Increased plasma levels of atrial natriuretic peptide and endocrine markers of volume depletion in patients with obstructive jaundice

The pathogenesis of renal injury in obstructive jaundice: A review of underlying mechanisms, inducible agents and therapeutic strategies

Kidney injury is one of the main complications of obstructive jaundice (OJ) and its pathogenesis has not been clarified. As an independent risk factor for OJ associated with significant morbidity and mortality, it can be mainly divided into two types of morphological injury and functional injury. We called these dysfunctions caused by OJ-induced kidney injury as OJKI. However, the etiology of OJKI is still not fully clear, and research studies on how OJKI becomes a facilitated factor of OJ are limited. This article reviews the underlying pathological mechanism from five aspects, including metabolisms of bile acids, hemodynamic disturbances, oxidative stress, inflammation and the organic transporter system. Some nephrotoxic drugs and measures that can enhance or reduce the renal function with potential intervention in perioperative periods to alleviate the incidence of OJKI were also described. Furthermore, a more in-depth study on the pathogenesis of OJKI from multiple aspects for exploring more targeted treatment measures were further put forward, which may provide new methods for the prevention and treatment of clinical OJKI and improve the prognosis.

Plasma BNP level combined with surgical Apgar score to predict operative major cardiac adverse events in malignant obstructive jaundice patients

Objective:

To investigate the predictive effect of major adverse cardiac events (MACE) in malignant obstructive jaundice (OJ) patients using plasma brain natriuretic peptide (BNP) level and surgical Apgar scoring (SAS) system.

Methods:

Forty one malignant OJ patients undergoing surgical treatments were studied at a single center. Pre-and postoperative plasma BNP level, total bilirubin (TBil) and data of cardiac function (HR, CVP, CI, LVEF%) were detected, the SAS was calculated during the surgery, the relationship of both plasma BNP level and SAS with MACE after surgery was analyzed.

Results:

Thirteen patients out of 41 (31.71%) experienced MACE without cardiac death. OJ patients had a higher plasma BNP level than baseline before operation (191.61±105.76 pg/ml VS 175 pg/ml, P<0.05), the cardiac function data was improved (CVP: t=4.761, p=0.000; CI: t=3.539, p=0.001; LVEF%: t=3.632, p=0.001) after the operation. Patients with lower SAS had increasing incidence of MACE after surgery.

Conclusion:

Malignant OJ patients with higher preoperative BNP level and lower surgical Apgar score were identified at high risk of MACE after surgery.

In vivo and ex vivo effects of propofol on myocardial performance in rats with obstructive jaundice

BACKGROUND

Responsiveness of the "jaundiced heart" to propofol is not completely understood. The purpose of this study was to evaluate the effect of propofol on myocardial performance in rats with obstructive jaundice.

METHODS

Male Sprague-Dawley rats (n = 40) were randomly allocated into two groups, twenty underwent bile duct ligation (BDL), and 20 underwent a sham operation. Seven days after the surgery, propofol was administered in vivo and ex vivo (Langendorff preparations). Heart rate, left ventricular end-systolic pressure (LVESP) left ventricular end-diastolic pressure (LVEDP), and maximal rate for left ventricular pressure rise and decline (± dP/dtmax ) were measured to determine the influence of propofol on the cardiac function of rats.

RESULTS

Impaired basal cardiac function was observed in the isolated BDL hearts, whereas in vivo indices of basal cardiac function (LVESP and ± dP/dt) in vivo were significantly higher in rats that underwent BDL compared with controls. With low or intermediate concentrations of propofol, these indices of cardiac function were within the normal physiologic range in both groups, and responsiveness to propofol was unaffected by BDL. When the highest concentration of propofol was administrated, a significant decline in cardiac function was observed in the BDL group.

CONCLUSIONS

In rats that underwent BDL, basal cardiac performance was better in vivo and worse ex vivo compared with controls. Low and intermediate concentrations of propofol did not appear to impair cardiac function in rats with obstructive jaundice.

