A 58-year-old man with alcoholic cirrhosis and tense ascites has serum creatinine rising from 0.9 to 2.4 mg/dL over 2 weeks. Urine sodium is 6 mEq/L, urine protein is negligible, and renal ultrasound is normal. Creatinine remains above 2 mg/dL after 2 days of diuretic withdrawal and albumin 1 g/kg/day. There is no shock or recent nephrotoxin exposure. What is the most appropriate next treatment?

• A Start terlipressin combined with intravenous albumin ✓
• B Start noradrenaline infusion alone
• C Add spironolactone and increase furosemide
• D Proceed directly to kidney transplant evaluation as sole therapy

Explanation

This fulfils criteria for hepatorenal syndrome-AKI: cirrhosis with ascites, creatinine rise, absent response to volume expansion with albumin, and absence of shock or nephrotoxins. The splanchnic vasodilation hypothesis explains the intense renal vasoconstriction, and the recommended therapy is a vasoconstrictor such as terlipressin together with albumin to improve effective arterial blood volume. Escalating diuretics worsens it, and liver transplantation addresses the underlying cause but pharmacological bridge therapy comes first.

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

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Written and medically reviewed by the StethoPrep medical team.