Hepatorenal Syndrome: Treatment Options

Hepatorenal syndrome (HRS) is thought to be caused by splanchnic vasodilatation with relative renal vasoconstriction. The reversible nature of HRS is highlighted by the observation that patients with HRS who undergo liver transplant usually see a complete reversal of renal failure.
For those who are unable or waiting to receive a liver transplant, however, what are the available treatments for HRS?

The "standard-of-care" at hospitals at which I have worked has become a cocktail of midodrine, octreotide, and albumin; I find this somewhat interesting as there is no randomized controlled trial which supports its use. The most quoted paper (Angeli et al; Hepatology 1999) compared 5 patients who received the midodrine/octreotide cocktail with 8 patients who received dopamine; patients in the midodrine/octreotide group saw a higher rate of improved renal function in a condition which had previously been seen as irreversible by some. With the lack of any competing therapies, this has appeared to become the standard. We use midodrine 5mg po tid which can be titrated up to 15mg po tid and octreotide 100mcg sc tid which can be titrated up to 200mcg sc tid.

Other treatment possibilities include albumin alone (e.g., 25gm tid), other vasodilators (e.g., terlipressin which is apparently used more commonly in Europe), and the TIPS procedure.