AKI is defined as an acute significant reduction in the glomerular filtration rate (GFR). sCr remains the most practical biomarker of renal function in patients with ARF (with or without cirrhosis). However, sCr as a biomarker of renal function has many limitations in clinical practice since it is influenced by bodyweight, race, age, and gender. The use of sCr in patients with cirrhosis is also affected by: (1) decreased formation of creatinine from creatine in muscles, secondary to muscle wasting;16 (2) increased renal tubular secretion of creatinine;17 (3) the increased volume of distribution in cirrhosis that may dilute sCr; (4) interference with assays for sCr by elevated bilirubin.18 As a consequence, measurement of sCr in patients with cirrhosis overestimates GFR or kidney function. Therefore, the use of a fixed threshold of sCr at 1.5 mg/dL (133 µmol/L) to define AKI in cirrhosis1 , 2 is problematic, because of two crucial problems. The first is that an sCr value of 1.5 mg/dL (133 µmol/L) often signifies that GFR is markedly decreased (to ∼30 mL/min);19 secondly, the fixed threshold does not take into account the dynamic changes in sCr that occur in the preceding days or weeks, which are needed to distinguish between acute and chronic kidney injury. Since the use of a single value of sCr is not sufficient to diagnose AKI, a dynamic definition referring to an acute increase of sCr to ≥50% from baseline to a final value ≥1.5 mg/dL (133 µmol/L) has been used in several clinical studies in patients with cirrhosis (table 1). AKI, as defined by these criteria, was a strong predictor of in-hospital mortality in patients with cirrhosis.20–23

Hepatorenal syndrome (HRS), a serious complication of cirrhosis, is associated with high mortality without treatment. Terlipressin with albumin is effective in the reversal of HRS. Where terlipressin is not available, as in the United States, midodrine and octreotide with albumin are used as an alternative treatment of HRS. The aim was to compare the effectiveness of terlipressin plus albumin versus midodrine and octreotide plus albumin in the treatment of HRS in a randomized controlled trial. Twenty‐seven patients were randomized to receive terlipressin with albumin (TERLI group) and 22 to receive midodrine and octreotide plus albumin (MID/OCT group). The TERLI group received terlipressin by intravenous infusion, initially 3 mg/24 hours, progressively increased to 12 mg/24 hours if there was no response. The MID/OCT group received midodrine orally at an initial dose of 7.5 mg thrice daily, with the dose increased to a maximum of 12.5 mg thrice daily, together with octreotide subcutaneously: initial dose 100 μg thrice daily and up to 200 μg thrice daily. Both groups received albumin intravenously 1 g/kg of body weight on day 1 and 20‐40 g/day thereafter. There was a significantly higher rate of recovery of renal function in the TERLI group (19/27, 70.4%) compared to the MID/OCT group (6/21, 28.6%), P = 0.01. Improvement in renal function and lower baseline Model for End‐Stage Liver Disease score were associated with better survival. Conclusion: Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS (Hepatology 2015;62:567–574