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Velez JCQ, Latt N, Rodby RA. Pathophysiology of Hepatorenal Syndrome. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:87-99. [PMID: 38649221 DOI: 10.1053/j.akdh.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/17/2023] [Accepted: 01/02/2024] [Indexed: 04/25/2024]
Abstract
Hepatorenal syndrome type 1 (HRS-1) is a unique form of acute kidney injury that affects individuals with decompensated cirrhosis with ascites. The primary mechanism leading to reduction of kidney function in HRS-1 is hemodynamic in nature. Cumulative evidence points to a cascade of events that led to a profound reduction in kidney perfusion. A state of increased intrahepatic vascular resistance characteristic of advanced cirrhosis and portal hypertension is accompanied by maladaptive peripheral arterial vasodilation and reduction in systemic vascular resistance and mean arterial pressure. As a result of a fall in effective arterial blood volume, there is a compensatory activation of the sympathetic nervous system and the renin-angiotensin system, local renal vasoconstriction, loss of renal autoregulation, decrease in renal blood flow, and ultimately a fall in glomerular filtration rate. Systemic release of nitric oxide stimulated by the fibrotic liver, bacterial translocation, and inflammation constitute key components of the pathogenesis. While angiotensin II and noradrenaline remain the critical mediators of renal arterial and arteriolar vasoconstriction, other novel molecules have been recently implicated. Although the above-described mechanistic pathway remains the backbone of the pathogenesis of HRS-1, other noxious elements may be present in advanced cirrhosis and likely contribute to the renal impairment. Direct liver-kidney crosstalk via the hepatorenal sympathetic reflex can further reduce renal blood flow independently of the systemic derangements. Tense ascites may lead to intraabdominal hypertension and abdominal compartment syndrome. Cardio-hemodynamic processes have also been increasingly recognized. Porto-pulmonary hypertension, cirrhotic cardiomyopathy, and abdominal compartment syndrome may lead to renal congestion and complicate the course of HRS-1. In addition, a degree of ischemic or toxic (cholemic) tubular injury may overlap with the underlying circulatory dysfunction and further exacerbate the course of acute kidney injury. Improving our understanding of the pathogenesis of HRS-1 may lead to improvements in therapeutic options for this seriously ill population.
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Affiliation(s)
- Juan Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia.
| | - Nyan Latt
- Virtua Center for Liver Disease, Virtua Health, Toms River, NJ
| | - Roger A Rodby
- Division of Nephrology, Rush University School of Medicine, Chicago, IL
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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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Chaney A. A Review for the Practicing Clinician: Hepatorenal Syndrome, a Form of Acute Kidney Injury, in Patients with Cirrhosis. Clin Exp Gastroenterol 2021; 14:385-396. [PMID: 34675586 PMCID: PMC8502008 DOI: 10.2147/ceg.s323778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022] Open
Abstract
The hepatorenal syndrome type of acute kidney injury (HRS-AKI), formerly known as type 1 hepatorenal syndrome, is a rapidly progressing renal failure that occurs in many patients with advanced cirrhosis and ascites. Accumulating evidence has led to a recent evolution of diagnostic criteria for this serious complication of end-stage liver disease. The aim of this review is to provide an overview of disease-related characteristics and therapeutic management of patients with HRS-AKI. Relevant literature was compiled to support discussion of the pathophysiology, diagnosis, prognosis, associated conditions, prevention, treatment, and management of HRS-AKI. Onset of HRS-AKI is characterized by sudden severe renal vasoconstriction, leading to an acute reduction in glomerular filtration rate and rapid, potentially life-threatening, renal deterioration. Although our understanding of disease pathophysiology continues to evolve, etiology of HRS-AKI likely involves systemic hemodynamic changes caused by liver disease, inflammation, and damage to renal parenchyma. There is currently no gold standard for diagnosis, which typically involves a clinical workup, abdominal imaging, and laboratory assessments. The current consensus definition of HRS-AKI includes proposed diagnostic criteria based on changes in serum creatinine levels tailored for high sensitivity, and rapid detection to accelerate diagnosis and treatment initiation. The only potential cure for HRS-AKI is liver transplantation; however, vasoconstrictive agents and other supportive measures are used as needed to help maintain survival for patients who are awaiting or are ineligible for transplantation. The severity of HRS-AKI, complex pathology, limited treatment options, and range of associated conditions pose significant challenges for both patients and care providers.
