Clinical Commander

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renal.hepatorenal.v1

Hepatorenal Syndrome (HRS-AKI)

nephrologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-8 expansion 2026-05-15: Hepatorenal Syndrome AKI (HRS-AKI) dossier authored from renal-domain perspective. ICA HRS-AKI consensus (Angeli J Hepatol 2015 PMID 25638527) is the binding spine. Companion engine gi.hepatorenal-syndrome.core.v1 covers the hepatology-side framing. 5-step vasoconstrictor + albumin regimen — Step 0 withdraw offenders → Step 1 albumin challenge (diagnostic) → Step 2 terlipressin + albumin (CONFIRM Wong NEJM 2021 PMID 33657294; FDA 2022) → Step 3 norepi (ICU) or octreotide-midodrine (ward) → Step 4 RRT bridge + expedited LT → Step 5 SBP-associated HRS abx + albumin (Sort NEJM 1999 PMID 10432325). 5 setting playbooks: home (rare; post-discharge / pre-LT) / outpatient (post-episode + Type-2 maintenance + LT workup) / ed (initial recognition + albumin challenge) / icu (Type-1 terlipressin protocol) / inpatient (Type-2 + bridge to LT). 10 severity triggers covering ICA-2019 phenotypes (Type-1, Type-2, SBP-associated, ICA-criteria-met) + clinical sub-phenotypes (pre-LT, post-TIPS, refractory-to-vasoconstrictor, ACLF+AKI) + safety triggers (terlipressin ischemic, terlipressin respiratory failure per FDA boxed warning). Sibling routing: gi.hepatorenal-syndrome.core.v1 (hepatology twin — overlap by design), gi.cirrhosis.core.v1 (chronic management baseline), renal.aki.prerenal.v1 (volume-responsive AKI — exclude before diagnosing HRS), neph.aki.core.v1 (general AKI parent). Schema-blocked calculator queue: MELD-Na, CLIF-SOFA (ACLF), HRS-AKI severity stage (Type-1/2 + ICA-2019 stages 1/2/3) — none registered in clinical-tools-registry. Surfaced as text in required_assessments + severity_triggers. Owner: shard-0 clinical-tools-registry maintainer. Status INTEGRATED (not PRODUCTION) — manifest stub authored; engine registry id (runtime class) not yet present in src/lib/engines/nephrology/; calculator registry IDs for MELD-Na / CLIF-SOFA / HRS-stage not yet present. Terlipressin RxCUI corrected 69552→57048 (RxNav-verified); CONFIRM Wong NEJM 2021 + FDA boxed warning informs safety triggers terlipressin_ischemic_complication + terlipressin_respiratory_failure. Citation + RxCUI remediation 2026-05-22: prior evidence block was entirely fabricated/mis-attributed (30668691=p53-network, 32101160=dbNSFP, 21520341=dbNSFP, 10387940=Shattuck-lecture, 25934892=retraction-notice, 31010807=yeast-Pho7). Replaced with PubMed-verified anchors: ICA-AKI Angeli 2015 (25638527), CONFIRM Wong 2021 (33657294), Sort SBP 1999 (10432325). Unverifiable Salerno/Ginès/ACG references removed (clinical text retained without PMID). RxCUIs corrected: terlipressin 69552→57048, octreotide 7514→7617, midodrine 30131→6963, cefotaxime 7517→2186 (norfloxacin 7517 confirmed correct).

Entry points (4)

  • lab_abnormality
    Rising creatinine in patient with cirrhosis + ascites (ICA 2019 HRS-AKI)
    rising_cr_in_cirrhosis
  • symptom
    Refractory ascites with rising creatinine (ICA 2019 HRS-AKI)
    refractory_ascites
  • problem_list
    Cirrhosis on problem list + AKI episode (ICA 2019 HRS-AKI)
    cirrhosis_with_aki
  • lab_abnormality
    AKI following SBP diagnosis (Sort NEJM 1999; ICA 2019 HRS-AKI)
    aki_post_sbp

Required inputs (8)

  • agerequired
    demographic • used at CONTEXT
    LT candidacy + terlipressin tolerability (ICA 2019 HRS-AKI; CONFIRM Wong NEJM 2021)
  • creatininerequired
    lab • used at CONTEXT
    AKI staging + ICA-2019 criterion + response to albumin challenge (ICA 2019 HRS-AKI)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Bland sediment expected; rule out ATN (muddy-brown casts), AIN, GN (ICA 2019 HRS-AKI)
  • ascitic_fluid_pmn
    lab • used at INITIAL_WORKUP
    SBP precipitant — diagnostic paracentesis PMN ≥250 (Sort NEJM 1999; ICA 2019 HRS-AKI)
  • maprequired
    vital • used at TREATMENT
    Terlipressin titrated to MAP increase; norepinephrine alternative needs central line (CONFIRM Wong NEJM 2021)
  • cirrhosisrequired
    history • used at FRAME
    Underlying advanced liver disease is sine-qua-non for HRS-AKI (ICA 2019 HRS-AKI)
  • recent_diuretic_or_nephrotoxinrequired
    history • used at CONTEXT
    ICA-2019 criterion requires withdrawal of nephrotoxins + diuretics for 48h prior to diagnosis (ICA 2019 HRS-AKI)
  • transplant_candidacy
    history • used at DISPOSITION
    Pre-LT bridge planning; expedited LT for refractory HRS (ICA 2019 HRS-AKI; ACG ALF 2014)

