AKI in Cirrhosis (Hepatorenal Syndrome)

Original chalk talk by Brandon Fainstad, MD
Edits, updates and graphics by Yilin Zhang, MD


  • Differential of AKI in ESLD
  • Pathophysiology of HRS (optional, ~ 7-10 min)
  • Diagnosis and management of HRS

Teaching Instructions: This talk is designed as a chalk talk. Each figure takes you through a step of the chalk talk and new additions are highlighted in green. Click on each figure to find the teaching script for each step of the chalk talk. For earlier learners (med students and interns), there is a simplified diagram of the pathophysiology, diagnosis and treatment available. 

There are also practice cases at the end which take ~ 5-10 min each. 

Skip to Cases


Board Set-Up:

Step 1: Differential of AKI in ESLD

Click for simplified pathophysiology, diagnosis and treatment of HRS.

Step 2: Pathophysiology of HRS (part 1)

Step 3: Pathophysiology of HRS (part 2)

Step 4: Diagnosis and Definition of HRS

Step 5: Treatment of HRS (Final Board)


CASES (~ 15 min)


A 55 year old woman with HCV cirrhosis presenting with fever and increased confusion. Reports taking her lactulose as directed. Admits to increased abdominal girth but no pain, decreased UOP. Denies SOB, cough or dysuria. On exam, she is afebrile, HR 92, BP 92/60, 98% on RA. She is diffusely edematous with a distended, nontender abdomen. Labs are notable for:

  • Na 127, BUN 30, Cr 2.4 (baseline 1.2)
  • WBC 12, Hct 30, Plt 90
  • Tbili 4 (baseline 2-3), alb 2
  • UA: RBCs, hyaline casts
  • Urine Na <10

What further work-up do you want? 

What is the cause for her AKI?  

How are you going to manage it? 


A 48 year old man with HCV/EtOH cirrhosis actively listed for transplant list presents from clinic with several lab abnormalities – worsening Cr, Tbili and INR. He reports increased fatigue, LE swelling and abdominal girth despite taking his diuretics. He reports mild abdominal diffuse abdominal discomfort but denies fever, chills, cough, SOB or dysuria. On exam, he is afebrile, HR 60, 92/45, 96% RA. He is diffusely edematous with a tight distended abdomen. Labs are notable for:

  • Na 126, BUN 40, Cr 2.4 (baseline 1.0 from 1 month prior)
  • WBC 8, Hct 28, Plt 80
  • Tbili 11 (baseline 4), INR 5 (baseline 2)
  • UA: 1+ protein, hyaline casts, occasional granular casts
  • Urine Na>65, FeUrea 30%

What additional work-up do you want? 

What is the cause for this patients AKI?

How are you going to manage this? 


A 45 year old man with PSC cirrhosis presenting to the ED with increased abdominal pain typical of his PSC flares. The pain has been going on for about a week and he was initially managing it with OTC pain medications (Tylenol and ibuprofen) but has progressively worsened. He denies fevers/chills, cough or abdominal pain. He reports decreased UOP and darker colored urine. On exam, he is AF, HR 90,  BP 120/80, 98% RA. He has a non-distended abdomen with mild RUQ tenderness without a Murphys’ sign. He has no CVA tenderness. Labs are notable for:

  • Na 132, K 5.8, Cr 3.6 (baseline of 0.9)
  • WBC 6, Hct 32, Plt 110
  • Tbili 4 (baseline of 3), INR 1.4
  • UA: hyaline casts, 1+ WBC
  • Urine Na 28, Urine Cr 60

What is the likely cause of this man’s AKI? 

How do you want to manage him? 


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  2. Ge, PS & Runyon, BA. Treatment of Patients with Cirrhosis. NEJM. 2016;375:767-77
  3. Liou, IU. Management of end-stage liver disease. Med Clin North Am. 2014 Jan;98(1):119-52.
  4. Sort, P, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. NEJM. 1999; 341:403-409.
  5. Runyon, BA. Renal Failure in Cirrhosis. NEJM. 2009; 361(13):1279-1290.