The patient might have renal failure. (http://emedicine.medscape.com/article/2096589-overview#a2) and (https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/ndt/28/1/10.1093_ndt_gfs339/3/gfs339.pdf?Expires=1487455599&Signature=WlKHFBpn~YETxo~uHkW0tE3dgNpLfKButvVzl6qP7HI8Hbn-9n19R0xDeIioqE0txZN9VlHfE5T3jTjdCYfH0qQW4E5iDukAW7WPD~E5XpYdxDhOhI2jHSTdoZrXHL1eCvjEL5rro8LUN8fXAvhLVi58e9SAmt3gWAJN66mbWpnc6qJQz78qDREhUMEEt74mhsfx7rPQCObSEv-lZZGcemh2zBdzcAGl5Ola5FjBR9IAv2JyfI12Oy6vwuNqx8dCBfCpc~bmkylLr9N7ReuXYklJKL6kCBHrvB2ktAcH~4OyWAQyH7JtuHwb0uGUDn8ie25PcOGLcUJPFOC~f06PSQ__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q)

What is the value for the creatinine clearance index? Renal elimination of procalcitonin is impaired in renal insufficiency. Also, in a patient with severe cirrhosis, like the one you described, the severity of the damage to the liver could cause a noninfectious systemic inflammatory response.  

http://emedicine.medscape.com/article/2096589-overview#a2

https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/ndt/28/1/10.1093_ndt_gfs339/3/gfs339.pdf?Expires=1487455599&Signature=WlKHFBpn~YETxo~uHkW0tE3dgNpLfKButvVzl6qP7HI8Hbn-9n19R0xDeIioqE0txZN9VlHfE5T3jTjdCYfH0qQW4E5iDukAW7WPD~E5XpYdxDhOhI2jHSTdoZrXHL1eCvjEL5rro8LUN8fXAvhLVi58e9SAmt3gWAJN66mbWpnc6qJQz78qDREhUMEEt74mhsfx7rPQCObSEv-lZZGcemh2zBdzcAGl5Ola5FjBR9IAv2JyfI12Oy6vwuNqx8dCBfCpc~bmkylLr9N7ReuXYklJKL6kCBHrvB2ktAcH~4OyWAQyH7JtuHwb0uGUDn8ie25PcOGLcUJPFOC~f06PSQ__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

Bacterial infections occur in one third of hospitalized cirrhotic patients and in approximately half of those admitted with gastrointestinal bleeding. C-reactive protein (CRP) and procalcitonin (PCT) are two plasma biomarkers included among the inflammatory variables in the diagnosis of sepsis. Based on a serum PCT cut-off value of 0.5 ng/mL for the diagnosis of infections, the sensitivity and specificity were reported as 92.5% and 77%, respectively. Some studies suggested serum PCT levels with WBC/PLT ratios can be used as diagnostic biomarkers of cirrhotic patients with infections.

Elevation of PCT could be due to

1.Localized mild-to-moderate bacterial infection

2.Noninfectious systemic inflammatory response

3.Untreated end-stage renal failure

PCT levels may be elevated in patients who do not have sepsis. The plasma levels usually are not very high (2-10 ng/mL). In addition, certain types of autoimmune disorders may induce significant amounts of PCT. Therefore, the etiology of that patient's liver cirrhosis should be learnt.

The renal function was good (BUN, creatinine in normal ranges , 1900 ml per day) so i performed additional blood work: CEA was high so i performed a thyroid ultrasound (procalcitonin is the precursor of calcitonin and is addition to infections it can be raised in thyroid medullary carcinoma) where we found an 3 cm inomogen nodule, hypervascularised, stiffer than the surounding parenchyma. Next step we will dose the calcitonin but most probable it is thyroid medullary carcinoma.

PS: the next step would be FNAB but her platelets are very low and she isnt a candidate for surgery.

Thanks for answers

This is a final diagnosis very well concluded.

Congratulations for your nice wok!