Contributions to nephrology
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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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Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely to be associated with high circulating endotoxin. In June 2009, the EUPHAS study (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis) was published in JAMA. ⋯ The PaO(2)/FiO(2) ratio increased slightly (235 to 264; p = 0.049) in the polymyxin B group, but not in the conventional therapy group (217 to 228; p = 0.79). SOFA scores improved in the polymyxin B group, but not in the conventional therapy group (change in SOFA: -3.4 vs. -0.1; p = 0.001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted HR: 0.43, 95% CI: 0.20-0.94; adjusted HR: 0.36, 95% CI:0.16-0.80). The study demonstrated how polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal Gram-negative infections.
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Diuretics are commonly used in the intensive care unit, especially for patients with oliguric acute kidney injury. This practice is controversial since there is a lack of evidence regarding any beneficial effects of diuretics either on prevention or treatment of acute kidney injury. ⋯ However, diuretics can minimize fluid overload, making patient management easier and potentially avoiding many cardiopulmonary and non-cardiopulmonary complications. We will briefly review the available evidence for and against the use of diuretics in the critically ill, including cardiorenal syndromes.
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In critically ill patients, fluid balance management is an integral part of the process of care. In patients in shock or severe sepsis, aggressive initial fluid resuscitation has been shown to improve overall prognosis. ⋯ Randomized clinical trials are urgently required to assess the role of fluid overload in mortality and morbidity in this population. In the meantime, we should not only focus on acute fluid resuscitation but also on cumulative fluid balance as the amount and duration of fluid accumulation may influence outcomes.
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Endotoxin, which consists of lipopolysaccharide (LPS), is an outer membrane component of the Gram-negative bacterial cell wall. Endotoxin in the blood stream from an infectious focus or through translocation from the gut plays an important role in the pathogenesis of severe sepsis and septic shock. It binds to monocytes and macrophages, activating them to trigger the production of a variety of mediators. ⋯ In Japan, PMX has been clinically used since 1994under the national health insurance system. It is estimated that over 80,000 patients have received PMX treatment in Japan. Not only has PMX been clinically used safely in Japan, but also in other countries.