Management of Acute Kidney Injury in Cirrhotic and Non-Cirrhotic Patients

General Principles

The American Journal of Kidney Diseases recommends that furosemide should NOT be used to prevent AKI or to convert oliguric to non-oliguric AKI in patients with acute kidney injury 1
The only indication for diuretics in AKI is management of volume overload, such as pulmonary edema or severe fluid overload, according to the American Journal of Kidney Diseases 1
Albumin is NOT recommended for general AKI management in non-cirrhotic patients, as stated by the American Journal of Kidney Diseases 1
In non-cirrhotic patients, isotonic crystalloids, rather than colloids like albumin, should be used for volume expansion, as recommended by the American Journal of Kidney Diseases 1

The Hepatology society recommends administering IV albumin 1 g/kg body weight (maximum 100 g/day) for 48 hours after withdrawing diuretics and treating precipitating factors in cirrhotic patients with AKI 2, 3
Albumin is superior to crystalloids in cirrhotic patients because it more effectively restores effective arterial blood volume, according to Gastroenterology 4
Lack of response to this albumin challenge is a diagnostic criterion for hepatorenal syndrome-AKI (HRS-AKI), as stated by Gastroenterology 4, 6
Vasoconstrictors plus albumin (20-40 g/day) are indicated ONLY for Stage 2 or greater HRS-AKI, NOT for other forms of AKI in cirrhosis, according to Gastroenterology 7, 4, 8, 3
The optimal duration of albumin with vasoconstrictors is unclear, but it is recommended to consider stopping after initial 1-2 days based on volume status, as stated by Gastroenterology and Hepatology 8, 3

Terlipressin (0.5-2.0 mg IV q6h or continuous infusion 2 g/24h IV) is first-line for vasoconstrictor therapy in cirrhotic patients with HRS-AKI, according to Gastroenterology and Hepatology 8, 3
Norepinephrine can be used as an alternative, especially in shock patients, as recommended by Hepatology 3
Octreotide/midodrine combination can be used where other agents are unavailable, according to Gastroenterology 7

Monitor carefully for volume overload and pulmonary edema in cirrhotic patients receiving albumin, as recommended by Gastroenterology and Clinical Gastroenterology and Hepatology 4, 5, 10
Routine fixed-dose albumin may cause pulmonary edema, particularly in patients with cirrhotic cardiomyopathy or diastolic dysfunction, according to Gastroenterology and Hepatology 4, 9

Identify patient population: Cirrhotic vs. non-cirrhotic, as recommended by Clinical Gastroenterology and Hepatology 10
Non-cirrhotic AKI: No albumin; furosemide only for volume overload, according to the American Journal of Kidney Diseases 1
Cirrhotic AKI: Stop diuretics, give albumin 1 g/kg/day × 48h, and add vasoconstrictors + albumin 20-40 g/day if no response and meets HRS-AKI criteria, as recommended by Hepatology and Gastroenterology 2, 3, 8