The International journal of artificial organs
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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.
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Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. ⋯ Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.
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To describe current knowledge on the epidemiology of cardiac surgery-associated acute kidney injury (CSA-AKI) and to formulate recommendations for clinical practice and a research agenda. ⋯ Existing data on the epidemiology of CSA-AKI are difficult to compare due to variations in definition and patient cohort. A modified Delphi analysis resulted in a series of recommendations for future research on CSA-AKI.