Blood purification
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The present review describes recent evidence on all aspects relating to acute kidney injury (AKI): epidemiology, definition, diagnosis, medical and extracorporeal therapy. AKI is often underrecognized, but its outcome still remains unfavorable. ⋯ Pharmacological therapy of AKI is still scarcely effective, but renal replacement therapy has progressed to a more accurate and safe treatment and new interesting high-level trials and observational studies have been performed and are reviewed and commented. In the near future, however, only increased awareness of AKI incidence and early treatment or prevention of kidney injury progression will hopefully improve outcome of critically ill patients with renal failure.
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The incidence of acute kidney injury (AKI) formerly referred to as acute renal failure (ARF) is increasing to epidemic proportions. Development of AKI portends excessive morbidity and mortality. AKI is associated with prolonged hospital stay, increased healthcare costs and high mortality especially in critically ill patients. ⋯ Delay in the diagnosis of AKI using conventional biomarkers like urine output and serum creatinine has been one of the important obstacles in applying effective early interventions. Several new biomarkers are being evaluated in a quest for early diagnosis of AKI, among which neutrophil gelatinase-associated lipocalin (NGAL) appears to be one of the most promising. This review summarizes the recent literature on these biomarkers.
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The pathogenesis of cardiac failure involves activation of the neurohumoral axis including stimulation of the sympathetic nervous system, the renin-angiotensin-aldosterone, and nonosmotic vasopressin systems. While these responses are critical in maintaining arterial pressure, they are associated with renal vasoconstriction, as well as sodium and water retention. In advanced circumstances, renal dysfunction and hyponatremia occur with cardiac failure. ⋯ One such agent, conivaptan, also is a V1 receptor antagonist which could theoretically benefit heart failure patients by decreasing cardiac afterload and remodeling. The effect of V2 receptor antagonists to correct hyponatremia in heart failure patients appears to be quite safe. However, to date no effect on mortality has been demonstrated.
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Despite advances in renal replacement therapy, the mortality of acute kidney injury (AKI) has remained high, especially when associated with distant organ dysfunction such as acute lung injury (ALI). Mortality rates for combined AKI/ALI reach 80% in critically ill patients. ⋯ New experimental data have emerged in recent years focusing on the interactive effects of kidney and lung dysfunction, and these studies have highlighted the pathophysiological importance of proinflammatory and proapoptotic pathways as well as the complex nature of interorgan crosstalk. This review will examine our current understanding of the deleterious kidney-lung crosstalk in the critically ill.
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Despite substantial advances in our understanding of the pathogenesis of sepsis, the mortality of patients with severe sepsis/septic shock is unacceptably high. The potential role of extracorporeal therapies in the adjunctive treatment of sepsis is highly controversial. ⋯ Conventional 'renal dose' continuous and discontinuous renal replacement technologies fail to achieve a biologically relevant reduction of target molecules. This may be accomplished by modified approaches, e.g. using high-dose protocols, high cut-off membranes, or (selective or unselective) adsorption techniques; however, their clinical value remains to be established by prospective studies using clinical end points.