Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders>>>>>Diagnosis and Monitoring in Renal Failure
Question 7#

A 64-year-old male with a history of cirrhosis secondary to hepatitis C is being evaluated for abdominal pain. The patient reports worsening generalized abdominal pain and fever for the past 4 days. He denies hematemesis or melena. His BP was 110/60 mm Hg, and HR was 95 beats per minute. His physical examination is significant for icterus, ascites, and generalized abdominal tenderness. Laboratory analysis is notable for:

• white blood cell count of 18 000/ µL
• creatinine 1.1 mmol/L (baseline 0.8 mmol/L)
• blood urea nitrogen 36 mg/dL
• total bilirubin is >4.3 mg/dL

The patient received broad-spectrum antibiotics.

Which of the following drugs is MOST appropriate to administer to reduce risk for renal failure in this patient?

A. Terlipressin 1 mg IV bolus now and then every 6 hours plus 1 g/kg of albumin
B. Albumin 1.5 g per kg now and 1.0 g/kg on day 3
C. Midodrine 7.5 mg orally now and then every 8 hours plus 1 g/kg of albumin
D. Octreotide subcutaneous injection 100 µg now and then every 8 hours plus 1 g/kg of albumin

Correct Answer is B

Comment:

Correct Answer: B

The patient in the vignette is presenting with signs and symptoms concerning for spontaneous bacterial peritonitis (SBP). Cirrhosis patients with SBP are at high risk of developing renal failure secondary to hepatorenal syndrome. The risk can be reduced (from 30% to 10%) with IV albumin infusion. Albumin appears to be most effective in patients with serum creatinine >1 mg/dL and total bilirubin >4 mg/dL, but its effect is unclear in patients who had lower creatinine and bilirubin levels. The European Association for the Study of the Liver guidelines recommend starting albumin infusion in all patients with SBP. The recommended dose is 1.5 g per kg at the time of diagnosis and 1.0 g/kg body weight on day 3. Terlipressin, midodrine, and octreotide used as treatment options for hepatorenal syndrome but not for prevention. 

References:

1. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53(3):397-417. doi:10.1016/j.jhep.2010.05.004. https://www.ncbi.nlm.nih.gov/pubmed/20633946.
2. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999;341:403-409. https://www.ncbi.nlm.nih.gov/pubmed/10432325.