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Abstract
As a consequence of the altered hepatic architecture in advanced liver disease, drug metabolism is modified by changes in pharmacokinetic and pharmacodynamic properties, leading to the appearance of adverse effects and drug interactions and increasing the risk of over- or underdosing of medications. However, there are no tests that accurately determine the degree of impairment of liver metabolic function; therefore, general recommendations are established based on the degree of hepatic extraction, degree of hepatic metabolism, and degree of protein binding. Although the hepatic toxicity of some frequently used drugs, such as acetaminophen, is well known, many health care professionals are unaware or not fully aware of the deleterious effects that other drugs can have on patients with advanced liver injury, as is the case for nonsteroidal anti-inflammatory drugs. It is very important to increase awareness among both health care professionals and patients with advanced liver disease to limit the use of inappropriate drugs and prevent drug-induced liver injury.
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García-Cortés M, Ortega-Alonso A, Andrade RJ. Safety of treating acute liver injury and failure. Expert Opin Drug Saf 2021; 21:191-203. [PMID: 34254839 DOI: 10.1080/14740338.2021.1955854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Acute liver injury and progression to acute liver failure can be life-threatening conditions that require prompt careful clinical assessment and therapeutic management. AREAS COVERED The aim of this article is to review the safety and side effect profile of pharmacological therapies used in the treatment of acute liver injury with specific focus on hepatic toxicity. We performed an extensive literature search with the terms 'acute liver injury,' 'acute liver failure,' 'therapy,' 'safety,' 'adverse reactions' and 'drug induced liver injury.' A thorough discussion of the main drugs and devices used in patients with acute liver injury and acute liver failure, its safety profile and the management of complications associated to therapy of these conditions is presented. EXPERT OPINION Several pharmacological approaches are used in acute liver injury and acute liver failure in an empirical basis. Whilst steroids are frequently tried in serious drug-induced liver injury there is concern on a potential harmful effect of these agents because of the higher mortality in patients receiving the drug; hence, statistical approaches such as propensity score matching might help resolve this clinical dilemma. Likewise, properly designed clinical trials using old and new drugs for subjects with serious drug-induced liver injury are clearly needed.
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Affiliation(s)
- Miren García-Cortés
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
| | - Aida Ortega-Alonso
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
| | - Raúl J Andrade
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
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Lucena MI, Sanabria J, García-Cortes M, Stephens C, Andrade RJ. Drug-induced liver injury in older people. Lancet Gastroenterol Hepatol 2020; 5:862-874. [DOI: 10.1016/s2468-1253(20)30006-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
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4
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Abstract
Patients are exposed to numerous prescribed and over-the-counter medications. Unfortunately, drugs remain a relatively common cause of acute and chronic kidney injury. A combination of factors including the innate nephrotoxicity of drugs, underlying patient characteristics that increase their risk for kidney injury, and the metabolism and pathway of excretion by the kidneys of the various agents administered enhance risk for drug-induced nephrotoxicity. This paper will review these clinically relevant aspects of drug-induced nephrotoxicity for the clinical nephrologist.
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Affiliation(s)
- Mark A Perazella
- Section of Nephrology, Department of Medicine, Yale University, New Haven, Connecticut and Veterans Affairs Medical Center, West Haven, Connecticut
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Robles-Diaz M, Medina-Caliz I, Lucena MI, Andrade RJ. Editorial: showing due DILIgence--the lessons from anabolic steroids; authors' reply. Aliment Pharmacol Ther 2015; 41:324. [PMID: 25946109 DOI: 10.1111/apt.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 12/08/2022]
Affiliation(s)
- M Robles-Diaz
- S Farmacología Clínica and UGC de Gastroenterología y Hepatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, University of Málaga, Málaga, Spain
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Robles-Diaz M, Gonzalez-Jimenez A, Medina-Caliz I, Stephens C, García-Cortes M, García-Muñoz B, Ortega-Alonso A, Blanco-Reina E, Gonzalez-Grande R, Jimenez-Perez M, Rendón P, Navarro JM, Gines P, Prieto M, Garcia-Eliz M, Bessone F, Brahm JR, Paraná R, Lucena MI, Andrade RJ. Distinct phenotype of hepatotoxicity associated with illicit use of anabolic androgenic steroids. Aliment Pharmacol Ther 2015; 41:116-25. [PMID: 25394890 DOI: 10.1111/apt.13023] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/15/2014] [Accepted: 10/21/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND We have observed an increase in hepatotoxicity (DILI) reporting related to the use of anabolic androgenic steroids (AAS) for bodybuilding. AIM To characterise phenotype presentation, outcome and severity of AAS DILI. METHODS Data on 25 cases of AAS DILI reported to the Spanish (20) and Latin-American (5) DILI Registries were collated and compared with previously published cases. RESULTS AAS DILI increased from representing less than 1% of the total cases in the Spanish DILI Registry in the period 2001-2009 to 8% in 2010-2013. Young men (mean age 32 years), requiring hospitalisation, hepatocellular injury and jaundice were predominating features among the AAS cases. AAS DILI caused significantly higher bilirubin values independent of type of damage when compared to other drug classes (P = 0.001). Furthermore, the cholestatic AAS cases presented significantly higher mean peak bilirubin (P = 0.029) and serum creatinine values (P = 0.0002), compared to the hepatocellular cases. In a logistic regression model, the interaction between peak bilirubin values and cholestatic damage was associated with the development of AAS-induced acute kidney impairment (AKI) [OR 1.26 (95% CI: 1.035-1.526); P = 0.021], with 21.5 ×ULN being the best bilirubin cut-off point for predicting AKI risk (AUCROC 0.92). No fatalities occurred. CONCLUSIONS Illicit recreational AAS use is a growing cause of reported DILI that can lead to severe hepatic and renal injury. AAS DILI is associated with a distinct phenotype, characterised by considerable bilirubin elevations independent of type of damage. Although hepatocellular injury predominates, acute kidney injury develops in cholestatic cases with pronounced jaundice.
