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Niendorf T, Gladytz T, Cantow K, Klein T, Tasbihi E, Velasquez Vides JR, Zhao K, Millward JM, Waiczies S, Seeliger E. MRI of kidney size matters. MAGMA (NEW YORK, N.Y.) 2024:10.1007/s10334-024-01168-5. [PMID: 38960988 DOI: 10.1007/s10334-024-01168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/06/2024] [Accepted: 05/15/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To highlight progress and opportunities of measuring kidney size with MRI, and to inspire research into resolving the remaining methodological gaps and unanswered questions relating to kidney size assessment. MATERIALS AND METHODS This work is not a comprehensive review of the literature but highlights valuable recent developments of MRI of kidney size. RESULTS The links between renal (patho)physiology and kidney size are outlined. Common methodological approaches for MRI of kidney size are reviewed. Techniques tailored for renal segmentation and quantification of kidney size are discussed. Frontier applications of kidney size monitoring in preclinical models and human studies are reviewed. Future directions of MRI of kidney size are explored. CONCLUSION MRI of kidney size matters. It will facilitate a growing range of (pre)clinical applications, and provide a springboard for new insights into renal (patho)physiology. As kidney size can be easily obtained from already established renal MRI protocols without the need for additional scans, this measurement should always accompany diagnostic MRI exams. Reconciling global kidney size changes with alterations in the size of specific renal layers is an important topic for further research. Acute kidney size measurements alone cannot distinguish between changes induced by alterations in the blood or the tubular volume fractions-this distinction requires further research into cartography of the renal blood and the tubular volumes.
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Affiliation(s)
- Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany.
- Experimental and Clinical Research Center, A Joint Cooperation Between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany.
| | - Thomas Gladytz
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
| | - Kathleen Cantow
- Institute of Translational Physiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Tobias Klein
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
- Experimental and Clinical Research Center, A Joint Cooperation Between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Digital Health-Machine Learning Research Group, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
| | - Ehsan Tasbihi
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jose Raul Velasquez Vides
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
- Institute for Medical Engineering, Otto Von Guericke University, Magdeburg, Germany
| | - Kaixuan Zhao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jason M Millward
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
- Experimental and Clinical Research Center, A Joint Cooperation Between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Sonia Waiczies
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Robert-Rössle-Str. 10, 13125, Berlin, Germany
- Experimental and Clinical Research Center, A Joint Cooperation Between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Erdmann Seeliger
- Institute of Translational Physiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
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Wang JY, Song QL, Wang YL, Jiang ZM. Urinary oxygen tension and its role in predicting acute kidney injury: A narrative review. J Clin Anesth 2024; 93:111359. [PMID: 38061226 DOI: 10.1016/j.jclinane.2023.111359] [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: 04/22/2023] [Revised: 11/12/2023] [Accepted: 12/01/2023] [Indexed: 01/14/2024]
Abstract
Acute kidney injury occurs frequently in the perioperative setting. The renal medulla often endures hypoxia or hypoperfusion and is susceptible to the imbalance between oxygen supply and demand due to the nature of renal blood flow distribution and metabolic rate in the kidney. The current available evidence demonstrated that the urine oxygen pressure is proportional to the variations of renal medullary tissue oxygen pressure. Thus, urine oxygenation can be a candidate for reflecting the change of oxygen in the renal medulla. In this review, we discuss the basic physiology of acute kidney injury, as well as techniques for monitoring urine oxygen tension, confounding factors affecting the reliable measurement of urine oxygen tension, and its clinical use, highlighting its potential role in early detection and prevention of acute kidney injury.
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Affiliation(s)
- Jing-Yan Wang
- Department of Anesthesia, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Qi-Liang Song
- Department of Anesthesia, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Yu-Long Wang
- Department of Anesthesia, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Zong-Ming Jiang
- Department of Anesthesia, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China.
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Guinot PG, Huette P, Bouhemad B, Abou-Arab O, Nguyen M. A norepinephrine weaning strategy using dynamic arterial elastance is associated with reduction of acute kidney injury in patients with vasoplegia after cardiac surgery: A post-hoc analysis of the randomized SNEAD study. J Clin Anesth 2023; 88:111124. [PMID: 37099874 DOI: 10.1016/j.jclinane.2023.111124] [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: 02/17/2023] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023]
Abstract
STUDY OBJECTIVE To evaluate the impact of a dynamic arterial elastance guided norepinephrine weaning strategy on the occurrence of acute kidney injury (AKI) in patients with vasoplegia after cardiac surgery. DESIGN A post-hoc analysis of a monocentric randomized controlled trial. SETTING A tertiary care hospital in France. PARTICIPANTS Vasoplegic cardiac surgical patients treated with norepinephrine. INTERVENTION Patients were randomized to an algorithm-based norepinephrine weaning intervention (dynamic arterial elastance) group or a control group. MEASUREMENTS The primary endpoint was the number of patients with AKI defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The secondary endpoint were major adverse cardiac post-operative events (new onset of atrial fibrillation or flutter, low cardiac output syndrome, and in-hospital death). End points were evaluated during the first seven post-operative days. RESULTS 118 patients were analyzed. In the overall study population, the mean age was 70 (62-76) years, 65% were male and the median EuroSCORE was 7 (5-10). Overall, 46 (39%) patients developed AKI (30 KDIGO 1, 8 KDIGO 2, 8 KDIGO 3), and 6 patients required renal replacement therapy. The incidence of AKI was significantly lower in the intervention group than in the control group (16 patients (27%) vs 30 patients (51%), p = 0.12). Higher dose and longer duration of norepinephrine were associated with AKI severity. CONCLUSION Decreasing norepinephrine exposure by using a dynamic arterial elastance guided norepinephrine weaning strategy was associated with a reduced incidence of acute kidney injury in patients with vasoplegia after cardiac surgery. Further prospective multicentric studies are needed to confirm these results.
