Advances in chronic kidney disease
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Adv Chronic Kidney Dis · Jan 2013
ReviewAn update on neurocritical care for the patient with kidney disease.
Patients with kidney disease have increased rates of neurologic illness such as intracerebral hemorrhage and ischemic stroke. The acute care of patients with critical neurologic illness and concomitant kidney disease requires unique management considerations including attention to hyponatremia, renal replacement modalities in the setting of high intracranial pressure, reversal of coagulopathy, and seizure management to achieve good neurologic outcomes.
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Adv Chronic Kidney Dis · Jan 2013
ReviewUpdates in the management of acute lung injury: a focus on the overlap between AKI and ARDS.
Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults and can result from several predisposing factors, such as sepsis and trauma, which also predispose patients to acute kidney injury (AKI). Animal models of AKI and ARDS suggest that AKI increases inflammatory cytokines in the circulation such that IL-6 may be a direct mediator of AKI induced lung injury. ⋯ The cornerstone of therapy for ARDS continues to be low tidal volume ventilation, and more recent trials illustrate that diuretic administration to shock-free ARDS patients may help them avoid the deleterious effects of volume overload. This review focuses on new developments in the care of ARDS patients with a specific focus on interactions between the lungs and kidneys in patients with overlapping ARDS and AKI.
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Adv Chronic Kidney Dis · Jan 2013
ReviewFluid management and use of diuretics in acute kidney injury.
Critically ill adult patients at risk for or with acute kidney injury (AKI) require careful attention to their hemodynamic status because hypotension and hypovolemia may contribute to or worsen kidney injury. Increasing evidence suggests that isotonic crystalloids should be used instead of colloids for initial expansion of intravascular volume in patients at risk for AKI or with AKI, such as those with sepsis, septic shock, or trauma. The timing and amount of volume to be administered to prevent AKI and other organ damage is still debated, but an aggressive fluid repletion in the early setting is probably beneficial. ⋯ Diuretics may prevent or treat fluid overload and may also affect kidney function. The efficacy of these procedures in critically ill AKI patients need to be confirmed with randomized controlled trials. This review focuses on early volume resuscitation, overall fluid management, and use of diuretics in critically ill adult patients at risk for or with AKI and their effect on mortality and kidney function in this setting.
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Hemodynamic monitoring is essential to the care of the critically ill patient. In the hemodynamically unstable patient where volume status is not only difficult to determine, but excess fluid administration can lead to adverse consequences, utilizing markers that guide resuscitation can greatly affect outcomes. ⋯ Technological advances have lead to the creation of invasive and noninvasive devices that guide the physician through the resuscitative process. In this manuscript, we review the physiologic rationale behind hemodynamic monitoring, define the markers of volume status and volume responsiveness, and explore the various devices and technologies available for the bedside clinician.