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Yang X, Zhang F, Zhan Y, Liu Z, Wang W, Shi J. Association between estimated plasma volume status and acute kidney injury in patients who underwent coronary revascularization: A retrospective cohort study from the MIMIC-IV database. PLoS One 2024; 19:e0300656. [PMID: 38865385 PMCID: PMC11168641 DOI: 10.1371/journal.pone.0300656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/03/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) remains a common complication of coronary revascularization and increases poor outcomes in critically ill surgical patients. Compared to the plasma volume status (PVS), estimated plasma volume status (ePVS) has the advantages of being noninvasive and simple and has been shown to be associated with worse prognosis in patients undergoing coronary revascularization. This study was to evaluate the association of ePVS with the risk of AKI in patients who underwent coronary revascularization. METHODS In this retrospective cohort study, data of patients who underwent coronary revascularization were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019). The outcome was the occurrence of AKI after ICU admission. The covariates were screened via the LASSO regression method. Univariate and multivariate Logistic regression models were performed to assess the association of ePVS and PVS and the odds of AKI in patients who underwent coronary revascularization, with results shown as odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, surgery, and anticoagulation agents and sequential organ failure assessment (SOFA) score were performed to further explore the association of ePVS with AKI. RESULTS A total of 3,961 patients who underwent coronary revascularization were included in this study, of whom 2,863 (72.28%) had AKI. The high ePVS was associated with the higher odds of AKI in patients who received coronary revascularization (OR = 1.06, 95%CI: 1.02-1.10), after adjusting for the covariates such as age, race, SAPS-II score, SOFA score, CCI, weight, heart rate, WBC, RDW-CV, PT, BUN, glucose, calcium, PH, PaO2, mechanical ventilation, vasopressors, and diuretic. Similar results were found in patients who underwent the CABG (OR = 1.07, 95%CI: 1.02-1.11), without anticoagulation agents use (OR = 1.07, 95%CI: 1.03-1.12) and with high SOFA score (OR = 1.10, 95%CI: 1.04-1.17). No relationship was found between PVS and the odds of AKI in patients who underwent the coronary revascularization. CONCLUSION The ePVS may be a promising parameter to evaluate the risk of AKI in patients undergoing coronary revascularization, which provides a certain reference for the risk stratification management of ICU patients who underwent coronary revascularization.
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Affiliation(s)
- Xinping Yang
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Fan Zhang
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yongqiang Zhan
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Zhiheng Liu
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Wenjing Wang
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Jiahua Shi
- Department of Anesthesiology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
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Aguirre-Villarreal D, Leal-Villarreal MADJ, García-Juárez I, Argaiz ER, Koratala A. Sound waves and solutions: Point-of-care ultrasonography for acute kidney injury in cirrhosis. World J Crit Care Med 2024; 13:91212. [PMID: 38855265 PMCID: PMC11155499 DOI: 10.5492/wjccm.v13.i2.91212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 06/03/2024] Open
Abstract
This article delves into the intricate challenges of acute kidney injury (AKI) in cirrhosis, a condition fraught with high morbidity and mortality. The complexities arise from distinguishing between various causes of AKI, particularly hemodynamic AKI, in cirrhotic patients, who experience hemodynamic changes due to portal hypertension. The term "hepatocardiorenal syndrome" is introduced to encapsulate the intricate interplay among the liver, heart, and kidneys. The narrative emphasizes the often-overlooked aspect of cardiac function in AKI assessments in cirrhosis, unveiling the prevalence of cirrhotic cardiomyopathy marked by impaired diastolic function. The conventional empiric approach involving volume expansion and vasopressors for hepatorenal syndrome is critically analyzed, highlighting potential risks and variable patient responses. We advocate for a nuanced algorithm for AKI evaluation in cirrhosis, prominently featuring point-of-care ultrasonography (POCUS). POCUS applications encompass assessing fluid tolerance, detecting venous congestion, and evaluating cardiac function.
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Affiliation(s)
- David Aguirre-Villarreal
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | | | - Ignacio García-Juárez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City 14080, Mexico
| | - Eduardo R Argaiz
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City 64710, Mexico
| | - Abhilash Koratala
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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Khan AA, Saeed H, Haque IU, Iqbal A, Du D, Koratala A. Point-of-care ultrasonography spotlight: Could venous excess ultrasound serve as a shared language for internists and intensivists? World J Crit Care Med 2024; 13:93206. [PMID: 38855280 PMCID: PMC11155496 DOI: 10.5492/wjccm.v13.i2.93206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/24/2024] [Accepted: 05/11/2024] [Indexed: 06/03/2024] Open
Abstract
Point-of-care ultrasonography (POCUS), particularly venous excess ultrasound (VExUS) is emerging as a valuable bedside tool to gain real-time hemodynamic insights. This modality, derived from hepatic vein, portal vein, and intrarenal vessel Doppler patterns, offers a scoring system for dynamic venous congestion assessment. Such an assessment can be crucial in effective management of patients with heart failure exacerbation. It facilitates diagnosis, quantification of congestion, prognostication, and monitoring the efficacy of decongestive therapy. As such, it can effectively help to manage cardiorenal syndromes in various clinical settings. Extended or eVExUS explores additional veins, potentially broadening its applications. While VExUS demonstrates promising outcomes, challenges persist, particularly in cases involving renal and liver parenchymal disease, arrhythmias, and situations of pressure and volume overload overlap. Proficiency in utilizing spectral Doppler is pivotal for clinicians to effectively employ this tool. Hence, the integration of POCUS, especially advanced applications like VExUS, into routine clinical practice necessitates enhanced training across medical specialties.
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Affiliation(s)
- Anosh Aslam Khan
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, United States
| | - Hasham Saeed
- Department of Internal Medicine, Trinitas Regional Medical Center, Elizabeth, NJ 07202, United States
| | - Ibtehaj Ul Haque
- Department of Anesthesiology, Dr. Ruth K M Pfau Civil Hospital, Karachi 74400, Pakistan
| | - Ayman Iqbal
- Department of Internal Medicine, Dow Medical College, Karachi 74200, Pakistan
| | - Doantrang Du
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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Guinot PG, Longrois D, Andrei S, Nguyen M, Bouhemad B. Exploring congestion endotypes and their distinct clinical outcomes among ICU patients: A post-hoc analysis. Anaesth Crit Care Pain Med 2024; 43:101370. [PMID: 38462160 DOI: 10.1016/j.accpm.2024.101370] [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: 01/11/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND In the intensive care unit (ICU) patients, fluid overload and congestion are associated with worse outcomes. Because of the heterogeneity of ICU patients, we hypothesized that there may exist different endotypes of congestion. The aim of this study was to identify endotypes of congestion and their association with outcomes. METHODS We conducted an unsupervised hierarchical clustering analysis on 145 patients admitted to ICU to identify endotypes. We measured several parameters related to clinical context, volume status, filling pressure, and venous congestion. These parameters included NT-proBNP, central venous pressure (CVP), the mitral E/e' ratio, the systolic/diastolic ratio of hepatic veins' flow velocity, the mean diameter of the inferior vena cava (IVC) and its variations, stroke volume changes following passive leg raising, the portal vein pulsatility index, and the venous renal impedance index. RESULTS Three distinct endotypes were identified: (1) "hemodynamic congestion" endotype (n = 75) with moderate alterations of ventricular function, increased CVP and left filling pressure values, and moderate fluid overload; (2) "volume overload congestion" endotype (n = 50); with normal cardiac function and filling pressure despite high positive fluid balance (fluid overload); (3) "systemic congestion" endotype (n = 20) with severe alterations of left and right ventricular functions, increased CVP and left ventricular filling pressure values. These endotypes vary significantly in ICU admission reasons, acute kidney injury rates, mortality, and length of ICU/hospital stay. CONCLUSIONS Our analysis revealed three unique congestion endotypes in ICU patients, each with distinct pathophysiological features and outcomes. These endotypes are identifiable through key ultrasonographic characteristics at the bedside. CLINICAL TRIAL GOV NCT04680728.
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Affiliation(s)
- Pierre-Gregoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | - Dan Longrois
- Anesthesiology and Intensive Care Department, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France
| | - Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
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Barone R, Di Terlizzi V, Goffredo G, Paparella D, Brunetti ND, Iacoviello M. Renal Arterial and Venous Doppler in Cardiorenal Syndrome: Pathophysiological and Clinical Insights. Biomedicines 2024; 12:1166. [PMID: 38927373 DOI: 10.3390/biomedicines12061166] [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: 03/11/2024] [Revised: 05/07/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
In recent decades, there has been considerable effort in investigating the clinical utility of renal Doppler measurements in both cardiovascular and renal disorders. In particular, a measure of renal arterial resistance, the renal resistive index (RRI), has been demonstrated to predict chronic kidney disease progression and acute kidney injury in different clinical settings. Furthermore, it is linked to a poorer prognosis in individuals suffering from chronic heart failure. Examining the renal venous flow through pulsed Doppler can offer additional insights into renal congestion and cardiovascular outcomes for these patients. This review seeks to summarize the existing data concerning the clinical significance of arterial and venous renal Doppler measurements across various cardiovascular and renal disease contexts.
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Affiliation(s)
- Roberta Barone
- Cardiology Unit, Polyclinic University Hospital of Foggia, 71121 Foggia, Italy
| | - Vito Di Terlizzi
- Cardiology Unit, Polyclinic University Hospital of Foggia, 71121 Foggia, Italy
| | - Giovanni Goffredo
- Department of Medical and Surgical Sciences, University of Foggia, 71121 Foggia, Italy
| | - Domenico Paparella
- Department of Medical and Surgical Sciences, University of Foggia, 71121 Foggia, Italy
| | - Natale Daniele Brunetti
- Cardiology Unit, Polyclinic University Hospital of Foggia, 71121 Foggia, Italy
- Department of Medical and Surgical Sciences, University of Foggia, 71121 Foggia, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Polyclinic University Hospital of Foggia, 71121 Foggia, Italy
- Department of Medical and Surgical Sciences, University of Foggia, 71121 Foggia, Italy
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Sovetova SA, Nikiforova TA, Charaya KV, Shchekochikhin DY, Kulikov VM, Dubovitsky AM, Suchkova SA, Bogdanova AA, Ananicheva NA, Andreev DA. Hemodynamic Changes in Intrarenal Blood Flow are Associated With Poor Prognosis in Patients With Acute Decompensated Heart Failure. KARDIOLOGIIA 2024; 64:38-44. [PMID: 38742514 DOI: 10.18087/cardio.2024.4.n2575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/29/2023] [Indexed: 05/16/2024]
Abstract
AIM To evaluate a potential role of different patterns of intrarenal blood flow using Doppler ultrasound as a part of determining the severity of venous congestion, predicting impairment of renal function and an unfavorable prognosis in patients with acute decompensated chronic heart failure (ADCHF). MATERIAL AND METHODS This prospective observational single-site study included 75 patients admitted in the intensive care unit for ADCHF. Upon admission all patients underwent bedside renal venous Doppler ultrasound to determine the blood flow pattern (continuous, biphasic, monophasic). In one hour after the initiation of intravenous diuretic therapy, sodium concentration was measured in a urine sample. The primary endpoint was the development of acute kidney injury (AKI). The secondary endpoints were the development of diuretic resistance (a need to increase the furosemide daily dose by more than 2 times compared with the baseline), decreased natriuretic response (defined as urine sodium concentration less than 50-70 mmol/l), and in-hospital death. RESULTS According to the data of Doppler ultrasound, normal renal blood flow was observed in 40 (53%) patients, biphasic in 21 (28%) patients, and monophasic in 14 (19%) patients. The monophasic pattern of intrarenal blood flow was associated with the highest incidence of AKI: among 14 patients in this group, AKI developed in 100% of cases (OR 3.8, 95% CI: 2.5-5.8, p<0.01), while among patients with normal and moderate impairment of renal blood flow, there was no significant increase in the risk of developing AKI. The odds of in-hospital death were increased 25.77 times in patients with monophasic renal blood flow (95% CI: 5.35-123.99, p<0.001). Patients with a monophasic intrarenal blood flow pattern were also more likely to develop diuretic resistance compared to patients with other blood flow patterns (p<0.001) and had a decreased sodium concentration to less than 50 mmol/l (p<0.001) in a spot urine test obtained one hour after the initiation of furosemide administration. CONCLUSION Patients with monophasic intrarenal blood flow are at a higher risk of developing AKI, diuretic resistance with decreased natriuretic response, and in-hospital death.
