Management of Acute Kidney Injury with Coagulopathy

Immediate Diagnostic and Management Steps

The American Association for the Study of Liver Diseases recommends immediately discontinuing all diuretics and nephrotoxic medications, aggressively screening for and treating infection with empirical antibiotics before culture results, and administering albumin 1 g/kg/day for two consecutive days while carefully monitoring for pulmonary edema, as sepsis with multiorgan dysfunction is the most urgent and reversible cause of this presentation 1, 2, 3
Infection screening is mandatory and must not be delayed, as bacterial infections are the most common precipitant of hepatorenal syndrome and multiorgan failure in this presentation, according to the European Association for the Study of the Liver 1, 3, 4
Obtain blood cultures, urine cultures, and chest radiography immediately, as recommended by the American College of Gastroenterology 1, 3
Perform diagnostic paracentesis if ascites is present to exclude spontaneous bacterial peritonitis, as suggested by the American Association for the Study of Liver Diseases 1, 4

The International Society of Nephrology recommends using vasopressors in conjunction with fluids for vasomotor shock with AKI, with no specific vasopressor preferred over another (norepinephrine, vasopressin, or dopamine can be used) 5
Prefer continuous kidney replacement therapy (CKRT) or prolonged intermittent kidney replacement therapy (PIKRT) over conventional intermittent hemodialysis for hemodynamically unstable patients, as recommended by the European Society of Intensive Care Medicine 6

Transfuse packed red blood cells to maintain hemoglobin between 7-9 g/dL for anemia with acute GI bleeding, as recommended by the American Association for the Study of Liver Diseases 2, 4
Avoid overtransfusion to prevent volume overload, as suggested by the American College of Gastroenterology 1

Promptly initiate vasoconstrictive drugs (terlipressin) in association with albumin if hepatorenal syndrome-AKI is diagnosed, as recommended by the European Association for the Study of the Liver 4
Perform therapeutic paracentesis with albumin infusion if tense ascites is present, as this improves renal function, according to the American Association for the Study of Liver Diseases 2, 4