Point of Care Ultrasound in Cirrhosis-Associated Acute Kidney Injury: Beyond Inferior Vena Cava

Koratala, Abhilash; Reisinger, Nathaniel

doi:10.34067/kid.0005522022

Cited by 17 publications

(14 citation statements)

References 21 publications

(29 reference statements)

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“…[45] The use of POCUS in classifying the type of AKI in cirrhosis is an important evolving domain in HRS-AKI management. [46] A recent study on pulmonary artery catheterization in cirrhosis-AKI showed that 62% of patients diagnosed with HRS by clinical criteria have elevated pulmonary capillary wedged pressure and were counterintuitively started on diuretics. [47] Patients can be better assessed for volume resuscitation in AKI using IVC dynamics, [48] and incorporation of POCUS is recommended in an updated HRS-AKI management algorithm.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

Premkumar,

Kajal,

Reddy

et al. 2023

Hepatology

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Background & Aims: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefit, but may be associated with cardiopulmonary complications. We analysed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo), cardiac and renal biomarkers. Approach: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6h of admission, at the time of starting terlipressin(48h), and at 72h. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic Cardiomyopathy(CCM) was defined per 2020 criteria. Results: One hundred and forty patients were enrolled [84% men, 59% alcohol-associated disease, mean MELDNa-25±standard deviation(SD) 5.6]. Median daily dose of infused terlipressin was 4.3(interquartile range:3.9-4.6)mg/day; mean duration-6.4± SD-1.9 days; complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cut-offs for prediction of terlipressin nonresponse were cardiac variables-[E/e’>12.5(indicating increased left filling pressures, C-statistic-0.774), e’ velocity<7 cm/s (indicating impaired relaxation; C-statistic-0.791), >20.5% reduction in cardiac index at 72h(C-statistic-0.885); p<0.001] and pre-treatment biomarkers (Cystatin C>2.2 mg/l, C-statistic-0.640 and NT-ProBNP>350 pg/mL, C-statistic-0.655;p<0.050). About 6% of all HRS-AKI patients and 26% of patients with CCM had pulmonary edema. Presence of CCM(aHR1.9;CI-1.8-4.5,p=0.009) and terlipressin nonresponse (aHR 5.2;CI-2.2-12.2, p<0.001) were predictors of mortality independent of age, gender, obesity, DM-2, etiology and baseline creatinine Conclusions: Cirrhotic cardiomyopathy and reduction in cardiac index, reliably predict terlipressin non-response. CCM is independently associated with poor survival in HRS-AKI.

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Section: Discussionmentioning

confidence: 99%

Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

Premkumar,

Kajal,

Reddy

et al. 2023

Hepatology

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“…This leads to incorrect interpretation during follow-up studies, particularly when different operators are performing the study. Therefore, the IVC must be examined in both long and short axis views, where feasible[ 27 , 28 ]. Also, in conditions such as cirrhosis, IVC size/shape may be altered by the local structural changes, making it unreliable to predict RAP.…”

Section: Point-of-care Ultrasoundmentioning

confidence: 99%

“…The term extended venous excess ultrasound score (E-VExUS) or extended VExUS has been proposed to include Doppler interrogation of additional veins such as the internal jugular, superior vena cava, splenic, and femoral veins in situations where the primary veins ( e.g. , hepatic, portal in cirrhosis, and intrarenal in advanced kidney disease) suffer from limitations[ 28 , 48 ]. This also includes estimation of RAP by greyscale POCUS of the internal jugular vein where IVC is not accessible or unreliable.…”

Section: Point-of-care Ultrasoundmentioning

confidence: 99%

Point-of-care ultrasound in diagnosis and management of congestive nephropathy

Turk¹,

Robertson²,

Koratala³

2023

World J Crit Care Med

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Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.

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“…37 Unfortunately, IVC size is not a reliable indicator of cardiac output may not be indicative of the patient's true volume status or fluid responsiveness. 38 For example, in a small, observational study of patients with acute liver failure and shock, IVC distensibility was a poor predictor of fluid responsiveness. 25 IVC indices are better indicators of fluid tolerance, meaning that if the clinical situation calls for fluid resuscitation and the IVC is collapsing, then the patient will likely be able to tolerate fluids.…”

Section: Ivc Diameter and Collapsibilitymentioning

confidence: 99%

“…Unfortunately, IVC size is not a reliable indicator of cardiac output may not be indicative of the patient's true volume status or fluid responsiveness 38 . For example, in a small, observational study of patients with acute liver failure and shock, IVC distensibility was a poor predictor of fluid responsiveness 25 .…”

Section: The Need For Precise Volume Assessment In Cirrhosismentioning

confidence: 99%

Review article: Practical considerations for fluid resuscitation in cirrhosis

Claudel

Jaganathan

Patel

et al. 2023

Aliment Pharmacol Ther

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Background: Standard clinical methods of assessing volume and providing resuscitation are not always applicable to patients with advanced or decompensated cirrhosis. Despite this being well known from a clinical perspective, there remains relatively little evidence to guide clinicians though fluid management in patients with cirrhosis and, often, multi-organ system dysfunction. Aims: This review summarises the current understanding of the circulatory dysfunction in cirrhosis, modalities for assessing volume status, and considerations for fluid selection. It additionally provides a practical approach to fluid resuscitation. Methods: We review current literature on cirrhosis pathophysiology in steady-state and shock, clinical implications of fluid resuscitation, and strategies to assess intravascular volume. Literature reviewed here was identified by the authors through PubMed search and review of selected papers' references. Results: Clinical management of resuscitation in advanced cirrhosis remains relatively stagnant. Although several trials have attempted to establish the superior resuscitative fluid, the lack of improvement in hard clinical outcomes leaves clinicians without clear guidance. Conclusions: The absence of consistent evidence for fluid resuscitation in patients with cirrhosis limits our ability to produce a clearly evidence-based protocol for fluid resuscitation in cirrhosis. However, we propose a preliminary practical guide to managing fluid resuscitation in patients with decompensated cirrhosis. Further studies are needed to develop and validate volume assessment tools in the specific context of cirrhosis, while randomised clinical trials of protocolized resuscitation may improve care of this patient population. 1 | INTRODUC TI ON Cirrhosis carries high morbidity and mortality in the United States (US), representing approximately 3.8 per 1000 hospitalizations in the US per year and is the fourth leading cause of death among US adults ages 45-64 years old. 1,2 Patients with cirrhosis pose unique clinical challenges secondary to their disordered circulation and the multi-system consequences of advanced cirrhosis. As patients with cirrhosis are often volume overloaded overall and simultaneously have decreased effective arterial volume, their brittle hemodynamics make them prone to bleeding, renal injury, and cardiac overload. Standard clinical methods of assessing volume and providing | 1067 CLAUDEL et al.resuscitation are therefore not always applicable. The current literature lacks a comprehensive assessment of available evidence to provide goal-directed care to the patient with decompensated cirrhosis. This review will discuss assessment of volume status and the evidence behind choice of resuscitative therapies in cirrhosis, with an emphasis on critical illness.

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Point of Care Ultrasound in Cirrhosis-Associated Acute Kidney Injury: Beyond Inferior Vena Cava

Abstract: This is an Early Access article. Please select the PDF button, above, to view it.

Cited by 17 publications

References 21 publications

Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography

Point-of-care ultrasound in diagnosis and management of congestive nephropathy

Review article: Practical considerations for fluid resuscitation in cirrhosis

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