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gi.hepatorenal-syndrome.core.v1PRODUCTION
gi.hepatorenal-syndrome.core.v1

Hepatorenal Syndrome (HRS-AKI)

hepatologyacuteadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm HRS-AKI scope — AKI in cirrhosis after volume challenge with bland sediment, no shock [ICA 2015 Angeli; AASLD 2023]

Inputs
1
Actions
0
Advance rule
Set
Advance when

cirrhosis + AKI confirmed

Patient inputs (15)

Transplant eligibility; HRS prognosis [AASLD 2023]

Hypotension is contributing physiology + drives vasoconstrictor titration [CONFIRM Wong NEJM 2021]

Hold diuretics during workup; rule out prerenal [AASLD 2023; ICA 2015]

Reversible drivers must be removed before diagnosing HRS [ICA 2015; AASLD 2023]

Hold ACEi/ARB/NSAIDs/aminoglycosides/IV contrast [AASLD 2023]

Defines HRS-AKI per ICA criteria; baseline + serial [ICA 2015 Angeli J Hepatol]

Hyponatremia common; MELD-Na [UNOS 2016]

MELD/MELD-Na component; cirrhosis severity [UNOS] (ACG 2024)

MELD component; coagulopathy [UNOS] (ACG 2024)

Albumin challenge component; nutritional [ICA 2015; AASLD 2023]

Bland sediment + low FeNa supports HRS over ATN [ICA 2015; EASL 2018]

FeNa <1% / urine Na <10 supports HRS [ICA 2015; EASL 2018]

MAP target with terlipressin/norepinephrine [CONFIRM Wong NEJM 2021]

LVP without albumin → post-paracentesis circulatory dysfunction [EASL 2018]

SBP precipitant — albumin 1.5g/kg day 1 + 1 g/kg day 3 reduces HRS risk [Sort NEJM 1999]

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateninghrs_aki_confirmed_after_volume_challenge (ACG 2024)
    AKI in cirrhotic + bland sediment + no shock + no nephrotoxin + no improvement after 2 days albumin 1 g/kg + diuretic withdrawal [ICA 2015 Angeli]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_precipitant_treat_to_prevent_hrs
    SBP diagnosed (ANC ≥250) with elevated Cr, BUN, or bilirubin [AASLD 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereterlipressin_pulmonary_edema
    Worsening hypoxemia, increased work of breathing, new pulmonary edema on CXR during terlipressin [CONFIRM Wong NEJM 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenon_response_day_14
    No 25% Cr reduction by day 14 of terlipressin + albumin [CONFIRM Wong NEJM 2021]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereshock_transition_to_acute_tubular_necrosis
    New shock or sepsis → switch from HRS pathway to sepsis-driven AKI / ATN management [EASL 2018; ICA 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremac_or_meld_qualification_for_transplant
    MELD ≥15 with HRS-AKI in transplant candidate [AASLD 2023; UNOS]
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

HRS-AKI — vasoconstrictor + albumin + transplant evaluation (CONFIRM 2022 + AASLD 2021 + ICA 2015)
axis: hrs_aki_pathwaystep 1 - Step 1 — Pre-HRS workup and reversible cause exclusion
Selected step "Step 1 — Pre-HRS workup and reversible cause exclusion" — AKI in cirrhosis (ICA AKI criteria — Cr rise ≥0.3 in 48h or ≥50% from baseline)
  • albumin_25_percent
    first line
    colloid
    1 g/kg/day IV (max 100 g/day) × 2 days • IV • daily
    triggers: AKI_in_cirrhosis_diagnostic_volume_challenge
    Volume challenge to distinguish prerenal from HRS; ICA criteria (ACG 2024)
    rxcui 828529
  • discontinue_diuretics_and_nephrotoxins
    first line
    medication_review
    STOP all diuretics, NSAIDs, ACEi, ARB, aminoglycosides, IV contrast • NA • one-time
    triggers: AKI_in_cirrhosis
    Reversible drivers must be removed before diagnosing HRS (ACG 2024)

inpatient playbook — drug actions (7)

