Utilization of methylene blue in the setting of hypotension associated with concurrent renal and hepatic failure: A concise review

Abstract

Renal failure, hepatic failure, and hepatorenal syndrome can be associated with clinically significant hypotension, a clinical state often referred to as vasoplegia or vasoplegic syndrome (VS). Vasoplegia is thought to be related to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction due to direct and indirect effects of various inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, including sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery. Among mechanisms thought to be contributory to VS, the nitric oxide (NO)/cyclic guanosine monophosphate pathway appears to play a prominent role. Methylene blue (MB), an inhibitor of NO synthase and guanylate cyclase, has been found to improve the hypotension associated with various clinical states. Evidence also suggests that MB may be effective in improving systemic hemodynamics and vasoplegia associated with hepatic failure. We describe two cases of vasoplegia associated with concurrent hepatic and renal failure – both demonstrating a favorable hemodynamic response to MB without apparent side effects. A review of MB use in the setting of hepatic and renal failure then follows. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Bosoy D, Axelband J, Pursell RN, Lukaszczyk JJ, Stawicki SP. Utilization of methylene blue in the setting of hypotension associated with concurrent renal and hepatic failure: A concise review. OPUS 12 Scientist 2008;2(1):21-29.