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Evaluation of Renal Blood Flow Using Contrast Enhanced Ultrasound for Differential Diagnosis of Acute Kidney Injury in Cirrhotic Patients: A Pilot Study

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02147470
Recruitment Status : Unknown
Verified May 2014 by Kambiz Kalantarinia, University of Virginia.
Recruitment status was:  Recruiting
First Posted : May 26, 2014
Last Update Posted : May 26, 2014
Information provided by (Responsible Party):
Kambiz Kalantarinia, University of Virginia

Brief Summary:

Hepatorenal syndrome (HRS) is a common cause of acute kidney injury (AKI) in cirrhotic patients and has a one month survival rate of 50% and a 3 month survival rate of 20%. The leading theory behind HRS is selective vasoconstriction of renal vasculature in the setting of decreased systemic vascular resistance. Patients with liver cirrhosis suffer from a large degree of third spacing in the form of peripheral edema and ascites. In addition treatment with multiple drugs, including diuretics puts these patients at higher risks of prerenal AKI and ischemic acute tubular necrosis (ATN). AKI occurring due to HRS, prerenal AKI and ischemic or nephrotoxic ATN have different pathophysiologic mechanisms and are treated differently with significantly different outcomes. While renal perfusion is expected to be reduced in HRS and prerenal AKI, it is normal or increased in ATN. Prerenal AKI has the most favorable prognosis among these pathologies and treatment simply consists of volume expansion with blood, albumin, crystalloids or colloids. In clinical practice vasoactive agents such as midodrine and octreotide are used to increase the tone of splanchnic vessels and to improve renal perfusion. These interventions would not affect renal function in cases with ATN. Unfortunately, the diagnostic criteria proposed by the International Club for Ascites (ICA) for HRS are not specific and do not always exclude patients with other forms of acute kidney injury. Therefore, availability of a simple diagnostic tool for measurement of renal blood flow (RBF) at the bedside would be of great value in management of cases with cirrhosis of the liver presenting with acute reduction in kidney function. However, currently, there are no practical and simple tools available for this purpose.

Contrast enhanced ultrasonography (CEU) involves the intravenous injection of gas-filled microbubbles to enhance the ultrasound image of the organs and mainly to assess tissue vascularity and blood flow. We and others have used CEU to assess changes in RBF in response to physiologic stimuli and therapeutic interventions. Here we propose a prospective, pilot diagnostic study to validate the use of CEU, in assessing RBF in cirrhotic patients with AKI, and to assess the utility of CEU to differentiate between causes of AKI in cirrhotic patients.

Our hypothesis is that CEU will show arteriolar vasoconstriction and decreased blood flow in the renal cortex in patients with HRS which would not change in response to volume expansion. On the contrary, patients with prerenal AKI will have reduced RBF which will increase after volume expansion. Finally, those with ATN will not have a reduced RBF at baseline.

We plan to enroll 25 patients with liver cirrhosis and acute kidney injury who are admitted to the University of Virginia hospital into the study.

CEU will be performed on all subjects to measure baseline RBF. CEU will be repeated in all subjects within 24 hours after volume expansion with at least 1gm/kg of albumin (up to 100 gm/day) to assess a potential change. Hourly urine output and serum creatinine will be monitored for potential renal response to the volume expansion as part of clinical care. For the subgroup of subjects who receive treatment with combination therapy with albumin, midodrine, and octreotide (AMO) RBF assessment with CEU will be repeated after at least 48 hours of receiving this combination. Renal response will be assessed by monitoring urine output and serum creatinine monitored as part of clinical care. All subjects will have measurements of fractional excretion of sodium (FENa) and urea (FEUrea) and urine microscopy as a part of their routine clinical care (work up of AKI). The results of these tests and the response to volume expansion will be used to categorize subjects into three categories of AKI (HRS, prerenal AKI, ATN). Correlations between RBF and its changes between different therapeutic interventions and renal diagnosis will be tested in this study.

Condition or disease Intervention/treatment Phase
Liver Cirrhosis and Acute Kidney Injury Drug: Definity ultrasound contrast agent Not Applicable

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 25 participants
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Diagnostic
Official Title: Evaluation of Renal Blood Flow Using Contrast Enhanced Ultrasound for Differential Diagnosis of Acute Kidney Injury in Cirrhotic Patients: A Pilot Study
Study Start Date : February 2013
Estimated Primary Completion Date : December 2015

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Cirrhosis Ultrasound
Drug Information available for: Perflutren

Arm Intervention/treatment
prerenal AKi, acute tubular necrosis and hepatorenal syndrome
All subjects will undergo CEUS with the use of Definity to measure renal blood flow. At the same time clinical tools (urine output, response to volume expansion, urine sodium, urine output, fractional excretion of sodium and urea and urine microscopy) will be used to differentiate between prerenal AKI, ATN and HRS. the quantity and patterns of RBF measured by CEUS will be compared between these three groups.
Drug: Definity ultrasound contrast agent
All subjects will undergo CEUS of the kidney at baseline to measure renal blood flow. This procedure will be repeated after volume expansion and if indicated, once again after treatment with albumin, midodrine and octreotide.
Other Name: Contrast Enhanced Ultrasound using Definity

Primary Outcome Measures :
  1. To assess the utility of monitoring of RBF using CEU in management of AKI in patients with liver cirrhosis. [ Time Frame: 24 - 48 hours ]

Secondary Outcome Measures :
  1. Pattern of blood flow distribution in the kidney in different cases of AKI [ Time Frame: 0 - 48 hours ]

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Age >18 years
  • Cirrhosis of liver
  • Hospitalization at University of Virginia Medical Center
  • Diagnosis of acute kidney injury based on AKIN criteria

Exclusion Criteria:

  • Known history of a right to left intracardiac shunt
  • Known history of pulmonary hypertension, including portopulmonary hypertension
  • Pregnancy or lactation
  • History of allergies to Definity®
  • History of Liver or Kidney Transplant
  • Patient on hemodialysis

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02147470

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Contact: Kambiz Kalantari, MD, MS 434-924-5125

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United States, Virginia
University of Virginia Health System Recruiting
Charlottesville, Virginia, United States, 22908
Contact: Kambiz Kalantari, MD, MS    434-924-5125   
Contact: Zachary Henry, MD   
Principal Investigator: Kambiz Kalantari, MD, MS         
Sub-Investigator: Zachary Henry, MD         
Sponsors and Collaborators
University of Virginia
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Responsible Party: Kambiz Kalantarinia, Associate Professor of Medicine, University of Virginia Identifier: NCT02147470    
Other Study ID Numbers: 16603
First Posted: May 26, 2014    Key Record Dates
Last Update Posted: May 26, 2014
Last Verified: May 2014
Keywords provided by Kambiz Kalantarinia, University of Virginia:
cirrhosis of the liver
Acute kidney injury
Additional relevant MeSH terms:
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Liver Cirrhosis
Acute Kidney Injury
Wounds and Injuries
Pathologic Processes
Liver Diseases
Digestive System Diseases
Renal Insufficiency
Kidney Diseases
Urologic Diseases