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Moreno J.A.,Autonomous University of Madrid | Martin-Cleary C.,Autonomous University of Madrid | Gutierrez E.,Institute Investigacion Hospital 12 Of Octubre | Rubio-Navarro A.,Autonomous University of Madrid | And 5 more authors.
Nephrology Dialysis Transplantation | Year: 2012

Haematuria is a frequent manifestation of glomerular disease. However, nephrologists devote more attention to the monitoring and therapeutic targeting of another key manifestation of glomerular injury, proteinuria. Recent reports have propelled haematuria to the forefront of clinical nephrology. Thus, glomerular macroscopic haematuria is associated with the development of acute kidney injury (AKI) with predominant tubular cell damage and there is increasing evidence for the negative impact of glomerular haematuria-associated AKI on long-term renal function outcome both in the context of IgA nephropathy and in anticoagulated patients. In addition, an epidemiological association between isolated microscopic haematuria in young adults and long-term incidence of end-stage renal disease has been described. Finally, a clearer understanding of how haematuria may cause tubular injury is emerging through detailed histological assessment of human biopsies and experimental models of haemoglobin-mediated nephrotoxicity. © 2011 The Author. Source


Gines P.,University of Barcelona | Gines P.,Instituto Reina Sofia Of Investigacion Nefrologica Irsin | Fernandez J.,University of Barcelona | Durand F.,Instituto Reina Sofia Of Investigacion Nefrologica Irsin
Journal of Hepatology | Year: 2012

Cirrhotic patients are prone to develop life-threatening complications that require emergency care and ICU admission. They can present specific decompensations related to cirrhosis such as variceal bleeding and hepatorenal syndrome (HRS) or other critical events also observed in the general population such as severe sepsis or septic shock. Clinical management of all these entities requires a specific approach in cirrhosis. Cirrhotic patients have a hyperdynamic circulation with high cardiac output and low systemic vascular resistance in the absence of infection [1,2]. Circulatory dysfunction increases the susceptibility of critically-ill cirrhotic patients to develop multiple organ failure and attenuates vascular reactivity to vasopressor drugs [3]. HRS, a severe functional renal failure occurring in patients with advanced cirrhosis and ascites, is also secondary to this circulatory dysfunction that leads to an extreme renal vasoconstriction [2]. Moreover, hypotensive cirrhotic patients require a carefully balanced replacement of volemia, since overtransfusion increases portal hypertension and the risk of variceal bleeding and undertransfusion causes tissue hypoperfusion which increases the risk of multiple organ failure [4,5]. Cirrhotic patients are also at a high risk for development of other bleeding complications and are more susceptible to nosocomial infections [6,7]. This extreme complexity of critically-ill cirrhotic patients requires a specific medical approach that should be known by general intensivists since it has a negative impact on patient prognosis. This review will focus on the diagnostic approach and treatment strategies currently recommended in the critical care management of patients with cirrhosis. © 2012 European Association for the Study of the Liver. Source


Sola E.,University of Barcelona | Sola E.,Institute D Investigacions Biomediques August Pi I Sunyer Idibaps | Sola E.,CIBER ISCIII | Sola E.,Instituto Reina Sofia Of Investigacion Nefrologica Irsin | And 8 more authors.
Current Hepatitis Reports | Year: 2014

Cirrhosis is associated with high morbidity rates due to complications of portal hypertension. Ascites is the most frequent complication in patients with cirrhosis, and refractory ascites will develop in approximately 10 % of patients during follow-up. Currently, the first-line treatment for patients with refractory ascites is large-volume paracentesis with albumin supplementation. In more advanced stages of the disease, dilutional hyponatremia may develop as the result of nonosmotic hypersecretion of vasopressin. Although vaptans have shown promising results as a potential pharmacologic approach to treating hypervolemic hyponatremia, their results on long-term efficacy and safety in patients with cirrhosis are not conclusive. Moreover, because of concerns regarding side effects, the US Food and Drug Administration recently removed the indication of tolvaptan for use in patients with cirrhosis. Finally, in late stages of the disease, intense renal vasoconstriction occurs and leads to the development of hepatorenal syndrome. The treatment of choice for patients with hepatorenal syndrome is vasoconstrictor drugs followed by liver transplantation. © Springer Science+Business Media New York 2014. Source


