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Tăluță C, Ștefănescu H, Crișan D. Seeing and Sensing the Hepatorenal Syndrome (HRS): The Growing Role of Ultrasound-Based Techniques as Non-Invasive Tools for the Diagnosis of HRS. Diagnostics (Basel) 2024; 14:938. [PMID: 38732353 PMCID: PMC11083774 DOI: 10.3390/diagnostics14090938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
More than half of patients hospitalized with liver cirrhosis are dealing with an episode of acute kidney injury; the most severe pattern is hepatorenal syndrome due to its negative prognosis. The main physiopathology mechanisms involve renal vasoconstriction and systemic inflammation. During the last decade, the definition of hepatorenal syndrome changed, but the validated criteria of diagnosis are still based on the serum creatinine level, which is a biomarker with multiple limitations. This is the reason why novel serum and urinary biomarkers have been intensively studied in recent years. Meanwhile, the imaging studies that use shear wave elastography are using renal stiffness as a surrogate for an early diagnosis. In this article, we focus on the physiopathology definition and highlight the novel tools used in the diagnosis of hepatorenal syndrome.
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Affiliation(s)
- Cornelia Tăluță
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Horia Ștefănescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Dana Crișan
- 5th Medical Clinic, Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania;
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He L, Li Z, Zhang Q, Chen Y, Gao Y, Chen T, Wang N, Jiang L, Fan Y. Evaluation of renal microperfusion in hyperuricemic nephropathy by Contrast-Enhanced Ultrasound imaging. Dis Model Mech 2022; 15:276106. [PMID: 35645166 PMCID: PMC9346517 DOI: 10.1242/dmm.049382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Abstract
Diagnostic tools for the early detection of renal injury caused by hyperuricemia are still lacking. Here, we investigated whether contrast-enhanced ultrasound (CEUS) could be used as a diagnostic tool for hyperuricemic nephropathy (HN). In the HN rat model, CEUS detected a significant decline in renal cortical perfusion compared with that in control rats. Peak intensity (PI) values correlated significantly with serum KIM-1 levels and fibrosis scores in HN rats. An early decline in PI values was also observed in chronic kidney disease (CKD) stage 1 patients with HN compared with the controls (61.1±4.52 dB versus 65.80±7.10 dB) and correlated with renal function in the patients with HN. In contrast, an increase in time to reach PI values was detected in HN patients with stage 1 CKD (15.14±1.75 s versus 14.52±4.75 s) and was more pronounced in CKD stage 4 patients (67.32±3.29 s). CEUS was able to detect abnormal renal perfusion in early CKD with HN, which correlated with renal function decline, suggesting that CEUS could be used as a noninvasive tool for assessing renal function in patients with HN.
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Affiliation(s)
- Li He
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Ze Li
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Qunzi Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Yini Chen
- Ultrasonic department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Yihui Gao
- Ultrasonic department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Teng Chen
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Niansong Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Lixin Jiang
- Ultrasonic department, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Ying Fan
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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Liu L, Chao Y, Wang X. Shock Resuscitation - the Necessity and Priority of Renal Blood Perfusion Assessment. Aging Dis 2022; 13:1056-1062. [PMID: 35855346 PMCID: PMC9286909 DOI: 10.14336/ad.2022.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/05/2022] [Indexed: 11/05/2022] Open
Abstract
Improving organ perfusion is the aim of shock resuscitation; therefore, improving organ blood perfusion is a direct indicator for shock resuscitation. During shock, different organs have different capacities for blood flow autoregulation. The kidney is an important organ with excellent ability to autoregulate the blood flow and with vulnerability to poor organ perfusion, which places kidney perfusion in a position of necessity and priority relative to that of other organs in shock. Critical-care ultrasonography provides the best evaluation of renal perfusion.
