Contributions to nephrology
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The incidence of the multiple organ dysfunction syndrome (MODS) is rapidly increasing in intensive care units (ICU). It usually combines with sepsis and is the most frequent cause of death in the ICU patients. The nature of the ICU patients has changed in the last years. ⋯ In the light of these observations, a new thought arises: Can extracorporeal blood purification have a positive impact on different organ systems? A possible answer might come from the simple observation that all organs share one aspect in common: contact with blood. All extracorporeal therapies also have one aspect in common: treatment of blood. Based on these observations and knowledge of the molecular biology of sepsis, a "humoral" theory of MODS makes pathophysiological sense and its consequence triggers the need to consider extracorporeal therapies as multiple organ support therapies and not just as single organ support.
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Renal replacement therapy (RRT) is commonly and increasingly utilized in critically ill patients with severe acute kidney injury (AKI). The issue of when to start RRT in a critically ill patient with AKI has long troubled clinicians. ⋯ Several large randomized trials are planned or ongoing, and the results of these trials will greatly inform best clinical practice and will help reduce unnecessary variation in the practice of RRT prescription. For now, the decision on the appropriate time to start RRT is naturally complex, integrating numerous variables, and should largely be individualized.
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The goal of fluid therapy in critical care medicine is to restore hemodynamic stability and vital organ perfusion while avoiding interstitial edema. Acute kidney injury (AKI) is a common complication in critically ill patients. Decisions regarding fluid management in critically ill patients with AKI are difficult, as these patients often have accompanying oliguria as well as body fluid overload. ⋯ Balanced solutions may reduce the risk of hyperchloremic acidosis and kidney injury. In summary, volume management is an integral part of the care of critically ill patients with AKI. An optimal strategy might involve a timely period of guided fluid resuscitation with appropriate solutions, followed by an appropriate fluid balance.
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Pathophysiological mechanisms of cardiorenal syndromes (CRS) types 1-5 are still sparsely characterized. In an attempt to address this issue, a consensus conference on CRS was held in Venice, Italy, in November 2012 under the auspices of the Acute Dialysis Quality Initiative (ADQI). ⋯ Pre-conference we performed a systematic search and review of the available literature using a modified Delphi analysis. Hereby identified and in this review discussed questions were: (i) What are the predominant pathophysiologic mechanisms of CRS type 1 in acute decompensated heart failure? (ii) Could biomarker profiling identify pathomechanisms or hemodynamic phenotype of patients with CRS type 1? Could predictive biomarkers improve renal safety of therapy in CRS type 1? (iii) How do the timing, severity and duration relate to the mechanisms and outcomes of CRS type 1? In summary, after discussion and appraisal of the best available evidence, working group 1 makes consensus recommendations for future research on pathologic mechanisms of CRS type 1 and recommendations for clinical practice where treatment is in either proof or disproof of a mechanism.
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Stroke is a leading cause of mortality and morbidity worldwide. Traditional cardiovascular risk factors - hypertension, diabetes and dyslipidemia - are related to the incidence of stroke. Chronic kidney disease has also been recognized to be a major public health problem as a cardiovascular risk factor. ⋯ Chronic kidney disease may also be associated with an increase in nontraditional risk factors such as hyperhomocysteinemia, inflammation, asymmetric dimethylarginine, oxidative stress, and anemia, and thrombogenic factors such as left ventricular hypertrophy, endothelial dysfunction, and arterial stiffness. Herein, we review the results of meta-analyses of published cohort studies for a better understanding of the precise nature of the relationship between chronic kidney disease and stroke, important to both the clinical and public health fields. Further studies are warranted to determine whether interventions to prevent the progression of kidney impairment are effective at reducing the risk of stroke.