Core IM | Internal Medicine Podcast #191 Hepatorenal Syndrome Part 2 on Management: 5 Pearls Segment
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Oct 22, 2025 Marina Serper, a hepatologist at the University of Pennsylvania, shares her expertise on managing hepatorenal syndrome (HRS) and discusses the role of vasoconstrictors like terlipressin and norepinephrine. They explore the complexities of albumin dosing, the safe use of diuretics, and the alarming mortality rates associated with HRS. Marina also emphasizes the importance of evaluating transplant candidacy and discusses when to involve palliative care for patients who aren't transplant candidates.
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Raise MAP To Reverse HRS
- Raising MAP by 10–15 mmHg is the primary physiologic goal to reverse HRS-AKI.
- Vasoconstrictors restore renal perfusion by increasing systemic pressure and resetting renal vasoconstrictive signals.
When To Use Terlipressin
- Use terlipressin as the most potent vasoconstrictor when available and appropriate.
- Avoid terlipressin with active ischemia, creatinine >5, MELD≥35, grade 3 ACLF, or high risk of volume/respiratory overload.
Choose Vasoconstrictor By Setting
- Norepinephrine is a potent ICU vasopressor alternative when infusion and monitoring are available.
- Midodrine/octreotide is least potent but safer and can be used when diagnosis is uncertain or terlipressin is contraindicated.