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Ricksten SE, Bragadottir G, Lannemyr L, Redfors B, Skytte J. Renal Hemodynamics, Function, and Oxygenation in Critically Ill Patients and after Major Surgery. KIDNEY360 2021; 2:894-904. [PMID: 35373068 PMCID: PMC8791344 DOI: 10.34067/kid.0007012020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
This review outlines the available data from the work of our group on renal hemodynamics, function, and oxygenation in patients who are critically ill with acute renal dysfunction, such as those with postoperative AKI, those in early clinical septic shock, in patients undergoing cardiac surgery with cardiopulmonary bypass, or in patients undergoing liver transplantation. We also provide information on renal hemodynamics, function, and oxygenation in patients with chronic renal impairment due to congestive heart failure. This review will argue that, for all of these groups of patients, the common denominator is that renal oxygenation is impaired due to a lower renal oxygen delivery or a pronounced increase in renal oxygen consumption.
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Scholtes RA, Nguyen ITN, van Bommel EJM, Willekes N, van Nieuwenhuijzen M, van Raalte DH, Joles JA. Glucosuria Interferes With Measurement of Effective Renal Plasma Flow Using para-Aminohippuric Acid, With a Focus on SGLT2 Inhibitors. Kidney Int Rep 2020; 5:2052-2054. [PMID: 33163726 PMCID: PMC7609950 DOI: 10.1016/j.ekir.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Rosalie A Scholtes
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Isabel T N Nguyen
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, the Netherlands
| | - Erik J M van Bommel
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Nel Willekes
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, the Netherlands
| | | | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, the Netherlands
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Starnberg K, Fridén V, Muslimovic A, Ricksten SE, Nyström S, Forsgard N, Lindahl B, Vukusic K, Sandstedt J, Dellgren G, Hammarsten O. A Possible Mechanism behind Faster Clearance and Higher Peak Concentrations of Cardiac Troponin I Compared with Troponin T in Acute Myocardial Infarction. Clin Chem 2020; 66:333-341. [PMID: 32040581 DOI: 10.1093/clinchem/hvz003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although cardiac troponin I (cTnI) and troponin T (cTnT) form a complex in the human myocardium and bind to thin filaments in the sarcomere, cTnI often reaches higher concentrations and returns to normal concentrations faster than cTnT in patients with acute myocardial infarction (MI). METHODS We compared the overall clearance of cTnT and cTnI in rats and in patients with heart failure and examined the release of cTnT and cTnI from damaged human cardiac tissue in vitro. RESULTS Ground rat heart tissue was injected into the quadriceps muscle in rats to simulate myocardial damage with a defined onset. cTnT and cTnI peaked at the same time after injection. cTnI returned to baseline concentrations after 54 h, compared with 168 h for cTnT. There was no difference in the rate of clearance of solubilized cTnT or cTnI after intravenous or intramuscular injection. Renal clearance of cTnT and cTnI was similar in 7 heart failure patients. cTnI was degraded and released faster and reached higher concentrations than cTnT when human cardiac tissue was incubated in 37°C plasma. CONCLUSION Once cTnI and cTnT are released to the circulation, there seems to be no difference in clearance. However, cTnI is degraded and released faster than cTnT from necrotic cardiac tissue. Faster degradation and release may be the main reason why cTnI reaches higher peak concentrations and returns to normal concentrations faster in patients with MI.
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Affiliation(s)
- Karin Starnberg
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vincent Fridén
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aida Muslimovic
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne Nyström
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Niklas Forsgard
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Kristina Vukusic
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Sandstedt
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Hammarsten
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Skytte Larsson J, Bragadottir G, Redfors B, Ricksten SE. Renal effects of norepinephrine-induced variations in mean arterial pressure after liver transplantation: A randomized cross-over trial. Acta Anaesthesiol Scand 2018; 62:1229-1236. [PMID: 29896798 DOI: 10.1111/aas.13156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute kidney injury is commonly seen after liver transplantation. The optimal perioperative target mean arterial pressure (MAP) for renal filtration, perfusion and oxygenation in liver recipients is not known. The effects of norepinephrine-induced changes in MAP on renal blood flow (RBF), oxygen delivery (RDO2 ), glomerular filtration rate (GFR) and renal oxygenation (=renal oxygen extraction, RO2 Ex) were therefore studied early after liver transplantation. METHODS Ten patients with an intra- and post-operative vasopressor-dependent systemic vasodilation were studied early after liver transplantation during sedation and mechanical ventilation. To achieve target MAP levels of 60, 75 and 90 mm Hg, the norepinephrine infusion rate was randomly and sequentially titrated. At each target MAP, data on cardiac index (CI), RBF and GFR were obtained by transpulmonary thermodilution (PiCCO), the renal vein thermodilution technique and renal extraction of chromium ethylenediaminetetraaceticacid (51 Cr-EDTA), respectively. Renal oxygen consumption (RVO2 ) and extraction (RO2 Ex) were calculated according to standard formulas. RESULTS At a target MAP of 75 mm Hg, CI (13%), RBF (18%), RDO2 (24%), GFR (31%) and RVO2 (20%) were higher while RO2 Ex was unchanged compared to a target MAP of 60 mm Hg. Increasing MAP from 75 up to 90 mm Hg increased RVR by 38% but had no further effects on CI, RBF, RDO2 or GFR. CONCLUSIONS In patients undergoing liver transplantation, RBF and GFR are pressure-dependent at MAP levels below 75 mm Hg. Our results suggest that MAP should probably be targeted to approximately 75 mm Hg for optimal perioperative renal filtration, perfusion and oxygenation in patients undergoing liver transplantation.
