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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The extracorporeal carbon dioxide removal (ECCO(2)R) concept, used as an integrated tool with conventional ventilation, plays a role in adjusting respiratory acidosis consequent to tidal volume (Vt) reduction in a protective ventilation setting. This concept arises from the extracorporeal membrane oxygenation (ECMO) experience. Kolobow and Gattinoni were the first to introduce extracorporeal support, with the intent to separate carbon dioxide removal from oxygen uptake; they hypothesized that to allow the lung to 'rest' oxygenation via mechanical ventilation could be dissociated from decarboxylation via extracorporeal carbon dioxide removal. ⋯ The future development of more and more efficient devices capable of removing a substantial amount of carbon dioxide production (30-100%) with blood flows of 250-500 ml/min is foreseeable. Moreover, in the future ARDS management should include a minimally invasive ECCO(2)R circuit associated with noninvasive ventilation. This would embody the modern mechanical ventilation philosophy: avoid tracheal tubes; minimize sedation, and prevent ventilator-induced acute lung injury and nosocomial infections.