The trigger matters - outcome of hepatorenal syndrome vs. specifically triggered acute kidney injury in cirrhotic patients with ascites.

BACKGROUND: Hepatorenal syndrome (HRS) represents a severe form of renal injury in cirrhotic patients with ascites in the absence of certain triggers. METHODS: Patients with cirrhosis and ascites were longitudinally screened for renal dysfunction. HRS was diagnosed by an increase in serum creatinine (SCr) by ≥100% to ≥1.5 mg/dl. If specific triggers (i.e. nephrotoxins, parenchymal kidney damage, hypovolaemia, infections) were found, these cases were defined as specifically triggered acute kidney injury (sAKI). RESULTS: Four hundred ninety-seven cirrhotic patients were screened for AKI and we identified 71 patients with HRS and 84 with sAKI. The most common triggers of sAKI were parenchymal damage in 33%, nephrotoxins in 30% and hypovolaemia in 29%. sAKI patients showed significantly more often complete remission than HRS patients (51% vs. 13%, P < 0.001), whereas persisting impairment of renal function was more common in HRS than in sAKI (56% vs. 37%, P = 0.006). Short-term (30 days) mortality was significantly higher in HRS than in sAKI (62% vs. 45%, P = 0.038). Remission rates and mortality varied between sAKI triggers. Transplant-free survival (TFS) was not significantly, but numerically lower in HRS than in sAKI [14 (IQR: 2-99) vs. 36 (IQR: 5-371) days; P = 0.102]. CONCLUSION: Patients with HRS show worse outcome and higher 30-day mortality than patients with severe triggered AKI. Different triggers of sAKI seem to influence prognosis. Prospective data are needed to implement effective screening and treatment algorithms for kidney injury in patients with cirrhosis and ascites.

Management of Acute Gastrointestinal Bleed.

Acute gastrointestinal bleeding is a common problem found in critically ill patients that can range from self-limited bleeding to a hemorrhaging emergency. Patients can quickly develop shock and altered mental status when they develop hemodynamic instability. Therefore, it is essential that the frontline critical care nurse develop self-efficacy for management of these disorders. This article overviews standards of practice for the management of upper and lower acute gastrointestinal bleeding. Common bleeding disorders are reviewed with expanded focus on peptic ulcer, acute variceal hemorrhage, colonic diverticular bleeding, and angiodysplasias, which are commonly found in the critical care setting.