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Affiliation(s)
- J. Skytte Larsson
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - G. Bragadottir
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - B. Redfors
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
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Renal Blood Flow, Glomerular Filtration Rate, and Renal Oxygenation in Early Clinical Septic Shock*. Crit Care Med 2018. [DOI: 10.1097/ccm.0000000000003088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Fridén V, Starnberg K, Muslimovic A, Ricksten SE, Bjurman C, Forsgard N, Wickman A, Hammarsten O. Clearance of cardiac troponin T with and without kidney function. Clin Biochem 2017; 50:468-474. [DOI: 10.1016/j.clinbiochem.2017.02.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 01/29/2023]
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Skytte Larsson J, Bragadottir G, Redfors B, Ricksten SE. Renal function and oxygenation are impaired early after liver transplantation despite hyperdynamic systemic circulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:87. [PMID: 28395663 PMCID: PMC5387193 DOI: 10.1186/s13054-017-1675-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
Background Acute kidney injury (AKI) occurs frequently after liver transplantation and is associated with the development of chronic kidney disease and increased mortality. There is a lack of data on renal blood flow (RBF), oxygen consumption, glomerular filtration rate (GFR) and renal oxygenation, i.e. the renal oxygen supply/demand relationship, early after liver transplantation. Increased insight into the renal pathophysiology after liver transplantation is needed to improve the prevention and treatment of postoperative AKI. We have therefore studied renal hemodynamics, function and oxygenation early after liver transplantation in humans. Methods Systemic hemodynamic and renal variables were measured during two 30-min periods in liver transplant recipients (n = 12) and post-cardiac surgery patients (controls, n = 73). RBF and GFR were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA (= filtration fraction), respectively. Renal oxygenation was estimated from the renal oxygen extraction. Results In the liver transplant group, GFR decreased by 40% (p < 0.05), compared to the preoperative value. Cardiac index and systemic vascular resistance index were 65% higher (p < 0.001) and 36% lower (p < 0.001), respectively, in the liver transplant recipients compared to the control group. GFR was 27% (p < 0.05) and filtration fraction 40% (p < 0.01) lower in the liver transplant group. Renal vascular resistance was 15% lower (p < 0.05) and RBF was 18% higher (p < 0.05) in liver transplant recipients, but the ratio between RBF and cardiac index was 27% lower (p < 0.001) among the liver-transplanted patients compared to the control group. Renal oxygen consumption and extraction were both higher in the liver transplants, 44% (p < 0.01) and 24% (p < 0.05) respectively. Conclusions Despite the hyperdynamic systemic circulation and renal vasodilation, there is a severe decline in renal function directly after liver transplantation. This decline is accompanied by an impaired renal oxygenation, as the pronounced elevation of renal oxygen consumption is not met by a proportional increase in renal oxygen delivery. This information may provide new insights into renal pathophysiology as a basis for future strategies to prevent/treat AKI after liver transplantation. Trial registration ClinicalTrials.gov, NCT02455115. Registered on 23 April 2015.
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Affiliation(s)
- Jenny Skytte Larsson
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden.
| | - Gudrun Bragadottir
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Bengt Redfors
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
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Lannemyr L, Bragadottir G, Krumbholz V, Redfors B, Sellgren J, Ricksten SE. Effects of Cardiopulmonary Bypass on Renal Perfusion, Filtration, and Oxygenation in Patients Undergoing Cardiac Surgery. Anesthesiology 2017; 126:205-213. [DOI: 10.1097/aln.0000000000001461] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Acute kidney injury is a common complication after cardiac surgery with cardiopulmonary bypass. The authors evaluated the effects of normothermic cardiopulmonary bypass on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen supply/demand relationship, i.e., renal oxygenation (primary outcome) in patients undergoing cardiac surgery.
Methods
Eighteen patients with a normal preoperative serum creatinine undergoing cardiac surgery procedures with normothermic cardiopulmonary bypass (2.5 l · min−1 · m−2) were included after informed consent. Systemic and renal hemodynamic variables were measured by pulmonary artery and renal vein catheters before, during, and after cardiopulmonary bypass. Arterial and renal vein blood samples were taken for measurements of renal oxygen delivery and consumption. Renal oxygenation was estimated from the renal oxygen extraction. Urinary N-acetyl-β-d-glucosaminidase was measured before, during, and after cardiopulmonary bypass.
