Table 4.

Proposed algorithm for management of children with liver disease and concomitant acute kidney injury

Treatment options in patients with AKI in liver disease
Treat associated conditions:   • GI bleeding/hypovolemia: fluid resuscitation   • Infections: aggressive antibiotics (as per local antibiogram)   • Adrenal insufficiency   • Avoid nephrotoxic drugs   • Treat raised IAP (drain and replace with albumin)   • Large volume ascites: paracentesis   • Differentiate between natural progression of liver disease with its complications vs. acute AKI with other organ dysfunction   • Once in ICU: cardiac output monitoring, fluids, full organ support, prioritize transplant listing   • Early vasoconstrictors and albumin
Pharmacological therapy:   • Albumin   • Vasoconstrictors including vasopressin and vasopressin analogues, octreotide, norepinephrine   • Vaptans (rarely used)
Assist devices:   • Continuous renal replacement therapy ± plasmapheresis   • MARS   • SPAD   • Prometheus
Surgical therapy   • TIPSS ((very rarely done)   • Liver transplant

GI, gastrointestinal; IAP, intra-abdominal pressure; TIPSS, trans-jugular Intrahepatic Porto-systemic shunt; ICU, intensive care unit, MARS, molecular adsorbent recirculation system; SPAD, single pass albumin dialysis