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Hepatorenal Syndrome — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyHepatorenal SyndromeRACP Adult Medicine

A 55-year-old man with alcohol-related cirrhosis develops spontaneous bacterial peritonitis (SBP) with ascitic fluid neutrophil count of 450 cells/mm³. He is treated with IV ceftriaxone. On day 3, he develops rising creatinine from 100 to 210 µmol/L despite albumin infusion. Urine output is adequate. What is the most likely complication?

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Correct answer: A — Hepatorenal syndrome type 1 (HRS-AKI)

SBP is a well-recognised precipitant of hepatorenal syndrome (HRS-AKI) in cirrhosis. Despite albumin infusion (1.5 g/kg on day 1, 1 g/kg on day 3 – which reduces HRS incidence), HRS can still develop. Management includes IV albumin, cessation of diuretics, and trial of terlipressin (the vasopressor with the best evidence for HRS-AKI). Criteria: rising creatinine, no improvement after 48 hours of volume expansion, absence of shock, no nephrotoxic drugs, and no structural kidney disease.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2018 – Decompensated Cirrhosis; ICA – 2023 – HRS Criteria