A 55-year-old man with HCV cirrhosis (Child-Pugh B) develops hepatorenal syndrome type 1 (HRS-1). Creatinine rises from 0.8 to 2.4 mg/dL over 48 hours. What is the MOST appropriate pharmacological treatment?
- A IV albumin alone
- B Terlipressin + albumin infusion ✓
- C Dopamine infusion for renal vasodilation
- D Furosemide to improve urine output
Explanation
HRS type 1 (now classified as AKI-HRS) is characterized by rapid AKI (creatinine doubling to ≥2.5 mg/dL in < 2 weeks) in cirrhosis due to severe splanchnic vasodilation and compensatory renal vasoconstriction with reduced GFR. First-line treatment is terlipressin (a vasopressin V1A agonist causing splanchnic vasoconstriction) combined with IV albumin (1 g/kg on day 1, then 20–40 g/day). The CONFIRM and REVERSE trials established terlipressin's superiority in reversing HRS and improving short-term survival. Dopamine has no proven benefit in HRS; diuretics worsen renal perfusion.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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