A 52-year-old woman with cirrhosis presents with progressive abdominal distension and oliguria over 5 days. She has no fever or abdominal pain. Serum creatinine is 2.8 mg/dL (baseline 0.8 mg/dL). Urine sodium is 8 mmol/L, urine osmolality 410 mOsm/kg, and urine microscopy is normal. There is no improvement after 48 hours of volume expansion with albumin 1 g/kg. What is the most likely diagnosis?
- A Acute tubular necrosis
- B Hepatorenal syndrome (HRS-AKI) ✓
- C Pre-renal azotemia
- D Glomerulonephritis
Correct answer: B. Hepatorenal syndrome (HRS-AKI)
Explanation
Hepatorenal syndrome (HRS-AKI type) is diagnosed in cirrhosis with ascites when serum creatinine rises ≥ 0.3 mg/dL within 48 hours or ≥ 1.5 times baseline, after withdrawal of diuretics and volume expansion with albumin (1 g/kg for 2 days), with no shock, no nephrotoxic drugs, and no parenchymal kidney disease. Low urine sodium (< 10 mmol/L) and concentrated urine are characteristic. ATN typically shows urine sodium > 40 mmol/L, granular casts, and is less responsive to volume expansion.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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