Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome

2019 ◽  
Vol 50 (3) ◽  
pp. 204-211 ◽  
Author(s):  
Juan Carlos Q. Velez ◽  
Bradley Petkovich ◽  
Nithin Karakala ◽  
J. Terrill Huggins
Keyword(s):  
Acute Kidney Injury ◽  
Kidney Function ◽  
Volume Expansion ◽  
Hepatorenal Syndrome ◽  
Point Of Care ◽  
Kidney Injury ◽  
Volume Status ◽  
Early Improvement ◽  
Abdominal Hypertension ◽  
The Mean

Introduction: Fulfillment of the diagnostic criteria for ­hepatorenal syndrome type 1 (HRS-1) requires prior failure of 2 days of intravenous volume expansion and/or diuretic withdrawal. However, no parameter of volume status is used to guide the need for volume expansion in patients with suspected HRS-1. We hypothesized that point-of-care echocardiography (POCE) may better characterize the volume status in patients with acute kidney injury (AKI) and cirrhosis to ascertain or disprove the diagnosis of HRS-1. Methods: A pilot observational study was conducted to determine the clinical utility of POCE-based examination of inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) to assess intravascular volume status in patients with cirrhosis and AKI who had been deemed adequately volume-repleted and thereby assigned a clinical diagnosis of HRS-1. Early improvement in kidney function was defined as ≥20% decrease in serum creatinine (sCr) at 48–72 h. Results: A total of 53 patients were included. The mean sCr at the time of volume assessment was 3.2 ± 1.5 mg/dL, and the mean Model for End-Stage Liver Disease score was 29 ± 8. Fifteen (23%) patients had an IVCD <1.3 cm and IVCCI >40% and were reclassified as fluid-depleted, 11 (21%) had an IVCD >2 cm and IVCCI <40% and were reclassified as fluid-expanded, and 8 (15%) had and IVCD <1.3 cm and IVCCI <40% and were reclassified as having intra-abdominal hypertension (IAH). Twelve (23%) patients exhibited early improvement in kidney function following a POCE-guided therapeutic maneuver, that is, volume expansion, diuresis, or paracentesis for those deemed fluid-depleted, fluid-expanded or having IAH, respectively. Conclusion: POCE-based assessment of volume status in cirrhotic individuals with AKI reveals marked heterogeneity. Unguided volume expansion in these patients may lead to premature or delayed diagnosis of HRS-1.

scholarly journals Diagnosis dan Tatalaksana Sindrom Hepatorenal

e-CliniC ◽  
2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Jovanca G. Timbul ◽  
Cerelia E. C. Sugeng ◽  
Bradley J. Waleleng
Keyword(s):  
Liver Transplantation ◽  
Acute Kidney Injury ◽  
Mortality Rate ◽  
Literature Review ◽  
Poor Prognosis ◽  
Hepatorenal Syndrome ◽  
Kidney Injury ◽  
Google Scholar ◽  
Definitive Therapy ◽  
The Mean

Abstract: Hepatorenal syndrome (HRS) is known as a complication of cirrhosis. Currently, there are no specific laboratory tests to diagnose HRS while liver transplantation, as the definitive therapy, is still problematic due to the poor prognosis and long waiting lists. HRS is typically associated with poor prognosis, with a mortality rate of more than 95%. Without liver transplantation or appropriate vasoconstrictor therapy, the life expectancy was less than 2 weeks. This study was aimed to describe the diagnosis and management of the hepatorenal syndrome. The study design was literature review. Published literature was obtained from three databases: PubMed, ScienceDirect, and Google Scholar. All articles that met the inclusion and exclusion criteria were included in this study. According to five studies regarding the diagnosis, both the incidence and mortality rate of HRS was relatively high (38.1% of all acute kidney injury cases and 64.5%, respectively), even with in-hospital therapy. Five other studies analyzed the management of HRS. It was reported that the mean age of the youngest SHR patients was 53.3 years and the mean oldest age was 65 years. The male gender predominated in all studies (50-79%). In conclusion, the latest revision classified HRS into three groups: HRS-AKI, HRS-AKD, and HRS-CKD. Pharmacological therapies for HRS including terlipressin, octreotide, midodrine, albumin, pentoxifylline, and various combinations of these therapies.                    Keywords: Hepatorenal Syndrome, Diagnosis of HRS, Management of HRSAbstrak: Komplikasi dari sirosis hati antara lain sindrom hepatorenal (HRS). Sampai saat ini pemeriksaan laboratorium secara spesifik untuk mendiagnosis HRS belum ada. Transplantasi hati secara teori merupakan terapi yang tepat namun masih merupakan masalah utama karena prognosisnya buruk dan daftar tunggu yang lama di pusat transplantasi. Prognosis HRS umumnya buruk dengan angka mortalitas lebih dari 95%, jika tidak melalui transplantasi hati atau terapi vasokonstriktor yang tepat maka rerata angka harapan hidup pasien kurang dari 2 minggu. Penelitian ini bertujuan untuk mengetahui diagnosis dan tatalaksana HRS. Jenis penelitian ialah literature review dengan menggunakan tiga database yaitu PubMed, Science Direct, dan Google Scholar sesuai dengan kriteria inklusi dan eksklusi yang ada. Berdasarkan lima literatur penegakan diagnosis HRS, diketahui insidensi dan angka kematian HRS relatif tinggi (38,1% dari seluruh kasus acute kidney injury (AKI) dan angka kematian 64,5%), meskipun telah mendapatkan terapi di rumah sakit. Lima literatur lainnya tentang tatalaksana SHR, diketahui rerata (mean) usia termuda pasien HRS 53,3 tahun dan rerata (mean) usia tertua 65 tahun, dan yang mendominasi sampel penelitian ialah jenis kelamin laki-laki (50-79%). Simpulan penelitian ini ialah revisi terbaru menunjukkan HRS diklasifikasikan menjadi tiga kelompok: HRS-AKI, HRS-AKD, dan HRS-CKD. Terapi medikamentosa untuk HRS di antaranya terlipressin, oktreotida, midodrine, albumin, pentoxifylline, serta berbagai kombinasi dari terapi tersebut.                                                    Kata kunci:  sindrom hepatorenal, diagnosis HRS, tatalaksana HRS 