  1. 1. discontinue diuretics + nephrotoxins (ACG 2024)
    STOP • NA • one-time
    trigger: AKI in cirrhosis (ACG 2024)
    Reversible cause exclusion [ICA 2015; AASLD 2023]
  2. 2. albumin volume challenge
    1 g/kg/day IV (max 100 g) × 2 days • IV • daily
    trigger: AKI in cirrhosis pre-HRS confirmation (ACG 2024)
    ICA 2015 criteria volume challenge [Angeli J Hepatol 2015]
  3. 3. terlipressin + albumin
    Terlipressin 1 mg IV q4-6h up to 14 days + albumin 1 g/kg d1 then 20-40 g/day • IV • q4-6h + daily
    trigger: HRS-AKI confirmed (ACG 2024)
    CONFIRM Wong NEJM 2021 (FDA 2022) [AASLD 2023]
  4. 4. midodrine + octreotide + albumin (alternative)
    Midodrine 7.5-12.5 mg PO TID + octreotide 100-200 mcg SC TID + albumin 20-40 g/day • PO/SC/IV • TID + daily
    trigger: Terlipressin unavailable (ACG 2024)
    Alternative regimen [AASLD 2023; EASL 2018]
  5. 5. norepinephrine in ICU
    0.5-3 mg/h titrated to MAP +10 • IV • continuous
    trigger: ICU setting (ACG 2024)
    ICU alternative to terlipressin [AASLD 2023]
  6. 6. ceftriaxone for SBP precipitant
    2 g IV daily × 5-7 days + albumin 1.5 g/kg d1 + 1 g/kg d3 • IV • daily
    trigger: Concurrent SBP (ACG 2024)
    Treat precipitant; reduces HRS risk [Sort NEJM 1999; AASLD 2023]
  7. 7. lactulose if HE overlap
    25 mL PO TID • PO • TID
    trigger: HE precipitant (ACG 2024)
    HE prophylaxis [AASLD 2023]

Auto-drafted A&P note

inpatient

Subjective

- Possible entry pathways: AKI in cirrhotic patient (rising creatinine) [ICA 2015 Angeli J Hepatol]; Oliguria / anuria in decompensated cirrhosis [AASLD 2023]; Cirrhosis with refractory ascites + new AKI [AASLD 2023; EASL 2018].

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hepatorenal Syndrome (HRS-AKI)** (gi.hepatorenal-syndrome.core.v1).
Phenotype framing: Distinguish HRS-AKI (Type 1) from prerenal (volume responsive), ATN (muddy casts), obstructive, glomerular (proteinuria) [ICA 2015; EASL 2018]
Scope: Confirm HRS-AKI scope — AKI in cirrhosis after volume challenge with bland sediment, no shock [ICA 2015 Angeli; AASLD 2023]

No severity triggers fired against current inputs.

Plan

Regimen axis: **HRS-AKI — vasoconstrictor + albumin + transplant evaluation (CONFIRM 2022 + AASLD 2021 + ICA 2015)** — step "Step 1 — Pre-HRS workup and reversible cause exclusion".
1. albumin_25_percent 1 g/kg/day IV (max 100 g/day) × 2 days IV daily (colloid, first line) — Volume challenge to distinguish prerenal from HRS; ICA criteria (ACG 2024)
2. discontinue_diuretics_and_nephrotoxins STOP all diuretics, NSAIDs, ACEi, ARB, aminoglycosides, IV contrast NA one-time (medication_review, first line) — Reversible drivers must be removed before diagnosing HRS (ACG 2024)

Setting playbook (inpatient) — Confirm HRS-AKI per ICA (after volume challenge), initiate terlipressin + albumin, hepatology + transplant referral, transplant center transfer if MELD ≥15 (ACG 2024)
3. discontinue diuretics + nephrotoxins (ACG 2024) STOP NA one-time — AKI in cirrhosis (ACG 2024) (Reversible cause exclusion [ICA 2015; AASLD 2023])
4. albumin volume challenge 1 g/kg/day IV (max 100 g) × 2 days IV daily — AKI in cirrhosis pre-HRS confirmation (ACG 2024) (ICA 2015 criteria volume challenge [Angeli J Hepatol 2015])
5. terlipressin + albumin Terlipressin 1 mg IV q4-6h up to 14 days + albumin 1 g/kg d1 then 20-40 g/day IV q4-6h + daily — HRS-AKI confirmed (ACG 2024) (CONFIRM Wong NEJM 2021 (FDA 2022) [AASLD 2023])
6. midodrine + octreotide + albumin (alternative) Midodrine 7.5-12.5 mg PO TID + octreotide 100-200 mcg SC TID + albumin 20-40 g/day PO/SC/IV TID + daily — Terlipressin unavailable (ACG 2024) (Alternative regimen [AASLD 2023; EASL 2018])
7. norepinephrine in ICU 0.5-3 mg/h titrated to MAP +10 IV continuous — ICU setting (ACG 2024) (ICU alternative to terlipressin [AASLD 2023])
8. ceftriaxone for SBP precipitant 2 g IV daily × 5-7 days + albumin 1.5 g/kg d1 + 1 g/kg d3 IV daily — Concurrent SBP (ACG 2024) (Treat precipitant; reduces HRS risk [Sort NEJM 1999; AASLD 2023])
9. lactulose if HE overlap 25 mL PO TID PO TID — HE precipitant (ACG 2024) (HE prophylaxis [AASLD 2023])