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Affiliation(s)
- Amanda Chaney
- Department of Transplant, College of Medicine, Mayo Clinic, Jacksonville, FL, USA
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Velez JCQ, Therapondos G, Juncos LA. Reappraising the spectrum of AKI and hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol 2019; 16:137-155. [PMID: 31723234 DOI: 10.1038/s41581-019-0218-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
The occurrence of acute kidney injury (AKI) in patients with end-stage liver disease constitutes one of the most challenging clinical scenarios in in-hospital and critical care medicine. Hepatorenal syndrome type 1 (HRS-1), which is a specific type of AKI that occurs in the context of advanced cirrhosis and portal hypertension, is associated with particularly high mortality. The pathogenesis of HRS-1 is largely viewed as a functional derangement that ultimately affects renal vasculature tone. However, new insights suggest that non-haemodynamic tubulo-toxic factors, such as endotoxins and bile acids, might mediate parenchymal renal injury in patients with cirrhosis, suggesting that concurrent mechanisms, including those traditionally associated with HRS-1 and non-traditional factors, might contribute to the development of AKI in patients with cirrhosis. Moreover, histological evidence of morphological abnormalities in the kidneys of patients with cirrhosis and renal dysfunction has prompted the functional nature of HRS-1 to be re-examined. From a clinical perspective, a diagnosis of HRS-1 guides utilization of vasoconstrictive therapy and decisions regarding renal replacement therapy. Patients with cirrhosis are at risk of AKI owing to a wide range of factors. However, the tools currently available to ascertain the diagnosis of HRS-1 and guide therapy are suboptimal. Short of liver transplantation, goal-directed haemodynamically targeted pharmacotherapy remains the cornerstone of treatment for this condition; improved understanding of the underlying pathogenic mechanisms might lead to better clinical outcomes. Here, we examine our current understanding of the pathophysiology of HRS-1 and existing challenges in its diagnosis and treatment.
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Affiliation(s)
- Juan Carlos Q Velez
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA, USA. .,Ochsner Clinical School, The University of Queensland, Brisbane, Australia.
| | - George Therapondos
- Department of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Luis A Juncos
- Division of Nephrology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Renal Section, Department of Medicine, Central Arkansas Veterans Affairs Medical Center, Little Rock, AR, USA
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1499] [Impact Index Per Article: 249.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Comparison of the impact of prolonged low-pressure and standard-pressure pneumoperitoneum on myocardial injury after robot-assisted surgery in the Trendelenburg position: study protocol for a randomized controlled trial. Trials 2016; 17:488. [PMID: 27724965 PMCID: PMC5057242 DOI: 10.1186/s13063-016-1609-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 09/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background Robot-assisted laparoscopic radical prostatectomy and robot-assisted radical cystectomy have gradually become the preferred choices for urologists as they allow surgeons to perform complex procedures more precisely and effectively. The pneumoperitoneum, which is normally applied in these surgeries to provide visual clarity and space to perform the procedure, may cause hemodynamic disturbance, potentially myocardial injury. Thus surgeons have recently considered opting for the low-pressure pneumoperitoneum to lower this negative impact. Herein we describe a protocol for a clinical trial to compare the impact of prolonged low-pressure and standard-pressure pneumoperitoneum on myocardial injury after robot-assisted surgery. Methods/design This study is designed to be a bicenter clinical trial. In total 280 patients scheduled to undergo robot-assisted laparoscopic radical prostatectomy or robot-assisted radical cystectomy will be enrolled and randomized into two groups, with standard- (12–16 mmHg) and low-pressure (7–10 mmHg) pneumoperitoneum, respectively. Troponin T will be measured as the primary endpoint to assess the extent of myocardial injury. Nt-proBNP and hemodynamic indexes will also be recorded for further analysis. Discussion The significance of this study is emphasized by the fact that there are few studies that have focused on the impact of prolonged pneumoperitoneum on myocardial injury, which is relevant to postoperative mortality. We hope that the conclusions drawn from this study could provide reference and basis to the future of the pneumoperitoneum in clinical practice. Trial registration Registered at https://www.clinicaltrials.gov with the Identifier NCT02600481 on November 5, 2015 Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1609-5) contains supplementary material, which is available to authorized users.
