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: rising creatinine in patient with cirrhosis + ascites (ica 2019 hrs-aki).

Other reasons your team may use this plan: refractory ascites with rising creatinine (ica 2019 hrs-aki); cirrhosis on problem list + aki episode (ica 2019 hrs-aki); aki following sbp diagnosis (sort nejm 1999; ica 2019 hrs-aki).

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
discontinue_offending_meds	Stop diuretics, NSAIDs, ACEi/ARB, aminoglycosides, IV contrast	PO	one-time	ICA 2019 HRS-AKI — withdraw nephrotoxins for ≥48h prior to diagnosing HRS-AKI; reversible prerenal AKI must be excluded

Plan: HRS-AKI vasoconstrictor + albumin regimen — diagnostic challenge → terlipressin (preferred) → norepi alternative → RRT bridge → expedited LT (ICA 2019 HRS-AKI; CONFIRM Wong NEJM 2021)

3. When to call your provider

Contact your care team if any of the following happen:

Rising Cr >0.3 from baseline in 48h → ED (HRS recurrence; ICA 2019 HRS-AKI)
New fever / abdominal pain → ED diagnostic paracentesis (SBP; Sort NEJM 1999)
New confusion / asterixis → ED for HE workup
Diuretic-refractory ascites OR hyponatremia <125 → admit for TIPS evaluation (Ginès Lancet 2017)

4. When to seek emergency care

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

Type-1 HRS-AKI — Cr doubles to >2.5 mg/dL in <2 weeks (rapid progression; emergent terlipressin) (ICA 2019 HRS-AKI; previously HRS-1)(life-threatening)
Type-2 HRS-AKI — Cr <2.5 mg/dL with slow progression; classically associated with refractory ascites (ICA 2019 HRS-AKI)
SBP + AKI worsening — empirical abx (cefotaxime) + albumin 1.5 g/kg day 1 + 1 g/kg day 3 reduces HRS incidence (Sort NEJM 1999 PMID 10432325)
ICA-2019 HRS-AKI criteria met: cirrhosis + ascites + AKI + no shock + no nephrotoxin in last 48h + no parenchymal disease (bland sediment, no proteinuria, normal renal US) + failed 2-day albumin 1 g/kg/d challenge (ICA 2019 HRS-AKI)
Pre-liver-transplant candidate with HRS-AKI — expedited LT listing with MELD-Na exception (Ginès Lancet 2017; ACG ALF 2014)
Refractory HRS — no Cr response after 14 days of terlipressin/norepi + albumin; bridge to RRT + expedited LT vs palliation (ICA 2019 HRS-AKI)(life-threatening)
Acute-on-chronic liver failure (ACLF) + AKI overlap — CLIF-SOFA ≥3 organ failures with HRS-AKI; very high short-term mortality (Ginès Lancet 2017)(life-threatening)
Terlipressin-related ischemia — peripheral / mesenteric / cardiac / cyanosis / chest pain / abdominal pain; discontinue + switch to norepi (CONFIRM Wong NEJM 2021 — boxed warning)
Terlipressin-related respiratory failure — desaturation / pulmonary edema / hypoxia; FDA boxed warning (CONFIRM Wong NEJM 2021)(life-threatening)

5. Follow-up

Outpatient hepatology + transplant clinic; SBP secondary prophylaxis (norfloxacin); nephrotoxin avoidance; salt restriction; serial paracentesis as needed (ICA 2019 HRS-AKI; Salerno 2011)

6. Sources

Guideline: International Club of Ascites (ICA) HRS-AKI consensus (Angeli J Hepatol 2015, revised AKI-in-cirrhosis criteria) + CONFIRM Wong NEJM 2021 (terlipressin FDA 2022) + Sort NEJM 1999 (albumin + cefotaxime in SBP prevention of HRS) + AASLD 2023 ACLF/ascites guidance