Results
Cardiopulmonary bypass induced a renal vasoconstriction and redistribution of blood flow away from the kidneys, which in combination with hemodilution decreased renal oxygen delivery by 20%, while glomerular filtration rate and renal oxygen consumption were unchanged. Thus, renal oxygen extraction increased by 39 to 45%, indicating a renal oxygen supply/demand mismatch during cardiopulmonary bypass. After weaning from cardiopulmonary bypass, renal oxygenation was further impaired due to hemodilution and an increase in renal oxygen consumption, accompanied by a seven-fold increase in the urinary N-acetyl-β-d-glucosaminidase/creatinine ratio.
Conclusions
Cardiopulmonary bypass impairs renal oxygenation due to renal vasoconstriction and hemodilution during and after cardiopulmonary bypass, accompanied by increased release of a tubular injury marker.
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Affiliation(s)
- Lukas Lannemyr
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudrun Bragadottir
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vitus Krumbholz
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bengt Redfors
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Sellgren
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- From the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Skytte Larsson J, Bragadottir G, Krumbholz V, Redfors B, Sellgren J, Ricksten SE. Effects of acute plasma volume expansion on renal perfusion, filtration, and oxygenation after cardiac surgery: a randomized study on crystalloid vs colloid. Br J Anaesth 2015; 115:736-42. [DOI: 10.1093/bja/aev346] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Effects of levosimendan on glomerular filtration rate, renal blood flow, and renal oxygenation after cardiac surgery with cardiopulmonary bypass: a randomized placebo-controlled study. Crit Care Med 2013; 41:2328-35. [PMID: 23921271 DOI: 10.1097/ccm.0b013e31828e946a] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Acute kidney injury develops in a large proportion of patients after cardiac surgery because of the low cardiac output syndrome. The inodilator levosimendan increases cardiac output after cardiac surgery with cardiopulmonary bypass, but a detailed analysis of its effects on renal perfusion, glomerular filtration, and renal oxygenation in this group of patients is lacking. We therefore evaluated the effects of levosimendan on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen demand/supply relationship, i.e., renal oxygen extraction, early after cardiac surgery with cardiopulmonary bypass. DESIGN Prospective, placebo-controlled, and randomized trial. SETTING Cardiothoracic ICU of a tertiary center. PATIENTS Postcardiac surgery patients (n=30). INTERVENTIONS The patients were randomized to receive levosimendan, 0.1 µg/kg/min after a loading dose of 12 µg/kg (n=15), or placebo (n=15). MEASUREMENTS AND MAIN RESULTS The experimental procedure started 4-6 hours after surgery in the ICU during propofol sedation and mechanical ventilation. Systemic hemodynamic were evaluated by a pulmonary artery thermodilution catheter. Renal blood flow and glomerular filtration rate were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA, respectively. Central venous pressure was kept constant by colloid/crystalloid infusion. Compared to placebo, levosimendan increased cardiac index (22%), stroke volume index (15%), and heart rate (7%) and decreased systemic vascular resistance index (21%), whereas mean arterial pressure was not affected. Levosimendan induced significant increases in renal blood flow (12%, p<0.05) and glomerular filtration rate (21%, p<0.05), decreased renal vascular resistance (18%, p<0.05) but caused no significant changes in filtration fraction, renal oxygen consumption, or renal oxygen extraction, compared to placebo. CONCLUSIONS After cardiac surgery with cardiopulmonary bypass, levosimendan induces a vasodilation, preferentially of preglomerular resistance vessels, increasing both renal blood flow and glomerular filtration rate without jeopardizing renal oxygenation. Due to its pharmacodynamic profile, levosimendan might be an interesting alternative for treatment of postoperative heart failure complicated by acute kidney injury in postcardiac surgery patients.
