23rd July 2023

A patient is admitted directly from the gastroenterology clinic

A patient is admitted directly from the gastroenterology clinic. They were attending a follow up appointment for cirrhosis secondary to ALD. At the clinic, they appeared clinically unwell, with a fever and tense ascites.

He was diagnosed with spontaneous bacterial peritonitis (SBP) and started on empirical antibiotics and regular albumin. Spironolactone is suspended.

You monitor him closely with daily blood tests. Three days into admission, you notice his renal function is deteriorating.

Blood tests on admission:

• Urea 8.6 mmol/L (2.5-7.8mmol/L)
• Creatinine 122 μmol/L (59-104 μmol/L)
• Sodium 130 mmol/L (135-145 mmol/L)
• Potassium 3.8 mmol/L (3.5-5.0 mmol/L)

Blood tests on day 3:

• Urea 9.6 mmol/L (2.5-7.8mmol/L)
• Creatinine 236 μmol/L (59-104 μmol/L)
• Urinalysis: negative for leukocytes, nitrites, blood and protein. No granular casts.

An ultrasound of the urinary tract shows normal appearances.

What is the most likely cause of acute kidney injury (AKI)?

Select the SINGLE most appropriate option from the list below. Select ONE option only.