Treatment of Liver Cirrhosis with Hepatorenal Syndrome and Acute Kidney Injury (HRS-AKI) Stage >1A
This protocol addresses liver cirrhosis complicated by hepatorenal syndrome with acute kidney injury (HRS-AKI) at a stage greater than 1A. Current guidance calls for expeditious initiation of targeted therapy in all patients meeting this definition.
Clinical Scenario
Patients with liver cirrhosis who develop HRS-AKI at stage greater than 1A require prompt treatment. Vasoconstrictors and albumin are recommended for all patients meeting the current definition of AKI-HRS stage >1A and should be initiated expeditiously.
First-Line Therapeutic Approach
Management centres on a vasoconstrictor agent combined with albumin infusion as the recognised first-line option. The specific agent, dosing strategy, escalation criteria, and duration are detailed in the complete structured protocol.
Treatment Goals
The primary target is a complete response, defined as a final serum creatinine within 0.3 mg/dl (26.5 µmol/L) of the baseline value. Treatment is maintained until complete response is achieved or until the maximum allowed treatment period is reached.
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).
- Terlipressin plus albumin should be considered as the first-line therapeutic option for the treatment of HRS-AKI. Telipressin can be used by i.v. boluses at the initial dose of 1 mg every 4–6 h. However, giving terlipressin by continuous i.v. infusion at initial dose of 2 mg/day makes it possible to reduce the global daily dose of the drug and, thus, the rate of its adverse effects. 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).
- Albumin solution (20%) should be used at the dose 20–40 g/day.
- 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).
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