A 52-year-old man with alcoholic cirrhosis and tense ascites has serum creatinine rising from 0.9 to 2.6 mg/dL over 12 days. He has had no shock, no nephrotoxic drugs, and no response to 48 hours of fluid challenge and diuretic withdrawal. Urine protein and microscopy are unremarkable. Which treatment has been shown to improve short-term reversal of this condition?

• A Dopamine infusion at renal doses
• B Noradrenaline alone through a central line
• C Intravenous furosemide with salt-poor albumin
• D Terlipressin combined with intravenous albumin ✓

Explanation

This is hepatorenal syndrome, driven by intense splanchnic vasodilation and reduced effective arterial volume. Terlipressin, a vasopressin V1 analogue, constricts the splanchnic bed and restores renal perfusion pressure, and its combination with albumin achieves reversal significantly better than placebo or albumin alone in randomised trials. Renal dose dopamine has no benefit and was abandoned decades ago. Noradrenaline works by a similar mechanism but requires central access and is less studied than terlipressin, which remains the standard pharmacological answer.

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

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Written and medically reviewed by the StethoPrep medical team.