Actas Urol Esp.

2013;37(5):273---279

Actas Urológicas Españolas

www.elsevier.es/actasuro

ORIGINAL ARTICLE

Renal consequences of intraabdominal hypertension in a porcine

model. Search for the choice indirect technique for
intraabdominal pressure measurement夽
L. Correa-Martín a,∗ , G. Castellanos b , M. García c , F.M. Sánchez-Margallo a

a
Unidad de Laparoscopia, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain
b
Servicio de Cirugía General, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
c
Unidad de Anestesiología, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain

Received 18 April 2012; accepted 30 June 2012

Available online 26 September 2013

KEYWORDS Abstract
Kidney; Objective: To study the effects on the renal system in a porcine model of intraabdominal
Intraabdominal hypertension, and to determine the indirect technique of choice for determination of the
hypertension; intraabdominal pressure.
Experimental Materials and methods: 30 pigs were used and divided into two groups according to increased
intraabdominal pressure values (20 mm Hg and 30 mm Hg). In both groups pressures were reg-
istered 8 times, summing up to 3 h, with a CO2 insufflator. Three different measures of the
intraabdominal pressure were taken: a direct transperitoneal measure, using a catheter of
Jackson-Pratt connected to a pressure transducer, and two indirect measures, a transvesical
by means of a Foley to manometer system, and a transgastric by introducing in the stomach
a catheter connected to a pressure monitor with electronic hardware. Mean arterial pressure
was calculated, along with the cardiac index, production of urine and serum creatinine.
Results: There was a greater correlation between the transvesical and the transperitoneal
intraabdominal pressures (R2 = 0.95). Average transgastric intraabdominal pressure was infe-
rior to the transperitoneal indicator in all taken measurements. The average arterial pressure
descended in both groups, with earlier significant differences observed at 30 mm Hg (p < 0.020).
Urine production was lower at 30 mm Hg compared with the 20 mm Hg group (9.63 ± 1.57 ml
versus 3.26 ± 1.73 ml). Serum creatinine increased in both groups being pathological at 30 mm
Hg after 1 h 20 min, with existing differences between early pressures (p < 0.027).
Conclusions: This study revealed marked renal affectation with higher severity at 30 mm Hg
pressures. The transvesical technique showed a greater correlation with the direct measure-
ment technique used, defining this as the method of choice for determination of intraabdominal
pressure.
© 2012 AEU. Published by Elsevier España, S.L. All rights reserved.

夽 Please cite this article as: Correa-Martín L, et al. Consecuencias renales de la hipertensión intraabdominal en modelo porcino. Búsqueda

de la técnica indirecta de elección de la medida de la presión intraabdominal. Actas Urol Esp. 2013;37:273---279.
∗ Corresponding author.

E-mail address: lcorreaccmijesususon@gmail.com (L. Correa-Martín).

2173-5786/$ – see front matter © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
274 L. Correa-Martín et al.

PALABRAS CLAVE Consecuencias renales de la hipertensión intraabdominal en modelo porcino.

Riñón; Búsqueda de la técnica indirecta de elección de la medida de la presión
Hipertensión intraabdominal
intraabdominal;
Experimental Resumen
Objetivo: Estudiar las consecuencias renales en un modelo porcino de hipertensión intraab-
dominal y determinar de la técnica indirecta de elección para la medida de la presión
intraabdominal.
Material y métodos: Se utilizaron 30 cerdos divididos en dos grupos, presión intraabdominal
incrementada en 20 mm Hg y en 30 mm Hg. En ambos, las presiones se registraron en 8 tiempos
hasta 3 horas con un insuflador de CO2 . Se realizaron tres medidas de la presión intraabdominal,
una directa trasperitoneal, empleando un catéter de Jackson-Prat conectado a un traductor de
presión, y dos indirectas, una transvesical mediante un sistema de la foley manometer y otra
transgástrica introduciendo en el estómago un catéter conectado a un monitor de presión con
hardware electrónico. Se calculó la presión arterial media, el gasto cardiaco, la producción de
orina y la creatinina sérica.
Resultados: Hubo una mayor correlación entre la presión intraabdominal transvesical y la
transperitoneal (R2 =0,95). La media de la presión intraabdominal transgástrica fue menor que
la trasperitoneal en todos los tiempos. La presión arterial media descendió en ambos grupos
observando diferencias significativas más precoces a 30 mm Hg (p<0,020). La producción de
orina fue menor a 30 mm Hg (9,63±1,57) vs (3,26ml±1,73). La creatinina aumentó en ambos
grupos siendo patológica a 30 mm Hg a partir de 1 h 20 min existiendo diferencias entre presiones
precoces (p<0,027).
Conclusiones: Hubo afectación renal más marcada a presiones de 30 mm Hg. La técnica trasvesi-
cal mostró una mayor correlación con la técnica directa empleada, por lo que consideramos
ésta como la de elección.
© 2012 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.