A clinical prospective comparison of anesthetics sensitivity and hemodynamic effect among patients with or without obstructive jaundice

BACKGROUND

To compare isoflurane anesthesia in patients with or without hyperbilirubinemia undergoing hepatobiliary surgery.

METHODS

Forty-two patients with obstructive jaundice and 40 control patients with normal liver function scheduled for hepatobiliary surgery under isoflurane anesthesia were studied. Anesthesia was induced with propofol (1.5-2 mg/kg) and remifentanil (2 microg/kg). After tracheal intubation, anesthesia was titrated using isoflurane in oxygen-enriched air, adjusted to maintain a bispectral index (BIS) value of 46-54. Ephedrine, atropine and remifentanil were used to maintain hemodynamic parameters within 30% of the baseline. The mean arterial blood pressure (MAP), heart rate (HR), drug doses and the time taken to recover from anesthesia were recorded.

RESULTS

Demographic data, duration and BIS values were similar in both groups. Anesthesia induction and maintenance were associated with more hemodynamic instability in the patients with jaundice and they received more ephedrine and atropine and less remifentanil and isoflurane (51.1+/-24.2 vs. 84.6+/-20.3 mg/min; P for all <0.05) than control patients. Despite less anesthetic use, the time to recovery and extubation was significantly longer than that in control.

CONCLUSION

Patients with obstructive jaundice have an increased sensitivity to isoflurane, more hypotension and bradycardia during anesthesia induction and maintenance and a prolonged recovery time compared with controls.

The effects of obstructive jaundice on the pharmacodynamics of propofol: does the sensitivity of intravenous anesthetics change among icteric patients?

BACKGROUND

Some studies suggest that certain clinical symptoms of cholestasis, such as fatigue and pruritus, result from altered neurotransmission. Patients with obstructive jaundice also have labile blood pressure and heart rate. In the present study, the authors investigated whether obstructive jaundice affects a patient's sensitivity to hypnotics and the haemodynamic profile of propofol.

METHODS

Thirty-six ASA physical status I/II/III patients with serum total bilirubin (TBL) from 7.8 to 362.7 micromol/l scheduled for bile duct surgery were recruited. A computer-controlled propofol infusion programmed for effect site target was used to rapidly attain and maintain sequential increase of the compartment concentration (from 1 to 3 microg/ml). Each target-controlled concentration was maintained for about 12 min, and arterial blood samples were drawn for propofol concentration determination. The bispectral index (BIS) and mean arterial pressures (MAP) were used as indices of the propofol effect. The relation between the concentration and the effects was described by the Hill equation. The pharmacodynamic parameters were optimized using a nonlinear mixed-effect model.

RESULTS

TBL was not a significant covariate of EC(50) for the pharmacodynamic model. For BIS and MAP, the parameters of the pharmacodynamic model were E(max)=75.77%, EC(50)=2.34 microg/ml, and gamma=1.82, and E(max)=47.83%, EC(50)=1.49 microg/ml, and gamma=1.88, respectively.

CONCLUSIONS

We demonstrated that obstructive jaundice with serum TBL from 7.8 to 362.7 micromol/l had no effect on propofol pharmacodynamics observed by BIS and MAP.

Effects of dexamethasone on small bowel and kidney oxidative stress and histological alterations in bile duct-ligated rats

