Low mean perfusion pressure is a risk factor for progression of acute kidney injury in critically ill patients – A retrospective analysis

Ostermann, Marlies; Hall, Anna; Crichton, Siobhan

doi:10.1186/s12882-017-0568-8

Cited by 62 publications

(56 citation statements)

References 27 publications

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“…Phosphodiesterase type III inhibitors (milrinone and enoximone), calcium sensitizers (levosimendan), and pulmonary vasodilators (inhaled nitric oxide, inhaled prostacyclin, and inhaled milrinone) can improve cardiac performance while reducing afterload on both right and left ventricles. Because the determinant for renal perfusion is the arterial and venous blood pressure, both left ventricle dysfunction and increased central venous pressure are associated with decreased renal perfusion and increased renal afterload contributing to CS‐AKI . As noted, increased renal venous pressure also causes an increase in the renal subcapsular pressure, thereby reducing glomerular filtration .…”

Section: Resultsmentioning

confidence: 91%

“…Because the determinant for renal perfusion is the arterial and venous blood pressure, both left ventricle dysfunction and increased central venous pressure are associated with decreased renal perfusion and increased renal afterload contributing to CS-AKI. 209 As noted, increased renal venous pressure also causes an increase in the renal subcapsular pressure, thereby reducing glomerular filtration. 210 The use of dynamic measures based on heart-lung interactions to predict fluid responsiveness, such as pulse pressure or stroke volume variation, has been shown to improve outcomes including renal function in both cardiac and noncardiac settings.…”

Section: Optimization Of Mechanical Ventilationmentioning

confidence: 90%

See 1 more Smart Citation

Cardiac and Vascular Surgery–Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group

Nadim

Forni

Bïhorac

et al. 2018

JAHA

Self Cite

210

191

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Section: Resultsmentioning

confidence: 91%

Section: Optimization Of Mechanical Ventilationmentioning

confidence: 90%

Cardiac and Vascular Surgery–Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group

Nadim

Forni

Bïhorac

et al. 2018

JAHA

Self Cite

210

191

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“…Traditionally, renal injury is considered to be caused by reduced renal perfusion due to decreased cardiac output or vascular volume [29]. Renal perfusion pressure, defined as mean arterial pressure minus renal venous pressure, is a potential risk factor for AKI progression in critically ill patients [30]. A high CVP is transmitted backwards increasing renal venous pressure, which reduces renal perfusion pressure and increases renal venous congestion [31].…”

Section: Main Findingsmentioning

confidence: 99%

Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis

Chen¹,

Zhou²,

Wang³

et al. 2020

Crit Care

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Background: The association of central venous pressure (CVP) and mortality and acute kidney injury (AKI) in critically ill adult patients remains unclear. We performed a meta-analysis to determine whether elevated CVP is associated with increased mortality and AKI in critically ill adult patients. Methods: We searched PubMed and Embase through June 2019 to identify studies that investigated the association between CVP and mortality and/or AKI in critically ill adult patients admitted into the intensive care unit. We calculated the summary odds ratio (OR) and 95% CI using a random-effects model. Results: Fifteen cohort studies with a broad spectrum of critically ill patients (mainly sepsis) were included. On a dichotomous scale, elevated CVP was associated with an increased risk of mortality (3 studies; 969 participants; OR, 1.65; 95% CI, 1.19-2.29) and AKI (2 studies; 689 participants; OR, 2.09; 95% CI, 1.39-3.14). On a continuous scale, higher CVP was associated with greater risk of mortality (5 studies; 7837 participants; OR, 1.10; 95% CI, 1.03-1.17) and AKI (6 studies; 5446 participants; OR, 1.14; 95% CI, 1.06-1.23). Furthermore, per 1 mmHg increase in CVP increased the odds of AKI by 6% (4 studies; 5150 participants; OR, 1.06; 95% CI, 1.01-1.12). Further analyses restricted to patients with sepsis showed consistent results. Conclusions: Elevated CVP is associated with an increased risk of mortality and AKI in critically ill adult patients admitted into the intensive care unit.

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“…It is calculated as the difference between systemic mean arterial pressure (MAP) and CVP, i.e., MPP = MAP − CVP [10,11]. Whether MPP is a better resuscitation target for patients with shock is unknown.…”

mentioning

confidence: 99%

MAP of 65: target of the past?

2018

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Septic shock is defined as sepsis with hypotension refractory to fluid challenge and requiring vasopressor support combined with an increase in arterial lactate reflecting impaired cellular energy metabolism and dysoxia. The use of vasoactive drugs to restore mean arterial pressure (MAP) is strongly recommended by the Surviving Sepsis Campaign [1] and the Task Force of the European Society of Intensive Care Medicine (ESICM) on circulatory shock management and monitoring [2].Resuscitation in septic shock aims to restore tissue perfusion pressure without excessive vasoconstriction, which impedes flow and paradoxically worsens organ dysfunction or leads to other adverse events. MAP is a key component of tissue perfusion and is often viewed as a surrogate of organ perfusion pressure. Both the SSC and ESICM guidelines suggest keeping MAP ≥ 65 mmHg and individualizing this target based on comorbidities.The current MAP target of 65 mmHg is mainly based on the results of two retrospective studies investigating sequential MAP readings and the time spent below different threshold values of MAP during the first 24 or 48 h of management of patients with septic shock [3,4]. Both studies showed a correlation between MAP thresholds and survival [3,4] and organ dysfunction [4,5]. Best results were seen with a MAP between 60 and 65 mmHg, and the time spent below these values correlated with risk of mortality [3,4]. There was no survival benefit with higher MAP thresholds. Furthermore, the risk of mortality increased markedly in patients treated with high doses of norepinephrine irrespective of the MAP [5]. Recently, two prospective randomized controlled trials, SEPSIS-PAM and Ovation, compared high versus low target MAP on chances of survival in patients with septic shock [6,7]. In SEPSISPAM, patients were enrolled within 6 h of initiation of vasoactive drug treatment. In OVATION, patients were recruited up to 24 h after the diagnosis of septic shock. Target values were 80-85 vs. 65-70 and 75-80 vs. 60-65 mmHg for the high vs. low MAP in SEP-SISPAM and OVATION, respectively. There was no significant survival difference between the treatment groups at day 28 in either trial. However, both trials were underpowered as the mortality rate in the control groups was lower than expected. In addition, patients assigned to the low MAP target groups achieved higher MAPs than planned according to the study protocol.In a recent article in Intensive Care Medicine, Maheshwari et al. report the results of a retrospective analysis of 8782 patients admitted to 110 US hospitals exploring the association between MAP and acute kidney and myocardial injury as well as in-hospital mortality in patients with septic shock [8]. Using routinely collected data from an electronic health records database, the authors defined total exposure to hypotension as the time-weighted average mean arterial pressure (TWA-MAP) and calculated the cumulative time spent below 55, 65, 75, and 85 mmHg thresholds. The main results were that (1) exposure to hypotension of TWA-M...

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Low mean perfusion pressure is a risk factor for progression of acute kidney injury in critically ill patients – A retrospective analysis

Cited by 62 publications

References 27 publications

Cardiac and Vascular Surgery–Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group

Cardiac and Vascular Surgery–Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group

Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis

MAP of 65: target of the past?

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