Approach

The diagnosis of HRS is based on clinical criteria.[2]​​[4][5][8]​​[18]​​​​​​​​ (See Classification and Diagnostic Criteria sections.)

HRS may develop in any patient with advanced liver disease and presence of portal hypertension-related ascites.[17]​ Patients rarely present with oliguria or symptoms of uraemia. The most common cause of type 1 HRS in Europe is alcoholic hepatitis. 

History and physical examination

Other causes of renal failure need to be excluded.[18] The patient should be asked about their current medicine use and whether there has been any recent change, such as an increase in diuretic dosage or use of non-steroidal anti-inflammatory drugs. A history of repeated vomiting or diarrhoea, or gastrointestinal bleeding (e.g., haematemesis or melaena stools) suggests volume depletion. Fever, a productive cough, dysuria, and abdominal pain may indicate the presence of infection.

Examination may show the signs of chronic liver disease, such as spider angioma, bruising, petechiae, palmar erythema, jaundice, and scratch marks. Encephalopathy with confusion, decreased level of consciousness, and asterixis may be present. Gynaecomastia may be present in men. Most patients have at least modest lowering of blood pressure.

Abdominal examination may reveal ascites, and the patient may also have splenomegaly. Abdominal tenderness may be suggestive of spontaneous bacterial peritonitis.

Tests

Blood should be sent for full blood count, electrolytes, renal function (creatinine and urea), liver tests, and coagulation profile.

To diagnose HRS-AKI, it is important to exclude structural kidney injury, which relies on history but may be supported by urine microscopy findings. Due to significant overlap between HRS, pre-renal renal failure, and acute tubular necrosis, urine sodium as well as fractional excretion of sodium are not part of the diagnostic criteria of HRS-AKI.[5]

A septic work-up consisting of blood, urine, and ascitic fluid culture, urinalysis, and chest x-ray must be performed to exclude sepsis.

Renal ultrasound also must be performed to exclude an obstructive cause of renal failure.

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