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Affiliation(s)
- M Robles-Diaz
- Servicio de Farmacología Clínica and Unidad de Gestión Clínica (UGC) de Gastroenterología y Hepatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria, Universidad de Málaga (UMA), Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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7
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Abstract
Pharmaceutical agents provide diagnostic and therapeutic utility that are central to patient care. However, all agents also carry adverse drug effect profiles. While most of these are clinically insignificant, some drugs may cause unacceptable toxicity that impacts negatively on patient morbidity and mortality. Recognizing adverse effects is important for administering appropriate drug doses, instituting preventive strategies, and withdrawing the offending agent due to toxicity. In the present article, we will review those drugs that are associated with impaired renal function. By focusing on pharmaceutical agents that are currently in clinical practice, we will provide an overview of nephrotoxic drugs that a treating physician is most likely to encounter. In doing so, we will summarize risk factors for nephrotoxicity, describe clinical manifestations, and address preventive and treatment strategies.
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Affiliation(s)
| | - Anushree C Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA
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Abstract
With the reintroduction of colistimethate and polymyxin B into clinical practice, a review of their individual and comparative nephrotoxicity attributes as reported in contemporary literature was undertaken. Given variability in definitions used for acute kidney injury, a particular focus was placed on studies utilizing the Risk-Injury-Failure-Loss-End Stage Kidney Disease (RIFLE) criteria of assessment to provide for standardized comparison. Primary risk factors examined included the influence of dosing and the receipt of concomitant nephrotoxins. The typical severity and time course of renal injury that develops were also analyzed. Nephrotoxicity rates with colistimethate appear to approach 50%, and could be of lower frequency and severity with polymyxin B based on limited literature. Acute kidney injury generally appears to be mild to moderate in magnitude and reversible in nature, though as many as 20% of patients experiencing it may require renal replacement therapy of some duration. The majority of studies showed some relationship with dosing- variably reported as being associated with daily dose or cumulative exposure. Traditional nephrotoxic agents did not appear to confer additional risk individually in the majority of investigations, though receipt of multiple concurrent nephrotoxins did yield a relationship in several. Further studies will be required to better characterize the renal adverse effect profile of these agents, particularly in the case of polymyxin B.
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Ara C, Karabulut AB, Kirimlioglu H, Coban S, Ugras M, Kirimliglu V, Yilmaz S. Protective Effect of Resveratrol Against Renal Oxidative Stress in Cholestasis. Ren Fail 2009. [DOI: 10.1081/jdi-65221] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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11
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Abstract
Chronic liver disease encompasses a large number of hepatic disorders. One of the most important etiologies of liver disease is drug-induced liver disease, which is the leading cause of liver failure in patients referred for liver transplantation in the United States. Drug-induced liver disease can present in all forms of acute and chronic liver disease with highly variable clinical presentations. There is no effective treatment for most drug-induced liver disease and the recognition and prevention of drug-induced liver disease remain the most important management strategy. Drug dosing in patients with liver disease represents an even more challenging task to clinicians, as there is only scant information on biomarkers that can be used to predict the pharmacokinetic changes of drugs in patients with underlying liver disease. Several factors contribute to alterations in drugs metabolism and clearance in cirrhotic patients, including the severity of the liver disease and the metabolic pathways of each individual drug. Only general guidelines on dosage adjustment in patients with hepatic impairment are available. When drugs with extensive hepatic metabolism are required in patients with preexisting liver disease, benefit of therapeutic effect must be evaluated against the risk of toxicity, and the drugs must be initiated with extreme caution with appropriate dosage reduction.
