Hepatorenal Syndrome

A person with advanced cirrhosis can carry substantial ascites and still have kidneys that behave as though the circulation is empty. A new creatinine rise after spontaneous bacterial peritonitis, gastrointestinal bleeding, aggressive diuresis, or large-volume paracentesis should raise concern for HRS-AKI—but not trigger a reflex diagnosis. HRS-AKI is diagnosed only after reversible volume depletion, shock, nephrotoxins, obstruction, and structural renal disease have been addressed. In Canada, the treatment decision centres on whether albumin plus midodrine–octreotide is restoring perfusion and when ICU norepinephrine is needed; terlipressin is not approved for this indication. NP prescribing must remain within provincial authority, formulary requirements, and local protocols.