Introduction abdominal distension and the presence of increased IAP. It

Abdominal compartment syndrome (ACS) is a clinical entity
characterized by increased intra-abdominal pressure with
marked abdominal distension and with potential to cause,
if not diagnosed and corrected in time, multiple organ dys-
function syndrome (MODS), and death of the patient.1
The clinical manifestations of this syndrome involve
mainly the cardiovascular, pulmonary, renal, and gastroin-
testinal systems, although others such as the neurological
one and even the abdominal wall are also included. These
systems can be affected by either direct compression, as
in the case of pulmonary dysfunction, or by a decrease in
perfusion of the various organs.2
At kidney level, there is a significant clinical associa-
tion between IAH and renal impairment, renal failure being
one of the main manifestations of ACS.3 Thus, renal alter-
ation and failure are a common cause of admission in ICU,
observing that this function is the most sensitive to the
increase of the IAH.4,5 Since 1913, it has been known that
IAH causes a dysfunction in this system. However, it was not
until 1947 when Bradley and Bradley6 studied, for the first
time, the effects caused by increased IAP on renal function
in humans, demonstrating the decrease in the glomeru-
lar filtration rate and the renal plasma flow, decreased
urine output being one of the first clinical manifestations
of IAH.7
Currently, one of the biggest problems is to establish a
proper diagnosis to apply treatment as early as possible.
In relation to this, and as demonstrated by Sugrue et al.,8
clinical examination cannot accurately assess the IAP. Simi-
larly, Malbrain et al.9 observed a poor correlation between
is therefore essential to have a reliable measurement tech-
nique of the IAP and, this way, act at the right moment.
Consequently, the IAP measurement is essential to diagnose
the IAH and the consequent ACS, the choice of the tech-
nique used being critical for a proper diagnosis. This measure
should be performed routinely in patients with a high prob-
ability of an IAH, with a measurement frequency of 4 h, with
the patient in supine and at the end of expiration.10 That is
why our goal has focused on comparing 2 types of indirect
measures observing their correlation with transperitoneal
intra-abdominal pressure to determine which the technique
of choice in patients admitted with abdominal hypertension
is, and early identifying the renal alterations that occur with
increased IAP.
Materials and methods
We used 30 healthy sows, weighing 20---30 kg. The study was
approved by the ethics committee of animal experimen-
tation, fulfilling the European regulations on protection of
animals used for experimental and other scientific purposes.
After the adaptation and quarantine period, the study
began. All the animals received the same anesthetic proto-
col, administering intraoperative analgesia.
For lifting the IAP, we used a CO2 insufflator (SCB Ther-
moflator Karl Storz-Endoskope) using an inflow of 1---2 l/min
to reach the desired pressures in each of the groups, 20 or
30 mm Hg.
After reaching the desired pressure in each group, 3 types
of IAP measurements were conducted.
Renal consequences of intraabdominal hypertension in a porcine model 275

Transperitoneal intra-abdominal pressure 35.00

y= 0.93x + 1.05
It was calculated continuously and directly; to do so, a R2=0.95
Jackson-Prat catheter connected to a pressure transducer, 30.00
and this to a S/5TM General Electric Datex-Ohmeda compact

TV-IAP, mmHg
anesthesia monitor, was introduced laparoscopically into
the abdominal cavity over the right hypochondrium.
25.00

