Hepatorenal Syndrome /Acute Kidney Injury (HRS-AKI)

Diagnosis and Management of Hepatorenal Syndrome / Acute Kidney Injury (HRS-AKI)
  • Cirrhosis; acute liver failure; acute-on-chronic liver failure
  • Increase in serum creatinine ≥ 0.3 mg/dl (≥ 26.5 μmoL/L) within 48 h or ≥ 50% from baseline value according to ICA consensus document and/or                        urinary output ≤ 0.5 mL/kg bodyweight ≥ 6h
  • No full or partial response, after at least 2 days of diuretic withdrawal and volume expansion with albumin (recommended dose of albumin is 1g/kg of body weight per day to a maximum of 100 g/day)
  • Absence of shock
  • No current or recent treatment with nephrotoxic drugs
  • Absence of parenchymal disease as indicated by proteinuria > 500 mg/day, microhematuria (> 50 red blood cells per high power field, urinary injury biomarkers (if available) and/or abnormal renal ultrasonography Suggestion of renal vasoconstriction with FENa of < 0.2% (with levels < 0.1% being highly predictive)
Recommended therapy Liver transplant (priority dependent on MELD score, see Liver Cirrhosis: Management). If person is on transplant list, MELD score should be updated daily and communicated to transplant centre, see Solid Organ Transplantation (SOT)
Alternative (bridging therapy) Vasoconstrictors


0.5-2.0 mg iv every 4-6 hours

or octreotide 100-200 μg sc tid
→ Goal to increase mean arterial pressure by 15 mmHg
+ midodrine 5-15 mg po tid
and iv albumin
(both for at least 7 days)
  50-100 g iv qd