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Affiliation(s)
- Pierre-Grégoire 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.
| | - Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, 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
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - 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
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Jufar AH, Evans RG, May CN, Hood SG, Betrie AH, Trask‐Marino A, Bellomo R, Lankadeva YR. The effects of recruitment of renal functional reserve on renal cortical and medullary oxygenation in non-anesthetized sheep. Acta Physiol (Oxf) 2023; 237:e13919. [PMID: 36598336 PMCID: PMC10909474 DOI: 10.1111/apha.13919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/18/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
AIM Recruitment of renal functional reserve (RFR) with amino acid loading increases renal blood flow and glomerular filtration rate. However, its effects on renal cortical and medullary oxygenation have not been determined. Accordingly, we tested the effects of recruitment of RFR on renal cortical and medullary oxygenation in non-anesthetized sheep. METHODS Under general anesthesia, we instrumented 10 sheep to enable subsequent continuous measurements of systemic and renal hemodynamics, renal oxygen delivery and consumption, and cortical and medullary tissue oxygen tension (PO2 ). We then measured the effects of recruitment of RFR with an intravenous infusion of 500 ml of a clinically used amino acid solution (10% Synthamin® 17) in the non-anesthetized state. RESULTS Compared with baseline, Synthamin® 17 infusion significantly increased renal oxygen delivery mean ± SD maximum increase: (from 0.79 ± 0.17 to 1.06 ± 0.16 ml/kg/min, p < 0.001), renal oxygen consumption (from 0.08 ± 0.01 to 0.15 ± 0.02 ml/kg/min, p < 0.001), and glomerular filtration rate (+45.2 ± 2.7%, p < 0.001). Renal cortical tissue PO2 increased by a maximum of 26.4 ± 1.1% (p = 0.001) and medullary tissue PO2 increased by a maximum of 23.9 ± 2.8% (p = 0. 001). CONCLUSIONS In non-anesthetized healthy sheep, recruitment of RFR improved renal cortical and medullary oxygenation. These observations might have implications for the use of recruitment of RFR for diagnostic and therapeutic purposes.
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Affiliation(s)
- Alemayehu H. Jufar
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Cardiovascular Disease Program, Department of PhysiologyBiomedicine Discovery Institute, Monash UniversityMelbourneVictoriaAustralia
| | - Roger G. Evans
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Cardiovascular Disease Program, Department of PhysiologyBiomedicine Discovery Institute, Monash UniversityMelbourneVictoriaAustralia
| | - Clive N. May
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Department of Critical CareMelbourne Medical School, University of MelbourneMelbourneVictoriaAustralia
| | - Sally G. Hood
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
| | - Ashenafi H. Betrie
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Melbourne Dementia Research CentreFlorey Institute of Neuroscience and Mental Health, The University of MelbourneMelbourneVictoriaAustralia
| | - Anton Trask‐Marino
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
| | - Rinaldo Bellomo
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Department of Critical CareMelbourne Medical School, University of MelbourneMelbourneVictoriaAustralia
| | - Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care UnitFlorey Institute of Neuroscience and Mental Health, University of MelbourneMelbourneVictoriaAustralia
- Department of Critical CareMelbourne Medical School, University of MelbourneMelbourneVictoriaAustralia
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5
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Vogiatjis J, Noe KM, Don A, Cochrane AD, Zhu MZL, Smith JA, Ngo JP, Martin A, Thrift AG, Bellomo R, Evans RG. Association Between Changes in Norepinephrine Infusion Rate and Urinary Oxygen Tension After Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:237-245. [PMID: 36435720 DOI: 10.1053/j.jvca.2022.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To determine if the administration of norepinephrine to patients recovering from on-pump cardiac surgery is associated with changes in urinary oxygen tension (PO2), an indirect index of renal medullary oxygenation. DESIGN Single center, prospective observational study. SETTING Surgical intensive care unit (ICU). PARTICIPANTS A nonconsecutive sample of 93 patients recovering from on-pump cardiac surgery. MEASUREMENTS AND MAIN RESULTS In the ICU, norepinephrine was the most commonly used vasopressor agent (90% of patients, 84/93), with fewer patients receiving epinephrine (48%, 45/93) or vasopressin (4%, 4/93). During the 30-to-60-minute period after increasing the infused dose of norepinephrine (n = 89 instances), urinary PO2 decreased by (least squares mean ± SEM) 1.8 ± 0.5 mmHg from its baseline level of 25.1 ± 1.1 mmHg. Conversely, during the 30-to-60-minute period after the dose of norepinephrine was decreased (n = 134 instances), urinary PO2 increased by 2.6 ± 0.5 mmHg from its baseline level of 22.7 ± 1.2 mmHg. No significant change in urinary PO2 was detected when the dose of epinephrine was decreased (n = 21). There were insufficient observations to assess the effects of increasing the dose of epinephrine (n = 11) or of changing the dose of vasopressin (n <4). CONCLUSIONS In patients recovering from on-pump cardiac surgery, changes in norepinephrine dose are associated with reciprocal changes in urinary PO2, potentially reflecting an effect of norepinephrine on renal medullary oxygenation.
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Affiliation(s)
- Johnny Vogiatjis
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Andrea Don
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.
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6
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Deng J, Li L, Feng Y, Yang J. Comprehensive Management of Blood Pressure in Patients with Septic AKI. J Clin Med 2023; 12:jcm12031018. [PMID: 36769666 PMCID: PMC9917880 DOI: 10.3390/jcm12031018] [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: 11/27/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis.
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Affiliation(s)
- Junhui Deng
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Lina Li
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Yuanjun Feng
- Department of Renal Rheumatology, Space Hospital Affiliated to Zunyi Medical University, Zunyi 563002, China
| | - Jurong Yang
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
- Correspondence: or
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Hu RT, Lankadeva YR, Yanase F, Osawa EA, Evans RG, Bellomo R. Continuous bladder urinary oxygen tension as a new tool to monitor medullary oxygenation in the critically ill. Crit Care 2022; 26:389. [PMID: 36527088 PMCID: PMC9758873 DOI: 10.1186/s13054-022-04230-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is common in the critically ill. Inadequate renal medullary tissue oxygenation has been linked to its pathogenesis. Moreover, renal medullary tissue hypoxia can be detected before biochemical evidence of AKI in large mammalian models of critical illness. This justifies medullary hypoxia as a pathophysiological biomarker for early detection of impending AKI, thereby providing an opportunity to avert its evolution. Evidence from both animal and human studies supports the view that non-invasively measured bladder urinary oxygen tension (PuO2) can provide a reliable estimate of renal medullary tissue oxygen tension (tPO2), which can only be measured invasively. Furthermore, therapies that modify medullary tPO2 produce corresponding changes in bladder PuO2. Clinical studies have shown that bladder PuO2 correlates with cardiac output, and that it increases in response to elevated cardiopulmonary bypass (CPB) flow and mean arterial pressure. Clinical observational studies in patients undergoing cardiac surgery involving CPB have shown that bladder PuO2 has prognostic value for subsequent AKI. Thus, continuous bladder PuO2 holds promise as a new clinical tool for monitoring the adequacy of renal medullary oxygenation, with its implications for the recognition and prevention of medullary hypoxia and thus AKI.
