Die akute Nierensch?digung

Acute kidney injury plays a pivotal role in intensive care medicine and exerts crucial adverse effects on the course of the disease and overall prognosis of the critically ill patient. Intensive renal support, including initiation of earlier dialysis or maximal uremic toxin removal by higher dosage and frequency of renal replacement therapy, and individualized selection of modality were not able to decrease excessive mortality in this population. Systemic acute inflammation, mediated, at least in part, by cytokines, and not secondary uremic side effects, seems to have a major impact on nonrenal organ damage. Assessment of short-term outcome in critically ill patients who develop acute kidney injury may underestimate the true burden of disease. The overall survival at 5?years in patients discharged alive after severe acute kidney injury necessitating renal replacement therapy is only 20?C30%, comparable to cancer patients. In addition, acute renal damage was identified as an independent risk factor for progression of chronic renal insufficiency. Current research focuses on strategies for the prevention of acute kidney injury and on the establishment of effective biomarkers for the early recognition and accurate diagnosis of subclinical renal damage.     

Management of Acute Renal Dysfunction in Sepsis

Acute kidney injury (AKI) often complicates sepsis, leading to greater complexity and a worsening prognosis. Advances in the clinical management of sepsis may have secondary benefits with respect to renal outcomes. In critically ill patients, this disorder typically produces multiple organ dysfunction. Among the several disorders encountered in sepsis, AKI is one of the most important because it is a life-threatening condition, increases the complexity and cost of care, and is an independent risk factor for mortality. The potential interventions in sepsis-related AKI consist of effective prevention/protection strategies for the kidney in patients at risk, early recognition and attenuation of renal damage, pathophysiology-driven pharmacologic support, efficient extracorporeal blood purification therapy, and strategies that promote recovery of renal function. Existing and hybrid extracorporeal therapies are being investigated not only as means to replace lost kidney function, but also to modulate the immune response to sepsis.     

Contrast-induced acute kidney injury

Cardiac angiography and coronary/vascular interventions depend on iodinated contrast media and consequently pose the risk of contrast-induced acute kidney injury (AKI). This is an important complication that accounts for a significant number of cases of hospital-acquired renal failure, with adverse effects on prognosis and health care costs. The epidemiology and pathogenesis of contrast-induced AKI, baseline renal function measurement, risk assessment, identification of high-risk patients, contrast medium use, and preventive strategies are discussed in this report. An advanced algorithm is suggested for the risk stratification and management of contrast-induced AKI as it relates to patients undergoing cardiovascular procedures. Contrast-induced AKI is likely to remain a significant challenge for cardiologists in the future because the patient population is aging and chronic kidney disease and diabetes are becoming more common.     

Akutes Nierenversagen bei Sepsis

Acute renal failure has a major impact on the prognosis of septic patients. Changes in the understanding of the pathophysiology and more precise definitions of acute kidney injury (AKI) are expected to lead to improved therapeutic options in the future. At present early recognition, early targeted fluid therapy with crystalloids and vasopressors, as well as the avoidance of nephrotoxic substances are the key measures in prevention and therapy of AKI. If renal replacement therapy (RRT) becomes necessary it should be started promptly following ICU admission. Different modalities of RRT with various advantages and disadvantages are available and should be applied differentially. While a sufficient dose of RRT is important, new studies suggest that further dose increases do not lead to improved outcome.     

