Dx on serum Creatinine (sCr) > 133 µmol/l which is not reduced with the administration of albumin (1g/kg of body weight), after a min. of 2 days off diuretics, plus no current or recent treatment with potentially nephrotoxic drugs, and no shock
Most AKI in Cirrhosis is not HRS
Investigations
Oliguria & Urinary Sodium <10 mmol/L
Type 1: sCr doubles in <2 weeks
Type 2: sCr doubles over longer
Management of AKI
Strict input/output monitoring, typically need to catheterise patient
68% of AKI in Cirrhosis is pre-renal, thus diuretics should be withheld
Discontinuation of all nephrotoxic and relevant drugs e.g.:
Vasodilators, NSAIDs
Beta-blockers, ARBs/ACE inhibitors
Investigate for alternative causes of AKI (±renal US
Give IV albumin (1g of albumin per kg of body weight (max dose 100g) daily, for two consecutive days)
If AKI failing to improve with above measures, treat as HRS:
Terlipressin at low dose initally 0.5–1 mg every 4–6 hr IV (or as a continuous iv infusion at 2mg/day initially), with an increase up to 2 mg every 4–6 hr (max 12mg/day) until sCr decreases below 133 µmol/L
Treatment should be maintained until a complete response (sCr below 133 µmol/L) or for a maximum of 14 days either in partial or non-response
ECG prior to Terlipressin administration
Contraindications including IHD
Albumin is used as an adjunct to Terlipressin at a typical dose of 20–40 g/day
Renal-replacement therapy may need to be considered in patients who do not have a response to vasoconstrictor drugs