Successful therapy of hepatorenal syndrome with norepinephrine

A 39-year-old female with alcoholic cirrhosis was admitted with signs of an alcoholic hepatitis. Within one week a hepatorenal syndrome (HRS) (Creatin in 5.83 mg/100 mi, Harnstoff 235 mg/100 mi) evolved in the absence of addit ional causes. She had a diminished water (urine volume 31 ml/h) and sodium excretion (10 mmol/l). Urine flow was increased to 131 ml/h by plasma expan sion with i.v. infusion of volume and albumin and with infusion of dopamine (3 mug/kg/min) and, as there was no diuretic pretreatment and thus, no HRS secondary to diuretic treatment, furosemide (500 mg/24 h). However, impair ment of renal function remained unchanged with this therapy. Therefore, nor epinephrine (NE) therapy was initiated. A dosage of 0.1-0.12 mug/kg/min was necessary to achieve the desired increase in the mean arterial pressure of 10-20 mm Hg. During the NE infusion the urine volume increased further to 231 ml/h, the sodium excretion raised to 44 mmol/l, and serum levels of cre atinine and urea decreased to 1.91 mg/100 ml and 141 mg/100 mi, respectivel y. With recovering liver function the NE infusions could be discontinued af ter 5 days without recurrence of a HRS until discharge after 3 weeks. Beside the vasopressin analogon ornipressin, the combination of norepinephr ine and dopamine seems to be useful for the therapy of HRS. Norepinephrine has the advantage of an easy accessibility in ICUs and seems to exert less side effects.