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O'Leary JG, Levitsky J, Wong F, Nadim MK, Charlton M, Kim WR. Protecting the Kidney in Liver Transplant Candidates: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice. Am J Transplant 2016; 16:2516-31. [PMID: 26990924 DOI: 10.1111/ajt.13790] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/18/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are common in patients awaiting liver transplantation, and both have a marked impact on the perioperative and long-term morbidity and mortality of liver transplant recipients. Consequently, we reviewed the epidemiology of AKI and CKD in patients with end-stage liver disease, highlighted strategies to prevent and manage AKI, evaluated the changing liver transplant waiting list's impact on kidney function, delineated important considerations in simultaneous liver-kidney transplant selection, and projected possible future transplant policy changes and outcomes. This review was assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestinal Community of Practice and Board of Directors and provides practice-based recommendations for preservation of kidney function in patients with end-stage liver disease.
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Affiliation(s)
- J G O'Leary
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - J Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - F Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - M K Nadim
- Division of Nephology and Hypertension, Department of Medicine, University of Southern California, Los Angeles, CA
| | - M Charlton
- Intermountain Transplant Center, Murray, UT
| | - W R Kim
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, CA
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Renal Allograft Compartment Syndrome: Is It Possible to Prevent? Transplant Proc 2016; 48:340-3. [DOI: 10.1016/j.transproceed.2015.12.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/30/2015] [Indexed: 10/21/2022]
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Abdominal compartment syndrome as a rare complication following component separation repair: case report and review of the literature. Hernia 2015; 19:293-9. [DOI: 10.1007/s10029-015-1362-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
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Mesens T, Tomsin K, Staelens AS, Oben J, Molenberghs G, Gyselaers W. Is there a correlation between maternal venous hemodynamic dysfunction and proteinuria of preeclampsia? Eur J Obstet Gynecol Reprod Biol 2014; 181:246-50. [PMID: 25190298 DOI: 10.1016/j.ejogrb.2014.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 07/24/2014] [Accepted: 08/07/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate in early and late preeclampsia a correlation of maternal venous Doppler flow characteristics with biochemical parameters in maternal serum and urine, or with gestational outcome. STUDY DESIGN In this observational cross-sectional study, renal interlobar vein impedance index (RIVI) was measured according to a standardised protocol for combined electrocardiogram-Doppler ultrasonography in 86 women with uncomplicated pregnancy, 78 women with late onset preeclampsia (≥34w) and 67 with early onset preeclampsia (<34w). For each group, maternal age, pre-gestational BMI and parity were recorded together with birth weight and -percentile. For both early onset and late onset preeclampsia, maternal serum was analysed for thrombocyte count and concentrations of creatinine, ASAT, ALAT and uric acid and 24h urine collections were analysed for creatinine clearance and proteinuria (mg/24h). A non-parametric Mann-Whitney U-tests was performed for continuous data and a Fisher's exact tests for categorical data. Significant linear dependence between variables was identified using Pearson's correlation coefficient at nominal level a=0.05. RESULTS Proteinuria was higher in early onset than in late onset preeclampsia (1756mg [838-6116mg] versus 877mg [416-1696mg], p<0.001), and this was also true for RIVI in both left (0.45 [0.40-0.55] versus 0.41 [0.35-0.45], p=0.001) and right kidney (0.45 [0.39-0.55] versus 0.38 [0.30-0.43], p<0.001). In our data set, there was a significant correlation between proteinuria and RIVI of left (correlation coefficient=0.172, p=0.036) and right kidney (correlation coefficient=0.218, p=0.009) in late onset but not early onset preeclampsia. CONCLUSION Maternal RIVI may correlate with proteinuria of late onset preeclampsia.
