A 48-year-old man is brought to the emergency department for what his wife describes as "bizarre behavior" for the last two days. His past medical history is significant for cirrhosis secondary to chronic hepatitis C infection. His daily medications are spironolactone, lactulose, and furosemide. He is an ex-heroin user. Examination shows a drowsy but restless patient. His blood pressure is 94/56 mmHg and heart rate is 112/min with a regular rhythm. The abdomen is distended, soft, and non-tender to palpation. Shifting dullness is present. There is no peripheral edema. Laboratory tests show the following:
The peritoneal fluid is sampled yielding 12 WBCs/mm³ and an albumin of 1.0 mg/dL. Renal ultrasound shows no evidence of hydronephrosis. Which of the following is the best next step in managing this patient?

Question

A 48-year-old man is brought to the emergency department for what his wife describes as "bizarre behavior" for the last two days. His past medical history is significant for cirrhosis secondary to chronic hepatitis C infection. His daily medications are spironolactone, lactulose, and furosemide. He is an ex-heroin user. Examination shows a drowsy but restless patient. His blood pressure is 94/56 mmHg and heart rate is 112/min with a regular rhythm. The abdomen is distended, soft, and non-tender to palpation. Shifting dullness is present. There is no peripheral edema. Laboratory tests show the following:

The peritoneal fluid is sampled yielding 12 WBCs/mm³ and an albumin of 1.0 mg/dL. Renal ultrasound shows no evidence of hydronephrosis. Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Explanation: This patient's abnormal LFTs can be attributed to his known cirrhosis. However, his elevated BUN and creatinine likely indicate acute renal failure, though correlation with any prior creatinine values is needed. The most likely diagnosis is hepatorenal syndrome, but it must be remembered that this is a diagnosis of exclusion. In hepatorenal syndrome, the urinary sediment is usually rather benign. An ultrasound should be performed to exclude the presence of urinary obstruction. Spontaneous bacterial peritonitis (SBP) is a frequent precipitant of hepatorenal syndrome and as such paracentesis is indicated if ascites is present. This patient's cell count is far below the 250 cells/mm³ needed for a diagnosis of SBP. Patients with cirrhosis develop decreased peripheral vascular resistance secondary to splanchnic vasodilation, which can cause the decreased renal perfusion of hepatorenal syndrome. Similarly, volume depletion due to over-diuresis can cause renal dysfunction of a pre-renal etiology. The patient's BUN/Cr ratio of 20:1 is compatible with either scenario. A volume challenge would be an appropriate next step to confirm a diagnosis of hepatorenal syndrome in this patient. A failure to respond would be consistent with hepatorenal syndrome. A combination of octreotide and midodrine or norepinephrine alone can be used if this patient's renal failure does not respond to fluids. Albumin should also be continued for at least 2-3 days. (Choice A) Corticosteroids are used for multiple autoimmune causes of acute renal failure, but are not helpful in the management of hepatorenal syndrome. (Choice B) Loop diuretics should not be given at this point because it is still possible that the patient is volume depleted from prior diuretic therapy. (Choice C) A combination of midodrine and octreotide is preferred to dopamine in the treatment of hepatorenal syndrome. (Choice D) Renal biopsy is generally indicated to identify intrinsic renal disease, such as glomerulonephritis, which can be associated with chronic hepatitis C. However, a BUN/Cr ratio of more than 20 typically indicates a pre-renal picture rather than intrinsic renal disease. Educational objective: Hepatorenal syndrome is a common cause of acute renal failure in patients with cirrhosis but should be considered a diagnosis of exclusion. A fluid bolus is needed to confirm that the renal failure is not secondary to intravascular volume depletion. A combination of midodrine and octreotide along with albumin is the treatment of choice after the diagnosis is confirmed. References: Pathogenetic background for treatment of ascites and hepatorenal syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19669317) Terlipressin and hepatorenal syndrome: what is important for nephrologists and hepatologists. (http://www.ncbi.nlm.nih.gov/pubmed/21049548) Incidence and prognosis of different types of functional renal failure in cirrhotic patients with ascites. (http://www.ncbi.nlm.nih.gov/pubmed/20399905) Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19885875)

A 48-Year-Old Man Is Brought to the Emergency Department for What