The American Association for the Study of Liver Diseases (AASLD) has updated their Guidance with a key recommendation: elimination of an absolute serum creatinine (SCr) threshold for diagnosis of hepatorenal syndrome acute kidney injury (HRS-AKI / HRS-1). This Guidance, which aligns with a 2015 recommendation from the International Club of Ascites (ICA), may lead to earlier diagnosis and improved treatment outcomes.1-3

New AASLD nomenclature and definition

Kidney Injury Definition

  • Previously known as

  • Doubling of SCr to a value >2.5 mg/dL within 2 weeks4

  • Now known as

  • Increase in SCr of ≥0.3 mg/dL within 48 hours1


    Percent increase in SCr that is ≥50% of what was known or presumed to have occurred within the prior 7 days1

Subtle SCr changes can be a reliable
predictor of HRS-AKI / HRS-1 mortality

Recent evidence suggests that subtle changes in SCr levels are prognostic indicators of patient outcomes.
Prompt identification of patients at risk for HRS-AKI / HRS-1 can increase the likelihood of positive treatment outcomes.1,5,6

An SCr increase of ≥0.3 mg/dL within the first 48 hours of hospitalization was shown to be the best predictor
of mortality risk among patients with cirrhosis.5,6

See the impact on clinical practice

Removal of an absolute SCr threshold
promotes earlier intervention

The 2021 AASLD Guidance advocates close monitoring of patients' SCr levels and tracking subtle changes from baseline to determine the appropriate intervention.1

This recommendation is based on the latest KDIGO/AKIN criteria for diagnosis of kidney injury and is a change from prior guidelines that recommended initiating differential diagnosis at an absolute SCr threshold of >2.5 mg/dL.1,4

Highlights of the new 2021 AASLD Guidance in
the context of HRS-AKI / HRS-1

The 2021 AASLD Guidance recommendations for assessment are:

Increase in SCr ≥0.3 mg/dL within 48 hours1
Percent increase in SCr that is ≥50% of what was known or
presumed to have occurred within the prior 7 days1

For management of HRS-AKI / HRS-1, the 2021 AASLD Guidance recommends
initiating vasoconstrictor therapy plus albumin if patients:

  • Demonstrate an increase in SCr >2-fold from baseline1
  • Meet the other criteria for HRS-AKI / HRS-1 diagnosis1

Earlier intervention may lead
to better outcomes

AASLD Guidance and ICA diagnosis criteria both support earlier diagnosis and treatment of HRS-AKI / HRS-1, which may lead to improved outcomes3

  • Earlier treatment by approximately 4 days3
  • Initiation of treatment when SCr levels were, on average, approximately 1 mg/dL lower3
  • Treatment before a further ≥1.5-fold increase in SCr (in 47% of patients)3

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  • References:

  • Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74:1014-1048.
  • Angeli P, Ginès P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015;64:531-537.

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