Oxidative stress plays an important role in the pathogenesis of toxic liver diseases and other hepatic alterations including obstruction of bile flow. It has been shown that the gastrointestinal tract and renal tissue is particularly affected during obstruction of bile flow. In this study, we aimed to evaluate the effects of dexamethasone on small bowel and kidney oxidative stress and histological alterations in bile duct-ligated (BDL) rats. A total of 40 male Sprague-Dawley rats weighing 200-240 g were used in this study. Group 1 (Sham-control, n = 10) rats underwent laparotomy and bile duct was dissected from the surrounding tissue. Group 2 (Dexa-control, n = 10) rats underwent laparotomy and bile duct was dissected from the surrounding tissue. The rats received daily dexamethasone. Group 3 (BDL/Untreated, n = 10) rats were subjected to bile duct ligation and no drug was applied. Group 4 (BDL/Dexa, n = 10) rats received daily dexamethasone by orogastric tube for 14 days after BDL. At the end of the 2-week period, superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), and malondialdehyde (MDA) were measured and biochemical and histological evaluation were processed. The mean serum bilirubin, liver enzymes, MDA level, and histopathological score significantly decreased and SOD, CAT, and GSH-Px values were significantly increased in group 4 when compared to group 3. Group 3 presented a significant increase in caecal count of E. coli and in aerobe/anaerobe ratio. In group 4, liver was moderately damaged. Ileal biopsies from group 4 demonstrated a significant increase in villus height, total mucosal thickness, and villus density when compared to group 3. Glomerular injury scores (GIS) and arterial injury scores (AIS) in group 3 rats were increased in the juxtamedullary region. In contrast to group 4, tubulo-interstitial lesions were diffuse in group 3 animals. Dexamethasone reduced small bowel and kidney oxidative stress and histological alterations in bile duct-ligated rats with increasing SOD, CAT, and GSH-Px and decreasing MDA levels in rats with obstructed bile duct.

Multivariate analysis of factors associated with renal dysfunction in patients with obstructive jaundice

BACKGROUND

The aim was to evaluate the factors determining preoperative renal dysfunction in patients with obstructive jaundice.

METHODS

In a prospective cross-sectional observational study, 63 patients, 27 with benign and 36 with malignant obstructive jaundice, were investigated at admission and compared with 25 healthy control subjects. Variables analysed included extracellular body water (ECW) compartment, plasma levels of aldosterone, renin, atrial natriuretic peptide, vasopressin, nitric oxide, endothelin (ET) 1 and prostaglandin E2 (PGE2), urinary nitric oxide and PGE2, serum albumin and renal function.

RESULTS

The metabolic profile of obstructive jaundice was characterized by a depletion of the ECW (P = 0.004), and increased plasma levels of atrial natriuretic peptide (P < 0.001), ET-1 (P = 0.044), vasopressin (P = 0.017), aldosterone (P = 0.005) and renin (P = 0.001). Increased plasma (P < 0.001) and urinary (P = 0.001) PGE2 levels were also found. Fifty-four per cent of patients had a creatinine clearance of less than 70 ml/min. In multivariate analysis, serum bilirubin, renin, ET-1, PGE2, decreased urinary sodium excretion and age were identified as predictors of renal dysfunction.

CONCLUSIONS

Renal dysfunction in patients with obstructive jaundice was associated with the degree of biliary obstruction, age of the patient and reduced urinary sodium excretion. These alterations were closely related to derangements in sodium- and water-regulating hormones.

Randomized clinical trial of the effect of intravenous fluid administration on hormonal and renal dysfunction in patients with obstructive jaundice undergoing endoscopic drainage

BACKGROUND

Renal dysfunction in patients with biliary obstruction is associated with extracellular water depletion. This study examined the effect of preoperative saline infusion before biliary drainage on hormonal and renal functional derangements in patients with obstructive jaundice.

METHODS

In a randomized study, 49 patients with malignant obstructive jaundice were investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days after internal endoscopic biliary drainage. Patients were randomized to receive (n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h before drainage. Variables analysed included extracellular water volume, creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), vasopressin and albumin.

RESULTS

Preoperative saline infusion produced a rise in creatinine clearance, diuresis, ANP concentration and extracellular water volume but this did not translate into better recovery of renal function after operation. Drainage produced a fall in creatinine clearance in all patients, but hormonal and renal function had recovered by 2 days after restoration of bile flow, independently of preoperative hydration.

CONCLUSION

Fluid administration expands the extracellular water compartment before drainage but fails to improve renal function after drainage. Definitive improvement in endocrine and renal function requires the restoration of bile flow into the duodenum.

Liver and kidney diseases

The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.