P0618PREOPERATIVE LOW URINE SPECIFIC GRAVITY PREDICTS ACUTE KIDNEY INJURY AFTER CARDIAC SURGERY

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Wonji Jo ◽  
Chan-Young Jung ◽  
Jaeyoung Kim ◽  
Jihye Kim ◽  
Sangmi Lee ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Specific Gravity ◽  
Kidney Function ◽  
Kidney Injury ◽  
Kidney Damage ◽  
Urine Specific Gravity ◽  
Normal Kidney ◽  
The Mean ◽  
Post Cardiac Surgery

Abstract Background and Aims Acute kidney injury (AKI) is a common and serious complication following cardiac surgery. However, strategies that effectively predict AKI risk before cardiac surgery are scarce. Recent investigations identified urinary osmolality to be associated with non-glomerular kidney damage in normal kidney function individuals, suggesting urine concentration ability to be a surrogate of early kidney damage. Therefore, hypothesizing that urine specific gravity (SG) could reflect asymptomatic kidney damage, the clinical implication of preoperative urine specific gravity on AKI occurrence after cardiac surgery was investigated in subjects with normal kidney function. Method A total of 4135 patients who underwent coronary artery bypass or valve surgery at Yonsei University Health System from were enrolled. Patients whose eGFR was lower than 60mL/min/1.73m2 were excluded. Fasting urinary SG was measured from the morning first void a day before the surgery. The patients were divided into tertiles based on urine SG. The primary outcome was occurrence of AKI within 48hours of cardiac surgery. AKI was defined according to Acute Kidney Injury Network criteria. Results The mean age of the patients was 60 years and 60% were male. Diabetes consisted of 25.6% of the patients and 54.5% were hypertensive. The mean eGFR and urine SG was 98.8mL/min/1.73m2 and 1.020, respectively. AKI developed in 1,089 (26.3%) patients. The incidence of AKI was highest in the lowest urine SG tertile group (410, 29.0%) and lowest in the highest tertile group (304, 23.5%) (P &lt; 0.001). Multivariable logistic regression analysis revealed that being included in the lowest preoperative urine SG tertile group was significantly related with higher post cardiac surgery AKI incidence risk (odd ratio (OR), 1.33; CI, 1.12-1.57; P =0.001). This association was significant even after adjustments were made for confounding factors. Conclusion Low urine SG was associated with increased risk of cardiac surgery associated AKI in patient with normal renal function. Evaluating preoperative urine SG may be useful in stratifying post cardiac surgery AKI risk.

scholarly journals COVID-19 and acute kidney injury: Point-of-care ultrasound in the assessment of volume status

2020 ◽  
Vol 0 (0) ◽  
pp. 0
Author(s):  
Subhrashis Guha Niyogi ◽  
KrishnaPrasad Gourav ◽  
Sunder Negi ◽  
Vikas Suri ◽  
GoverdhanDutt Puri
Keyword(s):  
Acute Kidney Injury ◽  
Point Of Care ◽  
Kidney Injury ◽  
Volume Status ◽  
Point Of Care Ultrasound

scholarly journals Role of Terlipressin in Cirrhotic Patients with Ascites and without Hepatorenal Syndrome: A Systematic Review of Current Evidence