Transvesical intra-abdominal pressure

It was obtained intermittently and indirectly; to do so,
the animal placed in dorsal decubitus, a cystoscopy
assisted catheter was introduced, to which we connected
a Foley manometer system (Holtech Medical, Copenhagen,
Denmark® ) between the diuresis bag calibrated with marks
in mm Hg from 0 to 40 mm Hg. After placing the system,
20 ml of saline solution were introduced for system purg-
ing. The measurement was obtained by placing the zero of
the measurement system at the level of the pubic symphysis
of the hip with the rest of the system in 90◦ position rela-
tive to the horizontal one of the animal. After opening the
existing forceps below the antibacterial filter, one can see
it descend, at first, the physiological saline used for purg-
ing, and subsequently the urine contained in the system to
stabilize and provide measurement of the IAP.
Transgastric intra-abdominal pressure
First, the animal was placed in right lateral decubitus to
perform an upper digestive endoscopy to empty the stom-
ach and thus avoid possible interferences. Once empty, a
catheter was inserted in the stomach to determine the trans-
gastric intra-abdominal pressure (TG-IAP) continuously. Its
proximal end was connected to a pressure monitor with
electronic hardware (Spiegelberg CD Pharma) which, after
filling the air balloon with a total volume of 0.05---0.1 ml
and automatically adjusting the zero, measured in real-time
graphically recording the TG-IAP.
For determining the hemodynamic parameters, we used
the PICCO® system. Blood samples were removed for deter-
mination of serum creatinine, and the production of urine
was taken into account.
The means of the monitored variables during the anes-
thetic procedure were calculated at the following times:
T1 after obtaining the appropriate pressure for each group;
T2 after 20 min to obtain the proper pressure (stabilization
20.00
15.00
15.00 20.00 25.00 30.00 35.00
TP-IAP, mmHg
Figure 1 Degree of correlation and regression line between
the measures of the TV-IAP and TP-IAP shown throughout the
study time. Pearson correlation coefficient.
Pearson correlation coefficient between every 2 variables.
The significance level in all cases was p < 0.05. To carry out
the statistical analysis, we used the SPSS 17.0 for Windows;
SPP, Chicago, IL, USA.
Results
In all the groups we were able to obtain the desired pressure.
The statistical analysis showed statistically significant
differences between the transperitoneal intra-abdominal
pressure (TP-IAP) and the TG-IAP, in which lower values than
in the rest of the pressures were obtained. There were no
statistically significant differences between the 2 pressures
measured indirectly (Table 1).
Figs. 1 and 2 show that there was a high degree of positive
correlation between the 3 IAPs measured in the study, the
regression coefficient (R2 ) being higher between the TP-IAP
and the TV-IAP.
Table 2 shows the hemodynamic parameters measured in
the 2 groups; in it we can see a progressive decrease in the
35.00
y= 0.86x + 1.26
R2=0.89
30.00
TG-IAP, mmHg

period); T3 after 30 min of T2; T4 after 60 min of T2; T5 after

90 min of T2; T6 after 120 min of T2; T7 after 150 min of T2;
25.00
and T8 after 180 min of T2.

Statistical analysis 20.00

We obtained a descriptive statistics for each variable obtain-

ing the mean ± standard deviation. The comparison between
15.00
groups 2-2, at each of the times, was performed using 15.00 20.00 25.00 30.00 35.00
the Student’s t-test. The evolution of the parameters was TP-IAP, mmHg
analyzed using a multivariate analysis, repeated measures
ANOVA. In the case of the urine output, we took the Figure 2 Degree of correlation and regression line between
basal level as 0 and we observed its variation over time. the measures of the TG-IAP and TP-IAP shown throughout the
The degree of correlation of the variables determined the study time. Pearson correlation coefficient.
276 L. Correa-Martín et al.

Table 1 Measures of the IAP collected throughout the study in the IAP 20 and 30 mm Hg groups for 3 h.

Measures of the IAP Times TP-IAP (mm Hg) TV-IAP (mm Hg) TG-IAP (mm Hg) Sig
IAP group T1 20.83 ± 1.02a 20.40 ± 0.89ab 19.92 ± 0.87b 0.036
20 mm Hg/3 h T2 21.34 ± 1.28a 20.43 ± 0.90ab 19.91 ± 1.04b 0.003
T3 21.02 ± 1.29a 20.33 ± 0.89ab 19.85 ± 1.38b 0.037
T4 20.78 ± 1.09a 20.30 ± 1.04ab 19.48 ± 1.09b 0.007
T5 20.93 ± 1.33a 20.16 ± 0.79ab 19.64 ± 1.39b 0.019
T6 21.01 ± 1.44a 20.23 ± 0.82ab 19.55 ± 1.38b 0.010
T7 20.69 ± 1.29a 20.20 ± 0.88ab 19.40 ± 1.36b 0.017
T8 20.60 ± 1.12a 20.00 ± 1.00ab 19.36 ± 1.16b 0.014
IAP group T1 31.20 ± 1.54a 30.20 ± 1.09ab 29.72 ± 1.36b 0.011
30 mm Hg/3 h T2 31.33 ± 1.49a 30.36 ± 0.97ab 29.53 ± 1.06b 0.001
T3 31.66 ± 1.11a 30.905 ± 0.80ab 30.14 ± 0.71b 0.0001
T4 31.66 ± 1.11a 30.83 ± 0.87ab 30.02 ± 0.94b 0.0001
T5 31.46 ± 1.55a 30.43 ± 0.88ab 29.28 ± 1.43b 0.0001
T6 31.40 ± 1.63a 30.10 ± 0.96ab 29.18 ± 1.75b 0.001
T7 31.33 ± 1.44a 30.26 ± 0.84ab 29.41 ± 1.40b 0.001
T8 31.26 ± 1.79a 30.20 ± 0.79ab 29.00 ± 1.69b 0.001

