AKI in an adult with cirrhosis
Adult with cirrhosis and a rise in serum creatinine (SCr). Baseline SCr: lowest stable value in the past 3 months (if none, up to 12 months).
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NephrologyManagement
Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL)
Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL): AKI in an adult with cirrhosis → Diagnose and stage AKI → All stages: remove precipita...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Action Diagnose and stage AKI
KDIGO criteria as used by ICA-ADQI 2024. EASL 2018 splits stage 1 into 1A and 1B.
- AKI: SCr rise ≥26.5 µmol/L (0.3 mg/dL) within 48 h, or ≥50% above baseline within 7 days, and/or urine output ≤0.5 mL/kg/h for ≥6 h
- Stage 1: rise ≥26.5 µmol/L or 1.5-2 times baseline. 1A: SCr <133 µmol/L (1.5 mg/dL). 1B: SCr ≥133 µmol/L
- Stage 2: SCr 2.0-2.9 times baseline
- Stage 3: more than 3 times baseline, or SCr ≥354 µmol/L (4.0 mg/dL) with an acute rise ≥26.5 µmol/L, or RRT started
03Action All stages: remove precipitants and look for the cause
Start at once, even before the cause is known.
- Stop diuretics, non-selective beta-blockers, NSAIDs, vasodilators and nephrotoxic drugs (for example aminoglycosides)
- Screen for infection now: diagnostic paracentesis if ascites (SBP if ascitic neutrophils >250/mm³), blood and urine cultures, chest X-ray. Treat infection promptly. SBP: antibiotics plus IV albumin
- Replace losses by cause: GI bleeding: red cells (target Hb 70-90 g/L); diarrhoea or over-diuresis: crystalloid, balanced solution preferred
- Reassess volume status often. Volume overload: give no more fluid; consider diuretic or RRT
- Urinalysis (protein, blood) and renal tract ultrasound for obstruction or kidney disease
- Tense ascites: therapeutic paracentesis with albumin, even for small volumes
- Avoid iodinated contrast if possible. Titrate lactulose to avoid diarrhoea
- Beta-blocker stopped: restart only after recovery; if it cannot be restarted, band ligation for varices
04Decision Stage 1A (SCr still below 133 µmol/L)?
Stage 1A: stage 1 AKI with SCr <133 µmol/L (1.5 mg/dL). Stage 1B, 2 or 3: go to volume correction.
- If Yes
- Stage 1A
05Action Stage 1A: monitor closely after removing precipitants
EASL 2018 algorithm for initial stage 1A.
- Repeat SCr closely and treat the cause
- Resolves (SCr back within 26.5 µmol/L of baseline): close follow-up
- Persists: further care case by case
- Progresses to stage 1B or higher: manage as stage 1B-3 (volume correction, then HRS-AKI criteria)
06Outcome Stage 1A: resolved or stable
Follow up kidney and liver function. If AKI progresses, manage as stage 1B-3.
If No- Stage 1B-3
07Action Stage 1B-3: assess volume; give fluid only if hypovolaemic
Volume overload or pulmonary oedema: give no fluid (stop albumin). Do not give a routine 48 h albumin challenge (ICA-ADQI 2024).
- Hypovolaemic: fluid by cause. Balanced crystalloid; red cells for GI bleeding; 20% albumin for SBP
- Volume status unclear: one fluid challenge, 250-500 mL crystalloid or 20% albumin 1 g/kg IV (max 100 g)
- Euvolaemic (adult): no fluid challenge; assess HRS-AKI criteria now so terlipressin is not delayed
- Reassess volume, SCr and urine output often; decide at 24 h. EASL 2018 alternative: 20% albumin 1 g/kg/day (max 100 g) for 2 days
08Decision SCr or urine output improving after volume correction?
Assess at 24 h (ICA-ADQI 2024, GESA 2026; EASL 2018 used 48 h). Euvolaemic with no fluid given: answer No. Full response: SCr within 26.5 µmol/L (0.3 mg/dL) of baseline.
- If Yes
- Improving
09Outcome Improving: volume-responsive AKI (not HRS)
Treat the cause. Monitor SCr until it is back within 26.5 µmol/L of baseline. Review diuretics and beta-blocker only after recovery.