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Schneider AG, Goodwin MD, Schelleman A, Bailey M, Johnson L, Bellomo R. Contrast-enhanced ultrasound to evaluate changes in renal cortical perfusion around cardiac surgery: a pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R138. [PMID: 23849270 PMCID: PMC4056320 DOI: 10.1186/cc12817] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/12/2013] [Indexed: 01/18/2023]
Abstract
Introduction Contrast-enhanced ultrasound (CEUS) is a new technique that might enable portable and non-invasive organ perfusion quantification at the bedside. However, it has not yet been tested in critically ill patients. We sought to establish CEUS's feasibility, safety, reproducibility and potential diagnostic value in the assessment of renal cortical perfusion in the peri-operative period in cardiac surgery patients. Methods We recruited twelve patients deemed at risk of acute kidney injury (AKI) planned for elective cardiac surgery. We performed renal CEUS with destruction-replenishment sequences before the operation, on ICU arrival and the day following the admission. Enhancement was obtained with Sonovue® (Bracco, Milano, Italy) at an infusion rate of 1 ml/min. We collected hemodynamic parameters before, during and after contrast agent infusion. At each study time, we obtained five video sequences, which were analysed using dedicated software by two independent radiologists blinded to patient and time. The main output was a perfusion index (PI), corresponding to the ratio of relative blood volume (RBV) over mean transit time (mTT). Results All 36 renal CEUS studies, including 24 in the immediate post-operative period could be performed and were well tolerated. Correlation between readers for PI was excellent (R2 = 0.96, P < 0.0001). Compared with baseline, there was no overall difference in median PI's on ICU admission. However, the day after surgery, median PI's had decreased by 50% (P < 0.01) (22% decrease in RBV (P = 0.09); 48% increase in mTT (P = 0.04), both suggestive of decreased perfusion). These differences persisted after correction for haemoglobin; vasopressors use and mean arterial pressure. Four patients developed AKI in the post-operative period. Conclusions CEUS appears feasible and well-tolerated in patients undergoing cardiac surgery even immediately after ICU admission. CEUS derived-parameters suggest a decrease in renal perfusion occurring within 24 hours of surgery.
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Bragadottir G, Redfors B, Ricksten SE. Assessing glomerular filtration rate (GFR) in critically ill patients with acute kidney injury--true GFR versus urinary creatinine clearance and estimating equations. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R108. [PMID: 23767877 PMCID: PMC4056314 DOI: 10.1186/cc12777] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/15/2013] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Estimation of kidney function in critically ill patients with acute kidney injury (AKI), is important for appropriate dosing of drugs and adjustment of therapeutic strategies, but challenging due to fluctuations in kidney function, creatinine metabolism and fluid balance. Data on the agreement between estimating and gold standard methods to assess glomerular filtration rate (GFR) in early AKI are lacking. We evaluated the agreement of urinary creatinine clearance (CrCl) and three commonly used estimating equations, the Cockcroft Gault (CG), the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, in comparison to GFR measured by the infusion clearance of chromium-ethylenediaminetetraacetic acid (51Cr-EDTA), in critically ill patients with early AKI after complicated cardiac surgery. METHODS Thirty patients with early AKI were studied in the intensive care unit, 2 to 12 days after complicated cardiac surgery. The infusion clearance for 51Cr-EDTA obtained as a measure of GFR (GFR51Cr-EDTA) was calculated from the formula: GFR (mL/min/1.73m2)=(51Cr-EDTA infusion rate×1.73)/(arterial 51Cr-EDTA×body surface area) and compared with the urinary CrCl and the estimated GFR (eGFR) from the three estimating equations. Urine was collected in two 30-minute periods to measure urine flow and urine creatinine. Urinary CrCl was calculated from the formula: CrCl (mL/min/1.73m2)=(urine volume×urine creatinine×1.73)/(serum creatinine×30 min×body surface area). RESULTS The within-group error was lower for GFR51Cr-EDTA than the urinary CrCl method, 7.2% versus 55.0%. The between-method bias was 2.6, 11.6, 11.1 and 7.39 ml/min for eGFRCrCl, eGFRMDRD, eGFRCKD-EPI and eGFRCG, respectively, when compared to GFR51Cr-EDTA. The error was 103%, 68.7%, 67.7% and 68.0% for eGFRCrCl, eGFRMDRD, eGFRCKD-EPI and eGFRCG, respectively, when compared to GFR51Cr-EDTA. CONCLUSIONS The study demonstrated poor precision of the commonly utilized urinary CrCl method for assessment of GFR in critically ill patients with early AKI, suggesting that this should not be used as a reference method when validating new methods for assessing kidney function in this patient population. The commonly used estimating equations perform poorly when estimating GFR, with high biases and unacceptably high errors.
