Contributions to nephrology
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Severity scoring systems were first introduced to intensive care units (ICUs) in 1980. The basis for their development was the intention to provide information on the prognosis of patients, the efficacy of therapeutic interventions, stratification for clinical studies, workload and benchmarking of ICUs. Despite the appearance of several specialized scoring systems, the general mortality prediction systems such as APACHE, SAPS and MPM scores and their constantly improved successors have become the most popular and widely tested models. The newest development in this field is SAPS III which is the first 'global' model using a data set acquired from 307 ICUs from all over the world.
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Continuous hemodiafiltration (CHDF) using a polymethymethacrylate (PMMA) membrane hemofilter (PMMA-CHDF) can effectively and continuously remove various cytokines from the circulating blood. PMMA-CHDF can decrease the blood levels of various cytokines when the blood levels of cytokines are high prior to the initiation of CHDF. ⋯ PMMA-CHDF could improve blood pressure, the depressed monocytic HLA-DR expression, and recover the delayed neutrophil apoptosis in septic patients. Thus, cytokine removal with PMMA-CHDF would be effective for the treatment of severe sepsis and septic shock.
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A reliable biomarker as an indicator of the presence of severe sepsis is an unmet medical need. ⋯ Despite their shortcomings, a number of existing and candidate biomarker assays are available and can provide some useful information to the clinician caring for septic patients. The relative merits of endotoxin measurement, interleukin-6 levels and a variety of other sepsis markers are reviewed. Full implementation of these biomarkers may improve diagnostic accuracy over the standard clinical criteria for sepsis.
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Review
Serum free light chains in the diagnosis and monitoring of patients with plasma cell dyscrasias.
Serum free light chain assay is a recently available test for diagnosis and monitoring of patients with plasma cell dyscrasias. In particular, this test is especially useful in patients that were previously difficult to follow with traditional laboratory methods. ⋯ Potential uses include assessing progression of patients with monoclonal gammopathy of undetermined significance, smoldering multiple myeloma, solitary bone plasmacytoma and extramedullary plasmacytoma to multiple meyloma. Analytical considerations for the assay are also discussed.
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Since the early 1990s, experts in the field have thought that a reduction in cytokines in the blood compartment could, in theory, reduce mortality, but this is perhaps too naive as the pharmacodynamics and pharmacokinetics of cytokines throughout the body are not well known and are probably much more complicated than previously thought. This ha now led to three leading theories and concepts. Ronco and Bellomo conceived the peak concentration hypothesis in which clinicians concentrate their efforts to remove mediators and cytokines from the blood compartment at the proinflammatory phase of sepsis. ⋯ This has been demonstrated by several reports and is obviously extremely important. Perhaps this can explain why some very recent studies using high-permeability hemofiltration in sepsis have not been effective in improving hemodynamics and survival in septic acute animal models. In summary various brand new theories will be reviewed here in depth.