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Kidney Week

Abstract: SA-PO127

Fractional Excretion of Urinary Sodium and Urinary Sediment Microscopy for Prediction of Response to Vasoconstrictors in Hepatorenal Syndrome Type 1

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Lam, Walter, Ochsner Health, New Orleans, Louisiana, United States
  • Wickman, Terrance Joseph, Ochsner Health, New Orleans, Louisiana, United States
  • Mohamed, Muner, Ochsner Health, New Orleans, Louisiana, United States
  • Velez, Juan Carlos Q., Ochsner Health, New Orleans, Louisiana, United States
Background

Because of diagnostic challenges around differentiating hepatorenal syndrome type 1 (HRS-1) from acute tubular injury (ATI), proper selection of patients who can benefit from vasoconstrictor therapy (VCT) remains suboptimal. We hypothesized that markers of tubular function or injury may correlate with therapeutic response to VCT.

Methods

Records from hospitalized patients with HRS-1 treated with VCT without shock were reviewed. We selected those who achieved ≥5 mmHg rise in mean arterial pressure (MAP) within 48 hours and had available fractional excretion of urinary sodium (FENa) (marker of tubular function) and microscopic examination of the urinary sediment (MicrExUrSed) (marker of tubular injury). Lower limit for urinary Na was <10 mEq/L. HRS-1 was diagnosed by ICA criteria + FENa <1% + no overt ATI by MicrExUrSed (abundant dark granular casts). Absence of ATI by MicrExUrSed was defined as bland sediment or only hyaline casts. The primary endpoint was percentage of change in serum creatinine (sCr) at the end therapy (day 7-14).

Results

A total of 44 patients with HRS-1 treated for 2-7 days with either norepinephrine (n=40) or midodrine/octreotide (n=4) were included. Median age was 52 (IQR 46-62), 41% female and 57% had alcoholic cirrhosis. At the start of VCT, median MAP was 71 mmHg (IQR 68-74) and median sCr was 3.8 mg/dL (IQR 2.8-4.9). Median FENa was 0.4% (IQR 0.29-0.49). FENa significantly correlated with change in serum Cr (r=0.395, p=0.007). Thus, lower FENa was associated with reduction in sCr. All patients with >30% reduction in sCr had FENa between 0.05 and 0.42%. Among those with MAP rise >10 mmHg (n=30), the correlation between FENa and change in sCr turned stronger (r=0.599, p=0.0004). Furthermore, the correlation between MAP rise and improvement in sCr was stronger among those with absence of ATI by MicrExUrSed (n=24) (r=-0.579, p=0.003) compared to those with scattered elements of ATI (n=20) (r=-0.23, p=0.32). Among those with MAP rise >10 mmHg, 10 of 16 (63%) of those with no ATI by MicrExUrSed achieved >30% reduction in sCr compared to 4 of 14 (27%) of those with ATI elements (p=0.06).

Conclusion

Functional and injury urinary markers may offer predictive information respect to response to VCT in HRS-1.