12-phase flow (12)

  1. 1FRAME
    Confirm cirrhosis + ascites + AKI; HRS-AKI is a diagnosis of exclusion among intrinsic causes (ICA 2019 HRS-AKI)
    inputs: creatinine, cirrhosis
    advance: Cirrhosis + AKI confirmed (ICA 2019 HRS-AKI)
  2. 2ENTRY
    Triggered by rising Cr in cirrhotic, refractory ascites flare, or post-SBP AKI (ICA 2019 HRS-AKI; Sort NEJM 1999)
    advance: Engine routed (ICA 2019 HRS-AKI)
  3. 3CONTEXT
    Discontinue diuretics + nephrotoxins (NSAIDs, ACEi/ARB, aminoglycosides, IV contrast); review beta-blockers in advanced liver disease (ICA 2019 HRS-AKI)
    inputs: recent_diuretic_or_nephrotoxin
    advance: Offending agents stopped (ICA 2019 HRS-AKI)
  4. 4RED_FLAGS
    Type-1 rapid progression Cr doubling to >2.5 in <2 weeks; SBP + AKI; ACLF + AKI; refractory shock (ICA 2019 HRS-AKI; Sort NEJM 1999)
    advance: Acuity tier assigned (ICA 2019 HRS-AKI)
  5. 5INITIAL_WORKUP
    BMP, LFTs, INR, CBC, ammonia, urinalysis with sediment, urine Na/FENa (though limited in cirrhosis), diagnostic paracentesis with PMN + culture (ICA 2019 HRS-AKI; Sort NEJM 1999)
    inputs: urinalysis, creatinine
    actions: panel.renal, panel.lft, panel.cbc, panel.coag
    advance: Initial labs back + paracentesis done (ICA 2019 HRS-AKI)
  6. 6BRANCHING_WORKUP
    Albumin challenge 1 g/kg/d × 2 d (diagnostic); renal US to exclude obstruction; if sediment active → consider GN (ICA 2019 HRS-AKI)
    advance: Albumin challenge complete + structural rule-out done (ICA 2019 HRS-AKI)
  7. 7DIFFERENTIAL
    HRS-AKI vs prerenal (responds to volume), ATN (muddy-brown casts), AIN (drug, eosinophils), GN (active sediment), obstruction (US) (ICA 2019 HRS-AKI; KDIGO 2012 AKI)
    advance: Differential resolved (ICA 2019 HRS-AKI)
  8. 8RISK_STRATIFICATION
    AKI staging (KDIGO); HRS-AKI Type-1 vs Type-2; MELD/MELD-Na for LT priority; CLIF-SOFA for ACLF (ICA 2019 HRS-AKI; Ginès Lancet 2017)
    inputs: creatinine
    actions: calc.ckd_epi_2021
    advance: Severity tier + LT priority documented (ICA 2019 HRS-AKI)
  9. 9TREATMENT
    Terlipressin 0.5-1 mg IV q4-6h titrate + albumin 20-40 g/d × 5-14 d (CONFIRM Wong NEJM 2021); alternative norepi-octreotide-midodrine; SBP — abx + albumin 1.5 g/kg d1 + 1 g/kg d3 (Sort NEJM 1999); RRT bridge; expedited LT (ICA 2019 HRS-AKI)
    inputs: map, creatinine
    advance: Vasoconstrictor regimen started + response tracked (ICA 2019 HRS-AKI)
  10. 10DISPOSITION
    ICU for Type-1 HRS terlipressin protocol; LT center referral; TIPS in select non-LT candidates with Type-2 (ICA 2019 HRS-AKI; Ginès Lancet 2017)
    inputs: transplant_candidacy
    advance: Disposition + LT referral set (ICA 2019 HRS-AKI)
  11. 11MONITORING
    Daily Cr + MAP + UOP; daily LFTs/INR; ischemic side-effects of vasoconstrictor (peripheral, mesenteric, cardiac); volume status (CONFIRM Wong NEJM 2021)
    inputs: creatinine, map
    actions: panel.renal, panel.lft, panel.coag
    advance: Monitoring schedule live (ICA 2019 HRS-AKI)
  12. 12FOLLOWUP
    Outpatient hepatology + transplant clinic; SBP secondary prophylaxis (norfloxacin); nephrotoxin avoidance; salt restriction; serial paracentesis as needed (ICA 2019 HRS-AKI; Salerno 2011)
    advance: Follow-up scheduled (ICA 2019 HRS-AKI)