# Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense ascites and mild confusion. He weighs 72 kg, has no peripheral edema, and has had no alcohol for 2 weeks. He takes spironolactone 100 mg and furosemide 40 mg daily, and lactulose three times a day. During the first 3 days, the nurse reviews his record. He still has no peripheral edema. Normal ranges: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L, creatinine 0.6–1.2 mg/dL (53–106 µmol/L). Day 1: weight 72.0 kg; sodium 134 mEq/L; potassium 4.2 mEq/L; creatinine 0.9 mg/dL (80 µmol/L) Day 2: weight 70.7 kg; sodium 131 mEq/L; potassium 4.4 mEq/L; creatinine 1.1 mg/dL (97 µmol/L) Day 3: weight 69.4 kg; sodium 129 mEq/L; potassium 4.6 mEq/L; creatinine 1.5 mg/dL (133 µmol/L) Which conclusion should the nurse report to the physician?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630293  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense ascites and mild confusion. He weighs 72 kg, has no peripheral edema, and has had no alcohol for 2 weeks. He takes spironolactone 100 mg and furosemide 40 mg daily, and lactulose three times a day.

During the first 3 days, the nurse reviews his record. He still has no peripheral edema. Normal ranges: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L, creatinine 0.6–1.2 mg/dL (53–106 µmol/L).
Day 1: weight 72.0 kg; sodium 134 mEq/L; potassium 4.2 mEq/L; creatinine 0.9 mg/dL (80 µmol/L)
Day 2: weight 70.7 kg; sodium 131 mEq/L; potassium 4.4 mEq/L; creatinine 1.1 mg/dL (97 µmol/L)
Day 3: weight 69.4 kg; sodium 129 mEq/L; potassium 4.6 mEq/L; creatinine 1.5 mg/dL (133 µmol/L)
Which conclusion should the nurse report to the physician?

## 보기

1. The rising potassium points to spironolactone toxicity
2. The sodium level now calls for a 1-liter fluid limit
3. Weight is falling at the expected rate for ascites
4. Fluid loss is too fast and is injuring the kidneys **✔ 정답**

**정답: 4**

## 해설

Without peripheral edema, weight loss on diuretics should be about 0.5 kg a day; he is losing about 1.3 kg a day. At the same time creatinine has risen above the normal range and sodium keeps falling, which points to over-diuresis with kidney injury, a known trigger of hepatic encephalopathy. The physician should be told before the next diuretic doses.

## 심화 해설

Interpreting the 3-day trend
This patient has tense ascites without peripheral edema, and the daily weights show a loss of 1.3 kg/day on average (72.0 → 70.7 → 69.4 kg). In a patient with ascites but no edema, the expected safe rate of fluid removal is about 0.5 kg/day. Losing more than twice that rate means the intravascular compartment is being depleted too aggressively. The rising creatinine from 0.9 to 1.5 mg/dL confirms that the kidneys are not keeping up with the rapid fluid shift.

Why the creatinine rise matters
In cirrhosis, kidney function is already fragile because of splanchnic vasodilation, reduced effective arterial blood volume, and activation of vasoconstrictor systems. When diuretics pull fluid too quickly, renal perfusion drops further. Creatinine kinetics are more informative than a single static value in cirrhosis, because even a modest rise can signal acute kidney injury before the creatinine crosses a fixed threshold. Here the creatinine has risen by 0.6 mg/dL from baseline, which meets the pattern of acute worsening. The sodium falling from 134 to 129 mEq/L also reflects water retention driven by reduced effective circulating volume and antidiuretic hormone release, not simply salt loss.

Why the other options are not the priority

| Option | Why it is not the best conclusion |
| --- | --- |
| 1. Rising potassium points to spironolactone toxicity | Potassium is 4.6 mEq/L, still within the normal range (3.5–5.0 mEq/L). A mild upward trend is expected with spironolactone, but this is not hyperkalemia or toxicity. |
| 2. Sodium level calls for a 1-liter fluid limit | Hyponatremia in cirrhosis is usually dilutional, caused by water retention from reduced effective arterial volume. Simply restricting fluid does not fix the underlying over-diuresis and may worsen renal perfusion. |
| 3. Weight is falling at the expected rate for ascites | Without peripheral edema, the expected loss is about 0.5 kg/day. A loss of 1.3 kg/day is too rapid and is the key clue to over-diuresis. |

Connecting over-diuresis to hepatic encephalopathy
The patient already has mild confusion. Rapid fluid removal can worsen hepatic encephalopathy through several mechanisms: reduced renal clearance of nitrogenous waste, electrolyte shifts, and worsening kidney function. Watch out! In cirrhosis, kidney injury and hepatic encephalopathy often travel together; a rising creatinine in a confused patient should trigger immediate reassessment of diuretic dosing rather than waiting for more obvious signs.

What to report
The nurse should report that fluid loss is exceeding the safe rate for a patient without peripheral edema and that creatinine has risen above the normal range, indicating kidney injury from over-diuresis. The physician needs this information before the next scheduled doses of spironolactone and furosemide, because continuing the same diuretic regimen risks further renal deterioration and worsening encephalopathy. Key point! In ascites without edema, a daily weight loss above 0.5 kg plus a rising creatinine is a red flag for iatrogenic kidney injury, not a sign of successful diuresis.

## 임상 시나리오

Cirrhosis Diuresis SafetyMonitoring weight and creatinine during ascites management
In ascites without peripheral edema, target weight loss is 0.5 kg/day. Faster loss depletes intravascular volume.

A rising creatinine from 0.9 to 1.5 mg/dL over 3 days indicates over-diuresis with kidney injury, even before creatinine crosses a fixed threshold.

CautionNotify the physician before the next diuretic dose when weight loss exceeds 0.5 kg/day without edema or creatinine rises from baseline.

## 핵심 개념

- **Over-diuresis** — Excessive diuretic-induced fluid removal that depletes intravascular volume and can impair renal perfusion
- **Effective arterial blood volume** — The portion of circulating volume that perfuses organs; reduced in cirrhosis despite total body fluid overload
- **Acute kidney injury** — Rapid decline in renal function, often identified by rising creatinine from baseline
- **Hepatic encephalopathy** — Neuropsychiatric complication of liver failure that can be precipitated by kidney injury and electrolyte shifts
- **Ascites without edema** — Fluid overload state where safe diuretic weight loss is limited to about 0.5 kg/day

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