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Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang 05001, China.
| | - Yangong Chao
- Department of Critical Care Medicine, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China.
| | - Xiaoting Wang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
- Correspondence should be addressed to: Dr. Xiaoting Wang, Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
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Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a common complication in critically ill patients. Understanding the pathophysiology of AKI is essential to guide patient management. Imaging techniques that inform the pathogenesis of AKI in critically ill patients are urgently needed, in both research and ultimately clinical settings. Renal contrast-enhanced ultrasonography (CEUS) and multiparametric MRI appear to be the most promising imaging techniques for exploring the pathophysiological mechanisms involved in AKI. RECENT FINDINGS CEUS and MRI can be used to noninvasively and safely evaluate renal macrocirculation and microcirculation and oxygenation in critical ill patients. These techniques show that a decrease in renal blood flow, particularly cortical blood flow, may be observed in septic AKI and may contribute to its development. MRI may be a valuable method to quantify long-term renal damage after AKI that cannot currently be detected using standard clinical approaches. SUMMARY CEUS and multiparametric renal MRI are promising imaging techniques but more evidence is needed to show how they can first be more widely used in a research setting to test key hypotheses about the pathophysiology and recovery of AKI, and then ultimately be adopted in clinical practice to guide patient management.
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Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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Selby NM, Williams JP, Phillips BE. Application of dynamic contrast enhanced ultrasound in the assessment of kidney diseases. Curr Opin Nephrol Hypertens 2021; 30:138-143. [PMID: 33186215 DOI: 10.1097/mnh.0000000000000664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Many forms of acute and chronic disease are linked to changes in renal blood flow, perfusion, vascular density and hypoxia, but there are no readily available methods to assess these parameters in clinical practice. Dynamic contrast enhanced ultrasound (DCE-US) is a method that provides quantitative assessments of organ perfusion without ionising radiation or risk of nephrotoxicity. It can be performed at the bedside and is suitable for repeated measurements. The purpose of this review is to provide updates from recent publications on the utility of DCE-US in the diagnosis or assessment of renal disease, excluding the evaluation of benign or malignant renal masses. RECENT FINDINGS DCE-US has been applied in clinical studies of acute kidney injury (AKI), renal transplantation, chronic kidney disease (CKD), diabetic kidney disease and to determine acute effects of pharmacological agents on renal haemodynamics. DCE-US can detect changes in renal perfusion across these clinical scenarios and can differentiate healthy controls from those with CKD. In sepsis, reduced DCE-US measures of perfusion may indicate those at increased risk of developing AKI, but this requires confirmation in larger studies as there can be wide individual variation in perfusion measures in acutely unwell patients. Recent studies in transplantation have not provided robust evidence to show that DCE-US can differentiate between different causes of graft dysfunction, although it may show more promise as a prognostic indicator of graft function 1 year after transplant. DCE-US can detect acute haemodynamic changes in response to medication that correlate with changes in renal plasma flow as measured by para-aminohippurate clearance. SUMMARY DCE-US shows promise and has a number of advantages that make it suitable for the assessment of patients with various forms of kidney disease. However, further research is required to evidence its reproducibility and utility before clinical use can be advocated.
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Affiliation(s)
- Nicholas M Selby
- Division of Medical Sciences and Graduate Entry Medicine, Centre for Kidney Research and Innovation, University of Nottingham, Royal Derby Hospital Centre
- Department of Renal Medicine, Royal Derby Hospital
| | - John P Williams
- Division of Medical Sciences and Graduate Entry Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre
- Department of Anaesthesia and Critical Care, Royal Derby Hospital, Derby, UK
| | - Bethan E Phillips
- Division of Medical Sciences and Graduate Entry Medicine, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre
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The Eye as a Non-Invasive Window to the Microcirculation in Liver Cirrhosis: A Prospective Pilot Study. J Clin Med 2020; 9:jcm9103332. [PMID: 33080821 PMCID: PMC7603064 DOI: 10.3390/jcm9103332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 12/19/2022] Open
Abstract
Microcirculatory dysfunction is associated with organ failure, poor response to vasoactive drugs and increased mortality in cirrhosis, but monitoring techniques are not established. We hypothesized that the chorioretinal structures of the eye could be visualized as a non-invasive proxy of the systemic microvasculature in cirrhosis and would correlate with renal dysfunction. Optical Coherence Tomography (OCT) was performed to image the retina in n = 55 cirrhosis patients being assessed for liver transplantation. OCT parameters were compared with established cohorts of age- and sex-matched healthy volunteers (HV) and patients with chronic kidney disease (CKD). Retinal thickness, macular volume and choroidal thickness were significantly reduced relative to HV and comparable to CKD patients (macular volume: HV vs. cirrhosis mean difference 0.44 mm3 (95% CI 0.26–0.61), p ≤ 0.0001). Reduced retinal thickness and macular volume correlated with renal dysfunction in cirrhosis (macular volume vs. MDRD-6 eGFR r = 0.40, p = 0.006). Retinal changes had resolved substantially 6 weeks following transplantation. There was an inverse association between choroidal thickness and circulating markers of endothelial dysfunction (endothelin-1 r = −0.49, p ≤ 0.001; von Willebrand factor r = −0.32, p ≤ 0.05). Retinal OCT may represent a non-invasive window to the microcirculation in cirrhosis and a dynamic measure of renal and endothelial dysfunction. Validation in different cirrhosis populations is now required.
