A 55-year-old man with alcoholic cirrhosis and ascites has serum creatinine rise from 0.9 to 2.4 mg/dL over 10 days. Urine output is reduced. He has received albumin 1 g/kg daily for 2 days without improvement. There is no shock, no nephrotoxic drug exposure, urine protein is negligible, and renal ultrasound is normal. What is the next step in management?
- A Add terlipressin with continued albumin ✓
- B Start haemodialysis
- C Increase furosemide to 160 mg daily
- D Perform urgent transjugular intrahepatic portosystemic shunt
Correct answer: A. Add terlipressin with continued albumin
Explanation
This is hepatorenal syndrome with acute kidney injury: cirrhosis with ascites, creatinine rise meeting AKI criteria, lack of response to 2 days of albumin, and absence of shock, nephrotoxins, and structural kidney disease. Terlipressin combined with albumin is the recommended first-line therapy and can reverse the syndrome. Diuretics are stopped in HRS because they worsen intravascular depletion. TIPS is contraindicated in advanced disease and dialysis is reserved for refractory cases.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.