Clinical Investigation

Kidney International (1985) 28, 206–211; doi:10.1038/ki.1985.142

Interrelationship between cardiac output and vascular resistance as determinants of effective arterial blood volume in cirrhotic patients

Michael D Shapiro1, Kathleen M Nicholls1, Bertron M Groves1, Rudiger Kluge1, Hsaio-Min Chung1, Daniel G Bichet1 and Robert W Schrier1

1Department of Medicine, University of Colorado Medical School, Denver, Colorado, USA

Correspondence: Dr R W Schrier, Department of Medicine, Division of Nephrology, C281, University of Colorado Medical School, 4200 E. 9th Avenue, Denver, Colorado 80262 USA.

Received 23 October 1984; Revised 30 January 1985.

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Abstract

Interrelationship between cardiac output and vascular resistance as determinants of effective arterial blood volume in cirrhotic patients. The effect of head-out water immersion (HWI) in decompensated cirrhotic patients to correct sodium and water excretion has been found to be incomplete and variable. The explanation may be that the efficacy of HWI in correcting a decreased effective arterial blood volume (EABV) in decompensated cirrhotic patients is limited by an accompanying decrease in systemic vascular resistance (SVR) and thus a relative increase in arterial vascular holding capacity. The present studies were undertaken to examine this possibility by maintaining SVR (dynes dot sec dot cm-5) nearly constant during HWI with an exogenous infusion of norepinephrine (HWI + NE). In six decompensated cirrhotic patients, neither HWI nor NE infusion alone significantly increased sodium excretion (UNaV, 13 vs. 19 and 13 microEq/min, respectively), but each maneuver increased the excretion of a 20 ml/kg water load (28 to 60 and 61%, respectively, both P < 0.05). The combination of HWI + NE, however, significantly increased UNaV to 70 microEq/min (P < 0.05) and percentage of water excretion to 95 (P < 0.001), values significantly greater than those achieved with either maneuver alone. These differences were not explained by any changes in inulin clearance. With HWI alone, cardiac index (CI) increased (4.2 to 5.3 liter/min/m2, P < 0.01), but SVR decreased (872 to 613 dynes dot sec dot cm-5, P < 0.001) and mean arterial pressure (MAP) remained constant (83 vs. 78 mm Hg). However, with HWI + NE, CI increased identically (4.2 to 5.3 liter/min/m2, P < 0.001), whereas SVR fell less (872 to 750 dynes dot sec dot cm-5, P < 0.05) and therefore MAP increased (83 to 98 mm Hg, P < 0.01). Thus, decompensated, hyponatremic cirrhotic patients with ascites demonstrate normal renal sodium and water excretion in response to increased central blood volume with concomitant maintenance of SVR. These results are supportive of a decrease in EABV mediating the sodium and water retention in decompensated cirrhotic patients.

Interrelation entre le débit cardiaque et les résistances vasculaires comme déterminants du volume sanguin artériel efficace chez des malades cirrhotiques. L'effet d'une immersion tête sortie (HWI) chez des malades cirrhotiques décompensés afin de corriger l'excrétion de sodium et d'eau a été trouvé incomplet et variable. L'explication pourrait être que l'efficacité d'HWI pour corriger une diminution du volume sanguin artériel efficace (EABV) chez des malades cirrhotiques décompensés est limitée par une baisse associée des résistances vasculaires systémiques (SVR) et donc une augmentation relative de la capacité de rétention vasculaire artérielle. Ces études ont été entreprises pour explorer cette possibilité en maintenant SVR (dynes dot sec dot cm-5) presque constant au cours d'HWI par une perfusion exogène de noradrenaline (HWI + NE). Chez six cirrhotiques décompensés, ni HWI ni une perfusion de NE seules n'ont significativement augmenté l'excrétion sodée (UNaV, 13 contre 19 et 13 microEq/min, respectivement) mais chaque manoeuvre a augmenté l'excrétion d'une charge hydrique de 20 ml/kg (de 28 à 60 et 61%, respectivement, chacune, P < 0,05). Cependant, l'association d'HWI + NE a accru significativement UNaV à 70 microEq/min (P < 0,05) et le percentage d'excrétion hydrique à 95 (P < 0,001), des valeurs significativement plus hautes que celles atteintes lors de chaque manoeuvre seule. Ces différences n'étaient pas expliquées par un changement de la clearance d l'inuline. Avec l'HWI seule, l'index cardiaque (CI) a augmenté (de 4,2 à 5,3 litre/min/m2, P < 0,01), mais SVR a diminué (de 872 à 613 dynes dot sec dot cm5, P < 0,001), et la pression artérielle moyenne (MAP) est restée constante (83 contre 78 mm Hg). Cependant, avec HWI + NE, CI a augmenté de façon identique (de 4,2 à 5,3 litre/min/m2, P < 0,001) tandis que SVR a moins baissé (de 872 à 750 dynes dot sec dot cm-5, P < 0,05) et MAP a donc augmenté (de 83 à 98 mm Hg, P < 0,01). Ainsi, des cirrhotiques décompensés, hyponatrémiques avec ascite démontrent une excrétion rénale de sodium et d'eau normale en réponse à une augmentation du volume sanguin central en maintenant en même temps SVR. Ces résultats sont en faveur d'une diminution d'EABV comme médiateur de la rétention hydro-sodée chez des cirrhotiques décompensés.

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