The Curbsiders Internal Medicine Podcast REBOOT #145 Hepatorenal Syndrome
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Mar 28, 2022 A case of cirrhosis and rising creatinine opens a lively tour of hepatorenal syndrome: how clinicians sort out kidney injury, assess fluid status, and choose between albumin, diuretics, and vasoconstrictors. The discussion also tackles renal ultrasound, paracentesis, transplant decisions, and the tricky line between treating aggressively and calling palliative care.
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Systematic Initial AKI Workup
- Start the AKI workup in cirrhosis with urinalysis and urine sodium/FENa to categorize injury patterns.
- Use a volume challenge if pre-renal is suspected and escalate if no response to test for hepatorenal physiology.
Low Urine Sodium Is Not Definitive
- A low urine sodium or low FENa in cirrhosis is common and nondiagnostic by itself.
- Interpret urine tests cautiously because bilirubin and concentrated urine can stain hyaline casts and mimic ATN.
Match Volume Strategy To Exam
- Tailor volume expansion decisions to the clinical exam: avoid blanket albumin in visibly volume‑overloaded patients.
- If exam suggests hypovolemia, trial 1 g/kg/day albumin (25 g IV q6h) for 48 hours to assess response.