A 55-year-old man with a history of alcohol-associated cirrhosis and esophageal varices is… — USMLE Step 3

A $55$ -year-old man with a history of alcohol-associated cirrhosis and esophageal varices is evaluated in the intensive care unit. He was admitted $3$ days ago for worsening ascites, confusion, and abdominal pain. Upon admission, diagnostic paracentesis revealed an absolute neutrophil count of $650 \text{ cells/mm}^3$ . Intravenous ceftriaxone was initiated for spontaneous bacterial peritonitis. His home medications include oral lactulose, spironolactone, furosemide, and nadolol. Upon admission, his diuretics were held, but nadolol was continued for primary prophylaxis of variceal bleeding.

Over the past $48$ hours, he has received volume expansion with intravenous albumin ( $1 \text{ g/kg/day}$ ). Despite these measures, his urine output has decreased to $300 \text{ mL/day}$ over the last $24$ hours.

Current vital signs:
Blood pressure: $86/52 \text{ mmHg}$
Heart rate: $105\text{/min}$
Temperature: $37.8^\circ\text{C}$ ( $100.0^\circ\text{F}$ )

Laboratory Test	Result
Serum sodium	$129 \text{ mEq/L}$
Serum potassium	$5.1 \text{ mEq/L}$
Blood urea nitrogen	$64 \text{ mg/dL}$
Serum creatinine	$3.2 \text{ mg/dL}$ (baseline $1.1 \text{ mg/dL}$ )
Urine sodium	$6 \text{ mEq/L}$

Microscopic urinalysis is normal with no red blood cells, casts, or protein. Renal ultrasound demonstrates normal kidneys without hydronephrosis.

Which of the following pharmacologic interventions are indicated at this time? (Select all that apply)

Discontinue oral nadololAnswer
Initiate intravenous terlipressinAnswer
Continue intravenous albuminAnswer
D
Administer intravenous furosemide
E
Substitute ceftriaxone with intravenous vancomycin

Answer

The correct interventions are to discontinue oral nadolol, initiate intravenous terlipressin, and continue intravenous albumin.

The patient has developed hepatorenal syndrome-acute kidney injury (HRS-AKI), diagnosed by worsening renal function despite diuretic withdrawal and albumin administration, alongside bland urine sediment and very low urine sodium. The standard of care for HRS-AKI is the combination of a splanchnic vasoconstrictor (such as terlipressin) and albumin to improve effective arterial blood volume and renal perfusion. Furthermore, non-selective beta-blockers (like nadolol) must be discontinued in patients who develop severe hypotension or HRS, as they worsen hemodynamics and survival. Therefore, initiating terlipressin, continuing albumin, and discontinuing nadolol are the correct interventions.

Step-by-Step Solution

Identify the clinical diagnosis based on the patient's presentation and lab findings.

The patient has Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI).

The patient has cirrhosis with ascites, acute kidney injury (creatinine increased significantly from baseline), no response to diuretic withdrawal and volume expansion with albumin, and normal urinalysis/renal ultrasound.

Determine the appropriate pharmacologic additions to treat HRS-AKI.

Initiate intravenous terlipressin and continue intravenous albumin.

Terlipressin reverses splanchnic vasodilation, and albumin expands the effective arterial blood volume. This combination is the first-line pharmacologic treatment for HRS-AKI.

Identify potentially harmful home medications that must be discontinued.

Discontinue oral nadolol.

Non-selective beta-blockers exacerbate systemic hypotension and decrease renal perfusion in the setting of refractory ascites and HRS, leading to increased mortality.

Key Concept

Diagnosis and multi-drug management of Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI)

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