Summary : This flowchart presents a suggested algorithm for the management of acute kidney injury (AKI) in patients with cirrhosis, distinguishing between structural and functional renal disease, and outlining stepwise treatment decisions based on response to interventions. flowchart: # Nodes : • AKI (start, red text) • Structural Renal disease (rectangle, yellow-green) • Functional Renal disease (rectangle, yellow-green) • Treat according to etiology (rectangle, white) • Remove & treat precipitating factors* (rectangle, yellow) • Volume expansion with albumin (rectangle, red) — "1gm/kg, max 100gm/day" • ? Response (diamond, blue) • Regression of AKI (rectangle, yellow) • Stable (rectangle, yellow) • Close Monitoring (rectangle, yellow) • Further Rx at physician’s discretion (rectangle, yellow) • Yes (diamond, blue) • No (diamond, blue) • Progression (rectangle, blue) • Treat according to AKI etiology if not HRS (rectangle, white) • Treat with vasoconstrictors & albumin if meeting AKI-HRS diagnostic criteria# (rectangle, blue) • ? Response (diamond, blue) • Yes (diamond, blue) • No (diamond, blue) • Start renal replacement therapy if patient is liver transplant candidate (rectangle, pink) # Connectors : • AKI splits into two branches: Structural Renal disease and Functional Renal disease. • Structural Renal disease → Treat according to etiology. • Functional Renal disease → Remove & treat precipitating factors* → Volume expansion with albumin. • Volume expansion with albumin → ? Response. • ? Response branches: – Yes → Regression of AKI → Close Monitoring. – Yes → Stable → Further Rx at physician’s discretion. – No → Treat according to AKI etiology if not HRS. – Progression → Treat with vasoconstrictors & albumin if meeting AKI-HRS diagnostic criteria# → ? Response. • Second ? Response: – Yes → Treat according to AKI etiology if not HRS. – No → Start renal replacement therapy if patient is liver transplant candidate. # Layout : • Top-down hierarchical flow. • Initial split into two main branches (structural vs. functional). • Functional branch has a more complex, multi-step decision tree with feedback loops. • Decision diamonds indicate response checkpoints. • Colour coding: yellow for initial steps, red for albumin intervention, blue for response/treatment, pink for renal replacement therapy. # Analysis : • The algorithm prioritises distinguishing structural from functional renal disease in AKI management for cirrhosis. • Functional renal disease is managed by removing precipitating factors and volume expansion with albumin, followed by assessment of response. • If AKI does not regress or progresses, further treatment with vasoconstrictors and albumin is considered if AKI-HRS criteria are met. • Non-responders may be considered for renal replacement therapy if they are liver transplant candidates. • The flowchart emphasises stepwise escalation of therapy and close monitoring, with decision points guiding further management.

Summary : This flowchart outlines the assessment and management of acute kidney injury (AKI) in patients with acute-on-chronic liver failure or critically ill patients with cirrhosis, including diagnostic steps, treatment options, and decision points for liver transplantation (LT) and renal replacement therapy. flowchart: # Nodes : • Start (rectangle): "Kidney failure" • Decision (rectangle): "Determine kidney failure phenotype" • Process (rectangle): "Structural renal disease / Pre-renal azotemia / HRS-AKI" • Process (rectangle): "Treat accordingly to AKI etiology" • Process (rectangle): - "Withdrawal of diuretics & nephrotoxic drugs" - "Treat infection when present" - "Blood transfusion for GI bleed when hemoglobin <7 g/dL" • Decision (rectangle): "Lack of improvement" • Process (rectangle): "Volume expansion with albumin 1 gm/kg body weight, max 100 gm/day, 48 hours" • Process (rectangle): "Close monitoring with daily blood work" • Decision (diamond): "sCr ≤ 0.3mg/dL of baseline value" • Terminal (rectangle): "Yes" • Terminal (rectangle): "No/Progression" • Process (rectangle): "Fulfilling diagnostic criteria for HRS-AKI" • Process (rectangle): "Treat with vasoconstrictors + albumin" • Decision (diamond): "Gradual dec in sCr to ≤ 0.3mg/dL of baseline value" • Terminal (rectangle): "Yes" • Terminal (rectangle): "No" • Process (rectangle): "Assess for LT candidacy" • Process (rectangle): "Consider renal replacement therapy" # Connectors : • Arrows flow top-down, with decision diamonds splitting into "Yes" and "No/Progression" branches. • After "Kidney failure" → "Determine kidney failure phenotype" → "Structural renal disease / Pre-renal azotemia / HRS-AKI". • "Treat accordingly to AKI etiology" and the box with withdrawal/treatment/transfusion are parallel options. • If "Lack of improvement", proceed to "Volume expansion with albumin". • Then to "Close monitoring with daily blood work". • At "sCr ≤ 0.3mg/dL of baseline value", "Yes" leads to "Assess for LT candidacy", then "Consider renal replacement therapy". • "No/Progression" leads to "Fulfilling diagnostic criteria for HRS-AKI", then "Treat with vasoconstrictors + albumin". • Next decision: "Gradual dec in sCr to ≤ 0.3mg/dL of baseline value" splits to "Yes" (to "Assess for LT candidacy") and "No" (to "Consider renal replacement therapy"). # Layout : • Vertical, top-down arrangement. • Parallel process boxes for initial treatment options. • Decision diamonds create branches for improvement vs. progression. • Merges at "Assess for LT candidacy" and "Consider renal replacement therapy". • Colour coding: green for process/decision nodes, tan for terminal/therapy nodes. # Analysis : • The flowchart provides a stepwise approach for AKI management in cirrhotic patients, emphasizing initial withdrawal of nephrotoxic agents, volume expansion, and close monitoring. • Decision points are based on serum creatinine (sCr) changes relative to baseline. • If AKI does not improve, further diagnostic criteria for hepatorenal syndrome (HRS-AKI) are applied, with escalation to vasoconstrictor therapy and albumin. • Final management options include assessment for liver transplantation and consideration of renal replacement therapy, depending on response to treatment. • The workflow is logical, with clear escalation steps and criteria for moving to advanced therapies.

Summary : This figure illustrates the progression of acute kidney injury (AKI) from normal kidney function through increased risk, damage, decreased glomerular filtration rate (↓GFR), kidney failure, and ultimately death. It also highlights the window for early intervention and the stages of clinical management over time. flowchart: # Stages of Acute Kidney Injury : • Normal • Increased risk • Damage • ↓GFR (decreased glomerular filtration rate) • Kidney failure • Death # Complications : • Arrow labeled "Complications" points from the "Damage" stage to the "↓GFR" stage. # Intervention and Management Timeline : • Time axis runs horizontally below the kidney stages. • Phases labeled: Risk assessment, Recognition, Response, Renal support, Rehabilitation. • "Window for early targeted intervention" indicated between "Increased risk" and "Damage" stages. • "Staging" indicated between "↓GFR" and "Kidney failure" stages. # Design Encodings : • Kidneys are depicted in a gradient from healthy red (Normal) to dark gray (Death). • Arrows indicate progression from left (Normal) to right (Death). • Coloured bars below the timeline represent different phases of clinical management. # Analysis : • The figure visually communicates that AKI is a progressive condition with distinct stages, and that early intervention is possible before significant damage occurs. • The timeline emphasizes the importance of risk assessment and recognition before irreversible kidney failure. • The colour gradient and arrows reinforce the concept of worsening kidney function over time, culminating in death if not managed.