Pharmacokinetics of antibiotics in continuous renal replacement therapies (CRRT)

In the critically ill patient, acute kidney injury (AKI) is frequently associated with infective complications requiring appropriate antimicrobial treatment. AKI and multiple organ dysfunction syndrome can affect the pharmacokinetic parameters of many drugs. Furthermore, the start of renal replacement therapy (RRT) is an additional variable to be taken into consideration to avoid inappropriate antimicrobial therapy. Continuous renal replacement therapies (CRRT) are widely adopted in the intensive care unit (ICU) and antibiotics that are significantly eliminated by the kidney are likely to be removed during RRT. Generally, drug-dosing adjustments are required if the extracorporeal clearance accounts for more than 25-30% of the total body clearance. The molecular weight cutoffs of the more widely used membranes are much higher than the molecular weight of most drugs. Therefore, molecular size will not be a limitation for the removal of the unbound fraction of the antibiotics most commonly used in ICU patients. However, CRRTs are still not standardized and the impact of RRT on plasma drug concentrations can be substantially different depending on the CRRT modality (diffusive, convective or both), membrane characteristics and delivered dialysis dose. In any case, drug-dosing adjustments should be based on the knowledge of the pharmacokinetic and pharmacodynamic properties of the different classes of antimicrobials, taking into account that high extracorporeal clearances could lead to drug underexposure in clinical conditions where appropriate antibiotic treatment is essential.     

Acute kidney injury: what's the prognosis?

Acute kidney injury (AKI) is common (especially during critical illness), increasing in incidence, and is associated with considerable morbidity and mortality. The Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE) classification currently provides a standardized estimate of incidence and outcomes from AKI. Despite advances in the understanding of the pathogenesis of human AKI, our ability to assess kidney function is limited and functional impairment poorly correlates with structural injury to the kidneys. Emerging novel biomarkers are, however, likely to further enhance risk stratification, facilitate early diagnosis, enable early enrollment in therapeutic trials, and assess prognosis. Sepsis remains the leading cause of AKI among the critically ill and over the past few years insights into the pathogenesis of AKI in sepsis are beginning to shift attention from renal blood flow to inflammation-mediated organ injury. Emerging evidence suggests that survivors of AKI incur long-term risks for developing chronic kidney disease and end-stage renal disease compared with those without AKI. Despite decades of research, no specific therapy for AKI other than supportive care currently exists and further work is required to better understand the pathogenesis of AKI during critical illness and to develop novel treatments.     

Timing for Initiation of Continuous Renal Replacement Therapy in Patients With Septic Shock and Acute Kidney Injury

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into “early” (simplified RIFLE Risk) or “late” (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long‐term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty‐one (26%) underwent “early” while 89 (74%) had “late” CRRT. No significant difference was noted between groups on improvement of total SOFA/non‐renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non‐renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non‐renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.     

Extracorporeal blood purification in sepsis and sepsis-related acute kidney injury

Sepsis-related acute kidney injury (AKI) is an important complicating feature of sepsis, and is associated with greater complexity of care and higher mortality. Until recently, AKI lacked a standard, widely accepted definition, rendering it difficult to compare previously published strategies to prevent, recognize and treat this entity. Recently, the RIFLE classification of AKI has been developed, and confirmed in observational studies to be associated with subsequent morbidity and mortality. The management of sepsis-related AKI is evolving with new basic discoveries and ongoing translational clinical research, and will likely include nephroprotective strategies to protect kidneys in patients at risk, early recognition and amelioration of renal damage and pharmacological interventions to minimize injury and promote recovery. Furthermore, extracorporeal blood purification (EBP) has an important role to play, not only in the replacement of certain aspects of renal organ function such as acid-base/electrolyte homeostasis and extracellular fluid volume, but also in an immunomodulatory fashion. As a therapy that has the potential to influence the course of disease in sepsis, EBP in sepsis and sepsis-related AKI is the subject of this review.     

