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Qi M, Liu R, Zhang F, Yao Z, Zhou ML, Jiang X, Ling S. Roles of mechanosensitive ion channel PIEZO1 in the pathogenesis of brain injury after experimental intracerebral hemorrhage. Neuropharmacology 2024; 251:109896. [PMID: 38490299 DOI: 10.1016/j.neuropharm.2024.109896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/17/2024] [Accepted: 03/03/2024] [Indexed: 03/17/2024]
Abstract
Secondary brain injury after intracerebral hemorrhage (ICH) is the main cause of poor prognosis in ICH patients, but the underlying mechanisms remain less known. The involvement of Piezo1 in brain injury after ICH was studied in a mouse model of ICH. ICH was established by injecting autologous arterial blood into the basal ganglia in mice. After vehicle, Piezo1 blocker, GsMTx4, Piezo1 activator, Yoda-1, or together with mannitol (tail vein injection) was injected into the left lateral ventricle of mouse brain, Piezo1 level and the roles of Piezo1 in neuronal injury, brain edema, and neurological dysfunctions after ICH were determined by the various indicated methods. Piezo1 protein level in neurons was significantly upregulated 24 h after ICH in vivo (human and mice). Piezo1 protein level was also dramatically upregulated in HT22 cells (a murine neuron cell line) cultured in vitro 24 h after hemin treatment as an in vitro ICH model. GsMTx4 treatment or together with mannitol significantly downregulated Piezo1 and AQP4 levels, markedly increased Bcl2 level, maintained more neurons alive, considerably restored brain blood flow, remarkably relieved brain edema, substantially decreased serum IL-6 level, and almost fully reversed the neurological dysfunctions at ICH 24 h group mice. In contrast, Yoda-1 treatment achieved the opposite effects. In conclusion, Piezo1 plays a crucial role in the pathogenesis of brain injury after ICH and may be a target for clinical treatment of ICH.
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Affiliation(s)
- Min Qi
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; The Institutes of Brain Science, Wannan Medical College, No. 22 Wenchang West Road, Higher Education Park, Wuhu, 241002, Anhui, China
| | - Ran Liu
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China
| | - Fan Zhang
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; School of Chemistry and Chemical Engineering & Interdisciplinary Innovation Institute for Medicine and Engineering, Southeast University, Nanjing, 211189, China
| | - Zhipeng Yao
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; School of Chemistry and Chemical Engineering & Interdisciplinary Innovation Institute for Medicine and Engineering, Southeast University, Nanjing, 211189, China
| | - Meng-Liang Zhou
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China
| | - Xiaochun Jiang
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; The Institutes of Brain Science, Wannan Medical College, No. 22 Wenchang West Road, Higher Education Park, Wuhu, 241002, Anhui, China.
| | - Shizhang Ling
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), No. 2 West Zheshan Road, Wuhu, 241001, Anhui, China; The Institutes of Brain Science, Wannan Medical College, No. 22 Wenchang West Road, Higher Education Park, Wuhu, 241002, Anhui, China.
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Zhang Q, Wang X, Chao Y, Liu L. Focus on oliguria during renal replacement therapy. J Anesth 2024:10.1007/s00540-024-03342-4. [PMID: 38777933 DOI: 10.1007/s00540-024-03342-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
Oliguria is a clinical symptom characterized by decreased urine output, which can occur at any stage of acute kidney injury and also during renal replacement therapy. In some cases, oliguria may resolve with adjustment of blood purification dose or fluid management, while in others, it may suggest a need for further evaluation and intervention. It is important to determine the underlying cause of oliguria during renal replacement therapy and to develop an appropriate treatment plan. This review looks into the mechanisms of urine production to investigate the mechanism of oliguria during renal replacement therapy from two aspects: diminished glomerular filtration rate and tubular abnormalities. The above conditions all implying a renal oxygen supply-demand imbalance, which is the signal of worsening kidney injury. It also proposes a viable clinical pathway for the treatment and management of patients with acute kidney injury receiving renal replacement therapy.
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Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit (ICU), The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, 550004, People's Republic of China
| | - Xiaoting Wang
- Department of Intensive Care Unit (ICU), Peking Union Medical College Hospital, Beijing, 100005, People's Republic of China
| | - Yangong Chao
- Department of Intensive Care Unit (ICU), The First Affiliated Hospital of Tsinghua University, Beijing, 100016, People's Republic of China
| | - Lixia Liu
- Department of Intensive Care Unit (ICU), The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People's Republic of China.
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Wayne G, Wei J, Demus T, Okhawere KE, Atri E, Wong V, Badani K, Bhandari A. Moving away from mannitol infusion for partial nephrectomy: has this altered renal function? J Robot Surg 2023; 17:43-48. [PMID: 35296977 DOI: 10.1007/s11701-022-01397-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
In recent years, research has questioned the theorized renal-protective value of mannitol infusion during partial nephrectomy. This study considers whether the cessation of routine mannitol administration has shown any benefit or detriment to patients in the contemporary era. We retrospectively reviewed a multi-institution database for an association between mannitol administration and subsequent renal function during follow-up. These patients were assessed for de novo stage III chronic kidney disease (CKD III) and followed with estimated glomerular filtration rate (eGFR). Statistical analysis included Mann-Whitney-U and Chi-squared tests for comparing baseline and perioperative variables with postoperative outcomes. eGFR changes were evaluated with a mixed-effects linear regression model. Nine hundred and fifteen patients were identified whose operative reports or surgeons' treatment algorithms explicitly described whether or not mannitol was administered. 667 (73%) did not receive mannitol. There were no differences in demographics, age, Charlson comorbidity index, nephrometry score, tumor size, grading, or baseline eGFR from those who received mannitol. Ischemia time and operative time appeared slightly longer with mannitol use. Patients were followed for a median of 5 months (IQR 0.5-19 months), during which mannitol use was associated with an increase in de novo CKD III (14% v. 9%, p = 0.041) and minimally worsened median eGFR on final follow-up (72.82 v. 76.06, p = 0.039). Our analysis of partial nephrectomy patients indicates that mannitol administration likely confers no short- or long-term renal benefit. Mannitol may be used at the surgeon's discretion, but if it prolongs surgery time or ischemia time, it may in fact be detrimental to outcomes.
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Affiliation(s)
- George Wayne
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Jeffrey Wei
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Timothy Demus
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elias Atri
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Vivian Wong
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Ketan Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akshay Bhandari
- Division of Urology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA.
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Hu RT, Lankadeva YR, Yanase F, Osawa EA, Evans RG, Bellomo R. Continuous bladder urinary oxygen tension as a new tool to monitor medullary oxygenation in the critically ill. Crit Care 2022; 26:389. [PMID: 36527088 PMCID: PMC9758873 DOI: 10.1186/s13054-022-04230-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is common in the critically ill. Inadequate renal medullary tissue oxygenation has been linked to its pathogenesis. Moreover, renal medullary tissue hypoxia can be detected before biochemical evidence of AKI in large mammalian models of critical illness. This justifies medullary hypoxia as a pathophysiological biomarker for early detection of impending AKI, thereby providing an opportunity to avert its evolution. Evidence from both animal and human studies supports the view that non-invasively measured bladder urinary oxygen tension (PuO2) can provide a reliable estimate of renal medullary tissue oxygen tension (tPO2), which can only be measured invasively. Furthermore, therapies that modify medullary tPO2 produce corresponding changes in bladder PuO2. Clinical studies have shown that bladder PuO2 correlates with cardiac output, and that it increases in response to elevated cardiopulmonary bypass (CPB) flow and mean arterial pressure. Clinical observational studies in patients undergoing cardiac surgery involving CPB have shown that bladder PuO2 has prognostic value for subsequent AKI. Thus, continuous bladder PuO2 holds promise as a new clinical tool for monitoring the adequacy of renal medullary oxygenation, with its implications for the recognition and prevention of medullary hypoxia and thus AKI.