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Affiliation(s)
| | | | - K V Charaya
- Sechenov First Moscow State Medical University
| | - D Yu Shchekochikhin
- Sechenov First Moscow State Medical University; Pirogov Municipal Clinical Hospital #1
| | - V M Kulikov
- Sechenov First Moscow State Medical University
| | | | | | | | | | - D A Andreev
- Sechenov First Moscow State Medical University
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7
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Mocan D, Lala RI, Puschita M, Pilat L, Darabantiu DA, Pop-Moldovan A. The Congestion "Pandemic" in Acute Heart Failure Patients. Biomedicines 2024; 12:951. [PMID: 38790913 PMCID: PMC11117769 DOI: 10.3390/biomedicines12050951] [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: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.
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Affiliation(s)
- Daniela Mocan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Radu Ioan Lala
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
| | - Maria Puschita
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Luminita Pilat
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | | | - Adina Pop-Moldovan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
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Kikuchi S, Kayama K, Kawada Y, Kitada S, Seo Y. Evaluation of renal circulation in heart failure using superb microvascular imaging, a microvascular flow imaging system. J Med Ultrason (2001) 2024; 51:283-292. [PMID: 38236503 DOI: 10.1007/s10396-023-01397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/15/2023] [Indexed: 01/19/2024]
Abstract
PURPOSE Renal circulation evaluation is essential in understanding the cardiorenal relationship in heart failure (HF), and there is a growing interest in imaging techniques that visualize renal circulation. This study aimed to assess the effectiveness of superb microvascular imaging (SMI) in evaluating renal circulation in HF patients. METHOD The study included 71 HF patients undergoing cardiac catheterization. Prior to catheterization, renal ultrasound examinations were performed. A control group of 18 subjects without HF was also included. SMI was used to measure the vascular index (VI), which was calculated as the percentage of blood flow signal area in the region of interest. The intrarenal perfusion index (IRPI) was determined as a fluctuation index of VI, reflecting variations in the number of blood cells moving through renal tissue during the cardiac cycle. RESULTS Using the upper 95% confidence interval of IRPI (0.6) from the control group, HF patients were classified into two groups. Patients with IRPI > 0.6 showed a more congestive profile. Right atrial pressure and biphasic or monophasic Doppler intrarenal flow pattern were independent determinants of IRPI > 0.6. In addition, IRPI remained a significant predictor of estimated glomerular filtration rate (eGFR). CONCLUSION The parameter IRPI as variations in SMI signal during the cardiac cycle may be a useful evaluation method for renal perfusion impairment in HF.
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Affiliation(s)
- Shohei Kikuchi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Kiyomi Kayama
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yu Kawada
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shuichi Kitada
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
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9
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Beaubien-Souligny W, Galarza L, Buchannan B, Lau VI, Adhikari NK, Deschamps J, Charbonney E, Denault A, Wald R. Prospective Study of Ultrasound Markers of Organ Congestion in Critically Ill Patients With Acute Kidney Injury. Kidney Int Rep 2024; 9:694-702. [PMID: 38481488 PMCID: PMC10927464 DOI: 10.1016/j.ekir.2023.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 06/03/2024] Open
Abstract
INTRODUCTION Organ congestion may be a mediator of adverse outcomes in critically ill patients with severe acute kidney injury (AKI). The presence of abnormal venous Doppler waveforms could identify patients with clinically significant organ congestion who may benefit from a decongestive strategy. METHODS This prospective multicenter cohort study enrolled patients with severe AKI defined as Kidney Disease: Improving Global Outcomes stage 2 or higher. Patients were not eligible if they received renal replacement therapy (RRT) for more than 72 hours at the time of screening. Participants underwent serial Doppler ultrasound examinations of the portal, hepatic and intrarenal veins during the week following enrolment. We calculated the venous excess ultrasound (VExUS) score based on these data. The primary outcome studied was major adverse kidney events at 30 days (MAKE30) defined as death, RRT dependence, or a persistent decrease in kidney function. RESULTS A total of 125 patients were included for whom 291 ultrasound assessments were performed. Severely abnormal venous waveforms were documented in 14.4% of portal vein assessments, 6.5% of intrarenal venous assessments, and 14.4% of hepatic vein assessments. The individual ultrasound markers were not associated with MAKE30. The VExUS score (grade 0-1: reference; grade 2: adjusted hazard ratio [aHR]: 4.03, confidence interval [CI]: 1.81-8.99; grade 3: aHR: 2.70, CI: 1.10-6.65; P = 0.03), as well as severely abnormal portal, hepatic and intrarenal vein Doppler were each independently associated with mortality. CONCLUSION Although not significantly associated with MAKE30, venous Doppler abnormalities suggestive of venous congestion were associated with higher mortality in critically ill patients with severe AKI.
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Affiliation(s)
- William Beaubien-Souligny
- Innovation hub, Centre de recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
- Division of Nephrology, Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitari de Castelló, Castelló de la Plana, Spain
| | - Brian Buchannan
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vincent I. Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton, Alberta, Canada
| | - Neill K.J. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean Deschamps
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emmanuel Charbonney
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - André Denault
- Division of Anesthesiology, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
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10
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Streng KW, Hillege HL, Ter Maaten JM, van Veldhuisen DJ, Dickstein K, Samani NJ, Ng LL, Metra M, Filippatos GS, Ponikowski P, Zannad F, Anker SD, van der Meer P, Lang CC, Voors AA, Damman K. Urinary Marker Profiles in Heart Failure with Reduced Versus Preserved Ejection Fraction. J Cardiovasc Transl Res 2024; 17:3-12. [PMID: 36795286 PMCID: PMC10896953 DOI: 10.1007/s12265-023-10356-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Recent data suggest different causes of renal dysfunction between heart failure with reduced (HFrEF) versus preserved ejection fraction (HFpEF). We therefore studied a wide range of urinary markers reflecting different nephron segments in heart failure patients. METHODS In 2070, in chronic heart failure patients, we measured several established and upcoming urinary markers reflecting different nephron segments. RESULTS Mean age was 70 ± 12 years, 74% was male and 81% (n = 1677) had HFrEF. Mean estimated glomerular filtration rate (eGFR) was lower in patients with HFpEF (56 ± 23 versus 63 ± 23 ml/min/1.73 m2, P = 0.001). Patients with HFpEF had significantly higher values of NGAL (58.1 [24.0-124.8] versus 28.1 [14.6-66.9] μg/gCr, P < 0.001) and KIM-1 (2.28 [1.49-4.37] versus 1.79 [0.85-3.49] μg/gCr, P = 0.001). These differences were more pronounced in patients with an eGFR > 60 ml/min/1.73m2. CONCLUSIONS HFpEF patients showed more evidence of tubular damage and/or dysfunction compared with HFrEF patients, in particular when glomerular function was preserved.
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Affiliation(s)
- Koen W Streng
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Kenneth Dickstein
- University of Bergen, 5007, Bergen, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, LE3 9QP, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gerasimos S Filippatos
- Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- University of Cyprus, Nicosia, Cyprus
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithe´Matique 1433, F-CRIN INI-CRCT, INSERM U1116, Universite´ de Lorraine, CHRU de Nancy, Nancy, France
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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11
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Gao Z, Li R, Li Q, Han Y, Huo Y, Zhang Q, Hu Z, Liu L. Central venous pressure combined with renal venous impedance index in predicting the acute kidney injury after thoracic and abdominal (non-cardiac) surgery. Asian J Surg 2024; 47:477-485. [PMID: 37438153 DOI: 10.1016/j.asjsur.2023.06.119] [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: 03/23/2023] [Revised: 06/12/2023] [Accepted: 06/22/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND In the 21st century, 13% of patients undergoing open abdominal surgery, 25% of patients undergoing heart surgery, and 57% of patients admitted to the intensive care unit (ICU) are affected by acute kidney injury (AKI). METHODS This prospective observational study included patients admitted directly to the ICU between June 2021 and December 2021. RESULTS A total of 81 patients were enrolled after thoracic and abdominal (non-cardiac) surgery; 36 patients (44.4%) were diagnosed with AKI occurred within 7 days after surgery. Six-hour postoperative central venous pressure(CVP) was a risk factor for AKI in thoracic and abdominal (non-cardiac) postoperative patients (odds ratio [OR], 1.418; 95% confidence intervals [CI], 1.106-1.819; P = 0.006). Six-hour postoperative vein impedance index(VII) and CVP were significantly positively correlated (P = 0.031). The combination of 6-h postoperative VII with CVP (VII ≥0.34, CVP ≥7.5 mmHg) showed an area under the curve (AUC) of 0.787, In the subgroup analysis of patients with 6-h postoperative CVP <7.5 mmHg, there was a significant statistical difference in 6-h postoperative VII between the groups and those without AKI (P = 0.048). At 6-h postoperative CVP <7.5 mmHg, VII of ≥0.44 had a predictive value for AKI after thoracic and abdominal (non-cardiac) surgery, with an AUC of 0.669, a sensitivity of 41.2%, and a specificity of 94.4%. CONCLUSION Six-hour postoperative CVP combined with VII can better predict the occurrence of AKI occurred within 7 days after thoracic and abdominal (non-cardiac) surgery but cannot predict the severity of AKI.
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Affiliation(s)
- Zetong Gao
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Rong Li
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Qiqi Li
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Yaqi Han
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Yan Huo
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Qian Zhang
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Zhenjie Hu
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China
| | - Lixia Liu
- Chinese Critical Ultrasound Study Group(CCUSG), Department of Critical Care, The Fourth Hospital of Hebei Medical University, China.
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12
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Sorolla-Romero JA, Navarrete-Navarro J, Martinez-Sole J, Garcia HMG, Diez-Gil JL, Martinez-Dolz L, Sanz-Sanchez J. Pharmacological Considerations during Percutaneous Treatment of Heart Failure. Curr Pharm Des 2024; 30:565-577. [PMID: 38477207 DOI: 10.2174/0113816128284131240209113009] [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: 10/05/2023] [Accepted: 01/25/2024] [Indexed: 03/14/2024]
Abstract
Heart Failure (HF) remains a global health challenge, marked by its widespread prevalence and substantial resource utilization. Although the prognosis has improved in recent decades due to the treatments implemented, it continues to generate high morbidity and mortality in the medium to long term. Interventional cardiology has emerged as a crucial player in HF management, offering a diverse array of percutaneous treatments for both acute and chronic HF. This article aimed to provide a comprehensive review of the role of percutaneous interventions in HF patients, with a primary focus on key features, clinical effectiveness, and safety outcomes. Despite the growing utilization of these interventions, there remain critical gaps in the existing body of evidence. Consequently, the need for high-quality randomized clinical trials and extensive international registries is emphasized to shed light on the specific patient populations and clinical scenarios that stand to benefit most from these innovative devices.