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Affiliation(s)
- Raymond T. Hu
- grid.410678.c0000 0000 9374 3516Department of Anaesthesia, Austin Health, Heidelberg, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia
| | - Yugeesh R. Lankadeva
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia
| | - Fumitake Yanase
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Eduardo A. Osawa
- Cardiology Intensive Care Unit, DF Star Hospital, Brasília, Brazil ,grid.472984.4D’Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
| | - Roger G. Evans
- grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, VIC Australia
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Parkville, Australia
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8
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Chang YM, Chou YT, Kan WC, Shiao CC. Sepsis and Acute Kidney Injury: A Review Focusing on the Bidirectional Interplay. Int J Mol Sci 2022; 23:ijms23169159. [PMID: 36012420 PMCID: PMC9408949 DOI: 10.3390/ijms23169159] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/06/2022] [Accepted: 08/12/2022] [Indexed: 11/25/2022] Open
Abstract
Although sepsis and acute kidney injury (AKI) have a bidirectional interplay, the pathophysiological mechanisms between AKI and sepsis are not clarified and worthy of a comprehensive and updated review. The primary pathophysiology of sepsis-associated AKI (SA-AKI) includes inflammatory cascade, macrovascular and microvascular dysfunction, cell cycle arrest, and apoptosis. The pathophysiology of sepsis following AKI contains fluid overload, hyperinflammatory state, immunosuppression, and infection associated with kidney replacement therapy and catheter cannulation. The preventive strategies for SA-AKI are non-specific, mainly focusing on infection control and preventing further kidney insults. On the other hand, the preventive strategies for sepsis following AKI might focus on decreasing some metabolites, cytokines, or molecules harmful to our immunity, supplementing vitamin D3 for its immunomodulation effect, and avoiding fluid overload and unnecessary catheter cannulation. To date, several limitations persistently prohibit the understanding of the bidirectional pathophysiologies. Conducting studies, such as the Kidney Precision Medicine Project, to investigate human kidney tissue and establishing parameters or scores better to determine the occurrence timing of sepsis and AKI and the definition of SA-AKI might be the prospects to unveil the mystery and improve the prognoses of AKI patients.
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Affiliation(s)
- Yu-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary’s Hospital Luodong, Yilan 26546, Taiwan
| | - Yu-Ting Chou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Wei-Chih Kan
- Department of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Biological Science and Technology, Chung Hwa University of Medical Technology, Tainan 71703, Taiwan
- Correspondence: (W.-C.K.); (C.-C.S.)
| | - Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary’s Hospital Luodong, Yilan 26546, Taiwan
- Saint Mary’s Junior College of Medicine, Nursing and Management, Yilan 26546, Taiwan
- Correspondence: (W.-C.K.); (C.-C.S.)
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9
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Lankadeva YR, May CN, Bellomo R, Evans RG. Role of perioperative hypotension in postoperative acute kidney injury: a narrative review. Br J Anaesth 2022; 128:931-948. [DOI: 10.1016/j.bja.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 12/20/2022] Open
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10
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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11
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Lankadeva YR, Evans RG, Cochrane AD, Marino B, Hood SG, McCall PR, Iguchi N, Bellomo R, May CN. Reversal of renal tissue hypoxia during experimental cardiopulmonary bypass in sheep by increased pump flow and arterial pressure. Acta Physiol (Oxf) 2021; 231:e13596. [PMID: 34347356 DOI: 10.1111/apha.13596] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
AIM Renal tissue hypoxia during cardiopulmonary bypass could contribute to the pathophysiology of acute kidney injury. We tested whether renal tissue hypoxia can be alleviated during cardiopulmonary bypass by the combined increase in target pump flow and mean arterial pressure. METHODS Cardiopulmonary bypass was established in eight instrumented sheep under isoflurane anaesthesia, at a target continuous pump flow of 80 mL·kg-1 min-1 and mean arterial pressure of 65 mmHg. We then tested the effects of simultaneously increasing target pump flow to 104 mL·kg-1 min-1 and mean arterial pressure to 80 mmHg with metaraminol (total dose 0.25-3.75 mg). We also tested the effects of transitioning from continuous flow to partially pulsatile flow (pulse pressure ~15 mmHg). RESULTS Compared with conscious sheep, at the lower target pump flow and mean arterial pressure, cardiopulmonary bypass was accompanied by reduced renal blood flow (6.8 ± 1.2 to 1.95 ± 0.76 mL·min-1 kg-1) and renal oxygen delivery (0.91 ± 0.18 to 0.24 ± 0.11 mL·O2 min-1 kg-1). There were profound reductions in cortical oxygen tension (PO2) (33 ± 13 to 6 ± 6 mmHg) and medullary PO2 (31 ± 12 to 8 ± 8 mmHg). Increasing target pump flow and mean arterial pressure increased renal blood flow (to 2.6 ± 1.0 mL·min-1 kg-1) and renal oxygen delivery (to 0.32 ± 0.13 mL·O2 min-1kg-1) and returned cortical PO2 to 58 ± 60 mmHg and medullary PO2 to 28 ± 16 mmHg; levels similar to those of conscious sheep. Partially pulsatile pump flow had no significant effects on renal perfusion or oxygenation. CONCLUSIONS Renal hypoxia during experimental CPB can be corrected by increasing target pump flow and mean arterial pressure within a clinically feasible range.