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Affiliation(s)
- Raymond T. Hu
- grid.410678.c0000 0000 9374 3516Department of Anaesthesia, Austin Health, Heidelberg, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia
| | - Yugeesh R. Lankadeva
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia
| | - Fumitake Yanase
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Eduardo A. Osawa
- Cardiology Intensive Care Unit, DF Star Hospital, Brasília, Brazil ,grid.472984.4D’Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
| | - Roger G. Evans
- grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, VIC Australia
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Parkville, Australia
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Tuttolomondo A, Maida C, Casuccio A, Di Raimondo D, Fonte R, Vassallo V, Puleo MG, Di Chiara T, Mogavero A, Del Cuore A, Daidone M, Ortello A, Pinto A. Effects of intravenous furosemide plus small-volume hypertonic saline solutions on markers of heart failure. ESC Heart Fail 2021; 8:4174-4186. [PMID: 34288546 PMCID: PMC8497323 DOI: 10.1002/ehf2.13511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS We sought to compare the effects of furosemide + hypertonic saline solution (HSS) treatment in patients with acute decompensated heart failure in comparison with furosemide alone and the response in a compensated state after an acute saline load with regard to serum levels of heart failure biomarkers. METHODS AND RESULTS We enrolled 141 patients with acute decompensated heart failure with reduced ejection fraction admitted to our Internal Medicine ward from March 2017 to November 2019. A total of 73 patients were randomized to treatment with i.v. high-dose furosemide plus HSS, whereas 68 patients were randomized to i.v. high-dose furosemide alone. Patients treated with furosemide plus HSS compared with controls treated with furosemide alone showed a comparable degree of reduction in the serum levels of interleukin (IL)-6, soluble suppression of tumorigenicity 2 (sST2), and N-terminal pro-brain natriuretic peptide (NT-proBNP) in the 'between-group' analysis. Nevertheless, patients treated with high-dose furosemide + HSS showed significantly higher absolute delta values of IL-6 (2.3 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005, and 2.0 ± 0.8 vs. 1.85 ± 1.1, P = 0.034), sST2 (41.2 ± 8.6 vs. 27.9 ± 7.6, P < 0.0005, and 37.1 ± 6.6 vs. 28.4 ± 6.7, P < 0.0005), high-sensitivity troponin T (0.03 ± 0.02 vs. 0.02 ± 0.01, P = 0.001, and 0.03 ± 0.02 vs. 0.02 ± 0.01, P = 0.009), NT-proBNP (7237 ± 7931 vs. 3244 ± 4159, P < 0.005, and 5381 ± 4829 vs. 4466 ± 4332, P = 0.004), and galectin-3 (15.7 ± 3.2 ng/mL vs. 11.68 ± 1.9 ng/mL, P < 0.0005, and 16.7 ± 3.9 ng/mL vs. 11.8 ± 2.4 ng/mL, P < 0.0005) than patients treated with furosemide alone. After acute saline load, patients treated with i.v. furosemide + HSS in comparison with subjects treated with furosemide alone showed a significantly lower increase in the serum concentrations of IL-6 (-0.26 ± 0.42 pg/mL vs. -1.43 ± 0.86 pg/mL, P < 0.0005), high-sensitivity troponin T (0 vs. -0.02 ± 0.02 ng/mL, P < 0.0005), sST2 (-8.5 ± 5.9 ng/mL vs. -14.6 ± 6.2 ng/mL, P < 0.0005), galectin-3 (-2.1 ± 1.5 ng/mL vs. -7.1 ± 3.6 ng/mL, P < 0.0005), and NT-proBNP (77 ± 1373 vs. -1706 ± 2259 pg/mL, P < 0.0005). CONCLUSIONS Our findings concerning a comparable degree of reduction in the serum levels of three cardinal biomarkers indicate that a reduction in serum heart failure markers is not linked to the higher degree of congestion relief with a more rapid achievement of a clinical compensation state. This issue may have possible benefits on clinical practice concerning its therapeutic effects over and beyond the simple amelioration of clinical congestion signs and symptoms. Nevertheless, our findings of higher delta values after treatment with i.v. furosemide plus HSS indicate a possible higher efficacy by means of modulation of the stretching and fibrosis mechanisms.
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Affiliation(s)
- Antonino Tuttolomondo
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Carlo Maida
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Alessandra Casuccio
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Domenico Di Raimondo
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Roberto Fonte
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Valerio Vassallo
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Maria Grazia Puleo
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Tiziana Di Chiara
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Alba Mogavero
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Alessandro Del Cuore
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Mario Daidone
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Antonella Ortello
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
| | - Antonio Pinto
- U.O. C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno‐Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D'Alessandro” (PROMISE)University of PalermoPiazza delle Cliniche n.2Palermo90127Italy
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Tholén M, Ricksten SE, Lannemyr L. Effects of levosimendan on renal blood flow and glomerular filtration in patients with acute kidney injury after cardiac surgery: a double blind, randomized placebo-controlled study. Crit Care 2021; 25:207. [PMID: 34118980 PMCID: PMC8199833 DOI: 10.1186/s13054-021-03628-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication after cardiac surgery, and current strategies aimed at treating AKI have proven ineffective. Levosimendan, an inodilatating agent, has been shown to increase renal blood flow and glomerular filtration rate in uncomplicated postoperative patients and in patients with the cardiorenal syndrome. We hypothesized that levosimendan through its specific effects on renal vasculature, a preferential vasodilating effect on preglomerular resistance vessels, could improve renal function in AKI-patients with who did not have clinical indication for inotropic support. METHODS In this single-center, double-blind, randomized controlled study, adult patients with postoperative AKI within 2 days after cardiac surgery, who were hemodynamically stable with a central venous oxygen saturation (ScvO2) ≥ 60% without inotropic support were eligible for inclusion. After randomization, study drug infusions, levosimendan (n = 16) or placebo (n = 13) were given for 5 h. A bolus infusion of levosimendan (12 µg/kg), were given for 30 min followed by 0.1 µg/kg/min for 5 h. Renal blood flow and glomerular filtration rate were measured using infusion clearance of para-aminohippuric acid and a filtration marker, respectively. As a safety issue, norepinephrine was administered to maintain mean arterial pressure between 70-80 mmHg. Intra-group differences were tested by Mann-Whitney U-tests, and a linear mixed model was used to test time and group interaction. RESULTS Twenty-nine patients completed the study. At inclusion, the mean serum creatinine was higher in the patients randomized to levosimendan (148 ± 29 vs 127 ± 22 µmol/L, p = 0.030), and the estimated GFR was lower (46 ± 12 vs 57 ± 11 ml/min/1.73 m2, p = 0.025). Levosimendan induced a significantly (p = 0.011) more pronounced increase in renal blood flow (15%) compared placebo (3%) and a more pronounced decrease in renal vascular resistance (- 18% vs. - 4%, respectively, p = 0.043). There was a trend for a minor increase in glomerular filtration rate with levosimendan (4.5%, p = 0.079), which did differ significantly from the placebo group (p = 0.440). The mean norepinephrine dose was increased by 82% in the levosimedan group and decreased by 29% in the placebo group (p = 0.012). CONCLUSIONS In hemodynamically stable patients with AKI after cardiac surgery, levosimendan increases renal blood flow through renal vasodilatation. Trial registration NCT02531724, prospectly registered on 08/20/2015. https://clinicaltrials.gov/ct2/show/NCT02531724?cond=AKI&cntry=SE&age=1&draw=2&rank=1.
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Affiliation(s)
- Maria Tholén
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden
| | - Lukas Lannemyr
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden.
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Covic A, Copur S, Tapoi L, Afsar B, Ureche C, Siriopol D, Nistor I, Kanbay M. Efficiency of Hypertonic Saline in the Management of Decompensated Heart Failure: A Systematic Review and Meta-Analysis of Clinical Studies. Am J Cardiovasc Drugs 2021; 21:331-347. [PMID: 33210263 DOI: 10.1007/s40256-020-00453-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Acute decompensated heart failure (ADHF), with an incidence of 1-2%, is a clinical syndrome with significant morbidity and mortality despite therapeutic advancements and ongoing clinical trials. A recent therapeutic approach to patients with ADHF includes combination therapy with hypertonic saline solution (HSS) and furosemide, based on the hypothesis that resistance to loop diuretics occurs because of achievement of plateau in water and sodium excretion in patients receiving long-term loop diuretic therapy. OBJECTIVE Our aim was to conduct a meta-analysis to evaluate the efficiency of combination HSS plus furosemide therapy in patients with ADHF in terms of mortality, readmissions, length of hospital stay, kidney function, urine output, body weight, and B-type natriuretic peptide (BNP). METHODS A total of 14 studies-four observational and ten randomized studies (total 3398 patients)-were included in the meta-analysis. RESULTS Our results demonstrate the superiority of combination HSS plus furosemide therapy over furosemide alone in terms of kidney function preservation (mean creatinine difference - 0.33 mg/dL; P < 0.00001), improved diuresis (mean difference [MD] 581.94 mL/24 h; P < 0.00001) and natriuresis (MD 57.19; P < 0.00001), weight loss (MD 0.99 kg; P < 0.00001), duration of hospital stay (MD - 2.72 days; P < 0.00001), readmissions (relative risk 0.63; P = 0.01), and mortality (relative risk 0.55; P < 0.00001). However, no difference in BNP levels was detected (MD 19.88 pg/mL; P = 0.50). CONCLUSION Despite the heterogeneity and possible risk of bias among the studies, results appear promising on multiple aspects. A clear need exists for future randomized controlled trials investigating the role of combination HSS plus furosemide therapy to clarify these effects and their possible mechanisms.
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Affiliation(s)
- Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Laura Tapoi
- Cardiovascular Diseases Institute, Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Carina Ureche
- Cardiovascular Diseases Institute, Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Dimitrie Siriopol
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - Ionut Nistor
- Department of Nephrology, Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
- Nephrology Clinic, Dialysis and Renal Transplant Centre, "Dr C. I. Parhon" Hospital, Iasi, Romania
- Evidence Based Medicine and Research Methodology Center, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010, Istanbul, Turkey.
