A 55-year-old man with cirrhosis and tense ascites develops acute kidney injury. Creatinine rises from 1.0 to 2.4 mg/dL. Urine sodium is 8 mEq/L, no proteinuria, and renal ultrasound is normal. After 2 days of albumin and diuretic withdrawal, creatinine remains 2.3 mg/dL. He has no shock. What is the most appropriate next step?

• A Start intravenous furosemide
• B Start terlipressin and albumin ✓
• C Start norepinephrine infusion
• D Initiate hemodialysis

Explanation

The patient meets diagnostic criteria for hepatorenal syndrome type 1 (rapid creatinine rise, low urine sodium, no improvement after volume expansion, no shock, no nephrotoxins). First-line therapy is terlipressin with albumin to reverse vasodilation. Norepinephrine is an alternative if terlipressin is unavailable. Furosemide worsens renal function. Hemodialysis is reserved for refractory cases or as a bridge to transplant.

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

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Written and medically reviewed by the StethoPrep medical team.