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Zhaohui Bai ◽  
Yang An ◽  
Xiaozhong Guo ◽  
Rolf Teschke ◽  
Nahum Méndez-Sánchez ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Randomized Controlled Trial ◽  
Renal Function ◽  
Mean Arterial Pressure ◽  
Hepatorenal Syndrome ◽  
Controlled Trial ◽  
Kidney Injury ◽  
Current Evidence ◽  
Randomized Controlled ◽  
The Mean

Ascites, a common complication in cirrhosis, is prone to the development of acute kidney injury or hepatorenal syndrome and can be complicated by circulatory dysfunction after paracentesis. Terlipressin has not been considered as the mainstay treatment option for ascites in cirrhosis yet. The present work aimed to systematically review the current evidence regarding the use of terlipressin in cirrhosis with ascites and without hepatorenal syndrome. PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. Twelve studies were eligible. In 3 studies (1 randomized controlled trial and 2 single-arm studies without controls) involving 32 patients who received terlipressin for nonrefractory ascites, terlipressin improved hemodynamics by decreasing the heart rate and cardiac output and increasing the mean arterial pressure and systemic vascular resistance. In 5 studies (1 randomized controlled trial, 2 single-arm studies without controls, and 2 comparative studies with controls) involving 67 patients who received terlipressin for refractory ascites, terlipressin improved renal function by increasing the glomerular filtration rate, renal blood flow, urinary sodium, and urine output and decreasing serum creatinine. In 4 studies (4 randomized controlled trials) involving 71 patients who received terlipressin for preventing from paracentesis-induced circulatory dysfunction, terlipressin prevented from paracentesis-induced circulatory dysfunction by increasing the mean arterial pressure and systemic vascular resistance and decreasing plasma renin. Terlipressin may improve hemodynamics, severity of ascites, and renal function and prevent from paracentesis-induced circulatory dysfunction in cirrhosis with ascites and without hepatorenal syndrome. However, no study has evaluated the effect of terlipressin for prevention of acute kidney injury.

scholarly journals The Current Management of Hepatorenal Syndrome‐Acute Kidney Injury in the United States and the Potential of Terlipressin

2021 ◽  
Author(s):  
Steven L. Flamm ◽  
Kimberly Brown ◽  
Hani M. Wadei ◽  
Robert S. Brown ◽  
Marcelo Kugelmas ◽  
...  
Keyword(s):  
United States ◽  
Acute Kidney Injury ◽  
Hepatorenal Syndrome ◽  
Kidney Injury ◽  
The United States ◽  
Current Management

scholarly journals Assessment of Kidney Function After Transcatheter Aortic Valve Replacement

2021 ◽  
Vol 8 ◽  
pp. 205435812110180
Author(s):  
Orit Kliuk-Ben Bassat ◽  
Sapir Sadon ◽  
Svetlana Sirota ◽  
Arie Steinvil ◽  
Maayan Konigstein ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Function ◽  
Kidney Function ◽  
Transcatheter Aortic Valve Replacement ◽  
Kidney Injury ◽  
Single Center ◽  
Transcatheter Aortic Valve ◽  
Single Center Study ◽  
Center Study

Background: Transcatheter aortic valve replacement (TAVR), although associated with an increased risk for acute kidney injury (AKI), may also result in improvement in renal function. Objective: The aim of this study is to evaluate the magnitude of kidney function improvement (KFI) after TAVR and to assess its significance on long-term mortality. Design: This is a prospective single center study. Setting: The study was conducted in cardiology department, interventional unit, in a tertiary hospital. Patients: The cohort included 1321 patients who underwent TAVR. Measurements: Serum creatinine level was measured at baseline, before the procedure, and over the next 7 days or until discharge. Methods: Kidney function improvement was defined as the mirror image of AKI, a reduction in pre-procedural to post-procedural minimal creatinine of more than 0.3 mg/dL, or a ratio of post-procedural minimal creatinine to pre-procedural creatinine of less than 0.66, up to 7 days after the procedure. Patients were categorized and compared for clinical endpoints according to post-procedural renal function change into 3 groups: KFI, AKI, or preserved kidney function (PKF). The primary endpoint was long-term all-cause mortality. Results: The incidence of KFI was 5%. In 55 out of 66 patients patients, the improvement in kidney function was minor and of unclear clinical significance. Acute kidney injury occurred in 19.1%. Estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 was a predictor of KFI after multivariable analysis (odds ratio = 0.93 to develop KFI; confidence interval [95% CI]: 0.91-0.95, P < .001). Patients in the KFI group had a higher Society of Thoracic Surgery (STS) score than other groups. Mortality rate did not differ between KFI group and PKF group (43.9% in KFI group and 33.8% in PKF group) but was significantly higher in the AKI group (60.7%, P < .001). Limitations: The following are the limitations: heterozygous definitions of KFI within different studies and a single center study. Although data were collected prospectively, analysis plan was defined after data collection. Conclusions: Improvement in kidney function following TAVR was not a common phenomenon in our cohort and did not reduce overall mortality rate.

