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Liu X, Qian N, Zhu L, Fan L, Fu G, Ma M, Bao J, Cao C, Liang X. Geniposide ameliorates acute kidney injury via enhancing the phagocytic ability of macrophages towards neutrophil extracellular traps. Eur J Pharmacol 2023; 957:176018. [PMID: 37634840 DOI: 10.1016/j.ejphar.2023.176018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Acute kidney injury (AKI) is a clinically serious disorder associated with high mortality rates and an increased risk of progression to end-stage renal disease. As an essential supportive treatment for patients with respiratory failure, mechanical ventilation not only save many critically ill patients, but also affect glomerular filtration function by changing renal hemodynamics, neurohumoral and positive end-expiratory pressure, eventually leading to AKI. AMP-activated protein kinase (AMPK), a crucial energy homeostasis regulator, could enhance macrophage phagocytic ability and inhibit inflammation, but whether it can engulf neutrophil extracellular traps (NETs) and alleviate mechanical ventilation-associated AKI is still unclear. In this study, we found that geniposide significantly ameliorated histopathological damage, reduced serum Cre and BUN levels. Besides, geniposide can also induce AMPK activation and enhance macrophage phagocytic ability toward NETs. Moreover, geniposide can markedly reduce the levels of high mobility group box 1 (HMGB1), and these effects were dependent on AMPK-PI3K/Akt signaling. Altogether, these results indicated that geniposide promoted macrophage efferocytosis by inducing AMPK-PI3K/Akt signaling activation, clearing NETs and ameliorating AKI.
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Affiliation(s)
- Xiaodong Liu
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China; The Second People's Hospital of Lianyungang, Affiliated to Kangda College of Nanjing Medical University, Lianyungang, 222006, Jiangsu, China
| | - Na Qian
- The Second People's Hospital of Lianyungang, Affiliated to Kangda College of Nanjing Medical University, Lianyungang, 222006, Jiangsu, China
| | - Li Zhu
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China
| | - Li Fan
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China; Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Guanghao Fu
- The Second People's Hospital of Lianyungang, Affiliated to Kangda College of Nanjing Medical University, Lianyungang, 222006, Jiangsu, China
| | - Mengqing Ma
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China
| | - Jiaxin Bao
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China
| | - Changchun Cao
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, 211100, Jiangsu, China.
| | - Xiubin Liang
- Department of Pathophysiology, Nanjing Medical University, Nanjing, 211166, Jiangsu, China.
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Bonavia A, Stiles N. Renohepatic crosstalk: a review of the effects of acute kidney injury on the liver. Nephrol Dial Transplant 2021; 37:1218-1228. [PMID: 33527986 DOI: 10.1093/ndt/gfaa297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Several theories regarding acute kidney injury (AKI)-related mortality have been entertained, although mounting evidence supports the paradigm that impaired kidney function directly and adversely affects the function of several remote organs. The kidneys and liver are fundamental to human metabolism and detoxification, and it is therefore hardly surprising that critical illness complicated by hepatorenal dysfunction portends a poor prognosis. Several diseases can simultaneously impact the proper functioning of the liver and kidneys, although this review will address the impact of AKI on liver function. While evidence for this relationship in humans remains sparse, we present supportive studies and then discuss the most likely mechanisms by which AKI can cause liver dysfunction. These include 'traditional' complications of AKI (uremia, volume overload and acute metabolic acidosis, among others) as well as systemic inflammation, hepatic leukocyte infiltration, cytokine-mediated liver injury and hepatic oxidative stress. We conclude by addressing the therapeutic implications of these findings to clinical medicine.
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Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Pharmacology, Penn State College of Medicine, Hershey, PA, USA
| | - Nicholas Stiles
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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El-Gazzar AG, El-Salahy MM, Essway TS, Mohammed SN, Elnaggar ME. Effect of acute kidney injury on weaning from mechanical ventilation in chronic obstructive pulmonary diseases patients with respiratory failure. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2020. [PMCID: PMC7371816 DOI: 10.1186/s43168-020-00013-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute kidney injury (AKI) worsens the outcome in mechanically ventilated patients. The occurrence of AKI may have an effect on weaning from mechanical ventilation (MV). The purpose of this work is to study the effect of AKI on weaning from MV for chronic obstructive pulmonary disease (COPD) patients with respiratory failure (RF). The study included 100 mechanically ventilated COPD patients with RF. Patients were classified into group 1, mechanically ventilated COPD patients with type 2 RF who developed AKI, and group 2, mechanically ventilated COPD patients with type 2 RF, who did not develop AKI. Results The age of the studied group ranged between 46 and 80 years, and serum creatinine on admission was within normal. There is a significant difference in a serum creatinine level after 2 days and after 1 week of MV in an intensive care unit (ICU) among AKI cases. There is a significant difference in weaning success between AKI and non-AKI patients with much higher weaning success in non-AKI group. Also, there is a significant reduction in glomerular filtration rate (GFR) in AKI patients after 48 h of admission. Conclusions AKI is frequent in COPD patients within 48 h of ICU admission and MV increases the risk of AKI in COPD patients.
