Abstract: PUB019
Refractory Hepatorenal Syndrome-AKI Despite Guideline-Concordant Albumin Replacement in Decompensated Cirrhosis Requiring Therapeutic Paracentesis
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Mittal, Ajay, BayCare Health System, Clearwater, Florida, United States
- Tai, Brent, BayCare Health System, Clearwater, Florida, United States
- D'Cunha, Prakas Thomas, BayCare Health System, Clearwater, Florida, United States
Introduction
Hepatorenal syndrome–acute kidney injury (HRS-AKI) represents a rapidly progressive and life-threatening cause of kidney dysfunction in patients with decompensated cirrhosis and ascites. While albumin replacement during therapeutic paracentesis is standard to reduce circulatory dysfunction and kidney injury risk, severe HRS-AKI may remain clinically significant despite guideline-concordant management, requiring escalation of renal support and transplant-directed care.
Case Description
A 68-year-old male with decompensated alcohol-associated cirrhosis (MELD 29), recurrent refractory ascites requiring serial outpatient paracenteses, and recent liver transplant evaluation presented with progressive fatigue and was found to have severe hyperkalemia (6.9 mmol/L) and stage 3 acute kidney injury. Baseline serum creatinine (SCr) was 1.1 mg/dL, increasing to 6.2 mg/dL on admission. Notably, the patient had missed a scheduled outpatient paracentesis the preceding week while undergoing transplant evaluation, with his last paracentesis performed approximately two weeks prior to presentation. Electrocardiogram demonstrated atrial fibrillation with slow ventricular response secondary to hyperkalemia. Despite standard temporizing therapy, persistent hyperkalemia (6.5 mmol/L) required emergent hemodialysis, followed by a second dialysis session. Therapeutic paracentesis during hospitalization removed 4.85 L of ascitic fluid with guideline-concordant 25% albumin replacement administered at 6 g/L removed. Ascitic fluid analysis showed 467 nucleated cells without evidence of spontaneous bacterial peritonitis. Despite appropriate albumin administration and exclusion of infectious precipitants, renal dysfunction remained refractory, consistent with severe HRS-AKI requiring transfer to a tertiary center for liver transplant.
Discussion
This case highlights that patients with advanced cirrhosis may develop severe dialysis-requiring HRS-AKI despite guideline-concordant albumin administration during therapeutic paracentesis. In high-MELD patients, albumin may mitigate but not fully reverse profound circulatory dysfunction, emphasizing the importance of early nephrology involvement, renal replacement therapy when indicated, and expedited transplant-centered management.