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renal.hepatorenal.v1PRODUCTION
renal.hepatorenal.v1

Hepatorenal Syndrome (HRS-AKI)

nephrologyacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm cirrhosis + ascites + AKI; HRS-AKI is a diagnosis of exclusion among intrinsic causes (ICA 2019 HRS-AKI)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Cirrhosis + AKI confirmed (ICA 2019 HRS-AKI)

Patient inputs (8)

LT candidacy + terlipressin tolerability (ICA 2019 HRS-AKI; CONFIRM Wong NEJM 2021)

AKI staging + ICA-2019 criterion + response to albumin challenge (ICA 2019 HRS-AKI)

ICA-2019 criterion requires withdrawal of nephrotoxins + diuretics for 48h prior to diagnosis (ICA 2019 HRS-AKI)

Underlying advanced liver disease is sine-qua-non for HRS-AKI (ICA 2019 HRS-AKI)

Bland sediment expected; rule out ATN (muddy-brown casts), AIN, GN (ICA 2019 HRS-AKI)

Terlipressin titrated to MAP increase; norepinephrine alternative needs central line (CONFIRM Wong NEJM 2021)

Pre-LT bridge planning; expedited LT for refractory HRS (ICA 2019 HRS-AKI; ACG ALF 2014)

SBP precipitant — diagnostic paracentesis PMN ≥250 (Sort NEJM 1999; ICA 2019 HRS-AKI)

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Severity triggers (10)

10 need judgement
  • informationallife_threateninghrs_aki_type1_rapid_progression
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghrs_refractory_to_vasoconstrictor
    Refractory HRS — no Cr response after 14 days of terlipressin/norepi + albumin; bridge to RRT + expedited LT vs palliation (ICA 2019 HRS-AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaclf_with_aki
    Acute-on-chronic liver failure (ACLF) + AKI overlap — CLIF-SOFA ≥3 organ failures with HRS-AKI; very high short-term mortality (Ginès Lancet 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningterlipressin_respiratory_failure
    Terlipressin-related respiratory failure — desaturation / pulmonary edema / hypoxia; FDA boxed warning (CONFIRM Wong NEJM 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehrs_aki_type2_slow_progression
    Type-2 HRS-AKI — Cr <2.5 mg/dL with slow progression; classically associated with refractory ascites (ICA 2019 HRS-AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_associated_hrs
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereica_2019_criteria_met
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepre_lt_candidate_hrs
    Pre-liver-transplant candidate with HRS-AKI — expedited LT listing with MELD-Na exception (Ginès Lancet 2017; ACG ALF 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereterlipressin_ischemic_complication
    Terlipressin-related ischemia — peripheral / mesenteric / cardiac / cyanosis / chest pain / abdominal pain; discontinue + switch to norepi (CONFIRM Wong NEJM 2021 — boxed warning)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_tips_hrs
    Post-TIPS HRS — TIPS in Type-2 HRS non-LT candidate may improve renal function but new HRS post-TIPS requires re-evaluation (Ginès Lancet 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

HRS-AKI vasoconstrictor + albumin regimen — diagnostic challenge → terlipressin (preferred) → norepi alternative → RRT bridge → expedited LT (ICA 2019 HRS-AKI; CONFIRM Wong NEJM 2021)
axis: hrs_aki_vasoconstrictor_albuminstep step_0_withdraw_offenders - Step 0 — Discontinue diuretics + nephrotoxins (ICA-2019 mandatory step before diagnosis)
Selected step "Step 0 — Discontinue diuretics + nephrotoxins (ICA-2019 mandatory step before diagnosis)" — Cirrhotic with AKI on initial presentation (ICA 2019 HRS-AKI)
  • discontinue_offending_meds
    first line
    lifestyle_action
    Stop diuretics, NSAIDs, ACEi/ARB, aminoglycosides, IV contrast • PO • one-time
    triggers: cirrhosis_with_aki
    ICA 2019 HRS-AKI — withdraw nephrotoxins for ≥48h prior to diagnosing HRS-AKI; reversible prerenal AKI must be excluded

outpatient playbook — drug actions (4)

  1. 1. diuretic combo (furosemide + spironolactone)
    40 + 100 mg PO daily titrated; max 160 + 400 • PO • daily
    trigger: Ascites control with Cr stable
    Hold or down-titrate if Cr trends up (ICA 2019 HRS-AKI)
  2. 2. norfloxacin secondary SBP prophylaxis
    400 mg PO daily • PO • daily
    trigger: Post-SBP
    ICA 2019 HRS-AKI
  3. 3. IV albumin (outpatient infusion if available)
    25 g IV after each large-volume paracentesis >5 L • IV • per paracentesis
    trigger: Large-volume paracentesis
    Salerno 2011 meta-analysis — albumin post-LVP reduces post-paracentesis circulatory dysfunction + HRS
  4. 4. rifaximin
    550 mg PO BID • PO • BID
    trigger: HE recurrence prophylaxis
    Standard chronic HE maintenance

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rising creatinine in patient with cirrhosis + ascites (ICA 2019 HRS-AKI); Refractory ascites with rising creatinine (ICA 2019 HRS-AKI); Cirrhosis on problem list + AKI episode (ICA 2019 HRS-AKI).

Objective

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

Assessment

**Hepatorenal Syndrome (HRS-AKI)** (renal.hepatorenal.v1).
Phenotype framing: 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)
Scope: Confirm cirrhosis + ascites + AKI; HRS-AKI is a diagnosis of exclusion among intrinsic causes (ICA 2019 HRS-AKI)

No severity triggers fired against current inputs.

