Contributions to nephrology
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Review Comparative Study
Acute kidney injury, acute lung injury and septic shock: how does mortality compare?
Acute kidney injury (AKI), acute lung injury (ALI) and sepsis are all commonly encountered in critically ill patients. Although considered as separate conditions, largely for therapeutic purposes, a common inflammatory response is often implicated in their pathophysiologies and they are frequently present simultaneously. Mortality rates in critically ill patients suffering from renal failure, respiratory failure or severe sepsis are quite similar at about 40%, and all increase substantially when these conditions coexist. Most intensive care unit patients will die from multiple rather than individual organ failure, and further research is needed to evaluate the patterns of organ failure in surviving and nonsurviving critically ill patients, as well as the importance and mechanisms of organ-organ crosstalk in such patients.
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Fluid management in critically ill patients is a complex process as aggressive fluid resuscitation is commonly utilized for initial hemodynamic support and fluid administration often contributes to fluid retention, particularly when there is impaired kidney function. Recent evidence suggests that fluid accumulation is associated with adverse outcomes. It is unclear whether fluid retention is simply a marker of the severity of organ failure or a mediator of events. In this article we review the evidence and provide a framework for future studies to refine these concepts further.
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Acute kidney injury (AKI) remains a major clinical challenge, especially in combination with acute lung injury (ALI). Clinical as well as experimental studies have provided evidence for clinically relevant kidney-lung interactions, ultimately leading to a drastic reduction in survival. The crosstalk between AKI and ALI is a consequence of both direct loss of normal organ function and inflammatory dysregulation resulting from each organ failure. ⋯ Lung protective ventilation, including low tidal volume ventilation, is a cornerstone in the management of ALI. This approach has been shown to attenuate both the direct mechanical effects of ventilation and the inflammatory response arising from ALI and mechanical ventilation, ultimately reducing the incidence of extrapulmonary organ failure. The fact that multiorgan failure is not only the sum of organ functions lost, but also includes inflammatory dysregulation together with a lack of treatment options greatly emphasizes the need for future research in this area.
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Comparative Study Controlled Clinical Trial
Comparison of efficacy between continuous hemodiafiltration with a PMMA high-performance membrane dialyzer and a PAN membrane hemofilter in the treatment of septic shock patients with acute renal failure.
The aim of this study was to investigate whether continuous hemodiafiltration (CHDF) with a high-performance membrane dialyzer made of polymethylmethacrylate (PMMA-CHDF) in the treatment of septic shock patients with acute renal failure (ARF) is clinically relevant. 30 patients were treated with PMMA-CHDF. 13 patients treated with CHDF used a hemofilter made of polyacrylonitrile membrane (PAN-CHDF). Systolic blood pressure significantly increased in the PMMA-CHDF group following 24 h of treatment (p < 0.01), whereas it did not improve in the PAN-CHDF group. Urine volume significantly increased in the PMMA-CHDF group following 24 h of treatment which was more than in the PAN-CHDF group (p < 0.05). 28-day survival was 83.3% in the PMMA-CHDF group and 30.8% in the PAN-CHDF group, respectively (p < 0.01). We can assume that PMMA-CHDF in the treatment of septic shock patients with ARF is clinically relevant.
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Pediatric acute kidney injury (AKI) epidemiology has shifted from primary kidney disease to secondary to another organ system illness or its treatment with nephrotoxic medications. Similar to adult patients, critically ill children with AKI with multiorgan failure exhibit high mortality rates, yet conducting interventional trials to prevent, treat or mitigate the effects of AKI in children have been hampered by relatively low event rates and the reliance on serum creatinine as the biomarker of AKI. However, recent advancements in standardizing the AKI definition via the pediatric modified RIFLE criteria, multicenter collaboration via the Prospective Pediatric CRRT Registry Group and multiple validation studies of novel AKI biomarkers in children have provided the essential components to evaluate preventive and therapeutic strategies to attack pediatric AKI as a disease state. The scope of this article is to review the advancements in the study of pediatric AKI over the past decade and offer a compelling and bright view of what is on the horizon for the prevention, treatment and rehabilitation of AKI in kids.