Noradrenaline Plus Albumin Regimen in Hepatorenal Syndrome

Efficacy of Noradrenaline in HRS

Noradrenaline, administered by continuous IV infusion at doses of 0.5-3 mg/h with albumin, has demonstrated efficacy comparable to terlipressin in increasing mean arterial pressure, reversing renal impairment, and improving one-month survival in HRS 1, 3
The total number of patients treated with noradrenaline in clinical trials remains relatively small compared to terlipressin, limiting the strength of evidence supporting its definitive efficacy 1, 4

Noradrenaline should be administered as a continuous IV infusion at an initial dose of 0.5 mg/h, with titration up to a maximum of 3 mg/h to achieve a target increase in mean arterial pressure of 10 mmHg 2, 5
Albumin should be administered concurrently at an initial dose of 1 g/kg (up to a maximum of 100 g/day) for the first 2 days, followed by 20-40 g/day thereafter 2, 5
Treatment should continue until reversal of HRS or for a maximum of 14 days in cases of partial response 6, 7

Unlike terlipressin, noradrenaline administration always requires a central venous line and, in most countries, transfer of the patient to an intensive care unit (ICU) 1, 4
Careful cardiac screening including electrocardiogram is recommended before starting treatment due to potential ischemic and cardiovascular adverse events 4, 8
Close monitoring of patients during treatment is essential, with modification or discontinuation of therapy based on the type and severity of side effects 4

Terlipressin plus albumin is considered the first-line therapeutic option for HRS-AKI based on more robust evidence 4, 8

Complete response to treatment should be defined as a final serum creatinine within 0.3 mg/dl from the baseline value 4
Partial response is defined as regression of AKI stage with a final serum creatinine ≥0.3 mg/dl from baseline 4
In cases of recurrence of HRS-AKI after treatment cessation, a repeat course of therapy should be given 4

Noradrenaline plus albumin is not recommended for HRS outside the criteria of AKI due to high recurrence rates after treatment withdrawal 4