Contributions to nephrology
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Review Case Reports
Diuretic therapy in fluid-overloaded and heart failure patients.
Diuretics are the most commonly used drugs to treat clinically diagnosed fluid overload in patients with heart failure. There is no conclusive evidence that they alter major outcomes such as survival to hospital discharge or time in hospital compared to other therapies. However, they demonstrably achieve fluid removal in the majority of patients, restore dry body weight, improve the breathlessness of pulmonary edema and are unlikely to be subjected to a large double-blind randomized controlled trial in this setting because of lack of equipoise. ⋯ Such therapy often requires more intensive monitoring than available in medical wards. If diuretic therapy fails to achieve its clinical goals, ultrafiltration by semipermeable membranes is reliably effective in achieving targeted fluid removal. The combination of diuretic therapy and/or ultrafiltration can achieve volume control in essentially all patients with heart failure.
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Blood purification in critical care can perform 2 main functions: as an artificial support for failing organs (such as artificial kidney or liver support) and as a remover of causative humoral mediators of critical illness (such as severe sepsis and acute respiratory distress syndrome). As an artificial kidney, continuous blood purification (such as continuous hemofiltration and continuous hemodiafiltration, CHDF) is widely applied in intensive care units. The intensity of renal replacement therapy, however, has been reported to have no impact upon the efficacy of the blood purification in terms of clinical outcome. ⋯ However, our understanding of the pathophysiology of sepsis has changed since the concept of pattern recognition receptors and pathogen-associated molecular patterns was introduced. According to this, CHDF with a cytokine-adsorbing polymethylmethacrylate membrane hemofilter is preferable and more effective than direct hemoperfusion with an endotoxin-adsorbing polymyxin-B immobilized column in the treatment of sepsis and septic shock. Blood purification in critical care is gaining popularity, and is widely for both renal and non-renal indications.
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It has been reported that various types of blood purification intended for the removal of humoral mediators, such as cytokines, were performed in patients with severe sepsis/septic shock. While high-volume hemofiltration, hemofiltration using high cut-off membrane filters, and direct hemoperfusion with a polymyxin-B immobilized column are widely used in the treatment of severe sepsis/septic shock, we perform continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA-CHDF), which shows an excellent cytokine-adsorbing capacity, for the treatment of severe sepsis/septic shock. ⋯ Furthermore, PMMA-CHDF could remove anti-inflammatory cytokines such as IL-10 from bloodstream, suggesting that it might improve immunoparalysis as well. These findings suggest that PMMA-CHDF is useful for the treatment of patients with severe sepsis/septic shock as a cytokine modulator.
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Diuretics are commonly used in the intensive care unit, especially for patients with oliguric acute kidney injury. This practice is controversial since there is a lack of evidence regarding any beneficial effects of diuretics either on prevention or treatment of acute kidney injury. ⋯ However, diuretics can minimize fluid overload, making patient management easier and potentially avoiding many cardiopulmonary and non-cardiopulmonary complications. We will briefly review the available evidence for and against the use of diuretics in the critically ill, including cardiorenal syndromes.
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Endotoxin, which consists of lipopolysaccharide (LPS), is an outer membrane component of the Gram-negative bacterial cell wall. Endotoxin in the blood stream from an infectious focus or through translocation from the gut plays an important role in the pathogenesis of severe sepsis and septic shock. It binds to monocytes and macrophages, activating them to trigger the production of a variety of mediators. ⋯ In Japan, PMX has been clinically used since 1994under the national health insurance system. It is estimated that over 80,000 patients have received PMX treatment in Japan. Not only has PMX been clinically used safely in Japan, but also in other countries.