老年单纯急性肾损伤与AonC近期预后分析

目的研究急性肾损伤(AKI)患者与慢性肾脏病(CKD)合并AKI(AonC)患者的预后。方法入选北京友谊医院医疗保健中心2009年8月至2013年10月期间收治的AonC患者147例,男性105例,女性42例,年龄(83.95±7.04)岁;同期单纯AKI患者270例,男性226例,女性44例,年龄(81.75±6.98)岁,比较两组患者近期(1年内)预后。结果单纯AKI患者随访30 d时的病死率高于AonC患者,差异有统计学意义(P0.05),随访90 d和1年时的病死率差异无统计学意义(P0.05);两组存活患者的肾功能恢复率差异无统计学意义(P0.05);不同估算肾小球滤过率(eGFR)水平的AonC患者随访30 d、90 d和1年病死率的差异无统计学意义(P0.05)。Cox多因素回归分析表明是否合并CKD与患者30 d病死率无关(P=0.068),与AKI分期、合并贫血、低蛋白血症、心力衰竭、恶性肿瘤和多器官功能障碍综合征(MODS)相关,肾脏替代治疗(RRT)为保护性因素。结论老年AKI患者患病率和病死率高,是否合并CKD与近期预后无明显相关。     

Rhabdomyolysis-Associated Acute Kidney Injury With Normal Creatine Phosphokinase

Rhabdomyolysis is a syndrome characterized by the breakdown of skeletal muscle and leakage of intracellular myocyte contents, such as creatine phosphokinase (CPK) and myoglobin, into the interstitial space and plasma resulting in acute kidney injury (AKI). Elevated CPK of at least 5 times the upper limit of normal is an important diagnostic marker of Rhabdomyolysis. We present a case of rhabdomyolysis with severe AKI with a normal CPK at presentation. A 32-year-old man presented with acute respiratory failure and AKI after an overdose of recreational drugs. Urinalysis at presentation showed trace amounts of blood, identified as rare red blood cells under microscopy. CPK was 156 U/L at presentation. Workup for glomerulonephritis and vasculitis was negative. He was initiated on renal replacement therapy, and a kidney biopsy showed severe acute tubular injury with positive myoglobin casts. Supportive management and renal replacement therapy was provided, and renal function spontaneously improved after a few weeks. This is an uncommon clinical presentation of severe rhabdomyolysis complicated by AKI. This suggests that CPK alone may not be a sensitive marker for rhabdomyolysis-induced AKI in some cases.     

短暂性与持续性急性肾损伤诊断及预后

急性肾损伤(AKI)是临床常见的危急重症,死亡率高,预后差,其诊断有赖于血肌酐的升高和尿量的减少。AKI目前尚无有效的治疗方法,严重时需进行肾脏替代治疗。2002年至2017年期间先后4次更新了AKI指南与共识,这对于早期识别AKI患者起到积极作用。但现有的AKI定义中,并未区分短暂性AKI和持续性AKI,现就目前短暂性与持续性AKI病理学、诊断治疗及远期预后的研究进展进行综述。     

The use of cell cycle arrest biomarkers in the early detection of acute kidney injury. Is this the new renal troponin?

Acute kidney injury (AKI) has a high prevalence in critical care patients. Early detection might prevent patients from developing chronic kidney disease and requirement for renal replacement therapy. If we compare AKI with acute coronary syndrome, in which an increase in cardiac troponin may trigger early diagnosis and therapeutic intervention, we could extrapolate a similar technique in patients with early AKI without changes in urinary frequency or serum creatinine. The objective is to identify biomarker-positive, creatinine-negative patients that would allow therapeutic interventions to be initiated before finding changes in serum creatinine, preventing kidney damage. Tissue inhibitor of metalloproteinase 2 and insulin-like growth factor binding protein 7 are cell cycle arrest biomarkers that have demonstrated, in recent clinical trials, to have good sensitivity and specificity for early detection of AKI. Other recent studies have shown that the joint use of these biomarkers with serum creatinine and urine production could improve the prognosis of AKI in critical patients. The application of these biomarkers in clinical practice would enable the early identification of patients at risk of AKI, establishing interventions that would improve the survival of renal function.     

