Critical care : the official journal of the Critical Care Forum
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Review Comparative Study
Pro/con debate: continuous versus intermittent dialysis for acute kidney injury: a never-ending story yet approaching the finish?
The question of whether renal replacement therapy should be applied in an intermittent or continuous mode to the patient with acute kidney injury has been the topic of several controlled studies and meta-analyses. Although continuous renal replacement therapy (CRRT) has a theoretical advantage due to offering the opportunity to remove excess fluid more gradually, none of the several outcome studies that have been undertaken in the meanwhile was able to demonstrate its superiority over intermittent renal replacement therapy (IRRT). In the present article, therefore, questions are raised regarding which are the specific advantages of each strategy, and which are the specific populations that might benefit from their application. ⋯ CRRT is claimed to be better tolerated in combined acute liver and kidney failure and in acute brain injury. IRRT is more practical, flexible and cost-effective, allows the clinician to discontinue or to minimize anticoagulation with bleeding risks, and removes small solutes such as potassium more efficiently in acute life-threatening conditions. Sustained low-efficiency daily dialysis is a hybrid therapy combining most of the advantages of both options.
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Review
Bench-to-bedside review: the role of C1-esterase inhibitor in sepsis and other critical illnesses.
The purpose of this bench-to-bedside review is to summarize the literature relating to complement activation in sepsis and other critical illnesses and the role of C1-esterase inhibitor (C1 INH) as a potential therapy.
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Organ donation offers opportunities for people in critical care units to help save the lives of other patients. It is not always easy, however, to handle the transition from treating a patient to preserving a potential donor, and organ donation consistently provokes ethical questions in critical care units. What do we expect ethics to deliver? In light of a recent ethics conference in Denmark, we suggest that by acknowledging that decisions made in the clinic rarely abide to rational decision trees with clear ethical priorities, we can better learn from each other's experiences. We suggest embracing an 'ethics of muddling through' to enhance relevant reflections and stimulate a productive dialogue among health professionals.
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Community-acquired pneumonia is a common disease. Abnormalities in the first step of host defense may severely compromise subsequent steps of successfully combating infections. In the previous issue of Critical Care, García-Laorden and colleagues reported genetic associations between single-nucleotide polymorphisms and haplotypes of the surfactant proteins with susceptibility, severity, and outcome of community-acquired pneumonia. ⋯ The lung is continually exposed to a host of irritants yet maintains health. It is plausible that, under physiologic conditions, surfactant protein A, in addition to having a dominant effect on anti-inflammatory processes, mediates a low level of proinflammatory processes that are essential for the health of the lung. Understanding the maintenance of the balance of the inflammatory state may be one of the keys to understanding pulmonary disease progression.
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Editorial Comment
Urine sTREM-1 assessment in diagnosing sepsis and sepsis-related acute kidney injury.
The triggering receptor expressed on myeloid cells-1 (TREM-1) is an immunoreceptor whose role is to amplify the inflammatory response mediated by the engagement of Toll-like and NOD-like receptors. As the expression of TREM-1 is believed to be upregulated during infection, this protein has been studied as a sepsis biomarker. ⋯ Importantly, the authors describe, for the first time, that urinary soluble TREM-1 measurement is able to predict the development of sepsis-associated acute kidney injury (AKI). If these results were to be confirmed by larger studies, urinary soluble TREM-1 would possibly become a new biomarker for sepsis-associated AKI.