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Evaluating Acute Renal Failure in Cirrhosis Based on a Point-of-Care Echocardiography Approach FREE TO VIEW

Kenneth Walters; John Huggins; Peter Doelken; Carlos Kummerfeldt; David Koch; Adrian Reuben
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Medical University of South Carolina, Charleston, SC

Chest. 2014;146(4_MeetingAbstracts):575A. doi:10.1378/chest.1995129
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SESSION TITLE: Diagnostic Procedures and Interventions Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: Differentiation of the cause of acute renal failure in cirrhotics is challenging. Recommendations include discontinuing diuretics and fluid challenges. Assessment of intravascular volume status and central hemodynamics are difficult to ascertain by clinical evaluation. Our goal was to use point-of-care echocardiography (POCE) to evaluate intravascular volume and central hemodynamics after initial clinical treatment failed to improve renal function.

METHODS: We evaluated cirrhotic patients admitted to our inpatient liver service with a diagnosis of acute renal failure. POCE measurements included: 1) Inferior vena cava (IVC) size and variation with respiration; 2) tricuspid annular plane systolic excursion (TAPSE); 3) mitral inflow velocities; 4) velocity time integral (VTI) of the left ventricular outflow tract (LVOT). Repeat measurements were performed to determine fluid responsiveness after a passive leg raise. Using our current POCE algorithm with the above results, we determined where the patient was on the Frank-Starling curve of heart function as it relates to intravascular volume and central hemodynamics.

RESULTS: Twenty-five patients, with an average MELD score of 28, were evaluated by POCE. Patients had received an average positive fluid balance of 3.8 liters (0L - +11L) crytalloid and had received 100grams (0g-250g) of Albumin. On average, the initial POCE occured on day five of admission (2-15 days). Fourteen (56%) patients were fluid responsive. For these patients, we recommended volume expansion with colloid. Six (24%) patients were hypervolemic and in a non-preload dependent state. For these patients, we recommended diuresis. Three (12%) patients were euvolemic. For these patients, we recommended no intervention. When pre-load augmentation was not seen on POCE, sometimes days after initial evaluation, large volume paracentesis (LVP) was performed. Six (24%) patients received an LVP with improvement in central hemodynamic parameters seen in four (IVC size, LVOT VTI, mitral E velocity).

CONCLUSIONS: The utilization of POCE to evaluate intravascular volume and central hemodynamics, led to a change in management in 88% of patients. Clinical evaluation of these dynamics, based on exam and laboratory data, are unreliable. POCE should be part of the evaluation of acute renal failure in this population.

CLINICAL IMPLICATIONS: Point-of-care echocardiography may provide a more precise evaluation of central hemodynamics and guide the clinician in treating acute renal failure in cirrhosis.

DISCLOSURE: The following authors have nothing to disclose: Kenneth Walters, John Huggins, Peter Doelken, Carlos Kummerfeldt, David Koch, Adrian Reuben

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