The Case

A 38-year old woman with obesity, diabetes mellitus type 2, non-alcoholic steatohepatitis cirrhosis, and recurrent hepatic encephalopathy presented to the Emergency department for 2 days of confusion.

Patient history

The patient is active on the liver transplant waiting list. She is somnolent.

Vital examination

Oral temperature is 38.4^○ C, BP is 88/46 mm HG, heart rate if 112 beats per minute, respiratory rate is 22 breaths per minute, oxygenation saturation is 98% on room air, and weight is 100 Kg.

Physical examination

Physical examination was significant for jaundice, bulging abdominal flanks, and oedema.

Patient history

Outpatient medications are furosemide, spironolactone, lactulose, potassium chloride, and metformin.

Laboratory investigations

Five weeks ago, her serum creatinine was 0.9 mg/dl, and Model for End Stage liver Disease score was 20. Her laboratory tests are shown below.

Radiographical investigations

Chest radiograph is clear.

The patient was intubated for airway protection, fluid resuscitated, pancultured, and admitted to the intensive care unit.

What is your answer?

• What should be the management approach?
• Should RRT be initiated?

Case resourced from:

Judd E, Tolwani A. Managing issues in dialysis for the patient with AKI. Clinical Journal of American Society of Nephrology. 2017; 12: 1538-1542.