Influence of hyperthermic intraperitoneal chemotherapy on renal blood perfusion

Abstract

Purpose: Hyperthermic intraperitoneal chemotherapy (HIPEC) is accompanied with an increased risk of acute kidney injury (AKI). Whether AKI is induced by chemotoxicity or hyperthermia-related changes in renal perfusion remains controversial. The influence of HIPEC on renal perfusion has not been evaluated in patients yet.

Methods: Renal blood perfusion was assessed in ten patients treated with HIPEC by intraoperative renal Doppler pulse-wave ultrasound. Ultrasound (US) examinations were performed pre-, intra-, and postoperative with analyses of time-velocity curves. Patient demographics, surgical details, and data regarding renal function were recorded perioperatively. For evaluation of renal Doppler US to predict AKI, patients were divided in two groups with (AKI +) and without (AKI -) kidney injury.

Results: Throughout HIPEC perfusion, neither significant nor consistent changes in renal perfusion could be observed. Postoperative AKI occurred in 6 of 10 participating patients. Intraoperative renal resistive index (RRI) values > 0.8 were observed in one patient developing stage 3 AKI according KDIGO criteria. At 30 min in perfusion, RRI values were significantly higher in AKI + patients.

Conclusion: AKI is a common and frequent complication after HIPEC, but underlying pathophysiology remains elusive. High intraoperative RRI values may indicate an increased risk of postoperative AKI. Present data challenges the relevance of hyperthermia-derived hypothesis of renal hypoperfusion with prerenal injury during HIPEC. More attention should be drawn towards chemotoxic-induced hypothesis of HIPEC-induced AKI and caution applying regimens containing nephrotoxic agents in patients. Further confirmatory and complementary studies on renal perfusion as well as pharmacokinetic HIPEC studies are required.

Keywords: Acute kidney injury; Doppler ultrasound; HIPEC; Renal perfusion; Renal resistive index.

Fig. 1

Flow chart diagram of study cohort

Fig. 2

A Long axis view of Doppler renal ultrasound and B spectral wave form of interlobar artery. Pyramids/medulla (grey circles), segmental vessels (a), interlobar vessels (b) and arcuate vessels (c). Acceleration index (AI), peak systolic velocity (PSV), end-diastolic velocity (EDV), time-averaged maximum velocity (TAmax), and systolic acceleration time (SAT)

Fig. 3

A Intraoperative perfusate (circles) and body core (squares) temperatures, B pre-, intra- and postoperative mean arterial pressures, and C intraoperative heart rates during HIPEC. All patients (n = 10) displayed in black, AKI- patients (n = 4) in dark grey and AKI + patients (n = 6) in light grey. Error bars represent one standard deviation. *p < 0.05

Fig. 4

Pre-, intra- and postoperative renal Doppler time-velocity curve analyses. A Peak systolic velocity, B end-diastolic velocity, C resistive index, D systolic acceleration time, E acceleration index, and F time-averaged maximum velocity of n = 10 patients (each curve represents one individual)

Fig. 5

Intraoperative renal Doppler parameters during HIPEC in patients (n = 9) with (grey) and without (black) AKI. A Peak systolic velocity, B end-diastolic velocity, C resistive index, D systolic acceleration time, E acceleration index, and F time-averaged maximum velocity. Circles represent mean values and error bars represent one standard deviation. *p < 0.05