Hepatorenal Syndrome and Other Post-Liver Transplantation Complications: Case Studies and Literature Review

Hepatorenal syndrome (HRS) was originally defined as a renal dysfunction caused by a decreased renal perfusion due to hemodynamic disturbances in the arterial circulation and an excessive activity of endogenous vasoactive systems in the course of cirrhosis. Considering the latest research, this syndrome may have a more complex pathomechanism. Equally often as in cirrhosis, HRS develops after orthotopic liver transplantation (OLTx) and worsens the prognosis significantly increasing mortality rates in this patient population. The prevalence of renal complications after OLTx and their negative prognostic impact on the survival of both the graft and the recipient prompted the authors of this work to analyze in detail 2 cases of HRS after OLTx to indicate the multiplicity of factors contributing to the pathophysiology of this syndrome. Attention was paid to risk factors for HRS found in the anamnesis before OLTx, especially a pre-existing renal dysfunction. In both cases early post-OLTx complications associated with the transplantation procedure were described: destabilization of the circulatory system, transfusions of blood products, prolonged stay at an intensive care unit, and necessity of introducing continuous renal replacement therapy. In the later period after the OLTx, infections (bacterial, fungal, viral) and drug nephrotoxicity, including the activity of immunosuppressants (tacrolimus), contributed primarily to the renal function impairment.

Use of bedside ultrasound to assess fluid status: a literature review

The assessment of a patient's body fluid status is a challenging task for modern clinicians. Ultrasonography has numerous advantages, the most important being reproducibility and bedside monitoring of the patient. The examination is quick and has a significant diagnostic value. We reviewed the literature to assess the possibility of using ultrasound methods for evaluating body fluid status. The search of PubMed and Medline databases was performed up to February 2019. Data from published reports and clinical observations show that the quick and noninvasive ultrasound examination facilitates the assessment of intravascular volume status and that the results correlate with other modalities, including invasive methods. Ultrasound enables physicians to determine the baseline status of hydration and to monitor the patient during fluid therapy. Additionally, it allows an assessment of asymptomatic patients, patients who are well adapted to chronic oxygen deficiency, and those who develop pulmonary congestion secondary to congestive heart failure or chronic kidney disease. The development of a protocol for an ultrasound assessment of the volume status would significantly facilitate the everyday practice of internal medicine specialists.

Orthostatic Hypotension in Asymptomatic Patients with Chronic Kidney Disease

Background and objective: Orthostatic hypotension (OH) is a decrease in systolic blood pressure (BP) of 20 mm Hg and in diastolic BP of 10 mm Hg when changing the position from lying to standing. Arterial hypertension (AH), comorbidities and polypharmacy contribute to its development. The aim was to assess the presence of OH and its predictors in asymptomatic chronic kidney disease (CKD) patients. Material and methods: 45 CKD patients with estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m² (CKD+) were examined for signs of OH and its predictors. The results were compared with the control group of 22 patients with eGFR > 60 mL/min/1.73 m² (CKD-). Asymptomatic patients without ischemic heart disease and previous stroke were qualified. Total blood count, serum creatinine, eGFR, urea, phosphates, calcium, albumins, parathyroid hormone, uric acid, C reactive protein, N-terminal pro b-type natriuretic peptide, lipid profile, and urine protein to creatinine ratio were assessed. Simultaneously, patients underwent echocardiography. To detect OH, a modified Schellong test was performed. Results: OH was diagnosed in 17 out of 45 CKD+ patients (average age 69.12 ± 13.2) and in 8 out of 22 CKD- patients (average age 60.50 ± 14.99). The CKD+ group demonstrated significant differences on average values of systolic and diastolic BP between OH+ and OH- patients, lower when standing. In the eGFR range of 30-60 mL/min/1.73 m² correlation was revealed between OH and β-blockers (p = 0.04), in the entire CKD+ group between β-blockers combined with diuretics (p = 0.007) and ACE-I (p = 0.033). Logistic regression test revealed that chronic heart failure (CHF, OR = 15.31), treatment with β-blockers (OR = 13.86) were significant factors influencing the presence of OH. Conclusions: Predictors of OH in CKD may include: CHF, treatment with β-blockers, combined with ACE-I and diuretics.