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Levine MA, Luke PP, Sener A. Canadian survey on the rates of use of intraoperative diuretics and justification for their use during renal allograft reperfusion. Can J Surg 2020. [PMID: 33107815 DOI: 10.1503/cjs.016019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the use of diuretics among transplant surgeons. METHODS An anonymous online survey was sent to all Canadian transplant programs where kidney transplants are routinely performed. Questions were related to the use and indications for mannitol and furosemide. Responses were collected and analyzed as counts and percentages of respondents. We used χ2 analysis to assess the relationship between demographic factors and survey responses. RESULTS Thirty-five surgeons completed the survey (response rate 50%). Seventy per cent of respondents reported performing 26 or more transplants per year, 88% had formal transplant fellowship training and 67% indicated that they currently train fellows. Only 24% and 12% reported believing that delayed graft function is reduced by mannitol and furosemide use, respectively. However, 73% routinely gave mannitol to patients and 53% routinely gave furosemide. The most common justification given for mannitol use was to induce diuresis (54%); 37% of respondents reported using mannitol because of training dogma. Likewise, 57% used furosemide for diuresis, with 23% reporting that their use of this agent was based on dogma. No relationship emerged between fellowship training, case volume or training program status and the use of any agent. Interestingly, 71% of respondents indicated that a randomized controlled trial evaluating the utility of intraoperative diuretics is needed and that they were interested in participating in such a trial. CONCLUSION Use of intraoperative diuretics and the rationale for their use vary among surgeons. A substantial proportion of surgeons use these medications on the basis of dogma alone. A randomized controlled trial is needed to clarify the role of intraoperative diuretics in kidney transplant surgery.
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Affiliation(s)
- Max A Levine
- From the Department of Surgery (Levine, Luke, Sener); and the Department of Microbiology and Immunology (Sener), Schulich School of Medicine and Dentistry, Western University, London, Ont.; the Matthew Mailing Centre for Translational Transplant Studies (Luke, Sener); and the Multi-Organ Transplant Program (Levine, Luke, Sener), London Health Sciences Centre, University Hospital, London, Ont
| | - Patrick P Luke
- From the Department of Surgery (Levine, Luke, Sener); and the Department of Microbiology and Immunology (Sener), Schulich School of Medicine and Dentistry, Western University, London, Ont.; the Matthew Mailing Centre for Translational Transplant Studies (Luke, Sener); and the Multi-Organ Transplant Program (Levine, Luke, Sener), London Health Sciences Centre, University Hospital, London, Ont
| | - Alp Sener
- From the Department of Surgery (Levine, Luke, Sener); and the Department of Microbiology and Immunology (Sener), Schulich School of Medicine and Dentistry, Western University, London, Ont.; the Matthew Mailing Centre for Translational Transplant Studies (Luke, Sener); and the Multi-Organ Transplant Program (Levine, Luke, Sener), London Health Sciences Centre, University Hospital, London, Ont
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9
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Heyman SN, Gorelik Y, Zorbavel D, Rosenberger C, Abassi Z, Rosen S, Khamaisi M. Near-drowning: new perspectives for human hypoxic acute kidney injury. Nephrol Dial Transplant 2020; 35:206-212. [PMID: 30768198 DOI: 10.1093/ndt/gfz016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/07/2019] [Indexed: 11/13/2022] Open
Abstract
Concepts regarding hypoxic acute kidney injury (AKI) are derived from widely used warm ischemia-reflow (WIR) models, characterized by extensive proximal tubular injury and associated with profound inflammation. However, there is ample clinical and experimental data indicating that hypoxic AKI may develop without total cessation of renal blood flow, with a different injury pattern that principally affects medullary thick limbs in the outer medulla. This injury pattern likely reflects an imbalance between blood and oxygen supply and oxygen expenditure, principally for tubular transport. Experimental models of hypoxic AKI other than WIR are based on mismatched oxygen delivery and consumption, particularly within the physiologically hypoxic outer medulla. However, evidence for such circumstances in human AKI is lacking. Recent analysis of the clinical course and laboratory findings of patients following near-drowning (ND) provides a rare glimpse into such a scenario. This observation supports the role of renal hypoxia in the evolution of AKI, as renal impairment could be predicted by the degree of whole-body hypoxia (reflected by lactic acidosis). Furthermore, there was a close association of renal functional impairment with indices of reduced oxygen delivery (respiratory failure and features of intense sympathetic activity) and of enhanced oxygen consumption for active tubular transport (extrapolated from the calculated volume of consumed hypertonic seawater). This unique study in humans supports the concept of renal oxygenation imbalance in hypoxic AKI. The drowning scenario, particularly in seawater, may serve as an archetype of this disorder, resulting from reduced oxygen delivery, combined with intensified oxygen consumption for tubular transport.
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Affiliation(s)
- Samuel N Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Yuri Gorelik
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | - Danny Zorbavel
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
| | | | - Zaid Abassi
- Department of Physiology, Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel.,Department of Laboratory Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Seymour Rosen
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mogher Khamaisi
- Department of Medicine D, Rambam Health Care Campus and Ruth & Bruce Rappaport Faculty of Medicine, Technion-IIT, Haifa, Israel
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10
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Heyman SN, Khamaisi M, Zorbavel D, Rosen S, Abassi Z. Role of Hypoxia in Renal Failure Caused by Nephrotoxins and Hypertonic Solutions. Semin Nephrol 2020; 39:530-542. [PMID: 31836036 DOI: 10.1016/j.semnephrol.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hypoxia plays a role in the pathogenesis of acute kidney injury under diverse clinical settings, including nephrotoxicity. Although some nephrotoxins exert direct renal parenchymal injury, likely with consequent altered oxygenation, others primarily reduce renal parenchymal oxygenation, leading to hypoxic tubular damage. As outlined in this review, nephrotoxin-related renal hypoxia may result from an altered renal oxygen supply (cyclosporine), enhanced oxygen consumption for tubular transport (agents inducing osmotic diuresis), or their combination (nonsteroidal anti-inflammatory drugs, radiocontrast agents, and others). Most agents causing hypoxic renal injury further supress physiologic low medullary Po2, in which a limited regional blood supply barely matches the intense regional tubular transport and oxygen consumption. The medullary tubular transport and blood supply are finely matched, securing oxygen sufficiency. Predisposition to hypoxia-mediated nephrotoxicity by medical conditions, such as chronic kidney disease or diabetes, may be explained by malfunctioning of control systems that normally maintain medullary oxygenation. However, this propensity may be diminished by hypoxia-mediated adaptive responses governed by hypoxia-inducible factors. Recent reports have suggested that inhibitors of sodium-glucose cotransporters and the administration of hypertonic saline may be added to the growing list of common therapeutic interventions that intensify medullary hypoxia, and potentially could lead to hypoxic acute kidney injury.
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Affiliation(s)
- Samuel N Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel.
| | - Mogher Khamaisi
- Department of Medicine D, Rambam Health Care Campus, Haifa, Israel; Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
| | - Danny Zorbavel
- Department of Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Seymour Rosen
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Pathology, Harvard Medical School, Boston, MA
| | - Zaid Abassi
- Department of Physiology, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel; Department of Laboratory Medicine, Rambam Health Care Campus, Haifa, Israel
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11
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Perioperative Risk Factors Associated With Acute Kidney Injury in Patients After Brain Tumor Resection. J Neurosurg Anesthesiol 2020; 34:51-56. [PMID: 32658102 DOI: 10.1097/ana.0000000000000716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication after surgery. The aim of this study is to identify risk factors for postoperative AKI in patients undergoing brain tumor surgery. METHODS This single-center, retrospective, matched case-control study included patients undergoing elective brain tumor surgery between January 2016 and December 2018 at Beijing Tiantan Hospital, Capital Medical University, China. Patients developing postoperative AKI were compared with controls without AKI matched by age, sex, and date of surgery in a ratio of 1:3. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. RESULTS A total of 9933 patients were identified for review, of which 115 (1.16%) developed AKI; 345 matched patients were included in the control group. AKI occurred most commonly within the first 24 hours (41/97, 42.3%) and 48 hours (33/94, 35.1%) after surgery. Preoperative administration of mannitol (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.04-2.60; P= 0.034), American Society of Anesthesiologists physical status III or higher (OR, 5.50; 95% CI, 2.23-13.59; P<0.001), preoperative blood glucose (OR, 2.53; 95% CI, 1.23-5.22; P=0.012), craniopharyngioma (OR, 8.96; 95% CI, 3.55-22.63; P<0.001), nonsteroidal anti-inflammatory drug administration (OR, 3.74; 95% CI, 1.66-8.42; P<0.001), and intraoperative hypotension (OR, 2.13; 95% CI, 1.21-3.75; P=0.009) were independent risk factors for postoperative AKI. CONCLUSION Multiple factors, including preoperative administration of mannitol, are independently associated with the development of postoperative AKI in patients undergoing brain tumor surgery.
