Hepatorenal Syndrome (HRS-AKI) Management (EASL)

Algorithm Steps

1. ▶

   Start

   AKI in Patient with Cirrhosis

   Acute kidney injury in setting of liver disease

   1. ●

      Action

      Stage AKI (ICA Criteria)

      Modified AKI criteria for cirrhosis

      • Stage 1A: SCr <1.5 mg/dL with increase ≥0.3 mg/dL
      • Stage 1B: SCr ≥1.5 mg/dL with increase ≥0.3 mg/dL
      • Stage 2: SCr increase 2-3× baseline
      • Stage 3: SCr increase >3× or SCr ≥4 mg/dL or need for RRT
      1. ●

         Action

         Initial Management (All Stages)

         EASL Algorithm Step 1

         • Stop diuretics immediately
         • Stop beta-blockers (if SBP <90 or MAP <65)
         • Stop nephrotoxins (NSAIDs, aminoglycosides, contrast)
         • Expand volume if hypovolemic (crystalloid or albumin)
         • Treat infections aggressively (paracentesis if ascites)
         • Lactulose for hepatic encephalopathy
         1. ●

            Action

            Albumin Challenge (Stage ≥1B)

            EASL Algorithm Step 2

            • Albumin 1 g/kg (max 100g) IV daily × 2 days
            • Purpose: Rule out hypovolemia as cause
            • Reassess creatinine after 48 hours
            • Skip if obvious volume overload
            1. ◆

               Decision

               Response to Albumin?

               Assess creatinine after albumin challenge

               • Response: SCr returns to <0.3 mg/dL above baseline
               • Non-response: SCr persists or worsens
               1. ✓

                  Outcome

                  Volume-Responsive AKI

                  Not HRS - continue supportive care

               2. ●

                  Action

                  Evaluate for HRS-AKI

                  HRS is diagnosis of exclusion

                  • Required criteria (all must be met):
                  • - Cirrhosis with ascites
                  • - AKI per ICA criteria
                  • - No response to albumin challenge
                  • - No nephrotoxins
                  • - No parenchymal disease (no proteinuria >500mg/day, no hematuria, normal US)
                  • - No shock
                  1. ◆

                     Decision

                     HRS-AKI Criteria Met?

                     All criteria must be met

                     1. ●

                        Action

                        Non-HRS AKI in Cirrhosis

                        ATN, drug-induced, obstructive, etc.

                        • ATN: Often from sepsis or hypotension
                        • Consider nephrology consult
                        • Supportive care, treat underlying cause
                        • May need RRT
                     2. ⚠

                        Warning

                        Initiate Vasoconstrictor + Albumin

                        HRS-AKI specific therapy

                        • First-line: Terlipressin 1mg IV q4-6h (if available)
                        • - Can increase to 2mg q4-6h if no response
                        • - Continue albumin 20-40g/day
                        • Alternative: Norepinephrine infusion (ICU)
                        • Alternative: Midodrine + Octreotide (outpatient/less severe)
                        • - Midodrine 7.5-12.5mg TID + Octreotide 100-200mcg TID
                        1. ●

                           Action

                           Monitor Response

                           Assess for treatment response

                           • Complete response: SCr <1.5 mg/dL
                           • Partial response: SCr decrease ≥25% but still elevated
                           • Non-response: No improvement
                           • Treatment duration: Up to 14 days
                           • Watch for ischemic complications (terlipressin)
                           1. ◆

                              Decision

                              Need for RRT?

                              Standard indications in setting of HRS

                              • Generally reserved for transplant candidates
                              • Non-transplant candidates: Discuss goals of care
                              • RRT does NOT reverse HRS
                              1. ✓

                                 Outcome

                                 HRS Response

                                 Continue monitoring, high recurrence risk

                              2. ●

                                 Action

                                 Initiate RRT

                                 Bridge to transplant

                                 • CRRT often preferred (hemodynamic tolerance)
                                 • Continue vasoconstrictor therapy
                                 • Close nephrology-hepatology coordination
                                 1. ✓

                                    Outcome

                                    Transplant Pathway

                                    Liver transplant is definitive therapy

                        2. ●

                           Action

                           Liver Transplant Evaluation

                           Definitive treatment for HRS

                           • HRS-AKI has poor prognosis without transplant
                           • MELD score increases with renal dysfunction
                           • Expedited listing if candidate
                           • TIPS may be bridge in select patients