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Loeffler J, Hassan M, Qaqish F, Dimachkie R, Dehghani S, Sasso R, Abou Yassine A, Deeb L. Predictors of Renal Replacement Therapy Requirement in Cirrhotic Patients with Acute Kidney Injury. Dig Dis Sci 2025; 70:1540-1546. [PMID: 39954191 DOI: 10.1007/s10620-025-08881-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 01/17/2025] [Indexed: 02/17/2025]
Abstract
BACKGROUND Renal failure is a well-known and often devastating complication in patients with liver cirrhosis and contributes to significant morbidity and mortality. AIMS This study aimed to evaluate the clinical profile and factors associated with the utilization of renal replacement therapy (RRT) requirement in cirrhotic patients presenting with AKI. METHODS We conducted a retrospective cohort study of cirrhotic inpatient visits across all Northwell Health hospitals between January 1, 2019 and December 31, 2020. Patients meeting inclusion criteria were identified using the International Classification of Disease, tenth revision clinical modification (ICD-10-CM) codes. Clinical variables, including demographics, medical history, laboratory data, and outcomes, were collected. Statistical analyses were performed to compare variables between patients requiring RRT and those not requiring RRT. RESULTS Of 701 cirrhotic patient encounters, 516 met inclusion criteria. The most common etiology of AKI was pre-renal (45.3%), followed by hepatorenal syndrome (18.6%) and acute tubular necrosis (14.7%). Sixty patients (11.6%) required RRT, with worse outcomes observed in this group. Independent predictors of RRT requirement included hepatorenal syndrome, acute tubular necrosis, and pneumonia. Pre-renal AKI was associated with decreased likelihood of requiring RRT. CONCLUSION This study identified clinical and laboratory factors predicting RRT requirement in cirrhotic patients with AKI. Hepatorenal syndrome, acute tubular necrosis, and pneumonia were associated with increased likelihood of RRT. Understanding these predictors may aid in prognostication and management decisions for cirrhotic patients presenting with AKI, warranting further prospective validation studies.
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Affiliation(s)
- Jeffrey Loeffler
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA.
| | - Mohammed Hassan
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Faris Qaqish
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Reem Dimachkie
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Shabnam Dehghani
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Roula Sasso
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Ahmad Abou Yassine
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Liliane Deeb
- Department of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
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Yi Y, Li L, Chen Y, Luo Y. Interaction between age and blood urea nitrogen to creatinine ratio on mortality in patients with severe cirrhosis: a retrospective cohort study from the MIMIC database. Front Endocrinol (Lausanne) 2025; 16:1544223. [PMID: 40110543 PMCID: PMC11919653 DOI: 10.3389/fendo.2025.1544223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Accepted: 02/14/2025] [Indexed: 03/22/2025] Open
Abstract
Background Cirrhosis is a leading cause of global disease burden, with high mortality, particularly in critically ill patients. The blood urea nitrogen to creatinine ratio (BCR) is a straightforward biochemical indicator of renal excretory function and is linked to negative outcomes across different conditions. However, the relationship between BCR and mortality in critically ill patients with cirrhosis is unclear, The purpose of this study is to explore this question. Methods A retrospective cohort study was performed utilizing the MIMIC-IV database. We divided BCR into quartiles and evaluated 180-day and 365-day mortality as the primary outcomes. Kaplan-Meier survival analysis and multivariate Cox regression modeling were used to assess the link between BCR and mortality. Linear relationships were further determined using restricted cubic spline (RCS) curves, and finally, subgroup analyses were also performed. Results In our study of 2,816 critically ill cirrhotic patients, elevated BCR was significantly linked to higher mortality at both 180 and 365 days. The top BCR quartile showed a 45% higher risk of 180-day mortality (HR=1.45, 95% CI: 1.21-1.73) and a 38% higher risk of 365-day mortality (HR=1.38, 95% CI: 1.17-1.63) relative to the bottom quartile. RCS analysis demonstrated a notable linear correlation between BCR and mortality risk. Subgroup analyses indicated a stronger association between BCR and mortality among older patients. Conclusion In critically ill cirrhotic patients, elevated BCR values are strongly linked to increased mortality risk. Our research highlights BCR's potential as a prognostic marker for cirrhosis, especially in elderly patients.
