Contributions to nephrology
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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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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.
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Continuous renal replacement therapy (CRRT) has been extensively used in Japan as renal support for critically ill patients managed in the ICU. In Japan, active research has also been conducted on non-renal indications for CRRT, i.e. the use of CRRT for purposes other than renal support. Various methods of blood purification have been attempted to remove inflammatory mediators, such as cytokines, in patients with severe sepsis or septic shock. ⋯ In evaluating the efficacy of CRRT for non-renal indications, it is essential to focus on patients subjected to be studied, such as severe sepsis or septic shock, and to evaluate its indication, commencement, termination of therapy and also its therapeutic effects based on analysis of blood levels of the target substances to be removed (e.g. cytokines). IL-6 blood level appears to be useful as a variable for this evaluation. It is expected that evidence endorsing the validity of these methods now being attempted in Japan will be reported near future.
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The correct selection of anticoagulation in acute blood purification is crucial for avoiding exacerbation of bleeding in critical care patients with acute renal failure, as these patients frequently exhibit hemorrhagic complications. The mode of acute blood purification is determined mainly by the patient's hemodynamic stability, and continuous renal replacement therapies (CRRTs) have been extensively performed for patients with hemodynamic instability. Unfractionated heparin, low molecular weight heparin and nafamostat mesilate (nafamostat) are available in acute blood purification for the patients. ⋯ This is especially the case with patients of small stature, which is the case for many Japanese people. Nafamostat can be used safely in CRRT for critical care patients with acute renal failure and bleeding risks, because it acts as a regional anticoagulant due to its pharmacological characteristics. Nafamostat has been widely used in acute blood purification at critical care units in Japan.
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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.