Criteria

Child-Pugh-Turcotte (CPT)[64][65]

One of the most commonly used scoring systems to determine disease severity in cirrhosis.[64][65] The CPT score is based on the presence of ascites and hepatic encephalopathy, serum bilirubin, albumin, and clotting (prothrombin time and international normalised ratio [INR]) and is divided into Child A, B, and C with increasing disease severity.

[Figure caption and citation for the preceding image starts]: Child-Pugh-Turcotte scoring systemFrom the collection of Dr Keith Lindor; used with permission [Citation ends].com.bmj.content.model.Caption@5dbf6b68

Model of End-Stage Liver Disease (MELD)[68]

A more recent scoring system for the determination of severity in cirrhosis, the MELD score is electronically calculated from the serum bilirubin, sodium, creatinine, and clotting (INR and prothrombin time) by a specific computer programme.[67][68] [ MELDNa scores (for liver transplantation listing purposes, not appropriate for patients under age 12 years) (SI units) Opens in new window ] ​​ This is the classification system used for the allocation of livers for transplantation in the US.

Hepatorenal syndrome-acute kidney injury (HRS-AKI)

Acute kidney injury (AKI) is an absolute increase in serum creatinine of ≥26.4 micromoles/L (≥0.3 mg/dL) in less than 48 hours, or a percentage increase in serum creatinine of at least 1.5-fold from baseline in less than 7 days, or a reduction in urine output of 0.5 mL/kg/h for more than 6 hours.[88][89][90]​​ AKI has three stages, as defined by the International Club of Ascites (ICA-AKI criteria):[91]

  • Stage 1: an increase in serum creatinine ≥26.4 micromoles/L (≥0.3 mg/dL) or an increase in serum creatinine ≥1.5-fold to twofold from baseline at diagnosis of AKI

  • Stage 2: an increase in serum creatinine greater than twofold to threefold from baseline

  • Stage 3: an increase of serum creatinine greater than threefold from baseline or serum creatinine ≥352 micromoles/L (≥4.0 mg/dL) with an acute increase ≥26.4 micromoles/L (≥0.3 mg/dL) or initiation of renal replacement therapy.

European Association for the Study of the Liver (EASL) guidelines recommend using an adapted staging system for AKI that splits AKI stage 1 into stage 1A and 1B according to a serum creatinine value of <133 micromoles/L (<1.5 mg/dL) or ≥133 micromoles/L (≥1.5 mg/dL), respectively.[88]

International Club of Ascites (ICA) diagnostic criteria for HRS-AKI:[89]

  • Cirrhosis with ascites

  • Diagnosis of AKI according to ICA-AKI criteria

    • Increase in serum creatinine ≥26.4 micromoles/L (≥0.3 mg/dL) within 48 hours, or

    • A percentage increase serum creatinine ≥50% from baseline which is known, or presumed, to have occurred within the prior 7 days.

  • No response after 2 consecutive days of diuretic withdrawal and plasma volume expansion with albumin

  • Absence of shock

  • No current or recent use of nephrotoxic drugs (non-steroidal anti-inflammatory drugs, aminoglycosides, or iodinated contrast media)

  • No macroscopic signs of structural kidney injury. Structural kidney injury is indicated by proteinuria (>500 mg/day), micro-haematuria (>50 red blood cells per high-power field), and/or abnormal renal ultrasonography.

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