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Don't Overlook the Role of Intraabdominal Pressure
LETTER
Don’t Overlook the Role of Intraabdominal Pressure To the Editor: We read with interest the review by Tapper et al1 concerning the prevention and treatment of acute kidney injury in patients with cirrhosis and ascites. Indeed, as stated by the authors, sepsis, hypovolemia, drug-associated nephrotoxicity, and hepatorenal syndrome should be considered. However, other mechanisms may contribute to acute kidney injury in cirrhotic patients. Voluminous or tense ascites can result in elevation of intraabdominal pressure. Intraabdominal pressure of more than 12 mm Hg defines intraabdominal hypertension and can lead to significant intrarenal venous congestion and impaired filtration rate.2 In a small uncontrolled trial in cirrhotic patients, Umgelter et al3 showed a significant decrease in renal resistive index and a significant increase in creatinine clearance and urine output when decreasing intraabdominal pressure by paracentesis. Furthermore, in a mouse model of cirrhosis, Chang et al4 found that intraabdominal hypertension was a significant Funding: None. Conflict of Interest: None. Authorship: Both authors participated in writing this manuscript.
0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
pathological mechanism and a potential independent risk factor of hepatorenal syndrome. Thus, the potential role of elevated intraabdominal pressure in the pathogenesis of acute kidney injury should not be overlooked, even in the presence of hepatorenal syndrome. In case of tense ascites, measurement of intraabdominal pressure and correction of intraabdominal hypertension must be seen as useful diagnostic and therapeutic procedures. Tahar Taleb-Bendiab, MD Frédéric M. Jacobs, MD Service de Réanimation Polyvalente Université Paris-Sud Hôpital Antoine Béclère APHP Clamart, France
http://dx.doi.org/10.1016/j.amjmed.2016.05.040
References 1. Tapper EB, Bonder A, Cardenas A. Preventing and treating acute kidney injury among hospitalized patients with cirrhosis and ascites: a narrative review. Am J Med. 2016;129:461-466. 2. Mohmand H, Goldfarb S. Renal dysfunction associated with intraabdominal hypertension and the abdominal compartment syndrome. J Am Soc Nephrol. 2011;22:615-621. 3. Umgelter A, Reindl W, Franzen M, et al. Renal resistive index and renal function before and after paracentesis in patients with hepatorenal syndrome and tense ascites. Intensive Care Med. 2009;35:152-156. 4. Chang Y, Qi X, Li Z, et al. Hepatorenal syndrome: insights into the mechanisms of intra-abdominal hypertension. Int J Clin Exp Pathol. 2013;6:2523-2528.
Don’t Overlook the Role of Intraabdominal Pressure To the Editor: We read with interest the review by Tapper et al1 concerning the prevention and treatment of acute kidney injury in patients with cirrhosis and ascites. Indeed, as stated by the authors, sepsis, hypovolemia, drug-associated nephrotoxicity, and hepatorenal syndrome should be considered. However, other mechanisms may contribute to acute kidney injury in cirrhotic patients. Voluminous or tense ascites can result in elevation of intraabdominal pressure. Intraabdominal pressure of more than 12 mm Hg defines intraabdominal hypertension and can lead to significant intrarenal venous congestion and impaired filtration rate.2 In a small uncontrolled trial in cirrhotic patients, Umgelter et al3 showed a significant decrease in renal resistive index and a significant increase in creatinine clearance and urine output when decreasing intraabdominal pressure by paracentesis. Furthermore, in a mouse model of cirrhosis, Chang et al4 found that intraabdominal hypertension was a significant Funding: None. Conflict of Interest: None. Authorship: Both authors participated in writing this manuscript.
0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
pathological mechanism and a potential independent risk factor of hepatorenal syndrome. Thus, the potential role of elevated intraabdominal pressure in the pathogenesis of acute kidney injury should not be overlooked, even in the presence of hepatorenal syndrome. In case of tense ascites, measurement of intraabdominal pressure and correction of intraabdominal hypertension must be seen as useful diagnostic and therapeutic procedures. Tahar Taleb-Bendiab, MD Frédéric M. Jacobs, MD Service de Réanimation Polyvalente Université Paris-Sud Hôpital Antoine Béclère APHP Clamart, France
http://dx.doi.org/10.1016/j.amjmed.2016.05.040
References 1. Tapper EB, Bonder A, Cardenas A. Preventing and treating acute kidney injury among hospitalized patients with cirrhosis and ascites: a narrative review. Am J Med. 2016;129:461-466. 2. Mohmand H, Goldfarb S. Renal dysfunction associated with intraabdominal hypertension and the abdominal compartment syndrome. J Am Soc Nephrol. 2011;22:615-621. 3. Umgelter A, Reindl W, Franzen M, et al. Renal resistive index and renal function before and after paracentesis in patients with hepatorenal syndrome and tense ascites. Intensive Care Med. 2009;35:152-156. 4. Chang Y, Qi X, Li Z, et al. Hepatorenal syndrome: insights into the mechanisms of intra-abdominal hypertension. Int J Clin Exp Pathol. 2013;6:2523-2528.