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Affiliation(s)
- Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Roger G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne VIC Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health) Monash University Melbourne VIC Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources Melbourne VIC Australia
| | - Sally G. Hood
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Peter R. McCall
- Department of Anaesthesia Austin Health Heidelberg VIC Australia
| | - Naoya Iguchi
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Health Heidelberg VIC Australia
| | - Clive N. May
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
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12
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Plummer MP, Lankadeva YR, Finnis ME, Harrois A, Harding C, Peiris RM, Okazaki N, May CN, Evans RG, Macisaac CM, Barge D, Bellomo R, Deane AM. Urinary and renal oxygenation during dexmedetomidine infusion in critically ill adults with mechanistic insights from an ovine model. J Crit Care 2021; 64:74-81. [PMID: 33794470 DOI: 10.1016/j.jcrc.2021.03.004] [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: 12/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Examine effects of dexmedetomidine on bladder urinary oxygen tension (PuO2) in critically ill patients and delineate mechanisms in an ovine model. MATERIALS AND METHODS In 12 critically ill patients: oxygen-sensing probe inserted in the bladder catheter and dexmedetomidine infusion at a mean (SD) rate of 0.9 ± 0.3 μg/kg/h for 24-h. In 9 sheep: implantation of flow probes around the renal and pulmonary arteries, and oxygen-sensing probes in the renal cortex, renal medulla and bladder catheter; dexmedetomidine infusion at 0.5 μg/kg/h for 4-h and 1.0 μg/kg/h for 4-h then 16 h observation. RESULTS In patients, dexmedetomidine decreased bladder PuO2at 2 (-Δ11 (95% CI 7-16)mmHg), 8 (-Δ 7 (0.1-13)mmHg) and 24 h (-Δ 11 (0.4-21)mmHg). In sheep, dexmedetomidine at 1 μg/kg/h reduced renal medullary oxygenation (-Δ 19 (14-24)mmHg) and bladder PuO2 (-Δ 12 (7-17)mmHg). There was moderate correlation between renal medullary oxygenation and bladder PuO2; intraclass correlation co-efficient 0.59 (0.34-0.80). Reductions in renal medullary oxygenation were associated with reductions in blood pressure, cardiac output and renal blood flow (P < 0.01). CONCLUSIONS Dexmedetomidine decreases PuO2in critically ill patients and in sheep. In sheep this reflects a decrease in renal medullary oxygenation, associated with reductions in cardiac output, blood pressure and renal blood flow.
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Affiliation(s)
- Mark P Plummer
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Yugeesh R Lankadeva
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Mark E Finnis
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.
| | - Anatole Harrois
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Anesthesia and Surgical Intensive Care, Paris-Saclay University, Bicêtre University Hospital, Le Kremlin Bicêtre, France
| | - Charlie Harding
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Rachel M Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Nobuki Okazaki
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Clive N May
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.
| | - Christopher M Macisaac
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Deborah Barge
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
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13
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Cantow K, Evans RG, Grosenick D, Gladytz T, Niendorf T, Flemming B, Seeliger E. Quantitative Assessment of Renal Perfusion and Oxygenation by Invasive Probes: Basic Concepts. Methods Mol Biol 2021; 2216:89-107. [PMID: 33475996 PMCID: PMC9703258 DOI: 10.1007/978-1-0716-0978-1_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Renal tissue hypoperfusion and hypoxia are early key elements in the pathophysiology of acute kidney injury of various origins, and may also promote progression from acute injury to chronic kidney disease. Here we describe basic principles of methodology to quantify renal hemodynamics and tissue oxygenation by means of invasive probes in experimental animals. Advantages and disadvantages of the various methods are discussed in the context of the heterogeneity of renal tissue perfusion and oxygenation.This chapter is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers. This introduction chapter is complemented by a separate chapter describing the experimental procedure and data analysis.
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Affiliation(s)
- Kathleen Cantow
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Dirk Grosenick
- Physikalisch-Technische Bundesanstalt (German Federal Metrologic Institute), Berlin, Germany
| | - Thomas Gladytz
- Physikalisch-Technische Bundesanstalt (German Federal Metrologic Institute), Berlin, Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine (MDC) in the Helmholtz Association, Berlin, Germany
| | - Bert Flemming
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Erdmann Seeliger
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany.
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14
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Cantow K, Ladwig-Wiegard M, Flemming B, Fekete A, Hosszu A, Seeliger E. Reversible (Patho)Physiologically Relevant Test Interventions: Rationale and Examples. Methods Mol Biol 2021; 2216:57-73. [PMID: 33475994 DOI: 10.1007/978-1-0716-0978-1_4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal tissue hypoperfusion and hypoxia are early key elements in the pathophysiology of acute kidney injury of various origins, and may also promote progression from acute injury to chronic kidney disease. Here we describe test interventions that are used to study the control of renal hemodynamics and oxygenation in experimental animals in the context of kidney-specific control of hemodynamics and oxygenation. The rationale behind the use of the individual tests, the physiological responses of renal hemodynamics and oxygenation, the use in preclinical studies, and the possible application in humans are discussed.This chapter is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers.
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Affiliation(s)
- Kathleen Cantow
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Mechthild Ladwig-Wiegard
- Institute of Animal Welfare, Animal Behavior and Laboratory Animal Science, Free University Berlin, Berlin, Germany
| | - Bert Flemming
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Andrea Fekete
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Adam Hosszu
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Erdmann Seeliger
- Working Group Integrative Kidney Physiology, Institute of Physiology, Charité-University Medicine Berlin, Berlin, Germany.
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15
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Bellomo R, Evans RG. Renal functional reserve: from physiological phenomenon to clinical biomarker and beyond. Am J Physiol Regul Integr Comp Physiol 2020; 319:R690-R702. [PMID: 33074016 DOI: 10.1152/ajpregu.00237.2020] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glomerular filtration rate (GFR) is acutely increased following a high-protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in preglomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a "renal reserve," which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in subclinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that once a decline in basal GFR can be detected, renal disease is already well progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
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16
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Abstract
Physical trauma can affect any individual and is globally accountable for more than one in every ten deaths. Although direct severe kidney trauma is relatively infrequent, extrarenal tissue trauma frequently results in the development of acute kidney injury (AKI). Various causes, including haemorrhagic shock, rhabdomyolysis, use of nephrotoxic drugs and infectious complications, can trigger and exacerbate trauma-related AKI (TRAKI), particularly in the presence of pre-existing or trauma-specific risk factors. Injured, hypoxic and ischaemic tissues expose the organism to damage-associated and pathogen-associated molecular patterns, and oxidative stress, all of which initiate a complex immunopathophysiological response that results in macrocirculatory and microcirculatory disturbances in the kidney, and functional impairment. The simultaneous activation of components of innate immunity, including leukocytes, coagulation factors and complement proteins, drives kidney inflammation, glomerular and tubular damage, and breakdown of the blood-urine barrier. This immune response is also an integral part of the intense post-trauma crosstalk between the kidneys, the nervous system and other organs, which aggravates multi-organ dysfunction. Necessary lifesaving procedures used in trauma management might have ambivalent effects as they stabilize injured tissue and organs while simultaneously exacerbating kidney injury. Consequently, only a small number of pathophysiological and immunomodulatory therapeutic targets for TRAKI prevention have been proposed and evaluated.