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Affiliation(s)
- Jose Antonio Sorolla-Romero
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
| | - Javier Navarrete-Navarro
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
| | - Julia Martinez-Sole
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
| | - Hector M Garcia Garcia
- Department of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Washington, DC 20010, United States
| | - Jose Luis Diez-Gil
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
| | - Luis Martinez-Dolz
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
| | - Jorge Sanz-Sanchez
- Department of Cardiology, Hospital Universitari i Politècnic La Fe, Avenida Fernando Abril Martorell 116, Valencia, Spain
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13
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Vella A, Labate V, Carenini G, Alfonzetti E, Milani V, Bandera F, Oliva O, Guazzi M. Phenotyping congestion in acute heart failure by renal flow and right heart to pulmonary circulation coupling. ESC Heart Fail 2023; 10:3546-3558. [PMID: 37743691 PMCID: PMC10682856 DOI: 10.1002/ehf2.14522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/03/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
AIMS In acute heart failure (AHF), kidney congestion is basic to treatment and prognosis. Its aetiology is manifold and quite unexplored in details mainly regarding the right heart to pulmonary circulation (Pc) coupling. We investigated the right heart to kidney interrelationship by Doppler renal flow pattern, right atrial dynamics, and right ventricular (RV) function to Pc coupling in AHF. METHODS AND RESULTS In 119 AHF patients, echocardiographic and renal Doppler data were analysed. Univariate and multivariate regression models were performed to define the determinants of a quantitative parameter of renal congestion, the renal venous stasis index (RVSI). When grouped according to different intra-renal venous flow patterns, no differences were observed in haemodynamics and baseline renal function. Nonetheless, patients with renal Doppler evidence of congestion showed a reduced RV function [tricuspid annular plane systolic excursion (TAPSE), S'-wave velocity, and fractional area change], impaired RV to Pc coupling [TAPSE/pulmonary artery systolic pressure (PASP) ratio], and right atrial peak longitudinal strain (RAPLS), along with signs of volume overload [increased inferior vena cava (IVC) diameters and estimated right atrial pressure]. Univariate and multivariate regression analyses confirmed TAPSE/PASP, RAPLS, and IVC diameter as independent determinants of the RVSI. RVSI was the only variable predicting the composite outcome (cardiac death, heart failure hospitalization, and haemodialysis). An easy-to-use echo-derived right heart score of four variables provided good accuracy in identifying kidney congestion. CONCLUSIONS In AHF, the renal venous flow pattern combined with a right heart study phenotypes congestion and clinical evolution. Keys to renal flow disruption are an impaired right atrial dynamics and RV-Pc uncoupling. Integration of four right heart echocardiographic variables may be an effective tool for scoring the renal congestive phenotype in AHF.
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Affiliation(s)
| | | | | | | | | | | | | | - Marco Guazzi
- Department of Biological SciencesUniversity of Milan School of MedicineMilanItaly
- Cardiology DivisionSan Paolo HospitalMilanItaly
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14
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Liu L, Liu D, Hu Z, Wang X, Chao Y, Wu J, Yin W, Zhang H, Zhang L, He W, Zhu R, Xu Q, Yang R, Huo Y, Zhang Q, Liu H, Zhu W, Zhang Q, Li R. Renal hemodynamic evaluation protocol based on the pathophysiological mechanism of acute kidney injury: Critical Care UltraSound Guided-A (KI)BCDE. Ren Fail 2023; 45:2284842. [PMID: 37994455 PMCID: PMC11001348 DOI: 10.1080/0886022x.2023.2284842] [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: 05/02/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
The multiple etiological characteristics of acute kidney injury (AKI) have brought great challenges to its clinical diagnosis and treatment. Renal injury in critically ill patients always indicates hemodynamic injury. The Critical Care UltraSound Guided (CCUSG)-A(KI)BCDE protocol developed by the Chinese Critical Ultrasound Study Group (CCUSG), respectively, includes A(KI) diagnosis and risk assessment and uses B-mode ultrasound, Color doppler ultrasound, spectral Doppler ultrasound, and contrast Enhanced ultrasound to obtain the hemodynamic characteristics of the kidney so that the pathophysiological mechanism of the occurrence and progression of AKI can be captured and the prognosis of AKI can be predicted combined with other clinical information; therefore, the corresponding intervention and treatment strategies can be formulated to achieve targeted, protocolized, and individualized therapy.
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Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Dawei Liu
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Zhenjie Hu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoting Wang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Affiliated Hospital of Tsinghua University, Beijing, China
| | - Jun Wu
- Department of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanhong Yin
- Department of Intensive Care, West China Hospital, Sichuan University, Chengdu, China
| | - Hongmin Zhang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Wei He
- Department of Intensive Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ran Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Rongli Yang
- Department of Critical Care Medicine, The Central Hospital of Dalian, Dalian, China
| | - Yan Huo
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qian Zhang
- Department of Intensive Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Haitao Liu
- Department of Critical Care Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
| | - Weihua Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qian Zhang
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rong Li
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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15
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Galarza Barrachina L, Colinas Fernández L, Martín Bermúdez R, Fernández Galilea A, Martín-Villén L. Abdominal ultrasound and VExUS score in critical care. Med Intensiva 2023; 47:658-667. [PMID: 38783747 DOI: 10.1016/j.medine.2023.06.008] [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: 03/01/2023] [Accepted: 06/23/2023] [Indexed: 05/25/2024]
Abstract
The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.
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Affiliation(s)
| | | | | | | | - Luis Martín-Villén
- UGC Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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16
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Turrini F, Galassi M, Sacchi A, Ricco' B, Chester J, Famiglietti E, Messora R, Bertolotti M, Pinelli G. Intrarenal Venous Doppler as a novel marker for optimal decongestion, patient management, and prognosis in Acute Decompensated Heart Failure. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:673-681. [PMID: 37406242 DOI: 10.1093/ehjacc/zuad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/18/2023] [Accepted: 07/04/2023] [Indexed: 07/07/2023]
Abstract
AIMS An increase in right atrial pressure is a common feature of acute decompensated heart failure (ADHF). Such increased pressure leads to persistent kidney congestion. A marker to guide optimal diuretic therapy is missing. We aim to correlate intrarenal Doppler (IRD) ultrasound in ADHF patients with clinical outcomes to assess whether renal haemodynamic parameter changes are useful for monitoring kidney congestion. METHODS AND RESULTS Between December 2018 and January 2020, ADHF patients requiring intravenous diuretic therapy for at least 48 h were considered for study selection. An IRD blinded examination was performed on Days 1, 3, and 5, and clinical and laboratory parameters were recorded. Venous Doppler profiles (VDP) were classified as continuous (C), pulsatile (P), biphasic (B), or monophasic (M) according to the congestion degree; B and M profiles were considered deranged. A VDP improvement (VDPimp) was defined as a change of ≥1 pattern degree or maintenance of C or P patterns. An arterial resistive index (RI) > 0.8 was considered elevated. Outcomes of death and rehospitalization were gathered at 60 days. Data were assessed by regression and Kaplan-Meier analyses. All 177 ADHF patients admitted were screened, and 72 were enrolled [27 females-median age 81 (76-87) years-median ejection fraction 40% (30-52)]. The VDP derangement decreased from 79.2% on Day 1 to 51.4% on Day 5 (P < 0.05). The RI elevation decreased from 60.6% on Day 1 to 43.1% on Day 5 (P < 0.05). At Day 5, VDPimp was registered in over half of the patients (59.7%). At Day 5, signs of congestion (dyspnoea/oedema/rales), fluid accumulation (pleural/peritoneal fluid), haematocrit, and brain natriuretic peptide improved (P > 0.05). After 60 days, 12 (16.7%) patients were readmitted and 9 (12.5%) died. The VDPimp was identified as the unique independent factor associated with readmission [Hazard Ratio (HR) 0.22, 95% (confidence interval) CI 0.05-0.94, P = 0.04] and death (HR 0.07, 95% CI 0.01-0.68, P = 0.02), with significantly better outcomes identified in VDPimp patients (log-rank test, P < 0.05). CONCLUSION Decongestion may be associated with improvements in many clinical and instrumental parameters, but only VDPimp was associated with better clinical outcomes. The VDPimp should be incorporated in ad hoc ADHF clinical trials to better define its role in everyday practice.
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Affiliation(s)
- Fabrizio Turrini
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Matteo Galassi
- Division of Geriatric Medicine, Department of Biomedical, Metabolic and Neural Sciences, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Andrea Sacchi
- Division of Geriatric Medicine, Department of Biomedical, Metabolic and Neural Sciences, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Beatrice Ricco'
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Johanna Chester
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Elena Famiglietti
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Roberto Messora
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Marco Bertolotti
- Division of Geriatric Medicine, Department of Biomedical, Metabolic and Neural Sciences, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
| | - Giovanni Pinelli
- Division of Internal and Emergency Medicine, Azienda Ospedaliera Universitaria-Ospedale Civile Sant'Agostino Estense, Via Giardini 1455, 41125 Modena, Italy
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17
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Athanassopoulos GD, Armenis I. A Glimpse for Venous Congestion Management in Pulmonary Hypertension by POCUS of Portal Vein Flow. Am J Cardiol 2023; 205:504-507. [PMID: 37661556 DOI: 10.1016/j.amjcard.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Affiliation(s)
| | - Iakovos Armenis
- Onassis Cardiac Surgery Center Cardiology Section, Athens, Greece
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18
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Guerrero-Gutiérrez MA, García-Guillén FJ, Adame-Encarnación H, Monera-Martínez F, Ñamendys-Silva SA, Córdova-Sánchez BM. Reliability of point-of-care ultrasound to evaluate fluid tolerance performed by critical care residents. Eur J Med Res 2023; 28:431. [PMID: 37828607 PMCID: PMC10571403 DOI: 10.1186/s40001-023-01397-9] [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: 09/21/2022] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Patients with hypotension usually receive intravenous fluids, but only 50% will respond to fluid administration. We aimed to assess the intra and interobserver agreement to evaluate fluid tolerance through diverse ultrasonographic methods. METHODS We prospectively included critically ill patients on mechanical ventilation. One trained intensivist and two intensive care residents obtained the left ventricular outflow tract velocity-time integral (VTI) variability, inferior vena cava (IVC) distensibility index, internal jugular vein (IJV) distensibility index, and each component of the venous excess ultrasound (VExUS) system. We obtained the intraclass correlation coefficient (ICC) and Gwet's first-order agreement coefficient (AC1), as appropriate. RESULTS We included 32 patients. In-training observers were unable to assess the VTI-variability in two patients. The interobserver agreement was moderate to evaluate the IJV-distensibility index (AC1 0.54, CI 95% 0.29-0.80), fair to evaluate VTI-variability (AC1 0.39, CI 95% 0.12-0.66), and absent to evaluate the IVC-distensibility index (AC1 0.19, CI 95% - 0.07 to 0.44). To classify patients according to their VExUS grade, the intraobserver agreement was good, and the interobserver agreement was moderate (AC1 0.52, CI 95% 0.34-0.69). CONCLUSIONS Point-of-care ultrasound is frequently used to support decision-making in fluid management. However, we observed that the VTI variability and IVC-distensibility index might require further training of the ultrasound operators to be clinically useful. Our findings suggest that the IJV-distensibility index and the VExUS system have acceptable reproducibility among in-training observers.
