Letter to the Editor: “Acute Renal Failure and Hypercalcaemia: Sarcoidosis May Be the Culprit”

Critically ill patients with acute renal failure are traditionally treated with low-protein diets to help control uremia. This dietary approach may be deleterious to the patient's nutritional status and unnecessary, especially if continuous renal replacement therapies (CRRT) are used. However, the optimal amount of protein supplementation during CRRT is unknown. In patients receiving CRRT, a high protein intake may result in a positive nitrogen balance in the absence of uncontrolled uremia. Accordingly, we studied nitrogen metabolism in two consecutive cohorts of acute renal failure patients receiving equal amounts of calories but variable amounts of nitrogen. One group received protein according to the preferences of the attending clinician, the other a high and fixed amount of protein (2.5 g/kg/day). Patients treated according to attending clinician preferences received significantly less dietary protein (1.2 g/kg/day vs. 2.5 g/kg/day; p < 0.0001) and had a negative mean nitrogen balance of -5.5 g/day. Patients receiving a high and fixed amount of protein had a less negative mean nitrogen balance (-1.92 g/day). Such patients were more likely to experience a positive nitrogen balance during any 24-h period (53.6% vs. 36.7%; p < 0.05). They also required more aggressive hemofiltration to maintain control of uremia (mean ultradiafiltrate volume: 2145 mL/h vs. 1658 mL/h; p < 0.0001) and had a significantly higher but still acceptable mean plasma urea level (26.6 mmol/L vs. 18 mmol/L; p < 0.0001). Survival was not significantly different in the two groups (37.5% vs. 31.3%). We conclude that a high-protein diet can be safely administered to critically ill patients with acute renal failure receiving continuous renal replacement therapy. Such a high protein intake improves nitrogen balance when compared to moderate protein intake. A low protein intake is unnecessary in patients treated with CRRT.     

Acute Sodium Chlorite Poisoning Associated with Renal Failure

Background and Objectives: Different techniques of continuous renal replacement therapy (CRRT) might have different effects on azotemic control. Accordingly, we tested whether continuous veno-venous hemodiafiltration (CVVHDF) or continuous veno-venous hemofiltration (CVVH) would achieve better control of serum creatinine and plasma urea levels. Design: Retrospective controlled study. Setting: Two tertiary Intensive Care Units. Patients: Critically ill patients with acute renal failure (ARF) treated with CVVHDF (n = 49) or CVVH (n = 50). Interventions: Retrieval of daily morning urea and creatinine values before and after the initiation of CRRT for up to 2 weeks of treatment. Measurements and Results: Before treatment, serum urea and creatinine concentrations were significantly lower in the CVVH group than in CVVHDF group (urea: 31.0 ± 15.0 mmol/L for CVVHDF and 24.7 ± 16.1 mmol/L for CVVH, p = 0.01, creatinine: 547 ± 308 µmol/L vs. 326 ± 250 µmol/L, p < 0.0001). These differences were still significant after 48 h of treatment (urea: 20.1 ± 8.3 mmol/L vs. 14.1 ± 6.1 mmol/L; p = 0.0003, creatinine: 360 ± 189 µmol/L vs. 215 ± 118 µmol/L; p < 0.0001). Throughout the duration of therapy, mean urea levels (22.3 ± 9.0 mmol/L for CVVHDF vs. 16.7 ± 7.8 mmol/L for CVVH, p < 0.0001) and mean creatinine levels (302 ± 167 vs. 211 ± 103 µmol/L, p < 0.0001) were better controlled in the CVVH group. Conclusions: CRRT strategies based on different techniques might have a significantly different impact on azotemic control.     

