Contributions to nephrology
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Malnutrition is common in critically ill patients with acute renal failure. The aim of this review is to describe the basis for nutritional support during renal replacement therapy. ⋯ Early aggressive enteral, parenteral or combine nutritional support is required in critically ill patients on replacement therapy.
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The pathogenesis of acute kidney injury (AKI) is complex and varies to some extent based on the particular cause. Inflammation contributes to this pathophysiology in a variety of contexts. Inflammation can result in reduction in local blood flow to the outer medulla with adverse consequences on tubule function and viability. ⋯ In collaboration with Serhan et al. we recently reported that, in response to bilateral ischemia/reperfusion injury, mouse kidneys produce D series resolvins (RvDs) and PD1 [J Immunol 2006;177:5902-5911]. Administration of RvDs or PD1 to mice prior to, or subsequent to, ischemia resulted in a reduction in functional and morphological kidney injury. Understanding how these anti-inflammatory processes are regulated may provide insight into how we might intervene to facilitate and enhance them so that we might prevent or mitigate the devastating consequences of AKI.
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Over last half century, the concept of acute renal failure has evolved and with it our estimates of the incidence, prevalence and mortality. Indeed, until very recently no standard definition of acute renal failure was available, and this lack of a common language created confusion and made comparisons all but impossible. In response to the need for a common definition and classification of acute renal failure, the Acute Dialysis Quality Initiative group of experts developed and published a set of consensus criteria for defining and classifying acute renal failure. ⋯ Renal dysfunction was no longer only considered significant when it reached the stage of failure, but a spectrum from early risk to long-term failure was recognized and codified. Subsequent studies have validated these criteria in various populations and have shown that relatively mild dysfunction is associated with adverse outcomes. The term acute kidney injury has subsequently been proposed to distinguish this new concept from the older terminology of failure.
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Sepsis and multiple organ failure are common complications in intensive care unit (ICU) patients and are associated with considerable morbidity and mortality. ⋯ Although there is some evidence that mortality rates may have decreased in recent years, the incidence of sepsis is increasing so that overall deaths from this disease are increasing. Improved diagnostic techniques and classification may help target therapies more rapidly and more appropriately.
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Sepsis is one of the main causes of death in critically ill patients worldwide, and in many cases it is associated with renal and/or other organ failure. However, we do not have a unique efficient therapy to reduce this extremely high mortality rate. ⋯ Early experimental studies and the following clinical trials have demonstrated impressive results regarding hemodynamics and respiratory parameters, even in patients without concomitant acute renal injury, paralleled by a quick tapering of vasoactive drugs. Considering the still high morbidity and mortality rates in septic shock patients, this new blood purification technique seems to have benefits when applied early in the course of sepsis, also without renal indications, suggesting that it might be performed to prevent rather than to treat acute kidney injury.