This protocol covers chronic liver failure occurring in patients with underlying liver cirrhosis who develop hepatorenal syndrome — acute kidney injury (HRS-AKI) at AKI stage greater than 1A — a complication requiring expeditious, targeted intervention.
Patients with liver cirrhosis who meet the current diagnostic criteria for HRS-AKI at a stage exceeding 1A are candidates for prompt active management. Evidence-based guidance identifies this stage threshold as the trigger for immediate treatment.
Management centres on a vasoconstrictor-based regimen combined with albumin supplementation, with defined agent preferences, structured alternatives, and a response-guided escalation framework — full details are in the complete protocol.
Complete response is defined as a final serum creatinine within 0.3 mg/dl of the patient’s baseline value (or serum creatinine below 1.5 mg/dl). Response is formally re-assessed at 2 days, with a clear definition of non-response guiding further management decisions.
DOI: 10.1016/j.jhep.2018.03.024
Vasoconstrictors and albumin are recommended in all patients meeting the current definition of AKI-HRS stage >1A, should be expeditiously treated with vasoconstrictors and albumin (III;1).
Terlipressin plus albumin should be considered as the first-line therapeutic option for the treatment of HRS-AKI. In case of non-response (decrease in SCr <25% from the peak value), after two days, the dose of terlipressin should be increased in a stepwise manner to a maximum of 12 mg/day (I;1).
Noradrenaline can be an alternative to terlipressin. However, limited information is available (I;2).
Midodrine plus octreotide can be an option only when terlipressin or noradrenaline are unavailable, but its efficacy is much lower than that of terlipressin (I;1).
According to the new definition of HRS-AKI, complete response to the treatment should be defined by a final SCr within 0.3 mg/dl (26.5 μmol/L) from the baseline value, while partial response should be defined by the regression of AKI stage to a final SCr ≥0.3 mg/dl (26.5 μmol/L) from the baseline value (III;1).
Treatment should be maintained until a complete response (SCr below 1.5 mg/dl) or for a maximum of 14 days either in case of partial response (decrease of SCr ≥50% with a final value still higher than 1.5 mg/dl) or in case of non-response.
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