NT-proBNP in the Prognosis of Death or Need for Renal Replacement Therapy in Patients with Stage 3-5 Chronic Kidney Disease

BACKGROUND

The risk of cardiovascular (CV) complications is much greater in patients with chronic kidney disease (CKD). The aim of this study was to assess predictors of mortality, renal failure progression, and the need for dialysis in patients with CKD.

METHODS

The study group consisted of 70 patients with stage 3-5 CKD, followed up on average for 33.4 ± 15.6 months. Laboratory tests and echocardiography were performed on all patients. Composite endpoints were defined as (1) all-cause mortality and (2) mortality or renal replacement therapy (RRT), defined as the initiation of dialysis therapy.

RESULTS

During the observation period, 13 patients died and 11 began dialysis therapy. NT-proBNP was found to be a significant predictor in receiver operating characteristic curve analysis for all study endpoints. The optimal cutoff value for NT-proBNP as a predictor of mortality was 569.8 pg/mL, with a sensitivity of 53.8% and a specificity of 89.1%. For mortality or RRT, the cutoff value for NT-proBNP was 384.9 pg/mL, with a sensitivity and specificity of 70.8 and 72.7%, respectively. In a multivariate regression analysis, NT-proBNP was an independent predictor of mortality with an OR = 7.5 (95% CI: 1.05-53.87; p = 0.044) and of mortality or RRT with an OR = 4.7 (95% CI: 1.01-22.66; p = 0.048).

CONCLUSIONS

NT-proBNP is an independent predictor of mortality in patients with CKD and can also be useful for CV risk stratification in this patient population.

Platelet distribution width as the prognostic marker in coronary bifurcation treatment

BACKGROUND

Mean platelet volume (MPV) was proved to be a reliable prognostic factor in cardiac patients. However, platelet distribution width (PDW) was disclosed to be more specific marker of platelet reactivity. The aim of study was to evaluate whether baseline PDW value can predict the outcome in patients undergoing percutaneous coronary interventions (PCI) with drug-eluting stent implantation within coronary bifurcation lesions.

MATERIALS AND METHODS

It was a two-centre observational study, which included patients who underwent PCI within bifurcation lesions between January 2014 and December 2014. Thrombocytopenia below 100 000/μL and STEMI were the exclusion criteria. Analysed data came entirely from in-hospital records and information obtained from the 12-month telephone follow-up.

RESULTS

We included 269 patients. Mean PDW value was 13·4 ± 2·5 fL, whereas median was 13 (Q1 < 11·6 fL, Q2 11·6-13 fL, Q3 13-14·8 fL and Q4 > 14·8 fL). We found strong correlation between PDW and MPV (r = 0·96, P < 0·001), but no correlation was revealed between red blood cell distribution width (RDW) and PDW (r = 0·003, P = 0·95) as well as RDW and MPV (r = 0·0018, P = 0·98). Receiver operating characteristics (ROC) curve showed that PDW for cutoff 15·8% can predict MACE rate with sensitivity of 79% and specificity of 47% (area under curve - AUC 0·654; P = 0·01). A ROC curve for PDW categorized by 1-year TLR rate was described by optimal cutoff 16·3%, with sensitivity 69% and specificity 54% (AUC 0·697; P = 0·0015).

CONCLUSIONS

PDW is an affordable and reliable predictor of 1-year MACE and TLR rate after PCI within coronary bifurcation lesions.

Dobutamine stress echocardiography in the diagnosis of asymptomatic ischemic heart disease in patients with chronic kidney disease--review of literature and single-center experience

BACKGROUND

Coronary artery disease (CAD) may be present in kidney transplant (KT) candidates without the presence of CAD clinical symptoms. This study joins an ongoing discussion about appropriate noninvasive diagnostic approaches for ischemic heart disease (IHD) assessment and patient selection for revascularization procedures. The aim of this study was to evaluate the role of dobutamine stress echocardiography (DSE) in IHD diagnosis in initially asymptomatic maintenance hemodialysis (HD) patients.

METHODS

Forty HD patients aged 52.4 ± 2.0 years, were studied for 2.5 years. At inclusion, they were free of both symptoms and history of IHD. Standard electrocardiography (ECG), chest X-ray, standard echocardiography, DSE, 24-hour Holter ECG, and Doppler ultrasonography (carotids and lower extremities) were performed. Results were analyzed according to a predefined diagnostic algorithm.