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Affiliation(s)
| | | | | | | | - Silvio A Ñamendys-Silva
- Instituto Nacional de Cancerología, San Fernando #22, Tlalpan, Mexico City, Mexico
- Instituto Nacional de Ciencias Medicas y de la Nutricion Salvador Zubiran, Mexico City, Mexico
- Hospital Medica Sur, Mexico City, Mexico
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19
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Kenneally LF, Lorenzo M, Romero-González G, Cobo M, Núñez G, Górriz JL, Barrios AG, Fudim M, de la Espriella R, Núñez J. Kidney function changes in acute heart failure: a practical approach to interpretation and management. Clin Kidney J 2023; 16:1587-1599. [PMID: 37779845 PMCID: PMC10539207 DOI: 10.1093/ckj/sfad031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Indexed: 10/03/2023] Open
Abstract
Worsening kidney function (WKF) is common in patients with acute heart failure (AHF) syndromes. Although WKF has traditionally been associated with worse outcomes on a population level, serum creatinine concentrations vary greatly during episodes of worsening heart failure, with substantial individual heterogeneity in terms of their clinical meaning. Consequently, interpreting such changes within the appropriate clinical context is essential to unravel the pathophysiology of kidney function changes and appropriately interpret their clinical meaning. This article aims to provide a critical overview of WKF in AHF, aiming to provide physicians with some tips and tricks to appropriately interpret kidney function changes in the context of AHF.
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Affiliation(s)
- Laura Fuertes Kenneally
- Cardiology Department, General Hospital of Alicante, Dr Balmis. Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). Alicante, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Gregorio Romero-González
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Marta Cobo
- CIBER Cardiovascular
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
| | - Gonzalo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Jose Luis Górriz
- Nephrology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, Valencia, Spain
| | - Ana Garcia Barrios
- Cardiology Department, General Hospital of Alicante, Dr Balmis. Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). Alicante, Spain
| | - Marat Fudim
- Cardiology Department, Duke University Medical Center. Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, Valencia, Spain
- CIBER Cardiovascular
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20
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Del Punta L, De Biase N, Mazzola M, Filidei F, Balletti A, Armenia S, Di Fiore V, Buralli S, Galeotti GG, De Carlo M, Giannini C, Masi S, Pugliese NR. Bio-Humoral and Non-Invasive Haemodynamic Correlates of Renal Venous Flow Patterns across the Heart Failure Spectrum. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1704. [PMID: 37893422 PMCID: PMC10608031 DOI: 10.3390/medicina59101704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
Background: We evaluated the bio-humoral and non-invasive haemodynamic correlates of renal congestion evaluated by Doppler renal venous flow (RVF) across the heart failure (HF) spectrum, from asymptomatic subjects with cardiovascular risk factors (Stage A) and structural heart disease (Stage B) to patients with clinically overt HF (Stage C). Methods: Ultrasound evaluation, including echocardiography, lung ultrasound and RVF, along with blood and urine sampling, was performed in 304 patients. Results: Continuous RVF was observed in 230 patients (76%), while discontinuous RVF (dRVF) was observed in 74 (24%): 39 patients had pulsatile RVF, 18 had biphasic RVF and 17 had monophasic RVF. Stage C HF was significantly more common among patients with dRVF. Monophasic RVF was associated with worse renal function and a higher urinary albumin-to-creatinine ratio (uACR). After adjusting for hypertension, diabetes mellitus, the presence of Stage C HF and serum creatinine levels, worsening RVF patterns were associated with higher NT-proBNP levels, worse right ventricular-arterial coupling, larger inferior vena cava and higher echo-derived pulmonary artery wedge pressure. This trend was confirmed when only patients with HF Stage C were analysed after adjusting for the left ventricle ejection fraction (LVEF). Conclusion: Abnormal RVF is common across the HF spectrum. Worsening RVF patterns are independently associated with increased congestion, worse non-invasive haemodynamics and impaired RV-arterial coupling. RVF evaluation could refine prognostic stratification across the HF spectrum, irrespective of LVEF.
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Affiliation(s)
- Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Matteo Mazzola
- Department of Pathology, Cardiology Division, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Alessio Balletti
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Simona Buralli
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Gian Giacomo Galeotti
- Department of Pathology, Cardiology Division, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Marco De Carlo
- Cardiac, Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (M.D.C.)
| | - Cristina Giannini
- Cardiac, Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy; (M.D.C.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
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21
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [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: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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22
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Husain‐Syed F, Singam NSV, Viehman JK, Vaughan L, Bauer P, Gall H, Tello K, Richter MJ, Yogeswaran A, Romero‐González G, Rosner MH, Ronco C, Assmus B, Ghofrani HA, Seeger W, Birk H, Kashani KB. Changes in Doppler-Derived Kidney Venous Flow and Adverse Cardiorenal Outcomes in Patients With Heart Failure. J Am Heart Assoc 2023; 12:e030145. [PMID: 37577933 PMCID: PMC10492931 DOI: 10.1161/jaha.123.030145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
Background The impact of changes in Doppler-derived kidney venous flow in heart failure (HF) is not well studied. We aimed to investigate the association of Doppler-derived kidney venous stasis index (KVSI) and intrakidney venous-flow (IKVF) patterns with adverse cardiorenal outcomes in patients with HF. Methods and Results In this observational cohort study, consecutive inpatients with HF referred to a nephrologist because of a history of diuretic resistance and abnormal kidney function (n=216) underwent spectral kidney assessments after admission (Doppler 1) and 25 to 35 days later (Doppler 2) to identify IKVF patterns (continuous/pulsatile/biphasic/monophasic) and KVSI levels. Cox proportional hazard regression models were used to evaluate the associations between KVSI/IKVF patterns at Doppler 1 as well as changes from Doppler 1 to Doppler 2 and risk of cardiorenal events up to 18 months after admission. Worsening HF or death occurred in 126 patients. Both baseline KVSI (hazard ratio [HR], 1.49 [95% CI, 1.37-1.61] per 0.1-unit increase) and baseline IKVF pattern (HR, 2.47 [95% CI, 2.01-3.04] per 1 pattern severity increase) were significantly associated with worsening HF/death. Increases in both KVSI and IKVF pattern severity from Doppler 1 to 2 were also associated with an increased risk of worsening HF/death (HR, 3.00 [95% CI, 2.08-4.32] per 0.1-unit increase change; and HR, 6.73 [95% CI, 3.27-13.86] per 1 pattern increase in severity change, respectively). Similar results were observed for kidney outcomes. Conclusions Baseline kidney venous flow predicted adverse cardiorenal events, and inclusion of serial kidney venous flow in cardiorenal risk stratification could facilitate clinical decision-making for patients with HF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03039959.
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Affiliation(s)
- Faeq Husain‐Syed
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Division of NephrologyUniversity of Virginia School of MedicineCharlottesvilleVA
| | - Narayana Sarma V. Singam
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMN
- Departments of Cardiology and Critical CareMedStar Washington Hospital CenterWashingtonDCUSA
| | - Jason K. Viehman
- Division of Clinical Trials and BiostatisticsMayo ClinicRochesterMN
| | - Lisa Vaughan
- Division of Clinical Trials and BiostatisticsMayo ClinicRochesterMN
| | - Pascal Bauer
- Division of Cardiology and Angiology, Department of Internal Medicine IUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
| | - Henning Gall
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio‐Pulmonary Institute, Member of the German Center for Lung ResearchGiessenGermany
| | - Khodr Tello
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio‐Pulmonary Institute, Member of the German Center for Lung ResearchGiessenGermany
| | - Manuel J. Richter
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio‐Pulmonary Institute, Member of the German Center for Lung ResearchGiessenGermany
| | - Athiththan Yogeswaran
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio‐Pulmonary Institute, Member of the German Center for Lung ResearchGiessenGermany
| | - Gregorio Romero‐González
- Department of NephrologyUniversity Hospital Germans Trias i PujolBarcelonaSpain
- International Renal Research Institute of Vicenza, Department of NephrologyDialysis and Transplantation, San Bortolo HospitalVicenzaItaly
| | - Mitchell H. Rosner
- Division of NephrologyUniversity of Virginia School of MedicineCharlottesvilleVA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of NephrologyDialysis and Transplantation, San Bortolo HospitalVicenzaItaly
- Department of MedicineUniversità di PadovaPaduaItaly
| | - Birgit Assmus
- Division of Cardiology and Angiology, Department of Internal Medicine IUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Department of PulmonologyKerckhoff‐KlinikBad NauheimGermany
| | - Werner Seeger
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center, Institute for Lung Health, Cardio‐Pulmonary Institute, Member of the German Center for Lung ResearchGiessenGermany
| | - Horst‐Walter Birk
- Department of Internal Medicine IIUniversity Hospital Giessen and Marburg, Justus‐Liebig‐University GiessenGiessenGermany
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMN
- Division of Nephrology and Hypertension, Department of Internal MedicineMayo ClinicRochesterMNUSA
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23
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Wallbach M, Valentova M, Schroeter MR, Alkabariti A, Iraki I, Leha A, Tampe D, Hasenfuß G, Zeisberg M, Hellenkamp K, Koziolek MJ. Intrarenal Doppler ultrasonography in patients with HFrEF and acute decompensated heart failure undergoing recompensation. Clin Res Cardiol 2023; 112:1087-1095. [PMID: 36964794 PMCID: PMC10359357 DOI: 10.1007/s00392-023-02184-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES Renal venous congestion due to backward heart failure leads to disturbance of renal function in acute decompensated heart failure (ADHF). Whether decongestion strategies have an impact on renal venous congestion is unknown. Objective was to evaluate changes in intrarenal hemodynamics using intrarenal Doppler ultrasonography (IRD) in patients with heart failure with reduced ejection fraction (HFrEF) and ADHF undergoing recompensation. METHODS Prospective observational study in patients with left ventricular ejection fraction (LV-EF) ≤ 35% hospitalized due to ADHF. IRD measurement was performed within the first 48 h of hospitalisation and before discharge. Decongestion strategies were based on clinical judgement according to heart failure guidelines. IRD was used to assess intrarenal venous flow (IRVF) pattern, venous impedance index (VII) and resistance index (RI). Laboratory analyses included plasma creatinine, eGFR and albuminuria. RESULTS A number of 35 patients with ADHF and LV-EF ≤ 35% were included into the study. IRD could be performed in 30 patients at inclusion and discharge. At discharge, there was a significant reduction of VII from a median of 1.0 (0.86-1.0) to 0.59 (0.26-1.0) (p < 0.01) as well as improvement of IRVF pattern categories (p < 0.05) compared to inclusion. Albuminuria was significantly reduced from a median of 78 mg/g creatinine (39-238) to 29 mg/g creatinine (16-127) (p = 0.02) and proportion of patients with normoalbuminuria increased (p = 0.01). Plasma creatinine and RI remained unchanged (p = 0.73; p = 0.43). DISCUSSION This is the first study showing an effect of standard ADHF therapy on parameters of renal venous congestion in patients with HFrEF and ADHF. Doppler sonographic evaluation of renal venous congestion might provide additional information to guide decongestion strategies in patients with ADHF.
