Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure.
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.
Division of Nephrology, Medical University of South Carolina, Charleston, S.C., USA.
Juan Carlos Q
JC
Velez
Manish
M
Kadian
Margarita
M
Taburyanskaya
Nicole M
NM
Bohm
Tracie A
TA
Delay
Nithin
N
Karakala
Don C
DC
Rockey
Paul J
PJ
Nietert
Andrew J
AJ
Goodwin
Timothy P
TP
Whelan
D058186:Acute Kidney Injury / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D000368:Aged; D062186:Arterial Pressure; D003404:Creatinine / Q000097:blood; D058625:End Stage Liver Disease / Q000473:pathology; D005260:Female; D006530:Hepatorenal Syndrome / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology; D006801:Humans; D007677:Kidney Function Tests; D008103:Liver Cirrhosis / Q000150:complications / Q000473:pathology; D008297:Male; D008875:Middle Aged; D008879:Midodrine / Q000627:therapeutic use; D009638:Norepinephrine / Q000627:therapeutic use; D015282:Octreotide / Q000627:therapeutic use; D012189:Retrospective Studies; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
D014662:Vasoconstrictor Agents; D008879:Midodrine; D003404:Creatinine; D015282:Octreotide; D009638:Norepinephrine