Acute kidney injury (AKI) continues to be a common complication of cirrhosis. Hepatorenal syndrome associated with AKI (HRS-AKI), which occurs in the setting of advanced chronic liver disease, portal hypertension, and ascites, carries an especially high mortality risk. The standard metric of renal function, i.e., serum creatinine, is fundamentally flawed and fails to identify kidney injury in those with earlier stages of kidney disease. Novel urinary biomarkers have the potential for earlier detection of kidney injury and for determining the etiology of AKI. This is especially important as early diagnosis and treatment of HRS-AKI with splanchnic vasoconstrictors and albumin may reverse AKI and serve as a bridge to liver transplantation (LT). Ultimately, the only option for those who do not respond to conventional medical therapy is LT.