Critical care clinics
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Perioperative acute kidney injury (AKI) is a common, morbid, and costly surgical complication. Current efforts to understand and manage AKI in surgical patients focus on prevention, mitigation of further injury when AKI has occurred, treatment of associated conditions, and facilitation of renal recovery. Lesser severity AKI is now understood to be much more common, and more morbid, than was previously thought. The ability to detect AKI within hours of onset would be helpful in protecting the kidney and in preserving renal function, and several imaging and biomarker modalities are currently being evaluated.
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Acute kidney injury (AKI) is a frequent complication of end-stage liver disease, especially in those with acute-on-chronic liver failure, occurring in up to 50% of hospitalized patients with cirrhosis. There is no specific blood or urine biomarker that can reliably identify the cause of AKI in cirrhotic patients. This review examines studies used to assess renal dysfunction in cirrhotic patients including new diagnostic criteria and potential novel biomarkers. Although biomarker development to differentiate the cause of AKI in cirrhosis has promise, the utility of biomarkers to determine irreversible renal dysfunction with liver transplant remains lacking, warranting further investigation.
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Most critically ill patients experience external or internal fluid shifts and hemodynamic instability. In response to these changes, intravenous fluids are frequently administered. ⋯ The authors consider the evidence of harm associated with fluid overload and the physiologic processes that lead to fluid accumulation in critical illness. The authors then consider methods to prevent fluid accumulation and/or manage its resolution.
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Acute kidney injury (AKI) is a serious yet potentially reversible complication of sepsis. Several molecular mechanisms involved in the development of septic AKI have been identified. ⋯ In addition, current evidence surrounding the management of patients with septic AKI is summarized. Finally, potential novel therapies for septic AKI are presented.
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Fluid therapy is the most common intervention received by acutely ill hospitalized patients; however, important questions on its optimal use remain. Its prescription should be patient and context specific, with clear indications and contradictions, and have the type, dose, and rate specified. Any fluid therapy, if provided inappropriately, can contribute unnecessary harm to patients. The quantitative toxicity of fluid therapy contributes to worse outcomes; this should prompt greater bedside attention to fluid prescription, fluid balance, development of avoidable complications attributable to fluid overload, and for the timely deresuscitation of patients whose clinical status and physiology allow active fluid mobilization.