A patient with cirrhosis and ascites may be an increased risk for developing the hepatorenal syndrome if certain findings are present. These risk factors can help identify patients who may require more aggressive therapy and closer monitoring.


Severity of liver disease:

(1) previous episodes of cirrhosis

(2) absence of hepatomegaly (reflecting shrunken organ)

(3) presence of esophageal varices

(4) poor nutritional status


Renal function:

(1) moderately reduced glomerular filtration rate (< 80 mL/min)

(2) moderately increased BUN (> 15 mg/dL)

(3) moderately increased serum creatinine (> 0.9 mg/dL)


Electrolyte disturbances:

(1) low serum sodium (<= 133 mEq/L)

(2) low urinary sodium excretion (<= 2 mEq/L)

(3) high serum potassium (> 4 mEq/L)

(4) low baseline serum osmolality (reflects hyponatremia; <= 279 mOsm per kg water)

(5) high baseline urine osmolality (> 553 mOsm per kg water)

(6) reduced free water excretion after a water load (<= 3.3 mL/min)


Endocrine and Vascular:

(1) low arterial blood pressure (need to exclude gastrointestinal hemorrhage)

(2) low mean arterial blood pressure (<= 85 mm Hg)

(3) high plasma renin activity (> 3.5 ng/mL•h)

(4) increased plasma norepinephrine (> 544 pg/mL)


Differential diagnosis:

• Gastrointestinal bleeding from varices might present with increased BUN and hypotension.



• Some measurements (plasma renin, plasma norepineprine) may show intra-laboratory variability.


To read more or access our algorithms and calculators, please log in or register.