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Schneider AG, Goodwin MD, Bellomo R. Measurement of kidney perfusion in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:220. [PMID: 23514525 PMCID: PMC3672528 DOI: 10.1186/cc12529] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bragadottir G, Redfors B, Ricksten SE. Mannitol increases renal blood flow and maintains filtration fraction and oxygenation in postoperative acute kidney injury: a prospective interventional study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R159. [PMID: 22901953 PMCID: PMC3580749 DOI: 10.1186/cc11480] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 08/16/2012] [Indexed: 12/31/2022]
Abstract
Introduction Acute kidney injury (AKI), which is a major complication after cardiovascular surgery, is associated with significant morbidity and mortality. Diuretic agents are frequently used to improve urine output and to facilitate fluid management in these patients. Mannitol, an osmotic diuretic, is used in the perioperative setting in the belief that it exerts reno-protective properties. In a recent study on uncomplicated postcardiac-surgery patients with normal renal function, mannitol increased glomerular filtration rate (GFR), possibly by a deswelling effect on tubular cells. Furthermore, experimental studies have previously shown that renal ischemia causes an endothelial cell injury and dysfunction followed by endothelial cell edema. We studied the effects of mannitol on renal blood flow (RBF), glomerular filtration rate (GFR), renal oxygen consumption (RVO2), and extraction (RO2Ex) in early, ischemic AKI after cardiac surgery. Methods Eleven patients with AKI were studied during propofol sedation and mechanical ventilation 2 to 6 days after complicated cardiac surgery. All patients had severe heart failure treated with one (100%) or two (73%) inotropic agents and intraaortic balloon pump (36%). Systemic hemodynamics were measured with a pulmonary artery catheter. RBF and renal filtration fraction (FF) were measured by the renal vein thermo-dilution technique and by renal extraction of chromium-51-ethylenediaminetetraacetic acid (51Cr-EDTA), respectively. GFR was calculated as the product of FF and renal plasma flow RBF × (1-hematocrit). RVO2 and RO2Ex were calculated from arterial and renal vein blood samples according to standard formulae. After control measurements, a bolus dose of mannitol, 225 mg/kg, was given, followed by an infusion at a rate of 75 mg/kg/h for two 30-minute periods. Results Mannitol did not affect cardiac index or cardiac filling pressures. Mannitol increased urine flow by 61% (P < 0.001). This was accompanied by a 12% increase in RBF (P < 0.05) and a 13% decrease in renal vascular resistance (P < 0.05). Mannitol increased the RBF/cardiac output (CO) relation (P = 0.040). Mannitol caused no significant changes in RO2Ext or renal FF. Conclusions Mannitol treatment of postoperative AKI induces a renal vasodilation and redistributes systemic blood flow to the kidneys. Mannitol does not affect filtration fraction or renal oxygenation, suggestive of balanced increases in perfusion/filtration and oxygen demand/supply.
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Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Effects of norepinephrine on renal perfusion, filtration and oxygenation in vasodilatory shock and acute kidney injury. Intensive Care Med 2010; 37:60-7. [PMID: 20949349 DOI: 10.1007/s00134-010-2057-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 09/21/2010] [Indexed: 01/17/2023]
Affiliation(s)
- Bengt Redfors
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Acute renal failure is NOT an "acute renal success"--a clinical study on the renal oxygen supply/demand relationship in acute kidney injury. Crit Care Med 2010; 38:1695-701. [PMID: 20512036 DOI: 10.1097/ccm.0b013e3181e61911] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Acute kidney injury occurs frequently after cardiac or major vascular surgery and is believed to be predominantly a consequence of impaired renal oxygenation. However, in patients with acute kidney injury, data on renal oxygen consumption (RVO2), renal blood flow, glomerular filtration, and renal oxygenation, i.e., the renal oxygen supply/demand relationship, are lacking and current views on renal oxygenation in the clinical situation of acute kidney injury are presumptive and largely based on experimental studies. DESIGN Prospective, two-group comparative study. SETTING Cardiothoracic intensive care unit of a tertiary center. PATIENTS Postcardiac surgery patients with (n = 12) and without (n = 37) acute kidney injury were compared with respect to renal blood flow, glomerular filtration, RVO2, and renal oxygenation. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Data on systemic hemodynamics (pulmonary artery catheter) and renal variables were obtained during two 30-min periods. Renal blood flow was measured using two independent techniques: the renal vein thermodilution technique and the infusion clearance of paraaminohippuric acid, corrected for renal extraction of paraaminohippuric acid. The filtration fraction was measured by the renal extraction of Cr-EDTA and the renal sodium resorption was measured as the difference between filtered and excreted sodium. Renal oxygenation was estimated from the renal oxygen extraction. Cardiac index and mean arterial pressure did not differ between the two groups. In the acute kidney injury group, glomerular filtration (-57%), renal blood flow (-40%), filtration fraction (-26%), and sodium resorption (-59%) were lower, renal vascular resistance (52%) and renal oxygen extraction (68%) were higher, whereas there was no difference in renal oxygen consumption between groups. Renal oxygen consumption for one unit of reabsorbed sodium was 2.4 times higher in acute kidney injury. CONCLUSIONS Renal oxygenation is severely impaired in acute kidney injury after cardiac surgery, despite the decrease in glomerular filtration and tubular workload. This was caused by a combination of renal vasoconstriction and tubular sodium resorption at a high oxygen demand.
