Patient handout

Hepatorenal Syndrome (HRS-AKI)

PRODUCTION

1. Your condition

This handout is for hepatorenal syndrome (hrs-aki). Your care team identified this based on: aki in cirrhotic patient (rising creatinine) [ica 2015 angeli j hepatol].

Other reasons your team may use this plan: oliguria / anuria in decompensated cirrhosis [aasld 2023]; cirrhosis with refractory ascites + new aki [aasld 2023; easl 2018].

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
albumin_25_percent	1 g/kg/day IV (max 100 g/day) × 2 days	IV	daily	Volume challenge to distinguish prerenal from HRS; ICA criteria (ACG 2024)
discontinue_diuretics_and_nephrotoxins	STOP all diuretics, NSAIDs, ACEi, ARB, aminoglycosides, IV contrast	NA	one-time	Reversible drivers must be removed before diagnosing HRS (ACG 2024)

Plan: HRS-AKI — vasoconstrictor + albumin + transplant evaluation (CONFIRM 2022 + AASLD 2021 + ICA 2015)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

AKI in cirrhotic + bland sediment + no shock + no nephrotoxin + no improvement after 2 days albumin 1 g/kg + diuretic withdrawal [ICA 2015 Angeli](life-threatening)
SBP diagnosed (ANC ≥250) with elevated Cr, BUN, or bilirubin [AASLD 2023]
Worsening hypoxemia, increased work of breathing, new pulmonary edema on CXR during terlipressin [CONFIRM Wong NEJM 2021]
No 25% Cr reduction by day 14 of terlipressin + albumin [CONFIRM Wong NEJM 2021]
New shock or sepsis → switch from HRS pathway to sepsis-driven AKI / ATN management [EASL 2018; ICA 2015]
MELD ≥15 with HRS-AKI in transplant candidate [AASLD 2023; UNOS]

5. Follow-up

Hepatology + transplant follow-up; SBP secondary prophylaxis [AASLD 2023]; recurrence counseling; renal recovery monitoring

6. Sources

Guideline: AASLD 2021 Practice Guidance on Ascites, SBP and Hepatorenal Syndrome + CONFIRM terlipressin RCT (NEJM 2021) + Sort albumin-in-SBP RCT (NEJM 1999)