scholarly journals Acute kidney injury and its outcomes in melioidosis

2021 ◽  
Author(s):  
Ravindra Attur Prabhu ◽  
Tushar Shaw ◽  
Indu Ramachandra Rao ◽  
Vandana Kalwaje Eshwara ◽  
Shankar Prasad Nagaraju ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Kidney Function ◽  
Univariate Analysis ◽  
Kidney Injury ◽  
Function Recovery ◽  
Kidney Involvement ◽  
Duration Of Hospitalization ◽  
Observational Cohort ◽  
Stage 1 ◽  
Urinary Abnormalities

Abstract Background Melioidosis is a potentially fatal tropical infection caused by Burkholderia pseudomallei. Kidney involvement is possible, but has not been well described. Aim This study aimed to assess the risk of acute kidney injury (AKI) and its outcomes in melioidosis. Methods A retrospective observational cohort study was performed. Case records of consecutive patients with culture-confirmed melioidosis, observed from January 1st, 2012 through December 31st, 2019 were analysed for demographics, presence of comorbidities, including chronic kidney disease (CKD), diabetes mellitus (DM), and presence of bacteraemia, sepsis, shock, AKI, and urinary abnormalities. The outcomes we studied were: mortality, need for hospitalisation in an intensive care unit (ICU), duration of hospitalization. We then compared the outcomes between patients with and without AKI. Results Of 164 patients, AKI was observed in 59 (35.98%), and haemodialysis was required in eight (13.56%). In the univariate analysis, AKI was associated with CKD (OR 5.83; CI 1.140–29.90, P = 0.03), bacteraemia (OR 8.82; CI 3.67–21.22, P < 0.001) and shock (OR 3.75; CI 1.63–8.65, P = 0.04). In the multivariate analysis, CKD (adjusted OR 10.68; 95% CI 1.66–68.77; P = 0.013) and bacteraemia (adjusted OR 8.22; 95% CI 3.15–21.47, P < 0.001) predicted AKI. AKI was associated with a greater need for ICU care (37.3% vs. 13.3%, P = 0.001), and mortality (32.2% vs. 5.7%, P < 0.001). Mortality increased with increasing AKI stage, i.e. stage 1 (OR 3.52, CI 0.9–13.7, P = 0.07), stage 2 (OR 6.79, CI 1.92–24, P = 0.002) and stage 3 (OR 17.8, CI 5.05–62.8, P < 0.001), however kidney function recovered in survivors. Hyponatremia was observed in 138 patients (84.15%) and isolated urinary abnormalities were seen in 31(18.9%). Conclusions AKI is frequent in melioidosis and occurred in 35.9% of our cases. Hyponatremia is likewise common. AKI was predicted by bacteraemia and CKD, and was associated with higher mortality and need for ICU care; however kidney function recovery was observed in survivors. Graphic abstract

scholarly journals Intensive care unit physician-delivered point of care renal tract ultrasound in acute kidney injury is feasible

2018 ◽  
Vol 19 (4) ◽  
pp. 313-318 ◽  
Author(s):  
Prashant Parulekar ◽  
Ed Neil-Gallacher ◽  
Alex Harrison
Keyword(s):  
Intensive Care Unit ◽  
Acute Kidney Injury ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Point Of Care ◽  
Kidney Injury ◽  
Diagnostic Quality ◽  
The Core ◽  
Low Incidence

Acute kidney injury is common in critically ill patients, with ultrasound recommended to exclude renal tract obstruction. Intensive care unit clinicians are skilled in acquiring and interpreting ultrasound examinations. Intensive Care Medicine Trainees wish to learn renal tract ultrasound. We sought to demonstrate that intensive care unit clinicians can competently perform renal tract ultrasound on critically ill patients. Thirty patients with acute kidney injury were scanned by two intensive care unit physicians using a standard intensive care unit ultrasound machine. The archived images were reviewed by a Radiologist for adequacy and diagnostic quality. In 28 of 30 patients both kidneys were identified. Adequate archived images of both kidneys each in two planes were possible in 23 of 30 patients. The commonest reason for failure was dressings and drains from abdominal surgery. Only one patient had hydronephrosis. Our results suggest that intensive care unit clinicians can provide focussed renal tract ultrasound. The low incidence of hydronephrosis has implications for delivering the Core Ultrasound in Intensive Care competencies.

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