Contributions to nephrology
-
Review Case Reports
Diuretic therapy in fluid-overloaded and heart failure patients.
Diuretics are the most commonly used drugs to treat clinically diagnosed fluid overload in patients with heart failure. There is no conclusive evidence that they alter major outcomes such as survival to hospital discharge or time in hospital compared to other therapies. However, they demonstrably achieve fluid removal in the majority of patients, restore dry body weight, improve the breathlessness of pulmonary edema and are unlikely to be subjected to a large double-blind randomized controlled trial in this setting because of lack of equipoise. ⋯ Such therapy often requires more intensive monitoring than available in medical wards. If diuretic therapy fails to achieve its clinical goals, ultrafiltration by semipermeable membranes is reliably effective in achieving targeted fluid removal. The combination of diuretic therapy and/or ultrafiltration can achieve volume control in essentially all patients with heart failure.
-
Blood purification in critical care can perform 2 main functions: as an artificial support for failing organs (such as artificial kidney or liver support) and as a remover of causative humoral mediators of critical illness (such as severe sepsis and acute respiratory distress syndrome). As an artificial kidney, continuous blood purification (such as continuous hemofiltration and continuous hemodiafiltration, CHDF) is widely applied in intensive care units. The intensity of renal replacement therapy, however, has been reported to have no impact upon the efficacy of the blood purification in terms of clinical outcome. ⋯ However, our understanding of the pathophysiology of sepsis has changed since the concept of pattern recognition receptors and pathogen-associated molecular patterns was introduced. According to this, CHDF with a cytokine-adsorbing polymethylmethacrylate membrane hemofilter is preferable and more effective than direct hemoperfusion with an endotoxin-adsorbing polymyxin-B immobilized column in the treatment of sepsis and septic shock. Blood purification in critical care is gaining popularity, and is widely for both renal and non-renal indications.
-
Multicenter Study Clinical Trial
Plasma dia-filtration for severe sepsis.
The mortality rate in severe sepsis is 30-50%, and independent liver and renal dysfunction impacts significantly on hospital and intensive care mortality. If 4 or more organs fail, mortality is > 90%. Recently, we reported a novel plasmapheresis--plasma diafiltration (PDF)--the concept of which is plasma filtration with dialysis. ⋯ On average, 12.0 +/- 16.4 sessions (range 2-70) per patient were performed. The 28-day mortality rate was 36.4%, while the predicted death rate was 68.0 +/- 17.7%. These findings suggest that PDF is a simple modality and may become a useful strategy for treatment of patients with septic multiple organ failure.
-
The risk of developing acute kidney injury (AKI) is significantly increased in the elderly. It is the age-related renal and systemic changes as well as frequent comorbidities that render older individuals greatly susceptible to acute renal impairment. ⋯ Serum creatinine is most commonly used for diagnosis, despite it having several limitations, especially in the elderly. The mainstay of management is prevention of further deterioration, as the chances of renal recovery may be lower in older patients.
-
Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely to be associated with high circulating endotoxin. In June 2009, the EUPHAS study (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis) was published in JAMA. ⋯ The PaO(2)/FiO(2) ratio increased slightly (235 to 264; p = 0.049) in the polymyxin B group, but not in the conventional therapy group (217 to 228; p = 0.79). SOFA scores improved in the polymyxin B group, but not in the conventional therapy group (change in SOFA: -3.4 vs. -0.1; p = 0.001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted HR: 0.43, 95% CI: 0.20-0.94; adjusted HR: 0.36, 95% CI:0.16-0.80). The study demonstrated how polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal Gram-negative infections.