Effect of internal biliary drainage on plasma levels of endotoxin, cytokines, and C-reactive protein in patients with obstructive jaundice

Preoperative biliary drainage may improve the cytokine and acute-phase response derangements observed in patients with obstructive jaundice. We conducted a prospective longitudinal, before-after trial in our 600-bed teaching hospital. Twenty-four patients with obstructive jaundice were investigated, 11 with benign obstruction and 13 with malignant disease. Endoscopic internal biliary drainage was performed in all patients (7 by papillotomy and 17 by endoprostheses). Endotoxin, tumor necrosis factor alpha (TNF-a), interleukin-6 (IL-6), nitric oxide production, and C-reactive protein (CRP) were determined at admission and on days 2 and 7 after internal biliary drainage was accomplished. Bile cultures were obtained before and at the time of drainage. Endotoxin, IL-6, TNF-a, and CRP were significantly higher in patients with cancer. After internal drainage, endotoxin (11.4 vs. 2 EU/L; p <0.05), TNF-a (87.5 vs. 48 pg/ml; p = 0.03), and IL-6 (324 vs. 232 pg/ml; p <0.05) plasma levels decreased significantly in the early postdrainage period in patients with cancer. Endotoxin, cytokines, as well as the CRP plasma values, however, increased again on day 7 after drainage. This trend was less marked in patients with benign obstruction. Patients with positive bile cultures after drainage displayed higher levels of CRP (115 vs. 62 mg/L; p = 0.03), IL-6 (598 vs. 330 pg/ml; p = 0.04), and endotoxin (10.6 vs. 4.8 EU/L; p = 0.02) than those with negative bile cultures. Biliary tract obstruction is associated with an increase in endotoxin levels, a positive acute-phase response, and plasma cytokine elevation. After biliary drainage a transitory improvement of these alterations was observed, although values remained high 1 week postdrainage. These findings were associated with positive bile cultures.

Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment

OBJECTIVE

To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage.

SUMMARY BACKGROUND DATA

Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction.

METHODS

Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined.

RESULTS

Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output.

CONCLUSIONS

Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.

Melatonin protects against renal oxidative stress after obstructive jaundice in rats

The goals of this study were to analyze the renal oxidative status in experimental biliary obstruction and to evaluate the impact of melatonin on renal oxidative stress. Cholestasis was done by double ligature and section of the extra-hepatic biliary duct. Melatonin was injected i.p. (500 microg/kg/day). Malondialdehyde, reduced glutathione, catalase, superoxide dismutase, glutathione reductase, glutathione peroxidase and glutathione transferase were determined in the renal tissue. After biliary obstruction, an increase in malondialdehyde (P<0.0001) and a fall in reduced glutathione (P<0.0001) were seen. Moreover, the scavenger enzyme activity had significantly diminished. After melatonin administration, the malondialdehyde fell significantly (P<0.0001), whereas reduced glutathione showed an important increase (P<0.0001) compared with the ligated bile duct group. Experimental bile duct obstruction was associated to an increase of renal oxidative stress. Treatment with melatonin decreased the renal lipid peroxidation, and both the reduced glutathione as well as the scavenger enzyme activity recovered.

The natriuretic peptides: universal volume controllers

Since the discovery of the natriuretic effect of atrial natriuretic peptide (ANP), a family of other natriuretic peptides similar to ANP were isolated, including atriopeptin, vessel dilator, long-acting natriuretic peptide, urodilatin, and brain natriuretic peptide (BNP) to name a few. ANP was noted to possess natriuretic and diuretic properties that controlled increases in intravascular volume. ANP was also found to be elevated in conditions of increased intraocular pressure and biliary obstruction. BNP was found to be elevated in conditions of increased intracranial pressure, pointing towards its role in controlling cerebrospinal fluid volume. While at the cellular level, ANP controlled individual cell size. This makes the natriuretic peptides not only controllers of intravascular volume, but also modulators of a myriad of cavity volumes down to the control of individual cell volume.