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Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Dopamine increases renal oxygenation: a clinical study in post-cardiac surgery patients. Acta Anaesthesiol Scand 2010; 54:183-90. [PMID: 19764906 DOI: 10.1111/j.1399-6576.2009.02121.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Imbalance of the renal medullary oxygen supply/demand relationship can cause ischaemic acute renal failure (ARF). The use of dopamine for prevention/treatment of ischaemic ARF has been questioned. It has been suggested that dopamine may increase renal oxygen consumption (RVO(2)) due to increased solute delivery to tubular cells, which may jeopardize renal oxygenation. Information on the effects of dopamine on renal perfusion, filtration and oxygenation in man is, however, lacking. We evaluated the effects of dopamine on renal blood flow (RBF), glomerular filtration rate (GFR), RVO(2) and renal O(2) demand/supply relationship, i.e. renal oxygen extraction (RO(2)Ex). METHODS Twelve uncomplicated, mechanically ventilated and sedated post-cardiac surgery patients with pre-operatively normal renal function were studied. Dopamine was sequentially infused at 2 and 4 ug/kg/min. Systemic haemodynamics were evaluated by a pulmonary artery catheter. Absolute RBF was measured using two independent techniques: by the renal vein thermodilution technique and by infusion clearance of paraaminohippuric acid (PAH), with a correction for renal extraction of PAH. The filtration fraction (FF) was measured by the renal extraction of (51)Cr-EDTA. RESULTS Neither GFR, tubular sodium reabsorption nor RVO(2) was affected by dopamine, which increased RBF (45-55%) with both methods, decreased renal vascular resistance (30-35%), FF (21-26%) and RO(2)Ex (28-34%). The RBF/CI ratio increased with dopamine. Dopamine decreased renal PAH extraction, suggestive of a flow distribution to the medulla. CONCLUSIONS In post-cardiac surgery patients, dopamine increases the renal oxygenation by a pronounced renal pre-and post-glomerular vasodilation with no increases in GFR, tubular sodium reabsorption or renal oxygen consumption.
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Affiliation(s)
- Bengt Redfors
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg, Sweden
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Bragadottir G, Redfors B, Nygren A, Sellgren J, Ricksten SE. Low-dose vasopressin increases glomerular filtration rate, but impairs renal oxygenation in post-cardiac surgery patients. Acta Anaesthesiol Scand 2009; 53:1052-9. [PMID: 19572935 DOI: 10.1111/j.1399-6576.2009.02037.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The beneficial effects of vasopressin on diuresis and creatinine clearance have been demonstrated when used as an additional/alternative therapy in catecholamine-dependent vasodilatory shock. A detailed analysis of the effects of vasopressin on renal perfusion, glomerular filtration, excretory function and oxygenation in man is, however, lacking. The objective of this pharmacodynamic study was to evaluate the effects of low to moderate doses of vasopressin on renal blood flow (RBF), glomerular filtration rate (GFR), renal oxygen consumption (RVO2) and renal oxygen extraction (RO2Ex) in post-cardiac surgery patients. METHODS Twelve patients were studied during sedation and mechanical ventilation after cardiac surgery. Vasopressin was sequentially infused at 1.2, 2.4 and 4.8 U/h. At each infusion rate, systemic haemodynamics were evaluated by a pulmonary artery catheter, and RBF and GFR were measured by the renal vein thermodilution technique and by renal extraction of 51chromium-ethylenediaminetetraacetic acid, respectively. RVO2 and RO2Ex were calculated by arterial and renal vein blood samples. RESULTS The mean arterial pressure was not affected by vasopressin while cardiac output and heart rate decreased. RBF decreased and GFR, filtration fraction, sodium reabsorption, RVO2, RO2Ex and renal vascular resistance increased dose-dependently with vasopressin. Vasopressin exerted direct antidiuretic and antinatriuretic effects. CONCLUSIONS Short-term infusion of low to moderate, non-hypertensive doses of vasopressin induced a post-glomerular renal vasoconstriction with a decrease in RBF and an increase in GFR in post-cardiac surgery patients. This was accompanied by an increase in RVO2, as a consequence of the increases in the filtered tubular load of sodium. Finally, vasopressin impaired the renal oxygen demand/supply relationship.
