Contributions to nephrology
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The modern definition and classification of acute kidney injury (AKI) has now been applied to thousands of patients around the world and in different settings. Epidemiology is shedding intense light on the credibility of our fundamental notions of how AKI occurs and why. It is clear from multiple studies that sepsis is the leading etiology of AKI, although other settings associated with systemic inflammation (polytrauma, burns, pancreatitis, cardiopulmonary bypass) also represent important means of exposure. ⋯ Dissonance of mediator secretion and cell responses may lead to persistent injury and de novo chronic kidney disease. A number of soluble mediators initiate a variety of pathophysiological processes as kidney injury evolves. In this chapter, we will discuss the pathogenesis of AKI in light of new information concerning injury and repair, and focus on the controversies arising from emerging evidence.
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In critically ill patients, acute kidney injury (AKI) is a common complication. In some cases, oliguria may be the only sign verifying this condition. The consensus definitions of RIFLE and AKIN are based on changes in creatinine and urine output and define classes of severity within AKI. ⋯ As a result, they may not be done timely and may be subject to inaccuracies due to human factors. The URINFO(®) system is an innovative digital urine meter that provides continuous minute-to-minute monitoring of urine output, thereby enhancing kidney monitoring and the acquisition of more reliable urine output information in realtime. Consequently, monitoring of urine output with URINFO may enable rapid therapeutic interventions and can be incorporated into patient data systems, thereby improving therapy management.
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Pediatric acute kidney injury (AKI) epidemiology has shifted from primary kidney disease to secondary to another organ system illness or its treatment with nephrotoxic medications. Similar to adult patients, critically ill children with AKI with multiorgan failure exhibit high mortality rates, yet conducting interventional trials to prevent, treat or mitigate the effects of AKI in children have been hampered by relatively low event rates and the reliance on serum creatinine as the biomarker of AKI. However, recent advancements in standardizing the AKI definition via the pediatric modified RIFLE criteria, multicenter collaboration via the Prospective Pediatric CRRT Registry Group and multiple validation studies of novel AKI biomarkers in children have provided the essential components to evaluate preventive and therapeutic strategies to attack pediatric AKI as a disease state. The scope of this article is to review the advancements in the study of pediatric AKI over the past decade and offer a compelling and bright view of what is on the horizon for the prevention, treatment and rehabilitation of AKI in kids.
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All aspects of current treatment of acute kidney injury (AKI), including renal replacement therapy (RRT), are basically supportive. Emergent RRT is indicated in the management of AKI with refractory pulmonary edema, hyperkalemia or metabolic acidosis, or when uremic symptoms or signs develop. More aggressive practitioners use prophylactic RRT inpatients with sustained anuria, persistent oliguria with progressive azotemia and a probable glomerular filtration rate < 10 ml/min, or to prevent uncontrolled positive fluid balance in patients with AKI. ⋯ The approach to RRT dosing in AKI is more evidence-based. Outcomes in single-center studies of higher intensity versus standard RRT (intermittent and/or continuous) have been in consistent. However, two large multicenter negative randomized trials have shifted the weight of evidence towards suggesting provision of an effectively delivered standard dose of RRT in AKI, rather than seeking to increase RRT intensity.
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Review Comparative Study
Acute kidney injury, acute lung injury and septic shock: how does mortality compare?
Acute kidney injury (AKI), acute lung injury (ALI) and sepsis are all commonly encountered in critically ill patients. Although considered as separate conditions, largely for therapeutic purposes, a common inflammatory response is often implicated in their pathophysiologies and they are frequently present simultaneously. Mortality rates in critically ill patients suffering from renal failure, respiratory failure or severe sepsis are quite similar at about 40%, and all increase substantially when these conditions coexist. Most intensive care unit patients will die from multiple rather than individual organ failure, and further research is needed to evaluate the patterns of organ failure in surviving and nonsurviving critically ill patients, as well as the importance and mechanisms of organ-organ crosstalk in such patients.