PRESENTATION AND DIAGNOSIS

Patients with HRS often have the typical stigmata of liver disease, which include jaundice, ascites, coagu-lopathies, and occasionally encephalopathy. Effective intraarterial volume depletion causes tachycardia, low-normal blood pressure, and low jugular venous pressure. The prerenal state leads to oliguria, edema, and worsening ascites.

Suggestive laboratory findings include an elevated serum creatinine concentration, benign urine sediment, and FENa less than 1%. The BUN : Cr ratio may be elevated, indicative of a prerenal state, but BUN must be carefully interpreted since gastrointestinal bleeding and malnutrition can both affect its value. In addition, hyperbilirubinemia may cause granular and epithelial cell casts, which should not be misinterpreted as evidence of acute tubular necrosis.