The implications and management of septic acute kidney injury

Sepsis is the most common and severe cause of morbidity and mortality among critically ill patients. Multiple organ dysfunction syndrome often complicates sepsis, leading to a worse prognosis that is proportional to the severity and number of damaged organs. Acute kidney injury (AKI) also complicates sepsis, with a linear relationship between the severity of kidney damage and sepsis prognosis. The management of sepsis and septic AKI involves intensive proactive preventive measures, medical and extracorporeal treatment of established sepsis, support of failing organs and rehabilitation of the residual effects left by this devastating syndrome. Unfortunately, although some innovations in the clinical management of sepsis are now available, their beneficial effects on renal function are still uncertain. The aim of this Review is to provide an update on the current state of interventions in sepsis-related AKI. Prevention, pharmacological support and extracorporeal blood purification for septic AKI will be reviewed and discussed.     

Prevention programs for chronic kidney disease in low-income countries

Chronic kidney disease (CKD) is an important determinant of the poor health outcome for major noncommunicable diseases that are the leading cause of death worldwide. Early recognition with screening programs of CKD and co-morbid conditions, like hypertension, diabetes, or toxic environments, can potentially slow progression to renal failure, improve quality of life and reduce healthcare cost. Effective multimodal tools are available to prevent CKD by managing its risk factors, and to slow or even halt disease progression to end-stage renal failure (ESRF). They can be adapted even to poor-resource settings of low- and middle-income countries for individual at high risk of CKD. CKD is also linked to acute kidney injury (AKI), that in poorest part of Africa, Asia and Latin America is preventable, treatable and often reversible, if managed adequately and in timely manner as proposed by the program "AKI 0by25" launched by the international Society of Nephrology in 2013. In addition to saving lives, prevention programs will create major heath gains, eventually reducing the current health inequity that arises from unaffordable or unobtainable renal replacement therapies in many part of the developing world if ESRF is not prevented.     

Novel biomarkers of acute kidney injury in chronic liver disease: Where do we stand after a decade of research?

Acute kidney injury (AKI) is a frequently encountered complication in decompensated chronic liver disease (CLD) with an estimated prevalence of 20%–50% among hospitalized patients. AKI often heralds the onset of a downhill course in the natural history of CLD. Serum creatinine has several limitations as a stand-alone marker of AKI in patients with decompensated CLD. The concept of hepatorenal syndrome, the prototype of AKI in decompensated CLD, has evolved tremendously over recent years. There is emerging evidence of an additional “structural” component in the pathophysiology of hepatorenal syndrome-AKI, which was previously identified as a purely “functional” form of renal impairment. Lacunae in the existent biochemical arsenal for diagnosis and prognosis of AKI have fueled enthusiastic research in the field of novel biomarkers of kidney injury in patients with cirrhosis. The advent of these biomarkers provides a crucial window of opportunity to improve the diagnosis and clinical outcomes of this vulnerable cohort of patients. This review summarizes the dynamic concept of renal dysfunction in CLD and the available literature on the role of novel biomarkers of AKI in assessing renal function, identifying AKI subtypes, and predicting prognosis. There is special emphasis on the renal tubular injury marker, neutrophil gelatinase-associated lipocalin, the most exhaustively studied biomarker of AKI in the CLD population.     

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??Abstract??As the growth of age??the aging of renal structure and function??self-adjusting capacity of the kidney is decreased??and the morbidity of acute kidney injury (AKI) is increased significantly in the elderly.AKI is one of the main risk factors increasing the mortality of hospitalized elderly patients prolonging the length of hospital stay and undergoing renal replacement therapy??and it is closely related to prognosis of the elderly.Although medical treatment level is progressing rapidly??prognosis of AKI is still not optimistic??especially in the intensive care unit??severe AKI patients are very commonly seen.Due to the lack of effective drugs in prevention and treatment of AKI??blood purification technology is still the main method for treatment of severe AKI.In combination with the latest research progress and experiences of experts??this paper introduces the characteristics of AKI in the elderly and its prevention strategies??so as to provide clinicians with practical guidance and help in management of the elderly patients with AKI.     

