Hepatorenal syndrome

Question: You are confronted with a very sick 41 year old Puerto Rican male with HCV and EtOH cirrhosis, MELD score of 36, hyponatremia, large ascites and jaundice.  His creatinine is rising and is now 2.3.  Which of the following is not necessary as part of his workup?

A. urinalysis

B. renal ultrasound

C. volume challenge

D. volume restriction

Answer: At the late stages of cirrhosis, renal dysfunction is common.  The most common causes are prerenal failure, hepatorenal syndrome and acute tubular necrosis (ATN, which may be related to contrast dye or hypovolemia).  It is your priority to undertake a workup for hepatorenal syndrome in such cases.  Large ascites and hyponatremia are two classic findings in people that develop HRS. 

The workup for HRS includes volume challenge for two consecutive days, as well as an investigation for intrinsic renal disease (urinalysis, ultrasound).  A paracentesis can diagnose SBP, which is a common trigger for HRS.  If the kidneys do not have evidence of intrinsic disease (no proteinuria or hematuria) and don’t respond to the volume challenge, the diagnosis of HRS is likely and treatment with midodrine, octreotide and albumin should be initiated. 

Volume restriction is often considered when patients are severely hyponatremic.  However, in a case such as this, the volume challenge is a far higher priority.

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