gi / hepatic

Cirrhosis with Progressive AKI / Suspected HRS-AKI

Exclude reversible/structural causes, treat precipitating infection or volume loss, then use albumin plus an appropriate vasoconstrictor while monitoring respiratory safety and transplant candidacy.

CLINICAL ALGORITHMMedically Verified (2026-09-15)

Cirrhosis + progressive AKI: exclude reversible/structural causes before labeling HRS-AKI

Level: Controlled React algorithm

Visual bedside algorithm

Cirrhosis + progressive AKI: exclude reversible/structural causes before labeling HRS-AKI

Step 1 · Assess / decide

Confirm AKI + exclude mimics

Look for infection, bleeding, true hypovolemia and nephrotoxins
Exclude obstruction, abdominal hypertension and structural renal injury
Urine sodium/FENa alone do not reliably distinguish HRS

Step 2 · Treat

Correct precipitants

Stop nephrotoxins and unnecessary diuretics
Treat infection/bleeding and optimize effective circulating volume
Use albumin when appropriate while avoiding indiscriminate volume loading

Step 3 · Treat

HRS-AKI phenotype

Albumin + vasoconstrictor
Terlipressin where appropriate/available
Norepinephrine is an effective ICU alternative
Midodrine + octreotide is generally less effective when preferred options are available

Step 4 · Escalate / reassess

Safety + destination

Monitor oxygenation and volume status closely with terlipressin
Reassess diagnosis if creatinine/urine output do not improve
Use RRT for standard indications
Early hepatology/transplant assessment when appropriate

Bedside bottom line

HRS-AKI is a diagnosis made after active exclusion and correction of competing causes; response to therapy must be reassessed continuously.

Figure: Cirrhosis + progressive AKI: exclude reversible/structural causes before labeling HRS-AKI. This action-focused visual summarizes the linked Clinical Problem; the full problem text, evidence references and local policy remain the source of truth.(Action pathway — use the full evidence-linked problem and local protocol for clinical decisions)

Recognize / exclude mimics

In cirrhosis with ascites and AKI, rapidly evaluate infection, GI/other bleeding, true hypovolemia, nephrotoxins, obstruction, abdominal hypertension and structural kidney injury. Urine sodium/FENa are often low in cirrhosis and cannot reliably distinguish HRS from other AKI.

Act

Treat the precipitant, stop nephrotoxins and optimize effective circulating volume. In an appropriate HRS-AKI phenotype, use albumin with a vasoconstrictor: terlipressin where appropriate/available, or norepinephrine as an effective ICU alternative. Midodrine plus octreotide is generally less effective when these options are available.

Terlipressin respiratory safety

Before and during terlipressin, assess oxygenation and volume status. Avoid or stop/escalate review in clinically important hypoxemia or evolving respiratory failure, and avoid excessive albumin/volume loading; terlipressin-associated respiratory failure risk is greatest in advanced illness and volume overload.