Acute kidney injury (AKI) is a serious medical condition affecting millions of people. Patients in intensive care unit (ICU) who develop AKI have increased morbidity and mortality, prolonged length of stay in ICU and hospital and increased costs, especially when they require renal. Critical Care Nephrology: Update in Critical Care for the Nephrologist. Like the tide, over the past 15 years critical care has changed—back and forth and back. Importantly, patients who had ARF or were treated with renal replacement therapy (RRT) had an overall hospital mortality of %. : Features of IHD, CRRT, and SLED/EDD in Acute Renal Failure. To this end, the term “acute kidney injury” has been proposed.
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Critical Care Nephrology. Wednesday, April 27; am – pm. Course Director: Laurie Benton PhD, PA-C, MPAS, RN, FNKF. Session ; Critical Care Nephrology - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. Comprehensive and clinically relevant, the 3rd Edition of Critical Care Nephrology provides authoritative coverage of the latest advances in critical care .
Abstract Emergency and critical care medicine have grown into robust self-supporting disciplines with an increasing demand for dedicated highly-skilled physicians. Introduction For decades, critical care medicine and nephrology have been fighting but finally emerged altogether with the concept of critical care nephrology almost 20 years ago.
Material and methods In order to further elaborate on this concept, we would like to present a case report highlighting this atypical presentation of a disease while the patient was in an intensive care unit ICU. Conclusion In conclusion, polyvalence is no longer a valid option in modern critical care.
Footnotes Disclosure The authors declare no conflicts of interest in this work. References 1.
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Multidisciplinarity in emergency and critical care medicine: Specific care is best care! Journal of Translational Internal Medicine.
Cultural competency training requirements in graduate medical education. J Grad Med Educ. Variability of subspecialty-specific anesthesia-controlled times at two academic institutions. J Med Syst. Yee J. Adv Chronic Kidney Dis. Dialy- and continuous renal replacement CRRT trauma during renal replacement therapy: Nephrol Dial Transplant.
The Vicenza Conference. Adv Ren Replace Ther. CRRT and Logistics: Contrib Nephrol.
Lui KD. Critical care nephrologist: Update in critical care for the nephrologist. Intensive Care Med.
Use of antifungal drugs during continuous hemofiltration therapies. Improving antibiotic dosing in special situations in the ICU: Curr Opin Crit Care. Antibiotic adsorption on CRRT membranes. Relevance and impact on antibiotic dosing in critically ill patients. Continuous renal replacement therapy allows higher colistin dosing without increasing toxicity.
Cruz DN. Cardiorenal syndromes in critical care: The acute cardiorenal and renocardiac syndromes. Definition and classification of Cardio-Renal Syndromes: Hollenberg SM. Vasodilators in acute heart failure. Heart Fail Rev. One-half of patients in the study had new or persistent AKI.
The development or progression of AKI, regardless of the level of fluid balance and positive end-expiratory pressure, was strongly associated with the CVP level. This suggests participation of venous congestion in the physiopathology of AKI in severe sepsis and septic shock. Although the role of renal hypoperfusion low cardiac output or hypovolemia is believed to contribute to the development of sepsis-induced renal dysfunction, AKI appears to be only partially reversible after the optimization of systemic hemodynamics [ 18 ].
Fluid resuscitation and pressure optimization is a landmark treatment for septic patients in order to improve renal perfusion pressure.
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For some patients, the induced CVP elevation may overcome the DAP increase, reducing renal perfusion with harmful effects on renal function. This aspect is supported by the recently reported association between fluid overload and mortality in critically ill patients, especially in patients with AKI or septic shock [ 19 ]. The creation of a vicious circle with oliguria and fluid-loading may then aggravate AKI. Therefore, targeting a pre-defined CVP as a therapeutic target might not be suitable in septic patients.
Legrand and colleagues suggested instead that hemodynamic targets are best achieved at low CVPs that is, a CVP less than 8 to 12 mmHg [ 18 ]. Therefore, a strategy of fluid restriction in these patients is an important option to be considered.
Poukkanen and coworkers [ 21 ] evaluated if a higher MAP maintained during the first 24 hours of ICU admission is associated with a lower risk of progression of AKI in patients with severe sepsis.
More than patients with severe sepsis were enrolled in this prospective observational study. AKI progressed in patients These authors also found that chronic kidney disease, higher lactate, higher dose of furosemide, use of dobutamine and time-adjusted MAP below 73 mmHg were independent predictors of progression of AKI.
