Hepatology (Baltimore, Md.) · 2025
Point-of-care ultrasound (POCUS)-guided volume management and the effect of cirrhotic cardiomyopathy on acute kidney injury outcomes in cirrhosis.
СтатьяНазвание и аннотация: Перевод в очереди
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Premkumar Madhumita, Kajal Kamal, Roy Akash, Izzy Manhal, Divyaveer Smita, Kulkarni Anand V, Artru Florent, Sharma Prerna, Sandhu Anchal, Sihag Bhupendra Kumar, Bahl Ajay, De Arka, Verma Nipun, Taneja Sunil, Duseja Ajay Kumar, Pal Arnab, Bhujade Harish, Reddy K Rajender
Аннотация
BACKGROUND AND AIMS: Point-of-care ultrasound (POCUS) helps in assessing volume status and cirrhotic cardiomyopathy (CCM). We evaluated POCUS-guided volume management and explored clinical predictors, including CCM, of acute kidney injury (AKI) reversal, need for renal replacement therapy (RRT), and survival in cirrhosis and AKI between January 2023 and November 2024. Exclusions were patients with structural cardiac disease, portopulmonary hypertension, acute variceal bleeding, and septic shock.
APPROACH AND RESULTS: POCUS was performed at ICU (intensive care unit) admission (Time zero ), 24 hours, 48 hours, 72 hours, and as needed to guide volume management and determine IVC indices and cardiac index. CCM was defined by ≥3 of 4 variables (septal e' velocity, E/e' integral, left atrial volume index, tricuspid regurgitant velocity); clinical data were collected.In all, 372 patients with AKI (84.7% men, aged 50.3±12 years, MELD-Na 23.9±5.1); 296 (79.6%), 42 (11.3%), and 34 (9.1%) were classified as hypovolemic, euvolemic, and hypervolemic at Time zero . Following POCUS-guided volume management, 231 (62%) had pre-renal AKI; 61 (16.4%) had hepatorenal syndrome (HRS-AKI); 25 (6.7%) had HRS-AKD; 32 (8.6%) had HRS-CKD, while 23 (6.2%) had a multifactorial etiology. CCM was diagnosed in 34.7%, 32.9% of pre-renal AKI, 75.4% in HRS-AKI, and 28% in HRS-AKD ( p <0.001). Higher MAP 0h (aHR 1.9, 95% CI 1.96-2, p =0.039) and cardiac index 0 h (aHR 1.2, 95% CI 1.1-1.3, p =0.005) predicted AKI reversal at day 7; 53/372 (14.2%) underwent RRT. Pulmonary edema developed in 4.8% overall; in 5.4% with CCM. Overall mortality was 46 (12.4%) and 107 (28.8%) at 90 days and 1 year. CCM predicted mortality at 90 days (aHR 8.9, 95% C: 3.9-20.4, p <0.001) and 1 year (aHR 1.7, 95% CI 1.2-2.5, p= 0.007). Cardiac index (aHR 0.6, 95% CI 0.4-0.9, p =0.005), and septal e' velocity (aHR 0.5, 95% CI 0.3-0.7, p =0.010) predicted need for RRT.
CONCLUSIONS: POCUS facilitates volume management and AKI reversal in cirrhosis. CCM predicts poor outcomes in HRS-AKI, need for RRT, and mortality.
APPROACH AND RESULTS: POCUS was performed at ICU (intensive care unit) admission (Time zero ), 24 hours, 48 hours, 72 hours, and as needed to guide volume management and determine IVC indices and cardiac index. CCM was defined by ≥3 of 4 variables (septal e' velocity, E/e' integral, left atrial volume index, tricuspid regurgitant velocity); clinical data were collected.In all, 372 patients with AKI (84.7% men, aged 50.3±12 years, MELD-Na 23.9±5.1); 296 (79.6%), 42 (11.3%), and 34 (9.1%) were classified as hypovolemic, euvolemic, and hypervolemic at Time zero . Following POCUS-guided volume management, 231 (62%) had pre-renal AKI; 61 (16.4%) had hepatorenal syndrome (HRS-AKI); 25 (6.7%) had HRS-AKD; 32 (8.6%) had HRS-CKD, while 23 (6.2%) had a multifactorial etiology. CCM was diagnosed in 34.7%, 32.9% of pre-renal AKI, 75.4% in HRS-AKI, and 28% in HRS-AKD ( p <0.001). Higher MAP 0h (aHR 1.9, 95% CI 1.96-2, p =0.039) and cardiac index 0 h (aHR 1.2, 95% CI 1.1-1.3, p =0.005) predicted AKI reversal at day 7; 53/372 (14.2%) underwent RRT. Pulmonary edema developed in 4.8% overall; in 5.4% with CCM. Overall mortality was 46 (12.4%) and 107 (28.8%) at 90 days and 1 year. CCM predicted mortality at 90 days (aHR 8.9, 95% C: 3.9-20.4, p <0.001) and 1 year (aHR 1.7, 95% CI 1.2-2.5, p= 0.007). Cardiac index (aHR 0.6, 95% CI 0.4-0.9, p =0.005), and septal e' velocity (aHR 0.5, 95% CI 0.3-0.7, p =0.010) predicted need for RRT.
CONCLUSIONS: POCUS facilitates volume management and AKI reversal in cirrhosis. CCM predicts poor outcomes in HRS-AKI, need for RRT, and mortality.