RESULTS

DSE yielded negative results in all patients. Left ventricular (LV) ejection fraction ≤ 60%, LV hypertrophy, and Holter ECG silent ischemia features were noticed in 15%, 70%, and 10% of patients, respectively. Atherosclerotic lesions in lower extremities and carotid arteries were present in 50% and 37.5% of patients, respectively. During the follow-up, 9/40 patients died, including 6 cardiovascular (CV) deaths: 2 with intermediate and 4 with high CV risk according to the proposed algorithm.

CONCLUSIONS

In asymptomatic KT candidates, not only DSE, but also other noninvasive tests (eg, echocardiography and Doppler ultrasonography of the carotid and peripheral arteries) along with a detailed profile of the remaining CV risk factors should be performed and analyzed. Defined composition of risk factors and particular changes in noninvasive tests may be an indication for coronary angiography.

[Was it necessary to modify the classification of chronic kidney disease stages designed by NKF KDOQI? - "Nefrotest" study results]

INTRODUCTION

The introduction of the classification of chronic kidney disease (CKD) by NKF KDOQI guidelines in 2002, including the staging and risk assessment of this disease, was a landmark event. The division of CKD into stages 1-5 turned out to be very useful and sensitive tool in the hands of both scientists and clinical practitioners; it established common nomenclature pertaining to CKD all over the world. This stratification profoundly changed the approach to CKD, transforming it from a somewhat neglected clinical problem to the phenomenon named "the epidemic of CKD". However, after a short period if clinical experience a heated debate was initiated in the literature, indicating the shortcomings of the adopted classification. The most questionable areas included methodological issues as well as dissimilar prognoses for patients depending on the cause of kidney dysfunction, the presence of proteinuria and comorbidities.

AIM

The aim of this study was to evaluate the prevalence of CKD and the risk factors based on NKF KDOQI classification of 2002 in the population of Ostróda administrative district.

MATERIAL AND METHOD

In total 437 individuals (F 277, M 160) aged 52.7±18.0 were examined. The study was conducted in Ostróda among randomly selected inhabitants of Ostróda adminstrative district. Serum creatinine was determined by a modified Jaffe method and eGFR was calculated (MDRD formula) for each individual. The correlations between serum creatinine and eGFR, gender and age were studied. Additionally, 326 of the examined participants were interviewed to establish CKD risk factors: kidney disease in the family, being overweight and/or obese, arterial hypertension, diabetes, smoking, heart attack, stroke.

RESULTS

58.6% of the examined individuals demonstrated abnormal eGFR values (<90 ml/min/l.73 m2), whereas serum creatinine above the laboratory norm was found in 1.3% of patients. Significant CKD risk factors included an increased prevalence of obesity (78.3%), arterial hypertension (38.6%), and smoking (26.8%); 23.9% reported kidney disease in the family.

CONCLUSIONS

Based on our study, it can be concluded that CKD prevalence evaluated according to the classification of 2002 seems to be overestimated, and the main factor contributing to a false CKD diagnosis is a physiological decline in eGFR values with aging. The modification of CKD classification carried out by NKF in 2012 requires further observation and evaluation of its usefulness in daily clinical practice.

Hyperuricemia is an independent predictive factor for left ventricular diastolic dysfunction in patients with chronic kidney disease

BACKGROUND

It has been reported that elevated serum uric acid (UA) levels is an independent factor of poor prognosis in patients with chronic heart failure and chronic kidney disease (CKD).

OBJECTIVES

In our study, we assessed the potential impact of hyperuricemia on left ventricular (LV) diastolic dysfunction (DD) in patient with CKD.

MATERIAL AND METHODS

The study group consisted of 50 patients with CKD, stages 2-5. Standard echocardiography and tissue Doppler imaging (TDI) were performed. The levels of UA and N-terminal prohormone brain natriuretic peptide (NT-proBNP) were determined. Patients were divided into two groups according to the results of peak mitral annular early diastolic velocity (EmLV): group with LV diastolic dysfunction (EmLV < 8 cm/s) DD (+) and group with normal LV diastolic function DD (-), when EmLV ≥ 8 cm/s.

