A 52-year-old man with decompensated cirrhosis (Child-Pugh C, MELD-Na 22) develops spontaneous bacterial peritonitis (SBP). Ascitic fluid PMN count is 380/µL. He is started on IV cefotaxime 2g every 8 hours. Which intervention significantly reduces the risk of hepatorenal syndrome (HRS) in this setting?
- A IV albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 ✓
- B Prophylactic terlipressin 1 mg IV every 6 hours
- C Oral norfloxacin 400 mg/day for secondary SBP prophylaxis
- D Octreotide 100 µg SC three times daily
Explanation
The Sort et al. (NEJM 1999) landmark randomised trial demonstrated that IV albumin infusion (1.5 g/kg body weight at diagnosis of SBP and 1 g/kg on day 3) significantly reduced the incidence of renal impairment (10% vs 33%) and in-hospital mortality (10% vs 29%) compared to cefotaxime alone in patients with SBP. Albumin expands intravascular volume, attenuates the systemic inflammatory response, and prevents the splanchnic vasodilation-induced reduction in effective arterial blood volume that precipitates hepatorenal syndrome. This is now standard of care in all guidelines (EASL, AASLD). Terlipressin is used for established HRS Type 1 but not as prophylaxis. Norfloxacin is for long-term SBP secondary prophylaxis, not acute HRS prevention.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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