Contributions to nephrology
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Continuous hemodiafiltration (CHDF) using a polymethymethacrylate (PMMA) membrane hemofilter (PMMA-CHDF) can effectively and continuously remove various cytokines from the circulating blood. PMMA-CHDF can decrease the blood levels of various cytokines when the blood levels of cytokines are high prior to the initiation of CHDF. ⋯ PMMA-CHDF could improve blood pressure, the depressed monocytic HLA-DR expression, and recover the delayed neutrophil apoptosis in septic patients. Thus, cytokine removal with PMMA-CHDF would be effective for the treatment of severe sepsis and septic shock.
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Current practices for renal replacement therapy (RRT) in ICU remain poorly defined. The observational DOse REsponse Multicentre International collaborative initiative (DO-RE-MI) survey addresses the issue of how the different modes of RRT are currently chosen and performed. The primary endpoint of DO-RE-MI will be the delivered dose versus in ICU, 28-day, and hospital mortality, and the secondary endpoint, the hemodynamic response to RRT. Here, we report the first preliminary descriptive analysis after 1-year recruitment. ⋯ Despite a large variability in the criteria of choice of RRT, CVVHDF remains the most used (49%). Clotting and clinical reasons were the most common causes for RRT downtime. In continuous RRT, a large variability in the delivered dose is observed in the majority of patients and often in the same patient from one day to another. Preliminary analysis suggests that in a large number of cases the delivered dose is far from the 'adequate' 35 ml/h/kg.
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A change in serum creatinine is the standard metric used to define and monitor the progression of acute kidney injury (AKI). This marker is inadequate for a number of reasons including the fact that changes in serum creatinine are delayed in time after kidney injury and hence creatinine is not a good indicator to use in order to target therapy in a timely fashion. There is an urgent need for early biomarkers for the diagnosis of AKI. ⋯ In this article the status of 5 potential urinary biomarkers for AKI are discussed: kidney injury molecule-1, N-acetyl-Beta-D-glucosaminidase, neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18. Considerable progress has been made although much continues to be needed to validate these markers for routine clinical use. Armed with these new tools the future will look much brighter for the patient with AKI as it is likely that early diagnosis and better predictors of outcome will lead to new therapies which can be introduced earlier in the course of disease.
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The application of modern quantitative physical chemical techniques to clinical acid-base has yielded important new information about the nature and clinical significance of metabolic acid-base disorders. Abnormalities identified by the strong ion gap appear to be common in critically ill patients and are associated with increased mortality especially when identified early in the course of critical illness. Attempts to identify the exact chemical nature of ions identified by the strong ion gap have only been of limited success and further study is needed.
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A reliable biomarker as an indicator of the presence of severe sepsis is an unmet medical need. ⋯ Despite their shortcomings, a number of existing and candidate biomarker assays are available and can provide some useful information to the clinician caring for septic patients. The relative merits of endotoxin measurement, interleukin-6 levels and a variety of other sepsis markers are reviewed. Full implementation of these biomarkers may improve diagnostic accuracy over the standard clinical criteria for sepsis.