A patient with cirrhosis may develop renal failure for a number of reasons. Appropriate management requires identification of the conditions that may be affecting the patient. Mackelaite et al proposed a diagnostic approach to evaluate these patients.


Conditions that need to be considered:

(1) extracellular fluid (ECF) loss with prenal azotemia

(2) nephrotoxic medications

(3) ischemic acute tubular necrosis

(4) glomerulonephropathy

(5) obstructive uropathy

(6) hepatorenal syndrome


Clue to Look For

Additional Finding

ECF fluid loss

rapid or excessive diuresis, vomiting, diarrhea, hemorrhage, large volume paracentesis, drugs such as NSAIDs or ACE inhibitors causing hemodynamic changes

improves if fluid loss controlled and/or albumin infused

nephrotoxic drugs or chemicals

radiocontrast material, aminoglycoside

improves if nephrotoxic exposure stops but recovery may be delayed

ischemic acute tubular necrosis

hypotension (sepsis, hemorrhage, other)



proteinuria, dysmorphic red cells or RBC casts in urine sediment

renal biopsy

obstructive uropathy

hydronephrosis, hydroureter, urinary retention

improves after relief of obstruction (unless long-standing)


portal hypertension with elevated serum creatinine



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