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Dai H, Thomson AW, Rogers NM. Dendritic Cells as Sensors, Mediators, and Regulators of Ischemic Injury. Front Immunol 2019; 10:2418. [PMID: 31681306 PMCID: PMC6803430 DOI: 10.3389/fimmu.2019.02418] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 09/27/2019] [Indexed: 12/18/2022] Open
Abstract
Dendritic cells (DCs) are highly specialized, bone marrow (BM)-derived antigen-processing and -presenting cells crucial to the induction, integration and regulation of innate, and adaptive immunity. They are stimulated by damage-associated molecular patterns (DAMPS) via pattern recognition receptors to promote inflammation and initiate immune responses. In addition to residing within the parenchyma of all organs as part of the heterogeneous mononuclear phagocyte system, DCs are an abundant component of the inflammatory cell infiltrate that appears in response to ischemia reperfusion injury (IRI). They can play disparate roles in the pathogenesis of IRI since their selective depletion has been found to be protective, deleterious, or of no benefit in mouse models of IRI. In addition, administration of DC generated and manipulated ex vivo can protect organs from IRI by suppressing inflammatory cytokine production, limiting the capacity of DCs to activate NKT cells, or enhancing regulatory T cell function. Few studies however have investigated specific signal transduction mechanisms underlying DC function and how these affect IRI. Here, we address current knowledge of the role of DCs in regulation of IRI, current gaps in understanding and prospects for innovative therapeutic intervention at the biological and pharmacological levels.
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Affiliation(s)
- Helong Dai
- Department of Urological Organ Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation of Hunan Province, Changsha, China
| | - Angus W. Thomson
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Natasha M. Rogers
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Center for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
- Renal Division, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Camperdown, NSW, Australia
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Domenech P, Perez T, Saldarini A, Uad P, Musso CG. Kidney-lung pathophysiological crosstalk: its characteristics and importance. Int Urol Nephrol 2017; 49:1211-1215. [PMID: 28401379 DOI: 10.1007/s11255-017-1585-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 04/05/2017] [Indexed: 12/11/2022]
Abstract
Crosstalk between the lung and the kidney is based on the similarities that these organs share. This is why different diseases that affect one organ can have repercussions on the other. Patients with acute kidney injury can present complications such as pulmonary edema and require mechanical ventilation in respiratory failure. This interaction occurs due to the increase in systemic immune mediators that cause inflammatory reactions, oxidative stress, and an increase in vascular permeability in the lung. With regard to lung-induced renal damage, the kidney can also be affected by chemical mediators, which are translocated into the bloodstream. Moreover, the kidneys are extremely sensitive to oxygen changes which can cause them to lose their autoregulation mechanism. In patients with acute lung injury (ALI), oxygen supply is decreased causing renal hypoxia. Besides, hypercapnia generated by ALI causes vasoconstriction in the renal vascular network and activation of the renal angiotensin aldosterone system. ALI not only can cause renal injury, but also worsening chronic obstructive pulmonary disease and obstructive sleep apnea. In conclusion, kidney-lung crosstalk is commonly present in certain pathological states, and knowing its characteristics is crucial for managing the complications which may arise from this vicious circle.
