A 45-Year-Old Hospitalized Man Is Evaluated for Worsening Kidney Function

question 18

Multiple Choice

A 45-year-old hospitalized man is evaluated for worsening kidney function.  The patient has a history of alcoholic cirrhosis and was admitted 3 days ago due to progressive abdominal pain and lethargy.  Evaluation revealed asterixis and 300/mm³ of neutrophils in the ascitic fluid.  He was started on intravenous cefotaxime and oral lactulose for treatment of spontaneous bacterial peritonitis complicated by hepatic encephalopathy.  The patient's symptoms have gradually improved with treatment, but his serum creatinine has increased from 0.9 mg/dL on admission to 2.1 mg/dL now.  Urine output during the last 24 hours is 450 mL.  He has no history of kidney disease or other medical problems.  The patient's home diuretic therapy with furosemide and spironolactone had been initially continued during the hospitalization but was stopped yesterday.  He stopped drinking alcohol after being diagnosed with cirrhosis 3 years ago and does not use tobacco.
Temperature is 37.2 C (99 F) , blood pressure is 110/70 mm Hg, pulse is 96/min, and respirations are 18/min.  The patient is somnolent but easily roused.  There is mild scleral icterus, and jugular venous pressure is normal.  Lungs are clear to auscultation.  The abdomen is soft, moderately distended with ascites, and nontender.  Bowel sounds are normoactive.  There is 2+ bilateral lower-extremity pitting edema.
Laboratory results are as follows:
Renal ultrasonography shows no hydronephrosis.
Which of the following is the most appropriate next step in management of this patient's renal dysfunction?

• A)Antibiotic discontinuation
• B)Intravenous albumin infusion
• C)Large-volume paracentesis
• D)Restarting diuretics
• E)Transjugular intrahepatic portosystemic shunt

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Definitions:

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