Hepatorenal syndrome–acute kidney injury (HRS-AKI) is a severe complication of portal hypertension presenting in patients with cirrhosis and ascites. When the preferred first-line approach fails to achieve HRS reversal, a structured next-line strategy is required.
Rapidly developing AKI defined as an increase in serum creatinine by ≥0.3 mg/dl within two days or ≥50% from baseline, and/or a decrease in urinary output ≤0.5 ml/kg over ≥6 h — in a patient with cirrhosis and ascites, with no other evident cause such as shock or nephrotoxins.
Terlipressin (with albumin as an essential adjunct), initiated early as the preferred first-line drug, did not achieve the goal: HRS reversal with reduction of serum creatinine to <1.5 mg/dL. This protocol addresses the next step.
The next-line strategy involves vasopressor alternatives to terlipressin combined with albumin. One option targets mean arterial pressure directly; another combines two complementary agents. The complete selection criteria, combination details, and sequencing are in the full protocol.
Improvement in serum creatinine — HRS reversal — to bridge toward liver transplantation.