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Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Prevention and treatment of sepsis-induced acute kidney injury: an update. Ann Intensive Care 2015; 5:51. [PMID: 26690796 PMCID: PMC4686459 DOI: 10.1186/s13613-015-0095-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive “kidney afterload” are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients’ refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rita Jacobs
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Inne Hendrickx
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Olivier Joannes-Boyau
- Haut Leveque University Hospital of Bordeaux, University of Bordeaux 2, Pessac, France.
| | - Willem Boer
- Department of Anaesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Elisabeth De Waele
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Viola Van Gorp
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Herbert D Spapen
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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202
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Association Between Progression and Improvement of Acute Kidney Injury and Mortality in Critically Ill Children. Pediatr Crit Care Med 2015; 16:703-10. [PMID: 26132741 DOI: 10.1097/pcc.0000000000000461] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine whether the progression and/or improvement of acute kidney injury in critically ill children is associated with mortality. DESIGN Retrospective. SETTING Multidisciplinary, tertiary care, 24-bed PICU. PATIENTS A TOTAL OF: 8,260 patients who were 1 month to 21 years old with no chronic kidney disease admitted between May 2003 and March 2012. INTERVENTIONS We analyzed patients based on their acute kidney injury stage as per the Kidney Disease Improving Global Outcomes acute kidney injury serum creatinine staging criteria on ICU admission, peak (highest acute kidney injury stage reached), and trough (lowest acute kidney injury stage after the peak) during their ICU stay. Nonrenal organ dysfunction was measured with a modified Pediatric Logistic Organ Dysfunction score. The primary outcome was 28-day mortality. p values were based on Yates-corrected chi-square test and logistic regression. MEASUREMENTS AND MAIN RESULTS Of the 8,260 patients, 529 (6.4%) had acute kidney injury on ICU admission and 974 (11.8%) had acute kidney injury during their ICU course. The 28-day mortality was 2.7% for patients with no acute kidney injury and 25.3% for patients with acute kidney injury. Patients in whom acute kidney injury developed or had worsening acute kidney injury from admission to peak and reached acute kidney injury stage 2 or 3 had higher mortality than those who remained at an acute kidney injury stage 1 (17.3-17.8% vs 32.2-37.9%; p ≤ 0.003). Patients whose acute kidney injury resolved after the peak had lower mortality than those who retained the same degree of acute kidney injury (9-13.5% vs 37.3-44%; p ≤ 0.04). Patients with acute kidney injury that resolved still had higher mortality than those who never developed acute kidney injury (11.2% vs 2.7%; p < 0.001). Multivariate regression demonstrated that the association between mortality and acute kidney injury progression was independent of severity of illness at admission and the severity of nonrenal organ dysfunction during the first week of ICU stay (p ≤ 0.01). CONCLUSION Progression of acute kidney injury per the Kidney Disease Improving Global Outcomes staging criteria is independently associated with increased mortality in the PICU while its improvement is associated with a stepwise decrease in mortality.
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203
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Abstract
Fluid therapy is the most common intervention received by acutely ill hospitalized patients; however, important questions on its optimal use remain. Its prescription should be patient and context specific, with clear indications and contradictions, and have the type, dose, and rate specified. Any fluid therapy, if provided inappropriately, can contribute unnecessary harm to patients. The quantitative toxicity of fluid therapy contributes to worse outcomes; this should prompt greater bedside attention to fluid prescription, fluid balance, development of avoidable complications attributable to fluid overload, and for the timely deresuscitation of patients whose clinical status and physiology allow active fluid mobilization.
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Affiliation(s)
- Oleksa Rewa
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street Northwest, Edmonton, Alberta T6G 2B7, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440-112 Street Northwest, Edmonton, Alberta T6G 2B7, Canada.
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204
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Abstract
Acute kidney injury (AKI) is a clinical diagnosis guided by standard criteria based on changes in serum creatinine, urine output, or both. Severity of AKI is determined by the magnitude of increase in serum creatinine or decrease in urine output. Patients manifesting both oliguria and azotemia and those in which these impairments are persistent are more likely to have worse disease and worse outcomes. Short- and long-term outcomes are worse when patients have some stage of AKI by both criteria. New biomarkers for AKI may substantially aid in the risk assessment and evaluation of patients at risk for AKI.
