First Things First (assess & treat for the following)

• Assess airway, breathing, circulation
• Determine the severity of liver disease, presence of ascites.
• Assess intravascular volume status.
• Assess renal function.
• Consider admission of patient to intensive care unit.
• Insert Foley catheter and measure strict intake/output.
• If breathing is stable and there is no evidence of pulmonary edema, administer a trial of volume expansion using albumin infusion 1 g/kg IV (not to exceed 100 g).

• Consider central venous pressure monitoring.
• Adjust medications for renal and hepatic insufficiency
• Determine the type of hepatorenal syndrome (HRS) if present.
  • Type 1 HRS: double creatinine to >2.5 mg/dL or 50% decrease in creatinine clearance to < 20 ml/min in < 2 weeks
  • Type 2 HRS: progressive decline in renal function with creatinine >1.5 mg/dL, paralleling the development of refractory ascites