Blood purification
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The pathogenesis of cardiac failure involves activation of the neurohumoral axis including stimulation of the sympathetic nervous system, the renin-angiotensin-aldosterone, and nonosmotic vasopressin systems. While these responses are critical in maintaining arterial pressure, they are associated with renal vasoconstriction, as well as sodium and water retention. In advanced circumstances, renal dysfunction and hyponatremia occur with cardiac failure. ⋯ One such agent, conivaptan, also is a V1 receptor antagonist which could theoretically benefit heart failure patients by decreasing cardiac afterload and remodeling. The effect of V2 receptor antagonists to correct hyponatremia in heart failure patients appears to be quite safe. However, to date no effect on mortality has been demonstrated.
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Despite advances in renal replacement therapy, the mortality of acute kidney injury (AKI) has remained high, especially when associated with distant organ dysfunction such as acute lung injury (ALI). Mortality rates for combined AKI/ALI reach 80% in critically ill patients. ⋯ New experimental data have emerged in recent years focusing on the interactive effects of kidney and lung dysfunction, and these studies have highlighted the pathophysiological importance of proinflammatory and proapoptotic pathways as well as the complex nature of interorgan crosstalk. This review will examine our current understanding of the deleterious kidney-lung crosstalk in the critically ill.
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Acute kidney injury (AKI) is a common complication in intensive care units (ICUs). However, its incidence and outcome vary in several studies depending on definitions used or even the geographic origin of the study. We aimed to evaluate the epidemiology of AKI in ICUs in Greece. ⋯ AKI involves a large number of patients in Greek ICUs and is associated with adverse outcomes.
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In recent years, a number of techniques have been studied and developed in the field of renal replacement therapy in the septic patient. Manipulation of ultrafiltrate dose, membrane porosity, mode of clearance, and combinations of techniques have yielded promising findings. ⋯ An ultrafiltration rate between 35 and 45 ml/kg/h, with adjustment for predilution and down time, can be recommended for the septic patient until other data are available. The results of further dose outcome studies with higher ultrafiltration rates will likely be the stepping stone to further improvements in daily clinical practice.
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In the last years, publications have questioned the classical dose of 35 ml/kg, but are those studies strong enough in terms of scientific power in order to change our practice? We will try to settle some recommendations for clinicians. Manipulation of dose, porosity, and combinations have yielded promising findings. However, conclusive evidence based on randomized trials remains scarce, limiting the practical implementation in daily practice. ⋯ An ultrafiltration rate of around 35 ml/kg/h, with adjustment for predilution, can be recommended for the septic patient. Recent studies do not have enough power to change this recommendation in view of its shortcomings. Finally the recommendation is to keep going with a continuous technique, a pure continuous veno-venous hemofiltration mode, and at a dose of 35 ml/kg/h while waiting for other studies to be published.