Interestingly, a more recent randomized controlled trial assigning septic shock patients to arms with MAP targets of 80 to 85 mmHg high-target group or 65 to 70 mmHg low-target group found renal outcome differences only in patients with chronic hypertension [ 22 ]. The main difference between the observational study of Poukkanen and colleagues and the prospective SEPSISPAM study is that, in the first, hypotensive patients were those with the highest vasopressor loads and, in the second, the high target group received the largest amount of vasoactive drugs.
It can only be concluded that, possibly, the underlying septic syndrome severity rather than MAP or inotropic score is the most important determinant of renal function. Outcome The impact of AKI on long-term clinical outcomes still remains controversial. However, long-term outcomes in a larger setting of patients still remain to be fully evaluated. For this purpose, Hansen and coworkers [ 23 ] conducted a cohort study including 1, patients scheduled for acute or elective cardiac surgery in order to examine the 5-year risk of death, myocardial infarction, and stroke after elective cardiac surgery complicated by AKI.
Patients where followed from the fifth post-operative day until myocardial infarction, stroke or death happened within 5 years. A total of The 5-year risk of death was The corresponding adjusted hazard ratio HR of death was 1.
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The 5-year risk of myocardial infarction was 5. The 5-year risk of stroke was 5. Adjusted HRs were 1. AKI within 5 days after elective cardiac surgery was associated with increased 5-year mortality but not with increased risk of myocardial infarction or stroke. In line with these results the work of Lopez-Delgado and coworkers [ 24 ] evaluated the impact of AKI on short- and long-term outcome 6.
Joining the different points of view and the various elements of knowledge will help to multiply the understanding of the complex syndrome and will allow to minimize possibility of errors or oversights. In light of the recent recommendation of precision medicine [ 10 , 11 , 12 ,] a team may better allow targeting treatments specifically chosen for an individual to find the best fit for this specific patient.
This will also provide a global vision of the patient rather than an organ-specific interpretation of a syndrome. Physicians should combine knowledge and expertise, be modest and collegial, be constructive and interdisciplinary in their approach to patient care [ 9 ].
AKI management is a continuum from detection to treatment, starts with an increase of susceptibility and might end with a complete failure of the organ because the approach of AKI does not often include continuous re-evaluation of treatment and need of RRT [ 6 , 13 ].
Early nephrology consultation for hospital-acquired AKI has been associated with reduced need for RRT, reduced mortality and reduced length of hospital stay [ 16 ]. Early identification of AKI may allow the application of protective measures and suitable management, geared to reduce progression and improve renal recovery [ 6 , 17 ].
AKI is a short-term event that can, however, have a sequel up to 3 months or even later late recovery [ 18 ]. In this view, we strongly advocate the inclusion of nephrology divisions into the critical care and emergency departments rather than in the department of medicine.
The need for a nephrologist in the ICU as a permanent staff member could be justified because of the high incidence of AKI. Nephrologists should make rounds in the ICU together with ICU physicians to avoid the development of emergency conditions that require urgent extracorporeal therapies [ 19 , 20 ]. The time of initiation of RRT can therefore be defined by every single patient need as suggested by precision medicine rather than being justified by conflicting randomized controlled trials [ 21 , 22 ].
Recently the ADQI consensus group proposed to uniform and harmonize the scientific language concerning RRTs in critically ill patients [ 23 , 24 , 25 ].
Standardization of terminology is also quintessential for the optimal utilization of big data files and electronic medical records in future pragmatic trials [ 10 ].
Clinicians must therefore take advantage of new technology to improve clinical care and patient outcome [ 6 , 26 ].
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Previous efforts have been taken to make a consensus about the importance of working together as a team in the area of CCN.
Ideally, this approach should provide significant benefits to the critically ill patients. However, there is still a lot of room for further improvement in many clinical settings to achieve a real implementation of a multidisciplinary approach to AKI, preventive strategies, management options and all actions tailored to specific patient's need or specific disease condition [ 10 ].
Standard criteria and decision making algorithms necessary to encompass the variety of factors that can influence clinical outcomes can only be developed in a collegial environment. From our experience in Vicenza, the implementation of the nephrology rapid response team [ 27 ] is one of the most advanced applications of the concept of CCN philosophy.
We hope that many other centers will implement the same project and will verify the utility of this multidisciplinary approach based on precision medicine. For additional information: All rights reserved.
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In each group.
Renal failure is common. Early identification of patients at risk and timely intervention in case of AKI diagnosis can be obtained by integrating the role of nephrologist in the ICU practice.
A modification of the urine osmolar gap: Ann Emerg Med Inotropic agents should be administered to any patient who does not respond to fluids or has pulmonary congestion.
The primary disadvantage of these agents is the risk of hypernatremia.