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17
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Lumlertgul N, Ostermann M. Roles of angiotensin II as vasopressor in vasodilatory shock. Future Cardiol 2020; 16:569-583. [PMID: 32462921 DOI: 10.2217/fca-2020-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK.,Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK
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18
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Busse LW, Ostermann M. Vasopressor Therapy and Blood Pressure Management in the Setting of Acute Kidney Injury. Semin Nephrol 2020; 39:462-472. [PMID: 31514910 DOI: 10.1016/j.semnephrol.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' National Health Service Foundation Hospital, London, United Kingdom
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19
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Abstract
Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine, decrease in urine output, or both. AKI occurs in approximately 10-15% of patients admitted to hospital, while its incidence in intensive care has been reported in more than 50% of patients. Kidney dysfunction or damage can occur over a longer period or follow AKI in a continuum with acute and chronic kidney disease. Biomarkers of kidney injury or stress are new tools for risk assessment and could possibly guide therapy. AKI is not a single disease but rather a loose collection of syndromes as diverse as sepsis, cardiorenal syndrome, and urinary tract obstruction. The approach to a patient with AKI depends on the clinical context and can also vary by resource availability. Although the effectiveness of several widely applied treatments is still controversial, evidence for several interventions, especially when used together, has increased over the past decade.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy; International Renal Research Institute of Vicenza, Vicenza, Italy; Department of Nephrology, San Bortolo Hospital, Vicenza, Italy.
| | - Rinaldo Bellomo
- Critical Care Department, Austin Hospital, Melbourne, VIC, Australia
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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20
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Lankadeva YR, Okazaki N, Evans RG, Bellomo R, May CN. Renal Medullary Hypoxia: A New Therapeutic Target for Septic Acute Kidney Injury? Semin Nephrol 2019; 39:543-553. [DOI: 10.1016/j.semnephrol.2019.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II. Crit Care Med 2019; 46:949-957. [PMID: 29509568 PMCID: PMC5959265 DOI: 10.1097/ccm.0000000000003092] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. Setting: ICUs. Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively). Interventions: IV angiotensin II or placebo. Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively. Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
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22
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Iguchi N, Lankadeva YR, Evans RG, Cochrane AD, Marino B, Bellomo R, May CN. Renal Cortical Perfusion, Measured by Superb Microvascular Imaging, during Infusion of Norepinephrine in Experimental Cardiopulmonary Bypass. Am J Respir Crit Care Med 2019; 199:1564-1565. [DOI: 10.1164/rccm.201807-1275im] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Naoya Iguchi
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, and
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yugeesh R. Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, and
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery and
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; and
| | | | - Rinaldo Bellomo
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Clive N. May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, and
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23
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Jadhav AP, Sadaka FG. Angiotensin II in septic shock. Am J Emerg Med 2019; 37:1169-1174. [PMID: 30935784 DOI: 10.1016/j.ajem.2019.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/13/2019] [Accepted: 03/18/2019] [Indexed: 01/21/2023] Open
Abstract
Septic shock is a life threatening condition and a medical emergency. It is associated with organ dysfunction and hypotension despite optimal volume resuscitation. Refractory septic shock carries a very high rate of mortality and is associated with ischemic and arrhythmogenic complications from high dose vasopressors. Angiotensin II (AT-II) is a product of the renin-angiotensin-aldosterone system. It is a vasopressor agent that has been recently approved by FDA to be used in conjunction with other vasopressors (catecholamines) in refractory shock and to reduce catecholamine requirements. We have reviewed the physiology and current literature on AT-II in refractory septic/vasodilatory shock. Larger trials with longer duration of follow-up are warranted to address the questions which are unanswered by the ATHOS-3 trial, especially pertaining to its effects on lungs, brain, microcirculation, inflammation, and venous thromboembolism risk.
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Affiliation(s)
- Amar P Jadhav
- Intensivist, SSM St. Mary's Hospital, Richmond Heights, St. Louis, United States of America..
| | - Farid G Sadaka
- Clinical Associate Professor, Critical care/Neurocritical care, Mercy Hospital St.Louis, St. Louis University School of Medicine Program, United States of America
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24
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Angiotensin II-induced hypertension in rats is only transiently accompanied by lower renal oxygenation. Sci Rep 2018; 8:16342. [PMID: 30397212 PMCID: PMC6218546 DOI: 10.1038/s41598-018-34211-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 10/09/2018] [Indexed: 02/08/2023] Open
Abstract
Activation of the renin-angiotensin system may initiate chronic kidney disease. We hypothesised that renal hypoxia is a consequence of hemodynamic changes induced by angiotensin II and occurs prior to development of severe renal damage. Male Sprague-Dawley rats were infused continuously with angiotensin II (350 ng/kg/min) for 8 days. Mean arterial pressure (n = 5), cortical (n = 6) and medullary (n = 7) oxygenation (pO2) were continuously recorded by telemetry and renal tissue injury was scored. Angiotensin II increased arterial pressure gradually to 150 ± 18 mmHg. This was associated with transient reduction of oxygen levels in renal cortex (by 18 ± 2%) and medulla (by 17 ± 6%) at 10 ± 2 and 6 ± 1 hours, respectively after starting infusion. Thereafter oxygen levels normalised to pre-infusion levels and were maintained during the remainder of the infusion period. In rats receiving angiotensin II, adding losartan to drinking water (300 mg/L) only induced transient increase in renal oxygenation, despite normalisation of arterial pressure. In rats, renal hypoxia is only a transient phenomenon during initiation of angiotensin II-induced hypertension.