If No- No improvement
10Action No improvement: check HRS-AKI criteria (ICA-ADQI 2024)
All 4 criteria must be met. HRS-AKI can coexist with other causes of AKI.
- 1. Cirrhosis with ascites
- 2. AKI by the criteria above
- 3. No improvement in SCr or urine output within 24 h of adequate volume resuscitation (when indicated)
- 4. No strong evidence of another main cause: septic shock needing vasopressors, nephrotoxic drugs, obstruction, acute glomerular injury
- Proteinuria, pre-existing CKD or some tubular injury do not exclude HRS-AKI
- Urine sediment and urine biomarkers (for example NGAL, where available) can help separate ATN
11Decision HRS-AKI criteria met?
If uncertain, a provisional diagnosis and treatment is reasonable; review as results return.
- If Yes
12Warning Before terlipressin: hypoxia, overload, ischaemia or pregnancy?
Terlipressin can cause fatal respiratory failure, mostly with volume overload or ACLF grade 3. Check SpO2, volume status and ECG first. If it cannot be given: noradrenaline in ICU (next step).
- Do not start if SpO2 <90%, new breathing difficulty or volume overload: stop albumin, give diuretic, start only when stable
- Do not give in pregnancy, ongoing coronary, mesenteric or peripheral ischaemia, unstable angina or recent MI, or septic shock with low cardiac output
- SCr ≥442 µmol/L (5 mg/dL), ACLF grade 3 or MELD ≥39: little benefit, more harm; only after liver unit review. Severe asthma or COPD: strict monitoring. Severe heart disease: do not increase the dose
13Action HRS-AKI: start terlipressin plus albumin now (adult)
Start as soon as HRS-AKI is diagnosed. Australian ampoule: 0.85 mg terlipressin (= 1 mg terlipressin acetate).
- Preferred: continuous IV terlipressin infusion (fewer adverse effects), start 1.7 mg per 24 h
- Or terlipressin bolus: 0.85 mg slow IV every 6 h (EASL: every 4-6 h)
- SCr daily. Not down ≥25% at 24 h (ICA-ADQI) or ≥30% at 2 days (AU PI): increase in steps to max 10.2 mg per 24 h (infusion) or 1.7 mg every 6 h (bolus)
- With it: 20% albumin 20-40 g/day IV. Adjust daily to volume status; stop if volume overload or pulmonary oedema
- Monitor: continuous SpO2, fluid balance, BP, ECG or heart rate, daily SCr, sodium, potassium and magnesium
- QT risk: correct low potassium and magnesium; caution with QT-prolonging drugs (torsades reported)
- Stop or reduce for ischaemia (chest or abdominal pain, cold or mottled fingers or skin), arrhythmia or breathing difficulty
- Terlipressin not possible: noradrenaline 0.5-3 mg/h IV via central line in ICU, plus albumin; increase by 0.5 mg/h every 4 h if MAP has not risen ≥10 mmHg
- Neither possible: midodrine 7.5-15 mg orally every 8 h plus octreotide 100-200 micrograms subcut every 8 h, plus albumin (much less effective)
14Action All HRS-AKI: refer early to a liver transplant unit
Liver transplant is the definitive treatment, whatever the response to vasoconstrictors.
- Discuss with the transplant unit at diagnosis for expedited assessment
- Simultaneous liver-kidney transplant: consider if AKI persists (for example RRT for ≥4 weeks) or significant CKD
- TIPS is not recommended to treat HRS-AKI (insufficient evidence)
- Not a transplant candidate: discuss goals of care and palliative care early
15Action Review response daily and apply stop rules
Full response: SCr back within 26.5 µmol/L (0.3 mg/dL) of baseline.
- Partial response: AKI stage falls but SCr stays ≥26.5 µmol/L above baseline
- Stop vasoconstrictor if: full response, serious adverse effect, no SCr improvement after 48-72 h at maximum tolerated dose, RRT started, liver transplant, or 14 days reached
- No response: look again for other causes of AKI
- HRS-AKI returns after stopping: give a repeat course
- After discharge: review kidney and liver function within 1 month (hepatology and nephrology)
16Decision Indication for RRT?
Refractory hyperkalaemia, acidosis or volume overload, uraemic complications, or worsening AKI with no response to vasoconstrictors.
