Clinical journal of the American Society of Nephrology : CJASN
-
Clin J Am Soc Nephrol · Mar 2008
ReviewPotential interventions in sepsis-related acute kidney injury.
Sepsis is an important cause of morbidity and mortality. Acute kidney injury often complicates sepsis, leading to greater complexity, cost of care, and worsening prognosis. In recent years, a consensus definition of acute kidney injury has been developed, facilitating research into the pathophysiology and epidemiology of this disorder. ⋯ Existing and hybrid extracorporeal therapies are being investigated not only as means to replace lost kidney function but also to modulate the immune response to sepsis. For those who have more advanced forms of kidney injury, strategies to promote renal recovery are being sought to minimize the long-term consequences of impaired kidney function. This review provides an update on the current state of the science and a glimpse toward the future of intervention in sepsis-related acute kidney injury.
-
Clin J Am Soc Nephrol · Mar 2008
ReviewAdvances in critical care for the nephrologist: hemodynamic monitoring and volume management.
The monitoring of physiologic variables is an integral part of the diagnosis and management of the critically ill patient. Restoration of tissue perfusion and oxygen delivery is the ultimate goal for any state of circulatory collapse. ⋯ This article reviews the physiologic parameters that best predict intravascular volume status and volume responsiveness. We examine the controversies surrounding the pulmonary arterial catheter and describe the less invasive methods of measuring cardiac performance.
-
Clin J Am Soc Nephrol · Mar 2008
ReviewWithholding and withdrawing dialysis in the intensive care unit: benefits derived from consulting the renal physicians association/american society of nephrology clinical practice guideline, shared decision-making in the appropriate initiation of and withdrawal from dialysis.
Despite advances in the technology of dialysis, mortality in patients who develop acute renal failure remains high. Scoring systems have been developed to improve the ability to define prognosis in seriously ill patients with acute renal failure but predicting outcomes for individual patients is uncertain. Decisions to withhold or withdraw dialysis in seriously ill patients are difficult for patients, families, and health care providers. ⋯ Estimating prognosis and addressing the issues of advance directives and patient and family preferences through the process of shared decision-making can clarify appropriate strategies for clinical management and interventions. Time-limited trials of dialysis may be an invaluable tool in this process. Increasing nephrologists' awareness of the guideline may facilitate decision-making around the issues of withholding and withdrawing dialysis in part by clarifying patients and situations in which it may be appropriate to withhold or withdraw dialysis.
-
Clin J Am Soc Nephrol · Mar 2008
Retrospective review of the frequency of ECG changes in hyperkalemia.
Experimentally elevated potassium causes a clear pattern of electrocardiographic changes, but, clinically, the reliability of this pattern is unclear. Case reports suggest patients with renal insufficiency may have no electrocardiographic changes despite markedly elevated serum potassium. In a prospective series, 46% of patients with hyperkalemia were noted to have electrocardiographic changes, but no clear criteria were presented. ⋯ Given the poor sensitivity and specificity of electrocardiogram changes, there is no support for their use in guiding treatment of stable patients. Without identifiable electrocardiographic markers of the risk for complications, management of hyperkalemia should be guided by the clinical scenario and serial potassium measurements.