A 58-year-old man with alcoholic cirrhosis and tense ascites is admitted with diarrhoea. Serum creatinine rises from 0.9 to 1.9 mg/dL over 6 days. Urine output is reduced but urinalysis shows no protein, no cells, and no casts. After volume expansion with albumin 1 g/kg daily for 2 days, creatinine remains 1.8 mg/dL. He is normotensive and has received no nephrotoxic drugs. What is the most appropriate next step?

• A Terlipressin with continued albumin infusion ✓
• B Increase furosemide dose to achieve diuresis
• C Immediate transjugular intrahepatic portosystemic shunt
• D Start empirical broad-spectrum antibiotics alone

Explanation

This satisfies criteria for hepatorenal syndrome type AKI: cirrhosis with ascites, creatinine rising without another identifiable cause, no response to albumin expansion, absence of shock and nephrotoxins, bland urine. Terlipressin, a vasopressin analogue that reverses splanchnic vasodilatation, combined with albumin is the established first-line medical therapy and improves reversal rates. Escalating loop diuretics worsens intravascular depletion, and TIPS is contraindicated by advanced liver failure.

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

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Written and medically reviewed by the StethoPrep medical team.