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Affiliation(s)
- John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, 604 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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205
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Abstract
Most critically ill patients experience external or internal fluid shifts and hemodynamic instability. In response to these changes, intravenous fluids are frequently administered. However, rapid losses of administered fluids from circulation and the indirect link between the short-lived plasma volume expansion and end points frequently result in transient responses to fluid therapy. Therefore, fluid overload is a common finding in intensive care units. The authors consider the evidence of harm associated with fluid overload and the physiologic processes that lead to fluid accumulation in critical illness. The authors then consider methods to prevent fluid accumulation and/or manage its resolution.
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Affiliation(s)
- Michael E O'Connor
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK; Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK; Centre for Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; Department of Renal and Transplant Medicine, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK.
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206
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Ronco C, Ricci Z, De Backer D, Kellum JA, Taccone FS, Joannidis M, Pickkers P, Cantaluppi V, Turani F, Saudan P, Bellomo R, Joannes-Boyau O, Antonelli M, Payen D, Prowle JR, Vincent JL. Renal replacement therapy in acute kidney injury: controversy and consensus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:146. [PMID: 25887923 PMCID: PMC4386097 DOI: 10.1186/s13054-015-0850-8] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Renal replacement therapies (RRTs) represent a cornerstone in the management of severe acute kidney injury. This area of intensive care and nephrology has undergone significant improvement and evolution in recent years. Continuous RRTs have been a major focus of new technological and treatment strategies. RRT is being used increasingly in the intensive care unit, not only for renal indications but also for other organ-supportive strategies. Several aspects related to RRT are now well established, but others remain controversial. In this review, we review the available RRT modalities, covering technical and clinical aspects. We discuss several controversial issues, provide some practical recommendations, and where possible suggest a research agenda for the future.
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Affiliation(s)
- Claudio Ronco
- Department Nephrology Dialysis & Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Viale Rodolfi, 36100, Vicenza, Italy.
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Daniel De Backer
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Michael Joannidis
- Division of Emergency and Intensive Care Medicine, Department of Internal Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Centre, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, University of Torino, Azienda Ospedaliera Universitaria 'Città della Salute e della Scienza di Torino Presidio Molinette', Corso Bramante 88, 10126, Turin, Italy.
| | - Franco Turani
- Department of Intensive Care, Aurelia Hospital and European Hospital, Via Portuense 694, 00416, Rome, Italy.
| | - Patrick Saudan
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 4 rue Gabrielle Perret-Gentil, CH 1211, Geneva, Switzerland.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - Olivier Joannes-Boyau
- Centre Hospitalier Universitaire (CHU) de Bordeaux, Service d'Anesthésie-Réanimation 2, Avenue de Magellan, F-33600, Pessac, France.
| | - Massimo Antonelli
- Università Cattolica del Sacro Cuore - Policlinico Universitario A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, 7 Denis Diderot, 75475, Paris, Cedex 10, France.
