis

• Agents: Low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) are preferred.
• Contraindications: Pharmacologic prophylaxis is generally held for severe thrombocytopenia (platelets <50,000/µL) or active bleeding.

Stress-Related Mucosal Disease (SRMD) Prophylaxis

• Indications: Mechanical ventilation for >48 hours, coagulopathy (INR >1.5), or shock requiring vasopressors.
• Options: Proton-pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs).

Infection Prevention

• SBP Prophylaxis: Consider for patients with low ascitic fluid protein (<1.5 g/dL). Norfloxacin 400 mg PO daily is a common regimen.
• Albumin in SBP: If Spontaneous Bacterial Peritonitis develops, administer albumin (1.5 g/kg on day 1, 1.0 g/kg on day 3) to reduce the risk of subsequent HRS.
• Central-Line Bundles: Strict adherence to hand hygiene, maximal barrier precautions, and chlorhexidine skin antisepsis is mandatory.

4. Management of Iatrogenic Complications

Life-saving supportive therapies can cause significant complications. Early detection and prompt intervention are vital to mitigate harm.

Vasoconstrictor-Induced Ischemia

• Causative Agents: Terlipressin, norepinephrine.
• Monitoring: Perform hourly limb checks for mottling or coolness, assess for new abdominal pain, and monitor serum lactate and serial ECGs for signs of cardiac ischemia.
• Action: Reduce the dose or discontinue the agent at the first sign of significant ischemia.

Arrhythmia Surveillance & Management

• Continuous telemetry monitoring is mandatory for all patients on vasopressors.
• Proactively maintain potassium (>4.0 mEq/L) and magnesium (>2.0 mg/dL) within target ranges.
• Apply standard ACLS protocols for any sustained ventricular arrhythmias.

5. Multidisciplinary Goals-of-Care

Aligning intensive ICU interventions with patient values and realistic prognoses is essential to ensure goal-concordant care in advanced HRS.

Early Goals-of-Care Discussions

• Involve a core multidisciplinary team: hepatology, nephrology, critical care, pharmacy, nursing, and palliative care.
• Proactively clarify patient and family understanding of the illness and preferences regarding life-sustaining therapies.

Palliative Care Integration

• Focus on aggressive symptom management, including dyspnea, pain, pruritus, and agitated delirium.
• Utilize structured family meetings to discuss prognosis, establish goals, and complete advance directives.

Therapy Escalation & De-escalation

• Escalate Therapy: Appropriate for transplant candidates and those with clearly reversible complications.
• De-escalate Therapy: Consider for non-transplant candidates who develop progressive multi-organ failure despite maximal medical therapy.