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Affiliation(s)
- Pilar Domenech
- Human Physiology Department, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Tomas Perez
- Human Physiology Department, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Agustina Saldarini
- Human Physiology Department, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pedro Uad
- Human Physiology Department, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos G Musso
- Human Physiology Department, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Kumar AB, Andrews W, Shi Y, Shotwell MS, Dennis S, Wanderer J, Summitt B. Fluid resuscitation mediates the association between inhalational burn injury and acute kidney injury in the major burn population. J Crit Care 2016; 38:62-67. [PMID: 27863270 DOI: 10.1016/j.jcrc.2016.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/19/2016] [Accepted: 10/12/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND It is known that acute respiratory distress syndrome and acute lung injury are independent risk factors for developing acute kidney injury (AKI) through complex pathophysiologic mechanisms. Our specific aim is to evaluate the risk factors for AKI postburn injury and whether inhalation thermal injury is an independent risk factor for developing AKI in the major burn population. METHODS This is an institutional review board-approved, retrospective cohort study of patients admitted to a tertiary burn intensive care unit between 2011 and 2013. We included adults (age 18 years or older) with major burn injury greater than or equal to 20% total burn surface area (TBSA) and patients with confirmed inhalation injury (±major burn). Acute kidney injury was defined using the acute kidney injury network serum creatinine criteria up to 5 days after admission. Patient demographics and clinical data were compared across cohorts using the Wilcoxon rank sum test or Pearson χ2 test, as appropriate. Multiple logistic regression was used to assess the effect of inhalation injury and major burn on the incidence of AKI, adjusting for clinical and demographic confounders. RESULTS Two hundred fifty-four patient records (90 with inhalation injury and 164 with major burn only) were evaluated. The mean age on admission was 47±19 years and 72% of the cohort were men. There were more men in the major burn group (78% vs 62%; P=.007). No other significant differences were observed in the baseline demographics. The overall incidence of AKI was 28% (95% confidence interval, 22, 33). The unadjusted odds of AKI were nearly double (odds ratio, 1.99; 95% confidence interval, 1.13, 3.49) among those with inhalation injury relative to those with major burn only. However, there was no evidence of an independent inhalational injury effect after adjusting for potential confounders. In particular, TBSA (P=.051), daily 24-hour fluid balance (P<.001), and most recent 24-hour albumin transfusion status (P=.002) were all significantly associated with AKI in the adjusted analysis. Age and packed red blood cell transfusion status were not significant. CONCLUSION Inhalation thermal injury is not an independent risk factor for AKI after adjusting for TBSA and surrogates for fluid resuscitation. In patients with major burns, intensity of fluid resuscitation may mediate the development of AKI.
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Affiliation(s)
- Avinash B Kumar
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212.
| | - William Andrews
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212.
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University, Nashville, TN 37212.
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University, Nashville, TN 37212.
| | - Scott Dennis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212.
| | - Jonathan Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212.
| | - Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212.
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The Complex Relationship of Extracorporeal Membrane Oxygenation and Acute Kidney Injury: Causation or Association? BIOMED RESEARCH INTERNATIONAL 2016; 2016:1094296. [PMID: 27006941 PMCID: PMC4783537 DOI: 10.1155/2016/1094296] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/29/2016] [Accepted: 01/31/2016] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass (CPB) circuit capable of providing prolonged cardiorespiratory support. Recent advancement in ECMO technology has resulted in increased utilisation and clinical application. It can be used as a bridge-to-recovery, bridge-to-bridge, bridge-to-transplant, or bridge-to-decision. ECMO can restitute physiology in critically ill patients, which may minimise the risk of progressive multiorgan dysfunction. Alternatively, iatrogenic complications of ECMO clearly contribute to worse outcomes. These factors affect the risk : benefit ratio of ECMO which ultimately influence commencement/timing of ECMO. The complex interplay of pre-ECMO, ECMO, and post-ECMO pathophysiological processes are responsible for the substantial increased incidence of ECMO-associated acute kidney injury (EAKI). The development of EAKI significantly contributes to morbidity and mortality; however, there is a lack of evidence defining a potential benefit or causative link between ECMO and AKI. This area warrants investigation as further research will delineate the mechanisms involved and subsequent strategies to minimise the risk of EAKI. This review summarizes the current literature of ECMO and AKI, considers the possible benefits and risks of ECMO on renal function, outlines the related pathophysiology, highlights relevant investigative tools, and ultimately suggests an approach for future research into this under investigated area of critical care.
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Bhatraju P, Hsu C, Mukherjee P, Glavan BJ, Burt A, Mikacenic C, Himmelfarb J, Wurfel M. Associations between single nucleotide polymorphisms in the FAS pathway and acute kidney injury. Crit Care 2015; 19:368. [PMID: 26477820 PMCID: PMC4610046 DOI: 10.1186/s13054-015-1084-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/27/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction To determine whether single nucleotide polymorphisms (SNPs) in FAS and related genes are associated with acute kidney injury (AKI) in patients with acute respiratory distress syndrome (ARDS). Methods We studied 401 (Caucasian N = 310 and African-American N = 91) patients aged ≥ 13 years with ALI who enrolled in the Fluid and Catheter Treatment Trial (FACTT) between 2000 and 2005 from 20 North American centers. We genotyped 367 SNPs in 45 genes of the Fas/Fas ligand pathway to identify associations between SNPs in Fas pathway genes and the development of AKI by day 2 after enrollment in FACTT, adapting Acute Kidney Injury Network (AKIN) criteria. Written informed consent was obtained from participants or legally authorized surrogates in the original FACTT study and available to use for secondary analysis. Results In Caucasian patients, we identified associations between two SNPs and the incidence of AKI (stage 1 and above): rs1050851 and rs2233417; both are found within the gene for nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor, alpha (NFKBIA). For rs1050851 and rs2233417, the odds ratios (ORs) were 2.34 (95 % confidence interval (CI) = 1.58–3.46, p = 1.06 × 10−5, FDR = 0.003) and 2.46 (CI = 1.61–3.76, p = 1.81 × 10−5, FDR = 0.003) for each minor allele, respectively. The associations were stronger still for AKIN stage 2–3 with respective ORs 4.00 (CI = 2.10–7.62, p = 1.05 × 10−5, FDR = 0.003) and 4.03 (CI = 2.09–7.77, p = 1.88 × 10−5, FDR = 0.003) for each minor allele homozygote. We observed no significant association between these SNPs and AKI in the smaller subset of African Americans. Conclusion In Caucasian patients with ALI, the presence of minor alleles in two SNPs in NFKBIA was strongly associated with the development of AKI. Trial registration NCT00281268. Registered 20/01/2006. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1084-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pavan Bhatraju
- Pulmonary Critical Care Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Box 359640, Seattle, WA, 98104, USA.