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Affiliation(s)
- Yu Yi
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Lin Li
- Department of Oncology, Zibo Municipal Hospital, Zibo, China
| | - Yinghua Chen
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Yawen Luo
- Department of Infectious Diseases, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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Agrawal N, Louis-Jean S, Ladiwala Z, Adnani H, Kamal A, Karpman M, Fleisher AS, Singh S. Reliability of neutrophil gelatinase-associated lipocalin in detecting acute tubular necrosis in decompensated cirrhosis: Systematic review and meta-analysis. World J Hepatol 2024; 16:1331-1338. [PMID: 39606167 PMCID: PMC11586751 DOI: 10.4254/wjh.v16.i11.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 09/01/2024] [Accepted: 10/08/2024] [Indexed: 11/06/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) in cirrhosis is common. The diagnosis of AKI in cirrhosis patients depends on clinical presentation and laboratory tests like serum creatinine. However, urine biomarkers could also be used to assess the type of AKI and the severity of the disease. We performed a systematic review with meta-analysis to evaluate the association with urine neutrophil gelatinase-associated lipocalin (NGAL) marker in identifying acute tubular necrosis (ATN) in patients with cirrhosis. AIM To assess the reliability of urine NGAL in the detection of ATN in patients with cirrhosis. METHODS We systematically searched MEDLINE and PubMed using keywords including "urine biomarkers", "NGAL", "kidney dysfunction", and "cirrhosis" to identify relevant studies. Data was screened and extracted. Included studies assessed hospitalized cirrhosis patients with AKI using the urine NGAL biomarker. We synthesized the data using diagnostic odds ratio (DOR), comparative and descriptive analyses, and Cochran Mantel-Haenszel (CMH) statistics to evaluate heterogeneity. RESULTS Three thousand seven hundred and one patients with cirrhosis were analyzed from a total of 21 cohort studies. The DOR of 14 of those studies [pooled DOR: 22.150, (95%CI: 17.58-27.89), P < 0.0001] demonstrated a significant association between urine NGAL levels and its identification of ATN. Following stratification by cirrhosis status, heterogeneity was analyzed and showed a significant non-zero correlation between NGAL and AKI (CMH statistic = 702.19, P < 0.0001). CONCLUSION In patients with cirrhosis, the use of urine NGAL is a reliable biomarker for detecting ATN and identifying the etiology of AKI.
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Affiliation(s)
- Nirav Agrawal
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, MD 21401, United States.
| | - Scarlet Louis-Jean
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Zoya Ladiwala
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Harsha Adnani
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Ayesha Kamal
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Mitchell Karpman
- Department of Biostatistics, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Albert Steven Fleisher
- Department of Gastroenterology, Anne Arundel Medical Center, Annapolis, MD 21401, United States
| | - Sanmeet Singh
- Department of Gastroenterology, Anne Arundel Medical Center, Annapolis, MD 21401, United States
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Vaishnav M, Biswas S, Anand A, Pathak P, Swaroop S, Aggarwal A, Arora U, Elhence A, Gamanagatti S, Goel A, Kumar R, Shalimar. Hepatic Venous Pressure Gradient Predicts Further Decompensation in Cirrhosis Patients with Acute Esophageal Variceal Bleeding. Diagnostics (Basel) 2023; 13:2385. [PMID: 37510129 PMCID: PMC10378396 DOI: 10.3390/diagnostics13142385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/03/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The role of hepatic venous pressure gradient (HVPG) in predicting further decompensation in cirrhosis patients with acute variceal bleeding (AVB) is not known. We aimed to evaluate the role of HVPG in predicting further decompensation in cirrhosis patients with AVB Methods: In this prospective study, 145 patients with cirrhosis with esophageal or gastric AVB were included. HVPG was measured on the day of the AVB. Decompensating events occurring after 42-days of AVB were considered further decompensation. RESULTS The median age of the study cohort was 44 years; 88.3% males. The predominant etiology of cirrhosis was alcohol (46.2%). Overall, 40 (27.6%) patients developed further decompensation during median follow-up of 296 days following AVB. Gastro intestinal bleeding n = 27 (18.6%) and new-onset/worsening ascites n = 20 (13.8%) were the most common decompensating events. According to the multivariate model, HVPG was an independent predictor of any further decompensation in esophageal AVB patients but not in gastric variceal bleeding patients. HVPG cut-off of ≥16 mmHg predicted further decompensation in the esophageal AVB. However, HVPG was not an independent predictor of mortality. CONCLUSION HVPG measured during an episode of acute variceal hemorrhage from esophageal varices predicts further decompensating events in cirrhosis patients.
