Review
Copyright ©The Author(s) 2025.
World J Hepatol. May 27, 2025; 17(5): 104724
Published online May 27, 2025. doi: 10.4254/wjh.v17.i5.104724
Table 2 Serum biomarkers, urinary biomarkers, and hemodynamic parameters to differentiate among pre-renal acute kidney injury, acute tubular necrosis, and hepatorenal syndrome
Parameters
Pre-renal AKI
Hepatorenal syndrome
Acute tubular necrosis
Comments
Clue to diagnoseHistory of fluid loss or overzealous use of diureticsPresence of refractory ascites, hyponatremiaPresence of sepsis and hypotensionHistory cannot be always reliable to diagnose the subtypes of kidney injury
Urine sediments[73,74]The lack of any casts suggests functional renal failure mostly pre-renal AKI[56]Usually absentMuddy brown casts and renal tubular epithelial cell castsShould be interpreted by expert renal pathologists
Sensitivity: 73%RETC and granular cast
Specificity: 75%PPV: 100%
However, bland, hyaline cast may be presentNPV: 40%
FENa[27,75]< 1< 1 for diagnosing HRS-AKIUsually > 1FENa is unable to distinguish between Pre-renal AKI and HRS-AKI
Sensitivity: 90%Sensitivity: 100%Sensitivity: 89%Not validated in patients on diuretics
Specificity: 82%Specificity: 14%Specificity: 71%FENa can be < 1 in patients with cirrhosis without AKI
To differentiate between intrinsic vs pre-renal kidney injuryAASLDFENa < 0.56 excludes ATN
< 0.1 suggests HRS[46]
FEUrea[29]< 21< 28.7> 33No standardized cut-off in patients with cirrhosis
Sensitivity: 90%Sensitivity: 75%< 34 to rule out ATN
Specificity: 61%Specificity: 83%Sensitivity: 70%
For PRA vs HRSFor non-HRS vs HRSSpecificity: 58%
NGAL-1[35,36,38,39]< 110< 100> 194 mcg/g Cr
Sensitivity: 88%Sensitivity: 91%
Specificity: 85%Specificity: 82%
Renal artery resistive index[76,77]Cannot differentiate between prerenal AKI and AKI-HRS> 0.7 predicts HRS[76]> 0.8 is suggestive of ATN[77]RARI is higher in patients with cirrhosis and ascites compared to healthy individuals
> 0.77 predicts HRS in cirrhosisRARI is higher in ATN than in HRS.
Sensitivity: 100%
Specificity: 77%