A 45-year-old man with cirrhosis and refractory ascites develops progressive oliguria over 5 days. Serum creatinine rises from 1.0 to 2.6 mg/dL. Urine sodium is 8 mEq/L, urine osmolality 380 mOsm/kg, and urinalysis shows no proteinuria or sediment abnormalities. He has been off diuretics for 48 hours and received albumin volume expansion with no improvement. Which diagnosis is MOST likely?
- A Acute tubular necrosis
- B Pre-renal azotaemia
- C Hepatorenal syndrome (HRS-AKI type) ✓
- D Glomerulonephritis
Correct answer: C. Hepatorenal syndrome (HRS-AKI type)
Explanation
HRS-AKI meets all International Ascites Club criteria: cirrhosis with ascites, creatinine rise >0.3 mg/dL in 48 hours or >50% from baseline, no improvement after diuretic withdrawal and albumin expansion, absence of shock, no nephrotoxins, and no macroscopic kidney disease (normal urinalysis, low urine sodium). ATN would show high urine sodium and granular casts. Pre-renal azotaemia should improve with volume expansion. GN would show active sediment.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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