Treatment of Anuria in Cirrhosis Patients
In a cirrhosis patient with no urination, immediately discontinue all diuretics and nephrotoxic medications, provide albumin volume expansion (1 g/kg/day for 2 days), and initiate vasoconstrictor therapy (terlipressin or norepinephrine) plus albumin if hepatorenal syndrome criteria are met after 48 hours of risk factor management. 1
Initial Emergency Assessment and Risk Factor Reversal
The first priority is determining whether this represents acute kidney injury (AKI) and identifying reversible causes. 1
Immediate actions within the first 48 hours:
- Stop all diuretics immediately (spironolactone, furosemide) as these worsen renal perfusion in AKI 1
- Discontinue all nephrotoxic medications: NSAIDs, ACE inhibitors, ARBs, and beta-blockers 1
- Rule out urinary obstruction with renal ultrasound to exclude postrenal causes 1, 2
- Treat any infections aggressively with broad-spectrum antibiotics, as sepsis is a major trigger for hepatorenal syndrome 1, 3
- Stop any ongoing bleeding and assess for hypovolemia from gastrointestinal hemorrhage 4, 5
Volume Expansion Protocol
Administer albumin 20-25% at 1 g/kg/day for 2 consecutive days to expand plasma volume and assess response. 1 This is critical for distinguishing hepatorenal syndrome from prerenal azotemia due to true hypovolemia. 4, 5
- Monitor closely for pulmonary edema during albumin administration, as fluid overload risk is significant in AKI 1
- Measure serum creatinine daily and urine output continuously 1
- Check urinary sodium excretion to assess tubular function 1
Hepatorenal Syndrome Diagnosis and Treatment
If after 48 hours of risk factor management and volume expansion the patient still has:
- Serum creatinine >1.5 mg/dL or doubled from baseline
- No improvement in renal function
- No proteinuria, hematuria, or structural kidney abnormalities on ultrasound
Then diagnose hepatorenal syndrome-AKI and immediately initiate vasoconstrictor therapy. 1
Vasoconstrictor Therapy Options:
First-line: Terlipressin (vasopressin analog) combined with albumin 4, 5, 6
- Terlipressin improves renal function by causing splanchnic vasoconstriction, which increases effective arterial blood volume 5, 6
- Continue albumin infusion throughout vasoconstrictor therapy 5
Alternative: Norepinephrine combined with albumin and furosemide 5
- May be used if terlipressin is unavailable 5
Alternative: Midodrine plus octreotide plus albumin 4, 5
The goal is normalization of serum creatinine, which occurs in many patients after 1-3 weeks of therapy. 6 Importantly, hepatorenal syndrome may not recur after discontinuation in responders, suggesting the progressive course can be interrupted. 6
Renal Replacement Therapy Indications
Consider urgent dialysis if the patient develops: 1, 3
- Uremic encephalopathy (altered mental status with elevated creatinine) 7
- Severe metabolic acidosis refractory to medical management 7
- Hyperkalemia >6.0 mmol/L unresponsive to treatment 1, 7
- Volume overload with pulmonary edema 1
- Pericarditis 7
Renal replacement therapy should be individualized based on candidacy for liver transplantation, as patients awaiting transplant may benefit from bridging dialysis. 3, 8
Critical Monitoring Parameters
- Daily serum creatinine and electrolytes until stabilization 1
- Continuous urine output monitoring (oliguria <0.5 mL/kg/h for >6 hours indicates worse mortality) 1
- Avoid fluid restriction unless serum sodium drops below 120-125 mmol/L 1
- Monitor for hepatic encephalopathy, which worsens with azotemia 1
Common Pitfalls to Avoid
Do not continue diuretics in the setting of anuria - this is a critical error that worsens renal perfusion and increases mortality. 1 Even if the patient has massive ascites, diuretics must be stopped until renal function improves. 1
Do not delay vasoconstrictor therapy once hepatorenal syndrome is diagnosed after the 48-hour volume challenge. 1 Early initiation improves response rates and survival. 5, 6
Do not rely solely on creatinine to assess renal function severity, as cirrhotic patients have reduced creatinine production from decreased muscle mass and impaired hepatic synthesis. 1 The absolute creatinine level underestimates the true degree of renal dysfunction. 1
Liver Transplantation Consideration
All cirrhotic patients with ascites and renal dysfunction should be evaluated for liver transplantation, as this is the definitive treatment for hepatorenal syndrome. 1 Development of AKI significantly worsens prognosis and increases post-transplant mortality if renal dysfunction persists. 8, 2