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12
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Lannemyr L, Bragadottir G, Redfors B, Ricksten SE. Effects of milrinone on renal perfusion, filtration and oxygenation in patients with acute heart failure and low cardiac output early after cardiac surgery. J Crit Care 2020; 57:225-230. [PMID: 31919012 DOI: 10.1016/j.jcrc.2019.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/07/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Early postoperative heart failure is common after cardiac surgery, and inotrope treatment may impact renal perfusion and oxygenation. We aimed to study the renal effects of the inodilator milrinone when used for the treatment of heart failure after weaning from cardiopulmonary bypass (CPB). MATERIAL AND METHODS In 26 patients undergoing cardiac surgery with CPB, we used renal vein catheterization to prospectively measure renal blood flow (RBF), glomerular filtration rate (GFR), and renal oxygenation. Patients who developed acute heart failure and low cardiac output (cardiac index <2.1 L/min/m2) at 30 min after weaning from CPB (n = 7) were given milrinone, and the remaining patients (n = 19) served as controls. Additional measurements were made at 60 min after CPB. RESULTS In patients with acute postoperative heart failure, before receiving milrinone, renal blood flow was lower (-33%, p < .05) while renal oxygen extraction was higher (41%, p < .05) compared to the control group. Milrinone increased cardiac index (21%, p < .001), RBF (36%, p < .01) and renal oxygen delivery (35%, p < .01), with no significant change in GFR and oxygen consumption compared to the control group. CONCLUSIONS In patients with acute heart failure after weaning from CPB, the milrinone-induced increase in cardiac output was accompanied by improved renal oxygenation. TRIAL REGISTRATION ClinicalTrials.gov; identifier NCT02405195, date of registration; March 27, 2015, and NCT02549066, date of registration; 9 September 2015.
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Affiliation(s)
- Lukas Lannemyr
- All at the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg, S-413 45 Gothenburg, Sweden.
| | - Gudrun Bragadottir
- All at the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg, S-413 45 Gothenburg, Sweden
| | - Bengt Redfors
- All at the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg, S-413 45 Gothenburg, Sweden
| | - Sven-Erik Ricksten
- All at the Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Gothenburg, S-413 45 Gothenburg, Sweden
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13
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Ullah MM, Ow CPC, Hilliard Krause LM, Evans RG. Renal oxygenation during the early stages of adenine-induced chronic kidney disease. Am J Physiol Renal Physiol 2019; 317:F1189-F1200. [DOI: 10.1152/ajprenal.00253.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
To assess whether renal hypoxia is an early event in adenine-induced chronic kidney disease, adenine (100 mg) or its vehicle was administered to male Sprague-Dawley rats by daily oral gavage for 7 days. Kidney oxygenation was assessed by 1) blood oximetry and Clark electrode in thiobutabarbital-anesthetized rats, 2) radiotelemetry in unanesthetized rats, and 3) expression of hypoxia-inducible factor (HIF)-1α and HIF-2α protein. After 7 days of treatment, under anesthesia, renal O2 delivery was 51% less, whereas renal O2 consumption was 65% less, in adenine-treated rats than in vehicle-treated rats. Tissue Po2 measured by Clark electrode was similar in the renal cortex but 44% less in the medulla of adenine-treated rats than in that of vehicle-treated rats. In contrast, in unanesthetized rats, both cortical and medullary tissue Po2 measured by radiotelemetry remained stable across 7 days of adenine treatment. Notably, anesthesia and laparotomy led to greater reductions in medullary tissue Po2 measured by radiotelemetry in rats treated with adenine (37%) than in vehicle-treated rats (16%), possibly explaining differences between our observations with Clark electrodes and radiotelemetry. Renal expression of HIF-1α was less after 7 days of adenine treatment than after vehicle treatment, whereas expression of HIF-2α did not differ significantly between the two groups. Renal dysfunction was evident after 7 days of adenine treatment, with glomerular filtration rate 65% less and serum creatinine concentration 183% greater in adenine-treated rats than in vehicle-treated rats. Renal cortical tissue hypoxia may not precede renal dysfunction in adenine-induced chronic kidney disease and so may not be an early pathological feature in this model.
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Affiliation(s)
- Md Mahbub Ullah
- Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Connie P. C. Ow
- Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Lucinda M. Hilliard Krause
- Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute, Department of Physiology, Monash University, Melbourne, Victoria, Australia
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14
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Nair SM, Power NE, Coleman JA. Examining Mannitol Use in Kidney Cancer Surgery: A Cautionary Tale of Extrapolated Surgical Data. Eur Urol Focus 2019; 5:930-934. [PMID: 31628080 PMCID: PMC8560078 DOI: 10.1016/j.euf.2019.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/30/2019] [Indexed: 11/30/2022]
Abstract
Mannitol for renal protection during partial nephrectomy is common but unsupported by evidence from clinical trials. The impact of mannitol on renal physiology includes both beneficial and harmful effects. Current understanding of renal ischemia reperfusion injury suggests potentially targetable processes that have a lower potential risk.
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Affiliation(s)
- Shiva M Nair
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada.
| | - Nicholas E Power
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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15
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Nensén O, Hansell P, Palm F. Role of carbonic anhydrase in acute recovery following renal ischemia reperfusion injury. PLoS One 2019; 14:e0220185. [PMID: 31465457 PMCID: PMC6715224 DOI: 10.1371/journal.pone.0220185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/10/2019] [Indexed: 11/18/2022] Open
Abstract
Ischemia reperfusion (IR) injury can cause acute kidney injury. It has previously been reported that kidney oxygen consumption (QO2) in relation to glomerular filtration rate (GFR), and thus tubular sodium load, is markedly increased following IR injury, indicating reduced electrolyte transport efficiency. Since proximal tubular sodium reabsorption (TNa) is a major contributor to overall kidney QO2, we investigated whether inhibition of proximal tubular sodium transport through carbonic anhydrase (CA) inhibition would improve renal oxygenation following ischemia reperfusion. Anesthetized adult male Sprague Dawley rats were administered the CA inhibitor acetazolamide (50 mg/kg bolus iv), or volume-matched vehicle, and kidney function, hemodynamics and QO2 were estimated before and after 45 minutes of unilateral complete warm renal ischemia. CA inhibition per se reduced GFR (-20%) and TNa (-22%), while it increased urine flow and urinary sodium excretion (36-fold). Renal blood flow was reduced (-31%) due to increased renal vascular resistance (+37%) without affecting QO2. IR per se resulted in similar decrease in GFR and TNa, independently of CA activity. However, the QO2/TNa ratio following ischemia-reperfusion was profoundly increased in the group receiving CA inhibition, indicating a significant contribution of basal oxygen metabolism to the total kidney QO2 following inhibition of proximal tubular function after IR injury. Ischemia increased urinary excretion of kidney injury molecule-1, an effect that was unaffected by CA. In conclusion, this study demonstrates that CA inhibition further impairs renal oxygenation and does not protect tubular function in the acute phase following IR injury. Furthermore, these results indicate a major role of the proximal tubule in the acute recovery from an ischemic insult.
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Affiliation(s)
- Oskar Nensén
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
| | - Peter Hansell
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Fredrik Palm
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
- * E-mail:
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16
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Wu CC, Tai CH, Liao WY, Wang CC, Kuo CH, Lin SW, Ku SC. Augmented renal clearance is associated with inadequate antibiotic pharmacokinetic/pharmacodynamic target in Asian ICU population: a prospective observational study. Infect Drug Resist 2019; 12:2531-2541. [PMID: 31496765 PMCID: PMC6701640 DOI: 10.2147/idr.s213183] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/16/2019] [Indexed: 01/09/2023] Open
Abstract
Background Augmented renal clearance (ARC) is common in critically ill patients and could result in subtherapeutic antibiotic concentration. However, data in the Asian population are still lacking. The aim of this study was to explore the incidence and risk factors of ARC and its effect on β-lactam pharmacokinetics/pharmacodynamics (PK/PD) in Asian populations admitted to a medical ICU. In addition, we evaluated the appropriateness of using three estimated glomerular filtration (eGFR) formulas [Cockcroft–Gault (CG), Modification of Diet in Renal Disease (MDRD), and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)] as screening tools. Methods We measured 2-, 8-, and 24-hr creatinine clearance (CLCr) and calculated eGFR by using three formulas for each. ARC was defined as CLCr24hr >130 mL/min/1.73 m2. Concentrations at the mid-dosing interval and prior to the next dose were collected if patients received the β-lactam antibiotic of piperacillin/tazobactam, cefepime, and meropenem, to determine the PK/PD index of fT > MIC. Multiple logistic regression analysis was conducted to identify the risk factors for ARC. Pearson correlation coefficient and the Bland and Altman method were applied to assess the accuracy of CLCr2hr, CLCr8hr, and eGFR for predicting ARC. Results Of 100 patients, 46 (46%) manifested ARC. Younger age (<50 years) and lower Sequential Organ Failure Assessment score increased the likelihood of ARC. ARC resulted in a low chance of achieving 50% fT >4MIC (33% vs 75%, p<0.01), 100% fT > MIC (23% vs 69%, p<0.01), and 100% fT >4MIC (3% vs 25%, p<0.02). CLCr8hr wielded the best correlation and agreement with CLCr24hr. eGFRCG was the most appropriate screening tool, and the optimal cutoff value for detecting ARC was 130.5 mL/min/1.73 m2. Conclusion ARC is associated with inadequate β-lactam PK/PD target in Asian ICU.
