To the Editor.—In the May 1978 issue of the Archives (113:581-858), LeVeen and co-workers reported their work on the treatment of renal failure in ascites secondary to hepatic, renal, and pancreatic disease.
The diagnosis of hepatorenal syndrome in patients with liver disease with azotemia and oliguria is difficult to make. Prerenal oliguria should be ruled out by a judicious trial of volume expanders to determine whether the decreased effective intravascular volume is the cause of oliguria. The reported cases of LeVeen secondary to liver disease or encephalopathy do not provide enough data regarding the nature of renal disease. It is of critical importance in making a diagnosis to obtain urine osmolality, urine-to-plasma osmolality ratio, and urine-to-plasma creatinine ratio.
In Table 2, patient 1, after many days of high urine output, the serum creatinine level did not change substantially and there was no improvement of the glomerular filtration rate. This