Contributions to nephrology
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The incidence of the multiple organ dysfunction syndrome (MODS) is rapidly increasing in intensive care units (ICU). It usually combines with sepsis and is the most frequent cause of death in the ICU patients. The nature of the ICU patients has changed in the last years. ⋯ In the light of these observations, a new thought arises: Can extracorporeal blood purification have a positive impact on different organ systems? A possible answer might come from the simple observation that all organs share one aspect in common: contact with blood. All extracorporeal therapies also have one aspect in common: treatment of blood. Based on these observations and knowledge of the molecular biology of sepsis, a "humoral" theory of MODS makes pathophysiological sense and its consequence triggers the need to consider extracorporeal therapies as multiple organ support therapies and not just as single organ support.
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Renal replacement therapy (RRT) is commonly and increasingly utilized in critically ill patients with severe acute kidney injury (AKI). The issue of when to start RRT in a critically ill patient with AKI has long troubled clinicians. ⋯ Several large randomized trials are planned or ongoing, and the results of these trials will greatly inform best clinical practice and will help reduce unnecessary variation in the practice of RRT prescription. For now, the decision on the appropriate time to start RRT is naturally complex, integrating numerous variables, and should largely be individualized.
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The goal of fluid therapy in critical care medicine is to restore hemodynamic stability and vital organ perfusion while avoiding interstitial edema. Acute kidney injury (AKI) is a common complication in critically ill patients. Decisions regarding fluid management in critically ill patients with AKI are difficult, as these patients often have accompanying oliguria as well as body fluid overload. ⋯ Balanced solutions may reduce the risk of hyperchloremic acidosis and kidney injury. In summary, volume management is an integral part of the care of critically ill patients with AKI. An optimal strategy might involve a timely period of guided fluid resuscitation with appropriate solutions, followed by an appropriate fluid balance.
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The type II sodium-dependent Pi (NaPi) cotransporters (NaPi-IIa, NaPi-IIb and NaPi-IIc) contribute to renal and intestinal Pi absorption. 1,25-Dihydroxyvitamin D [1,25(OH)2D3] is an important factor for NaPi-II transporters in the small intestine and kidney. In a previous study, low levels of 1,25(OH)2D3 appeared to suppress the expression of renal NaPi cotransporters. We identified a functional vitamin D receptor-responsive element in the human NaPi-IIa and NaPi-IIc genes in renal epithelial cells. ⋯ Klotho functions as a co-receptor for FGF23 and is increased by 1,25(OH)2D3. Klotho induces phosphaturia by inhibiting the renal NaPi-IIa transporter. In this review, we discuss the roles of 1,25(OH)2D3/VDR in the regulation of renal type II NaPi cotransporters in the kidney and small intestine.
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Chronic kidney disease and atrial fibrillation (AF) commonly coexist, and data suggest that renal patients have AF rates in excess of double that encountered in the general population. These patients are at increased risk of stroke, regardless of the presence or absence of AF. Furthermore, a lower GFR causes increased thromboembolic risk in patients with AF - independent of other risk factors. ⋯ The new oral anticoagulants have relatively little data in patients with severe renal impairment, and all have an element of renal excretion. There is a need for large randomised control trials in patients with renal insufficiency and on haemodialysis to provide a bank of high-quality scientific data on which clinicians can base their management decisions. Until then, we must adopt a pragmatic approach which involves careful consideration of the relative risk of stroke and bleeding in each individual patient.