RESULTS

Patients DD (+) group, as compared to DD (-) patients were characterized by significantly higher serum UA levels [6.7 (4.4-14.3) mg/dL vs 5.8 (1.9-8.9) mg/dL, p = 0.004] respectively. The area under the receiver operating characteristic (ROC) curve was of serum UA levels for the detection of LV diastolic dysfunction was 0.734, 95% confidence interval (CI) 0.590-0.849, p = 0.001, whereas ROC derived UA value of > 6.0 mg/dL was characterized by a sensitivity of 76.9% and specificity of 62.5% for diagnosing LV diastolic dysfunction. The independent variable predicting LV diastolic dysfunction as measured by a multivariate logistic regression analysis was UA level > 6.0 mg/dL with odds ratio (OR) = 14.3 (95% CI 2.0-103.2), p = 0.006.

CONCLUSIONS

Hyperuricemia is an independent predictive factor for LV diastolic dysfunction in patients with CKD.

Red cell distribution width is an independent factor for left ventricular diastolic dysfunction in patients with chronic kidney disease

BACKGROUND

The increased value of the red cell distribution width (RDW) was reported to indicate poor prognosis in patients with chronic heart failure. We evaluated the value of the RDW in the diagnosis of left ventricular diastolic dysfunction (LVDD) in patients without diastolic heart failure among the chronic kidney disease (CKD) population.

METHODS

The study group consisted of 73 ambulatory patients with CKD, stages 2-5. Standard echocardiography and tissue Doppler imaging (TDI) were performed, and the level of RDW was determined. Patients were divided into four groups according to the results of peak early diastolic velocity of mitral annulus (EmLV) and the stage of CKD: group with early stage CKD (eGFR > 30 ml/min/1.73 m(2)) without LVDD (EmLV ≥ 8 cm/s), early stage CKD with LVDD (EmLV < 8 cm/s), group with advanced stage CKD (eGFR ≤ 30 ml/min/1.73 m(2)) without LVDD, and group with advanced stage CKD with LVDD.

RESULTS

Patients with advanced stage CKD with LVDD were characterized by higher RDW levels than patients with advanced stage CKD without LVDD and with early stage CKD groups with and without LVDD [14.5 (13.8-19.5) % vs. 13.7 (11.4-15,4) %, p = 0.049, vs. 13.8(13.1-14.9) %, p = 0.031, vs. 13.7(12.1-16.2) %, p = 0.0007], respectively. The area under the receiver operating characteristic (ROC) curve of RDW level for the detection of LVDD was 0.649, 95 % confidence interval (CI) 0.528-0.758, p = 0.021, whereas ROC derived RDW value of >13.5 % was characterized by a sensitivity of 83.3 % and specificity of 45.2 % for predicting LVDD. The only independent factor of LVDD was RDW level >13.5 % with odds ratio (OR) = 3.92 (95 % CI 1.05-14.56), p = 0.037.

CONCLUSION

RDW can be used as an additional factor for the diagnosis of LVDD in patients with advanced stage of CKD.

The significance of mitral and tricuspid valve systolic lateral annular velocities in the diagnosis of acute pulmonary embolism in patients with chronic heart failure

INTRODUCTION

The diagnosis of acute pulmonary embolism (APE) in patients with chronic heart failure (CHF) remains a difficult task, despite the refinement of imaging techniques. The goal of this study was to assess the value of measuring tricuspid and mitral valve systolic annular velocities in CHF patients with suspected PE by tissue Doppler imaging (TDI).

MATERIAL AND METHODS

The study included 75 patients with previously diagnosed CHF, admitted due to resting dyspnea, with a maximum tricuspid regurgitation pressure gradient (TRPG) of ≥ 35 mm Hg and positive D-dimer assay. Spiral computed tomography (sCT) was performed on all subjects to confirm APE. Acute pulmonary embolism was diagnosed in 35 patients (PE+), and excluded in 40 others (PE-). Tissue Doppler imaging was performed to measure maximum systolic lateral annular velocities in the mitral (SmLV) and tricuspid (SmRV) valves, as well as the SmRV/SmLV ratio.

