A 47-year-old man with alcoholic cirrhosis, listed for liver transplantation, presents with confusion. His medications include spironolactone 100 mg daily and furosemide 80 mg daily. On examination he is afebrile, confused with a blood pressure of 99/73 mmHg. His abdomen is distended with a fluid wave. Laboratory tests one week ago showed a serum creatinine of 1.1 mg/dL (97 mmol/L). At that time, an abdominal ultrasound showed ascites, a patent portal vein, and no evidence of liver cancer. Laboratory tests in the emergency department show a serum creatinine of 2.6 mg/dL (229 mmol/L), and a potassium of 4.9 mEq/L. A diagnostic paracentesis reveals 550 neutrophils/mm3. Urine output in the emergency department is 10 ml/hr. Urinalysis shows 75 RBC/hpf with casts.

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In addition to withdrawal of diuretics and initiation of antibiotics, what is the next best step in the management of this patient?

  • A. Begin intravenous albumin
  • B. Initiate dialysis
  • C. List for simultaneous liver and kidney transplantation
  • D. Start treatment with intravenous terlipressin
  • E. Start treatment with midodrine and octreotide
The correct answers are indicated in green.


This patient has an AKI > stage 1a. In this patient, the presence of increased creatinine and hematuria with casts suggests tubular injury. This patient does not fulfill criteria for HRS-AKI, therefore D and E are incorrect. At present, potassium is not in a range which would indicate urgent need for dialysis. Initial management consists of volume expansion with albumin and continued monitoring. Simultaneous liver/kidney transplantation can be considered for patients with AKI on renal replacement therapy for ≥4 weeks or those with an estimated GFR ≤ 35 ml/min for 4 weeks.


EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69(2):406-460.

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