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Affiliation(s)
- G Bragadottir
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrens University Hospital, Göteborg, Sweden
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INVERSE THERMODILUTION WITH CONVENTIONAL PULMONARY ARTERY CATHETERS FOR THE ASSESSMENT OF CEREBRAL, HEPATIC, RENAL, AND FEMORAL BLOOD FLOW. Shock 2009; 32:194-200. [DOI: 10.1097/shk.0b013e318194c73a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Redfors B, Swärd K, Sellgren J, Ricksten SE. Effects of mannitol alone and mannitol plus furosemide on renal oxygen consumption, blood flow and glomerular filtration after cardiac surgery. Intensive Care Med 2008; 35:115-22. [PMID: 18612627 DOI: 10.1007/s00134-008-1206-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 06/10/2008] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Imbalance of the renal medullary oxygen supply/demand relationship can cause hypoxic medullary damage and ischaemic acute renal failure (ARF). The use of mannitol for prophylaxis/treatment of clinical ischaemic ARF is controversial and the effect of mannitol on renal oxygenation in man has not yet been investigated. We evaluated the effects of mannitol on renal oxygen consumption (RVO(2))(,) renal blood flow (RBF) and glomerular filtration rate (GFR) in postoperative patients. DESIGN Prospective interventional study. SETTING University hospital cardiothoracic ICU. PATIENTS Ten uncomplicated mechanically ventilated and sedated postcardiac surgery patients with preoperatively normal renal function. INTERVENTIONS Mannitol infusion (225 mg/kg + 75 mg/kg/h) and combined mannitol and furosemide infusion (0.25 mg/kg + 0.25 mg/kg/h). MEASUREMENTS AND RESULTS Systemic haemodynamics were evaluated by a pulmonary artery catheter. RBF and GFR were measured by the renal vein thermodilution technique and by renal extraction of (51)Cr-EDTA, respectively. Mannitol increased urine flow (60%), GFR (20%) and filtration fraction (FF) (20%) with no change in RBF. This was accompanied by an increase in renal sodium reabsorption (18%), RVO(2) (19%) and renal oxygen extraction (21%). When combined with mannitol, furosemide normalised sodium reabsorption, RVO(2), renal oxygen extraction with no change in RBF, while GFR and FF were still elevated compared to control. CONCLUSIONS In patients with normal renal function, mannitol increases GFR, which increases tubular sodium load, sodium reabsorption and RVO(2) after cardiac surgery. The lack of effect on RBF, indicates that mannitol impairs the renal oxygen supply/demand relationship. Furosemide normalised renal oxygenation when combined with mannitol.
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Affiliation(s)
- Bengt Redfors
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 41345, Göteborg, Sweden
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Ronco C, Kellum JA, Bellomo R, House AA. Potential interventions in sepsis-related acute kidney injury. Clin J Am Soc Nephrol 2008; 3:531-44. [PMID: 18235149 DOI: 10.2215/cjn.03830907] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Sepsis is an important cause of morbidity and mortality. Acute kidney injury often complicates sepsis, leading to greater complexity, cost of care, and worsening prognosis. In recent years, a consensus definition of acute kidney injury has been developed, facilitating research into the pathophysiology and epidemiology of this disorder. New and emerging biomarkers to recognize kidney injury before functional abnormalities are manifest may allow early recognition and facilitate prevention or treatment. Furthermore, advances in the clinical management of sepsis may have secondary benefits with respect to renal outcomes. Existing and hybrid extracorporeal therapies are being investigated not only as means to replace lost kidney function but also to modulate the immune response to sepsis. For those who have more advanced forms of kidney injury, strategies to promote renal recovery are being sought to minimize the long-term consequences of impaired kidney function. This review provides an update on the current state of the science and a glimpse toward the future of intervention in sepsis-related acute kidney injury.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, St. Bortolo Hospital, International Renal Research Institute Vicenza, Vicenza, Italy
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Langenberg C, Bellomo R, May CN, Egi M, Wan L, Morgera S. Renal Vascular Resistance in Sepsis. ACTA ACUST UNITED AC 2006; 104:p1-11. [PMID: 16691034 DOI: 10.1159/000093275] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Accepted: 02/03/2006] [Indexed: 01/19/2023]
Abstract
AIMS To assess changes in renal vascular resistance (RVR) in human and experimental sepsis and to identify determinants of RVR. METHODS We performed a systematic interrogation of two electronic reference libraries using specific search terms. Subjects were animals and patients involved in experimental and human studies of sepsis and septic acute renal failure, in which the RVR was assessed. We obtained all human and experimental articles reporting RVR during sepsis. We assessed the role of various factors that might influence the RVR during sepsis using statistical methods. RESULTS We found no human studies, in which the renal blood flow (and, therefore, the RVR) was measured with suitably accurate direct methods. Of the 137 animal studies identified, 52 reported a decreased RVR, 16 studies reported no change in RVR, and 69 studies reported an increased RVR. Consciousness of animals, duration of measurement, method of induction of sepsis, and fluid administration had no effect on the RVR. On the other hand, on univariate analysis, size of the animals (p < 0.001), technique of measurement (p = 0.017), recovery after surgery (p = 0.004), and cardiac output (p < 0.001) influenced the RVR. Multivariate analysis, however, showed that only cardiac output (p = 0.028) and size of the animals (p = 0.031) remained independent determinants of the RVR. CONCLUSIONS Changes in RVR during sepsis in humans are unknown. In experimental sepsis, several factors not directly related to sepsis per se appear to influence the RVR. A high cardiac output and the use of large animals predict a decreased RVR, while a decreased cardiac output and the use of small animals predict an increased RVR.
