Contributions to nephrology
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Acute kidney injury (AKI) is a major medical problem in critical illness, and has a separate independent effect on the risk of death. Septic shock and cardiac surgery utilizing cardiopulmonary bypass are the two most common factors contributing to AKI. Clinical predictors and biochemical markers identified for the development of AKI can only explain a part of this individual risk. ⋯ However, to date our knowledge on the importance of such genetic polymorphisms in influencing the susceptibility to and severity of AKI remains limited. There is evidence that several genetic polymorphisms accounting for sepsis- or cardiopulmonary bypass-associated AKI involve genes which participate in the control of inflammatory or vasomotor processes. In this article, we will review current knowledge concerning the role of genetic polymorphism in the pathogenesis of sepsis- and cardiopulmonary bypass-associated AKI and discuss possible areas for future developments and research in this field.
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Current practices for renal replacement therapy (RRT) in ICU remain poorly defined. The observational DOse REsponse Multicentre International collaborative initiative (DO-RE-MI) survey addresses the issue of how the different modes of RRT are currently chosen and performed. The primary endpoint of DO-RE-MI will be the delivered dose versus in ICU, 28-day, and hospital mortality, and the secondary endpoint, the hemodynamic response to RRT. Here, we report the first preliminary descriptive analysis after 1-year recruitment. ⋯ Despite a large variability in the criteria of choice of RRT, CVVHDF remains the most used (49%). Clotting and clinical reasons were the most common causes for RRT downtime. In continuous RRT, a large variability in the delivered dose is observed in the majority of patients and often in the same patient from one day to another. Preliminary analysis suggests that in a large number of cases the delivered dose is far from the 'adequate' 35 ml/h/kg.
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From the recent past, hemofiltration, particularly high-volume hemofiltration, has rapidly evolved from a somewhat experimental treatment to a potentially effective 'adjunctive' therapy in severe septic shock and especially refractory or catecholamine-resistant hypodynamic septic shock. Nonetheless, this approach lacks prospective randomized studies (PRTs) evaluating the critical role of early hemofiltration in sepsis. An important milestone, which could be called the 'big bang' in terms of hemofiltration, was the publication of a PRT in patients with acute renal failure (ARF). ⋯ This could be called the big bang of hemofiltration as one could have never anticipated that an adequate dose of hemofiltration could markedly influence the survival rate of septic ARF patients in the ICU. Apart from the use of an early and adequate dose of Honoré/Joannes-Boyau/Gressens 372 hemofiltration in sepsis, a higher dose could also provide a better renal recovery rate and reduce the risk of associate chronic dialysis in these patients. Furthermore, this presentation will also review brand-new papers regarding the use of hemofiltration in systemic inflammatory response syndrome and out-of-hospital cardiac arrest.
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A change in serum creatinine is the standard metric used to define and monitor the progression of acute kidney injury (AKI). This marker is inadequate for a number of reasons including the fact that changes in serum creatinine are delayed in time after kidney injury and hence creatinine is not a good indicator to use in order to target therapy in a timely fashion. There is an urgent need for early biomarkers for the diagnosis of AKI. ⋯ In this article the status of 5 potential urinary biomarkers for AKI are discussed: kidney injury molecule-1, N-acetyl-Beta-D-glucosaminidase, neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18. Considerable progress has been made although much continues to be needed to validate these markers for routine clinical use. Armed with these new tools the future will look much brighter for the patient with AKI as it is likely that early diagnosis and better predictors of outcome will lead to new therapies which can be introduced earlier in the course of disease.
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Diuretics are a common intervention in critically ill patients with acute kidney injury (AKI). However, there is no information that describes the practice patterns of diuretic use by clinicians. ⋯ Diuretics are frequently used in AKI. Clinicians are most familiar with furosemide given intravenously and titrated to a physiologic endpoint of urine output. Most clinicians believe an RCT on diuretic use in AKI is justified and ethical. This survey confirms clinical agreement and a need for higher quality evidence on diuretic use in AKI.