Clinical Commander

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gi.hepatorenal-syndrome.core.v1

Hepatorenal Syndrome (HRS-AKI)

hepatologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch23 SCAFFOLD only (defineBatch23ScaffoldManifest with single sourceWorkupId hepatorenal_syndrome); no phenotypes/red-flags/medications/dosing authored. Problem-package at src/lib/tier3/problem-package/packages/hepatorenal-syndrome/ exists with full atom set; no `_design-brief.md`. Workup `hepatorenal_syndrome` is registered in clinical-tools-registry (KDIGO + Wong CONFIRM terlipressin). MELD-Na + MELD 3.0 calculators wired. Gaps for AUTHORED+: empty terminology arrays (codes live in workup adapter); no PMIDs; regimen_axes empty (terlipressin, midodrine, octreotide, norepinephrine, albumin all need RxCUI verification); no design brief; no test_files.

Entry points (3)

  • lab_abnormality
    AKI in cirrhotic patient (rising creatinine) [ICA 2015 Angeli J Hepatol]
    aki_in_cirrhosis
  • symptom
    Oliguria / anuria in decompensated cirrhosis [AASLD 2023]
    oliguria_anuria
  • problem_list
    Cirrhosis with refractory ascites + new AKI [AASLD 2023; EASL 2018]
    cirrhosis_with_ascites

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Transplant eligibility; HRS prognosis [AASLD 2023]
  • sbprequired
    vital • used at CONTEXT
    Hypotension is contributing physiology + drives vasoconstrictor titration [CONFIRM Wong NEJM 2021]
  • maprequired
    vital • used at TREATMENT
    MAP target with terlipressin/norepinephrine [CONFIRM Wong NEJM 2021]
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Defines HRS-AKI per ICA criteria; baseline + serial [ICA 2015 Angeli J Hepatol]
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia common; MELD-Na [UNOS 2016]
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    MELD/MELD-Na component; cirrhosis severity [UNOS] (ACG 2024)
  • inrrequired
    lab • used at INITIAL_WORKUP
    MELD component; coagulopathy [UNOS] (ACG 2024)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Albumin challenge component; nutritional [ICA 2015; AASLD 2023]
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Bland sediment + low FeNa supports HRS over ATN [ICA 2015; EASL 2018]
  • urine_sodiumrequired
    lab • used at INITIAL_WORKUP
    FeNa <1% / urine Na <10 supports HRS [ICA 2015; EASL 2018]
  • recent_diuretic_userequired
    history • used at CONTEXT
    Hold diuretics during workup; rule out prerenal [AASLD 2023; ICA 2015]
  • recent_paracentesis
    history • used at CONTEXT
    LVP without albumin → post-paracentesis circulatory dysfunction [EASL 2018]
  • recent_sbp
    history • used at CONTEXT
    SBP precipitant — albumin 1.5g/kg day 1 + 1 g/kg day 3 reduces HRS risk [Sort NEJM 1999]
  • nsaid_nephrotoxin_userequired
    history • used at CONTEXT
    Reversible drivers must be removed before diagnosing HRS [ICA 2015; AASLD 2023]
  • current_medsrequired
    medication • used at CONTEXT
    Hold ACEi/ARB/NSAIDs/aminoglycosides/IV contrast [AASLD 2023]

12-phase flow (12)

  1. 1FRAME
    Confirm HRS-AKI scope — AKI in cirrhosis after volume challenge with bland sediment, no shock [ICA 2015 Angeli; AASLD 2023]
    inputs: age
    advance: cirrhosis + AKI confirmed
  2. 2ENTRY
    Recognize rising creatinine in cirrhotic patient — most often hospitalized with ascites/SBP [AASLD 2023]
    advance: AKI in cirrhotic patient identified
  3. 3CONTEXT
    Diuretic / NSAID / ACEi / nephrotoxin / contrast / paracentesis / SBP history; current meds; volume status [AASLD 2023; ICA 2015]
    inputs: recent_diuretic_use, recent_paracentesis, recent_sbp, nsaid_nephrotoxin_use, current_meds
    advance: precipitants documented
  4. 4RED_FLAGS
    Sepsis (SBP, pneumonia), GI bleed, contrast injury, ATN with muddy brown casts, obstructive uropathy [EASL 2018]
    inputs: sbp, creatinine
    advance: alternative AKI cause excluded or escalated
  5. 5INITIAL_WORKUP
    Serial Cr/BUN, urinalysis (bland sediment), urine sodium / FeNa, MELD components (Bili/INR/Na/Alb), renal US (rule out obstruction), diagnostic paracentesis if ascites [ICA 2015; AASLD 2023]
    inputs: creatinine, sodium, total_bilirubin, inr, albumin, urinalysis, urine_sodium
    actions: panel.renal, panel.lft, panel.ascites
    advance: workup complete; ATN excluded
  6. 6BRANCHING_WORKUP
    Albumin 1 g/kg/day x 2 days + diuretic withdrawal — if no improvement → HRS-AKI [ICA 2015]; SBP workup if ascites [AASLD 2023]
    actions: hepatorenal_syndrome, sbp_workup
    advance: albumin/diuretic challenge complete; HRS-AKI vs prerenal/ATN distinguished
  7. 7DIFFERENTIAL
    Distinguish HRS-AKI (Type 1) from prerenal (volume responsive), ATN (muddy casts), obstructive, glomerular (proteinuria) [ICA 2015; EASL 2018]
    advance: HRS-AKI confirmed or alternative routed
  8. 8RISK_STRATIFICATION
    MELD / MELD-Na for transplant priority [UNOS 2016]; CLIF-C ACLF if multiorgan failure [Jalan J Hepatol 2014]
    inputs: creatinine, sodium, total_bilirubin, inr, albumin
    actions: calc.meld_na, calc.meld3
    advance: priority score documented
  9. 9TREATMENT
    Terlipressin (FDA 2022 per CONFIRM Wong NEJM 2021) + IV albumin 1 g/kg day 1 then 20-40 g/day; alternatives midodrine + octreotide + albumin or norepinephrine in ICU [AASLD 2023]; transplant evaluation
    inputs: map, sbp
    advance: vasoconstrictor + albumin started; transplant referral made
  10. 10DISPOSITION
    ICU for terlipressin / norepinephrine; step-down for midodrine-octreotide-albumin; transplant center transfer if MELD ≥ 15 [AASLD 2023]
    inputs: sbp
    advance: destination + transplant disposition set
  11. 11MONITORING
    Daily Cr / BMP / lactate; MAP target ≥ 82 mmHg or ≥ 10 mmHg above baseline; UOP hourly; respiratory monitoring (terlipressin pulmonary edema risk 5-10%) [CONFIRM Wong NEJM 2021]
    inputs: creatinine, map
    advance: response (Cr decrease) or non-response by day 7-14
  12. 12FOLLOWUP
    Hepatology + transplant follow-up; SBP secondary prophylaxis [AASLD 2023]; recurrence counseling; renal recovery monitoring
    advance: follow-up scheduled