Acute kidney injury (AKI) in a patient with acute or chronic liver disease complicated by severe liver failure and portal hypertension, when other causes of AKI have been excluded (see Chapter 25).
Hepatorenal syndrome occurs in around 20–25% of patients with acute liver failure and decompensated chronic liver disease. Spontaneous bacterial peritonitis (Appendix 24.1) is complicated by AKI in 30–40% of cases, and is a common precipitant of hepatorenal syndrome.
Acute kidney injury (see Chapter 25 for definition and staging)
- Exclusion of other causes of acute kidney injury (Chapter 25)
- No or minimal proteinuria
- Normal or near-normal urine microscopy
- Urine sodium concentration <10 mmol/L (if not taking diuretic); urine osmolality greater than plasma osmolality
- Failure of renal function to improve after withdrawal of diuretics and with volume expansion with human albumin solution 1g/kg (up to 100g) IV daily for two days.
- Seek advice from a hepatologist
- Treat the underlying liver disease
- Exclude/treat spontaneous bacterial peritonitis (Appendix 24.1)
- General management of acute kidney injury (Chapter 25)
- Consider treatment with terlipressin (0.5–2.0 mg IV every 4–12h) for 5–15 days plus human albumin solution, 1g/kg (up to 100g) IV on days 1 and 2, followed by 20–40g daily, for 5–15 days