The patient is admitted and treatment for likely hepatic encephalopathy is started with lactulose. She is also started on intravenous albumin (25%, 25 g every 6 hours). Spironolactone is discontinued.
Take a look at some initial testing below (click!):
Basic labs
Urinalysis and urine electrolytes
Urine microscopy
2 days after albumin therapy, the creatinine has not improved and the patient remains oliguric. A kidney ultrasound is normal.
Which of the following are the next best diagnostic tests or steps in management?
Kidney biopsy
Not so fast! We have some more work to do before we jump to an invasive procedure. Remember that the urinalysis and urine sediment are bland.
Intravenous diuretics
Though diuretics may help decrease the volume of ascites, diuretics may worsen this patient’s acute kidney injury. Try again!
Large volume paracentesis (LVP)
Though this patient has tense ascites, it might be better to perform a few additional tests before performing an LVP as this may worsen this patient’s AKI.
Diagnostic paracentesis
Excellent! Here are the results, the culture has just been sent to the microbiology lab.
*White blood cells: 2,000/µL, 1,200 polymorphic mononuclear cells (PMNs)
*Red blood cells: 0-2/µL
*Protein: 2 g/dL
*Albumin 1.7 g/dL
*White blood cells: 2,000/µL, 1,200 polymorphic mononuclear cells (PMNs)
*Red blood cells: 0-2/µL
*Protein: 2 g/dL
*Albumin 1.7 g/dL
Bladder pressure
Good idea. The bladder pressure is 11 mg Hg, within the normal range.
Click here to wrap up this case!
Case 34 Index
Case 34 Introduction
Case 34 Physical Exam