The kidney in the critically ill

Acute kidney injury (AKI) is a common and serious complication in the intensive care setting. It seldom occurs in isolation, but is mostly part of a multiple organ dysfunction syndrome. The pathogenesis is frequently multifactorial, with sepsis contributing to 50% of the cases.The development of AKI in critically-ill patients is "bad news": patients with AKI have a high morbidity and mortality. In addition, AKI, even in its mildest from, is not only a marker of illness severity but appears to be independently associated with mortality. Prevention of AKI is therefore a major goal to improve outcome of critically-ill patients. Treatment of established AKI is largely supportive. The optimal modality for renal replacement therapy in critically-ill patients still remains a matter of debate). The majority of survivors recover renal function.     

老年住院患者急性肾损伤病因及预后相关因素分析

目的研究我科老年人急性肾损伤(acute kidney injury,AKI)的发生率、病因构成及预后。方法通过调查2008年我科住院老年(≥60岁)患者肾功能检测结果,筛检出AKI患者,进行复习病史,总结分析患者的临床特征、肾功能受损的性质、导致AKI的基础疾病等。结果共收集患者123例,AKI的发生率占同期老年肾科住院患者的11.28%。肾前性AKI96例(占78.0%),肾实质性AKI20例(占16.3%),肾后性AKI7例(占5.7%)。AKI3期患者衰竭器官数目最多。单因素分析显示,血清白蛋白水平、血红蛋白、衰竭器官数目、血肌酐上升的百分比、血白细胞计数是影响预后的因素。进一步使用logistic回归分析提示器官衰竭数和血肌酐上升百分比是AKI患者死亡的危险因素。结论老年人AKI病因以肾前性所占比例最大,器官衰竭数目和血肌酐上升的百分比(即上升幅度)是影响老年人AKI预后的因素。早期诊断有助于AKI的治愈,提高存活率。     

Sepsis-induced acute kidney injury in patients with cirrhosis

Acute kidney injury (AKI) is a common and life-threatening complication in patients with cirrhosis. Recently, new criteria for the diagnosis of AKI have been proposed in patients with cirrhosis by the International Club of Ascites. Almost all types of bacterial infections can induce AKI in patients with cirrhosis representing its most common precipitating event. The bacterial infection-induced AKI usually meets the diagnostic criteria of hepatorenal syndrome (HRS). Well in keeping with the “splanchnic arterial vasodilation hypothesis”, it has been stated that HRS develops as a consequence of a severe reduction of effective circulating volume related to splanchnic arterial vasodilation and to an inadequate cardiac output. Nevertheless, the role of bacterial infections in precipitating organ failures, including renal failure, is enhanced when their course is characterized by the development of a systemic inflammatory response syndrome (SIRS), thus, when sepsis occurs. Sepsis has been shown to be capable to induce “per se” AKI in animals as well as in patients conditioning also the features of renal damage. This observation suggests that when precipitated by sepsis, the pathogenesis and the clinical course of AKI also in patients with cirrhosis may differentiate to a certain extent from AKI with another or no precipitating factor. The purpose of this review is to describe the features of AKI precipitated by bacterial infections and to highlight whether infection and/or the development of SIRS may influence its clinical course, and, in particular, the response to treatment.     

Continuous Renal Replacement Therapy During Extracorporeal Membrane Oxygenation in Patients Treated in Medical Intensive Care Unit: Technical Considerations

Extracorporeal membrane oxygenation (ECMO) is used as a salvage therapy in refractory acute respiratory distress syndrome (ARDS). Although technological progress in the ECMO systems improved the survival rate, prognosis is still significantly worsened by acute kidney injury (AKI), particularly if renal replacement therapy (RRT) is required. There are no exact guidelines recommending which techniques of ECMO and continuous RRT (CRRT) should be used for management of AKI coexisting with respiratory or circulatory failure, and how to combine them. The aim of this review is to describe methods of CRRT and ECMO simultaneous application, and to present advantages of various technical approaches versus possible complications.