Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome

Am J Nephrol. 2019;50(3):204-211. doi: 10.1159/000501299. Epub 2019 Aug 8.


Introduction: Fulfillment of the diagnostic criteria for -hepatorenal syndrome type 1 (HRS-1) requires prior failure of 2 days of intravenous volume expansion and/or diuretic withdrawal. However, no parameter of volume status is used to guide the need for volume expansion in patients with suspected HRS-1. We hypothesized that point-of-care echocardiography (POCE) may better characterize the volume status in patients with acute kidney injury (AKI) and cirrhosis to ascertain or disprove the diagnosis of HRS-1.

Methods: A pilot observational study was conducted to determine the clinical utility of POCE-based examination of inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) to assess intravascular volume status in patients with cirrhosis and AKI who had been deemed adequately volume-repleted and thereby assigned a clinical diagnosis of HRS-1. Early improvement in kidney function was defined as ≥20% decrease in serum creatinine (sCr) at 48-72 h.

Results: A total of 53 patients were included. The mean sCr at the time of volume assessment was 3.2 ± 1.5 mg/dL, and the mean Model for End-Stage Liver Disease score was 29 ± 8. Fifteen (23%) patients had an IVCD <1.3 cm and IVCCI >40% and were reclassified as fluid-depleted, 11 (21%) had an IVCD >2 cm and IVCCI <40% and were reclassified as fluid-expanded, and 8 (15%) had and IVCD <1.3 cm and IVCCI <40% and were reclassified as having intra-abdominal hypertension (IAH). Twelve (23%) patients exhibited early improvement in kidney function following a POCE-guided therapeutic maneuver, that is, volume expansion, diuresis, or paracentesis for those deemed fluid-depleted, fluid-expanded or having IAH, respectively.

Conclusion: POCE-based assessment of volume status in cirrhotic individuals with AKI reveals marked heterogeneity. Unguided volume expansion in these patients may lead to premature or delayed diagnosis of HRS-1.

Keywords: Ascites; Assessment; Bedside; Inferior vena cava; POCUN; POCUS; Ultrasonography; Ultrasound; Volume status.

Publication types

  • Observational Study

MeSH terms

  • Acute Kidney Injury / classification
  • Acute Kidney Injury / diagnostic imaging*
  • Adult
  • Aged
  • Delayed Diagnosis
  • Diagnostic Errors
  • Echocardiography*
  • End Stage Liver Disease / classification
  • End Stage Liver Disease / diagnostic imaging
  • Female
  • Hemodynamics
  • Hepatorenal Syndrome / classification
  • Hepatorenal Syndrome / diagnostic imaging*
  • Humans
  • Hypertension
  • Kidney Function Tests
  • Liver Cirrhosis / physiopathology
  • Male
  • Middle Aged
  • Pilot Projects
  • Point-of-Care Systems*
  • Prospective Studies
  • Vena Cava, Inferior / pathology