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Darmon M, Truche AS, Abdel-Nabey M, Schnell D, Souweine B. Early Recognition of Persistent Acute Kidney Injury. Semin Nephrol 2020; 39:431-441. [PMID: 31514907 DOI: 10.1016/j.semnephrol.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite the vast amount of literature dedicated to acute kidney injury (AKI) and its clinical consequences, short-term renal recovery has been relatively neglected. Recent studies have suggested that timing of renal recovery is associated with longer-term risk of death, residual renal function, and end-stage renal failure risk. In addition, longer AKI duration is associated with an increased requirement for renal replacement therapy. Comorbidities, especially renal and cardiovascular, severity of AKI, criteria to reach AKI diagnosis, as well as severity of critical illness have been associated with longer AKI duration, and, more specifically, risk of persistent renal dysfunction. Because predicting short-term renal recovery is clinically relevant, several tests, imaging, and biomarkers have been tested in a way to predict the course of AKI and chances for early renal recovery. In this review, the definition of recovery, consequences of persistent AKI, and tools proposed to predict recovery are described. The performance of these tools and their limits are discussed.
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Affiliation(s)
- Michaël Darmon
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA Team (Epidémiologie Clinique et Statistiques pour la Recherche en sAnté), Biostatistics and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistic Sorbonne Paris Cité, INSERM, Paris, France.
| | - Anne-Sophie Truche
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | | | - David Schnell
- Medical-Surgical Intensive Care Unit, Angoulême Hospital, Angoulême, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
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Jeong S, Park SB, Kim SH, Hwang JH, Shin J. Clinical significance of contrast-enhanced ultrasound in chronic kidney disease: a pilot study. J Ultrasound 2019; 22:453-460. [PMID: 31606854 DOI: 10.1007/s40477-019-00409-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Contrast-enhanced ultrasound (CEUS) has the potential to improve the imaging of renal blood flow and renal lesional vascularity in real time with high temporal and spatial resolution. PURPOSE This study investigated the clinical significance of real-time CEUS in cases of chronic kidney disease (CKD). MATERIALS AND METHODS Included patients were stratified according to their estimated glomerular filtration rate (eGFR): Group I (CKD stage I and II), eGFR ≥ 60 ml/min/1.73 m2; group II (CKD stage III), eGFR of 30 ≤ eGFR < 60 ml/min/1.73 m2; and group III (CKD stage IV and V), eGFR of eGFR < 30 ml/min/1.73 m2. Real-time and dynamic imaging of the renal cortex was performed using CEUS. Several bolus model perfusion and laboratory parameters were compared. The differences in perfusion or laboratory parameters among the groups and correlation between perfusion or laboratory parameters and eGFR were assessed. RESULTS Of the 24 patients, 4 were classified into group I, 13 into group II, and 7 into group III. No significant differences were found among the three groups in the perfusion parameter analysis. No parameter was significantly positively correlated with eGFR. In the laboratory parameter analysis, significant differences in several parameters (RBC, BUN, SCr, glucose, TCh, phosphorus, TP, p < 0.05) were detected among the three groups. These parameters significantly correlated with eGFR (correlation coefficient, R = - 0.7625 to 0.6026). CONCLUSIONS Kidney perfusion parameters in CEUS do not correlate with kidney function in this pilot study.
