Contributions to nephrology
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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.
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Tumor lysis syndrome (TLS) is a constellation of metabolic disturbances that may be observed in patients with malignancies. Clinically significant TLS can occur spontaneously, but most often is seen 48-72 h after initiation of cancer treatment. The metabolic abnormalities observed in patients with TLS include hyperkalemia, hyperuricemia, and hyperphosphatemia, which leads to secondary hypocalcemia. ⋯ Hemodynamic changes reducing glomerular flow due to still undefined mediators are also involved in TLS pathophysiology. Pre-existing volume depletion or renal dysfunction may worsen metabolic derangements and ARF. A good comprehension of TLS pathophysiology has provided the basis for an effective and rational treatment of this complication, adversely affecting the outcome of cancer patients.
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Uric acid nephropathy is a potentially reversible cause of acute renal failure resulting from diffuse urate crystal depositions in the tubules in the setting of excessive uricosuria. Hyperuricemia is frequently encountered in ICU patients with acute renal failure of any etiology, but it is rarely a prominent feature or a major pathophysiological element in the renal failures of nonhematology/ oncology patients. ⋯ The most frequent clinical context is, nevertheless, hematological, when patients with large tumor burden and rapid cell turnover develop acute tumor lysis syndrome (ATLS). The purpose of this chapter is to review the pharmacological tools currently available and their optimal use in the treatment of patients admitted in intensive care unit with hyperuricemia and severe acute renal failure.