A 34-year-old man with a history of depression and alcoholism presented with altered mental status after tapering off his alcohol intake. On examination, he appeared obtunded, jaundiced, and cachectic. Blood pressure was 98/54mmHg and heart rate was 104 beats/min. Cardiopulmonary and abdominal examination findings were unremarkable. Neurologic examination showed lethargy, disorientation, and tremulousness, but no focal signs. Blood tests revealed the following values: hemoglobin, 8.3g/dL; platelet count, 66 ×103/μL; ammonia, 35μmol/L; serum sodium, 138 mEq/L; serum potassium, 2.6 mEq/L; and serum creatinine, 2.18mg/dL (corresponding to estimated glomerular filtration rate of 38mL/min/1.73m2 by the CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration] equation).