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Affiliation(s)
- Seokmin Jeong
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea.
| | - Su-Hyun Kim
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Jin Ho Hwang
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Jungho Shin
- Division of Nephrology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
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Muskiet MHA, Emanuel AL, Smits MM, Tonneijck L, Meijer RI, Joles JA, Serné EH, van Raalte DH. Assessment of real‐time and quantitative changes in renal hemodynamics in healthy overweight males: Contrast‐enhanced ultrasonography vs para‐aminohippuric acid clearance. Microcirculation 2019; 26:e12580. [DOI: 10.1111/micc.12580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/06/2019] [Accepted: 07/12/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Marcel H. A. Muskiet
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Anna L. Emanuel
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Mark M. Smits
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Lennart Tonneijck
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Rick I. Meijer
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Jaap A. Joles
- Department of Nephrology and Hypertension University Medical Center Utrecht The Netherlands
| | - Erik H. Serné
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
| | - Daniël H. van Raalte
- Department of Internal Medicine, Diabetes Center Amsterdam University Medical Centers, location VUMC Amsterdam The Netherlands
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Drudi FM, Cantisani V, Granata A, Angelini F, Messineo D, De Felice C, Ettorre E. Multiparametric ultrasound in the evaluation of kidney disease in elderly. J Ultrasound 2019; 23:115-126. [PMID: 31197634 DOI: 10.1007/s40477-019-00390-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/29/2019] [Indexed: 01/15/2023] Open
Abstract
After the age of 30 years, GFR progressively declines at an average rate of 8 mL/min/1.73 m/decade. A problem of advanced age is that the evaluation of renal function on the basis of indicators valid in young adults, such as creatininemia, is unreliable. In fact, many patients with chronic renal failure may have serum creatinine levels within the normal range even if they have a significant reduction in renal function. Ultrasound has become a routine method of investigation in renal disease: kidney size and parenchymal echogenicity are considered markers of renal function, so US is useful in assessing the presence and degree of renal failure. CEUS is useful in the evaluation of kidney disease in the elderly: the increased hemodynamic resistance of renal microvessels reduces perfusion in the renal cortex, so fewer microbubbles enter the renal cortex. EcoColor and EcoDoppler are also useful in the evaluation of senile alterations: here, the distribution of color-signals, as compared to that in the young adult population, appears more attenuated, limited to intersegmental and interlobar districts. Among the ecoDoppler parameters, the resistance index can be considered a marker of renal damage progression, with attention needing to paid to possible concomitant confounding factors. Ultrasonography, color-Doppler and CEUS are a non-invasive and convenient modality for managing kidney disease; their integration with anamnestic, objective and laboratory data permits fast and reliable clinical, diagnostic, and therapeutic classification. It also allows early therapeutic intervention and, ultimately, improvements in patient management.
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Affiliation(s)
- Francesco Maria Drudi
- Department of Radiological, Oncological and Path. Sciences, Sapienza University of Rome, Rome, Italy.
| | - Vito Cantisani
- Department of Radiological, Oncological and Path. Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonio Granata
- Department of Nephrology and Dyalisis, San Giovanni di Dio Hospital, Agrigento, Italy
| | - Flavia Angelini
- Department of Radiological, Oncological and Path. Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniela Messineo
- Department of Radiological, Oncological and Path. Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo De Felice
- Department of Radiological, Oncological and Path. Sciences, Sapienza University of Rome, Rome, Italy
| | - Evaristo Ettorre
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
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Francoz C, Durand F, Kahn JA, Genyk YS, Nadim MK. Hepatorenal Syndrome. Clin J Am Soc Nephrol 2019; 14:774-781. [PMID: 30996046 PMCID: PMC6500947 DOI: 10.2215/cjn.12451018] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatorenal syndrome is a severe complication of end-stage cirrhosis characterized by increased splanchnic blood flow, hyperdynamic state, a state of decreased central volume, activation of vasoconstrictor systems, and extreme kidney vasoconstriction leading to decreased GFR. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of hepatorenal syndrome has been highlighted in recent years. The mechanisms by which systemic inflammation precipitates kidney circulatory changes during hepatorenal syndrome need to be clarified. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage. Vasoconstrictive agents (terlipressin in particular) and albumin are the first-line treatment option. Several controlled studies proved that terlipressin is effective at reversing hepatorenal syndrome and may improve short-term survival. Not all patients are responders, and even in responders, early mortality rates are very high in the absence of liver transplantation. Liver transplantation is the only curative treatment of hepatorenal syndrome. In the long term, patients transplanted with hepatorenal syndrome tend to have lower GFR compared with patients without hepatorenal syndrome. Differentiating hepatorenal syndrome from acute tubular necrosis (ATN) is often a challenging yet important step because vasoconstrictors are not justified for the treatment of ATN. Hepatorenal syndrome and ATN may be considered as a continuum rather than distinct entities. Emerging biomarkers may help differentiate these two conditions and provide prognostic information on kidney recovery after liver transplantation, and potentially affect the decision for simultaneous liver-kidney transplantation.
