Contributions to nephrology
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Review Case Reports
Diuretic therapy in fluid-overloaded and heart failure patients.
Diuretics are the most commonly used drugs to treat clinically diagnosed fluid overload in patients with heart failure. There is no conclusive evidence that they alter major outcomes such as survival to hospital discharge or time in hospital compared to other therapies. However, they demonstrably achieve fluid removal in the majority of patients, restore dry body weight, improve the breathlessness of pulmonary edema and are unlikely to be subjected to a large double-blind randomized controlled trial in this setting because of lack of equipoise. ⋯ Such therapy often requires more intensive monitoring than available in medical wards. If diuretic therapy fails to achieve its clinical goals, ultrafiltration by semipermeable membranes is reliably effective in achieving targeted fluid removal. The combination of diuretic therapy and/or ultrafiltration can achieve volume control in essentially all patients with heart failure.
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The risk of developing acute kidney injury (AKI) is significantly increased in the elderly. It is the age-related renal and systemic changes as well as frequent comorbidities that render older individuals greatly susceptible to acute renal impairment. ⋯ Serum creatinine is most commonly used for diagnosis, despite it having several limitations, especially in the elderly. The mainstay of management is prevention of further deterioration, as the chances of renal recovery may be lower in older patients.
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Acute heart failure (HF) and acute kidney injury (AKI) are common. These syndromes are each associated with considerable morbidity, mortality, and health resource utilization and are increasingly encountered. Fluid accumulation and overload are common themes in the pathophysiology and clinical course of both HF and AKI. ⋯ To date, the impact of fluid balance in both of these syndromes, more so with AKI, has likely been underappreciated. There is little to no data specifically on fluid balance in the cardiorenal syndrome, where acute/chronic heart disease can directly contribute to acute/chronic worsening of kidney function that likely exacerbates fluid homeostasis. Additional investigations are needed.
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Acute kidney injury (AKI) requiring dialysis occurs frequently, and its pathogenesis involves multiple pathways within which hemodynamic, inflammatory and nephrotoxic factors overlap. Several studies have tried to assess the risk factors leading to AKI, and found, among other factors, that preoperative renal dysfunction is important. Currently, it is uncertain when dialysis therapy should start. However, AKI after cardiac surgery should be treated early by continuous hemodialysis.
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Multicenter Study Clinical Trial
Plasma dia-filtration for severe sepsis.
The mortality rate in severe sepsis is 30-50%, and independent liver and renal dysfunction impacts significantly on hospital and intensive care mortality. If 4 or more organs fail, mortality is > 90%. Recently, we reported a novel plasmapheresis--plasma diafiltration (PDF)--the concept of which is plasma filtration with dialysis. ⋯ On average, 12.0 +/- 16.4 sessions (range 2-70) per patient were performed. The 28-day mortality rate was 36.4%, while the predicted death rate was 68.0 +/- 17.7%. These findings suggest that PDF is a simple modality and may become a useful strategy for treatment of patients with septic multiple organ failure.