Contributions to nephrology
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Fortunately with improvements in initial medical resuscitation, such as the avoidance of nephrotoxins, the incidence of acute kidney injury requiring renal support in patients with acute traumatic brain injury remains low. However the incidence of cerebral hemorrhage in patients on chronic dialysis programs appears to be increasing. By carefully adapting renal replacement to minimize cardiovascular instability and reduce the rate of change of serum osmolality, patient survival in this group of critically ill patients is increasing and starting to approach that of patients with traumatic brain injury without kidney injury.
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Acute kidney injury (AKI) is a major medical problem in critical illness, and has a separate independent effect on the risk of death. Septic shock and cardiac surgery utilizing cardiopulmonary bypass are the two most common factors contributing to AKI. Clinical predictors and biochemical markers identified for the development of AKI can only explain a part of this individual risk. ⋯ However, to date our knowledge on the importance of such genetic polymorphisms in influencing the susceptibility to and severity of AKI remains limited. There is evidence that several genetic polymorphisms accounting for sepsis- or cardiopulmonary bypass-associated AKI involve genes which participate in the control of inflammatory or vasomotor processes. In this article, we will review current knowledge concerning the role of genetic polymorphism in the pathogenesis of sepsis- and cardiopulmonary bypass-associated AKI and discuss possible areas for future developments and research in this field.
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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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The questions as to which treatment is the most effective for the replacement of renal function in critically ill patients with acute renal failure and the qualifications needed by nurses to manage the continuous renal replacement therapy (CRRT) device are part of an ongoing debate between nephrologists and intensivists, between nurses of the renal ward and the ICU. ⋯ Initiating and maintaining a CRRT program is a great challenge for the ICU nurse. The possible problems remain within the ICU staff's ability to solve if they follow an education program. If the workload for the nurses is well monitored, extra personnel can be avoided.