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Affiliation(s)
- Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
| | - Shivanand Gamanagatti
- Department of Radiology, All India Institute of Medical Sciences, New Delhi 110029, India;
| | - Amit Goel
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India;
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India;
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; (M.V.); (S.B.); (A.A.); (P.P.); (S.S.); (A.A.); (U.A.); (A.E.)
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Urinary neutrophil gelatinase-associated lipocalin: Acute kidney injury in liver cirrhosis. Clin Chim Acta 2021; 523:339-347. [PMID: 34666028 DOI: 10.1016/j.cca.2021.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/01/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022]
Abstract
Acute kidney injury (AKI) in liver cirrhosis is associated with poor clinical outcomes including an increased long and short-term mortality. The common type of AKI observed in patients with cirrhosis are prerenal AKI (PRA), hepatorenal syndrome (HRS) and acute tubular necrosis (ATN). Despite the growing knowledge and uniform definition for the diagnosis of AKI, there are several challenges including, early diagnosis and management. Precisely differentiating the type of AKI is critical, as therapies differ significantly. In this review, we summarize AKI in liver cirrhosis, their definition, pathophysiology and deficiencies of using the existing biomarker, serum creatinine. We outline the current clinical evidence on the novel biomarker urinary neutrophil gelatinase-associated lipocalin (uNGAL) and its potential role as a biomarker in the early detection, differentiation and prognostication of AKI. This review also briefly talks about other forthcoming biomarkers which hold promise in the management of AKI in liver cirrhosis.
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Bellar A, Welch N, Dasarathy S. Exercise and physical activity in cirrhosis: opportunities or perils. J Appl Physiol (1985) 2020; 128:1547-1567. [PMID: 32240017 DOI: 10.1152/japplphysiol.00798.2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Reduced exercise capacity and impaired physical performance are observed in nearly all patients with liver cirrhosis. Physical activity and exercise are physiological anabolic stimuli that can reverse dysregulated protein homeostasis or proteostasis and potentially increase muscle mass and contractile function in healthy subjects. Cirrhosis is a state of anabolic resistance, and unlike the beneficial responses to exercise reported in physiological states, there are few systematic studies evaluating the response to exercise in cirrhosis. Hyperammonemia is a mediator of the liver-muscle axis with net skeletal muscle ammonia uptake in cirrhosis causing signaling perturbations, mitochondrial dysfunction with decreased ATP content, modifications of contractile proteins, and impaired ribosomal function, all of which contribute to anabolic resistance in cirrhosis and have the potential to impair the beneficial responses to exercise. English language-publications in peer-reviewed journals that specifically evaluated the impact of exercise in cirrhosis were reviewed. Most studies evaluated responses to endurance exercise, and readouts included peak or maximum oxygen utilization, grip strength, and functional capacity. Endurance exercise for up to 12 wk is clinically tolerated in well-compensated cirrhosis. Data on the safety of resistance exercise are conflicting. Nutritional supplements enhance the benefits of exercise in healthy subjects but have not been evaluated in cirrhosis. Whether the beneficial physiological responses with endurance exercise and increase in muscle mass with resistance exercise that occur in healthy subjects also occur in cirrhotics is not known. Specific organ-system responses, changes in body composition, or improved long-term clinical outcomes with exercise in cirrhosis need evaluation.