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Affiliation(s)
- Tinne Mesens
- Dept. Obstetrics & Gynaecology, Ziekenhuis Oost Limburg, Genk, Belgium.
| | - Kathleen Tomsin
- Dept. Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jolien Oben
- Dept. Obstetrics & Gynaecology, Ziekenhuis Oost Limburg, Genk, Belgium
| | | | - Wilfried Gyselaers
- Dept. Obstetrics & Gynaecology, Ziekenhuis Oost Limburg, Genk, Belgium; Dept. of Physiology, Hasselt University, Hasselt, Belgium
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Cleva RD, Assumpção MSD, Sasaya F, Chaves NZ, Santo MA, Fló C, Lunardi AC, Jacob Filho W. Correlation between intra-abdominal pressure and pulmonary volumes after superior and inferior abdominal surgery. Clinics (Sao Paulo) 2014; 69:483-6. [PMID: 25029580 PMCID: PMC4081878 DOI: 10.6061/clinics/2014(07)07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/04/2013] [Accepted: 01/29/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Patients undergoing abdominal surgery are at risk for pulmonary complications. The principal cause of postoperative pulmonary complications is a significant reduction in pulmonary volumes (FEV1 and FVC) to approximately 65-70% of the predicted value. Another frequent occurrence after abdominal surgery is increased intra-abdominal pressure. The aim of this study was to correlate changes in pulmonary volumes with the values of intra-abdominal pressure after abdominal surgery, according to the surgical incision in the abdomen (superior or inferior). METHODS We prospectively evaluated 60 patients who underwent elective open abdominal surgery with a surgical time greater than 240 minutes. Patients were evaluated before surgery and on the 3rd postoperative day. Spirometry was assessed by maximal respiratory maneuvers and flow-volume curves. Intra-abdominal pressure was measured in the postoperative period using the bladder technique. RESULTS The mean age of the patients was 56 ± 13 years, and 41.6% 25 were female; 50 patients (83.3%) had malignant disease. The patients were divided into two groups according to the surgical incision (superior or inferior). The lung volumes in the preoperative period showed no abnormalities. After surgery, there was a significant reduction in both FEV1 (1.6 ± 0.6 L) and FVC (2.0 ± 0.7 L) with maintenance of FEV1/FVC of 0.8 ± 0.2 in both groups. The maximum intra-abdominal pressure values were similar (p=0.59) for the two groups. There was no association between pulmonary volumes and intra-abdominal pressure measured in any of the groups analyzed. CONCLUSIONS Our results show that superior and inferior abdominal surgery determines hypoventilation, unrelated to increased intra-abdominal pressure. Patients at high risk of pulmonary complications should receive respiratory care even if undergoing inferior abdominal surgery.
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Affiliation(s)
- Roberto de Cleva
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marianna Siqueira de Assumpção
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Flavia Sasaya
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Natalia Zuniaga Chaves
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Aurelio Santo
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Fló
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Adriana C Lunardi
- Gastroenterology Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Wilson Jacob Filho
- Geriatric Medicine, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Khan S, Verma AK, Ahmad SM, Ahmad R. Analyzing intra-abdominal pressures and outcomes in patients undergoing emergency laparotomy. J Emerg Trauma Shock 2011; 3:318-25. [PMID: 21063552 PMCID: PMC2966562 DOI: 10.4103/0974-2700.70747] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 01/02/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Studies have documented the impact of intra-abdominal hypertension (IAH) on virtually every organ. However, it still remains strangely underdiagnosed. The aims of the study were to assess, in patients undergoing emergency laparotomy, whether intra-abdominal pressure (IAP) is an independent predictor of morbidity and mortality, to evaluate the effects of IAH, and to identify hidden cases of abdominal compartment syndrome (ACS). MATERIALS AND METHODS The study comprised 197 patients undergoing emergency laparotomy. IAP was measured preoperatively and then postoperatively at 0, 6, and 24 hours. Duration of hospital stay, occurrence of burst abdomen, and mortality were noted as outcomes. RESULTS At admission, incidence of IAH was 80%. No significant association was found between IAP and occurrence of burst abdomen (P > 0.1). IAP was found to be a significant predictor of mortality in patients undergoing laparotomy (P < 0.001). Elevated IAP was found to affect all the organ systems adversely. The incidence of post-op ACS was 3.05% in the general population and 13.16% in trauma patients. The mortality rate for this subgroup was 100%. CONCLUSIONS IAP is a significant predictor of mortality in patients undergoing laparotomy. IAH has detrimental effects on various organ systems. A more frequent monitoring with prompt decompression may be helpful in decreasing the mortality rate. Further studies are required to establish a screening protocol in patients undergoing laparotomy to detect and manage cases of IAH and ACS.