RESULTS

PE+ subjects were found to have higher SmLV than PE- subjects (6.0 cm/s (2.0-13.8 cm/s) vs. 4.2 cm/s (1.3-9.1 cm/s), p = 0.003). SmRV/SmLV ratios were 1.05 (0.50-2.50) and 1.56 (0.62-4.30), respectively (p < 0.0001). Areas under ROC curves for diagnosis of APE were 0.700 for SmLV and 0.789 for SmRV/SmLV. In multivariate logistic regression analysis, only SmRV/SmLV was statistically significant, with an odds ratio for APE of 6.26 (95% CI: 1.53-25.59; p = 0.009).

CONCLUSIONS

Tissue Doppler imaging of the lateral tricuspid and mitral annuli is a useful clinical tool that can help identify PE in CHF patients. Those patients who fulfill these criteria should be considered for further diagnostic studies to confirm PE.

[Renal artery thrombosis and renal infarction, diagnostic and therapeutic difficulties--reports of two cases]

Renal artery thrombosis (RAT) is a rare condition, with a poor prognosis, which can lead to renal infarction (RI). RAT has both cardiogenic etiology (arrhythmia, endocarditis, valvular heart disease, coronary disease) and noncardiogenic etiology (renal artery injury and/or instrumentation, fibromuscular dysplasia, coagulation disorders, homocystinuria, cocaine intake). In 30% of cases RAT etiology remains undetermined and then it is labeled idiopathic RAT. Because of the absence of typical symptoms and abnormalities in laboratory tests as well as often ambiguous results of imaging scans, RAT frequently remains undiagnosed. Presently RAT treatment standards are lacking due to its being a rare disease, which renders making treatment decisions difficult. However, because of a high risk of developing its serious complication in the form of RI, it seems necessary to introduce patient-tailored treatment in each case. Two cases presented in this paper demonstrate diagnostic difficulties and the necessity to introduce personalized treatment. Case 1 concerns idiopathic RAT in which anticoagulation therapy was introduced. Case 2 describes cardiogenic RAT with renal artery stenosis treated interventionally, i.e., percutaneous transluminal angioplasty (PTA) combined with antiplatelet drugs. In both cases recanalization of the renal artery was successful and a stable renal function was achieved.

Patient with purulent pericarditis: a case doomed to fail?

Exudative pericarditis, and in particular a purulent type, is a rare condition which requires emergency medical intervention. In our paper we present a case report concerning a patient with purulent pericarditis.

Tamponada serca jako pierwszy objaw raka płuca

Wysięk w jamie osierdzia jest dosyć częstym problemem klinicznym, natomiast bardzo rzadko bywa pierwszym objawem choroby nowotworowej. Wystąpienie tamponady serca świadczy o zaawansowanym stadium choroby nowotworowej i jest czynnikiem rokowniczo niekorzystnym. W pracy przedstawiono przypadek chorego, u którego pierwszym objawem raka płuca była tamponada serca—63-letni mężczyzna palący papierosy został przyjęty do szpitala z powodu objawów narastającej od kilku dni duszności wysiłkowej i bólów w klatce piersiowej. W wykonanym badaniu echokardiograficznym rozpoznano dużą ilość płynu w jamie osierdziowej z echokardiograficznymi cechami zagrażającej tamponady serca. Po wykonaniu punkcji jamy osierdziowej i badań dodatkowych rozpoznano raka gruczołowego płuca. Z powodu nawrotu zagrażającej tamponady serca u chorego wykonano wideotorakoskopową fenestrację worka osierdziowego i zastosowano chemioterapię ogólną z dobrym efektem.

[The role of combination therapy in the management of hypertension in patients with chronic kidney disease]