Sig: significance level for the group.

Tukey test, a,b,c: different letters indicate statistically different means.

MAP in both study groups, being earlier under pressures of
30 mm Hg, there being differences between pressures after
50 min following the increase in the pressure. In the cardiac
output (CO), no significant changes were observed, we could
only observe in the T6 differences between pressures.
Table 3 reflects the values of serum creatinine through-
out the study. An increase thereof can be observed in both
study groups, there being significant differences between
pressures from the T3. In the group of 30 mm Hg, a patho-
logical increase in creatinine can be observed from the T4.
Fig. 3 represents the urine output of each group at each
time. The differences between pressures are present from
the start of the study, showing a lower urine output at
pressures of 30 mm Hg.
Discussion
In the last decade, thanks to the World Society of Abdominal
Compartment Syndrome, great progress has been made to
better understand both the etiology and pathophysiology of
the IAH and ACS.11,12 That is why, one of the biggest prob-
lems we face is determining the precise point at which to
act so that the patient does not develop a MODS. This may

Table 2 Hemodynamic measures collected throughout the study in the IAP 20 and 30 mm Hg roups for 3 h.

Hemodynamic measures Times IAP group IAP group

20 mm Hg/3 h 30 mm Hg/3 h
Mean blood pressure T1 60.26 ± 4.23 59.66 ± 1.38
(mm Hg) T2 57.40 ± 3.73 55.93 ± 1.38
T3 56.66 ± 7.43 51.53 ± 3.06*,**
T4 55.80 ± 8.54 48.66 ± 3.26*,**
T5 53.40 ± 9.37 47.33 ± 3.35*,**
T6 49.33 ± 8.78* 45.86 ± 4.85*,**
T7 46.53 ± 8.65* 44.20 ± 3.74*,**
T8 44.66 ± 7.52* 42.00 ± 4.45*,**
Cardiac output T1 1.75 ± 0.37 1.81 ± 0.38
(l/min/m2 ) T2 1.30 ± 0.23 1.21 ± 0.39
T3 1.34 ± 0.25 1.37 ± 0.29
T4 1.42 ± 0.45 1.51 ± 0.47
T5 1.50 ± 0.55 1.53 ± 0.54
T6 1.52 ± 0.57 1.76 ± 0.41**
T7 1.48 ± 0.53 1.83 ± 0.30
T8 1.47 ± 0.54 1.77 ± 0.52
* p < 0.05 vs. baseline.
** p < 0.05 vs. groups with IAP.
Renal consequences of intraabdominal hypertension in a porcine model
Table 3 Value of serum creatinine collected throughout the study in the IAP 20 and 30 mm Hg groups for 3 h.
Renal measures
Creatinine
* p < 0.05 vs. baseline.
** p < 0.05 vs. IAP groups.
be related to late diagnoses,9 poor prognoses, and infec-
tious complications. Therefore, the objectives of this work
have focused on early determining renal alterations occur-
ring in the face of increased IAP and determining an indirect
technique of choice able to reliably measure the existing
IAP in the patient to establish an early diagnosis and proper
treatment.
Clinically, renal involvement presents with a progres-
sive decrease in the diuresis as the pressure increases. This
oliguria does not respond to fluid therapy, diuretics, or
vasoactive drugs. In general, the changes in the IAP affect
the production of urine more than the MAP, thus, decreased
urine output being one of the first visible signs of IAH.7,13 This
is in agreement with our results, where we observe a more
marked decrease in the urine output in the 30 mm Hg group,
finding oliguria without actually occurring anuria at the set
times of the study. This may be because a longer study time
would be needed for anuria to occur, as demonstrated by
long-term studies in pigs from 24 h of study.14,15 This is con-
sistent with the pathological increase in creatinine to 30 mm
Hg that we observe in our results. Like us, Toens et al.15
12.00
10.00
Change in urine output (ml)
8.00
6.00
4.00
2.00
0.00
1 2 3 4 5 6
Times of study
Groups PIA
20 mm Hg
Figure 3 Changes in the urine output during all the study
times at the 2 pressures studied: 20 mm Hg (green) and 30 mm
Hg (blue). *p < 0.05 vs. baseline; † p < 0.05 vs. groups with IAP.
277
Times IAP group IAP group
20 mm Hg/3 h 30 mm Hg/3 h
T1 1.96 ± 0.57 2.34 ± 0.60
T2 2.05 ± 0.63 2.43 ± 0.62
T3 2.12 ± 0.59 2.62 ± 0.15**
T4 2.27 ± 0.50 2.81 ± 0.49**
T5 2.41 ± 0.53 2.88 ± 0.54**
T6 2.57 ± 0.56 3.10 ± 0.47*,**
T7 2.59 ± 0.58 3.17 ± 0.41*,**
T8 2.69 ± 0.54* 3.26 ± 0.44*,**
