Targeting an Early and Substantial Increase in Mean Arterial Pressure Is Critical in the Management of Type 1 Hepatorenal Syndrome: A Combined Retrospective and Pilot Study

Maddukuri, Geetha; Cai, Cindy X.; Munigala, Satish; Mohammadi, Farnaz; Zhang, Zhiwei

doi:10.1007/s10620-013-2899-z

Cited by 21 publications

(25 citation statements)

References 20 publications

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“…Moreover, our findings demonstrate a significant correlation between the magnitude of the increase in MAP and improvement in kidney function during either midodrine/octreotide or norepinephrine therapy for hepatorenal AKI. These results are in agreement with previous reports demonstrating a relationship between MAP gain and renal outcomes [20–22,30]. Because our findings were generated from a large number of data points per patient and from close examination of a wide range of MAP changes, the signal detected was robust and strengthens the notion of MAP gain as a therapeutic target.…”

Section: Discussionsupporting

confidence: 92%

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Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

Kadian¹,

Taburyanskaya²,

Bohm³

et al. 2015

Nephron

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Background: The efficacy of vasoconstrictors in hepatorenal syndrome (HRS) is variable. We hypothesized that the effectiveness of vasoconstrictor therapy in improving kidney function ultimately relates to the magnitude of the achieved mean arterial pressure (MAP) increase. Methods: A retrospective study was conducted to identify cirrhotic individuals treated with vasoconstrictors for acute kidney injury (AKI) presumably caused by HRS to examine the relationship between change in MAP and change in serum creatinine (sCr) using multivariate mixed linear regression. Results: Among 73 patients treated with midodrine/octreotide, change in MAP inversely correlated with change in sCr (p = 0.0005). The quartile with the greatest increase in MAP (+15.9 to +29.4 mm Hg) was associated with a subsequent absolute decrease in sCr. The strength of the correlation increased when the analysis was restricted to those who met the HRS criteria (n = 27, p = 0.002), where the third (+5.3 to +15.6 mm Hg) and fourth (+15.9 to +20.9 mm Hg) quartiles of MAP change were associated with a decrease in sCr. A similar but stronger correlation was found among 14 patients treated with norepinephrine either after failing midodrine/octreotide (n = 10) or de novo (n = 4; p = 0.002), where a rise in MAP of +19.2 to 25 mm Hg was associated with a larger reduction in sCr. Associations remained significant after adjustment for baseline parameters. Conclusions: The magnitude of MAP rise during HRS therapy with midodrine/octreotide or norepinephrine correlated with a reduction in sCr concentration. Our results suggest that achieving a pre-specified target of MAP increase might improve renal outcomes in hepatorenal AKI.

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Section: Discussionsupporting

confidence: 92%

“…However, that relationship seemed lost after adjustment for serum bilirubin. Others have shown that a MAP gain > 10 mmHg might be associated with a positive renal outcome [30,45]. Moreover, clinical trials assessing the use of norepinephrine have been designed to target a rise in MAP of 10 mmHg.…”

Section: Discussionmentioning

confidence: 99%

Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

Kadian¹,

Taburyanskaya²,

Bohm³

et al. 2015

Nephron

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“…A systemic review of randomized controlled studies has indicated that vasoconstrictor therapy of HRS improves short-term patient survival [8]. Prolonged transplant-free survival could also be achieved by the use of such combination therapy via targeting an early and sustained increase in MAP as shown in our recent studies [9,10]. The advent of pharmacological treatment led to renewed interest in RRT as a supportive modality for patients with HRS, either as a bridge to liver transplantation or modality to possibly improve long-term survival without transplantation.…”

Section: Introductionmentioning

confidence: 85%

“…Indeed, systemic review of randomized controlled studies has indicated that vasoconstrictor therapy of HRS improves HRS patient survival [8]. Currently, treatment with combined vasoconstrictors and albumin in patients with HRS has been considered either as a bridge to liver transplantation or modality to possibly improve long-term survival without transplantation [9]. Renal replacement therapy is being used more frequently in such patient populations, but the clinical outcomes are unknown.…”

Section: Discussionmentioning

confidence: 99%

Role of renal replacement therapy in patients with type 1 hepatorenal syndrome receiving combination treatment of vasoconstrictor plus albumin

Zhang

Maddukuri

Jaipaul

et al. 2015

Journal of Critical Care

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“…In one randomized unblinded pilot study, albumin was compared to hetastarch in patients with SBP. 56 Several pharmacological agents have been used in the management of HRS. 52 However, the current evidence suggest that the use of hydroxyethyl starch (HES) increases the risk of AKI and mortality.…”

Section: Managementmentioning

confidence: 99%

Hepatorenal Disorders

Al‐Khafaji

Kellum

2015

Chest

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Renal dysfunction is common in patients with end-stage liver disease (ESLD); it takes on many forms from acute to chronic renal injury and may involve a variety of mechanisms. Hepatorenal syndrome (HRS) is a specific type of hepatorenal disorder (HRD) with a unique pathophysiology. HRS is characterized by splanchnic arterial vasodilatation and decreased effective intravascular volume that leads to renal vasoconstriction and decreased renal blood flow. The incidence of HRS in relation to other forms of HRD is unknown; however, it is estimated that 35% to 40% patients with ESLD and ascites eventually develop the condition. Two subtypes of HRS have been described. Type 1 HRS is rapidly progressive, whereas the renal function in type 2 HRS deteriorates slowly over weeks or months. Type 1 HRS may be precipitated by sepsis or acute alcoholic hepatitis and occasionally develops in patients who already have type 2 HRS. The diagnosis of HRS is based on the exclusion of other causes of renal dysfunction because no specific test is available. The definitive treatment of HRS is liver transplant. As a bridge to liver transplant, medical management with volume expansion and the use of vasoconstrictors is often implemented. A transjugular intrahepatic portosystemic shunt has been attempted in treating HRS, although there is little evidence of its efficacy compared with standard therapy. Renal replacement therapy is often used if the patient is a liver transplant candidate. Artificial liver assist devices are in the research phase.

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Targeting an Early and Substantial Increase in Mean Arterial Pressure Is Critical in the Management of Type 1 Hepatorenal Syndrome: A Combined Retrospective and Pilot Study

Abstract: Using an early and substantial increase in MAP as a therapeutic target is associated with favorable clinical outcomes in the management of type 1 HRS.

Cited by 21 publications

References 20 publications

Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

Role of renal replacement therapy in patients with type 1 hepatorenal syndrome receiving combination treatment of vasoconstrictor plus albumin

Hepatorenal Disorders

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