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Affiliation(s)
- M Wallbach
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany.
| | - M Valentova
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
| | - M R Schroeter
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - A Alkabariti
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - I Iraki
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
- Deutsches Herzzentrum Göttingen, Göttingen, Germany
- Deutschen Gesellschaft Für Kardiologie (Young DGK), University Medical Center, Göttingen, Germany
| | - A Leha
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - D Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - G Hasenfuß
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - M Zeisberg
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - K Hellenkamp
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - M J Koziolek
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany.
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24
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Fujii K, Nakayama I, Izawa J, Iida N, Seo Y, Yamamoto M, Uenishi N, Terasawa T, Iwata M. Association between intrarenal venous flow from Doppler ultrasonography and acute kidney injury in patients with sepsis in critical care: a prospective, exploratory observational study. Crit Care 2023; 27:278. [PMID: 37430356 PMCID: PMC10332034 DOI: 10.1186/s13054-023-04557-9] [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: 03/30/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Intrarenal venous flow (IRVF) patterns assessed using Doppler renal ultrasonography are real-time bedside visualizations of renal vein hemodynamics. Although this technique has the potential to detect renal congestion during sepsis resuscitation, there have been few studies on this method. We aimed to examine the relationship between IRVF patterns, clinical parameters, and outcomes in critically ill adult patients with sepsis. We hypothesized that discontinuous IRVF was associated with elevated central venous pressure (CVP) and subsequent acute kidney injury (AKI) or death. METHODS We conducted a prospective observational study in two tertiary-care hospitals, enrolling adult patients with sepsis who stayed in the intensive care unit for at least 24 h, had central venous catheters placed, and received invasive mechanical ventilation. Renal ultrasonography was performed at a single time point at the bedside after sepsis resuscitation, and IRVF patterns (discontinuous vs. continuous) were confirmed by a blinded assessor. The primary outcome was CVP obtained at the time of renal ultrasonography. We also repeatedly assessed a composite of Kidney Disease Improving Global Outcomes of Stage 3 AKI or death over the course of a week as a secondary outcome. The association of IRVF patterns with CVP was examined using Student's t-test (primary analysis) and that with composite outcomes was assessed using a generalized estimating equation analysis, to account for intra-individual correlations. A sample size of 32 was set in order to detect a 5-mmHg difference in CVP between IRVF patterns. RESULTS Of the 38 patients who met the eligibility criteria, 22 (57.9%) showed discontinuous IRVF patterns that suggested blunted renal venous flow. IRVF patterns were not associated with CVP (discontinuous flow group: mean 9.24 cm H2O [standard deviation: 3.19], continuous flow group: 10.65 cm H2O [standard deviation: 2.53], p = 0.154). By contrast, the composite outcome incidence was significantly higher in the discontinuous IRVF pattern group (odds ratio: 9.67; 95% confidence interval: 2.13-44.03, p = 0.003). CONCLUSIONS IRVF patterns were not associated with CVP but were associated with subsequent AKI in critically ill adult patients with sepsis. IRVF may be useful for capturing renal congestion at the bedside that is related to clinical patient outcomes.
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Affiliation(s)
- Kenichiro Fujii
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi, 470-1192, Japan.
| | - Izumi Nakayama
- Division of Intensive Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
- Department of Public Health, School of Medicine, Yokohama City University, Yokohama, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junichi Izawa
- Division of Intensive Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Noriko Iida
- Clinical Laboratory, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masayoshi Yamamoto
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Norimichi Uenishi
- Department of Emergency and General Internal Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi, 470-1192, Japan
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi, 470-1192, Japan
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25
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Laou E, Papagiannakis N, Ntalarizou N, Choratta T, Angelopoulou Z, Annousis K, Sakellakis M, Kyriakaki A, Ragias D, Michou A, Chalkias A. The Relation of Calculated Plasma Volume Status to Sublingual Microcirculatory Blood Flow and Organ Injury. J Pers Med 2023; 13:1085. [PMID: 37511698 PMCID: PMC10381119 DOI: 10.3390/jpm13071085] [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: 05/21/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The calculated plasma volume status (cPVS) was validated as a surrogate of intravascular filling. The aim of this study is to assess the cPVS in relation to sublingual perfusion and organ injury. METHODS Pre- and postoperative cPVS were obtained by determining the actual and ideal plasma volume levels in surgical patients. The sublingual microcirculation was assessed using SDF imaging, and we determined the De Backer score, the Consensus Proportion of Perfused Vessels (Consensus PPV), and the Consensus PPV (small). Our primary outcome was the assessment of the distribution of cPVS and its association with intraoperative sublingual microcirculation and postoperative complications. RESULTS The median pre- and postoperative cPVS were -7.25% (IQR -14.29--1.88) and -0.4% (IQR -5.43-6.06), respectively (p < 0.001). The mean intraoperative administered fluid volume was 2.5 ± 2.5 L (1.14 L h-1). No statistically significant correlation was observed between the pre- or postoperative cPVS and sublingual microcirculation variables. Higher preoperative (OR = 1.04, p = 0.098) and postoperative cPVS (OR = 1.057, p = 0.029) were associated with postoperative organ injury and complications (sepsis (30%), anemia (24%), respiratory failure (13%), acute kidney injury (6%), hypotension (6%), stroke (3%)). CONCLUSIONS The calculated PVS was associated with an increased risk of organ injury and complications in this cohort.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, 11527 Athens, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Nicoletta Ntalarizou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Theodora Choratta
- First Department of Surgery, Metaxa Cancer Hospital, 18537 Piraeus, Greece
| | - Zacharoula Angelopoulou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | | | - Minas Sakellakis
- Department of Medical Oncology, Metropolitan Hospital, 10461 Piraeus, Greece
| | - Aikaterini Kyriakaki
- High Dependency Unit, General Hospital of Syros Vardakeio and Proio, 84100 Syros, Greece
| | - Dimitrios Ragias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Anastasia Michou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Institute for Translational Medicine and Therapeutics, School of Medicine, University of Pennsylvania Perelman, Philadelphia, PA 19104, USA
- Outcomes Research Consortium, Cleveland, OH 44195, USA
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26
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Pugliese NR, Pellicori P, Filidei F, Del Punta L, De Biase N, Balletti A, Di Fiore V, Mengozzi A, Taddei S, Gargani L, Mullens W, Cleland JGF, Masi S. The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure. Eur Heart J Cardiovasc Imaging 2023; 24:961-971. [PMID: 36595324 DOI: 10.1093/ehjci/jeac254] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/25/2022] [Indexed: 01/04/2023] Open
Abstract
AIMS We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients. METHODS AND RESULTS Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03). CONCLUSION Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.
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Affiliation(s)
- Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow G12 8QQ, UK
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Alessio Balletti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
| | - Luna Gargani
- Department of Pathology, Cardiology Division, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow G12 8QQ, UK
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124, Pisa, Italy
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27
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Graham FJ, Iaconelli A, Sonecki P, Campbell RT, Hunter D, Cleland JGF, Pellicori P. Defining Heart Failure Based on Imaging the Heart and Beyond. Card Fail Rev 2023; 9:e10. [PMID: 37427007 PMCID: PMC10326661 DOI: 10.15420/cfr.2022.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/19/2023] [Indexed: 07/11/2023] Open
Abstract
Water and salt retention, in other words congestion, are fundamental to the pathophysiology of heart failure and are important therapeutic targets. Echocardiography is the key tool with which to assess cardiac structure and function in the initial diagnostic workup of patients with suspected heart failure and is essential for guiding treatment and stratifying risk. Ultrasound can also be used to identify and quantify congestion in the great veins, kidneys and lungs. More advanced imaging methods might further clarify the aetiology of heart failure and its consequences for the heart and periphery, thereby improving the efficiency and quality of care tailored with greater precision to individual patient need.
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Affiliation(s)
- Fraser J Graham
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | | | - Ross T Campbell
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - David Hunter
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - John GF Cleland
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of GlasgowGlasgow, UK
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28
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Poh KW, Ngan CH, Tan SN, Burhan AA, Wong JY, Er CK, Sivandan S. Clinical role of intrarenal venous flow patterns in decompensated heart failure with worsening renal function. ULTRASOUND (LEEDS, ENGLAND) 2023; 31:119-125. [PMID: 37144225 PMCID: PMC10152316 DOI: 10.1177/1742271x221124467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/02/2022] [Indexed: 05/06/2023]
Abstract
Introduction The clinical implication of intrarenal venous flow patterns in decompensated heart failure with worsening renal function is unknown. We aimed to study the relationship between intrarenal venous flow patterns, inferior vena cava volume status, caval index, clinical degree of congestion and the renal outcome in patients with decompensated heart failure and worsening renal function. Secondary objectives were to study the combined endpoint of readmission and mortality rate within 30 days (after the last scan) among intrarenal venous flow patterns and the effect of congestion status on the renal outcome. Methods Twenty-three patients admitted for decompensated heart failure (ejection fraction ⩽40%) with worsening renal function (absolute increase in serum creatinine of 26.5 µmol/L or ⩾1.5-fold increment from baseline) were enrolled in this study. A total of 64 scans were performed. Patients were visited on day 0, 2, 4 and 7 (or earlier if discharged). Patients were called 30 days after discharge to evaluate readmission or mortality. Intrarenal venous flow patterns were ranked from continuous, interrupted, biphasic, to monophasic. Clinical congestion was scored from 0 to 7. Results Intrarenal venous flow patterns had statistically significant positive correlations with inferior vena cava volume status (Spearman's ρ, 0.51; p < 0.01) and congestion score (ρ, 0.65; p < 0.01) and a significant negative correlation with caval index (ρ, -0.53; p < 0.01). Intrarenal venous flow patterns were not significant in predicting estimated glomerular filtration rate improvement or the combined endpoint. Reduced congestion significantly predicted an estimated glomerular filtration rate improvement on the following scan day (p = 0.04, odds ratio = 4.3, 95% confidence interval = 1.1-17.2). Conclusion Although intrarenal venous flow patterns correlate with other congestive parameters, clinical congestion status rather than intrarenal venous flow patterns predicted the renal outcome.
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Affiliation(s)
- Kok Wei Poh
- International Medical University, Kuala
Lumpur, Malaysia
| | | | - Siok Nee Tan
- Hospital Tuanku Ja’afar Seremban,
Seremban, Malaysia
| | | | - Ji Yin Wong
- Hospital Tuanku Ja’afar Seremban,
Seremban, Malaysia
| | - Chee Kent Er
- Hospital Tuanku Ja’afar Seremban,
Seremban, Malaysia
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Łagosz P, Biegus J, Urban S, Zymliński R. Renal Assessment in Acute Cardiorenal Syndrome. Biomolecules 2023; 13:biom13020239. [PMID: 36830608 PMCID: PMC9953721 DOI: 10.3390/biom13020239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
Cardiorenal syndrome (CRS) is a complex, heterogeneous spectrum of symptoms that has kept cardiologists awake for decades. The heart failure (HF) population being burdened with multimorbidity poses diagnostic and therapeutic challenges even for experienced clinicians. Adding deteriorated renal function to the equation, which is one of the strongest predictors of adverse outcome, we measure ourselves against possibly the biggest problem in modern cardiology. With the rapid development of new renal assessment methods, we can treat CRS more effectively than ever. The presented review focuses on explaining the pathophysiology, recent advances and current practices of monitoring renal function in patients with acute CRS. Understanding the dynamic interaction between the heart and the kidney may improve patient care and support the selection of an effective and nephroprotective treatment strategy.