| | - Christine Hsu
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA, USA.
| | - Paramita Mukherjee
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA, USA.
| | - Bradford J Glavan
- Pulmonary Critical Care and Sleep Medicine, The Oregon Clinic, Portland, OR, USA.
| | - Amber Burt
- Biostatistics University of Washington, Seattle, WA, USA.
| | - Carmen Mikacenic
- Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA, USA.
| | - Mark Wurfel
- Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.
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Partial extracorporeal carbon dioxide removal using a standard continuous renal replacement therapy device: a preliminary study. ASAIO J 2015; 60:564-9. [PMID: 25000386 DOI: 10.1097/mat.0000000000000114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
To test the feasibility, safety, and efficacy of partial extracorporeal CO2 removal (PECCO2R) using a standard continuous renal replacement (CRRT) device with a pediatric oxygenation membrane introduced into the circuit in a serial manner. In this retrospective single-center study, we have studied mechanically ventilated patients with persistent significant respiratory acidosis and acute renal failure requiring ongoing CRRT. Sixteen patients were treated with our PECCO2R device. PaCO2 and arterial pH were measured before as well as at 6 and 12 hours after PECCO2R implementation. Hemodynamic parameters were continuously monitored. Our PECCO2R system was efficient to significantly reduce PaCO2 and increase arterial pH. The median PaCO2 before treatment was 77 mm Hg (59-112) with a median reduction of 24 mm Hg after 6 hours and 30 mm Hg after 12 hours (31% and 39%, respectively). The median pH increase was 0.16 at 6 hours and 0.23 at 12 hours. Partial extracorporeal CO2 removal treatment had no effect on oxygenation. No complication was observed. Our PECCO2R approach based on the simple introduction of a pediatric extracorporeal membrane oxygenation membrane into the circuit of a standard CRRT device is easy to implement, safe, and efficient to improve respiratory acidosis.
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Tomozawa A, Ishikawa S, Shiota N, Cholvisudhi P, Makita K. Perioperative risk factors for acute kidney injury after liver resection surgery: an historical cohort study. Can J Anaesth 2015; 62:753-61. [PMID: 25925634 DOI: 10.1007/s12630-015-0397-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/13/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE This study aimed to identify the incidence and risk factors for acute kidney injury (AKI) after liver resection surgery and to clarify the relationship between postoperative AKI and outcome. METHODS We conducted a historical cohort study of patients who underwent liver resection surgery with sevoflurane anesthesia from January 2004 to October 2011. Acute kidney injury was diagnosed based on the Acute Kidney Injury Network classification within 72 hr after the surgery. Patient data, surgical and anesthetic data, and laboratory data were extracted manually from the patients' electronic charts. Multivariable logistic regression analysis was used to identify perioperative risk factors for postoperative AKI. RESULTS Acute kidney injury was diagnosed in 78 of 642 patients (12.1%; 95% confidence interval [CI]: 9.7 to 14.9). Multivariable analysis showed an independent association between postoperative AKI and preoperative estimated glomerular filtration rate (adjusted odds ratio [aOR] 0.74; 95% CI: 0.64 to 0.85), preoperative hypertension (aOR 2.10; 95% CI: 1.11 to 3.97), and intraoperative red blood cell transfusion (aOR 1.04; 95% CI: 1.01 to 1.07). Development of AKI within 72 hr after liver resection surgery was associated with increased hospital mortality, prolonged length of stay, and increased rates of mechanical ventilation, reintubation, and renal replacement therapy. CONCLUSION Perioperative risk factors for AKI after liver resection surgery are similar to those established for other surgical procedures. Further studies are needed to establish causality and to determine whether interventions on modifiable risk factors can reduce the incidence of postoperative AKI and improve patient outcome. This study was registered at the University Hospital Medical Information Network (UMIN) Center (UMIN 000008089).