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25
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Lankadeva YR, Evans RG, Kosaka J, Booth LC, Iguchi N, Bellomo R, May CN. Alterations in regional kidney oxygenation during expansion of extracellular fluid volume in conscious healthy sheep. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1242-R1250. [PMID: 30332304 DOI: 10.1152/ajpregu.00247.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Expansion of extracellular fluid volume with crystalloid solutions is a common medical intervention, but its effects on renal cortical and medullary oxygenation are poorly understood. Therefore, we instrumented sheep under general anesthesia to enable continuous measurement of systemic and renal hemodynamics, global renal oxygen delivery and consumption, and intrarenal tissue perfusion and oxygen tension (Po2) in conscious animals ( n = 7). The effects of three sequential intermittent infusions of 500 ml of compound sodium lactate solution, administered at hourly intervals, were determined. Volume expansion induced transient increases in mean arterial pressure (+7 ± 2%), central venous pressure (+50 ± 19%), and cardiac output (+15 ± 3%). There were sustained increases in renal medullary tissue Po2 (+35 ± 10%) despite increases in global renal oxygen consumption (+66 ± 18%) and renal oxygen extraction (+64 ± 8%). Volume expansion did not significantly alter renal blood flow, renal oxygen delivery, or medullary perfusion. The sustained increase in medullary Po2 was paralleled by increased bladder urine Po2 (34 ± 4%). Cortical perfusion and Po2 did not change significantly. Our findings indicate that extracellular fluid volume expansion can increase renal medullary oxygenation, providing a potential mechanistic basis for its use as prophylaxis against iatrogenic acute kidney injury. They also indicate that continuous measurement of bladder urine Po2 could be used to monitor the effects of volume expansion on medullary oxygenation. However, the mechanisms mediating increased medullary oxygenation during volume expansion remain to be determined.
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Affiliation(s)
- Yugeesh R Lankadeva
- Florey Institute of Neuroscience and Mental Health , Victoria , Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne , Victoria , Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University , Victoria , Australia
| | - Junko Kosaka
- Florey Institute of Neuroscience and Mental Health , Victoria , Australia
| | - Lindsea C Booth
- Florey Institute of Neuroscience and Mental Health , Victoria , Australia
| | - Naoya Iguchi
- Florey Institute of Neuroscience and Mental Health , Victoria , Australia
| | - Rinaldo Bellomo
- School of Medicine, University of Melbourne , Victoria , Australia
| | - Clive N May
- Florey Institute of Neuroscience and Mental Health , Victoria , Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne , Victoria , Australia
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26
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Haddock BT, Francis ST, Larsson HB, Andersen UB. Assessment of Perfusion and Oxygenation of the Human Renal Cortex and Medulla by Quantitative MRI during Handgrip Exercise. J Am Soc Nephrol 2018; 29:2510-2517. [PMID: 30206141 PMCID: PMC6171273 DOI: 10.1681/asn.2018030272] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/08/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Renal flow abnormalities are believed to play a central role in the pathogenesis of nephropathy and in primary and secondary hypertension, but are difficult to measure in humans. Handgrip exercise is known to reduce renal arterial flow (RAF) by means of increased renal sympathetic nerve activity. METHODS To monitor medullary and cortical oxygenation under handgrip exercise-reduced perfusion, we used contrast- and radiation-free magnetic resonance imaging (MRI) to measure regional changes in renal perfusion and blood oxygenation in ten healthy normotensive individuals during handgrip exercise. We used phase-contrast MRI to measure RAF, arterial spin labeling to measure perfusion, and both changes in transverse relaxation time (T2*) and dynamic blood oxygenation level-dependent imaging to measure blood oxygenation. RESULTS Handgrip exercise induced a significant decrease in RAF. In the renal medulla, this was accompanied by an increase of oxygenation (reflected by an increase in T2*) despite a significant drop in medullary perfusion; the renal cortex showed a significant decrease in both perfusion and oxygenation. We also found a significant correlation (R2=0.8) between resting systolic BP and the decrease in RAF during handgrip exercise. CONCLUSIONS Renal MRI measurements in response to handgrip exercise were consistent with a sympathetically mediated decrease in RAF. In the renal medulla, oxygenation increased despite a reduction in perfusion, which we interpreted as the result of decreased GFR and a subsequently reduced reabsorptive workload. Our results further indicate that the renal flow response's sensitivity to sympathetic activation is correlated with resting BP, even within a normotensive range.
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Affiliation(s)
- Bryan Thomas Haddock
- Department of Clinical Physiology, Nuclear Medicine and Positron Emission Tomography, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; and
| | - Susan T. Francis
- Sir Peter Mansfield Imaging Centre School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Henrik B.W. Larsson
- Department of Clinical Physiology, Nuclear Medicine and Positron Emission Tomography, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; and
| | - Ulrik B. Andersen
- Department of Clinical Physiology, Nuclear Medicine and Positron Emission Tomography, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; and
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27
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Ma S, Evans RG, Iguchi N, Tare M, Parkington HC, Bellomo R, May CN, Lankadeva YR. Sepsis-induced acute kidney injury: A disease of the microcirculation. Microcirculation 2018; 26:e12483. [PMID: 29908046 DOI: 10.1111/micc.12483] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022]
Abstract
AKI is a common complication of sepsis and is significantly associated with mortality. Sepsis accounts for more than 50% of the cases of AKI, with a mortality rate of up to 40%. The pathogenesis of septic AKI is complex, but there is emerging evidence that, at least in the first 48 hours, the defects may be functional rather than structural in nature. For example, septic AKI is associated with an absence of histopathological changes, but with microvascular abnormalities and tubular stress. In this context, renal medullary hypoxia due to redistribution of intra-renal perfusion is emerging as a critical mediator of septic AKI. Clinically, vasopressor drugs remain the cornerstone of therapy for maintenance of blood pressure and organ perfusion. However, in septic AKI, there is insensitivity to vasopressors such as norepinephrine, leading to persistent hypotension and organ failure. Vasopressin, angiotensin II, and, paradoxically, α2 -adrenergic receptor agonists (clonidine and dexmedetomidine) may be feasible adjunct therapies for catecholamine-resistant vasodilatory shock. In this review, we outline the recent progress made in understanding how these drugs may influence the renal microcirculation, which represents a crucial step toward developing better approaches for the circulatory management of patients with septic AKI.
