A 60-year-old man with alcoholic cirrhosis (Child-Pugh C) and refractory ascites develops progressive oliguria and rising creatinine over 5 days (from 1.0 to 2.6 mg/dL). Urine sodium is 8 mEq/L, urine osmolality 380 mOsm/kg, no sediment abnormalities, and no improvement after volume expansion with albumin 1 g/kg for 2 days. There is no shock, nephrotoxic drug exposure, or proteinuria. Which type of hepatorenal syndrome is this?

• A Prerenal azotemia
• B Type 2 hepatorenal syndrome
• C Acute tubular necrosis (ATN)
• D Type 1 hepatorenal syndrome ✓

Explanation

Type 1 HRS is defined by a doubling of serum creatinine to >2.5 mg/dL within 2 weeks, fitting this rapid course. Type 2 HRS has a slower, more gradual rise, usually with refractory ascites as the dominant feature. ATN is unlikely with urine sodium <10 mEq/L and bland sediment, and it typically follows a clear ischemic or nephrotoxic insult. Prerenal azotemia would improve with volume expansion; lack of response after albumin rules it out.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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