The Fellowship of the European Board of Surgery in Transplant Surgery (UEMS/ESOT) covers abdominal organ transplantation. Practise with FEBS-TS questions on kidney, liver and pancreas transplantation, donor procurement, machine perfusion, immunosuppression and rejection, each referenced to ESOT position statements and the Banff classification.
Content reviewed 26 August 2026 against current guidelines.
Start practising freeTaken from the bank, not written for this page. Answer it in your head, then open the explanation.
A 54-year-old man with NASH cirrhosis and MELD-Na 24 has been on the liver transplant waiting list for 8 months. Over the last 2 weeks, creatinine has risen from 1.1 to 2.9 mg/dL, urine sodium is 9 mmol/L, urine output 450 mL/day, and urine microscopy is bland (no casts). He has tense ascites treated with diuretics (stopped 48 hours ago) and norfloxacin prophylaxis. Blood cultures are negative. Serum creatinine does not improve after 48 hours of volume expansion with albumin 1 g/kg. He is now diagnosed with hepatorenal syndrome type AKI (HRS-AKI). Which of the following is the most appropriate pharmacological treatment for HRS-AKI while awaiting liver transplantation?
Correct answer: A
Hepatorenal syndrome type AKI (HRS-AKI, formerly HRS-1) is a severe functional kidney injury in cirrhotic patients caused by progressive splanchnic vasodilation leading to reduced effective arterial blood volume and intense renal vasoconstriction. **Diagnosis of HRS-AKI (EASL/ICA 2015 updated criteria):** 1. Cirrhosis with ascites 2. Creatinine rise ≥0.3 mg/dL in 48h OR ≥1.5× baseline within 7 days 3. Lack of improvement after 48h of diuretic withdrawal + volume expansion (albumin 1 g/kg × 2 days) 4. Absence of shock 5. No recent nephrotoxic drugs, no HRS-excluding cause (intrinsic renal disease: proteinuria >500 mg/day, haematuria >50 RBC/hpf, obstructive uropathy, structural renal disease) This patient meets all criteria: cirrhosis, rising creatinine, bland urine, no improvement after albumin/diuretic stop. **Treatment: Terlipressin + Albumin** - **Terlipressin**: vasopressin analogue with selective V1 receptor activity → splanchnic vasoconstriction → increases MAP → improves renal perfusion - Dose: 0.5–2 mg IV bolus every 4–6 hours (or 2 mg/hour continuous infusion — higher efficacy) - Albumin: 20–40 g/day to maintain plasma oncotic pressure **CONFIRM Trial (Wong F et al. NEJM 2021):** - RCT: terlipressin vs placebo in HRS-1 (HRS-AKI) - Primary endpoint (verified HRS reversal = creatinine ≤1.5 mg/dL ×2): - Terlipressin: 32% vs Placebo: 17% — significantly superior (p<0.001) - Concern: higher serious adverse events (respiratory failure, ischaemic events) in terlipressin arm - **FDA approved terlipressin for HRS-AKI in 2022 in the USA** (was already used in Europe) Option C: Dialysis manages electrolytes but does not treat the underlying pathophysiology; LT should not be deferred unless creatinine trajectory can be improved. Option E: Albumin is critical in combination — not contraindicated; pulmonary oedema risk is manageable with monitoring. Option D: Midodrine + octreotide is a second-line alternative, used primarily in resource-limited settings or where terlipressin is unavailable; evidence is weaker. Option B: ACE-I/ARBs are CONTRAINDICATED in HRS — reducing RAAS removes the compensatory mechanism maintaining renal perfusion in the setting of reduced effective arterial volume. **BOARD PEARL**: HRS-AKI treatment = terlipressin + albumin (CONFIRM NEJM 2021). Goal = creatinine ≤1.5 mg/dL (verified reversal). LT is definitive treatment — HRS reversal pre-transplant improves post-LT renal outcomes. ACE-I contraindicated.
Teaching point. HRS-AKI treatment is terlipressin IV (0.5–2 mg every 4–6h) combined with albumin (20–40 g/day), confirmed by the CONFIRM trial (NEJM 2021) to achieve HRS reversal in 32% vs 17% with placebo — liver transplantation remains the definitive treatment.
Referenced to Wong F et al. (CONFIRM trial) NEJM 2021;385:935–45; EASL Clinical Practice Guidelines on Decompensated Cirrhosis 2018; Runyon BA et al. AASLD HRS practice guidance 2021
Every question is explained like this — start with 50 free ›Every question is written by Pablo Lozano Lominchar, MD, PhD, and mapped to this board’s published syllabus. Before it enters the bank it has to pass an automated check: five options, a written explanation, and a citation — a named society guideline or a named trial. Benign and functional topics cannot be published without a society guideline; oncological ones cite NCCN, ESMO or AJCC, and the classification systems that govern a topic — Bethesda, TIRADS, Atlanta, Prague, Chicago — have to appear where they apply. The author has audited the full active bank against current guideline versions: what fails is re-cited, rewritten or withdrawn. 650 questions are currently withdrawn and are served to nobody.
Scope of authorship. FEBS-TS sits outside the author’s own subspecialty practice, which is surgical oncology — peritoneal malignancy, sarcoma, hepatopancreatobiliary and complex pelvic surgery. No diplomate of this board has signed these questions off. What they offer is traceability rather than personal authority: every answer names the current guideline or trial it rests on, so you can check it at the source before you trust it. Found an error? Tell us — it gets corrected or withdrawn.
Know the Banff 2019/2022 rejection classification precisely, the evidence base for normothermic and hypothermic machine perfusion, and MELD-based organ allocation. Practise timed transplant questions and rehearse allocation and prioritisation scenarios for the oral viva.
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The exam covers kidney, liver and pancreas transplantation, donor procurement and machine perfusion, and immunosuppression and rejection.
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