Hepatorenal
A patient with cirrhosis has an increase in serum creatinine of 0.4 mg/dL over 48 hours. Which creatinine criterion for acute kidney injury used in the diagnosis of HRS-AKI does this meet?
What is ≥0.3 mg/dL within 48 hours?
This gut-derived neurotoxin is most strongly associated with the pathogenesis of hepatic encephalopathy.
What is ammonia?
Define hepatopulmonary syndrome.
What is a syndrome is defined by the combination of chronic liver disease, pulmonary vascular abnormalities, and impaired arterial oxygenation?
“Shock liver,” also called ischemic hepatitis or acute cardiogenic liver injury, occurs when this hemodynamic parameter acutely falls.
What is cardiac output?
EGPA is a systemic small- to medium-vessel vasculitis strongly associated with these clinical features. Name two.
What are (any two of the following)?
A patient's baseline creatinine is 1.0 mg/dL. Seven days later, it is 1.6 mg/dL. What alternative creatinine criterion for HRS-AKI does this meet?
What is ≥1.5 times baseline within 7 days?
Hepatic encephalopathy results from impaired hepatic detoxification of neurotoxins combined with increased blood flow through this type of vascular pathway.
What is portosystemic shunting?
A patient with cirrhosis reports that dyspnea becomes worse when standing and improves when lying down. Oxygen saturation also decreases when upright.
Name the two clinical phenomena.
What are platypnea and orthodeoxia?
Platypnea: dyspnea that worsens in the upright position
Orthodeoxia: oxygen desaturation when upright
A patient in cardiogenic shock develops dramatic elevations in AST and ALT. In ischemic hepatitis, aminotransferase levels commonly rise to this level.
What is >5000?
True or False: Heart failure causes kidney dysfunction, but kidney dysfunction does not cause cardiovascular disease.
What is false- cardiorenal is bidirectional?
In addition to the serum creatinine criteria, oliguria meeting this threshold for this duration supports AKI.
What is urine output <0.5 mL/kg/hour for ≥6 hours?
A patient with cirrhosis presents with acute confusion. Before attributing the mental-status change solely to hepatic encephalopathy, the AGACNP should assess for common precipitants. Name four.
What are (any four of the following)?
In a patient with cirrhosis, this pulse-oximetry finding should raise suspicion for hepatopulmonary syndrome.
What is an SpO₂ ≤96%?
This laboratory relationship can help distinguish ischemic hepatitis from other causes of severe aminotransferase elevation.
What is an ALT-to-LDH ratio <1.5?
The traditional concept of cardiorenal syndrome focused primarily on interactions between the heart and kidneys. A broader framework was developed to recognize the important role of metabolic disease in driving both cardiovascular and kidney dysfunction.
What is this broader concept called?
What is cardiovascular-kidney-metabolic (CKM) syndrome?
A patient with decompensated cirrhosis develops AKI. Diuretics are discontinued and the patient receives volume expansion with albumin. After 48 hours, renal function has not improved. There is no shock, nephrotoxin exposure, or evidence of structural kidney disease. What diagnosis should you strongly consider, and what pathophysiologic process is responsible?
What is HRS-AKI caused by severe splanchnic vasodilation and reduced effective arterial blood volume, resulting in renal vasoconstriction and decreased renal perfusion?
A patient with cirrhosis has altered mental status. When asked to extend both arms with wrists dorsiflexed, the patient's hands demonstrate brief, irregular downward movements.
What is this finding, and why is it clinically relevant?
What is asterixis, a manifestation of metabolic encephalopathy that supports the diagnosis of hepatic encephalopathy in the appropriate clinical context?
A patient with cirrhosis has unexplained hypoxemia. A screening study is ordered to determine whether intrapulmonary vascular dilatation is present. What test is particularly sensitive for this purpose?
What is contrast-enhanced transthoracic echocardiography with agitated saline (bubble study)?
A patient with severe right-sided heart failure develops hepatic congestion. The liver becomes enlarged and tender, and bilirubin rises. What process contributes to the bilirubin elevation?
What is hypoxia of perivenular hepatocytes?
An AGACNP is managing a patient with heart failure and persistent volume overload despite escalating loop-diuretic doses. What pharmacologic strategy can be used to overcome diuretic resistance?
What is sequential nephron blockade/combining a loop diuretic with a thiazide-type diuretic to inhibit sodium reabsorption at different nephron sites.
A patient with HRS-AKI remains hypotensive despite albumin administration. What pharmacologic strategy should be initiated, and what is its physiologic goal?
What is vasoconstrictor therapy, particularly terlipressin when appropriate, with albumin, to increase effective arterial blood volume and improve renal perfusion?
Pearl:
The fundamental problem is functional renal hypoperfusion, not primary structural renal disease.
A patient with cirrhosis develops acute confusion and asterixis after an upper GI bleed. The AGACNP suspects hepatic encephalopathy and initiates lactulose.
What is the mechanism by which lactulose reduces systemic ammonia levels, and what medication can be added when episodes of hepatic encephalopathy recur despite lactulose therapy?
What are conversion of ammonia (NH₃) to nonabsorbable ammonium (NH₄⁺) in the colon with increased fecal nitrogen elimination, and rifaximin as add-on therapy to reduce intestinal ammonia production?
patient with portal hypertension develops progressive dyspnea. Echocardiography suggests pulmonary hypertension.
What vascular mediator has been implicated in portopulmonary hypertension, and what invasive study is used to confirm the diagnosis and characterize its severity?
What is endothelin-1, and what is right-heart catheterization?
An AGACNP is evaluating a patient with ascites and must distinguish cardiac ascites from cirrhotic ascites. Both conditions may have a high serum-ascites albumin gradient.
What ascitic-fluid finding favors cardiac ascites?
What is ascitic protein ≥2.5 g/dL in the setting of a SAAG ≥1.1 g/dL?
Pearl: High SAAG indicates portal-hypertension physiology. The higher protein concentration helps point toward cardiac rather than cirrhotic ascites.
A patient with advanced CKD and heart failure is receiving several medications. The AGACNP should be particularly alert for this electrolyte abnormality and this potential hemodynamic effect.
What are hyperkalemia and excessive reduction in blood pressure?