A 50-year-old man with alcoholic cirrhosis and tense ascites has serum creatinine rising from 0.9 to 2.6 mg/dL over two weeks. Urine output is 700 mL/day, urine sodium is 8 mEq/L, and there is no sepsis, shock, or nephrotoxic drug exposure. Creatinine fails to improve after 48 hours of albumin challenge. The most appropriate drug therapy is:

• A Spironolactone dose escalation
• B Intravenous furosemide infusion
• C Dopamine infusion
• D Terlipressin with continued albumin ✓

Explanation

This is hepatorenal syndrome-AKI: marked splanchnic vasodilatation with intense renal vasoconstriction in advanced cirrhosis. Terlipressin, a vasopressin analogue that reverses splanchnic vasodilatation, combined with albumin, improves reversal of HRS and is the standard therapy. Furosemide and spironolactone are ineffective and may worsen renal perfusion, while low-dose dopamine has been conclusively shown not to protect the kidney.

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

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Written and medically reviewed by the StethoPrep medical team.