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Affiliation(s)
- Shehtaj Khan
- Department of Surgery, J. N. Medical College, AMU, Aligarh-202002, Uttar Pradesh, India
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Gyselaers W, Mesens T, Tomsin K, Molenberghs G, Peeters L. Maternal renal interlobar vein impedance index is higher in early- than in late-onset pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:69-75. [PMID: 20178114 DOI: 10.1002/uog.7591] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To test the hypothesis that Doppler characteristics of maternal renal interlobar veins (RIV) are different between pregnancies affected by early-onset pre-eclampsia (EP) and those affected by late-onset pre-eclampsia (LP). METHODS A gestational age of 34 weeks was considered to differentiate EP from LP. All women had a renal duplex scan according to a standard protocol, with known intraobserver correlation coefficient (0.88). Maximum (Vmax) and minimum (Vmin) RIV velocities were measured on two occasions (between 28 and 32 and between 34 and 37 weeks) in 18 women with uncomplicated pregnancy (UP). In women with EP (n = 32) or LP (n = 41), these variables were measured once, within 3 days following hospital admission. Delta velocity (DeltaV) was calculated as Vmax - Vmin and the RIV impedance index (RIVI) was calculated as DeltaV/Vmax. Data on neonatal outcome and maternal renal function were obtained for UP and those with EP and LP, and group-specific means +/- SD were calculated and compared. RESULTS Compared with UP, the RIVI of both left and right kidneys was higher in those with EP (0.49 +/- 0.13 vs. 0.36 +/- 0.04, P = 0.0001, and 0.46 +/- 0.15 vs. 0.33 +/- 0.04, P = 0.0008) and in those with LP (0.41 +/- 0.07 vs. 0.37 +/- 0.06, P = 0.04, and 0.38 +/- 0.12 vs. 0.30 +/- 0.05, P = 0.009). RIVI was higher in pregnancies with EP than in those with LP (P < or = 0.01), and this difference was associated with lower median birth-weight percentiles (22.5 (interquartile range (IQR), 15-35) vs. 40.0 (IQR, 12-55), P = 0.01), higher maternal serum uric acid concentrations (419 +/- 84 vs. 374 +/- 85 micromol/L, P = 0.03) and higher proteinuria (4131 +/- 3885 vs. 1190 +/- 1133 mg/24 h, P < 0.0001). CONCLUSION Maternal vascular maladaption in pre-eclampsia is associated with abnormal Doppler findings in the venous compartment. RIVI is higher in EP than in LP pregnancies and this is associated with lower birth-weight percentiles and higher proteinuria.
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Affiliation(s)
- W Gyselaers
- Department of Obstetrics & Gynecology, Ziekenhuis Oost Limburg, Genk, Belgium.
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Peces R, Vega C, Peces C, Trébol J, González JA. Massive gastric dilatation and anuria resolved with naso-gastric tube decompression. Int Urol Nephrol 2009; 42:831-4. [PMID: 20041295 DOI: 10.1007/s11255-009-9698-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 12/17/2009] [Indexed: 12/20/2022]
Abstract
We report for the first time a case of acute kidney injury associated with severe gastric distention after a laparoscopic Nissen-Rossetti fundoplication of the stomach for hiatal hernia. An abdominal compartment syndrome secondary to intra-abdominal hypertension was suspected. Naso-gastric tube decompression resulted in immediate resaturation of the diuresis and progressive recovery of renal function.