中医药治疗慢性肾衰竭疗效的系统评价

目的：评价中医药治疗慢性肾衰竭是否有助于提高临床疗效。方法：随机对照试验系统评价;采用电子和手工检索中国生物医学文献数据库CBMdisc、中国期刊全文数据库CNKI、维普资讯中文科技期刊数据库、Pubmed数据库和国内相关中医期刊;搜集和比较中药结合西药与单纯西药治疗慢性肾衰竭的临床随机对照试验;采用Cochrance协作网Review Manager4.2进行统计分析。结果：共纳入RCTs16篇,共1305例病人,Meta-分析结果表明,中西医结合治疗对慢性肾衰竭的临床疗效比单纯西医治疗有提高作用。但是,这些研究存在许多方法学上的问题,导致分析结果可信性降低。结论：中医药治疗能提高慢性肾衰竭的临床疗效,但这需要严格设计的大样本、多中心的随机双盲对照实验和系统评价来进一步证实。     

谷氨酰胺增强型肠内营养对危重病患者临床结局的影响:随机对照试验的系统评价

目的 系统评价谷氨酰胺(Gln)增强型肠内营养治疗对危重病患者预后及治疗费用的影响.方法 检索8个生物医学数据库(<中国生物医学文献数据库>、、<科学引文索引数据库>等)1976年以后的文献资料.鉴定随机对照试验(RCT),纳人研究的标准包括:(1)采用随机对照的临床研究,设立平行对照;(2)危重病患者,急性生理与慢性健康评估评分Ⅱ大于10分或烧伤面积大于30%TBSA者;(3)以肠内营养中是否添加Gln作为研究组与对照组的惟一差别;(4)临床结局指标包括患者死亡、院内感染、器官功能衰竭发生情况、住院日及费用.研究方法学质量按照Cochrane系统评价员手册及Jadad评分量表进行评定.用Rev Man 5.0软件进行Meta分析.结果 224篇相关文献中,共7项RCT符合全部纳入标准.死亡情况:共5项研究报告了545例患者中的死亡例数,研究间无异质性(P=0.46),合并相对危险度(RR)为0.94,95%置信区间(CI)为0.68～1.30,P=0.70.Gln组死亡风险与对照组比较,差异无统计学意义(P>0.05).院内感染:共3项研究报告了489例患者中的院内感染发生情况.研究间无异质性(P=0.08),采用固定效应模型,合并RR=0.72,95%CI为0.52～0.99,P=0.04.与对照组比较,Gln组院内感染率下降了28%.器官功能衰竭:共3项研究报告了460例患者中发生器官功能衰竭或MODS的情况,研究间无异质性(P=0.65),采用固定效应模型,合并RR=1.27,95%CI为0.70～2.30,P=0.43.Gln组与对照组比较,差异无统计学意义(P>0.05).住院时间:4项研究报告了患者入住重症监护病房(ICU)的时间,其中3项研究以中位数(四分位间距)形式表示结果,2组患者比较差异无统计学意义(P>0.05);另1项研究给出了2组患者入住ICU时间的x±s,差异亦无统计学意义(P>0.05).此外,有3项关于重症烧伤患者的研究给出了住院时间,研究间无异质性(P=0.08),采用固定效应模型,合并均数差值为-7.24,95%CI为-13.28～-1.19,P=0.02.与对照组比较,Gln组住院时间约缩短7.24 d.结论 Gln增强型肠内营养用于危重病患者,可以降低院内感染的发生率,有可能缩短重症烧伤患者住院时间,但病死率及经济学指标尚需进行更多大样本研究进一步验证.     

Kidney and contrast media: Common viewpoint of the French Nephrology societies (SFNDT,FIRN, CJN) and the French Radiological Society (SFR) following ESUR guidelines

Contrast medium administration is classically considered to cause or worsen kidney failure, but recent data may moderate this assertion. The European Society of Urogenital Radiology recently published guidelines re-evaluating the precautions before administering contrast media. Kidney injury does not constitute a contra-indication to the administration of iodinated contrast medium, as long as the benefit–risk ratio justifies it. Intravenous hydration with 0.9% NaCl or 1.4% sodium bicarbonate is the only validated measure for the prevention of post-iodine contrast nephropathy. This is necessary for intravenous or intra-arterial administration of iodinated contrast agent without first renal pass when the glomerular filtration rate is less than 30 mL/min/1.73 m², for intra-arterial administration of iodinated contrast agent with first renal passage when the glomerular filtration rate is less than 45 mL/min/1.73 m², or in patients with acute renal failure. The use of iodinated contrast medium should allow the carrying out of relevant examinations based on an analysis of the benefit–risk ratio and the implementation of measures to prevent toxicity when necessary.