How should the final diagnosis be written for a patient with decompensated liver cirrhosis and acute kidney injury (AKI)?

How to Write the Final Diagnosis in Decompensated Cirrhosis with AKI

The final diagnosis should list both conditions separately with appropriate staging: "Decompensated liver cirrhosis" followed by "Acute kidney injury, Stage [1/2/3], [specific etiology if identified]" - this approach reflects the International Club of Ascites consensus that AKI in cirrhosis requires distinct diagnostic classification based on dynamic creatinine changes and underlying cause. 1

Diagnostic Framework for Writing the Final Diagnosis

Primary Diagnosis Structure

List decompensated cirrhosis first, followed by AKI with specific staging and etiology: 1

• Decompensated liver cirrhosis (specify etiology if known: alcoholic, viral, etc.) 2, 3
• Acute kidney injury, Stage [1/2/3] based on ICA-AKI criteria 1
• Specify the AKI subtype when identified: HRS-AKI, acute tubular necrosis (ATN), prerenal azotemia, or other structural causes 1, 2

AKI Staging Criteria to Include

Use the International Club of Ascites staging system in your diagnosis: 1

• Stage 1: Increase in serum creatinine ≥0.3 mg/dL within 48 hours OR increase to 1.5-2 times baseline 1
• Stage 2: Increase in serum creatinine >2-3 times baseline 1
• Stage 3: Increase in serum creatinine >3 times baseline OR serum creatinine >4 mg/dL with acute increase ≥0.3 mg/dL OR initiation of renal replacement therapy 1

Specific Etiologic Diagnosis When Applicable

If HRS-AKI is diagnosed, document it explicitly as this changes management: 1

• HRS-AKI requires: Stage 2 or 3 AKI (or Stage 1 with progression), no response to 2 days of diuretic withdrawal and albumin (1 g/kg), absence of shock, no nephrotoxic drugs, and no structural kidney injury (proteinuria >500 mg/day, microhematuria >50 RBCs/hpf, or abnormal renal ultrasound) 1
• Note: The old requirement for creatinine >2.5 mg/dL has been removed from HRS-AKI criteria 1

If ATN is diagnosed, specify this as it represents 35-68% of AKI cases in cirrhosis: 1, 4, 2

• ATN diagnosis is supported by urinary biomarkers (NGAL, KIM-1), fractional excretion of sodium, or presence of tubular casts 1, 5
• ATN requires different management than HRS-AKI (supportive care vs. vasoconstrictors) 4, 6

If prerenal azotemia, document as volume-responsive AKI: 2, 3

• Prerenal AKI accounts for approximately 50% of AKI episodes in cirrhosis 1
• This responds to volume expansion with albumin, distinguishing it from HRS-AKI 2, 3

Example Diagnostic Statements

For HRS-AKI:

"Decompensated alcoholic cirrhosis with ascites; Acute kidney injury, Stage 2, hepatorenal syndrome type" 1

For ATN:

"Decompensated cirrhosis; Acute kidney injury, Stage 3, acute tubular necrosis" 1, 4, 2

For Prerenal AKI:

"Decompensated cirrhosis; Acute kidney injury, Stage 1, prerenal azotemia (volume-responsive)" 2, 3

For Undifferentiated AKI:

"Decompensated cirrhosis; Acute kidney injury, Stage 2, etiology under investigation" 1

Critical Diagnostic Pitfalls to Avoid

Do not use the outdated term "acute renal failure" or "type 1 hepatorenal syndrome" - these have been replaced by AKI and HRS-AKI respectively 1

Do not wait for creatinine >2.5 mg/dL to diagnose HRS-AKI - this outdated threshold delays treatment and worsens outcomes 1

Do not assume HRS-AKI is a diagnosis of exclusion - it can coexist with other forms of AKI such as ATN or develop on pre-existing chronic kidney disease 6

Do not use a fixed creatinine threshold of 1.5 mg/dL alone - this often indicates GFR ≤30 mL/min and misses earlier, treatable AKI 1

Do not diagnose HRS-AKI without documenting the 48-hour albumin trial - failure to respond to volume expansion is a required diagnostic criterion 1

Additional Diagnostic Considerations

Document baseline creatinine in the diagnosis when possible: 1

• Use stable creatinine within 3 months, or the closest stable value, or admission creatinine if no prior values available 1

Include progression or regression status if applicable: 1

• Progression: advancement to higher AKI stage or need for renal replacement therapy 1
• Regression: improvement to lower AKI stage 1
• Response to treatment: complete (creatinine <0.3 mg/dL from baseline) vs. partial (creatinine remains ≥0.3 mg/dL from baseline) 1

Consider documenting ACLF grade if present - 19-40% of patients with HRS-AKI have ACLF Grade 3, which affects prognosis and treatment decisions 7, 6