Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2017
ReviewRenal replacement therapy for AKI: When? How much? When to stop?
Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious clinical disorder in the intensive care unit (ICU), occurring in a significant proportion of critically ill patients. However, many questions remain about the optimal administration of RRT with regard to several important considerations, including treatment dose, timing of treatment initiation and cessation, therapy mode, type of anticoagulation, and management of fluid overload. While Level 1 evidence exists for RRT dosing in AKI, all the studies contributing to this evidence base employed fixed-dose regimens throughout a patient's continuous RRT (CRRT) course, without regard for the possibility of individualizing treatment dose according to the clinical status of a given patient at a specific time. ⋯ While numerous clinical trials over the past 40 years have attempted to assess "early" versus "late" initiation of RRT, they have been plagued by a myriad of methodological problems, including their largely observational nature and the widely varying definitions of early and late initiation. Although questions about the appropriate timing of CRRT discontinuation arise very frequently in clinical practice, even less information is available in the literature to guide this important decision. The aim of this review is to provide a comprehensive update on RRT delivery to critically ill AKI patients, with specific attention paid to treatment dose and timing and emphasis on addressing the practical questions that arise in daily clinical practice.
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Acute kidney injury (AKI) is highly prevalent among hospitalized children, especially those who are critically ill. The incorporation of pediatric elements into consensus definitions has led to a greater understanding of pediatric AKI epidemiology, risk factors, and outcomes. The best available data suggest that AKI occurs in 5% and 27% of non-critically ill and critically ill children, respectively. ⋯ However, novel biomarker discovery and new risk stratification techniques have led to enhanced detection and diagnostic strategies. Although no specific treatments exist, strategies designed to prevent AKI are being developed and there is growing evidence that early detection may improve outcomes. We hope that advances in AKI management will follow the diagnostic innovations seen in the past decade.
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Acute kidney injury is a prevalent but underdiagnosed complication that is associated with increased in-hospital morbidity and mortality. The importance of this complication is being increasingly recognized. The lack of timely diagnostic methods and effective preemptive and therapeutic strategies make its perioperative management challenging. ⋯ Previous studies demonstrated improved patients' outcome following remote ischemic preconditioning in high-risk patients. Other studies reached an opposite result. To date, renal replacement therapy is the "gold standard" for the treatment of severe acute kidney injury, although the ideal timing, technique, and application of this therapy remain under debate.
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Best Pract Res Clin Anaesthesiol · Sep 2017
ReviewEpidemiology of cardiac surgery-associated acute kidney injury.
Acute kidney injury (AKI) is defined by the KDIGO definition into 3 stages on basis of an increase in serum creatinine or a period of oliguria. AKI is defined as rapid reversal when the episode is 48 h or less. When AKI persists for 7 days or longer, the term acute kidney disease is used. ⋯ In contrast to this, functional AKI is defined by the KDIGO definition, wherein the AKI biomarker concentration is not increased. AKI is multifactorial and heterogeneous and occurs in half of ICU patients as defined by the current KDIGO definition for AKI. In this review, we specifically describe the epidemiology of cardiac surgery-associated AKI and describe the role of scoring systems and specific AKI biomarkers.
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Best Pract Res Clin Anaesthesiol · Sep 2017
ReviewImpact of volume status and volume therapy on the kidney.
Volume resuscitation to correct hypotension in surgical and critically ill patients is a common practice. Available evidence suggests that iatrogenic volume overload is associated with worse outcomes in established acute kidney injury. Intraoperative arterial hypotension is associated with postoperative renal dysfunction, and prompt correction with fluid management protocols that combine inotrope infusions with volume therapy targeted to indices of volume responsiveness should be considered. ⋯ Available evidence and expert opinion suggest that balanced crystalloid solutions are preferable to isotonic saline for volume resuscitation. Moreover, albumin has a similar safety profile as crystalloids. Hetastarch-containing colloids have a clear association with acute kidney injury.