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Preventing kidney injury by avoiding fluid overload in patients with sepsis.
Dodd, RL, Archambault, ME
JAAPA : official journal of the American Academy of Physician Assistants. 2019;(12):40-45
Abstract
The global epidemiologic burden of sepsis is difficult to ascertain. Sepsis affects more than 31.5 million people worldwide every year, potentially resulting in 5 million deaths. Up to one-third of patients with sepsis also develop sepsis-associated acute kidney injury. This article describes the need for restraint in fluid resuscitation in patients with sepsis, in order to mitigate end-organ damage and ultimately to save lives.
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2.
Continuous Renal Replacement Therapy: Who, When, Why, and How.
Tandukar, S, Palevsky, PM
Chest. 2019;(3):626-638
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Abstract
Continuous renal replacement therapy (CRRT) is commonly used to provide renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. A variety of techniques that differ in their mode of solute clearance may be used, including continuous venovenous hemofiltration with predominantly convective solute clearance, continuous venovenous hemodialysis with predominantly diffusive solute clearance, and continuous venovenous hemodiafiltration, which combines both dialysis and hemofiltration. The present article compares CRRT with other modalities of renal support and reviews indications for initiation of renal replacement therapy, as well as dosing and technical aspects in the management of CRRT.
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Interventions for improving outcomes in acute kidney injury.
Sarnowski, A, Doyle, JF, Forni, LG
Current opinion in nephrology and hypertension. 2019;(6):567-572
Abstract
PURPOSE OF REVIEW Since the adoption of the classification of acute kidney injury (AKI) through changes in serum creatinine and/or urine output, much data have accumulated as to the associated risks in terms of morbidity and mortality after the development of AKI. However, until recently, a nihilistic approach persisted which implied that little could be done to alter the clinical course of a patient with AKI even where early identification was achieved. This view is reinforced by the opinion that given the broad cause underlying the syndrome of AKI, a 'one size fits all' approach is unlikely to be successful. RECENT FINDINGS Recent evidence suggests that the management of AKI may be improved somewhat by simple measures, such as the use of care bundles particularly in the intensive care setting. Moreover, there are other interventions using common treatments, which may prove to be of benefit as well as some early evidence that specific therapeutics may be on the horizon. SUMMARY Although a syndrome of significantly differing causes, the application of standardized care bundles appears promising and this approach may be improved by the use of specific therapies, including recombinant alkaline phosphatase, the use of intravenous bicarbonate and remote ischaemic preconditioning may also ameliorate the effects of AKI.
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Acute Renal Failure of Nosocomial Origin.
Alscher, MD, Erley, C, Kuhlmann, MK
Deutsches Arzteblatt international. 2019;(9):149-158
Abstract
BACKGROUND 10-20% of hospitalized patients develop acute kidney injury (AKI)/acute renal failure during their hospital stay. The mortality of nosocomial AKI is approximately 30%. METHODS This review is based on relevant publications retrieved by a search in multiple databases (PubMed and Uptodate), archives, and pertinent medical journals. RESULTS The most common causes of nosocomial AKI are volume depletion, sepsis, heart diseases, polytrauma, liver diseases, and drug toxicity. AKI can also be of postrenal (obstructive) origin, or a result of renal diseases including glomeruloneph- ritis, vasculitis, tubulointerstitial nephritis, and cholesterol embolism. In about 13% of cases, nosocomial AKI develops on the basis of pre-existing chronic renal disease. Patients with AKI are at elevated risk of developing chronic renal disease and must be followed up appropriately after they are discharged from the hospital. Indispens- able elements of the evaluation of nosocomial AKI include renal ultrasonography, the exclusion of postrenal obstruction, urine chemistry, and microbiological urinaly- sis. Potentially nephrotoxic drugs and those that impair renal hemodynamics must be avoided to the greatest possible extent in patients with acute renal damage. Hypotension must be avoided as well. CONCLUSION Early, specific nephrological diagnosis and treatment are important components of the management of nosocomial AKI, particularly because causally directed treatment is available for some of the conditions that underlie it.
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Prevention of rhabdomyolysis-induced acute kidney injury - A DASAIM/DSIT clinical practice guideline.
Michelsen, J, Cordtz, J, Liboriussen, L, Behzadi, MT, Ibsen, M, Damholt, MB, Møller, MH, Wiis, J
Acta anaesthesiologica Scandinavica. 2019;(5):576-586
Abstract
BACKGROUND Rhabdomyolysis-induced acute kidney injury (AKI) is a common and serious condition. We aimed to summarise the available evidence on this topic and provide recommendations according to current standards for trustworthy guidelines. METHODS This guideline was developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The following preventive interventions were assessed: (a) fluids, (b) diuretics, (c) alkalinisation, (d) antioxidants, and (e) renal replacement therapy. Exclusively patient-important outcomes were assessed. RESULTS We suggest using early rather than late fluid resuscitation (weak recommendation, very low quality of evidence). We suggest using crystalloids rather than colloids (weak recommendation, low quality of evidence). We suggest against routine use of loop diuretics as compared to none (weak recommendation, very low quality of evidence). We suggest against use of mannitol as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of any diuretic as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of alkalinisation with sodium bicarbonate as compared to none (weak recommendation, low quality of evidence). We suggest against the routine use of any alkalinisation as compared to none (weak recommendation, low quality of evidence). We suggest against routine use of renal replacement therapy as compared to none (weak recommendation, low quality of evidence). For the remaining PICO questions, no recommendations were issued. CONCLUSION The quantity and quality of evidence supporting preventive interventions for rhabdomyolysis-induced AKI is low/very low. We were able to issue eight weak recommendations and no strong recommendations.
