AKI in Patient with Cirrhosis
Acute kidney injury in setting of liver disease
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NephrologyManagement
Hepatorenal Syndrome (HRS-AKI) Management (EASL)
Hepatorenal Syndrome (HRS-AKI) Management (EASL): AKI in Patient with Cirrhosis → Stage AKI (ICA Criteria) → Initial Management (All Stages) → Albumin C...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action 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
03Action 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
04Action 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
05Decision Response to Albumin?
Assess creatinine after albumin challenge
- Response: SCr returns to <0.3 mg/dL above baseline
- Non-response: SCr persists or worsens
06Outcome Volume-Responsive AKI
Not HRS - continue supportive care
07Action 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
08Decision HRS-AKI Criteria Met?
All criteria must be met
09Action 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
10Warning 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
11Action 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)
12Decision 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
13Outcome HRS Response
Continue monitoring, high recurrence risk
14Action Initiate RRT
Bridge to transplant
- CRRT often preferred (hemodynamic tolerance)
- Continue vasoconstrictor therapy
- Close nephrology-hepatology coordination
15Outcome Transplant Pathway
Liver transplant is definitive therapy
16Action 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
- Path rejoins step 15Shared downstream outcome
Guideline Source
EASL Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- HRS-AKI is a diagnosis of exclusion
- Terlipressin availability varies by region
- Does not address liver transplant evaluation
- Prognosis depends heavily on liver function
Applicable Regions
EUUSglobal
EU: Terlipressin first-line per EASL
US: Terlipressin approved 2022; norepinephrine or midodrine/octreotide alternatives
Version 1Next review: 2027-01-01
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eGFR (CKD-EPI 2021)
Estimated glomerular filtration rate using CKD-EPI 2021 equation (race-free)
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Frequently Asked Questions
What is the Hepatorenal Syndrome (HRS-AKI) Management (EASL)?
The Hepatorenal Syndrome (HRS-AKI) Management (EASL) is a management clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on EASL Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis.
What guideline is the Hepatorenal Syndrome (HRS-AKI) Management (EASL) based on?
This algorithm is based on EASL Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis (DOI: 10.1016/j.jhep.2018.03.024).
What are the limitations of the Hepatorenal Syndrome (HRS-AKI) Management (EASL)?
Known limitations include: HRS-AKI is a diagnosis of exclusion; Terlipressin availability varies by region; Does not address liver transplant evaluation; Prognosis depends heavily on liver function. Individual patient factors may require deviation from these recommendations.
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