A 52-year-old man with decompensated alcoholic cirrhosis (Child-Pugh C) and refractory ascites develops acute kidney injury. Serum creatinine rises from 1.2 to 3.1 mg/dL over 48 hours. Urine sodium is 8 mEq/L, urine output 350 mL/day, and renal ultrasound is normal. There is no recent NSAID use, shock, or nephrotoxin exposure. Which is the most appropriate first-line pharmacotherapy?

• A Intravenous furosemide bolus followed by continuous infusion
• B Midodrine plus octreotide plus intravenous albumin
• C Terlipressin plus intravenous albumin ✓
• D Norepinephrine infusion alone

Explanation

This patient meets criteria for hepatorenal syndrome type 1 (HRS-AKI). International guidelines recommend terlipressin plus albumin as first-line pharmacotherapy. Terplipressin is a vasopressin analogue that causes splanchnic vasoconstriction, effectively reversing the splanchnic arterial vasodilation driving HRS. Midodrine plus octreotide plus albumin is an alternative used where terlipressin is unavailable, but terlipressin-based regimens have superior reversal rates. Furosemide would worsen kidney injury in HRS.

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

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Written and medically reviewed by the StethoPrep medical team.