Contributions to nephrology
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Blood purification in critical care can perform 2 main functions: as an artificial support for failing organs (such as artificial kidney or liver support) and as a remover of causative humoral mediators of critical illness (such as severe sepsis and acute respiratory distress syndrome). As an artificial kidney, continuous blood purification (such as continuous hemofiltration and continuous hemodiafiltration, CHDF) is widely applied in intensive care units. The intensity of renal replacement therapy, however, has been reported to have no impact upon the efficacy of the blood purification in terms of clinical outcome. ⋯ However, our understanding of the pathophysiology of sepsis has changed since the concept of pattern recognition receptors and pathogen-associated molecular patterns was introduced. According to this, CHDF with a cytokine-adsorbing polymethylmethacrylate membrane hemofilter is preferable and more effective than direct hemoperfusion with an endotoxin-adsorbing polymyxin-B immobilized column in the treatment of sepsis and septic shock. Blood purification in critical care is gaining popularity, and is widely for both renal and non-renal indications.
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Fluid balance management in pediatric critically ill patients is a challenging task, since fluid overload (FO) in the pediatric ICU is considered a trigger of multiple organ dysfunction. In particular, the smallest patients with acute kidney injury are at highest risk to develop severe interstitial edema, capillary leak syndrome and FO. Several studies previously showed a statistical difference in the percentage of FO among children with severe renal dysfunction requiring renal replacement therapy. ⋯ The present review will shortly describe nutrition strategies in critically ill children, it will discuss dosages, benefits and drawbacks of diuretic therapy, and alternative diuretic/nephroprotective drugs currently proposed in the pediatric setting. Finally, specific modalities of pediatric extracorporeal fluid removal will be presented. Fluid management, furthermore, is not only the discipline of removing water: it should also address the way to optimize fluid infusions and, above all, one of the most important fluids infused to all ICU patients with renal dysfunction: parenteral nutrition.
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It has been reported that various types of blood purification intended for the removal of humoral mediators, such as cytokines, were performed in patients with severe sepsis/septic shock. While high-volume hemofiltration, hemofiltration using high cut-off membrane filters, and direct hemoperfusion with a polymyxin-B immobilized column are widely used in the treatment of severe sepsis/septic shock, we perform continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA-CHDF), which shows an excellent cytokine-adsorbing capacity, for the treatment of severe sepsis/septic shock. ⋯ Furthermore, PMMA-CHDF could remove anti-inflammatory cytokines such as IL-10 from bloodstream, suggesting that it might improve immunoparalysis as well. These findings suggest that PMMA-CHDF is useful for the treatment of patients with severe sepsis/septic shock as a cytokine modulator.
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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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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.