In this episode, we provide a concise overview of the diagnosis and treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI) with a focus on the new HRS-1 definition (now called HRS-AKI), new data with terlipressin, and the AASLD 2021 guidelines.

Key Concepts

1. At a basic level, HRS-AKI is caused by portal hypertension leading to systemic vasodilation and a prerenal state.  Our treatment focuses on increasing vascular volume (usually with albumin) and vasoconstriction to increase renal perfusion.
2. The newest HRS-AKI definition borrows most of the AKI definitions from the KDIGO criteria for AKI.  HRS-AKI requires cirrhosis, ascites, AKI, and an exclusion of other etiologies of AKI.
3. In AKI and HRS-AKI, concentrated (25%) albumin is given. A dose of 1 gm/kg/day (max 100 gm) for two days is used for AKI.  For HRS-AKI, a dose of 20-50 grams/day is recommended.
4. The preferred vasoconstrictor in HRS-AKI is terlipressin; however, it is not available in the US. Norepinephrine (if in the ICU) is second-line.  If not in the ICU, midodrine and octreotide are recommended.  Therapy is continued until renal function recovers, if there is no improvement at 4 days, or if a full 14 days of therapy has been given.

References

1. Biggins SW, Angeli P, Garcia-Tsao G, 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;74(2):1014-1048. doi:10.1002/hep.31884
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69(2):406-460. doi:10.1016/j.jhep.2018.03.024

In this episode, we review the pharmacology, indications, adverse effects, and unique drug characteristics of the most common SSRIs on the market.

Key Concepts

1. SSRIs (selective serotonin reuptake inhibitors) are the drug of choice for depression, anxiety, and a variety of other psychiatric indications.
2. Fluoxetine (Prozac) and paroxetine (Paxil) inhibit CYP2D6, a metabolic pathway for several opioid analgesics, tamoxifen, and many other antidepressants.
3. Adverse effects of SSRIs start immediately but the beneficial psychiatric effects take up to 1 to 2 months to occur. Patient counseling about the timing of adverse effects and efficacy are important!
4. SSRIs should not be abruptly discontinued in patients taking the medication chronically. Withdrawal symptoms can include flu-like symptoms, changes in mood or sleep, and (rarely) even electric-like shocks. To discontinue, the SSRI dose should be tapered down over the period of several weeks.