A 45-year-old man with alcoholic cirrhosis develops acute kidney injury (creatinine rise from 0.9 to 2.8 mg/dL over 48 hours). Urine sodium is <10 mEq/L, urinary sediment is bland. Urine output is reduced. Volume challenge with albumin 1 g/kg (max 100 g) over 48 hours does not improve renal function. The MOST likely diagnosis is:

• A Prerenal AKI from dehydration
• B Acute tubular necrosis
• C Hepatorenal syndrome type 1 (HRS-AKI) ✓
• D Contrast-induced nephropathy

Explanation

Hepatorenal syndrome type 1 (now termed HRS-AKI per ICA 2015 criteria) is characterised by rapid AKI (creatinine doubling to ≥2.5 mg/dL in <2 weeks) in cirrhosis with no improvement after volume challenge with albumin (1 g/kg/day for 48 hours), bland urinary sediment, and low urine sodium (<10 mEq/L). It reflects intense renal vasoconstriction due to splanchnic vasodilation. ATN shows granular casts. Treatment is terlipressin + albumin, with liver transplant as definitive therapy. Prerenal AKI reverses with volume.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.