Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · May 2008
Delivery of renal replacement therapy in acute kidney injury: what are the key issues?
The prescription and delivery of renal replacement therapy for acute kidney injury is subject to a wide variation and is conditioned by a multiplicity of factors. A variety of renal replacement therapy modalities are now available to treat acute kidney injury; however, there are no standards for the dosage, choice of modality, and intensity and duration of these therapies. Although several observational and interventional studies have addressed these topics, there are no consensus recommendations in this field. ⋯ This report summarizes the available evidence and elaborates on the key questions and the methods that should be used so that the goal of standardizing the care of patients with acute kidney injury and improving outcomes can be achieved.
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Clin J Am Soc Nephrol · Mar 2008
ReviewPotential interventions in sepsis-related acute kidney injury.
Sepsis is an important cause of morbidity and mortality. Acute kidney injury often complicates sepsis, leading to greater complexity, cost of care, and worsening prognosis. In recent years, a consensus definition of acute kidney injury has been developed, facilitating research into the pathophysiology and epidemiology of this disorder. ⋯ Existing and hybrid extracorporeal therapies are being investigated not only as means to replace lost kidney function but also to modulate the immune response to sepsis. For those who have more advanced forms of kidney injury, strategies to promote renal recovery are being sought to minimize the long-term consequences of impaired kidney function. This review provides an update on the current state of the science and a glimpse toward the future of intervention in sepsis-related acute kidney injury.
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Clin J Am Soc Nephrol · Mar 2008
Retrospective review of the frequency of ECG changes in hyperkalemia.
Experimentally elevated potassium causes a clear pattern of electrocardiographic changes, but, clinically, the reliability of this pattern is unclear. Case reports suggest patients with renal insufficiency may have no electrocardiographic changes despite markedly elevated serum potassium. In a prospective series, 46% of patients with hyperkalemia were noted to have electrocardiographic changes, but no clear criteria were presented. ⋯ Given the poor sensitivity and specificity of electrocardiogram changes, there is no support for their use in guiding treatment of stable patients. Without identifiable electrocardiographic markers of the risk for complications, management of hyperkalemia should be guided by the clinical scenario and serial potassium measurements.
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Clin J Am Soc Nephrol · Mar 2008
ReviewAdvances in critical care for the nephrologist: acute lung injury/ARDS.
Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are a major cause of acute respiratory failure in the critically ill patient. ALI and ARDS are characterized by the acute onset of severe hypoxemia and bilateral pulmonary infiltrates in the absence of clinical evidence for left atrial hypertension. These conditions are differentiated from one another by the ratio of the partial pressure of oxygen in the arterial blood to the inspired fraction of oxygen; ARDS requires a more severe oxygenation defect. ⋯ Of these, a low tidal volume, lung protective ventilation strategy is the only strategy that has been demonstrated in a large, multicenter randomized clinical trial to reduce mortality for patients with ALI/ARDS. Based on a recent randomized trial, a conservative fluid management strategy reduces the duration of mechanical ventilation without increasing the incidence of renal failure. Pharmacologic strategies and other ventilator management strategies have not been successful to date; however, several randomized, placebo controlled treatment trials are ongoing.
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Clin J Am Soc Nephrol · Mar 2008
ReviewAdvances in critical care for the nephrologist: hemodynamic monitoring and volume management.
The monitoring of physiologic variables is an integral part of the diagnosis and management of the critically ill patient. Restoration of tissue perfusion and oxygen delivery is the ultimate goal for any state of circulatory collapse. ⋯ This article reviews the physiologic parameters that best predict intravascular volume status and volume responsiveness. We examine the controversies surrounding the pulmonary arterial catheter and describe the less invasive methods of measuring cardiac performance.