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Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Disease, Department of Medicine
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, and
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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12
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Gray Scale Ultrasound, Color Doppler Ultrasound, and Contrast-Enhanced Ultrasound in Renal Parenchymal Diseases. Ultrasound Q 2018; 34:250-267. [DOI: 10.1097/ruq.0000000000000383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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13
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Contrast-enhanced ultrasonography for assessment of tubular atrophy/interstitial fibrosis in immunoglobulin A nephropathy: a preliminary clinical study. Abdom Radiol (NY) 2018; 43:1423-1431. [PMID: 29110052 DOI: 10.1007/s00261-017-1301-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To investigate the potential of contrast-enhanced ultrasonography (CEUS) for evaluating the severity of tubular atrophy/interstitial fibrosis (TA/IF) in immunoglobulin A nephropathy (IgAN) patients. MATERIALS AND METHODS A total of 80 patients with IgAN and 33 healthy adults were investigated. Patients were divided into three groups according to the TA/IF (T) grade of the Oxford classification: T0 (n = 28), T1 (n = 35), and T2 (n = 17). Patients and control subjects underwent conventional ultrasound (US) and CEUS. Time-intensity curves of CEUS were drawn for regions of interest located in the renal cortex and medulla using QLab software. Conventional US and CEUS quantitative parameters were analyzed. One-way analysis of variance (ANOVA), binary logistic regression, and receiver operating characteristic (ROC) curves were used. RESULTS There were no significant differences in renal size, cortical thickness, and medullary perfusion parameters (P > 0.05), whereas the differences in peak intensity (PI), area under the time-intensity curve (AUC) and wash-in slope (WIS) of cortical perfusion parameters between the control subjects and patients were significant (P < 0.05). PI was significantly lower with the increasing degree of T (P < 0.05). PI was associated independently with the degree of T in IgAN patients (P < 0.05). ROC analysis revealed that using the optimal cutoff values of 15.38 dB for diagnosis of T0-T1 (sensitivity 83.30% and specificity 63.00%) and 14.69 dB for diagnosis of T2 (sensitivity 100.00% and specificity 66.70%), the corresponding areas under the ROC curve were found to be 0.782 and 0.952, respectively. CONCLUSIONS CEUS can potentially be used as a noninvasive imaging marker to evaluate the severity of TA/IF in IgAN patients.
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Cao W, Cui S, Yang L, Wu C, Liu J, Yang F, Liu Y, Bin J, Hou FF. Contrast-Enhanced Ultrasound for Assessing Renal Perfusion Impairment and Predicting Acute Kidney Injury to Chronic Kidney Disease Progression. Antioxid Redox Signal 2017; 27:1397-1411. [PMID: 28715949 DOI: 10.1089/ars.2017.7006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIMS Acute kidney injury (AKI) is increasingly recognized as a major risk factor leading to progression to chronic kidney disease (CKD). However, the diagnostic tools for predicting AKI to CKD progression are particularly lacking. Here, we tested the utility of contrast-enhanced ultrasound (CEUS) for predicting progression to CKD after AKI by using both mild (20-min) and severe (45-min) bilateral renal ischemia-reperfusion injury mice. RESULTS Renal perfusion measured by CEUS reduced to 25% ± 7% and 14% ± 6% of the pre-ischemic levels in mild and severe AKI 1 h after ischemia (p < 0.05). Renal perfusion returned to pre-ischemic levels 1 day after mild AKI followed by restoration of kidney function. However, severe AKI caused persistent renal perfusion impairment (60% ± 9% of baseline levels) accompanied by progressive renal fibrosis and sustained decrease in renal function. Renal perfusion at days 1-21 significantly correlated with tubulointerstitial fibrosis 42 days after AKI. For predicting renal fibrosis at day 42, the area under the receiver operating characteristics curve of renal perfusion impairment at day 1 was 0.84. Similar changes in the renal image of CEUS were observed in patients with AKI-CKD progression. INNOVATION This study demonstrates that CEUS enables dynamic and noninvasive detection of renal perfusion impairment after ischemic AKI and the perfusion abnormalities shown by CEUS can early predict the progression to CKD after AKI. CONCLUSIONS These results indicate that CEUS enables the evaluation of renal perfusion impairment associated with CKD after ischemic AKI and may serve as a noninvasive technique for assessing AKI-CKD progression. Antioxid. Redox Signal. 27, 1397-1411.
