Hepatorenal syndrome

Extending

Step 1: View clinicals

A 52-year-old Caucasian man presents with mild dyspnea, abdominal distension, bilateral leg swelling, and reduced urine output for four days. There was no history of fever, cough, wheezing, hematemesis, melena, or urinary or bowel symptoms. He was diagnosed with end-stage liver disease (ESLD) due to alcohol abuse one year ago and is currently on the combination of furosemide, spironolactone, and propranolol. He has stopped drinking since the time of diagnosis but shows poor drug compliance. His medical and surgical histories are otherwise unremarkable, and he is not on any other medications, including over-the-counter drugs, or herbal supplements. There are no known allergies. His last clinic visit was approximately one week ago. At that time, his serum creatinine was 1.4 mg/dL (0.3-1.7).


Step 2: Order all relevant investigations

CBC + liver profile + renal profile

Complete blood count ------------------------ WBC: 10,000/mm3 (4,600-11,000) Hb: 10.1 g/dL (11-18) Plt: 88,000/mm3 (150,000-400,000) Liver profile ------------- ALT: 88 U/L (9–51) AST: 62 U/L (13–40) ALP: 150 U/L (34–122) GGT: 159 U/L (13–58) Tot. bilirubin: 1.9 mg/dL (0.1–1.1) Conj. bilirubin: 0.6 mg/dL (0–0.3) Albumin: 2.2 mg/dL (3.5-5.5) INR: 1.8 (0.9-1.1) LDH: 140 U/L (100–190) Renal profile -------------- Blood urea nitrogen: 84 mg/dL (7–23) Serum creatinine: 3.2 mg/dL (0.3–1.7) Sodium: 132 mEq/L (135-145) Potassium: 3.3 mEq/L (3.5-5.5)

Urinalysis

Appearance: turbid Color: brown WBC: 5/hpf (0-5) RBC: 3/hpf (0-3) Hyaline casts: 3 (0-5) Tubular cells: absent Protein: 20 mg/dL (0-20) Bilirubin: 0.1 mg/dL Sodium: 8 mEq/L (≤20) Osmolarity: 315 mOsm/kg (275-295)

Ultrasound abdomen

Both kidneys are normal in size, with proper corticomedullary differentiation. No obstructive pathology is noted. The liver shows nodular changes suggestive of cirrhosis. A significant amount of free fluid is present.

Diagnostic ascitic tap

Color: clear Triglycerides: 80 mg/dL (<110) Protein: 0.4 mg/dL (0.3-4.0) Glucose: 7.1 mg/dL (7-10) LDH: 70 U/L RBC: nil/µL (<100) WBC: 280/µL (<300) Microscopy: no organisms Cultures: results will be available in 48 to 72 hours


Step 3: Select appropriate management

Omit furosemide
Omit propranolol
Albumin
Antibiotics


Score: ★★☆