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Affiliation(s)
- Piotr Łagosz
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
- Correspondence:
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
| | - Szymon Urban
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Institute of Heart Diseases, University Clinical Hospital, 50-556 Wroclaw, Poland
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Corradi F, Santori G, Brusasco C, Robba C, Wong A, Di Nicolò P, Tecchi L, Dazzi F, Taddei E, Isirdi A, Coccolini F, Forfori F, Tavazzi G. Electrocardiographic Time-Intervals Waveforms as Potential Predictors for Severe Acute Kidney Injury in Critically Ill Patients. J Clin Med 2023; 12:jcm12020700. [PMID: 36675629 PMCID: PMC9866689 DOI: 10.3390/jcm12020700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/17/2023] Open
Abstract
Background: Acute kidney injury (AKI) is common in critically ill patients admitted to intensive care units (ICU) and is frequently associated with poorer outcomes. Hence, if an indicator is available for predicting severe AKI within the first few hours of admission, management strategies can be put into place to improve outcomes. Materials and methods: This was a prospective, observational study, involving 63 critically ill patients, that aimed to explore the diagnostic accuracy of different Doppler parameters in predicting AKI in critically ill patients from a mixed ICU. Participants were enrolled at ICU admission. All underwent ultrasonographic examinations and hemodynamic assessment. Renal Doppler resistive index (RDRI), venous impedance index (VII), arterial systolic time intervals (a-STI), and venous systolic time intervals (v-STI) were measured within 2 h from ICU admission. Results: Cox proportional hazards models, including a-STI, v-STI, VII, and RDRI as independent variables, returned a-STI as the only putative predictor for the development of AKI or severe AKI. An overall statistically significant difference (p < 0.001) was observed in the Kaplan−Meier plots for cumulative AKI events between patients with a-STI higher or equal than 0.37 and for cumulative severe AKI-3 between patients with a-STI higher or equal than 0.63. As assessed by the area under the receiver operating curves (ROC) curves, a-STI performed best in diagnosing any AKI and/or severe AKI-3. Positive correlations were found between a-STI and the N-terminal brain natriuretic peptide precursor (NT-pro BNP) (ρ = 0.442, p < 0.001), the sequential organ failure assessment (SOFA) score (ρ: 0.361, p = 0.004), and baseline serum creatinine (ρ: 0.529, p < 0.001). Conclusions: Critically ill patients who developed AKI had statistically significant different a-STI (on admission to ICU), v-STI, and VII than those who did not. Moreover, a-STI was associated with the development of AKI at day 5 and provided the best diagnostic accuracy for the diagnosis of any AKI or severe AKI compared with RDRI, VII, and v-STI.
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Affiliation(s)
- Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
- Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2, 56124 Pisa, Italy
- Correspondence: ; Tel.: +39-348-2311657
| | - Gregorio Santori
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16126 Genoa, Italy
| | - Claudia Brusasco
- Anesthesia and Intensive Care Unit, E.O. Ospedali Galliera, 16128 Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, 16126 Genoa, Italy
| | - Adrian Wong
- Department of Critical Care, King’s College Hospital, London SE5 9RS, UK
| | - Pierpaolo Di Nicolò
- Nephrology and Dialysis Unit, “S. Maria della Scaletta” Hospital, 40026 Imola, Italy
| | - Ludovica Tecchi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Federico Dazzi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Erika Taddei
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Alessandro Isirdi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Federico Coccolini
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Guido Tavazzi
- Department of Clinical Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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Deschamps J, Denault A, Galarza L, Rola P, Ledoux-Hutchinson L, Huard K, Gebhard CE, Calderone A, Canty D, Beaubien-Souligny W. Venous Doppler to Assess Congestion: A Comprehensive Review of Current Evidence and Nomenclature. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:3-17. [PMID: 36207224 DOI: 10.1016/j.ultrasmedbio.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/29/2022] [Accepted: 07/21/2022] [Indexed: 06/16/2023]
Abstract
Organ congestion from venous hypertension is an important pathophysiological mechanism mediating organ injury in several clinical contexts including critical illness, congestive heart failure and end-stage chronic kidney disease. However, the practical evaluation of venous congestion is often challenging at the bedside because of the limitations of traditional methods. Point-of-care ultrasound (POCUS) enables the clinician to assess venous velocity profiles during the cardiac cycle using Doppler modalities. Venous Doppler profile abnormalities at multiple sites are detected when elevated venous pressure results in hemodynamic changes within the systemic venous circulation. The detection of these abnormal Doppler profiles may identify patients with clinically significant systemic venous congestion. These patients have been reported to be at increased risk of medical complications. Improving the evaluation of venous congestion may lead to individualized treatment and improved patient outcomes. In this review, we describe the physiologic principles necessary to understand venous Doppler assessment. We also propose a nomenclature for the description of venous Doppler profiles. Finally, we provide a narrative review of the current clinical evidence related to use of venous Doppler assessment in various clinical contexts.
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Affiliation(s)
- Jean Deschamps
- Division of Intensive Care, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - André Denault
- Department of Anesthesiology and Intensive Care, Montreal Heart Institute, Montréal, Canada
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Philippe Rola
- Division of Intensive Care, Hôpital Santa-Cabrini, Montréal, Canada
| | | | | | | | | | - David Canty
- Department of Surgery (Royal Melbourne Hospital), University of Melbourne, Parkville, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine and Nursing (Monash Medical Centre), Monash University, Clayton, Australia
| | - William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Innovation Hub, Centre de Recherche du CHUM, Montréal, Canada.
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Menéndez-Suso JJ, Rodríguez-Álvarez D, Sánchez-Martín M. Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:211-220. [PMID: 35811405 DOI: 10.1002/jum.16057] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The Venous Excess Ultrasound (VExUS) score has been described as a useful tool to estimate the degree of venous congestion in adult patients. The present study aimed to analyze the feasibility and usefulness of the VExUS score to detect and grade central venous pressure (CVP) elevation in critically ill children. METHODS A cross-sectional pilot study was conducted in a tertiary-care pediatric intensive care unit between November 2020 and June 2021. All children in whom CVP was monitored, were enrolled. At the time of central venous catheter placement, CVP and VExUS score grade were determined, analyzing the inferior vena cava (IVC) diameter and the hepatic (HVD), portal (PVD), and intrarenal (IRVD) venous Doppler waveforms. RESULTS A total of 33 children were studied (median age 12.2 [interquartile range (IQR) 4.1-100.6] months old; median weight 8.5 [IQR 5.6-35] kg; 20 [60.6%] males). The VExUS score was successfully obtained in 100% of the patients and its severity was strongly associated with the CVP levels (P < .001). Analyzing the VExUS score components separately, IVC dilation (P < .001) and severe HVD (P = .026), mild IRVD (P = .005), and severe IRVD (P = .025) patterns were associated with elevated CVP. After adjustment for confounding factors, IRVD pattern remained the only independent variable associated with elevated CVP. CONCLUSIONS The VExUS score appears to be a feasible and potentially useful bedside noninvasive monitoring tool for the detection and grading of CVP elevation in critically ill children. Among all its components, IRVD assessment seems most associated with high CVP in this population.
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Effects of changes in position, positive end-expiratory pressure and mean arterial pressure on renal, portal and hepatic Doppler ultrasound perfusion indices: a randomized crossover study in cardiac surgery patients. J Clin Monit Comput 2022; 36:1841-1850. [PMID: 35230558 DOI: 10.1007/s10877-022-00834-0] [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: 12/13/2021] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
Abstract
Point-of-care ultrasound perfusion indices can be used for detection of AKI and venous congestion. Patients in the postoperative- and intensive care units are frequently exposed to alternating treatment and loading conditions. We aimed to study the effects of changes in preload (patient positioning), positive end-expiratory pressure (PEEP) and afterload (phenylephrine) on renal, portal and hepatic ultrasound indices. We hypothesized that renal resistive index was not influenced by changes in PEEP and patient positioning. This was a single-site, randomized, crossover study. Patients above 18 years scheduled for elective open-heart surgery at Aarhus University Hospital, Denmark, were available for inclusion. Patients were randomized to a sequence of six combinations of PEEP and position in addition to an increase in mean arterial pressure by phenylephrine. Thirty-one patients participated in the study. Resistive index was influenced by positional change (P = 0.007), but not by change in PEEP (P = 0.50) (Table 1). Renal venous stasis index and portal pulsatility fraction increased in the raised legs position (P ≤ 0.019), but not with increases in PEEP. Renal venous flow pattern and hepatic venous flow pattern were affected by position (P ≤ 0.019), but not by PEEP. None of the ultrasound indices were significantly changed by infusion of phenylephrine. Doppler perfusion indices were significantly affected by changes in preload, but not by changes in PEEP or afterload. Although the changes in the Doppler ultrasound indices were significant, they were small in absolute numbers. Therefore, from a clinical perspective, the ultrasound indices were robust.Trial registration Registered at clinicaltrials.com, first posted online June 5th 2020, identifier: NCT04419662.
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Qian X, Zhen J, Meng Q, Li L, Yan J. Intrarenal Doppler approaches in hemodynamics: A major application in critical care. Front Physiol 2022; 13:951307. [PMID: 36311236 PMCID: PMC9597190 DOI: 10.3389/fphys.2022.951307] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/28/2022] [Indexed: 10/04/2023] Open
Abstract
The treatment of severe cases usually requires multimodality hemodynamic monitoring approaches, particularly for tissue and organ perfusion tracking. Currently, only a few studies have investigated renal perfusion status at the bedside. Ultrasound has become increasingly utilized to guide the hemodynamic management of severe patients. Similarly, intrarenal Doppler (IRD) is widely used to assess renal perfusion from both the intrarenal artery and vein perspectives. The renal resistive index (RRI), which reflects the renal arterial blood flow profile, is often applied to predict the reversibility of renal dysfunction and to titrate hemodynamic support. Intrarenal venous flow (IRVF) patterns and the renal venous stasis index (RVSI), which reflects the intrarenal vein blood flow profile, are now being used to assess intravenous congestion. They may also be useful in predicting the risk of acute kidney injury and avoiding fluid overload. IRD can provide diverse and supplemental information on renal perfusion and may help to establish the early diagnosis in severe patients. This review focused on the specific operational methods, influencing factors, and applications of IRD in hemodynamics.
