Acute kidney injury (AKI) is widely prevalent in the intensive care unit and is associated with significant morbidity and mortality. However, no accurate prediction model exists to determine which AKI cases will progress and, if so, to what severity. Chawla et al developed and standardized a furosemide stress test (FST), and Koyner et al assessed the utility of the FST plus biomarkers for prediction of AKI severity. The development of the FST and utility of the FST plus biomarkers were studied in the same two cohorts. Ultimately, the studies proposed, respectively, that (1) the FST in early AKI identifies those with severe and progressive AKI, and (2) the addition of biomarker levels to the FST improves the risk stratification of these patients.
In the end, the FST showed that, at the two-hour time point, urine output of 200 mL or less had the best sensitivity and specificity to predict progression to Acute Kidney Injury Network (AKIN) stage 3. The studies also showed that the FST was superior to the panel of biochemical biomarkers for all end points.
Early fluid resuscitation remains an integral therapy in most critically ill children with sepsis. However, as of late, an increasing body of literature (i.e., studies by Modem et al and Sutherland et al) has reported that fluid overload in critical illness may be associated with increasing mortality. Sinitsky and colleagues investigated the association of early fluid overload with respiratory parameters and mortality in a general pediatric intensive care unit (PICU) population.
The authors found that, in this general PICU population, fluid overload percent (%FO) at 48 hours was associated with oxygenation index at 48 hours and need for invasive ventilation in survivors. However, no association was detected between %FO and mortality.
Acute renal failure (ARF) requiring dialysis is a common and frequently lethal problem encountered in the intensive care unit (ICU). Despite two multicenter trials and a meta-analysis, a survival benefit for continuous venovenous hemofiltration (CVVH) versus intermittent hemodialysis (IHD) renal replacement therapy has not been convincingly demonstrated. Schefold and colleagues conducted the CONVINT trial (continuous versus intermittent renal replacement therapy on the outcome of critically ill patients with acute renal failure) to study the impact of the initial choice of renal replacement therapy on patient outcomes in a medical ICU.
The authors concluded that IHD and CVVH might be considered equivalent approaches for a population of critically ill patients with dialysis-dependent ARF treated in a medical ICU. The study has several major limitations. For example, CVVH dosing practices used may differ from those employed at other institutions, potentially limiting the external generalizability. Nevertheless, data from this trial add to the accumulating evidence that CVVH may be equivalent to IHD in selected ICU populations.
More than 90,000 patients await kidney transplant, according to the U.S. Organ Procurement and Transplantation Network. Approximately 16,000 transplants occur every year, but 35,000 patients are added to the list annually.
Because of this growing list of patients with end-stage renal disease who need new kidneys, transplant surgeons are seeking innovative ways to increase the donor pool. Recently, a number of transplant surgeons began utilizing younger and smaller kidney donors by transplanting their organs en bloc into single recipients. Common reported complications of using smaller kidneys include increased graft thrombosis and hyperfiltration injury. However, in their report on outcomes utilizing kidneys transplanted from donors weighing less than 15 kg (even some less than 10 kg), Sharma and coworkers reported 5-year graft survival at 92%, statistically no different than standard deceased or living donor kidney transplants.
The presence of acute kidney injury (AKI) and fluid overload can adversely affect outcomes in children with critical illness. Continuous renal replacement therapy (CRRT) is one therapeutic modality that can improve outcomes in these patients. However, the trigger when to initiate this therapy is not known. There are studies suggesting that degree of fluid overload may be such a trigger but this does not seem to provide the entire answer. In adults, some studies have suggested that early initiation of CRRT in critically ill patients can improve outcomes compared to late initiation, although there is a paucity of evidence in children. The authors of this study sought to assess the effect timing of CRRT has on mortality in critically ill children.
The U.S. Food and Drug Administration (FDA) has found data that indicate an increased risk of mortality and renal injury requiring renal replacement therapy in critically ill adult patients treated with hydroxyethyl starch (HES) solutions. HES solutions are used for the treatment of hypovolemia when plasma volume expansion is indicated. After a public workshop, the FDA concluded that HES solutions should not be used in this patient population, and a Boxed Warning to include the risk of mortality and severe renal injury is warranted. In addition, the FDA reviewed a meta-analysis of studies conducted in patients undergoing open heart surgery in association with cardiopulmonary bypass and determined that an additional warning about excessive bleeding was needed in the Warnings and Precautions Section of the package insert. The FDA has created a list of recommendations for patients and healthcare providers to consider before use of HES solutions.
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