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health, Whitechapel Road, London, E1 1BB, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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207
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Powell TC, Warnock DG. The Furosemide Stress Test and Predicting AKI Outcomes. J Am Soc Nephrol 2015; 26:1762-4. [PMID: 25655066 DOI: 10.1681/asn.2014121160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - David G Warnock
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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208
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Koyner JL, Davison DL, Brasha-Mitchell E, Chalikonda DM, Arthur JM, Shaw AD, Tumlin JA, Trevino SA, Bennett MR, Kimmel PL, Seneff MG, Chawla LS. Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity. J Am Soc Nephrol 2015; 26:2023-31. [PMID: 25655065 DOI: 10.1681/asn.2014060535] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/19/2014] [Indexed: 01/22/2023] Open
Abstract
Clinicians have access to limited tools that predict which patients with early AKI will progress to more severe stages. In early AKI, urine output after a furosemide stress test (FST), which involves intravenous administration of furosemide (1.0 or 1.5 mg/kg), can predict the development of stage 3 AKI. We measured several AKI biomarkers in our previously published cohort of 77 patients with early AKI who received an FST and evaluated the ability of FST urine output and biomarkers to predict the development of stage 3 AKI (n=25 [32.5%]), receipt of RRT (n=11 [14.2%]), or inpatient mortality (n=16 [20.7%]). With an area under the curve (AUC)±SEM of 0.87±0.09 (P<0.0001), 2-hour urine output after FST was significantly better than each urinary biomarker tested in predicting progression to stage 3 (P<0.05). FST urine output was the only biomarker to significantly predict RRT (0.86±0.08; P=0.001). Regardless of the end point, combining FST urine output with individual biomarkers using logistic regression did not significantly improve risk stratification (ΔAUC, P>0.10 for all). When FST urine output was assessed in patients with increased biomarker levels, the AUC for progression to stage 3 improved to 0.90±0.06 and the AUC for receipt of RRT improved to 0.91±0.08. Overall, in the setting of early AKI, FST urine output outperformed biochemical biomarkers for prediction of progressive AKI, need for RRT, and inpatient mortality. Using a FST in patients with increased biomarker levels improves risk stratification, although further research is needed.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | | | | | - John M Arthur
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James A Tumlin
- Renal Division, University of Tennessee College of Medicine at Chattanooga, Chattanooga, Tennessee
| | - Sharon A Trevino
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Michael R Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, Ohio; and
| | - Paul L Kimmel
- Department of Medicine, George Washington University Medical Center, Washington DC
| | | | - Lakhmir S Chawla
- Department of Medicine, Division of Intensive Care Medicine and Division of Nephrology, Washington DC Veterans Affairs Medical Center, Washington, DC
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209
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Kellum JA, Sileanu FE, Murugan R, Lucko N, Shaw AD, Clermont G. Classifying AKI by Urine Output versus Serum Creatinine Level. J Am Soc Nephrol 2015; 26:2231-8. [PMID: 25568178 DOI: 10.1681/asn.2014070724] [Citation(s) in RCA: 342] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/17/2014] [Indexed: 12/14/2022] Open
Abstract
Severity of AKI is determined by the magnitude of increase in serum creatinine level or decrease in urine output. However, patients manifesting both oliguria and azotemia and those in which these impairments are persistent are more likely to have worse disease. Thus, we investigated the relationship of AKI severity and duration across creatinine and urine output domains with the risk for RRT and likelihood of renal recovery and survival using a large, academic medical center database of critically ill patients. We analyzed electronic records from 32,045 patients treated between 2000 and 2008, of which 23,866 (74.5%) developed AKI. We classified patients by levels of serum creatinine and/or urine output according to Kidney Disease Improving Global Outcomes staging criteria for AKI. In-hospital mortality and RRT rates increased from 4.3% and 0%, respectively, for no AKI to 51.1% and 55.3%, respectively, when serum creatinine level and urine output both indicated stage 3 AKI. Both short- and long-term outcomes were worse when patients had any stage of AKI defined by both criteria. Duration of AKI was also a significant predictor of long-term outcomes irrespective of severity. We conclude that short- and long-term risk of death or RRT is greatest when patients meet both the serum creatinine level and urine output criteria for AKI and when these abnormalities persist.
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Affiliation(s)
- John A Kellum
- Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
| | - Florentina E Sileanu
- Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; and
| | - Raghavan Murugan
- Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicole Lucko
- Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D Shaw
- Center for Critical Care Nephrology and Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gilles Clermont
- Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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210
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Goldstein S, Bagshaw S, Cecconi M, Okusa M, Wang H, Kellum J, Mythen M, Shaw A. Pharmacological management of fluid overload. Br J Anaesth 2014; 113:756-63. [DOI: 10.1093/bja/aeu299] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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211
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Long-term outcomes after dialysis-requiring acute kidney injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:365186. [PMID: 25187902 PMCID: PMC4145550 DOI: 10.1155/2014/365186] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/10/2014] [Accepted: 06/09/2014] [Indexed: 02/07/2023]
Abstract
AKI-dialysis patients had a higher incidence of long-term ESRD and mortality than the patients without AKI. The patients who recovered from dialysis were associated with a lower incidence of long-term ESRD and mortality than in the patients who still required dialysis.
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212
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van der Voort PHJ, Boerma EC, Pickkers P. The furosemide stress test to predict renal function after continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:429. [PMID: 25033085 PMCID: PMC4057371 DOI: 10.1186/cc13871] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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