Liver Cirrhosis with HRS-AKI (Stage >1A): What to Do After Vasoconstrictor Treatment Fails
This protocol addresses chronic liver failure in patients with liver cirrhosis who develop hepatorenal syndrome — acute kidney injury (HRS-AKI) at a stage greater than 1A and who have not achieved an adequate response to the standard first-line vasoconstrictor-based regimen.
Clinical Scenario
The target population is patients with liver cirrhosis presenting with HRS-AKI (AKI stage >1A). Current evidence supports prompt vasoconstrictor and albumin therapy in all patients meeting this definition; however, a subset does not achieve the required serum creatinine response.
Previous Treatment & Failure Condition
First-line therapy — terlipressin plus albumin (or noradrenaline plus albumin as an alternative) — is considered to have failed when the complete response criterion is not met: a final serum creatinine within 0.3 mg/dl of the baseline value (or below 1.5 mg/dl), assessed at 48 hours (non-response defined as a decrease in serum creatinine of less than 25% from peak value).
This protocol describes the structured, evidence-based next step for patients who do not reach that target.
Next-Line Approach (Partial Overview)
In patients who do not respond to vasoconstrictors, a renal replacement strategy may be considered — with the decision shaped by the individual's overall severity of illness. The complete algorithm, selection criteria, and sequencing are available in the full protocol.
References
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).
- Renal replacement therapy should be considered in the management of AKI, whatever the type. As far as HRS-AKI, it should be considered in non-responders to vasoconstrictors.
- The decision to initiate RRT should be based on the individual severity of illness (I;2).
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