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Affiliation(s)
- Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsun Tai
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-You Liao
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Wen Lin
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Chi Ku
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Waskowski J, Pfortmueller CA, Erdoes G, Buehlmann R, Messmer AS, Luedi MM, Schmidli J, Schefold JC. Mannitol for the Prevention of Peri-Operative Acute Kidney Injury: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:130-140. [PMID: 31078413 DOI: 10.1016/j.ejvs.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/04/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE/BACKGROUND Post-operative acute kidney injury (AKI) is a frequent peri-operative complication that negatively affects morbidity and mortality. Mannitol is frequently used peri-operatively for renal protection, although evidence for its use is ambiguous. A systematic review was conducted to clarify whether there is evidence supporting peri-operative mannitol administration for the prevention of post-operative AKI. METHODS A systematic literature search was performed in MEDLINE/Pubmed, Embase, the Cochrane Library, Clinical Trials registry, and the Cochrane Central Register of Controlled Trials (CENTRAL). Eligibility criteria were (i) population (studies involving adult patients undergoing surgery or a related intervention); (ii) intervention (intravenous mannitol administered in either the pre- or intra-operative period with comparison to controls); and (iii) predefined outcomes (post-operative AKI or respective renal end points/surrogates). RESULTS In total, 1,538 articles published between January 1990 and October 2018 were identified. After checking for eligibility, 22 studies, including 17 prospective and/or randomised controlled trials and five retrospective studies, were included. The investigations involved various fields of surgery, such as aortic surgery, cardiac surgery with cardiopulmonary bypass, and urological procedures, including partial nephrectomy. Significant heterogeneity, limited sample size, and mostly short follow up periods were noted. CONCLUSION Given the available evidence, the peri-operative use of mannitol to prevent AKI cannot be considered an evidence based intervention in cardiac surgery, partial nephrectomy, and/or other major surgery. Further research is required with a focus on patients at high risk of post-operative AKI.
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Affiliation(s)
- Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roman Buehlmann
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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18
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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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Lannemyr L, Ricksten S, Rundqvist B, Andersson B, Bartfay S, Ljungman C, Dahlberg P, Bergh N, Hjalmarsson C, Gilljam T, Bollano E, Karason K. Differential Effects of Levosimendan and Dobutamine on Glomerular Filtration Rate in Patients With Heart Failure and Renal Impairment:A Randomized Double-Blind Controlled Trial. J Am Heart Assoc 2018; 7:e008455. [PMID: 30369310 PMCID: PMC6201411 DOI: 10.1161/jaha.117.008455] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/02/2018] [Indexed: 01/07/2023]
Abstract
Background The management of the cardiorenal syndrome in advanced heart failure is challenging, and the role of inotropic drugs has not been fully defined. Our aim was to compare the renal effects of levosimendan versus dobutamine in patients with heart failure and renal impairment. Methods and Results In a randomized double-blind study, we assigned patients with chronic heart failure (left ventricular ejection fraction <40%) and impaired renal function (glomerular filtration rate <80 mL/min per 1.73 m2) to receive either levosimendan (loading dose 12 μg/kg+0.1 μg/kg per minute) or dobutamine (7.5 μg/kg per minute) for 75 minutes. A pulmonary artery catheter was used for measurements of systemic hemodynamics, and a renal vein catheter was used to measure renal plasma flow by the infusion clearance technique for PAH (para-aminohippurate) corrected by renal extraction of PAH . Filtration fraction was measured by renal extraction of chromium ethylenediamine tetraacetic acid. A total of 32 patients completed the study. Following treatment, the levosimendan and dobutamine groups displayed similar increases in renal blood flow (22% and 26%, respectively) with no significant differences between groups. Glomerular filtration rate increased by 22% in the levosimendan group but remained unchanged in the dobutamine group ( P=0.012). Filtration fraction was not affected by levosimendan but decreased by 17% with dobutamine ( P=0.045). Conclusions In patients with chronic heart failure and renal impairment, levosimendan increases glomerular filtration rate to a greater extent than dobutamine and thus may be the preferred inotropic agent for treating patients with the cardiorenal syndrome. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02133105.
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Affiliation(s)
- Lukas Lannemyr
- Department of Anesthesiology and Intensive Care MedicineUniversity of GothenburgSahlgrenska UniversityGothenburgSweden
| | - Sven‐Erik Ricksten
- Department of Anesthesiology and Intensive Care MedicineUniversity of GothenburgSahlgrenska UniversityGothenburgSweden
| | - Bengt Rundqvist
- Department of TransplantationSahlgrenska University HospitalGothenburgSweden
| | - Bert Andersson
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Sven‐Erik Bartfay
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | | | - Pia Dahlberg
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Niklas Bergh
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Clara Hjalmarsson
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Thomas Gilljam
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Entela Bollano
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Kristjan Karason
- Department of TransplantationSahlgrenska University HospitalGothenburgSweden
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20
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Evans RG, Lankadeva YR, Cochrane AD, Marino B, Iguchi N, Zhu MZL, Hood SG, Smith JA, Bellomo R, Gardiner BS, Lee C, Smith DW, May CN. Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass. Acta Physiol (Oxf) 2018; 222. [PMID: 29127739 DOI: 10.1111/apha.12995] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 12/12/2022]
Abstract
Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery-associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models that medullary ischaemia and hypoxia occur during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra-operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimization of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interventions. We propose a multi-disciplinary pathway for translation comprising three components. Firstly, large-animal models of CPB to continuously monitor both whole kidney and regional kidney perfusion and oxygenation. Secondly, computational models to obtain information that can be used to interpret the data and develop rational interventions. Thirdly, clinically feasible non-invasive methods to continuously monitor renal oxygenation in the operating theatre and to identify patients at risk of AKI. In this review, we outline the recent progress on each of these fronts.
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Affiliation(s)
- R. G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - Y. R. Lankadeva
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - A. D. Cochrane
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - B. Marino
- Department of Perfusion Services Austin Hospital Heidelberg Vic. Australia
| | - N. Iguchi
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - M. Z. L. Zhu
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - S. G. Hood
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - J. A. Smith
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - R. Bellomo
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
| | - B. S. Gardiner
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C.‐J. Lee
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - D. W. Smith
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C. N. May
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
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21
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Gorelik Y, Darawshi S, Yaseen H, Abassi Z, Heyman SN, Khamaisi M. Acute Renal Failure Following Near-Drowning. Kidney Int Rep 2018; 3:833-840. [PMID: 29989059 PMCID: PMC6035158 DOI: 10.1016/j.ekir.2018.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/22/2018] [Accepted: 02/18/2018] [Indexed: 01/23/2023] Open
Abstract
Introduction Acute kidney injury associated with near-drowning (ND-AKI) has rarely been reported and its incidence among survivors is unknown. A patient with AKI and urine biomarkers indicating tubular injury led us to assess the occurrence and clinical characteristics of ND-AKI and to evaluate possible causative mechanisms. Methods We evaluated medical records of patients rescued from near-drowning in the Mediterranean Sea and treated in a tertiary-level medical center during 2000 to 2017. Results Ninety-five patients with the diagnosis of near-drowning in seawater were treated. Forty-two of these patients (43%) developed ND-AKI and 17 (18%) were classified as AKI Kidney Disease: Improving Global Outcomes stages 2 to 3. ND-AKI was associated with the need for resuscitation and mechanical ventilation, with the calculated seawater volume ingestion (extrapolated from rising plasma sodium) and with the degree of acidemia, lactemia, and ventilatory failure. This series and 28 additional published cases of ND-AKI in the literature showed an overall male predisposition. Conclusion AKI is a common complication of near-drowning and is associated with increased in-hospital mortality. Data analysis suggests a predominant role of hypoxic tubular injury due to systemic hypoxemia in ND-AKI, combined with intense sympathetic activity (reflected by tachyarrhythmias, hyperglycemia, and relative hypokalemia) and increased oxygen expenditure for intensified distal tubular sodium transport. Androgen-related reduced renal vasodilatory capacity may explain male gender predominance.
