Contributions to nephrology
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Endotoxin is one of the principal biological substances that cause gram-negative septic shock. Lack of clinical success with antiendotoxin or anticytokine therapy has shifted interest to extracorporeal therapies to reduce circulating levels of the mediators of sepsis. Direct hemoperfusion with polymyxin-B-immobilized fiber (PMX-F) is a promising treatment of gram-negative sepsis in critically ill patients. ⋯ In a systematic review of 28 studies (pooled sample size 1,390 patients), the preliminary results of which are described here, PMX-F therapy appeared to significantly lower endotoxin levels, improve blood pressure, and reduce mortality. However, publication bias and lack of blinding need to be considered. These encouraging results need to be verified with large-scale controlled clinical trials.
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Malnutrition is common in critically ill patients with acute renal failure. The aim of this review is to describe the basis for nutritional support during renal replacement therapy. ⋯ Early aggressive enteral, parenteral or combine nutritional support is required in critically ill patients on replacement therapy.
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Acute kidney injury (AKI) is a common complication of severe sepsis. Severe sepsis is the most common cause of AKI in ICU. ⋯ Whether this is true, however, remains uncertain. In this paper, we discuss salient pathophysiological aspects of AKI, review the evidence available on the need for fluid resuscitation, the amount and the type of fluid that might be best suited to AKI and discuss all major aspects of fluid resuscitation for septic AKI in humans and experimental animals.
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Over last half century, the concept of acute renal failure has evolved and with it our estimates of the incidence, prevalence and mortality. Indeed, until very recently no standard definition of acute renal failure was available, and this lack of a common language created confusion and made comparisons all but impossible. In response to the need for a common definition and classification of acute renal failure, the Acute Dialysis Quality Initiative group of experts developed and published a set of consensus criteria for defining and classifying acute renal failure. ⋯ Renal dysfunction was no longer only considered significant when it reached the stage of failure, but a spectrum from early risk to long-term failure was recognized and codified. Subsequent studies have validated these criteria in various populations and have shown that relatively mild dysfunction is associated with adverse outcomes. The term acute kidney injury has subsequently been proposed to distinguish this new concept from the older terminology of failure.
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The questions as to which treatment is the most effective for the replacement of renal function in critically ill patients with acute renal failure and the qualifications needed by nurses to manage the continuous renal replacement therapy (CRRT) device are part of an ongoing debate between nephrologists and intensivists, between nurses of the renal ward and the ICU. ⋯ Initiating and maintaining a CRRT program is a great challenge for the ICU nurse. The possible problems remain within the ICU staff's ability to solve if they follow an education program. If the workload for the nurses is well monitored, extra personnel can be avoided.