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Affiliation(s)
- Arisa Tomozawa
- Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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de Abreu KLS, da Silva Junior GB, Muniz TD, Barreto AGC, Lima RSA, Holanda MA, Pereira EDB, Libório AB, Daher EDF. Acute kidney injury in critically ill patients with lung disease: kidney-lung crosstalk. Rev Bras Ter Intensiva 2015; 25:130-6. [PMID: 23917978 PMCID: PMC4031835 DOI: 10.5935/0103-507x.20130024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/18/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To examine the factors associated with acute kidney injury and outcome in patients
with lung disease. Methods A prospective study was conducted with 100 consecutive patients admitted to a
respiratory intensive care unit in Fortaleza (CE), Brazil. The risk factors for
acute kidney injury and mortality were investigated in a group of patients with
lung diseases. Results The mean age of the study population was 57 years, and 50% were male. The
incidence of acute kidney injury was higher in patients with
PaO2/FiO2<200 mmHg (54% versus 23.7%; p=0.02). Death was observed in
40 cases and the rate of mortality of the acute kidney injury group was higher
(62.8% versus 27.6%; p=0.01). The independent factor that was found to be
associated with acute kidney injury was PaO2/FiO2<200
mmHg (p=0.01), and the independent risk factors for death were PEEP at admission
(OR: 3.6; 95%CI: 1.3-9.6; p=0.009) and need for hemodialysis (OR: 7.9; 95%CI:
2.2-28.3; p=0.001). Conclusion There was a higher mortality rate in the acute kidney injury group. Increased
mortality was associated with mechanical ventilation, high PEEP, urea and need for
dialysis. Further studies must be performed to better establish the relationship
between kidney and lung injury and its impact on patient outcome.
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Santos LLD, Magro MCDS. Ventilação mecânica e a lesão renal aguda em pacientes na unidade de terapia intensiva. ACTA PAUL ENFERM 2015. [DOI: 10.1590/1982-0194201500025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objetivo Verificar o impacto do emprego da ventilação mecânica em pacientes internados na Unidade de Terapia Intensiva e a ocorrência de lesão renal aguda. Métodos Estudo de coorte, prospectivo, quantitativo, desenvolvido com 27 pacientes sob suporte de ventilação mecânica internados na unidade de terapia intensiva em um hospital público. Resultados A maioria (55,6%) dos pacientes foi classificada no estágio de lesão renal, de acordo com a classificação Risk, Injury, Failure, Loss, End-Stage (RIFLE). Dentre os pacientes, 45,8% estavam sob ventilação mecânica com pressão expiratória final positiva entre 5cmH2O e 10cmH2O, os quais evoluíram com lesão renal aguda. Acute Physiology and Chronic Health Disease Classification System II (APACHE II) apresentou associação significativa com disfunção renal (p=0,046). Conclusão O emprego da ventilação mecânica invasiva com pressão expiratória final positiva em pacientes graves pode determinar prejuízos à função renal dos pacientes internados em unidade de terapia intensiva.
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Shekar K, Fraser JF. Can timely ECMO initiation mitigate pre-ECMO risk factors for acute kidney injury? Ann Thorac Surg 2014; 98:1523. [PMID: 25282233 DOI: 10.1016/j.athoracsur.2014.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 04/10/2014] [Accepted: 05/12/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Kiran Shekar
- Critical Care Research Group and The University of Queensland, Brisbane, The Prince Charles Hospital, Chermside, Queensland 4032.