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Affiliation(s)
- Shuai Ma
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Division of Nephrology & Unit of Critical Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Naoya Iguchi
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Marianne Tare
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia.,Monash Rural Health, Monash University, Melbourne, VIC, Australia
| | - Helena C Parkington
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- School of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Clive N May
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Yugeesh R Lankadeva
- Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
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28
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Ow CPC, Ngo JP, Ullah MM, Hilliard LM, Evans RG. Renal hypoxia in kidney disease: Cause or consequence? Acta Physiol (Oxf) 2018; 222:e12999. [PMID: 29159875 DOI: 10.1111/apha.12999] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 02/06/2023]
Abstract
Tissue hypoxia has been proposed as an important factor in the pathophysiology of both chronic kidney disease (CKD) and acute kidney injury (AKI), initiating and propagating a vicious cycle of tubular injury, vascular rarefaction, and fibrosis and thus exacerbation of hypoxia. Here, we critically evaluate this proposition by systematically reviewing the literature relevant to the following six questions: (i) Is kidney disease always associated with tissue hypoxia? (ii) Does tissue hypoxia drive signalling cascades that lead to tissue damage and dysfunction? (iii) Does tissue hypoxia per se lead to kidney disease? (iv) Does tissue hypoxia precede pathology? (v) Does tissue hypoxia colocalize with pathology? (vi) Does prevention of tissue hypoxia prevent kidney disease? We conclude that tissue hypoxia is a common feature of both AKI and CKD. Furthermore, at least under in vitro conditions, renal tissue hypoxia drives signalling cascades that lead to tissue damage and dysfunction. Tissue hypoxia itself can lead to renal pathology, independent of other known risk factors for kidney disease. There is also some evidence that tissue hypoxia precedes renal pathology, at least in some forms of kidney disease. However, we have made relatively little progress in determining the spatial relationships between tissue hypoxia and pathological processes (i.e. colocalization) or whether therapies targeted to reduce tissue hypoxia can prevent or delay the progression of renal disease. Thus, the hypothesis that tissue hypoxia is a "common pathway" to both AKI and CKD still remains to be adequately tested.
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Affiliation(s)
- C. P. C. Ow
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - J. P. Ngo
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - M. M. Ullah
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - L. M. Hilliard
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - R. G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
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29
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Evans RG, Lankadeva YR, Cochrane AD, Marino B, Iguchi N, Zhu MZL, Hood SG, Smith JA, Bellomo R, Gardiner BS, Lee C, Smith DW, May CN. Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass. Acta Physiol (Oxf) 2018; 222. [PMID: 29127739 DOI: 10.1111/apha.12995] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 12/12/2022]
Abstract
Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery-associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models that medullary ischaemia and hypoxia occur during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra-operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimization of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interventions. We propose a multi-disciplinary pathway for translation comprising three components. Firstly, large-animal models of CPB to continuously monitor both whole kidney and regional kidney perfusion and oxygenation. Secondly, computational models to obtain information that can be used to interpret the data and develop rational interventions. Thirdly, clinically feasible non-invasive methods to continuously monitor renal oxygenation in the operating theatre and to identify patients at risk of AKI. In this review, we outline the recent progress on each of these fronts.
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Affiliation(s)
- R. G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - Y. R. Lankadeva
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - A. D. Cochrane
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - B. Marino
- Department of Perfusion Services Austin Hospital Heidelberg Vic. Australia
| | - N. Iguchi
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - M. Z. L. Zhu
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - S. G. Hood
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - J. A. Smith
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - R. Bellomo
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
| | - B. S. Gardiner
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C.‐J. Lee
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - D. W. Smith
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C. N. May
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
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30
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Urinary Oxygenation as a Surrogate Measure of Medullary Oxygenation During Angiotensin II Therapy in Septic Acute Kidney Injury. Crit Care Med 2017; 46:e41-e48. [PMID: 29077618 DOI: 10.1097/ccm.0000000000002797] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Angiotensin II is an emerging therapy for septic acute kidney injury, but it is unknown if its vasoconstrictor action induces renal hypoxia. We therefore examined the effects of angiotensin II on intrarenal PO2 in ovine sepsis. We also assessed the validity of urinary PO2 as a surrogate measure of medullary PO2. DESIGN Interventional study. SETTING Research Institute. SUBJECTS Sixteen adult Merino ewes (n = 8/group). INTERVENTIONS Sheep were instrumented with fiber-optic probes in the renal cortex, medulla, and within a bladder catheter to measure PO2. Conscious sheep were infused with Escherichia coli for 32 hours. At 24-30 hours, angiotensin II (0.5-33.0 ng/kg/min) or saline vehicle was infused. MEASUREMENTS AND MAIN RESULTS Septic acute kidney injury was characterized by hypotension and a 60% ± 6% decrease in creatinine clearance. During sepsis, medullary PO2 decreased from 36 ± 1 to 30 ± 3 mm Hg after 1 hour and to 20 ± 2 mm Hg after 24 hours; at these times, urinary PO2 was 42 ± 2, 34 ± 2, and 23 ± 2 mm Hg. Increases in urinary neutrophil gelatinase-associated lipocalin (12% ± 3%) and serum creatinine (60% ± 23%) were only detected at 8 and 24 hours, respectively. IV infusion of angiotensin II, at 24 hours of sepsis, restored arterial pressure and improved creatinine clearance, while not exacerbating medullary or urinary hypoxia. CONCLUSIONS In septic acute kidney injury, renal medullary and urinary hypoxia developed several hours before increases in currently used biomarkers. Angiotensin II transiently improved renal function without worsening medullary hypoxia. In septic acute kidney injury, angiotensin II appears to be a safe, effective therapy, and urinary PO2 may be used to detect medullary hypoxia.
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31
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Post EH, Kellum JA, Bellomo R, Vincent JL. Renal perfusion in sepsis: from macro- to microcirculation. Kidney Int 2016; 91:45-60. [PMID: 27692561 DOI: 10.1016/j.kint.2016.07.032] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/01/2016] [Accepted: 07/07/2016] [Indexed: 12/16/2022]
Abstract
The pathogenesis of sepsis-associated acute kidney injury is complex and likely involves perfusion alterations, a dysregulated inflammatory response, and bioenergetic derangements. Although global renal hypoperfusion has been the main target of therapeutic interventions, its role in the development of renal dysfunction in sepsis is controversial. The implications of renal hypoperfusion during sepsis probably extend beyond a simple decrease in glomerular filtration pressure, and targeting microvascular perfusion deficits to maintain tubular epithelial integrity and function may be equally important. In this review, we provide an overview of macro- and microcirculatory dysfunction in experimental and clinical sepsis and discuss relationships with kidney oxygenation, metabolism, inflammation, and function.
