History and exam

Key diagnostic factors

common

advanced cirrhosis

HRS may develop in any patient with advanced cirrhosis and presence of ascites.

jaundice

Common feature of liver failure.

ascites

Presence of ascites is required for a diagnosis of HRS-AKI.

Other diagnostic factors

common

moderate lowering of BP

Due to reduced total systemic vascular resistance.[19]

peripheral edema

May be a feature of renal and liver failure.

splenomegaly

Sign of chronic liver disease.

spider angioma

Sign of chronic liver disease.

uncommon

oliguria

Oliguria is defined as urine output in adults <400 mL/day.

bruising

Sign of chronic liver disease.

petechiae

Sign of chronic liver disease.

palmar erythema

Sign of chronic liver disease.

scratch marks

Sign of chronic liver disease.

gynecomastia

May be present in men.

encephalopathy

Encephalopathy with confusion, decreased level of consciousness, and asterixis may be present.

pruritus

May be a feature of renal and liver failure.

confusion

May be a feature of renal and liver failure.

drowsiness

May be a feature of renal and liver failure.

Risk factors

strong

advanced cirrhosis

HRS may develop in any patient with advanced cirrhosis and presence of ascites.[17]

ascites

Presence of ascites is required for a diagnosis of HRS-AKI.

alcohol-related hepatitis

HRS may develop in chronic liver diseases, such as alcohol-related hepatitis, which are associated with acute-on-chronic liver failure and portal hypertension.[13]

hyponatremia

Sodium ≤133 mEq/L is an independent predictive value of HRS occurrence in multivariate analysis.[9]

high plasma renin activity (PRA)

PRA >3.5 nanograms/mL is an independent predictive value of HRS occurrence in multivariate analysis.[9]

spontaneous bacterial peritonitis

One of the most common triggers for the development of HRS-AKI.[5][18]​​

In approximately 10% of patients, the renal impairment is reversible after the resolution of infection and does not meet the criteria of HRS.[19]​ Infection with septic shock is a common precipitant of acute tubular necrosis.

weak

large volume paracentesis

Precipitating factor that may occur in close correlation with HRS. Up to 15% of patients develop HRS when >5 L is drained without concomitant use of intravenous albumin.[20]

gastrointestinal (GI) bleeding

Renal failure occurs in 10% of patients with cirrhosis and GI bleeding, and it is considered a precipitating factor for HRS-AKI. However, a substantial proportion of patients have acute tubular necrosis caused by hypovolemic shock.[18][20]

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