Contributions to nephrology
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In critically ill patients, fluid balance management is an integral part of the process of care. In patients in shock or severe sepsis, aggressive initial fluid resuscitation has been shown to improve overall prognosis. ⋯ Randomized clinical trials are urgently required to assess the role of fluid overload in mortality and morbidity in this population. In the meantime, we should not only focus on acute fluid resuscitation but also on cumulative fluid balance as the amount and duration of fluid accumulation may influence outcomes.
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Endotoxin, which consists of lipopolysaccharide (LPS), is an outer membrane component of the Gram-negative bacterial cell wall. Endotoxin in the blood stream from an infectious focus or through translocation from the gut plays an important role in the pathogenesis of severe sepsis and septic shock. It binds to monocytes and macrophages, activating them to trigger the production of a variety of mediators. ⋯ In Japan, PMX has been clinically used since 1994under the national health insurance system. It is estimated that over 80,000 patients have received PMX treatment in Japan. Not only has PMX been clinically used safely in Japan, but also in other countries.
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Sepsis and septic shock are major causes of morbidity and mortality in the intensive care unit. Endotoxin produced by Gram-negative bacteria contributes to the pathogenesis of sepsis and septic shock. As an adsorbent, a polymyxin B convalently immobilized fiber (PMX) was developed. This review discusses, designing of the PMX, its application in clinical practice and the clinical outcomes.
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Acute kidney injury (AKI) is a common complication among critical illnesses. In severe cases, renal replacement therapy (RRT) is required. It has been reported that hospital mortality of the patients who require RRT is more than 60%. ⋯ RRT practice is not aligned with the best evidence and variations in practice may be responsible for significant morbidity. The BEST Kidney Study has generated several hypotheses related to RRT practice in the intensive care unit. Such hypotheses will need to be tested in future clinical trials and hopefully help reduce practice variations for patients with AKI requiring RRT.
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Sepsis involves a complex interaction between bacterial toxins and the host immune system. Endotoxin, a component of the outer membrane of Gram-negative bacteria, is involved in the pathogenesis of sepsis producing proinflammatory cytokines and activating the complement system, and is thus an ideal potential therapeutic target. Direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-F) has been shown to bind and neutralize endotoxin in both in vitro and in vivo studies. ⋯ In this study, PMX-F, when added to conventional therapy, significantly improved hemodynamics and organ dysfunction, and reduced 28-day mortality in this targeted population. There is clear biological rationale for endotoxin removal in the clinical management of severe sepsis and septic shock. The current literature seems to provide some support for this premise, and provides the basis for further rigorous study.