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Affiliation(s)
- Christoph Langenberg
- Departments of Intensive Care and Medicine, Austin Hospital and University of Melbourne, Heidelberg, Melbourne, Australia
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Langenberg C, Bellomo R, May C, Wan L, Egi M, Morgera S. Renal blood flow in sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R363-74. [PMID: 16137349 PMCID: PMC1269441 DOI: 10.1186/cc3540] [Citation(s) in RCA: 199] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Revised: 04/01/2005] [Accepted: 04/14/2005] [Indexed: 02/12/2023]
Abstract
Introduction To assess changes in renal blood flow (RBF) in human and experimental sepsis, and to identify determinants of RBF. Method Using specific search terms we systematically interrogated two electronic reference libraries to identify experimental and human studies of sepsis and septic acute renal failure in which RBF was measured. In the retrieved studies, we assessed the influence of various factors on RBF during sepsis using statistical methods. Results We found no human studies in which RBF was measured with suitably accurate direct methods. Where it was measured in humans with sepsis, however, RBF was increased compared with normal. Of the 159 animal studies identified, 99 reported decreased RBF and 60 reported unchanged or increased RBF. The size of animal, technique of measurement, duration of measurement, method of induction of sepsis, and fluid administration had no effect on RBF. In contrast, on univariate analysis, state of consciousness of animals (P = 0.005), recovery after surgery (P < 0.001), haemodynamic pattern (hypodynamic or hyperdynamic state; P < 0.001) and cardiac output (P < 0.001) influenced RBF. However, multivariate analysis showed that only cardiac output remained an independent determinant of RBF (P < 0.001). Conclusion The impact of sepsis on RBF in humans is unknown. In experimental sepsis, RBF was reported to be decreased in two-thirds of studies (62 %) and unchanged or increased in one-third (38%). On univariate analysis, several factors not directly related to sepsis appear to influence RBF. However, multivariate analysis suggests that cardiac output has a dominant effect on RBF during sepsis, such that, in the presence of a decreased cardiac output, RBF is typically decreased, whereas in the presence of a preserved or increased cardiac output RBF is typically maintained or increased.
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Affiliation(s)
- Christoph Langenberg
- Research fellow, Department of Intensive Care and Department of Medicine, Austin Hospital, and University of Melbourne, Heidelberg, Melbourne, Australia
| | - Rinaldo Bellomo
- Director of Intensive Care Research, Department of Intensive Care and Department of Medicine, Austin Hospital, and University of Melbourne, Heidelberg, Melbourne, Australia
| | - Clive May
- Senior Researcher, Howard Florey Institute, University of Melbourne, Parkville, Melbourne, Australia
| | - Li Wan
- Research fellow, Department of Intensive Care and Department of Medicine, Austin Hospital, and University of Melbourne, Heidelberg, Melbourne, Australia
| | - Moritoki Egi
- Research fellow, Department of Intensive Care and Department of Medicine, Austin Hospital, and University of Melbourne, Heidelberg, Melbourne, Australia
| | - Stanislao Morgera
- Consultant Nephrologist, Department of Nephrology, Charité Campus Mitte, Berlin, Germany
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Petersson M, Friberg P, Eisenhofer G, Lambert G, Rundqvist B. Long-term outcome in relation to renal sympathetic activity in patients with chronic heart failure. Eur Heart J 2005; 26:906-13. [PMID: 15764611 DOI: 10.1093/eurheartj/ehi184] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Although cardiac sympathetic activation is associated with adverse outcome in patients with chronic heart failure (CHF), the influence of renal sympathetic activity on outcome is unknown. We assessed the hypothesis that renal noradrenaline (NA) spillover is a predictor of the combined endpoint of all-cause mortality and heart transplantation in CHF. METHODS AND RESULTS Sixty-one patients with CHF, New York Heart Association (NYHA) I-IV (66% NYHA III-IV), and left ventricular ejection fraction (LVEF) 26+/-9% (mean+/-SD) were studied with cardiac and renal catheterizations at baseline and followed for 5.5+/-3.7 years (median 5.5 years, range 12 days to 11.6 years). Nineteen deaths and 13 cases of heart transplantation were registered. Only renal NA spillover above median, 1.19 (interquartile range 0.77-1.43) nmol/min, was independently associated with an increased relative risk (RR) of the combined endpoint (RR 3.1, 95% CI 1.2-7.6, P=0.01) in a model also including total body NA spillover, LVEF, glomerular filtration rate (GFR), renal blood flow, cardiac index, aetiology, and age. CONCLUSION Renal noradrenergic activation has a strong negative predictive value on outcome independent of overall sympathetic activity, GFR, and LVEF. These findings suggest that treatment regimens that further reduce renal noradrenergic stimulation could be advantageous by improving survival in patients with CHF.
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Affiliation(s)
- Magnus Petersson
- Department of Cardiology, The Cardiovascular Institute, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden.
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R, Vallet B. Year in review in intensive care medicine, 2004. II. Brain injury, hemodynamic monitoring and treatment, pulmonary embolism, gastrointestinal tract, and renal failure. Intensive Care Med 2005; 31:177-88. [PMID: 15678311 DOI: 10.1007/s00134-004-2552-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 12/23/2004] [Indexed: 12/20/2022]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
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