Non-pharmacologic actions:
- Hepatology consult day 1 (ACG 2024)
- Transplant team referral if MELD ≥15 and candidate (ACG 2024)
- Diagnostic paracentesis to exclude SBP (ACG 2024)
- Renal US to exclude obstruction (ACG 2024)
- Avoid contrast unless essential (ACG 2024)
- Strict I&O (ACG 2024)
- Daily weight (ACG 2024)
- Sodium/fluid restriction in ascites (ACG 2024)

AVOID / contraindication checks:
- NSAID_avoid_in_HRS (ACG 2024)
- Aminoglycoside_avoid (ACG 2024)
- Contrast_avoid_unless_essential (ACG 2024)
- ACEi_ARB_avoid (ACG 2024)
- Terlipressin_caution_severe_CV_disease_pulmonary_edema_risk (ACG 2024)
- Norepinephrine_requires_central_line_ICU_monitoring (ACG 2024)

Monitoring

Regimen monitoring:
- daily Cr BMP (ACG 2024)
- MAP target >=82 or +10 above baseline (ACG 2024)
- hourly UOP (ACG 2024)
- continuous SpO2 for terlipressin pulmonary edema risk (ACG 2024)
- serum lactate q6h (ACG 2024)
- response definition Cr decrease by 25% in first 4 days (ACG 2024)
- duration up to 14 days terlipressin then reassess (ACG 2024)

Setting (inpatient) monitoring:
- Daily Cr, BMP, lactate (ACG 2024)
- MAP target ≥82 mmHg or ≥10 mmHg above baseline (ACG 2024)
- Hourly UOP (target ≥0.5 mL/kg/h) (ACG 2024)
- Continuous SpO2 (terlipressin pulmonary edema risk) (ACG 2024)
- Daily MELD-Na recalculation (ACG 2024)
- Response (Cr drop 25%) by day 4 (ACG 2024)

Follow-up plan: Hepatology + transplant follow-up; SBP secondary prophylaxis [AASLD 2023]; recurrence counseling; renal recovery monitoring
- Close-out criterion: follow-up scheduled

Monitoring phase: 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]

Disposition

Current setting: inpatient — Confirm HRS-AKI per ICA (after volume challenge), initiate terlipressin + albumin, hepatology + transplant referral, transplant center transfer if MELD ≥15 (ACG 2024)

Disposition criteria:
- Step-down: Cr improving with terlipressin response, hemodynamic stability, no respiratory compromise (ACG 2024)
- Transplant center transfer: MELD ≥15 + candidate (ACG 2024)

Escalation triggers (move to higher acuity):
- Pulmonary edema with terlipressin → discontinue, switch to norepinephrine (ACG 2024)
- Non-response by day 14 → RRT + transplant priority (ACG 2024)
- New ACLF organ failure → ICU + transplant transfer (ACG 2024)
- Septic shock → ICU + sepsis bundle (ACG 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] AKI in cirrhotic + bland sediment + no shock + no nephrotoxin + no improvement after 2 days albumin 1 g/kg + diuretic withdrawal [ICA 2015 Angeli]
- [SEVERE] SBP diagnosed (ANC ≥250) with elevated Cr, BUN, or bilirubin [AASLD 2023]
- [SEVERE] Worsening hypoxemia, increased work of breathing, new pulmonary edema on CXR during terlipressin [CONFIRM Wong NEJM 2021]

Citations

- AASLD 2021 Practice Guidance on Ascites, SBP and Hepatorenal Syndrome + CONFIRM terlipressin RCT (NEJM 2021) + Sort albumin-in-SBP RCT (NEJM 1999) [PMID:33657294](https://pubmed.ncbi.nlm.nih.gov/33657294/)
- Cited evidence (PMID 10432325) [PMID:10432325](https://pubmed.ncbi.nlm.nih.gov/10432325/)
- Cited evidence (PMID 33942342) [PMID:33942342](https://pubmed.ncbi.nlm.nih.gov/33942342/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD 2021 Practice Guidance on Ascites, SBP and Hepatorenal Syndrome + CONFIRM terlipressin RCT (NEJM 2021) + Sort albumin-in-SBP RCT (NEJM 1999) — PMID:33657294
  • Cited evidence (PMID 10432325) — PMID:10432325
  • Cited evidence (PMID 33942342) — PMID:33942342