Seminars in nephrology
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Acute kidney injury (AKI) usually is defined as a decline in glomerular filtration rate over hours to days that can occur either in a person with previously normal kidney function, or in the setting of pre-existing chronic kidney disease. The incidence of AKI has increased steadily in recent years, and this increase is associated strongly with advancing age in the population because epidemiologic data indicate that AKI is much more common in the elderly. In the aging population there is heightened susceptibility to drug toxicity, partially owing to altered drug pharmacokinetics and pharmacodynamics. ⋯ Age-related alterations in renal tubular function also may heighten susceptibility to AKI because renal sodium conservation in response to dietary sodium restriction is attenuated in the elderly. A recently published study showed that elderly subjects with AKI, particularly those with chronic kidney disease, are more likely to develop end-stage renal disease. The increasing prevalence and extended clinical consequences of AKI in the elderly are of great concern from a clinical and public health perspective.
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Seminars in nephrology · May 2009
The syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a disorder of water balance characterized by hypotonic hyponatremia and impaired water excretion. The diagnosis of SIADH is based on the exclusion of other hyponatremic conditions, the presence of hyposmolality with inappropriate urine osmolality and a urine sodium concentration usually above 30 mEq/L. Some simple and readily available biologic parameters can be helpful in the diagnosis of SIADH (low urea and uric acid levels). The recent syndrome of nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is also discussed and the association of asymptomatic hyponatremia with falls and bone fractures.
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Seminars in nephrology · Sep 2008
ReviewThe future of pediatric acute kidney injury management--biomarkers.
Acute kidney injury (AKI) represents a common and devastating problem in clinical medicine. A major reason is the lack of early biomarkers for AKI, and hence an unacceptable delay in initiating therapy. ⋯ These biomarkers have completed initial validation, and have entered the prospective screening stage in the biomarker development process, facilitated by the development of commercial tools for their reproducible measurement across laboratories. The availability of a panel of validated biomarkers will revolutionize renal and critical care, and enable the practice of personalized and predictive medicine at an unprecedented level.
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Seminars in nephrology · Sep 2008
ReviewPediatric critical care management of septic shock prior to acute kidney injury and renal replacement therapy.
A high index of suspicion for bacterial sepsis and recognition of the potential for rapid deterioration is essential for impacting patient outcome. Meningococcemia produces a stereotypical clinical and biochemical constellation of profound septic shock and purpura fulminans with marked inflammatory disturbance and a complex disruption of coagulation. Meningococcal infections preferentially affect infants and young children, but adolescents are also at risk. ⋯ A variety of efforts to manipulate the coagulation abnormalities may be considered, although evidence is lacking. Extracorporeal support remains a consideration both for the failing cardiorespiratory systems but also potentially for the use of plasma exchange. A team approach between the intensivist and subspecialist is important in managing the frequent multiorgan complications seen with meningococcemia.
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The development of recent standardized definitions of acute kidney injury (AKI) has allowed us to begin understanding pediatric AKI epidemiology and risk factors and to stratify outcome by AKI severity. AKI incidence will vary with illness severity of the population studied and definition type, ranging from less than 1% when need for dialysis is used to 82% when less conservative definitions (such as > or =1.5 times baseline serum creatinine) are used to define AKI. ⋯ A key feature in diagnosis and management includes identifying the presence of ATN versus a reversible hypovolemic state because patients with ATN may quickly develop fluid overload with overaggressive fluid therapy, requiring dialytic removal. Despite advances in acute pediatric dialysis therapy and in overall care of critically ill children, severe AKI still is associated with a high mortality rate, necessitating more research in early AKI identification and therapeutic trials.