A 58-year-old man with decompensated cirrhosis due to alcohol-associated liver disease is admitted to the hospital for worsening abdominal distention and lower extremity edema. His medications include spironolactone, furosemide, and lactulose. During hospitalization, his serum creatinine increases from 1.0 mg/dL to 2.8 mg/dL over 5 days. Temperature is 36.9°C (98.4°F), blood pressure is 94/58 mm Hg, pulse is 96/min, and respiratory rate is 16/min. Physical examination reveals tense ascites, jaundice, and peripheral edema. Urinalysis is bland without proteinuria or hematuria. Renal ultrasonography is normal. Intravenous fluids do not improve kidney function.
Which of the following is the most likely diagnosis?
The correct answer is:
C: Hepatorenal syndrome.
This patient with advanced cirrhosis has progressive renal dysfunction without evidence of intrinsic kidney disease. Hepatorenal syndrome results from severe splanchnic vasodilation and renal vasoconstriction, leading to functional renal failure. The diagnosis is suggested by cirrhosis, worsening renal function, bland urinalysis, normal renal imaging, and failure to improve with volume expansion.
Answer choice A: Acute tubular necrosis, is incorrect.
Acute tubular necrosis (ATN) is a common cause of acute kidney injury and may occur in hospitalized patients. However, ATN typically produces urinary sediment abnormalities such as muddy brown casts and is usually associated with ischemic or nephrotoxic injury.
Answer choice B: Glomerulonephritis, is incorrect.
Glomerulonephritis generally causes hematuria, proteinuria, or red blood cell casts, none of which are present.
Answer choice D: Nephrolithiasis, is incorrect.
Kidney stones cause flank pain and hematuria rather than progressive renal failure in the setting of decompensated cirrhosis.
Answer choice E: Prerenal azotemia, is incorrect.
Prerenal azotemia may initially resemble hepatorenal syndrome. However, kidney function usually improves with volume resuscitation, unlike this patient’s condition.
Key Learning Point
Hepatorenal syndrome is a functional renal failure occurring in advanced cirrhosis and is characterized by progressive kidney injury without intrinsic renal disease.