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Cardiorenal Syndrome in Acute Kidney Injury.
Di Lullo, L, Reeves, PB, Bellasi, A, Ronco, C
Seminars in nephrology. 2019;(1):31-40
Abstract
Varying degrees of cardiac and kidney dysfunction commonly are observed in hospitalized patients. As a demonstration of the significant interplay between the heart and kidneys, dysfunction or injury of one organ often contributes to dysfunction or injury of the other. The term cardiorenal syndrome (CRS) was proposed to describe this complex organ cross-talk. Type 3 CRS, also known as acute renocardiac syndrome, is a subtype of CRS that occurs when acute kidney injury contributes to or precipitates the development of acute cardiac dysfunction. Acute kidney injury may directly or indirectly produce acute cardiac dysfunction by way of volume overload, metabolic acidosis, electrolyte disorders such as hyperkalemia and hypocalcemia, and other mechanisms. In this review, we examine the definition, epidemiology, pathophysiology, and treatment options for CRS with an emphasis on type 3 CRS.
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[Contrast medium-induced renal failure : Useful protective measures prior to contrast medium administration].
Wiora, J, Westenfeld, R
Der Internist. 2019;(9):996-1003
Abstract
BACKGROUND Iodinated contrast is essential for diagnosis and treatment in contemporary interventional cardiology. An important complication of percutaneous intervention is contrast-induced nephropathy, which is associated with increased morbidity and mortality, while prolonged hospitalization is responsible for economic consequences. OBJECTIVES This article reviews the definition of contrast-induced nephropathy, the role of biomarkers in early diagnosis to identify high-risk patients and potential therapeutic options for preventing acute nephropathy. CURRENT DATA The optimization of patients' circulating volume remains the main aspect for preventing contrast-induced nephropathy, as recent studies confirm. Several medications are known to be nephrotoxic, whereas several are nephroprotective and the subject of recent research. CONCLUSION Interventions to improve outcomes of established acute kidney injury have not been developed as yet. Prevention and early diagnosis are relevant factors in clinical management. It is important to identify patients at risk and to treat them preemptively.
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[Choice and management of anticoagulation during CRRT].
Ricci, D, Panicali, L, Cavallari, G, Facchini, MG, Mancini, E
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia. 2019;(2)
Abstract
Continuous renal replacement therapies (CRRT) are widely used in the treatment of acute kidney injury. Several causes, related to the treatment itself or to the patient's condition, determine the coagulation of the extracorporeal circuit. These interruptions (or down-time) have a negative impact on the effectiveness of the treatment in terms of solute clearance and fluid balance. Historically, the choice of anticoagulant has fallen on unfractionated heparin because it is cheap and easy to use. Today, the use of citrate is recommended in most instances because of its high efficacy and safety. Several studies demonstrate the superiority of citrate in terms of filter survival. The reduction of down-time results in a reduction of the delta between the prescribed dialysis dose and the dose that is actually administered (ml/Kg/hour of collected effluent). The literature also agrees that there is a reduction in the incidence of major bleeding events when citrate is used instead of heparin, although there is no impact on mortality rates. Some technical and clinical complexities, secondary to citrate action both as anticoagulant and buffer, still exist in the use of regional citrate anticoagulation. However, complications due to citrate use, such as acid-base balance disorders and hypocalcaemia, are rare and easily reversible. There is not much data about the costs and benefits of using citrate instead of heparin; according to the experience within our own Unit, we have observed a reduction in costs when the data is normalized for 35 ml of effluent administered. Appropriate protocols, accurate surveillance and the automated management of regional citrate anticoagulation thanks to dedicated software make this technique safe and effective.
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Continuous renal replacement therapy: Principles, modalities, and prescription.
Karkar, A
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia. 2019;(6):1201-1209
Abstract
The mortality rate of critically ill patients with severe acute kidney injury (AKI) remains high. The associated sepsis and septic shock, as well as the presence of multiorgan failure, further increase the risk of death. Renal replacement therapy (RRT) represents the cornerstone of the management of severe AKI. Continuous RRT (CRRT) has been considered the predominant form of dialysis in the intensive care unit due to its accurate volume control, steady acid-base, and electrolyte correction and achievement of hemodynamic stability. This narrative review covers an introduction to CRRT, its physiologic principles, modalities, requirements, indications, and different elements of adequate prescription.
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10.
Contrast Nephropathy Associated with Percutaneous Coronary Angiography and Intervention.
Novak, JE, Handa, R
Cardiology clinics. 2019;(3):287-296
Abstract
Contrast nephropathy (CN) is acute kidney injury (AKI) that occurs within 24 to 72 hours of iodinated contrast medium (ICM) administration. Mechanisms of CN include hyperviscosity, free radical formation, and renal medullary oxygen supply/demand mismatch. Although risk factors for CN have been identified, it remains uncertain whether ICM causes or is simply associated with AKI. The cornerstones of CN prevention are using low-osmolal ICM, intravenous hydration, and statins, especially in patients with chronic kidney disease. With appropriate CN risk mitigation, coronary angiography and intervention should not be routinely withheld from patients with acute coronary syndromes.