also observed an increase in serum creatinine from 6 h. This
circumstance is because they make the first measurement
from that time without being able to determine whether
that increase occurred before that time. Therefore, we con-
sider important to determine measurements over time of
this parameter, since it has been reported that the degree
to which serum creatinine changes with regard to a baseline
value can reflect changes in the GFG.16
A decrease in the CO has been described as the
main mechanism of renal function impairment17 due to
a decrease of renal perfusion and an increase of the
renin---angiotensin---aldosterone activity. However, both
the compression of the vein and the renal parenchyma have
also been involved as primary mediators of renal function.18
This is because as previous studies have shown,5,19,20 nor-
malization of the CO does not improve renal disorders
caused by increased IAP. Our results show no alteration
in the CO but a renal involvement possibly attributed to
the compression of the vessels themselves and the renal
parenchyma as a consequence of increased pressure. Thus,
we can say that there was renal involvement; however, we
consider necessary further studies that correlate the histo-
logical alterations, loss of functionality, and changes in the
renin---angiotensin---aldosterone system that occurs before
renal impairment.
It has been described that an isolated elevation of the IAP
should not be considered as a criterion for making decisions
for critical patients.8,9 Because there are several studies
that show that neither the IAH nor the ACS should be diag-
nosed by means of physical examination,8,9 several methods
have been used to determine the measure of the IAP, both
directly and indirectly.
In connection with the measurement systems that have
been used directly and invasively to measure the IAP, there
are different methods, such as intraperitoneal catheters
connected to a pressure transducer, or during laparoscopic
surgery using a Veress needle.7,9,21,22 However, these direct
methods are considered too invasive and, therefore, not
7 8 suitable for critical patients due to increased risk of infec-
tion that they might involve,23 currently being used to
validate indirect methods.24 In our study, we used a Jackson-
30 mm Hg Prat catheter connected to a pressure transducer as a
measure of the IAP directly and continuously. This way, the
pressure in the abdomen could be determined, at all times,
continuously showing a high correlation with the indirect
measured PIA methods.
278
In relation to the 2 indirect methods used in our study,
both have been validated by several authors.25---28 Although
the measure of the TG-IAP may have advantages over the
TV-IAP, being a continuous method, the same as Lee et al.29
and Malbrain et al.,26 our results show a high degree of
correlation between the two pressures, showing a higher
correlation between the measure of the IAP directly and the
TV-IAP in both study groups. This shows that both pressures
are closely related to each other, behaving similarly faced
with the increase of the pressure, so we can consider the TV-
IAP as the technique of choice in patients admitted to the
ICU. Thus, we agree with Malbrain et al.,26,30 and De Pot-
ter et al.,27 on considering that it is an accurate method for
estimating the IAP, besides being easy and safe to perform.
Before the results shown, we consider that with ele-
vated IAP continuously at pressures of 30 mm Hg, there
begins to be damage to the kidney, the first clinical man-
ifestation being decreased urine output. With regard to the
measurement methods, we consider, as the first option,
the manometry technique employed in this study because
of the advantages that it presents, such as being easy to per-
form, cost-effective, rapid, and requiring minimal handling.
Funding
This work was supported by the Fundación Mutua Madrileña.
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgement
To the Personnel of the Surgical Area of the Minimally Inva-
sive Surgery Center Jesus Usón.
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