The International journal of artificial organs
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Management of fluid balance is one of the basic but vital tasks in the care of critically ill patients. Hypovolemia results in a decrease in cardiac output and tissue perfusion and may lead to progressive multiple organ dysfunction, including the development of acute renal injury (AKI). However, in an effort to reverse pre-renal oliguria, it is not uncommon for patients with established oliguric acute renal failure, particularly when associated with sepsis, to receive excessive fluid resuscitation, leading to fluid overload. ⋯ Some CRRT machines have potential for significant fluid errors if alarms can be overridden. Threshold values for fluid balance error have been developed which can be used to predict the severity of harm. It is important that RRT education programs emphasize the risk associated with fluid balance errors and with overriding machine alarms.
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Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. ⋯ This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.
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Numerous strategies have been evaluated to prevent early CSA-AKI. Although correction of hemodynamic problems is paramount, there are no clinical studies that compare different hemodynamic management or monitoring strategies with regard to their effect on kidney function. Pharmacologic strategies including diuretics, different classes of vasodilators and drugs with anti-inflammatory effects such as N-acetyl-cysteine, do not appear to be effective. ⋯ Tranexamic acid or aminocaproic acid should be preferred over aprotinin. No pharmacologic intervention has been adequately tested in the prevention of late CSA-AKI. A singlecenter study, including a predominance of patients after cardiac surgery, showed a decrease of kidney injury with tight glycemic control.
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Volume management is an integral component of the care of patients with acute kidney injury (AKI). Considerable controversy exists regarding the use of pharmacological agents for volume management. Although overt fluid overload is often seen in AKI and may prompt attention for the use of diuretics, often these agents are used in the absence of fluid retention. ⋯ We reviewed the literature on this topic and addressed four key questions for the appropriate utilization of these agents. These include the drug targets and mechanism of action of available agents; clinical goals and criteria for timing of intervention; adaptation of therapy for specific clinical settings and measures required for monitoring effectiveness and patient safety. This report details our current knowledge in this area, provides evidence-based clinical practice recommendations where appropriate, and formulates a research agenda to address unanswered questions.
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Cardiac surgery associated acute kidney injury (CSA-AKI) is a significant clinical problem. Its pathogenesis is complex and multifactorial. It likely involved at least six major injury pathways: exogenous and endogenous toxins, metabolic factors, ischemia and reperfusion, neurohormonal activation, inflammation and oxidative stress. ⋯ Echocardiography may be useful in minimizing atheroembolic complications. The administration of N-acetylcysteine to protect the kidney from oxidative stress is not recommended. There is marked lack of randomised controlled trials in this field.