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Affiliation(s)
- Yuri Gorelik
- Internal Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Said Darawshi
- Internal Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Hiba Yaseen
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
| | - Zaid Abassi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel
| | - Samuel N Heyman
- Departments of Medicine, Hadassah Hebrew University Hospitals, Jerusalem, Israel
| | - Mogher Khamaisi
- Internal Medicine, Rambam Health Care Campus, Haifa, Israel.,Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel
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22
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Shah PH, Leibovich BC, Lyon TD. Should Urologists Abandon the Use of Mannitol During Partial Nephrectomy? Eur Urol 2017; 73:60-61. [PMID: 28985968 DOI: 10.1016/j.eururo.2017.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 09/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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23
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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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24
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Thomas JL, Pham H, Li Y, Hall E, Perkins GA, Ali SS, Patel HH, Singh P. Hypoxia-inducible factor-1α activation improves renal oxygenation and mitochondrial function in early chronic kidney disease. Am J Physiol Renal Physiol 2017; 313:F282-F290. [PMID: 28331062 DOI: 10.1152/ajprenal.00579.2016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 02/07/2023] Open
Abstract
The pathophysiology of chronic kidney disease (CKD) is driven by alterations in surviving nephrons to sustain renal function with ongoing nephron loss. Oxygen supply-demand mismatch, due to hemodynamic adaptations, with resultant hypoxia, plays an important role in the pathophysiology in early CKD. We sought to investigate the underlying mechanisms of this mismatch. We utilized the subtotal nephrectomy (STN) model of CKD to investigate the alterations in renal oxygenation linked to sodium (Na) transport and mitochondrial function in the surviving nephrons. Oxygen delivery was significantly reduced in STN kidneys because of lower renal blood flow. Fractional oxygen extraction was significantly higher in STN. Tubular Na reabsorption was significantly lower per mole of oxygen consumed in STN. We hypothesized that decreased mitochondrial bioenergetic capacity may account for this and uncovered significant mitochondrial dysfunction in the early STN kidney: higher oxidative metabolism without an attendant increase in ATP levels, elevated superoxide levels, and alterations in mitochondrial morphology. We further investigated the effect of activation of hypoxia-inducible factor-1α (HIF-1α), a master regulator of cellular hypoxia response. We observed significant improvement in renal blood flow, glomerular filtration rate, and tubular Na reabsorption per mole of oxygen consumed with HIF-1α activation. Importantly, HIF-1α activation significantly lowered mitochondrial oxygen consumption and superoxide production and increased mitochondrial volume density. In conclusion, we report significant impairment of renal oxygenation and mitochondrial function at the early stages of CKD and demonstrate the beneficial role of HIF-1α activation on renal function and metabolism.
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Affiliation(s)
- Joanna L Thomas
- Department of Biomedical Engineering, School of Engineering, Mercer University, Macon, Georgia
| | - Hai Pham
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, and VA San Diego Healthcare System, San Diego, California
| | - Ying Li
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, and VA San Diego Healthcare System, San Diego, California
| | - Elanore Hall
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, and VA San Diego Healthcare System, San Diego, California
| | - Guy A Perkins
- National Center for Microscopy and Imaging Research, La Jolla, California
| | - Sameh S Ali
- Center for Aging and Associated Diseases, Helmy Institute of Medical Science, Zewail City of Science and Technology, Giza, Egypt; and.,Department of Anesthesiology, University of California, San Diego, California and VA San Diego Healthcare System, San Diego, California
| | - Hemal H Patel
- Department of Anesthesiology, University of California, San Diego, California and VA San Diego Healthcare System, San Diego, California
| | - Prabhleen Singh
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, and VA San Diego Healthcare System, San Diego, California;
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25
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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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26
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Zazzeron L, Ottolina D, Scotti E, Ferrari M, Bruzzone P, Sibilla S, Marenghi C, Gattinoni L, Caironi P. Real-time urinary electrolyte monitoring after furosemide administration in surgical ICU patients with normal renal function. Ann Intensive Care 2016; 6:72. [PMID: 27447787 PMCID: PMC4958084 DOI: 10.1186/s13613-016-0168-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background Although the loop-diuretic furosemide is widely employed in critically ill patients with known long-term effects on plasma electrolytes, accurate data describing its acute effects on renal electrolyte handling and the generation of plasma electrolyte alterations are lacking. We hypothesized that the long-term effects of furosemide on plasma electrolytes and acid–base depend on its immediate effects on electrolyte excretion rate and patient clinical baseline characteristics. By monitoring urinary electrolytes quasi-continuously, we aimed to verify this hypothesis in a cohort of surgical ICU patients with normal renal function. Methods We retrospectively enrolled 39 consecutive patients admitted to a postoperative ICU after major surgery, and receiving single low-dose intravenous administration of furosemide. Urinary output, pH, sodium [Na+], potassium [K+], chloride [Cl−] and ammonium [NH4+] concentrations were measured every 10 min for three to 8 h. Urinary anion gap (AG), electrolyte excretion rate, fractional excretion (Fe) and time constant of urinary [Na+] variation (τNa+) were calculated. Results Ten minutes after furosemide administration (12 ± 5 mg), urinary [Na+] and [Cl−], and their excretion rates, increased to similar levels (P < 0.001). After the first hour, urinary [Cl−] decreased less rapidly than [Na+], leading to a reduction in urinary AG and pH and an increment in urinary [NH4+] (P < 0.001). Median urinary [Cl−] over the first 3-h period was higher than baseline urinary and plasmatic [Cl−] (P < 0.001). During the first 2 h, difference between FeCl− and FeNa+ increased (P < 0.05). Baseline higher values of central venous pressure and FeNa+ were associated with greater increases in FeNa+ after furosemide (P = 0.03 and P = 0.007), whereas higher values of mean arterial and central venous pressures were associated with a longer τNa+ (P < 0.05). In patients receiving multiple administrations (n = 11), arterial pH, base excess and strong ion difference increased, due to a decrease in plasmatic [Cl−]. Conclusions Low-dose furosemide administration immediately modifies urinary electrolyte excretion rates, likely in relation to the ongoing proximal tubular activity, unveiled by its inhibitory action on Henle’s loop. Such effects, when cumulative, found the bases for the long-term alterations observed. Real-time urinary electrolyte monitoring may help in tailoring patient diuretic and hemodynamic therapies. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0168-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luca Zazzeron
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Davide Ottolina
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Eleonora Scotti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Michele Ferrari
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Paola Bruzzone
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvio Sibilla
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Marenghi
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology and Intensive Care Medicine, Georg-August-University Göttingen, Göttingen, Germany
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy. .,Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
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27
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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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28
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De Vecchis R, Esposito C, Ariano C, Cantatrione S. Hypertonic saline plus i.v. furosemide improve renal safety profile and clinical outcomes in acute decompensated heart failure. Herz 2014; 40:423-35. [DOI: 10.1007/s00059-013-4041-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 11/27/2013] [Accepted: 12/16/2013] [Indexed: 11/25/2022]
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Micozkadioglu H. Higher diastolic blood pressure at admission and antiedema therapy is associated with acute kidney injury in acute ischemic stroke patients. Int J Nephrol Renovasc Dis 2014; 7:101-5. [PMID: 24570596 PMCID: PMC3933720 DOI: 10.2147/ijnrd.s59443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Antiedema therapy with mannitol and furosemide is widely used for prevention and management of cerebral edema, elevated intracranial pressure, and cerebral hernia. There are some reports about mannitol and furosemide as risk factors of acute kidney injury (AKI). We investigated the risk factors for AKI including antiedema therapy in acute ischemic stroke patients. The subjects were 129 patients with acute ischemic stroke including 56 females and 73 males with a mean age 68.16±12.29 years. Patients were divided into two groups: patients with AKI and without AKI according to Acute Kidney Injury Network criteria. All patients had undergone cranial, carotid, and vertebral artery evaluation with magnetic resonance imaging. The number of patients with AKI was 14 (10.9%). Subjects experiencing atrial fibrillation (P=0.043) and higher diastolic blood pressure (DBP) (P=0.032) treated with mannitol (P=0.019) and furosemide (P=0.019) disclosed significant association with AKI. Regression analysis revealed that higher DBP (P=0.029) and management with mannitol (P=0.044) were the risk factors for AKI. Higher DBP at admission is the most important risk factor for AKI. However antiedema therapy should be used carefully in patients with acute ischemic stroke. Serum creatinine levels or estimated glomerular filtration rate should be watched frequently to prevent AKI.
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Affiliation(s)
- Hasan Micozkadioglu
- Department of Nephrology, Faculty of Medicine Hospital of Adana, Baskent University School of Medicine, Adana, Turkey
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30
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Evans RG, Harrop GK, Ngo JP, Ow CPC, O'Connor PM. Basal renal O2 consumption and the efficiency of O2 utilization for Na+ reabsorption. Am J Physiol Renal Physiol 2014; 306:F551-60. [PMID: 24431201 DOI: 10.1152/ajprenal.00473.2013] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We examined how the presence of a fixed level of basal renal O2 consumption (Vo2(basal); O2 used for processes independent of Na(+) transport) confounds the utility of the ratio of Na(+) reabsorption (TNa(+)) to total renal Vo2 (Vo2(total)) as an index of the efficiency of O2 utilization for TNa(+). We performed a systematic review and additional experiments in anesthetized rabbits to obtain the best possible estimate of the fractional contribution of Vo2(basal) to Vo2(total) under physiological conditions (basal percent renal Vo2). Estimates of basal percent renal Vo2 from 24 studies varied from 0% to 81.5%. Basal percent renal Vo2 varied with the fractional excretion of Na(+) (FENa(+)) in the 14 studies in which FENa(+) was measured under control conditions. Linear regression analysis predicted a basal percent renal Vo2 of 12.7-16.5% when FENa(+) = 1% (r(2) = 0.48, P = 0.001). Experimentally induced changes in TNa(+) altered TNa(+)/Vo2(total) in a manner consistent with theoretical predictions. We conclude that, because Vo2(basal) represents a significant proportion of Vo2(total), TNa(+)/Vo2(total) can change markedly when TNa(+) itself changes. Therefore, caution should be taken when TNa(+)/Vo2(total) is interpreted as a measure of the efficiency of O2 utilization for TNa(+), particularly under experimental conditions where TNa(+) or Vo2(total) changes.