Plan

Regimen axis: **HRS-AKI vasoconstrictor + albumin regimen — diagnostic challenge → terlipressin (preferred) → norepi alternative → RRT bridge → expedited LT (ICA 2019 HRS-AKI; CONFIRM Wong NEJM 2021)** — step "Step 0 — Discontinue diuretics + nephrotoxins (ICA-2019 mandatory step before diagnosis)".
1. discontinue_offending_meds Stop diuretics, NSAIDs, ACEi/ARB, aminoglycosides, IV contrast PO one-time (lifestyle_action, first line) — ICA 2019 HRS-AKI — withdraw nephrotoxins for ≥48h prior to diagnosing HRS-AKI; reversible prerenal AKI must be excluded

Setting playbook (outpatient) — Post-discharge follow-up after HRS episode resolution OR Type-2 HRS slow progression management; LT workup acceleration; SBP prophylaxis; salt/diuretic optimization (ICA 2019 HRS-AKI; Salerno 2011)
2. diuretic combo (furosemide + spironolactone) 40 + 100 mg PO daily titrated; max 160 + 400 PO daily — Ascites control with Cr stable (Hold or down-titrate if Cr trends up (ICA 2019 HRS-AKI))
3. norfloxacin secondary SBP prophylaxis 400 mg PO daily PO daily — Post-SBP (ICA 2019 HRS-AKI)
4. IV albumin (outpatient infusion if available) 25 g IV after each large-volume paracentesis >5 L IV per paracentesis — Large-volume paracentesis (Salerno 2011 meta-analysis — albumin post-LVP reduces post-paracentesis circulatory dysfunction + HRS)
5. rifaximin 550 mg PO BID PO BID — HE recurrence prophylaxis (Standard chronic HE maintenance)

Non-pharmacologic actions:
- Pre-LT workup acceleration (Ginès Lancet 2017)
- Salt restriction <2 g/day reinforcement (ICA 2019 HRS-AKI)
- Nutrition counseling — protein + branched-chain amino acids (ICA 2019 HRS-AKI)
- Vaccinations per ACIP 2026 (HAV, HBV, PCV20, flu, COVID)
- Alcohol abstinence counseling (ICA 2019 HRS-AKI)
- Patient action card for HRS recurrence (ICA 2019 HRS-AKI)

AVOID / contraindication checks:
- Terlipressin ischemic vascular cardiac screen (CONFIRM Wong NEJM 2021)
- Terlipressin respiratory failure contraindicated (CONFIRM Wong NEJM 2021 — boxed warning)
- Albumin pulmonary edema monitor (ICA 2019 HRS AKI)
- Norepi central line arterial monitoring (ICA 2019 HRS AKI)
- Rrt only as bridge to lt not isolated hrs (ICA 2019 HRS AKI)

Monitoring

Regimen monitoring:
- Cr q12-24h during vasoconstrictor titration (ICA 2019 HRS-AKI)
- MAP target increase ≥10 mmHg from baseline (CONFIRM Wong NEJM 2021)
- UOP hourly during ICU (ICA 2019 HRS-AKI)
- ECG + peripheral perfusion daily during terlipressin (ischemic AE; CONFIRM Wong NEJM 2021)
- SpO2 continuous on terlipressin (respiratory failure signal; CONFIRM Wong NEJM 2021)
- Daily LFTs + INR + lactate + ammonia (ICA 2019 HRS-AKI)

Setting (outpatient) monitoring:
- Cr + BMP + LFTs q1-2 weeks early post-discharge (ICA 2019 HRS-AKI)
- MELD-Na q1 month (Ginès Lancet 2017)
- Beta-blocker safety review each visit (ICA 2019 HRS-AKI)

Follow-up plan: Outpatient hepatology + transplant clinic; SBP secondary prophylaxis (norfloxacin); nephrotoxin avoidance; salt restriction; serial paracentesis as needed (ICA 2019 HRS-AKI; Salerno 2011)
- Close-out criterion: Follow-up scheduled (ICA 2019 HRS-AKI)

Monitoring phase: Daily Cr + MAP + UOP; daily LFTs/INR; ischemic side-effects of vasoconstrictor (peripheral, mesenteric, cardiac); volume status (CONFIRM Wong NEJM 2021)

Disposition

Current setting: outpatient — Post-discharge follow-up after HRS episode resolution OR Type-2 HRS slow progression management; LT workup acceleration; SBP prophylaxis; salt/diuretic optimization (ICA 2019 HRS-AKI; Salerno 2011)

Disposition criteria:
- Continue clinic q2-4 weeks if stable (ICA 2019 HRS-AKI)
- Admit if HRS recurrence / SBP / GI bleed / refractory HE (ICA 2019 HRS-AKI)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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)

Citations

- 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 [PMID:25638527](https://pubmed.ncbi.nlm.nih.gov/25638527/)
- Cited evidence (PMID 33657294) [PMID:33657294](https://pubmed.ncbi.nlm.nih.gov/33657294/)
- Cited evidence (PMID 10432325) [PMID:10432325](https://pubmed.ncbi.nlm.nih.gov/10432325/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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 — PMID:25638527
  • Cited evidence (PMID 33657294) — PMID:33657294
  • Cited evidence (PMID 10432325) — PMID:10432325