| | - John F Fraser
- Critical Care Research Group and The University of Queensland, Brisbane, The Prince Charles Hospital, Chermside, Queensland 4032
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Lung-Targeted RNA Interference Against Angiopoietin-2 Ameliorates Multiple Organ Dysfunction and Death in Sepsis. Crit Care Med 2014; 42:e654-62. [DOI: 10.1097/ccm.0000000000000524] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gil-Ruiz Gil-Esparza MA, Alcaraz Romero AJ, Romero Otero A, Gil Villanueva N, Sanavia Morán E, Rodríguez Sánchez de la Blanca A, Lorente Romero J, Bellón Cano JM. Prognostic relevance of early AKI according to pRIFLE criteria in children undergoing cardiac surgery. Pediatr Nephrol 2014; 29:1265-72. [PMID: 24496588 DOI: 10.1007/s00467-014-2757-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/07/2013] [Accepted: 01/06/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute renal injury increases risk of death after cardiac surgery. The objective of the study was to evaluate the ability of the pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria to characterize the development of postoperative renal damage in children after cardiopulmonary bypass (CPB) and to evaluate the relationship between the severity of kidney injury and mortality, pediatric intensive care unit (PICU) length of stay, and the duration of mechanical ventilation (MV). METHODS In this retrospective study including children undergoing CPB surgery during a 3-year period in the PICU of a tertiary hospital, demographic, clinical, surgery-related, and postoperative clinical data were collected. Kidney damage was assessed with pRIFLE criteria. RESULTS Four hundred and nine patients were included. Early acute kidney injury (AKI) was found in 82 patients (achieving categories Risk 44; Injury 16; Failure 22). Early AKI was associated with younger age (P = 0.010), longer CPB, deep hypothermic circulatory arrest (DHCA) use, ICU stay >12 days, MV >4 days, and death (P < 0.001). Controlling the effect of age, CPB, DHCA use, previous cardiac surgeries, and Risk Adjustment in Congenital Heart Surgery Surgical Severity Score (RACHS-1), early AKI development proved to predict ICU stay >12 days [odds ratio (OR) 3.5; 95% confidence interval (CI) 1.9-6.5, P < 0.001)] and need of MV >4 days (OR 5.1; 95% CI 2.6-10.2, P < 0.001). CONCLUSIONS Early AKI when evaluated with the pRIFLE criteria can predict prolonged ICU stay, need of prolonged MV, and mortality.
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Affiliation(s)
- Maite Augusta Gil-Ruiz Gil-Esparza
- Division of Pediatric Critical Care, Gregorio Marañón General University Hospital, Calle Paseo de la Habana n°74, Torre Norte 6°A, 28036, Madrid, Spain,
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dos Santos El Halal MG, Carvalho PRA. Acute kidney injury according to pediatric RIFLE criteria is associated with negative outcomes after heart surgery in children. Pediatr Nephrol 2013; 28:1307-14. [PMID: 23695031 DOI: 10.1007/s00467-013-2495-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/11/2013] [Accepted: 04/12/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND The aim of this study was to investigate the association between the occurrence of acute kidney injury (AKI) according to pediatric RIFLE (pRIFLE) criteria and adverse outcomes in children after heart surgery. METHODS Children undergoing heart surgery in a tertiary hospital in Southern Brazil were followed during their stay in the pediatric intensive care unit (PICU) or until death. The exposure variable was occurrence of AKI according to pRIFLE criteria which place AKI in three categories: R (risk), I (injury), and F (failure). The outcomes studied were death, length of mechanical ventilation (MV), and length of PICU stay. RESULTS Eighty-five children were enrolled in the study. Of these, 47 (55.3 %) did not have AKI, while 22 (25.9 %), seven (8.2 %), and nine (10.6 %) were classified into pRIFLE categories R, I, and F, respectively. The incidence of death was 18.4 and 4.2 % in patients with and without AKI, respectively. Compared to children who did not develop AKI, the adjusted odds ratio for death was 1.05 [95 % confidence interval (CI) 0.09-11.11], 8.36 (95 % CI 1.32-52.63), and 7.85 (95 % CI 1.53-40.29) in the R, I, and F groups, respectively (p = 0.022). Duration of MV and of PICU stay were significantly higher in those children with AKI. CONCLUSIONS The occurrence of AKI according to pRIFLE criteria is associated to adverse outcomes in children after heart surgery.
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White LE, Santora RJ, Cui Y, Moore FA, Hassoun HT. TNFR1-dependent pulmonary apoptosis during ischemic acute kidney injury. Am J Physiol Lung Cell Mol Physiol 2012; 303:L449-59. [PMID: 22728466 DOI: 10.1152/ajplung.00301.2011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Despite advancements in renal replacement therapy, the mortality rate for acute kidney injury (AKI) remains unacceptably high, likely due to remote organ injury. Kidney ischemia-reperfusion injury (IRI) activates cellular and soluble mediators that incite a distinct pulmonary proinflammatory and proapoptotic response. Tumor necrosis factor receptor 1 (TNFR1) has been identified as a prominent death receptor activated in the lungs during ischemic AKI. We hypothesized that circulating TNF-α released from the postischemic kidney induces TNFR1-mediated pulmonary apoptosis, and we aimed to elucidate molecular pathways to programmed cell death. Using an established murine model of kidney IRI, we characterized the time course for increased circulatory and pulmonary TNF-α levels and measured concurrent upregulation of pulmonary TNFR1 expression. We then identified TNFR1-dependent pulmonary apoptosis after ischemic AKI using TNFR1-/- mice. Subsequent TNF-α signaling disruption with Etanercept implicated circulatory TNF-α as a key soluble mediator of pulmonary apoptosis and lung microvascular barrier dysfunction during ischemic AKI. We further elucidated pathways of TNFR1-mediated apoptosis with NF-κB (Complex I) and caspase-8 (Complex II) expression and discovered that TNFR1 proapoptotic signaling induces NF-κB activation. Additionally, inhibition of NF-κB (Complex I) resulted in a proapoptotic phenotype, lung barrier leak, and altered cellular flice inhibitory protein signaling independent of caspase-8 (Complex II) activation. Ischemic AKI activates soluble TNF-α and induces TNFR1-dependent pulmonary apoptosis through augmentation of the prosurvival and proapoptotic TNFR1 signaling pathway. Kidney-lung crosstalk after ischemic AKI represents a complex pathological process, yet focusing on specific biological pathways may yield potential future therapeutic targets.
