Contributions to nephrology
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The pathogenesis of acute kidney injury (AKI) is complex and varies to some extent based on the particular cause. Inflammation contributes to this pathophysiology in a variety of contexts. Inflammation can result in reduction in local blood flow to the outer medulla with adverse consequences on tubule function and viability. ⋯ In collaboration with Serhan et al. we recently reported that, in response to bilateral ischemia/reperfusion injury, mouse kidneys produce D series resolvins (RvDs) and PD1 [J Immunol 2006;177:5902-5911]. Administration of RvDs or PD1 to mice prior to, or subsequent to, ischemia resulted in a reduction in functional and morphological kidney injury. Understanding how these anti-inflammatory processes are regulated may provide insight into how we might intervene to facilitate and enhance them so that we might prevent or mitigate the devastating consequences of AKI.
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Implementing continuous renal replacement therapy (CRRT) in a intensive care unit (ICU) is a somewhat difficult issue and quiet different from starting a new ventilation mode or a new hemodynamic device. It may indeed require an on-call medical emergency CRRT team as expertise in this field is really a key issue to success. Education for the nursing team is another key point, especially as ongoing or continuous education is changing very quickly. ⋯ Therefore, a nursing group composed of 5-8 nurses who would be taught beforehand was started, and this dedicated group would then teach the rest CRRT Technology and Logistics 355 of the staff nurses. This group exists today and has at least 6-8 meetings/year in which all the problems that must be faced in the implementation of CRRT are dealt with. Here all the steps made by our and other units in this field will be discussed, including an overview of the various protocols implemented and a description of our dedicated nursing group with regard to CRRT.
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Sepsis and multiple organ failure are common complications in intensive care unit (ICU) patients and are associated with considerable morbidity and mortality. ⋯ Although there is some evidence that mortality rates may have decreased in recent years, the incidence of sepsis is increasing so that overall deaths from this disease are increasing. Improved diagnostic techniques and classification may help target therapies more rapidly and more appropriately.
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Fortunately with improvements in initial medical resuscitation, such as the avoidance of nephrotoxins, the incidence of acute kidney injury requiring renal support in patients with acute traumatic brain injury remains low. However the incidence of cerebral hemorrhage in patients on chronic dialysis programs appears to be increasing. By carefully adapting renal replacement to minimize cardiovascular instability and reduce the rate of change of serum osmolality, patient survival in this group of critically ill patients is increasing and starting to approach that of patients with traumatic brain injury without kidney injury.
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From the recent past, hemofiltration, particularly high-volume hemofiltration, has rapidly evolved from a somewhat experimental treatment to a potentially effective 'adjunctive' therapy in severe septic shock and especially refractory or catecholamine-resistant hypodynamic septic shock. Nonetheless, this approach lacks prospective randomized studies (PRTs) evaluating the critical role of early hemofiltration in sepsis. An important milestone, which could be called the 'big bang' in terms of hemofiltration, was the publication of a PRT in patients with acute renal failure (ARF). ⋯ This could be called the big bang of hemofiltration as one could have never anticipated that an adequate dose of hemofiltration could markedly influence the survival rate of septic ARF patients in the ICU. Apart from the use of an early and adequate dose of Honoré/Joannes-Boyau/Gressens 372 hemofiltration in sepsis, a higher dose could also provide a better renal recovery rate and reduce the risk of associate chronic dialysis in these patients. Furthermore, this presentation will also review brand-new papers regarding the use of hemofiltration in systemic inflammatory response syndrome and out-of-hospital cardiac arrest.