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Affiliation(s)
- Wei Cao
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
| | - Shuang Cui
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
| | - Li Yang
- 2 Division of Pharmacology, Nanfang Hospital , Southern Medical University, Guangzhou, P.R. China
| | - Chunyi Wu
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
| | - Jian Liu
- 3 Division of Cardiology, Nanfang Hospital , Southern Medical University, Guangzhou, P.R. China
| | - Fang Yang
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
| | - Youhua Liu
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
| | - Jianping Bin
- 3 Division of Cardiology, Nanfang Hospital , Southern Medical University, Guangzhou, P.R. China
| | - Fan Fan Hou
- 1 Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University , Guangzhou, P.R. China
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15
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Davies T, Wythe S, O'Beirne J, Martin D, Gilbert-Kawai E. Review article: the role of the microcirculation in liver cirrhosis. Aliment Pharmacol Ther 2017; 46:825-835. [PMID: 29023881 DOI: 10.1111/apt.14279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 04/11/2017] [Accepted: 08/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis of multiple organ failure in end stage liver cirrhosis. AIM To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation. METHODS A Medline literature search was conducted using the following search terms: 'cirrhosis', 'microcirculation', 'circulation', 'systemic', 'inflammation', 'peripheral', 'hepatorenal' and 'hepatopulmonary'. RESULTS Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood. CONCLUSIONS Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy.
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Affiliation(s)
- T Davies
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - S Wythe
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - J O'Beirne
- Department of Hepatology, Nambour General Hospital, Sunshine Coast Hospital and Health Service, Nambour, Qld, Australia
| | - D Martin
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - E Gilbert-Kawai
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
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16
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Georgieva M, Beyer L, Goecze I, Stroszczynski C, Wiggermann P, Jung E. Contrast-enhanced ultrasound (CEUS) in an interdisciplinary intensive care unit (ICU): Diagnostic efficacy in the assessment of post-operative complications compared to contrast-enhanced computed tomography (CECT): First results. Clin Hemorheol Microcirc 2017; 66:277-282. [DOI: 10.3233/ch-179101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M. Georgieva
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany
| | - L. Beyer
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany
| | - I. Goecze
- Klinik und Poliklinik für Chirurgie, Universität Regensburg, Regensburg, Germany
| | - C. Stroszczynski
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany
| | - P. Wiggermann
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany
| | - E.M. Jung
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany
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17
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Molecular Ultrasound Imaging of Tissue Inflammation Using an Animal Model of Acute Kidney Injury. Mol Imaging Biol 2016; 17:786-92. [PMID: 25905474 DOI: 10.1007/s11307-015-0860-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The objective of this study was to evaluate the use of molecular ultrasound (US) imaging for monitoring the early inflammatory effects following acute kidney injury. PROCEDURES A population of rats underwent 30 min of renal ischemia (acute kidney injury, N = 6) or sham injury (N = 4) using established surgical methods. Animals were divided and molecular US imaging was performed during the bolus injection of a targeted microbubble (MB) contrast agent to either P-selectin or vascular cell adhesion molecule 1 (VCAM-1). Imaging was performed before surgery and 4 and 24 h thereafter. After manual segmentation of renal tissue space, the molecular US signal was calculated as the difference between time-intensity curve data before MB injection and after reaching steady-state US image enhancement. All animals were terminated after the 24 h imaging time point and kidneys excised for immunohistochemical (IHC) analysis. RESULTS Renal inflammation was analyzed using molecular US imaging. While results using the P-selectin and VCAM-1 targeted MBs were comparable, it appears that the former was more sensitive to biomarker expression. All molecular US imaging measures had a positive correlation with IHC findings. CONCLUSIONS Acute kidney injury is a serious disease in need of improved noninvasive methods to help diagnose the extent of injury and monitor the tissue throughout disease progression. Molecular US imaging appears well suited to address this challenge and more research is warranted.
