Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Liver
Question 5#

A 62-year-old male with a history of hepatic cirrhosis complicated by ascites and esophageal varices presents with decreased urine output. His creatinine is elevated at 1.4 mg/dL. Investigation of the urine reveals fractional excretion of sodium <1%, no casts or blood cells, no protein, and renal ultrasound was normal. No improvement in urine output or creatinine is achieved after several doses of albumin. His white blood cell count is 7600 cells/µL, diagnostic paracentesis was not suggestive of infection, and his blood pressure is 98/62 mm Hg. 

Which of the following is the MOST effective next treatment?

A. Norepinephrine infusion
B. 2 L of normal saline bolus
C. Broad spectrum antibiotics
D. Corticosteroids
E. Diuretics

Correct Answer is A

Comment:

Correct Answer: A

This patient likely has hepatorenal syndrome (HRS). This is a diagnosis of exclusion that appears clinically very similar to prerenal acute kidney injury but fails to improve with administration of volume, such as albumin. Infection in patients with portal hypertension can increase the risk of HRS, but this patient has no signs of infection so would likely not be helpful in this case. Increasing the mean arterial pressure by 10 mm Hg in patients with HRS has been shown to increase urine output and decrease creatinine even if the patient is not initially hypotensive.

References:

  1. Testino G, Ferro C. Hepatorenal syndrome: a review. Hepatogastroenterology. 2010; 57(102-103):1279-1284.
  2. Nanda A, Reddy R, Safraz H, et al. Pharmacological therapies for hepatorenal syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2018;52(4):323-330.
  3. Gupta K, Rani P, Rohatgi A, et al. Noradrenaline for reverting hepatorenal syndrome: a prospective, observational, single-center study. Clin Exp Gastroenterol. 2018;11:317-324.