Decompensated liver disease and acute kidney failure

• It is more common in association with spontaneous bacterial peritonitis. 
•  Search for causes: nefrotoxic,  infection?Perform urinalysis and urine culture, looking for infection or evidence of parenchymal kidney injury. 
• Withdraw diuretics and nephrotoxic drugs.
•  Euvolaemia should be achieved with albumin or a crystalloid.
•  If renal function in a patient with cirrhosis and ascites deteriorates despite initial treatment, the most likely cause is hepatorenal syndrome: Terlipressin and albumin treatment improves renal perfusion. Reduction in the effective circulating blood volume and  hypoperfusion of the kidney is the  underlying pathogenetic mechanism for the development of hepatorenal syndrome.

Terlipressin is a vasopressin analogue that generates vasocontrction . It ncreases mean arterial pressure and systemic vascular resistance; while the heart rate, cardiac output, HVPG and portal venous blood flow decrease significantly. This decrease correlates well with the decrease in plasma renin activity. 

The improvement in hemodynamics with Terlipressin is associated with an increase in glomerular filtration rate and deactivation of the vasoconstrictor and sodium-conserving hormones with reduced activity of the RAAS resulting in increased natriuresis. Patients with HRS who show an improvement in renal function with Terlipressin and albumin seem to have an excellent post-transplantation outcome similar to that of patients without HRS. 

BMJ 2016;352:i124 doi: I/bmj.i124 (Published 26 January 2016)

J Gastroenterol Hepatol. 2011 Jan;26 Suppl 1:109-14. doi: 10.1111/j.1440-1746.2010.06583.x.