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Affiliation(s)
- Ramón Peces
- Servicio de Nefrología, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain.
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Abstract
Renal failure in cirrhosis poses unique diagnostic and therapeutic challenges. Laboratory values and predictive equations grossly overestimate renal function in patients with cirrhosis. Development of renal failure connotes a worse prognosis; mortality is especially high with hepatorenal syndrome. Classification of the causes of renal failure in patients with cirrhosis is provided with more extensive discussion of selected causes. Finally, a suggested diagnostic approach to renal failure in cirrhosis is given.
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Affiliation(s)
- Lina Mackelaite
- Division of Nephrology, Department of Medicine, Drexel University College of Medicine, 245 North 15th Street, Room 6144, Philadelphia, PA 19102, USA
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Rasner JN, Parrott K, Tekulve R, Leavell JK, Iocono J. Management of abdominal compartment syndrome in a very low birth weight neonate using Penrose drains and subsequent management of abdominal-wall defects. J Laparoendosc Adv Surg Tech A 2008; 18:657-60. [PMID: 18721027 DOI: 10.1089/lap.2007.0226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Percutaneous drainage of the peritoneal cavity has been recently evaluated for the treatment of perforated viscous in the very low birth weight (VLBW) neonate and percutaneous decompression for abdominal compartment syndrome (ACS) has been studied in older patient populations. This is the first reported case of using this technique to treat ACS in a VLBW neonate.
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Affiliation(s)
- Justin N Rasner
- Division of Pediatric Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky 40436-0298, USA
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Galloway E, Doughty L. Electrolyte Emergencies and Acute Renal Failure in Pediatric Critical Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2007. [DOI: 10.1016/j.cpem.2007.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cheatham ML, Malbrain MLNG, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppäniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Wilmer A. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations. Intensive Care Med 2007; 33:951-62. [PMID: 17377769 DOI: 10.1007/s00134-007-0592-4] [Citation(s) in RCA: 657] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2006] [Accepted: 02/21/2007] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. DESIGN An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. METHODS Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. RESULTS The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. CONCLUSIONS These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.
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Affiliation(s)
- Michael L Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, 86 West Underwood, Orlando 32806, FL, USA
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Kimball EJ, Rollins MD, Mone MC, Hansen HJ, Baraghoshi GK, Johnston C, Day ES, Jackson PR, Payne M, Barton RG. Survey of intensive care physicians on the recognition and management of intra-abdominal hypertension and abdominal compartment syndrome. Crit Care Med 2006; 34:2340-8. [PMID: 16878034 DOI: 10.1097/01.ccm.0000233874.88032.1c] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess current understanding and clinical management of intra-abdominal hypertension and abdominal compartment syndrome among critical care physicians. DESIGN A ten-question, written survey. SETTING University health sciences center. SUBJECTS Physician members of the Society of Critical Care Medicine (SCCM). INTERVENTIONS The survey was sent to 4,538 SCCM members with a response rate of 35.7% (1622). MEASUREMENTS AND MAIN RESULTS Primary training, intensive care unit type, and methods for management of abdominal compartment syndrome were assessed. Surgically trained intensivists managed the highest number of abdominal compartment syndrome cases (47% managed 4-10 cases, 16% managed >10 cases). No cases were seen by 25% of medically trained and pediatric trained intensivists. Respondents agreed that bladder pressures and clinical variables were needed to diagnose abdominal compartment syndrome (70%) vs. bladder pressure (7%) or clinical variables (20%) alone. Two percent of surgical intensivists were unaware of a bladder pressure measurement procedure compared with 24% (p < .0001) of pediatric and 23% (p < .0001) of medical intensivists. Forty-two percent of respondents believed bladder pressures of 20-27 mm Hg may cause physiologic compromise. However, 25-27% of pediatric, medicine, or anesthesia trained intensivists believed that compromise occurs between 12 and 19 mm Hg compared with 18% of surgeons. No respondent believed that physiologic compromise occurred at <8 mm Hg. Thirty-eight percent of pediatric intensivists believed that physiologic compromise was patient dependent vs. 7-17% from other specialties (p < .0001; all comparisons). In managing intra-abdominal hypertension, 33% of pediatric intensivists and 19.6% of medical intensivists would never use decompression laparotomy to treat abdominal compartment syndrome compared with 3.6% of intensivists with surgical training (p < .0001; both comparisons). CONCLUSIONS Significant variation across medical training exists in the management of intra-abdominal hypertension and abdominal compartment syndrome. A significant percentage of intensivists may be unaware of current approaches to abdominal compartment syndrome management including monitoring bladder pressures and decompression laparotomy. Future research and education are necessary to establish clear diagnostic criteria and standards for treatment of this relatively common life-threatening disease process.