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Affiliation(s)
- Annette Bellar
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Welch
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Gastroenterology, Hepatology Cleveland Clinic, Cleveland, Ohio
| | - Srinivasan Dasarathy
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Gastroenterology, Hepatology Cleveland Clinic, Cleveland, Ohio
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Rho-kinase inhibitor coupled to peptide-modified albumin carrier reduces portal pressure and increases renal perfusion in cirrhotic rats. Sci Rep 2019; 9:2256. [PMID: 30783172 PMCID: PMC6381202 DOI: 10.1038/s41598-019-38678-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/07/2019] [Indexed: 02/07/2023] Open
Abstract
Rho-kinase (ROCK) activation in hepatic stellate cells (HSC) is a key mechanism promoting liver fibrosis and portal hypertension (PTH). Specific delivery of ROCK-inhibitor Y-27632 (Y27) to HSC targeting mannose-6-phosphate-receptors reduces portal pressure and fibrogenesis. In decompensated cirrhosis, presence of ascites is associated with reduced renal perfusion. Since in cirrhosis, platelet-derived growth factor receptor beta (PDGFRβ) is upregulated in the liver as well as the kidney, this study coupled Y27 to human serum albumin (HSA) substituted with PDGFRβ-recognizing peptides (pPB), and investigated its effect on PTH in cirrhotic rats. In vitro collagen contraction assays tested biological activity on LX2 cells. Hemodynamics were analyzed in BDL and CCl4 cirrhotic rats 3 h, 6 h and 24 h after i.v. administration of Y27pPBHSA (0.5/1 mg/kg b.w). Phosphorylation of moesin and myosin light chain (MLC) assessed ROCK activity in liver, femoral muscle, mesenteric artery, kidney and heart. Three Y27 molecules were coupled to pPBHSA as confirmed by HPLC/MS, which was sufficient to relax LX2 cells. In vivo, Y27pPBHSA-treated rats exhibited lower portal pressure, hepatic vascular resistance without effect on systemic vascular resistance, but a tendency towards lower cardiac output compared to non-treated cirrhotic rats. Y27pPBHSA reduced intrahepatic resistance by reduction of phosphorylation of moesin and MLC in Y27pPBHSA-treated cirrhotic rats. Y27pPBHSA was found in the liver of rats up to 6 hours after its injection, in the HSC demonstrated by double-immunostainings. Interestingly, Y27pPBHSA increased renal arterial flow over time combined with an antifibrotic effect as shown by decreased renal acta2 and col1a1 mRNA expression. Therefore, targeting the ROCK inhibitor Y27 to PDGFRβ decreases portal pressure with potential beneficial effects in the kidney. This unique approach should be tested in human cirrhosis.
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Deep A, Saxena R, Jose B. Acute kidney injury in children with chronic liver disease. Pediatr Nephrol 2019; 34:45-59. [PMID: 29497824 PMCID: PMC6244855 DOI: 10.1007/s00467-018-3893-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 12/16/2022]
Abstract
Acute kidney injury (AKI) is a common accompaniment in patients with liver disease. The causes, risk factors, manifestations and management of AKI in these patients vary according to the liver disease in question (acute liver failure, acute-on-chronic liver failure, post-liver transplantation or metabolic liver disease). There are multiple causes of AKI in patients with liver disease-pre-renal, acute tubular necrosis, post-renal, drug-induced renal failure and hepatorenal syndrome (HRS). Definitions of AKI in liver failure are periodically revised and updated, but pediatric definitions have still to see the light of the day. As our understanding of the pathophysiology of liver disease and renal involvement improves, treatment modalities have become more advanced and rationalized. Treatment includes reversing precipitating factors, such as infections and gastrointestinal bleeding, volume expansion, paracentesis and vasoconstrictors. This approach is tried and tested in adults. A pediatric tailored approach is still lacking due to inadequate numbers of patients, differences in causes of AKI and paucity of literature. In this review, we attempt to explore the pathophysiological basis, treatment modalities and controversies in the diagnosis and treatment of AKI in pediatric patients with chronic liver disease and discuss our own personal practice. We recognize that, although it is not a very commonly encountered entity in pediatric population, HRS has specific diagnostic criteria and treatment modalities that differ from other causes of AKI in patients with chronic liver disease; hence among the etiologies of kidney injury in patients with chronic liver disease, we focus here on HRS.
