A 55-year-old man with decompensated cirrhosis (Child-Pugh C) develops acute kidney injury with creatinine rising from 0.9 to 3.2 mg/dL over 5 days. Urine sodium is 8 mEq/L, urine osmolality higher than plasma. No response to albumin challenge for 48 hours. Ultrasound shows no obstruction. Urinalysis is bland. What is the diagnosis and first-line treatment?
- A Pre-renal AKI; intravenous saline challenge
- B Hepatorenal syndrome type 1; terlipressin plus albumin ✓
- C Acute tubular necrosis; N-acetylcysteine infusion
- D Hepatorenal syndrome type 2; furosemide and spironolactone
Explanation
Hepatorenal syndrome type 1 (now AKI-HRS) is characterised by rapid creatinine rise >2.5 mg/dL within 2 weeks in cirrhosis, with no response to volume resuscitation (albumin challenge), bland urinalysis, low urine sodium (<10 mEq/L), and exclusion of other causes. First-line treatment is terlipressin (a vasopressin analogue) plus albumin, which reverses HRS by splanchnic vasoconstriction; this combination is shown in CONFIRM trial to reverse HRS. ATN would show renal tubular casts and does not respond to terlipressin. HRS type 2 is slower and associated with refractory ascites.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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