Case 022: Cirrhosis and Portal Hypertension

PATIENT PRESENTATION

Chief Complaint

“I feel weak and awful, I think I have an infection again”

History of Present Illness

Patient with history of decompensated cirrhosis (variceal bleeding 4 months ago and SBP twice in past year) presents with ascites and abdominal pain. The patient was discharged from this facility approximately 1 month ago after being hospitalized for SBP. Patient reports decreased oral intake over past 3 days. Upon physical and laboratory examination, the patient is diagnosed with SBP and HRS-AKI (previously termed type-1 HRS).

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What is/are the likely pathogens causing the patient’s SBP?

   Hint: See Pathophysiology in PPP

2. What is the most appropriate treatment of SBP for this patient? Are the recommendations different in a patient with a recurrent infection?

   Hint: See Treatment of Portal Hypertension, Cirrhosis, and Complications in PPP

3. What are the most common causes of HRS-AKI? What is/are the likely causes in this patient?

   Hint: See Pathophysiology in PPP

4. What is the role of albumin in treatment of SBP and HRS?

   Hint: See Treatment of Portal Hypertension, Cirrhosis, and Complications in PPP

5. What drugs should be avoided to decrease the risk of HRS-AKI in patients with cirrhosis?

   Hint: See Pathophysiology in PPP, also think about other drugs that have the potential to decrease renal perfusion

FOLLOW-UP

Should the patient continue prophylaxis for variceal bleeding? SBP? What factors are involved in this decision?

Hint: See Treatment of Portal Hypertension, Cirrhosis, and Complications in PPP

CASE SUMMARY

Global Perspective

HRS-AKI is associated with extraordinarily high mortality. Median mortality is approximately 2 weeks and 3-month survival is estimated at only 20%. Because HRS-AKI is the result of decreased renal perfusion and is not associated with intrinsic renal disease, it is potentially reversible if recognized early and treated promptly. Although early diagnosis and treatment is associated with improved probability of response, there is no definitive diagnostic test for HRS. The terminology and diagnosis of HRS have evolved with the appreciation that even small decreases in renal function and delays in diagnosis are associated poor patient outcomes. The current definition of HRS-AKI aligns with the Acute Kidney Injury Network (AKIN) definition of acute kidney injury (AKI). The update also removed the requirement for serum creatinine to double to meet the diagnostic criteria, allowing for earlier recognition and treatment.

Key References