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Ackerman Z, Karmeli F, Pizov G, Ben-Dov I, Pappo O. Renal effects of gentamicin in chronic bile duct ligated rats. Dig Dis Sci 2006; 51:406-15. [PMID: 16534689 DOI: 10.1007/s10620-006-3145-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 04/20/2005] [Indexed: 12/09/2022]
Abstract
Patients with advanced cirrhosis and rats with short-term bile duct ligation (BDL) are prone to develop nephrotoxicity from aminoglycosides. In this study, we characterized the renal response to gentamicin in rats with chronic BDL. BDL and sham-operated (SO) rats were given gentamicin (20 and 40 mg/kg/d) for 7 consecutive days, starting on the 18th postoperative day. Administration of gentamicin to SO group caused a decrease in cortical and medullary prostaglandin E(2)(PGE(2)) generation. However, mild reduction in creatinine clearance and an increase in fractional excretion of sodium occurred only in the BDL rats given the high gentamicin dose. This was accompanied by a reduction in cortical and medullary PGE(2) generation and a reduction in plasma nitric oxide production. In conclusion, gentamicin administration to rats with chronic BDL causes impairment of renal function. This happens only after the occurrence of simultaneous multiple insults to the renal protective mechanisms.
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Affiliation(s)
- Zvi Ackerman
- Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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13
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Abstract
The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Room 220, 9th Floor, Eaton Wing, M5G 2C4, ON, Canada.
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Padillo J, Puente J, Gómez M, Dios F, Naranjo A, Vallejo JA, Miño G, Pera C, Sitges-Serra A. Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment. Ann Surg 2001; 234:652-6. [PMID: 11685028 PMCID: PMC1422089 DOI: 10.1097/00000658-200111000-00010] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage. SUMMARY BACKGROUND DATA Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction. METHODS Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined. RESULTS Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output. CONCLUSIONS Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.
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Affiliation(s)
- J Padillo
- Department of Surgery, Hospital Universitario Reina Sofía, Córdoba, Spain
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15
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Chen CY, Shiesh SC, Tsao HC, Chen FF, Lin XZ. Protective effect of melatonin on renal injury of rats induced by bile duct ligation. Dig Dis Sci 2001; 46:927-31. [PMID: 11330436 DOI: 10.1023/a:1010793526884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Oxygen radicals have been implicated in the pathogenesis of renal injury induced by extrahepatic cholestasis. We conduct this study to investigate whether melatonin can have a protective effect against such injury. Either normal saline or gentamicin with or without melatonin was injected into rats that received either a bile duct ligation or a sham operation. The serum levels of malondialdehyde and total antioxidative activity were measured. The kidney was fixed for histologic scoring of renal injury. The serum malondialdehyde level was highest in the rats that received both bile duct ligation and gentamicin injection. Treatment with melatonin significantly increased the serum total antioxidative activity and reduced the serum malondialdehyde concentration. The mean score of renal injury, highest in the rats receiving bile duct ligation and gentamicin injection, was significantly reduced with melatonin treatment. By reducing the systemic oxygen radicals, supplementation with antioxidants exerts a protective effect on the renal injury induced by extrahepatic cholestasis.
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Affiliation(s)
- C Y Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
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16
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Affiliation(s)
- L S Friedman
- Gastrointestinal Unit (Medical Services), Massachusetts General Hospital and the Department of Medicine, Harvard Medical School, Boston, MA, USA.
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Martínez-Ródenas F, Pereira JA, Jiménez W, Gubern JM, Sitges-Serra A. Circulating bile is the main factor responsible for atrial natriuretic peptide release in experimental obstructive jaundice. Br J Surg 1998; 85:480-4. [PMID: 9607527 DOI: 10.1046/j.1365-2168.1998.00661.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Biliary obstruction in the rabbit causes increased release of atrial natriuretic peptide (ANP). Circulating bile, raised biliary pressure or absence of bile in the duodenum may be implicated in this hepatocardiac syndrome. METHODS An experimental model was developed to elucidate the mechanism linking obstructive jaundice and increased plasma ANP. Hepatic and renal function, biliary tree pressure and ANP plasma concentrations were investigated in conscious rabbits 4 and 24 h after common bile duct ligation, biliovenous shunting or external drainage via a biliary fistula. RESULTS Bilirubin concentration increased after bile duct ligation and creation of a biliovenous shunt. Plasma creatinine increased abruptly in rabbits with a biliovenous shunt. At 4 h, the ANP increase in animals with a biliovenous shunt was ninefold that observed after bile duct obstruction while no change was noted after external biliary diversion (mean 350 versus 45 versus 9 fmol/l; P < 0.01). Relief of biliary tree obstruction was associated with a return of ANP levels towards basal normal values. CONCLUSION Raised plasma ANP in obstructive jaundice is not the result of an increased biliary pressure per se or absence of bile in the proximal duodenum but of the passage of bile components to the circulation.