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Affiliation(s)
- Laura E White
- Department of Surgery and Research Institute, The Methodist Hospital, Houston, Texas, USA
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Wu SC, Fu CY, Lin HH, Chen RJ, Hsieh CH, Wang YC, Yeh CC, Huang HC, Huang JC, Chang YJ. Late Initiation of Continuous Veno-Venous Hemofiltration Therapy is Associated with a Lower Survival Rate in Surgical Critically Ill Patients with Postoperative Acute Kidney Injury. Am Surg 2012. [DOI: 10.1177/000313481207800245] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
There is controversy about the appropriate timing for renal replacement therapy in patients with acute kidney injury (AKI). We are interested in the appropriate timing for initiation of continuous renal replacement therapy in critically ill surgical patients with postoperative acute kidney injury. Seventy-three critically ill surgical patients with postoperative AKI who received continuous renal replacement therapy (CRRT) were enrolled. Indications for CRRT were: 1) AKI with hyperkalemia, 2) metabolic acidosis, 3) pulmonary edema refractory to diuretics, and 4) oliguria with progressive azotemia, especially in unstable hemodynamics. Using RIFLE (Risk, Injury, Failure, Loss, End stage) classification, patients who received CRRT in the “Risk” stage were defined as early group, whereas those in the “Injury/ Failure” stage were labeled as late group. We used continuous veno-venous hemofiltration as CRRT in this series. There were 20 patients in the early group and 53 patients in the late group. The mean ages were 61.5 ± 21.8 years versus 60.8 ± 17.5 years. The mortality rate was 50 per cent versus 84.9 per cent. There were no significant differences in demographic characteristics or type of surgery or physiological scores. Our data show that late initiation of CRRT is associated with a lower survival rate in critically ill surgical patients with postoperative AKI; however, further studies are required.
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Affiliation(s)
- Shih-Chi Wu
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; the, Changhua, Taiwan
- China Medical University, Taichung, Taiwan; the, Changhua, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Wanfang Hospital, Taipei, Taiwan; the, Changhua, Taiwan
| | - Hsin-Hung Lin
- Department of Nephrology, China Medical University Hospital, Taichung, Taiwan; and the, Changhua, Taiwan
| | - Ray-Jade Chen
- Department of Trauma and Emergency Surgery, Wanfang Hospital, Taipei, Taiwan; the, Changhua, Taiwan
| | - Chi-Hsun Hsieh
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; the, Changhua, Taiwan
- China Medical University, Taichung, Taiwan; the, Changhua, Taiwan
| | - Yu-Chun Wang
- Department of Trauma and Emergency Surgery, Wanfang Hospital, Taipei, Taiwan; the, Changhua, Taiwan
| | - Chun-Chieh Yeh
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; the, Changhua, Taiwan
| | - Hung-Chang Huang
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; the, Changhua, Taiwan
| | - Jui-Chien Huang
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; the, Changhua, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
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Campos R, Shimizu MHM, Volpini RA, de Bragança AC, Andrade L, Lopes FDTQDS, Olivo C, Canale D, Seguro AC. N-acetylcysteine prevents pulmonary edema and acute kidney injury in rats with sepsis submitted to mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2012; 302:L640-50. [PMID: 22268121 DOI: 10.1152/ajplung.00097.2011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Sepsis is a common cause of acute kidney injury (AKI) and acute lung injury. Oxidative stress plays as important role in such injury. The aim of this study was to evaluate the effects that the potent antioxidant N-acetylcysteine (NAC) has on renal and pulmonary function in rats with sepsis. Rats, treated or not with NAC (4.8 g/l in drinking water), underwent cecal ligation and puncture (CLP) 2 days after the initiation of NAC treatment, which was maintained throughout the study. At 24 h post-CLP, renal and pulmonary function were studied in four groups: control, control + NAC, CLP, and CLP + NAC. All animals were submitted to low-tidal-volume mechanical ventilation. We evaluated respiratory mechanics, the sodium cotransporters Na-K-2Cl (NKCC1) and the α-subunit of the epithelial sodium channel (α-ENaC), polymorphonuclear neutrophils, the edema index, oxidative stress (plasma thiobarbituric acid reactive substances and lung tissue 8-isoprostane), and glomerular filtration rate. The CLP rats developed AKI, which was ameliorated in the CLP + NAC rats. Sepsis-induced alterations in respiratory mechanics were also ameliorated by NAC. Edema indexes were lower in the CLP + NAC group, as was the wet-to-dry lung weight ratio. In CLP + NAC rats, α-ENaC expression was upregulated, whereas that of NKCC1 was downregulated, although the difference was not significant. In the CLP + NAC group, oxidative stress was significantly lower and survival rates were significantly higher than in the CLP group. The protective effects of NAC (against kidney and lung injury) are likely attributable to the decrease in oxidative stress, suggesting that NAC can be useful in the treatment of sepsis.