Despite an increasing number of hypotensive drugs available on the market, an unsatisfactory percentage of patients achieve expected therapeutic effects in the management of arterial hypertension (HTN). This issue is especially significant as regards patients with chronic kidney disease (CKD), due to a high HTN prevalence in this population of patients and because inappropriately controlled arterial blood pressure (ABP) constitutes an additional factor leading to the progression of this disease. Kidneys play a significant role in the pathophysiology of HTN. Some of the impaired mechanisms for controlling ABP in CKD can be corrected pharmacologically. However, in order to achieve therapeutic effectiveness, a simultaneous intervention at many pathophysiological levels is necessary, and this is associated with the necessity to administer more than one hypotensive drug. It is actually polytherapy that is the real challenge in managing HTN, as it disturbs the so-called compliance, i.e., cooperation and a proper adherence to the physician's orders by the patient. Combined drugs facilitate a multidirectional intervention on the impaired mechanisms for controlling ABP, while offering an uncomplicated treatment protocol. They are especially recommended in groups of patients with a high cardiovascular risk, diabetes and/or with CKD. However, despite a large body of evidence for the improved effectiveness of hypotensive treatment with the use of combination therapy in the general population, there are no multicenter studies performed on the population of CKD patients. Also there are only few reports referring to this issue in the literature. The authors of the present paper have overviewed literature concerning the distinctness of the pathogenesis of HTN in patients with CKD and have evaluated the usefulness of combination therapy in the correction mechanism of the impaired pathophysiological paths. On the basis of the conducted analysis, the combinations of drugs preferred in CKD have been presented. The usefulness of combination therapy in the early stages of CKD has been evidenced. Spe cial attention has been given to the limitations and risks associ ated with combination therapy in CKD, mainly in the advance stages and when the disease progresses rapidly. It has been pointed out that it is particularly important to monitor renal pa rameters, potassium concentrations and clinical situations that require the therapy to be changed into a standard one. It appean that despite the pros and cons of this type of HTN management in CKD, an increasing number of combined drugs available on the market and the chances for a more effective control of ABP in this group of patients with a high cardiovascular risk necessitate further studies.

[Cardiac tamponade as the first symptom of lung cancer]

Pericardial effusion is a relatively common clinical problem. It is, however, rarely the first symptom of cancer. Cardiac tamponade testifies to an advanced stage of cancer and is a negative prognostic factor. This paper presents a patient in whom cardiac tamponade was the first symptom of lung cancer. A 63-year-old male, habitual smoker, was admitted to hospital due to progressive symptoms of exertional dyspnoea lasting for a few days and chest pain. Echocardiographic examination revealed a large amount of fluid in the pericardium with echocardiographic signs of a life-threatening cardiac tamponade. The patient underwent pericardial puncture and additional imaging examinations. Lung adenocarcinoma was recognized as the underlying disease. Due to the recurrence of the life-threatening cardiac tamponade, video-assisted thoracoscopic pericardial fenestration was performed and systemic chemotherapy was introduced with good results.

[The role of tissue Doppler imaging in diagnosis of pulmonary embolism]

Pulmonary embolism (PE), despite improvement of diagnostic methods often remains undiagnosed. Importantly, the lack of correct diagnosis is one of major factors negatively influencing the prognosis of PE for patients. Echocardiography is frequently performed on patients suspected of PE. However, the majority of signs reported by echocardiography only indirectly indicate PE. However, new parameters characteristic of pulmonary embolism by means of novel echo-cardiographic methods may increase the probability of a correct diagnosis, thus improving the prognosis in this group of patients. The aim of this study was to present a potential role of echo-cardiography with tissue Doppler imaging in diagnosing pulmonary embolism. Tissue Doppler echocardiography (TDE) is a based on the Doppler effect in order to assess movements of the heart structures. Due to a selective measurements of the velocities of selected fragments of myocardium, TDE allows for a fully quantitative and objective assessment of the regional myocardial function. One of the new parameters helpful in PE diagnosis is M-index, which is ratio of early diastolic mitral inflow velocity and right ventricular Tei index. M-index < 112, showed 92% sensitivity and 92% specificity for the PE diagnosis. Another parameter V-index, which is the ratio of right ventricular Tei index to left ventricular Tei index was assessed in PE diagnosis in patients with pulmonary hypertension (PH). The value of V-index > 1.2 confirmed PE with a sensitivity of 82% and a specificity of 83%. In our study, it was shown that patients with PE manifest hyperkinetic left ventricular function. Peak systolic velocity of the mitral annulus lateral portion (SmLV) = 5.5 cm/s had a sensitivity of 60% and a specificity of 86% in diagnosing PE in patients with congestive heart failure (CHF), whereas the ratio of peak systolic velocity of the tricuspid annulus to peak systolic velocity of the mitral annulus (SmRV/LV) = 1.2 showed a sensitivity of 76% and a specificity of 93% in diagnosing PE. The mentioned above date showing that echocardiography combined with tissue Doppler imaging may be useful in diagnosing PE.