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Affiliation(s)
- F Martínez-Ródenas
- Department of Surgery, Hospital Universitari del Mar, Institut Municipal d'Investigacions Mèdiques, Barcelona, Spain
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Rodríguez-Mendizábal M, Lucena MI, Cabello MR, Blanco E, López-Rodríguez B, Sánchez de la Cuesta F. Variations in blood levels of aminoglycosides related to in vitro anticoagulant usage. Ther Drug Monit 1998; 20:88-91. [PMID: 9485561 DOI: 10.1097/00007691-199802000-00016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aminoglycosides (AMG) remain an important therapeutic modality for the treatment of gram-negative infections. Adequate AMG levels have been associated with a lower risk of toxicity. Because AMG levels cannot be predicted with confidence, drug concentrations need to be measured. The authors studied the effect of different anticoagulants on AMG concentrations, which were determined by enzyme immunoanalysis. Blood samples from patients treated with AMG were obtained, and were immediately distributed in five tubes containing EDTA, sodium-citrate, or heparin at concentrations of 5 and 50 U/ml; one serum aliquot was kept as a control. All AMG determinations were performed by the enzyme multiplied immunoassay technique with Cobas-Mira equipment. The average coefficient of variations was < 3%. All samples were run the same day. Analysis of variance for repeated measures was used. Twenty-four patients (21 male and 6 female) with a mean age of 50 years (95% confidence interval = 43 to 58) and mean serum creatinine concentrations of 0.87 to 0.29 +/- Standard Deviation received 89% gentamicin and 11% tobramycin. Peak levels of AMG obtained from plasma collected with sodium citrate or heparin were significantly lower (p < 0.001) than in serum or plasma collected with EDTA. The higher the level of AMG in serum, the greater the discrepancies between drug concentrations measured with different anticoagulants. The anticoagulant used was of critical importance in determining AMG blood levels, which were underestimated when citrate or heparin were present.
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Gallardo JM, Padillo J, Martín-Malo A, Miño G, Pera C, Sitges-Serra A. Increased plasma levels of atrial natriuretic peptide and endocrine markers of volume depletion in patients with obstructive jaundice. Br J Surg 1998; 85:28-31. [PMID: 9462378 DOI: 10.1046/j.1365-2168.1998.00572.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypovolaemia may cause renal dysfunction in obstructive jaundice. This study investigated whether, in patients with obstructive jaundice: (1) atrial natriuretic peptide (ANP) is increased; (2) fluid-regulating hormones are altered; and (3) biliary drainage improves fluid homoeostasis. METHODS Forty-three patients with obstructive jaundice were investigated. A renal profile was obtained and levels of ANP, renin, aldosterone and vasopressin were determined. In a subset of 18 patients, studies were repeated 3 days after endoscopic biliary drainage and changes in extracellular volume were measured. RESULTS Creatinine clearance was impaired in ten of 30 patients. Patients with obstructive jaundice had higher mean levels of ANP (118 versus 40 pg/ml, P = 0.0001) and aldosterone (156 versus 43 pg/ml, P = 0.0001) than matched controls. Increased renin levels were observed in ten of the 43 patients and were associated with impaired creatinine clearance. After biliary drainage ANP concentration decreased (110 versus 67 pg/ml, P = 0.004) as well as aldosterone level (182 versus 85 pg/ml, P = 0.0002) and the mean extracellular volume increased (20.5 versus 23.1 per cent of body-weight, P = 0.001). CONCLUSION Plasma ANP concentration is increased in obstructive jaundice. Endocrine markers of hypovolaemia are activated in obstructive jaundice. After biliary drainage there is an improvement of endocrine and fluid derangements.
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Affiliation(s)
- J M Gallardo
- Department of Surgery, Hospital Reina Sofía, Universidad de Córdoba, Barcelona, Spain
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20
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Affiliation(s)
- J Reichen
- Department of Clinical Pharmacology, University of Berne, Switzerland.
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21
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Jolobe OM. Renal dysfunction in obstructive jaundice. Br J Surg 1995; 82:1699. [PMID: 8548250 DOI: 10.1002/bjs.1800821242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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