Guevara M.,University of Barcelona | Guevara M.,Institute dInvestigacions Biomediques August Pi Sunyer IDIBAPS | Guevara M.,Research Center Biomedica En Red Of Enfermedades Hepaticas gestivas | Guevara M.,Instituto Reina Sofia Of Investigacion Nefrologica Irsin | And 25 more authors.
Journal of Hepatology | Year: 2012

Background & Aims: Treatment with albumin in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) prevents renal failure and improves survival. Whether albumin has similar beneficial effects in patients with infections other than SBP is unknown. Methods: One hundred and ten patients with cirrhosis hospitalized for infections other than SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kg bw at diagnosis and 1 g/kg bw at day 3) (albumin group; n = 56) or antibiotics alone (control group; n = 54). The primary end point was survival at 3 months. Secondary end points were effects on renal and circulatory function. Results: The renal function, as evaluated by differences in changes in serum creatinine and estimated glomerular filtration rate between the two groups, improved in patients treated with albumin. The circulatory function improved significantly in patients treated with albumin, but not in those from the control group. There was a trend for a lower frequency of type 1 hepatorenal syndrome in the albumin group compared to the control group (1 vs. 4 patients, respectively; p = n.s.). Probability of survival at 3 months was not significantly different among the two groups. However, when adjusted for factors with independent prognostic value, treatment with albumin was an independent predictive factor of survival. Conclusions: As compared with standard antibiotic therapy alone, treatment with albumin together with antibiotics has beneficial effects on the renal and circulatory function and shows a potential survival benefit. Further studies with large sample sizes should be performed to confirm these findings. © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Source


Nazar A.,University of Barcelona | Nazar A.,Institute dInvestigacions Biomediques August Pi Sunyer IDIBAPS | Nazar A.,Research Center Biomedica En Red Of Enfermedades Hepaticas gestivas | Nazar A.,Instituto Reina Sofia Of Investigacion Nefrologica Irsin | And 24 more authors.
Journal of Hepatology | Year: 2013

Background & Aims: The current study aimed at assessing the potential role of cardiac abnormalities in the pathogenesis of circulatory and renal dysfunction in cirrhosis. Methods: One hundred and fifty-two patients (34 without ascites, 95 with ascites without renal failure and 21 with hepatorenal syndrome) were evaluated using Doppler echocardiography. In 102 patients, diastolic function was assessed by measuring parameters related to ventricular filling velocity, mitral annulus velocity and left atrial dimensions. Cardiopulmonary pressures were also measured by cardiac catheterization in 54 patients. In 50 additional patients, left ventricular myocardial strain was performed to estimate myocardial contractility and systolic function. Results: Grade 1 and 2 diastolic dysfunction was present in 41% and 16% of the patients, respectively. There was no patient with severe grade 3 diastolic dysfunction. Grade 2 diastolic dysfunction was associated with higher cardiopulmonary pressures but values were within the normal limits in all cases. Diastolic dysfunction directly correlated with liver failure but not with the degree of impairment in circulatory and renal function. The proportion of patients without or with grade 1 or 2 diastolic dysfunction was similar in patients with compensated cirrhosis, with ascites without renal failure or with hepatorenal syndrome despite marked differences in the degree of circulatory dysfunction, as indicated by plasma renin activity and noradrenaline concentration. The heart rate and systolic function were normal in all cases. There were no differences between patients without ascites, with ascites without renal failure or with HRS, despite marked differences in the activity of the renin-angiotensin system and sympathetic nervous system. These features indicate an impaired response of cardiac chronotropic and inotropic function to changes in systemic hemodynamics. Conclusions: These data indicates that: (1) diastolic dysfunction is frequent in cirrhosis but in most cases it is of mild degree and does not increase the cardiopulmonary pressure to abnormal levels. This feature, which may be due to the central hypovolemia of cirrhosis, probably accounts for the lack of symptoms associated with this condition. (2) Diastolic dysfunction in cirrhosis is unrelated to circulatory dysfunction, ascites and HRS. (3) In cirrhosis, there is a lack of response of the left ventricular systolic and chronotropic function to peripheral arterial vasodilation and activation of the sympathetic nervous system and this feature is an important contributory factor to the progression of circulatory dysfunction and the pathogenesis of ascites and HRS. © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Source

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