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Affiliation(s)
- Xiaoling Qian
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Junhai Zhen
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Qingxiang Meng
- Department of Ultrasound Medicine, Zhejiang Hospital, Hangzhou, China
| | - Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
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Guinot PG, Bahr PA, Andrei S, Popescu BA, Caruso V, Mertes PM, Berthoud V, Nguyen M, Bouhemad B. Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation. Crit Care 2022; 26:305. [PMID: 36199091 PMCID: PMC9535945 DOI: 10.1186/s13054-022-04180-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fluid overload and venous congestion are associated with morbi-mortality in the ICU (intensive care unit). Administration of diuretics to correct the fluid balance is common, although there is no strong relationship between the consequent fluid loss and clinical improvement. The aim of the study was to evaluate the ability of the portal pulsatility index, the renal venous impedance index, and the VEXUS score (venous ultrasound congestion score) to predict appropriate diuretic-induced fluid depletion. METHODS The study had a prospective, observational, single-center observational design and was conducted in a university-affiliated medico-surgical ICU. Adult patients for whom the clinician decided to introduce loop diuretic treatment were included. Hemodynamic and ultrasound measurements (including the portal pulsatility index, renal venous impedance index and VEXUS score) were performed at inclusion and 2 hours after the initiation of the diuretics. The patients' characteristics were noted at inclusion, 24 h later, and at ICU discharge. The appropriate diuretic-induced fluid depletion was defined by a congestive score lower than 3 after diuretic fluid depletion. The congestive score included clinical and biological parameters of congestion. RESULTS Eighty-one patients were included, and 43 (53%) patients presented with clinically significant congestion score at inclusion. Thirty-four patients (42%) had an appropriate response to diuretic-induced fluid depletion. None of the left- and right-sided echocardiographic parameters differed between the two groups. The baseline portal pulsatility index was the best predictor of appropriate response to diuretic-induced fluid depletion (AUC = 0.80, CI95%:0.70-0.92, p = 0.001), followed by the renal venous impedance index (AUC = 0.72, CI95% 0.61-0.84, p = 0.001). The baseline VEXUS score (AUC of 0.66 CI95% 0.53-0.79, p = 0.012) was poorly predictive of appropriate response to diuretic-induced fluid depletion. CONCLUSION The portal pulsatility index and the renal venous impedance index were predictive of the appropriate response to diuretic-induced fluid depletion in ICU patients. The portal pulsatility index should be evaluated in future randomized studies.
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Affiliation(s)
- Pierre-Grégoire Guinot
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France ,grid.5613.10000 0001 2298 9313University of Burgundy and Franche-Comté, LNC UMR1231, 21000 Dijon, France
| | - Pierre-Alain Bahr
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France ,grid.5613.10000 0001 2298 9313University of Burgundy and Franche-Comté, LNC UMR1231, 21000 Dijon, France
| | - Stefan Andrei
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France ,grid.8194.40000 0000 9828 7548Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Bogdan A. Popescu
- Euroecolab, Emergency Institute for Cardiovascular Diseases “Prof Dr C C Iliescu”, Bucharest, Romania
| | - Vincenza Caruso
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Paul-Michel Mertes
- grid.11843.3f0000 0001 2157 9291Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Vivien Berthoud
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Maxime Nguyen
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France ,grid.5613.10000 0001 2298 9313University of Burgundy and Franche-Comté, LNC UMR1231, 21000 Dijon, France
| | - Belaid Bouhemad
- grid.5613.10000 0001 2298 9313Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France ,grid.5613.10000 0001 2298 9313University of Burgundy and Franche-Comté, LNC UMR1231, 21000 Dijon, France
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Kramer T, Brinkkoetter P, Rosenkranz S. Right Heart Function in Cardiorenal Syndrome. Curr Heart Fail Rep 2022; 19:386-399. [PMID: 36166185 PMCID: PMC9653308 DOI: 10.1007/s11897-022-00574-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Since CRS is critically dependent on right heart function and involved in interorgan crosstalk, assessment and monitoring of both right heart and kidney function are of utmost importance for clinical outcomes. This systematic review aims to comprehensively report on novel diagnostic and therapeutic paradigms that are gaining importance for the clinical management of the growing heart failure population suffering from CRS. Recent Findings Cardiorenal syndrome (CRS) in patients with heart failure is associated with poor outcome. Although systemic venous congestion and elevated central venous pressure have been recognized as main contributors to CRS, they are often neglected in clinical practice. The delicate hemodynamic balance in CRS is particularly determined by the respective status of the right heart. Summary The consideration of hemodynamic and CRS profiles is advantageous in tailoring treatment for better preservation of renal function. Assessment and monitoring of right heart and renal function by known and emerging tools like renal Doppler ultrasonography or new biomarkers may have direct clinical implications.
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Affiliation(s)
- Tilmann Kramer
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany. .,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.
| | - Paul Brinkkoetter
- Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Klinik II Für Innere Medizin, Nephrologie, Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
| | - Stephan Rosenkranz
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany.,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
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Rodríguez-Espinosa D, Guzman-Bofarull J, De La Fuente-Mancera JC, Maduell F, Broseta JJ, Farrero M. Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach. Front Physiol 2022; 13:913580. [PMID: 35874534 PMCID: PMC9304751 DOI: 10.3389/fphys.2022.913580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/20/2022] [Indexed: 01/12/2023] Open
Abstract
Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.
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Affiliation(s)
- Diana Rodríguez-Espinosa
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic of Barcelona, Barcelona, Spain
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D’Elia JA, Bayliss GP, Weinrauch LA. The Diabetic Cardiorenal Nexus. Int J Mol Sci 2022; 23:ijms23137351. [PMID: 35806355 PMCID: PMC9266839 DOI: 10.3390/ijms23137351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/10/2022] Open
Abstract
The end-stage of the clinical combination of heart failure and kidney disease has become known as cardiorenal syndrome. Adverse consequences related to diabetes, hyperlipidemia, obesity, hypertension and renal impairment on cardiovascular function, morbidity and mortality are well known. Guidelines for the treatment of these risk factors have led to the improved prognosis of patients with coronary artery disease and reduced ejection fraction. Heart failure hospital admissions and readmission often occur, however, in the presence of metabolic, renal dysfunction and relatively preserved systolic function. In this domain, few advances have been described. Diabetes, kidney and cardiac dysfunction act synergistically to magnify healthcare costs. Current therapy relies on improving hemodynamic factors destructive to both the heart and kidney. We consider that additional hemodynamic solutions may be limited without the use of animal models focusing on the cardiomyocyte, nephron and extracellular matrices. We review herein potential common pathophysiologic targets for treatment to prevent and ameliorate this syndrome.
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Affiliation(s)
- John A. D’Elia
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
| | - George P. Bayliss
- Division of Organ Transplantation, Rhode Island Hospital, Providence, RI 02903, USA;
| | - Larry A. Weinrauch
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
- Correspondence: ; Tel.: +617-923-0800; Fax: +617-926-5665
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Méndez AB, Azancot MA, Olivella A, Soler MJ. New aspects in cardiorenal syndrome and HFpEF. Clin Kidney J 2022; 15:1807-1815. [PMID: 36158149 PMCID: PMC9494528 DOI: 10.1093/ckj/sfac133] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiorenal syndrome (CRS) is a complex disease in which the heart and kidneys are simultaneously affected, and subsequently, the malfunction of one organ promotes the deterioration of the other. Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. The pathophysiology of CRS is not well known and several mechanisms have been proposed. An elevation of central venous pressure seems to be one of the key points to consider, among others such as an increase in intraabdominal pressure. Several diagnostic tools have been identified to establish the diagnosis of CRS in patients with HFpEF. Currently, the availability of biomarkers of renal and cardiac injury, the use of pulmonary ultrasound, the monitoring of the size of the inferior vena cava and the study of the renal venous pattern offer a new dimension in accurately diagnosing and quantifying organ damage in CRS. Beyond the symptomatic treatment of congestion, until recently specific therapeutic tools for patients with CRS and HFpEF were not available. Interestingly, the development of new drugs such as the angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new therapeutic strategies with potential benefits in reduction of cardiorenal adverse outcomes in this population. Randomized clinical trials that focus on patients with HFpEF are currently ongoing to delineate optimal new treatments that may be able to modify their prognosis. In addition, multidisciplinary teamwork (nephrologist, cardiologist and nurse) is expected to decrease the number of visits and the rate of hospitalizations, with a subsequent patient benefit.
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Affiliation(s)
- Ana Belén Méndez
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Maria Antonieta Azancot
- Nephrology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Nephrology and Kidney Transplant Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Aleix Olivella
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Nephrology and Kidney Transplant Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
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Ilieșiu AM, Hodorogea AS, Balahura AM, Bădilă E. Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure. Diagnostics (Basel) 2022; 12:diagnostics12040962. [PMID: 35454010 PMCID: PMC9024731 DOI: 10.3390/diagnostics12040962] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/04/2023] Open
Abstract
Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.
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Affiliation(s)
- Adriana Mihaela Ilieșiu
- Cardiology and Internal Medicine Department, Theodor Burghele Clinical Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andreea Simona Hodorogea
- Cardiology and Internal Medicine Department, Theodor Burghele Clinical Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Correspondence: ; Tel.: +40-72-631-5872
| | - Ana-Maria Balahura
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.B.); (E.B.)
| | - Elisabeta Bădilă
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.B.); (E.B.)
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Kashani K, Omer T, Shaw AD. The Intensivist's Perspective of Shock, Volume Management, and Hemodynamic Monitoring. Clin J Am Soc Nephrol 2022; 17:706-716. [PMID: 35379765 PMCID: PMC9269574 DOI: 10.2215/cjn.14191021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may lead to entirely different clinical pathways for management. Among patients with hypovolemic and distributive shock, fluid therapy is one of the leading management strategies. Although an appropriate amount of fluid administration might save a patient's life, inadequate (or excessive) fluid use could lead to more complications, including organ failure and mortality due to either hypovolemia or volume overload. Currently, intensivists have access to a wide variety of information sources and tools to monitor the underlying hemodynamic status, including medical history, physical examination, and specific hemodynamic monitoring devices. Although appropriate and timely assessment and interpretation of this information can promote adequate fluid resuscitation, misinterpretation of these data can also lead to additional mortality and morbidity. This article provides a narrative review of the most commonly used hemodynamic monitoring approaches to assessing fluid responsiveness and fluid tolerance. In addition, we describe the benefits and disadvantages of these tools.
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Affiliation(s)
- Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tarig Omer
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Andrew D. Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
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Ohara H, Yoshihisa A, Horikoshi Y, Ishibashi S, Matsuda M, Yamadera Y, Sugawara Y, Ichijo Y, Hotsuki Y, Watanabe K, Sato Y, Misaka T, Kaneshiro T, Oikawa M, Kobayashi A, Takeishi Y. Renal Venous Stasis Index Reflects Renal Congestion and Predicts Adverse Outcomes in Patients With Heart Failure. Front Cardiovasc Med 2022; 9:772466. [PMID: 35321106 PMCID: PMC8934863 DOI: 10.3389/fcvm.2022.772466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIt has been recently reported that the renal venous stasis index (RVSI) assessed by renal Doppler ultrasonography provides information to stratify pulmonary hypertension that can lead to right-sided heart failure (HF). However, the clinical significance of RVSI in HF patients has not been sufficiently examined. We aimed to examine the associations of RVSI with parameters of cardiac function and right heart catheterization (RHC), as well as with prognosis, in patients with HF.MethodsWe performed renal Doppler ultrasonography, echocardiography and RHC in hospitalized patients with HF (n = 388). RVSI was calculated as follows: RVSI = (cardiac cycle time-venous flow time)/cardiac cycle time. The patients were classified to three groups based on RVSI: control group (RVSI = 0, n = 260, 67%), low RVSI group (0 < RVSI ≤ 0.21, n = 63, 16%) and high RVSI group (RVSI > 0.21, n = 65, 17%). We examined associations of RVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF.ResultsThere were significant correlations of RVSI with mean right atrial pressure (mRAP; R = 0.253, P < 0.001), right atrial area (R = 0.327, P < 0.001) and inferior vena cava diameter (R = 0.327, P < 0.001), but not with cardiac index (R = −0.019, P = 0.769). During the follow-up period (median 412 days), cardiac events occurred in 60 patients. In the Kaplan–Meier analysis, the cumulative cardiac event rate increased with increasing RVSI (log-rank, P = 0.001). In the multivariate Cox proportional hazard analysis, the cardiac event rate was independently associated with RVSI (high RVSI group vs. control group: hazard ratio, 1.908; 95% confidence interval, 1.046–3.479, P = 0.035).ConclusionRVSI assessed by renal Doppler ultrasonography reflects right-sided overload and is associated with adverse prognosis in HF patients.
