Pt w Child B cirrhosis and portal HTN (varices). Comes w UTI and Cr of 5.8 mg/dl (baseline 1.1 mg/dl). BP 70/50. Lactate 5. Initially tx w crystalloid UOP 0.3 ml/kg/hr for 14 hrs. Norepinephrine and albumin were started with improved UOP 0.7 ml/kg/hr. CT scan on admission: 
#EchoFirst PLAx
Apical View
Apical With Color
LVOT VTI 21.1, TAPSE 19, TRVmax 3.82 m/s
No portal vein pulsatility and normal hepatic vein doppler despite severe TR. However, given kidneys show congestion, this is most likely severe venous congestion. HV and PV don't show congestion due to Liver parenchymal fibrosis.
❤️➡️severe chronic PH, RH enlargement and severe TR. Given this findings we stopped albumin infusion (in retrospect may have never needed it). UOP by now was 2.0 ml/kg/hr so I continued NE gtt (lower dose needed now) and did not start diuretics. Will check again tomorrow
Creatinine improved with NE and albumin (and single dose lasix). It is interesting because I would not have used albumin in this case (Which is very expensive). Interesting physiology where (I believe) both low MABP and renosarca contributed to severe AKI.
What do you guys think? @Thind888 @msiuba @NephroP @ThinkingCC @khaycock2 @ICUnephroSuarez @VelezNephHepato
So I continued norepinephrine, no albumin, no diuretic. Patient persisted with high urine output. Balance -4.8 L. Creatinine now 1.1. Here is today’s VExUS (IVC and Intrarenal Venous Doppler). I attach original scan for comparison
Again interesting that this patient fully decongested without needing diuretics! Thanks to @VelezNephHepato for pointing out that this patients are exquisitely sensitive to norepinephrine
