A 55-year-old man with decompensated alcoholic cirrhosis (Child-Pugh C) and refractory ascites develops progressive oliguria and rising creatinine (2.8 mg/dL) over one week. Urine sodium is 8 mEq/L, urine osmolality 320 mOsm/kg, no proteinuria, and normal renal ultrasound. He is not on nephrotoxic drugs. Which is the most appropriate first-line pharmacotherapy?

• A Intravenous furosemide
• B Terlipressin with albumin ✓
• C Oral midodrine alone
• D Dopamine infusion

Explanation

This patient meets criteria for hepatorenal syndrome type 1 (HRS-AKI): cirrhosis with ascites, creatinine rise >0.3 mg/dL in 48 hours or >1.5x baseline, no shock, no nephrotoxic drugs, and no parenchymal kidney disease. Terlipressin (a vasopressin analog) combined with intravenous albumin is the first-line pharmacological treatment, improving renal function in approximately 40-50% of patients. Furosemide worsens renal function. Dopamine has no proven benefit.

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

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