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Affiliation(s)
- Himika Ohara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science, Fukushima, Japan
| | - Yuko Horikoshi
- Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science, Fukushima, Japan
- Department of Clinical Laboratory Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shinji Ishibashi
- Department of Clinical Laboratory Medicine, Fukushima Medical University, Fukushima, Japan
| | - Mitsuko Matsuda
- Department of Clinical Laboratory Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yukio Yamadera
- Department of Clinical Laboratory Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yukiko Sugawara
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuhiro Ichijo
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yu Hotsuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Koichiro Watanabe
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kaneshiro
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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Do the Current Guidelines for Heart Failure Diagnosis and Treatment Fit with Clinical Complexity? J Clin Med 2022; 11:jcm11030857. [PMID: 35160308 PMCID: PMC8836547 DOI: 10.3390/jcm11030857] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/01/2022] [Accepted: 02/04/2022] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a clinical syndrome defined by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to inadequate cardiac output and/or increased intraventricular filling pressure. Importantly, HF becomes progressively a multisystemic disease. However, in August 2021, the European Society of Cardiology published the new Guidelines for the diagnosis and treatment of acute and chronic HF, according to which the left ventricular ejection fraction (LVEF) continues to represent the pivotal parameter for HF patients’ evaluation, risk stratification and therapeutic management despite its limitations are well known. Indeed, HF has a complex pathophysiology because it first involves the heart, progressively becoming a multisystemic disease, leading to multiorgan failure and death. In these terms, HF is comparable to cancer. As for cancer, surviving, morbidity and hospitalisation are related not only to the primary neoplastic mass but mainly to the metastatic involvement. In HF, multiorgan involvement has a great impact on prognosis, and multiorgan protective therapies are equally important as conventional cardioprotective therapies. In the light of these considerations, a revision of the HF concept is needed, starting from its definition up to its therapy, to overcome the old and simplistic HF perspective.
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Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
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Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Torres-Arrese M, García de Casasola-Sánchez G, Méndez-Bailón M, Montero-Hernández E, Cobo-Marcos M, Rivas-Lasarte M, Caurcel-Díaz L, Rodríguez-Fuertes P, Villén-Villegas T, Tung-Chen Y. Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:124. [PMID: 35056432 PMCID: PMC8780545 DOI: 10.3390/medicina58010124] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE × US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation-SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE × US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE × US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE × US score, should be further studied before expanding its use in AHF patients.
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Affiliation(s)
- Marta Torres-Arrese
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, 28922 Madrid, Spain; (M.T.-A.); (G.G.d.C.-S.)
| | | | - Manuel Méndez-Bailón
- Department of Internal Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Esther Montero-Hernández
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain;
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, CIBERCV, Majadahonda, 28222 Madrid, Spain; (M.C.-M.); (M.R.-L.)
| | - Mercedes Rivas-Lasarte
- Department of Cardiology, Hospital Universitario Puerta de Hierro, CIBERCV, Majadahonda, 28222 Madrid, Spain; (M.C.-M.); (M.R.-L.)
| | - Luis Caurcel-Díaz
- Department of Palliative Medicine, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | | | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain;
- Department of Medicine, Universidad Alfonso X, 28691 Madrid, Spain
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Liu L, Chao Y, Wang X. Shock Resuscitation - the Necessity and Priority of Renal Blood Perfusion Assessment. Aging Dis 2022; 13:1056-1062. [PMID: 35855346 PMCID: PMC9286909 DOI: 10.14336/ad.2022.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/05/2022] [Indexed: 11/05/2022] Open
Abstract
Improving organ perfusion is the aim of shock resuscitation; therefore, improving organ blood perfusion is a direct indicator for shock resuscitation. During shock, different organs have different capacities for blood flow autoregulation. The kidney is an important organ with excellent ability to autoregulate the blood flow and with vulnerability to poor organ perfusion, which places kidney perfusion in a position of necessity and priority relative to that of other organs in shock. Critical-care ultrasonography provides the best evaluation of renal perfusion.
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Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang 05001, China.
| | - Yangong Chao
- Department of Critical Care Medicine, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China.
| | - Xiaoting Wang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
- Correspondence should be addressed to: Dr. Xiaoting Wang, Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
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Trpkov C, Grant AD, Fine NM. Intrarenal Doppler Ultrasound Renal Venous Stasis Index Correlates With Acute Cardiorenal Syndrome in Patients With Acute Decompensated Heart Failure. CJC Open 2021; 3:1444-1452. [PMID: 34993456 PMCID: PMC8712550 DOI: 10.1016/j.cjco.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/11/2021] [Indexed: 11/05/2022] Open
Abstract
Background Acute cardiorenal syndrome (ACRS) is associated with adverse outcomes in patients with acute decompensated heart failure (ADHF). Intrarenal venous blood flow can be assessed using Doppler ultrasound and has prognostic significance in ADHF. Although intrarenal Doppler (IRD) may be sensitive to renal congestion, an association between IRD parameters and ACRS has not been demonstrated in an ADHF population. Methods Hospitalized patients with ADHF (n = 21) or acute coronary syndrome (ACS; n = 21) were prospectively enrolled. Patients underwent echocardiography, including IRD, using a standard cardiac ultrasound transducer. Intrarenal venous flow was quantified with the renal venous stasis index (RVSI), defined as the duration of absent venous flow time divided by cardiac cycle duration. The primary outcome was acute kidney injury (AKI) as assessed using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results ADHF patients had a similar cardiac index (2.0 ± 0.6 vs 2.1 ± 0.4 L/min per m2, P = 0.91) but higher estimated central venous pressure (13.0 ± 3.2 vs 4.6 ± 2.4 mm Hg, P < 0.001) measured using echocardiography, compared with ACS patients. IRD was abnormal in all ADHF patients and normal in all ACS patients (RVSI 0.62 ± 0.20 vs 0.0 ± 0, P < 0.001). AKI stage II/III occurred in 10 of 21 ADHF patients (48%) vs 0 of 21 ACS patients (P < 0.001), with a mean rise in serum creatinine of 97.7 ± 79.3 vs 16.8 ± 10.9 μmol/L (P < 0.001), respectively. RVSI was correlated with AKI severity in ADHF patients (r = 0.57; P = 0.004). Conclusions RVSI is associated with AKI among ADHF patients and may be a useful diagnostic biomarker for ACRS in this setting. Further studies are needed to validate this finding and evaluate the potential efficacy of IRD-guided decongestive therapy in this setting.
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Petramala L, Concistrè A, Circosta F, Gigante A, Sarlo F, Schina M, Soldini M, Iannucci G, Cianci R, Letizia C. Evaluation of Intra-Renal Stiffness in Patients with Primary Aldosteronism. High Blood Press Cardiovasc Prev 2021; 29:49-56. [PMID: 34757582 DOI: 10.1007/s40292-021-00485-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/28/2021] [Indexed: 11/27/2022] Open
Abstract
INTORDUCTION Aldosterone is known to play important role in developing cardiovascular, metabolic, renal damage in hypertensive patients. AIM Aim of study was to evaluate parameters obtained by eco-color Doppler study, as non-invasive and easly performed method in asyntomatic patients with Essential Hypertension (EH) and Primary Aldosteronism (PA), without overt organ damage. METHODS From April 2019 to March 2020 we consecutively enrolled 73 hypertensive subjects (48 males, 25 women), distinguished in two groups: 30 EH patients (mean age 49.5 ± 18.7 years) and 43 PA patients (mean age 53.1 ± 11.6 years)] [23 with aldosterone-secreting adrenal adenoma (APA), 20 with idiopathic aldosteronism (IHA)]. RESULTS PA group showed higher renal filtration rate and 24-h urinary excretion of albumin respect to EH; moreover, in PA we found higher Pulsatility Index, altered percentage of Renale Resistance Index, Atrophy Index, and reducted parietal thickness than EH. The correlation study showed that plasma aldosterone were positively correlated with pulsatility index in PA group (right r = 0.35; p < 0.05; left r = 0.36; p < 0.05). CONCLUSION parameters obtained through the intra-renal eco-color Doppler examination, easly performed and non-invasive, can be useful in the early-stage identification of subclinical microvascular alterations, especially in PA, condition characterized by increased risk of cardio-vascular remodelling and metabolic alterations.
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Affiliation(s)
- Luigi Petramala
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | - Antonio Concistrè
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | - Francesco Circosta
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | - Antonietta Gigante
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | | | - Mauro Schina
- Department of Clinical, Intenal Medicine, Anesthesiologic and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Maurizio Soldini
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | - Gino Iannucci
- Department of Clinical, Intenal Medicine, Anesthesiologic and Cardiovascular Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Rosario Cianci
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy
| | - Claudio Letizia
- Unit of Secondary Arterial Hypertension, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Policlinico "Umberto I", Viale del Policlinico 155, 00185, Rome, Italy.
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Hermansen JL, Pettey G, Sørensen HT, Nel S, Tsabedze N, Hørlyck A, Chakane PM, Gammelager H, Juhl-Olsen P. Perioperative Doppler measurements of renal perfusion are associated with acute kidney injury in patients undergoing cardiac surgery. Sci Rep 2021; 11:19738. [PMID: 34611205 PMCID: PMC8492663 DOI: 10.1038/s41598-021-99141-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/16/2021] [Indexed: 01/17/2023] Open
Abstract
Acute kidney injury (AKI) is a frequent and severe complication in cardiac surgery. Normal renal function is dependent on adequate renal perfusion, which may be altered in the perioperative period. Renal perfusion can be assessed with Doppler measurement. We aimed to determine the association between Doppler measurements of renal perfusion and the development of AKI. This was a prospective, observational study of 100 patients with ≥ one risk factor for postoperative AKI undergoing open-heart surgery. Doppler ultrasound examinations were performed before surgery and on the first and fourth postoperative day. AKI was defined according to the KDIGO criteria and subdivided into mild (KDIGO stage 1) and severe AKI (KDIGO stage 2 + 3). Thirty-three patients developed AKI, 25 developed mild and eight developed severe AKI. Abnormal renal venous flow pattern on the first postoperative day was significantly associated with the development of severe AKI (OR 8.54 (95% CI 1.01; 72.2), P = 0.046), as were portal pulsatility fraction (OR 1.07 (95% CI 1.02; 1.13), P = 0.005). Point-of-care Doppler ultrasound measurements of renal perfusion are associated with the development of AKI after cardiac surgery. Renal and portal Doppler ultrasonography can be used to identify patients at high risk or very low risk of AKI after cardiac surgery.
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Affiliation(s)
- Johan Lyngklip Hermansen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Gabriela Pettey
- Department of Anaesthesiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 17 Jubilee Road, Parktown, Johannesburg, 2193, South Africa
| | - Heidi Tofte Sørensen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Samantha Nel
- Division of Cardiology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 17 Jubilee Road, Parktown, Johannesburg, 2193, South Africa
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 17 Jubilee Road, Parktown, Johannesburg, 2193, South Africa
| | - Arne Hørlyck
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Palesa Motshabi Chakane
- Department of Anaesthesiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 17 Jubilee Road, Parktown, Johannesburg, 2193, South Africa
| | - Henrik Gammelager
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.,Department of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
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