What is the diagnostic work up and initial management of the patient with cirrhosis and AKI?
A trial of diuretic withdrawal, together with intravascular volume replacement should be done, as this can replenish the effective arterial blood volume.
The intravascular volume replacement can be blood if the patient is anemic or albumin at the dose of 1 g/kg of body weight up to a maximum of 100 g/day.
The work-up should consist of a full work-up, including blood cultures, chest x-ray, urine and sputum cultures, a diagnostic paracentesis to exclude SBP, and the swabbing of any possible skin sources of infection.
The threshold for starting antibiotics should be low. In order to exclude parenchymal kidney disease, the urine should be examined for the presence of protein, blood, and casts.
An abdominal ultrasound should be performed to exclude small kidneys—indicative of parenchymal kidney disease—or structural abnormalities in the kidneys.
Postrenal obstruction is an extremely uncommon cause of AKI in cirrhosis, and bladder catheterization is usually not done to avoid instrumentation-induced infections.
