'Point-of-Care Ultrasound (POCUS) guided volume management and the effect of cirrhotic cardiomyopathy on acute kidney injury outcomes in cirrhosis'.

IF 15.8 1区医学 Q1 GASTROENTEROLOGY & HEPATOLOGY

Hepatology Pub Date : 2025-09-23 DOI:10.1097/hep.0000000000001524

Madhumita Premkumar,Kamal Kajal,Akash Roy,Manhal Izzy,Smita Divyaveer,Anand V Kulkarni,Florent Artru,Prerna Sharma,Anchal Sandhu,Bhupendra Sihag,Ajay Bahl,Arka De,Nipun Verma,Sunil Taneja,Ajay Kumar Duseja,Arnab Pal,Harish Bhujade,K Rajender Reddy

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引用次数: 0

Abstract

BACKGROUND 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 and 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. METHODS POCUS was performed at ICU admission(Timezero), 24h,48h,72h, and as needed to guide volume management, and determine inferior vena cava(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. RESULTS 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 Timezero. Following POCUS-guided volume management, 231(62%) had pre-renal AKI; 61(16.4%) hepatorenal syndrome(HRS-AKI); 25(6.7%) HRS-AKD; 32(8.6%) 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 MAP0h (aHR1.9, 95%CI:1.96-2, p=0.039) and cardiac index0h(aHR1.2,95%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%CI:3.9-20.4,p<0.001) and one year(aHR1.7,95%CI:1.2-2.5,p=0.007). Cardiac index (aHR0.6,95%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.

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“即时超声（POCUS）引导的容量管理和肝硬化心肌病对肝硬化急性肾损伤结果的影响”。

目的：即时超声（POCUS）有助于评估容量状态和肝硬化心肌病（CCM）。我们评估了pocus引导下的容积管理，并探讨了2023年1月至2024年11月期间肝硬化和AKI患者急性肾损伤（AKI）逆转、肾替代治疗（RRT）需求和生存的临床预测因素，包括CCM。排除了结构性心脏病、门脉高压、急性静脉曲张出血和感染性休克的患者。方法在ICU入院时（Timezero）、24h、48h、72h，并根据需要进行spocus，以指导容积管理，测定下腔静脉（IVC）指数和心脏指数。4个变量（室间隔流速、e /e积分、左房容积指数、三尖瓣反流速度）中≥3个定义CCM；收集临床资料。结果372例AKI患者[男性84.7%，年龄50.3±12岁，MELD-Na 23.9±5.1]；296例（79.6%）、42例（11.3%）和34例（9.1%）在Timezero时被分类为低血容量、低血容量和高血容量。在pocus引导下进行容积管理后，231例（62%）患有肾前AKI；肝肾综合征（hr - aki） 61例（16.4%）；25 (6.7%) HRS-AKD;32例（8.6%）为rs - ckd， 23例（6.2%）为多因素病因。诊断为CCM的占34.7%；肾前AKI为32.9%，rs -AKI为75.4%，rs - akd为28% （p<0.001）。较高的MAP0h （aHR1.9, 95%CI:1.96-2, p=0.039）和心脏指数（aHR1.2,95%CI:1.1-1.3,p=0.005）预测第7天AKI逆转；53/372（14.2%）接受了RRT。肺水肿发生率为4.8%；5.4%为CCM。90天和1年总死亡率分别为46例（12.4%）和107例（28.8%）。CCM预测90天死亡率（aHR 8.9,95%CI:3.9-20.4,p<0.001）和1年死亡率（aHR1.7,95%CI:1.2-2.5,p=0.007）。心脏指数（aHR0.6,95%CI:0.4-0.9,p=0.005）和室间隔流速（ahr0.5,95%CI: 0.3-0.7,p=0.010）预测RRT的需要。结论聚焦有助于肝硬化患者的容积管理和AKI逆转。CCM预测HRS-AKI的不良结局、RRT的需要和死亡率。

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来源期刊

Hepatology 医学-胃肠肝病学

CiteScore

27.50

自引率

3.70%

发文量

609

审稿时长

1 months

期刊介绍： HEPATOLOGY is recognized as the leading publication in the field of liver disease. It features original, peer-reviewed articles covering various aspects of liver structure, function, and disease. The journal's distinguished Editorial Board carefully selects the best articles each month, focusing on topics including immunology, chronic hepatitis, viral hepatitis, cirrhosis, genetic and metabolic liver diseases, liver cancer, and drug metabolism.