Advances in chronic kidney disease
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Adv Chronic Kidney Dis · Jan 2009
ReviewImaging in diagnosis, treatment, and follow-up of stone patients.
Imaging has an essential role in the diagnosis, management, and follow-up of patients with stone disease. A variety of imaging modalities are available to the practicing urologist, including conventional radiography (KUB), intravenous urography (IVU), ultrasound (US), magnetic resonance urography, and computed tomography (CT) scans, each with its advantages and limitations. Traditionally, IVU was considered the gold standard for diagnosing renal calculi, but this modality has largely been replaced by unenhanced spiral CT scans at most centers. ⋯ Patients with asymptomatic calyceal stones who prefer an observational approach should have a yearly KUB to monitor progression of stone burden. Current research has been aimed toward the development of a micro-CT scan and coherent-scatter analysis to determine stone composition in vivo. This may have a significant impact on the future clinical management of renal calculi by facilitating selection of the most appropriate surgical intervention based on stone composition at the time of presentation.
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Adv Chronic Kidney Dis · Oct 2008
ReviewInterventional management of critical limb ischemia in renal patients.
Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease (PAD), defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The occurrence of CLI in patients with kidney insufficiency portends a strikingly high rate of subsequent morbidity and mortality. Generally, the primary therapy for CLI is revascularization of the affected limb. ⋯ In contemporary practice, endovascular techniques are fast replacing surgical bypass as the first-line revascularization strategy for CLI, based on high technical success rates and low rates of procedure-related morbidity and mortality. However, a large series on endovascular outcomes for the treatment of CLI in patients with kidney insufficiency is lacking. Based on the severely reduced long-term survival rates of patients with CLI and kidney insufficiency, future efforts should focus on early detection of PAD in patients with kidney insufficiency and institution of aggressive medical therapy to prevent progression in the global burden of atherosclerosis in this patient population.
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Acute kidney injury (AKI) is common in the intensive care unit and is associated with significant morbidity and mortality. Based on the RIFLE criteria, AKI occurs in up to 67% of patients in the intensive care unit (ICU), with approximately 4% of critically ill patients requiring renal replacement therapy (RRT). It is well known that this subset of AKI patients who require RRT have an in-hospital mortality rate exceeding 50%. ⋯ According to the United States Renal Data System, "acute tubular necrosis without recovery" as a cause of end-stage kidney disease increased from 1.2% in 1994 to 1998 to 1.7% in 1999 to 2003. The incidence will likely continue to rise with the aging population, increase in comorbidities, and expansion of intensive care unit capabilities. AKI is an underrecognized cause of chronic kidney disease (CKD) and patients who survive should be followed closely for new CKD and/or progression of underlying CKD.
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Adv Chronic Kidney Dis · Jul 2008
ReviewRenal replacement therapy in acute kidney injury: intermittent versus continuous? How much is enough?
Approximately 4% of all critically ill patients will require renal replacement therapy (RRT). Despite its potential reversibility, acute kidney injury has a significant impact on morbidity and mortality. Numerous studies have addressed the questions of modality choice and dose of RRT in the intensive care unit setting. ⋯ Another key aspect in the treatment of acute kidney injury is the consequence of RRT on long-term renal function. Although cohort studies have shown that continuous RRT shortens dialysis-dependence compared with intermittent hemodialysis, randomized trials and meta-analyses do not support these findings. Several unanswered questions, such as the timing of initiation and cessation of RRT, the modification of dialysis parameters over the course of acute kidney injury and the influence of fluid status need to be addressed in future trials in order to improve outcomes related to this condition.
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Adv Chronic Kidney Dis · Jul 2008
ReviewAcute kidney injury and chronic kidney disease after cardiac surgery.
Kidney dysfunction is common after cardiac surgery and predicts mortality risk and poorer long-term outcome, particularly when acute injury superimposes upon chronic kidney disease. Numerous insults contribute to perioperative renal impairment including major surgical trespass, procedure-specific interventions (eg, deep hypothermic circulatory arrest), and postoperative complications. Regardless of cause, evidence supports a role for renal impairment and accumulation of "uremic toxins" as direct contributors to adverse outcome. ⋯ Despite considerable research focus, progress in development of interventions aimed at perioperative renoprotection has been disappointing. However, practice modifications can influence the likelihood of acute kidney injury, and several recent advances provide hope for the future. We review pathophysiologic understanding of this disorder; evaluate the confusing relationship (causal v epiphenomena) among acute kidney injury, chronic kidney disease, and adverse outcome after cardiac surgery; and provide an evidence-based assessment of the conduct of cardiac surgery and renoprotection strategies.