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Chapter 10: Hepatorenal Syndrome

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A 62-year-old woman with nonalcoholic steatohepatitis induced cirrhosis and ascites underwent insertion of a transjugular intrahepatic portosystemic shunt (TIPS) as a definitive treatment of refractory ascites. One month later, an abdominal ultrasound revealed that the TIPS had become stenosed at the portal venous end. So it was organized for her to undergo an interventional radiological procedure to dilate the TIPS. Her serum creatinine immediately after TIPS insertion was 0.84 mg/dL, which was the similar to her serum creatinine for the previous 3 months. However, at the time that the TIPS revision was organized 1 month later, her creatinine was 1.26 mg/dL.

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A. The patient had developed acute kidney injury (AKI) because her serum creatinine had risen by greater than or equal to 50% from a stable baseline in the previous 3 months.

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B. The patient did not developed AKI because her serum creatinine increase did not occur within 48 hours.

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C. We cannot make a diagnosis of AKI without having given her a fluid challenge to determine whether the rise in serum creatinine would return to baseline.

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D. We cannot diagnose AKI without knowing the urine output, urinalysis, or urine microscopy.

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E. The patient may have had a creatinine increase, but the change is too trivial to be of any clinical importance. It is best to repeat the serum creatinine to confirm the rise in serum creatinine.

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The answer is A. The patient had developed acute kidney injury (AKI) because her serum creatinine had risen by ≥50% from a stable baseline in the previous 3 months. The International Ascites Club has defined AKI in cirrhosis as either a rise in serum creatinine by 0.3 mg/dL in ≤48 hours, or if a baseline serum creatinine is not available within 48 hours, the a ≥50% increase in serum creatinine from a stable baseline reading will also be acceptable.

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An AKI diagnosis in cirrhosis does not require any abnormal urine findings or the use of a fluid challenge.

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Such a small rise in serum creatinine cannot be ignored, as we can see that the patient subsequently had further rise in her serum creatinine.

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Repeat serum creatinine the next day showed it to be 1.38 mg/dL. Patient reported that her urine output had decreased, and her ascites had not gone down as she had expected. What should be done next?

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A. Urinalysis, urine microscopy, mid-stream urine.

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B. Monitor her blood pressure to ensure that her mean arterial pressure was adequate.

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C. Enquire about ...

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