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Affiliation(s)
- Emiel Hendrik Post
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, Australia
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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32
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Emans TW, Janssen BJ, Pinkham MI, Ow CPC, Evans RG, Joles JA, Malpas SC, Krediet CTP, Koeners MP. Exogenous and endogenous angiotensin-II decrease renal cortical oxygen tension in conscious rats by limiting renal blood flow. J Physiol 2016; 594:6287-6300. [PMID: 27426098 PMCID: PMC5088249 DOI: 10.1113/jp270731] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/08/2016] [Indexed: 01/08/2023] Open
Abstract
KEY POINTS Our understanding of the mechanisms underlying the role of hypoxia in the initiation and progression of renal disease remains rudimentary. We have developed a method that allows wireless measurement of renal tissue oxygen tension in unrestrained rats. This method provides stable and continuous measurements of cortical tissue oxygen tension (PO2) for more than 2 weeks and can reproducibly detect acute changes in cortical oxygenation. Exogenous angiotensin-II reduced renal cortical tissue PO2 more than equi-pressor doses of phenylephrine, probably because it reduced renal oxygen delivery more than did phenylephrine. Activation of the endogenous renin-angiotensin system in transgenic Cyp1a1Ren2 rats reduced cortical tissue PO2; in this model renal hypoxia precedes the development of structural pathology and can be reversed acutely by an angiotensin-II receptor type 1 antagonist. Angiotensin-II promotes renal hypoxia, which may in turn contribute to its pathological effects during development of chronic kidney disease. ABSTRACT We hypothesised that both exogenous and endogenous angiotensin-II (AngII) can decrease the partial pressure of oxygen (PO2) in the renal cortex of unrestrained rats, which might in turn contribute to the progression of chronic kidney disease. Rats were instrumented with telemeters equipped with a carbon paste electrode for continuous measurement of renal cortical tissue PO2. The method reproducibly detected acute changes in cortical oxygenation induced by systemic hyperoxia and hypoxia. In conscious rats, renal cortical PO2 was dose-dependently reduced by intravenous AngII. Reductions in PO2 were significantly greater than those induced by equi-pressor doses of phenylephrine. In anaesthetised rats, renal oxygen consumption was not affected, and filtration fraction was increased only in the AngII infused animals. Oxygen delivery decreased by 50% after infusion of AngII and renal blood flow (RBF) fell by 3.3 ml min-1 . Equi-pressor infusion of phenylephrine did not significantly reduce RBF or renal oxygen delivery. Activation of the endogenous renin-angiotensin system in Cyp1a1Ren2 transgenic rats reduced cortical tissue PO2. This could be reversed within minutes by pharmacological angiotensin-II receptor type 1 (AT1 R) blockade. Thus AngII is an important modulator of renal cortical oxygenation via AT1 receptors. AngII had a greater influence on cortical oxygenation than did phenylephrine. This phenomenon appears to be attributable to the profound impact of AngII on renal oxygen delivery. We conclude that the ability of AngII to promote renal cortical hypoxia may contribute to its influence on initiation and progression of chronic kidney disease.
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Affiliation(s)
- Tonja W Emans
- Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands.,Internal Medicine-Nephrology, Academic Medical Centre at the University of Amsterdam, The Netherlands
| | - Ben J Janssen
- Department of Pharmacology and Toxicology, Maastricht University, Maastricht, The Netherlands
| | | | - Connie P C Ow
- Cardiovascular Disease Program, Biosciences Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biosciences Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Jaap A Joles
- Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Simon C Malpas
- Department of Physiology, University of Auckland, Auckland, New Zealand.,Millar Inc, Auckland, New Zealand
| | - C T Paul Krediet
- Internal Medicine-Nephrology, Academic Medical Centre at the University of Amsterdam, The Netherlands
| | - Maarten P Koeners
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK.
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33
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Lankadeva YR, Kosaka J, Evans RG, Bailey SR, Bellomo R, May CN. Intrarenal and urinary oxygenation during norepinephrine resuscitation in ovine septic acute kidney injury. Kidney Int 2016; 90:100-8. [PMID: 27165831 DOI: 10.1016/j.kint.2016.02.017] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 01/26/2016] [Accepted: 02/11/2016] [Indexed: 10/21/2022]
Abstract
Norepinephrine is the principal vasopressor used to restore blood pressure in sepsis, but its effects on intrarenal oxygenation are unknown. To clarify this, we examined renal cortical, medullary, and urinary oxygenation in ovine septic acute kidney injury and the response to resuscitation with norepinephrine. A renal artery flow probe and fiberoptic probes were placed in the cortex and medulla of sheep to measure tissue perfusion and oxygenation. A probe in the bladder catheter measured urinary oxygenation. Sepsis was induced in conscious sheep by infusion of Escherichia coli for 32 hours. At 24 to 30 hours of sepsis, either norepinephrine, to restore mean arterial pressure to preseptic levels or vehicle-saline was infused (8 sheep per group). Septic acute kidney injury was characterized by a reduction in blood pressure of ∼12 mm Hg, renal hyperperfusion, and oliguria. Sepsis reduced medullary perfusion (from an average of 1289 to 628 blood perfusion units), medullary oxygenation (from 32 to 16 mm Hg), and urinary oxygenation (from 36 to 24 mm Hg). Restoring blood pressure with norepinephrine further reduced medullary perfusion to an average of 331 blood perfusion units, medullary oxygenation to 8 mm Hg and urinary oxygenation to 18 mm Hg. Cortical perfusion and oxygenation were preserved. Thus, renal medullary hypoxia caused by intrarenal blood flow redistribution may contribute to the development of septic acute kidney injury, and resuscitation of blood pressure with norepinephrine exacerbates medullary hypoxia. The parallel changes in medullary and urinary oxygenation suggest that urinary oxygenation may be a useful real-time biomarker for risk of acute kidney injury.
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Affiliation(s)
- Yugeesh R Lankadeva
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Junko Kosaka
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Bioscience Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Simon R Bailey
- Faculty of Veterinary Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care and Department of Medicine, Austin Health, Heidelberg and The Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia
| | - Clive N May
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.
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34
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Evans RG. Oxygen regulation in biological systems. Am J Physiol Regul Integr Comp Physiol 2016; 310:R673-8. [PMID: 26911461 DOI: 10.1152/ajpregu.00004.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/17/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Melbourne, Australia
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