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Affiliation(s)
- Roger G Evans
- Dept. of Physiology, PO Box 13F, Monash Univ., Victoria 3800, Australia.
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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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Singh P, Ricksten SE, Bragadottir G, Redfors B, Nordquist L. Renal oxygenation and haemodynamics in acute kidney injury and chronic kidney disease. Clin Exp Pharmacol Physiol 2013; 40:138-47. [PMID: 23360244 DOI: 10.1111/1440-1681.12036] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/29/2022]
Abstract
Acute kidney injury (AKI) is a major burden on health systems and may arise from multiple initiating insults, including ischaemia-reperfusion injury, cardiovascular surgery, radiocontrast administration and sepsis. Similarly, the incidence and prevalence of chronic kidney disease (CKD) continues to increase, with significant morbidity and mortality. Moreover, an increasing number of AKI patients survive to develop CKD and end-stage renal disease. Although the mechanisms for the development of AKI and progression to CKD remain poorly understood, initial impairment of oxygen balance likely constitutes a common pathway, causing renal tissue hypoxia and ATP starvation that, in turn, induce extracellular matrix production, collagen deposition and fibrosis. Thus, possible future strategies for one or both conditions may involve dopamine, loop diuretics, atrial natriuretic peptide and inhibitors of inducible nitric oxide synthase, substances that target kidney oxygen consumption and regulators of renal oxygenation, such as nitric oxide and heme oxygenase-1.
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Affiliation(s)
- Prabhleen Singh
- Division of Nephrology-Hypertension, VA San Diego Healthcare System, University of California San Diego, San Diego, CA, USA
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Hultström M. Neurohormonal interactions on the renal oxygen delivery and consumption in haemorrhagic shock-induced acute kidney injury. Acta Physiol (Oxf) 2013; 209:11-25. [PMID: 23837642 DOI: 10.1111/apha.12147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 12/14/2022]
Abstract
Haemorrhagic shock is a common cause of acute kidney injury (AKI), which is a major risk factor for developing chronic kidney disease. The mechanism is superficially straightforward. An arterial pressure below the kidney's autoregulatory region leads to a direct reduction in filtration pressure and perfusion, which in turn cause renal failure with reduced glomerular filtration rate and AKI because of hypoxia. However, the kidney's situation is further worsened by the hormonal and neural reactions to reduced perfusion pressure. There are three major systems working to maintain arterial pressure in shock: sympathetic signalling, the renin-angiotensin system and vasopressin. These work to retain electrolytes and water and to increase peripheral resistance and cardiac output. In the kidney, the increased electrolyte reabsorption consumes oxygen. At the same time, at the signalling level seen in shock, all of these hormones reduce renal perfusion and thereby oxygen delivery. This creates an exaggerated hypoxic situation that is liable to worsen the AKI. The present review will examine this mechanistic background and identify a number of areas that require further studies. At this time, the ideal treatment of haemorrhagic shock appears to be slow fluid resuscitation, possibly with hyperosmolar sodium, low chloride and no artificial colloids. From the standpoint of the kidney, renin-angiotensin system inhibitors appear fruitful for further study.
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Affiliation(s)
- M Hultström
- Unit for Integrative Physiology, Department of Medical Cellbiology, Uppsala University, Uppsala, Sweden; Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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JBP485 improves gentamicin-induced acute renal failure by regulating the expression and function of Oat1 and Oat3 in rats. Toxicol Appl Pharmacol 2013; 271:285-95. [DOI: 10.1016/j.taap.2013.04.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 11/18/2022]
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Ricksten SE, Bragadottir G, Redfors B. Renal oxygenation in clinical acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:221. [PMID: 23514538 PMCID: PMC3672481 DOI: 10.1186/cc12530] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Morgan CJ, Gill PJ, Lam S, Joffe AR. Peri-operative interventions, but not inflammatory mediators, increase risk of acute kidney injury after cardiac surgery: a prospective cohort study. Intensive Care Med 2013; 39:934-41. [PMID: 23417202 DOI: 10.1007/s00134-013-2849-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/21/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE Cardiopulmonary bypass (CPB)-related inflammatory response might be one mechanism by which cardiac surgery associated acute kidney injury (CS-AKI) occurs. Interventions that may attenuate inflammation, including glucocorticoids or phosphodiesterase inhibitors, could therefore have a role in its prevention. We aimed to determine the role of inflammatory mediators in CS-AKI in children and the efficacy of commonly used peri-operative interventions to reduce CS-AKI risk. METHODS We prospectively studied 109 children undergoing heart surgery. Using regression modeling (adjusting for covariates), we (1) evaluated the association between inflammatory mediators [interleukin (IL)-6, IL-8, C-reactive protein, and tumor necrosis factor-α levels] and CS-AKI, and (2) evaluated risk/prevention factors for CS-AKI including glucocorticoid and milrinone administration. CS-AKI was defined based on pRIFLE methods. RESULTS CS-AKI occurred in 68% of children. No inflammatory mediator measured had an independent association with CS-AKI. Higher pre-operative glomerular filtration rate (GFR), sustained decrease in mean arterial pressure during CPB, post-operative single ventricle physiology, deep hypothermic circulatory arrest, and milrinone use at 24 h post-operatively were significant independent predictors of CS-AKI. Intra-operative steroid administration had no effect on the rate of CS-AKI. CONCLUSIONS Although inflammatory mediators are up-regulated following CPB, we found no association between levels of inflammatory cytokines and CS-AKI. CS-AKI has complex pathophysiology and the observation that milrinone was associated with increased AKI risk (and that higher GFR predicts more injury) suggests that mechanisms beyond inflammation play a significant role. Intra-operative administration of glucocorticoid does not appear to be an effective intervention for reducing the risk of CS-AKI.
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Evans RG, Ince C, Joles JA, Smith DW, May CN, O'Connor PM, Gardiner BS. Haemodynamic influences on kidney oxygenation: Clinical implications of integrative physiology. Clin Exp Pharmacol Physiol 2013; 40:106-22. [DOI: 10.1111/1440-1681.12031] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 10/21/2012] [Accepted: 11/15/2012] [Indexed: 01/08/2023]
Affiliation(s)
- Roger G Evans
- Department of Physiology; Monash University; Melbourne; Victoria; Australia
| | - Can Ince
- Department of Translational Physiology; Academic Medical Center; University of Amsterdam; Amsterdam; The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension; University Medical Center; Utrecht; The Netherlands
| | - David W Smith
- School of Computer Science and Software Engineering; The University of Western Australia; Perth; Western Australia; Australia
| | - Clive N May
- Florey Institute of Neuroscience and Mental Health; University of Melbourne; Melbourne; Victoria; Australia
| | - Paul M O'Connor
- Department of Physiology; Georgia Health Sciences University; Augusta; GA; USA
| | - Bruce S Gardiner
- School of Computer Science and Software Engineering; The University of Western Australia; Perth; Western Australia; Australia
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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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Sigmund EE, Vivier PH, Sui D, Lamparello NA, Tantillo K, Mikheev A, Rusinek H, Babb JS, Storey P, Lee VS, Chandarana H. Intravoxel incoherent motion and diffusion-tensor imaging in renal tissue under hydration and furosemide flow challenges. Radiology 2012; 263:758-69. [PMID: 22523327 DOI: 10.1148/radiol.12111327] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the reproducibility and the distribution of intravoxel incoherent motion (IVIM) and diffusion-tensor (DT) imaging parameters in healthy renal cortex and medulla at baseline and after hydration or furosemide challenges. MATERIALS AND METHODS Using an institutional review board-approved HIPAA-compliant protocol with written informed consent, IVIM and DT imaging were performed at 3 T in 10 volunteers before and after water loading or furosemide administration. IVIM (apparent diffusion coefficient [ADC], tissue diffusivity [D(t)], perfusion fraction [f(p)], pseudodiffusivity [D(p)]) and DT (mean diffusivity [MD], fractional anisotropy [FA], eigenvalues [λ(i)]) imaging parameters and urine output from serial bladder volumes were calculated. (a)Reproducibility was quantified with coefficient of variation, intraclass correlation coefficient, and Bland-Altman limits of agreement; (b) contrast and challenge response were quantified with analysis of variance; and (c) Pearson correlations were quantified with urine output. RESULTS Good reproducibility was found for ADC, D(t), MD, FA, and λ(i) (average coefficient of variation, 3.7% [cortex] and 5.0% [medulla]), and moderate reproducibility was found for D(p), f(p), and f(p) · D(p) (average coefficient of variation, 18.7% [cortex] and 25.9% [medulla]). Baseline cortical diffusivities significantly exceeded medullary values except D(p), for which medullary values significantly exceeded cortical values, and λ(1,) which showed no contrast. ADC, D(t), MD, and λ(i) increased significantly for both challenges. Medullary diffusivity increases were dominated by transverse diffusion (1.72 ± 0.09 [baseline] to 1.79 ± 0.10 [hydration] μm(2)/msec, P = .0059; or 1.86 ± 0.07 [furosemide] μm(2)/msec, P = .0094). Urine output correlated with cortical ADC with furosemide (r = 0.7, P = .034) and with medullary λ(1) (r = 0.83, P = .0418), λ(2) (r = 0.85, P = .0301), and MD (r = 0.82, P = .045) with hydration. CONCLUSION Diffusion MR metrics are sensitive to flow changes in kidney induced by diuretic challenges. The results of this study suggest that vascular flow, tubular dilation, water reabsorption, and intratubular flow all play important roles in diffusion-weighted imaging contrast.
