MAP in HRS-AKI-1

Q: What is the Mean Arterial Pressure (MAP) goal in active treatment of Acute Kidney Injury (AKI) from hepatorenal syndrome? (select one)

A) > 65 mm Hg

B) > 70 mm Hg

C) > 80 mm Hg

Answer: C

Many of us may find such a high MAP goal unusual, but the concept behind goal MAP > 80 mm Hg (to be precise, 82 mmHg) is to minimize renal injury by keeping renal perfusion pressure high. All anti-hypertensives should be discontinued. An immediate goal is to raise MAP by 10 to 15 mmHg from the baseline. The preferred vasopressor is Norepinephrine, along with an infusion of albumin. Vasopressin infusion is also an appropriate choice.

To achieve this goal, other modalities, such as terlipressin, midodrine, and octreotide, should also be applied.

As a rule of thumb, 9 mmHg increase in MAP predicts 1 mg/dL decrease in serum creatinine. It is predicted that an increase in MAP of 9 to 13 mmHg is needed to achieve resolution in most patients with hepatorenal syndrome-acute kidney injury (HRS-AKI)/type 1 hepatorenal syndrome.

#hepatology

#nephrology

#hemodynamics

References:

1. Velez JC, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: a pooled analysis of clinical trials. Am J Kidney Dis 2011; 58:928.

2. Jung CY, Chang JW. Hepatorenal syndrome: Current concepts and future perspectives. Clin Mol Hepatol. 2023 Oct;29(4):891-908. doi: 10.3350/cmh.2023.0024. Epub 2023 Apr 13. PMID: 37050843; PMCID: PMC10577351.

3. Maiwall R, Rao Pasupuleti SS, Hidam AK, Kumar A, Tevethia HV, Vijayaraghavan R, Majumdar A, Prasher A, Thomas S, Mathur RP, Kumar G, Sarin SK. A randomised-controlled trial (TARGET-C) of high vs. low target mean arterial pressure in patients with cirrhosis and septic shock. J Hepatol. 2023 Aug;79(2):349-361. doi: 10.1016/j.jhep.2023.04.006. Epub 2023 Apr 23. PMID: 37088310.