Contributions to nephrology
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Acute kidney injury (AKI) is associated with both short- and long-term clinical consequences including progression to chronic kidney disease. Recovery of renal function has gained importance, as interventions to prevent or treat AKI are limited. Basing recovery on a return of serum creatinine values excludes mounting evidence that AKI, even when reversible, is a very serious clinical event that will result in a significant number of both renal and extra-renal complications such as late stage kidney disease, major cardiovascular events, and death. ⋯ Development of a definition for renal recovery is critical to organizing research in AKI treatment. Assessment of serum creatinine remains the primary measure of renal recovery despite known limitations. Patterns of renal recovery are highly associated with clinical outcomes including survival. Additional research in basic mechanisms of renal injury and repair is needed to help formulate a more comprehensive assessment of renal recovery. Novel biomarkers for assessment of AKI may also aid in the determination of renal recovery. Key Messages: (1) The concept of acute kidney disease (7-90 days post AKI) should direct clinicians as well as researchers to pay attention to a critical time period for renal recovery in which interventions may alter long-term outcomes. (2) Recent studies have evaluated AKI recovery patterns, or trajectories, and is an important step towards defining long-term prognosis. (3) Serum creatinine alone is not a reliable marker of recovery after AKI and is associated with poor clinical outcomes despite a return to baseline levels. This is a work of the U.S. Government and is not subject to copyright protection in the United States. Foreign copyrights may apply. Published by S. Karger AG, Basel.
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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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Acute kidney injury (AKI) is a common but complex clinical syndrome with multiple etiologies. These etiologies target different sites and pathways within the kidney. Novel biomarkers of 'kidney damage' (which can be tubular or glomerular) can be used to diagnose AKI, even in the absence of an increase in serum creatinine or oliguria. ⋯ The presence of underlying CKD or of sepsis poses additional challenges in differential diagnosis, since these conditions alter both baseline biomarker excretion and biomarker performance. We recommend that biomarkers be validated within the clinical context in which they are to be used. Within that context, combinations of biomarkers may, in the future, allow differentiation of the site, mechanism and phase of injury.
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Stroke is a leading cause of mortality and morbidity worldwide. Traditional cardiovascular risk factors - hypertension, diabetes and dyslipidemia - are related to the incidence of stroke. Chronic kidney disease has also been recognized to be a major public health problem as a cardiovascular risk factor. ⋯ Chronic kidney disease may also be associated with an increase in nontraditional risk factors such as hyperhomocysteinemia, inflammation, asymmetric dimethylarginine, oxidative stress, and anemia, and thrombogenic factors such as left ventricular hypertrophy, endothelial dysfunction, and arterial stiffness. Herein, we review the results of meta-analyses of published cohort studies for a better understanding of the precise nature of the relationship between chronic kidney disease and stroke, important to both the clinical and public health fields. Further studies are warranted to determine whether interventions to prevent the progression of kidney impairment are effective at reducing the risk of stroke.