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Affiliation(s)
- Edward J Kimball
- University of Utah Health Sciences Center, Salt Lake City, 84132, USA.
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Maione C, Gambino G, Di Bona A, Luna E, Turco D, Scio A, Damiano G, Virzì C, Gioviale MC, Buscemi G, Romano M, Lo Monte AI. PTFE Mesh in Renal Allograft Compartment Syndrome. Transplant Proc 2006; 38:1049-50. [PMID: 16757260 DOI: 10.1016/j.transproceed.2006.02.139] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We report a case of anuria in a 42-year-old female kidney transplant patient that occurred secondary to extrinsic compression from a large kidney being placed extraperitoneally in a small iliac fossa. Prompt reexploration in the immediate postoperative period resulted in salvage of the graft with restoration of kidney function. The abdominal wall was reconstructed using prosthetic mesh, which decreased the compartment pressure within the iliac fossa sufficiently to allow the renal vein patency and the kidney perfusion. We think that this tension-free surgical technique should be applied in those cases in which the retroperitoneal space is less than the size of the kidney to avoid renal allograft compartment syndrome or incisional hernia.
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Affiliation(s)
- C Maione
- Department of General Surgery and Organ Transplantation, University of Palermo School of Medicine, Italy
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Maslovitz S, Jaffa A, Eytan O, Wolman I, Many A, Lessing JB, Gamzu R. Renal Blood Flow Alteration After Paracentesis in Women With Ovarian Hyperstimulation. Obstet Gynecol 2004; 104:321-6. [PMID: 15292006 DOI: 10.1097/01.aog.0000129956.97012.0d] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate renal arterial resistance to flow by Doppler indices concurrently with ascites drainage in women with severe ovarian hyperstimulation syndrome. METHODS We conducted an interventional clinical study of 19 women with severe ovarian hyperstimulation syndrome, manifested by free peritoneal fluid. The subjects were evaluated before and after therapeutic paracentesis by measuring urine output, blood urea nitrogen, intra-abdominal pressure, and renal artery flow measures by Doppler ultrasonography (systolic/diastolic ratio [S/D] and resistance index). RESULTS An average of 3,340 mL of ascitic fluid was drained, and the intra-abdominal pressure decreased from 17.5 +/- 1.24 cm H2O to 10 +/- 1.22 cm H2O. Urine output was increased (by 65%, from 925 +/- 248 mL/d before paracentesis to 1,523 +/- 526 mL/d on the day after paracentesis, P <.001). The mean renal arterial S/D decreased from 3 +/- 0.15 to 2.29 +/- 0.13 (P =.001). Most of the decrease in intra-abdominal pressure as well as in renal vasculature resistance was apparent after an initial drainage of 2,000 mL. Additional fluid drainage had only negligible effect on intra-abdominal pressure and renal flow. CONCLUSION Paracentesis lowered intra-abdominal pressure and decreased renal arterial resistance (lowered S/D and resistance index), ultimately resulting in increased urine production. It is plausible that the beneficial effects of paracentesis on urine output in ovarian hyperstimulation syndrome are due to improved renal blood flow from a direct decompression effect.
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Affiliation(s)
- Sharon Maslovitz
- Department of Obstetrics and Gynecologic, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Kapadia F. The cost implications of surveillance of ICU infections. Indian J Crit Care Med 2004. [DOI: 10.5005/ijccm-8-1-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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