A 48-year-old man with cirrhosis and tense ascites develops progressive renal failure over 2 weeks: creatinine rose from 0.8 to 2.6 mg/dL. Urine output is 700 mL/day, urinary sodium 8 mEq/L, urine protein negative, sediment bland. He received 100 mL of 25% albumin daily for 2 days without improvement. No recent NSAIDs, aminoglycosides, or contrast exposure. What is the most appropriate next step in management?

• A Start broad spectrum antibiotics for spontaneous bacterial peritonitis
• B Start furosemide to improve urine output
• C Start terlipressin with continued albumin infusion ✓
• D Proceed directly to intermittent hemodialysis

Explanation

This fulfills criteria for hepatorenal syndrome: cirrhosis with ascites, creatinine rise, bland urine with low sodium, no response to volume expansion with albumin, and no other cause of kidney injury. Splanchnic vasodilatation with activation of vasoconstrictor systems reduces renal perfusion. Terlipressin, a vasopressin analogue, combined with albumin is the standard therapy. Furosemide worsens intravascular depletion and is contraindicated, while dialysis is reserved 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.