- If Yes
17Action RRT indicated: start RRT with ICU and nephrology
Decide by severity of illness, prognosis and patient wishes, not by transplant status alone. Stop the vasoconstrictor when RRT starts.
- CRRT is often better tolerated (more stable BP; slower sodium correction in hyponatraemia)
- Consider RRT early if encephalopathy persists or volume overload does not respond to diuretics
- Close hepatology, nephrology and ICU coordination
18Outcome On RRT: bridge to transplant or kidney recovery
Review goals of care often. Consider simultaneous liver-kidney transplant if RRT is needed for ≥4 weeks.
If No19Outcome No RRT needed: continue care and follow-up
HRS-AKI often recurs. Review kidney and liver function within 1 month of discharge.
If No20Action Criteria not met: treat the other cause of AKI
For example ATN, drug-induced AKI, obstruction or glomerular disease. Discuss with nephrology.
- ATN (often sepsis, shock or bleeding): supportive care; avoid nephrotoxins
- Obstruction: relieve it
- Septic shock: treat sepsis in ICU
- RRT for refractory hyperkalaemia, acidosis or volume overload, or uraemic complications; decide on severity of illness
- Any AKI in decompensated cirrhosis: expedited liver transplant assessment
21Outcome Non-HRS AKI: treat cause with nephrology and hepatology
Review kidney and liver function within 1 month of discharge.
Guideline Source
Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting (Nadim et al., J Hepatol 2024); with EASL Clinical Practice Guidelines for decompensated cirrhosis (2018)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Terlipressin doses use the Australian 0.85 mg ampoule (= 1 mg terlipressin acetate, the unit used in EASL doses).
- Sources differ on the volume step: EASL 2018 uses 2 days of albumin; ICA-ADQI 2024 and GESA 2026 assess for HRS-AKI 24 h after volume correction.
- Glypressin is TGA-approved for type 1 HRS in patients being considered for liver transplant; other use is off-label.
- Does not cover acute liver failure, HRS-AKD or HRS-CKD (formerly type 2 HRS), or transplant listing rules.
- Prognosis depends heavily on liver function.
Contraindicated Populations
Children under 18 years (adult doses; not covered by the source guidelines)Pregnancy (terlipressin is contraindicated)Ongoing coronary, mesenteric or peripheral ischaemia, unstable angina or recent MI (terlipressin)Hypoxia (SpO2 <90%) or volume overload (terlipressin: stabilise first)
Applicable Regions
AUEUUSglobal
AU: Glypressin (terlipressin 0.85 mg/8.5 mL ampoule) is on the ARTG for type 1 HRS in patients actively being considered for liver transplant; other use is off-label. AU PI: 0.85 mg IV every 6 h, max 1.7 mg every 6 h; infusion 1.7-10.2 mg per 24 h. GESA 2026 uses the 24 h HRS-AKI criteria. Midodrine tablets are on the ARTG.
EU: EASL 2018: terlipressin 1 mg (acetate) IV every 4-6 h, or infusion from 2 mg/day up to 12 mg/day; noradrenaline is the alternative.
US: Terlivaz (terlipressin 0.85 mg vial) is FDA-approved (2022) with a boxed warning for respiratory failure: do not start if SpO2 <90%; patients with SCr >5 mg/dL are unlikely to benefit.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL)?
The Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL) is a management clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting (Nadim et al., J Hepatol 2024); with EASL Clinical Practice Guidelines for decompensated cirrhosis (2018).
What guideline is the Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL) based on?
This algorithm is based on Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting (Nadim et al., J Hepatol 2024); with EASL Clinical Practice Guidelines for decompensated cirrhosis (2018) (DOI: 10.1016/j.jhep.2024.03.031).
What are the limitations of the Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL)?
Known limitations include: Adults only. Terlipressin doses use the Australian 0.85 mg ampoule (= 1 mg terlipressin acetate, the unit used in EASL doses).; Sources differ on the volume step: EASL 2018 uses 2 days of albumin; ICA-ADQI 2024 and GESA 2026 assess for HRS-AKI 24 h after volume correction.; Glypressin is TGA-approved for type 1 HRS in patients being considered for liver transplant; other use is off-label.; Does not cover acute liver failure, HRS-AKD or HRS-CKD (formerly type 2 HRS), or transplant listing rules.; Prognosis depends heavily on liver function.. Individual patient factors may require deviation from these recommendations.
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