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18
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Hsu HC, Wang L, Wang LV. In vivo photoacoustic microscopy of human cuticle microvasculature with single-cell resolution. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:56004. [PMID: 27207113 PMCID: PMC5998605 DOI: 10.1117/1.jbo.21.5.056004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 04/19/2016] [Indexed: 05/24/2023]
Abstract
As a window on the microcirculation, human cuticle capillaries provide rich information about the microvasculature, such as its morphology, density, dimensions, or even blood flow speed. Many imaging technologies have been employed to image human cuticle microvasculature. However, almost none of these techniques can noninvasively observe the process of oxygen release from single red blood cells (RBCs), an observation which can be used to study healthy tissue functionalities or to diagnose, stage, or monitor diseases. For the first time, we adapted single-cell resolution photoacoustic (PA) microscopy (PA flowoxigraphy) to image cuticle capillaries and quantified multiple functional parameters. Our results show more oxygen release in the curved cuticle tip region than in other regions of a cuticle capillary loop, associated with a low of RBC flow speed in the tip region. Further analysis suggests that in addition to the RBC flow speed, other factors, such as the drop of the partial oxygen pressure in the tip region, drive RBCs to release more oxygen in the tip region.
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Affiliation(s)
- Hsun-Chia Hsu
- Washington University in St. Louis, Department of Biomedical Engineering, Optical Imaging Laboratory, One Brookings Drive, St. Louis, Missouri 63130, United States
| | | | - Lihong V. Wang
- Washington University in St. Louis, Department of Biomedical Engineering, Optical Imaging Laboratory, One Brookings Drive, St. Louis, Missouri 63130, United States
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19
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Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Prevention and treatment of sepsis-induced acute kidney injury: an update. Ann Intensive Care 2015; 5:51. [PMID: 26690796 PMCID: PMC4686459 DOI: 10.1186/s13613-015-0095-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive “kidney afterload” are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients’ refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rita Jacobs
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Inne Hendrickx
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Olivier Joannes-Boyau
- Haut Leveque University Hospital of Bordeaux, University of Bordeaux 2, Pessac, France.
| | - Willem Boer
- Department of Anaesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Elisabeth De Waele
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Viola Van Gorp
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Herbert D Spapen
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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20
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Schnell D, Darmon M. Bedside Doppler ultrasound for the assessment of renal perfusion in the ICU: advantages and limitations of the available techniques. Crit Ultrasound J 2015; 7:24. [PMID: 26058500 PMCID: PMC4461647 DOI: 10.1186/s13089-015-0024-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/05/2015] [Indexed: 01/20/2023] Open
Abstract
Three Doppler-derived techniques have been proposed to assess renal perfusion at bedside: Doppler-based renal resistive index (RI) which has been extensively but imperfectly studied in assessing renal allograft status and changes in renal perfusion in critically ill patients and for predicting the reversibility of an acute kidney injury (AKI), semi-quantitative evaluation of renal perfusion using colour-Doppler which may be easier to perform and may give similar information than RI and contrast-enhanced sonography that may allow more precise renal and cortical perfusion assessment. These promising tools have several obvious advantages including their feasibility, non-invasiveness, repeatability and potential interest in assessing renal function or perfusion. However, several limits need to be taken into account with these techniques, and promising results remain associated with large areas of uncertainty. This editorial will describe more carefully advantages and limits of these techniques and will discuss their potential interest in assessing renal perfusion.
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Affiliation(s)
- David Schnell
- Medical-Surgical Intensive Care Unit, Angoulême Hospital, Angoulême, France
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