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Affiliation(s)
- Akash Deep
- Paediatric Intensive Care Unit (PICU), King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Romit Saxena
- Paediatric Intensive Care Unit (PICU), King’s College Hospital, Denmark Hill, London, SE5 9RS UK
| | - Bipin Jose
- Paediatric Intensive Care Unit (PICU), King’s College Hospital, Denmark Hill, London, SE5 9RS UK
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Abstract
PURPOSE OF REVIEW The current review aims to explain the different systems available to clinicians for predicting clinical outcomes in patients with cirrhosis. RECENT FINDINGS Cirrhosis is the final stage of chronic liver disease and is associated with high morbidity and mortality. The most commonly utilized tools to predict outcomes in patients with cirrhosis include the following: assessing severity of portal hypertension using hepatic venous pressure gradient (HVPG) measurements, using scoring systems such as the Model for End-stage Liver Disease (MELD) and Child-Pugh-Turcotte (CPT) scores, and recently, clinical staging systems based on cirrhosis-related clinical complications. Assessing portal pressure with HVPG measurements provides valuable prognostic information, yet is costly, time-consuming, and invasive. MELD and CPT scores can be calculated quickly and not only assess liver function, but also yield predictive information. However, they represent only one point in time, and do not take into account the full clinical picture. Clinical staging systems have traditionally been focused on compensated and decompensated stages, with newer models assessing the influence of cirrhosis-related complications. However, these are not commonly utilized. SUMMARY Predicting clinical outcomes in patients with cirrhosis is challenging, and is likely best accomplished with a combination of objective data (such as MELD and HVPG provide) in addition to the clinical course of cirrhosis.
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Mori T, Ohsaki Y, Oba-Yabana I, Ito S. Diuretic usage for protection against end-organ damage in liver cirrhosis and heart failure. Hepatol Res 2017; 47:11-22. [PMID: 26990144 DOI: 10.1111/hepr.12700] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 02/08/2023]
Abstract
Volume overload is common in liver cirrhosis, heart failure, and chronic kidney disease, being an independent risk factor for mortality. Loop diuretics have been widely used for treating volume overload in these patients. However, there is a tendency to increase the dose of loop diuretics partly because of diuresis resistance. Neurohormonal factors are also enhanced in these patients, which play a role in volume overload and organ ischemia. Loop diuretics cannot improve neurohormonal factors and could result in end-organ damage. The water diuretic tolvaptan has been approved for use for volume overload in heart failure and liver cirrhosis. Despite causing similar increases in urine volume, its characteristics differ from those of loop diuretics. Renal blood flow is maintained with tolvaptan but decreased with furosemide in heart failure patients. Neurohormonal factors and blood pressure are not markedly altered by tolvaptan administration. It is expected that these mechanisms of tolvaptan can protect against worsening renal function by volume overload diseases compared with loop diuretics. It has also been reported that some patients do not respond well to tolvaptan. Loop diuretics and tolvaptan share the same mechanism with regard to decreasing renal interstitial osmolality, which plays a fundamental role in water diuresis. Thus, a high dose of loop diuretics could result in resistance to tolvaptan, so tolvaptan should be administered before increasing the loop diuretic dose. Therefore, volume control without enhancing end-organ damage can be achieved by adding tolvaptan to a tolerable dose of Na-sparing diuretics.
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Affiliation(s)
- Takefumi Mori
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yusuke Ohsaki
- Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Ikuko Oba-Yabana
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Appréciation du débit de filtration glomérulaire et de la dysfonction rénale chez le cirrhotique. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1215-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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