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Affiliation(s)
- Eric E Sigmund
- Department of Radiology, NYU Langone Medical Center, 660 First Ave, 4th Floor, New York, NY 10016, USA.
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The effects of warm ischaemia time on renal function after laparoscopic partial nephrectomy in patients with normal contralateral kidney. World J Urol 2011; 30:257-63. [DOI: 10.1007/s00345-011-0729-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 06/30/2011] [Indexed: 01/20/2023] Open
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Turagam MK, Velagapudi P, Kalra AS, Ramalingam VS, Sinnakirouchenan R, Holley JL. Outcomes of furosemide-mannitol infusion in hospitalized patients with heart failure: an observational single-center cohort study of 122 patients. Int J Cardiol 2011; 151:232-4. [PMID: 21703703 DOI: 10.1016/j.ijcard.2011.06.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/06/2011] [Indexed: 11/25/2022]
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The authors reply:. Crit Care Med 2010. [DOI: 10.1097/ccm.0b013e3181fd6702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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De Vecchis R, Ciccarelli A, Ariano C, Pucciarelli A, Cioppa C, Giasi A, Fusco A, Cantatrione S. [Renoprotective effect of small volumes of hypertonic saline solution in chronic heart failure patients with marked fluid retention: results of a case-control study]. Herz 2010; 36:12-7. [PMID: 20978728 DOI: 10.1007/s00059-010-3394-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 09/06/2010] [Accepted: 09/19/2010] [Indexed: 12/20/2022]
Abstract
During intensive therapy of chronic heart failure (CHF) patients with marked fluid retention using high doses of i.v. furosemide the additional effect of agents which might exert osmotic attraction of interstitial fluids has been proposed. They are thought to impede the impairment of renal blood supply and glomerular filtration rate, which may be caused by a combined action of cardiac preload acute reduction, hypotension and neurohormonal activation.We therefore assessed in CHF patients with NYHA class III and BNP values from 900 to 1500 pg/ml, who were treated with i.v. furosemide, the predictors of iatrogenic short term creatinine impairment by means of a case-control observational study from two centers. Patients with CHF had been treated for 6-8 days with intravenous loop diuretics alone or with an additional i.v. administration of other agents (plasma expanders, albumin, mannitol, inotropic support etc.). A rise in serum creatinine ≥ 25% of the basal value was considered as renal impairment.A total of 15 cases and 38 controls were enrolled. At univariate analysis, serum creatinine basal value ≥ 2.2 mg/dl, absence of hypertonic saline solution (HSS) in the therapeutic protocol, hyposodic diet and refractory oligoanuria were associated with an increased risk of worsening renal function precipitated by i.v. diuretic therapy. At multivariate analysis as a predictor of loop diuretic-related renal function impairment, we found a serum creatinine ≥ 2.2 mg/dl at baseline (OR: 63.33, 95% CI: 3.68-1088.73, p=0.0043) and the absence of HSS in the therapeutic regimen (OR: 25.0461, 95% CI: 2.07-302.53, p=0.0113). Moreover, in multivariate analysis ascites had some predictive value of renal deterioration (OR: 13.28, 95% CI: 1.0055-175.41, p=0,0495).
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Affiliation(s)
- R De Vecchis
- Presidio Sanitario Intermedio Elena d'Aosta, Cardiology Unit, via Cagnazzi 29, 80137 Naples, Italy.
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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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De Vecchis R, Ciccarelli A, Pucciarelli A. Unloading therapy by intravenous diuretic in chronic heart failure: a double-edged weapon? J Cardiovasc Med (Hagerstown) 2010; 11:571-4. [PMID: 20588135 DOI: 10.2459/jcm.0b013e32833d37b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A well established part of therapeutic approaches applying to cases of chronic heart failure (CHF) with extreme fluid retention is represented by intensive intravenous (i.v.) therapy with loop diuretics. This kind of therapy, if appropriately modulated according to the individual clinical picture and biohumoral pattern, is able to decrease the abnormally high ventricular filling pressures, thereby relieving the breathlessness while being able to retrieve a suitable urine output, so as to propitiate regression or disappearance of edema without unfavorable influences on renal clearance of nitrogenous compounds. Nevertheless, the intensive i.v. diuretic therapy should be tailored on the basis of a close assessment of baseline hemodynamic data and hemodynamic response to the medications, in addition to the careful diuretic dose titration and cautious evaluation of risk/benefit ratio. Actually, by using this kind of therapy, there is a risk that a tubular or glomerular injury can be generated and that a frequently preexisting renal dysfunction can be aggravated, especially when excessive doses of loop diuretics are being erroneously administered, so as to cause hypotension, hypoperfusion and/or relative dehydration in patients with decompensated CHF who could have expressly benefitted from intensive unloading therapy. Recently, the genesis of CHF-related progressive renal deterioration has been highlighted by affirming that a major role may be played rather by neurovegetative disorders, that is, by increase in sympathetic tone and abnormalities in kidney's vasomotility than by cardiac inotropism deficiency. The measures, thought to be able to prevent renal arterial constriction and to impede deterioration of glomerular filtration rate (GFR) due to the ischemic-necrotic tubular injury, as occurring in the set of intensive unloading therapy with i.v. furosemide or other loop diuretic, are represented by application of inotropic and renal vasodilator support by dopamine i.v. infusion at low doses or by other inotropic agents provided with recognized renal vasodilator properties and/or by addition to i.v. furosemide of osmotic agents able to expand the hematic volume, so counteracting or minimizing the reflex renal vasoconstriction induced by furosemide-related reduction in intravascular circulating volume: i.v. infusion of small volumes of hypertonic saline solution, as well as administration of albumin, mannitol and/or plasma expanders. Because renal impairment, as developing in the setting of CHF, has proven to represent a very important indicator of adverse outcome, every effort should be addressed to prevent any significant (>25% of basal value) rise in serum creatinine consequent to diuretic unloading therapy or to other procedures (paracentesis of tense ascites, ultrafiltration) aimed at rapid fluid removal in edematous or ascitic CHF or cardiogenetic anasarca. Ultrafiltration, even though a promising technique highly valued for its acknowledged property to obtain a more rapid fluid and weight loss in CHF patients with marked fluid retention, has been demonstrated so far to produce neurohumoral activation, creatinine abnormalities and symptomatic hypotensions similar to those due to i.v. loop diuretics; thus, the hypothesized advantages of this technique remain to be further clarified and confirmed, with regard to its safety profile and cost-effectiveness.
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Affiliation(s)
- Renato De Vecchis
- Cardiology Unit, Presidio Sanitario Intermedio Elena d'Aosta, Naples, Italy.
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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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Slagman MCJ, Sinkeler SJ, Hemmelder MH, Waanders F, Vogt L, Kluin-Nelemans HC, Navis G, Laverman GD. Erythropoietin is reduced by combination of diuretic therapy and RAAS blockade in proteinuric renal patients with preserved renal function. Nephrol Dial Transplant 2010; 25:3256-60. [PMID: 20339099 DOI: 10.1093/ndt/gfq149] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renin-angiotensin-aldosterone system (RAAS) blockade improves prognosis in renal patients, but usually requires diuretic co-treatment. RAAS blockade can decrease erythropoietin (EPO) and/or haemoglobin (Hb) levels. Diuretics decrease EPO in rodents, but their effect on EPO and Hb in humans is unknown. METHODS Proteinuric renal patients with preserved renal function were treated during 6-week periods with placebo, losartan 100 mg/day (LOS) and LOS plus hydrochlorothiazide 25 mg/day (LOS/HCT), in random order. RESULTS Hb was inversely related to proteinuria, and EPO levels were inappropriately low in relation to Hb. Hb was lowered by LOS with and without HCT. EPO was decreased by LOS/HCT, but not by LOS. CONCLUSIONS EPO and Hb are reduced by HCT added to LOS in proteinuric renal patients with preserved renal function. We hypothesize that EPO reduction by HCT is caused by a decrease in renal oxygen requirement, which is the main stimulus for EPO production, due to the inhibition of active tubular sodium reabsorption. Further studies should explore the exact mechanism of this phenomenon and its clinical impact.
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Affiliation(s)
- Maartje C J Slagman
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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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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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 2010; 36:196-209. [PMID: 20057995 PMCID: PMC2816797 DOI: 10.1007/s00134-009-1742-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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Ricksten SE, Swärd K. Atrial Natriuretic Peptide in Postoperative Acute Renal Failure. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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