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Affiliation(s)
- Renata Campos
- Laboratory for Medical Research, Nephrology Department, University of SãoPaulo School of Medicine, São Paulo, Brazil
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Kaushik M, Wojewodzka-Zelezniakowicz M, Cruz DN, Ferrer-Nadal A, Teixeira C, Iglesias E, Kim JC, Braschi A, Piccinni P, Ronco C. Extracorporeal Carbon Dioxide Removal: The Future of Lung Support Lies in the History. Blood Purif 2012; 34:94-106. [DOI: 10.1159/000341904] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Acute kidney injury reduces the hepatic metabolism of midazolam in critically ill patients. Intensive Care Med 2011; 38:76-84. [DOI: 10.1007/s00134-011-2360-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 07/11/2011] [Indexed: 10/16/2022]
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White LE, Hassoun HT. Inflammatory Mechanisms of Organ Crosstalk during Ischemic Acute Kidney Injury. Int J Nephrol 2011; 2012:505197. [PMID: 21826270 PMCID: PMC3118535 DOI: 10.4061/2012/505197] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 03/10/2011] [Indexed: 01/22/2023] Open
Abstract
Acute kidney injury (AKI) is a common complication during inpatient hospitalization, and clinical outcomes remain poor despite advancements in renal replacement therapy. AKI in the setting of multiple organ failure (MOF) remains a formidable challenge to clinicians and incurs an unacceptably high mortality rate. Kidney ischemia-reperfusion injury (IRI) incites a proinflammatory cascade and releases cellular and soluble mediators with systemic implications for remote organ injury. Evidence from preclinical models cites mechanisms of organ crosstalk during ischemic AKI including the expression of cellular adhesion molecules, lymphocyte trafficking, release of proinflammatory cytokines and chemokines, and modification of the host innate and adaptive immune response systems. In this paper, the influence of kidney IRI on systemic inflammation and distant organ injury will be examined. Recent experimental data and evolving concepts of organ crosstalk during ischemic AKI will also be discussed in detail.
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Affiliation(s)
- Laura E White
- Department of Surgery, The Methodist Hospital and Research Institute, Houston, TX 77030, USA
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Abstract
OBJECTIVES To inform the pediatric intensivist of recent advancements in acute kidney injury diagnosis and management. DATA SOURCES Studies were identified from MEDLINE (OVID), PubMed, and the Cochrane Library for topics relevant to acute kidney injury. We also reviewed bibliographies of relevant studies. DATA EXTRACTION, SYNTHESIS, AND OUTLINE REVIEW: Because of the lack of prospective trials, a majority of information is extracted from observational and retrospective data. The pathophysiology section reviews acute kidney injury mechanisms and highlights data regarding distal injury from experimental acute kidney injury. The epidemiology section focuses on incidence and outcomes of acute kidney injury, highlighting new strategies for diagnosis. The management section cites studies investigating hemodynamic optimization, nutrition, and fluid management, including the indications and impact of continuous renal replacement therapy in fluid overload. CONCLUSIONS There is limited data-driven evidence in pediatrics regarding effective therapy for acute kidney injury, a significant problem in the pediatric intensive care unit extending length of stay, ventilator days, and overall mortality. Sublethal kidney injury may be contributing to overall morbidity. We conclude that prospective clinical trials are needed to evaluate specific diagnostic aids, such as biomarkers, and therapeutic strategies, such as early initiation of continuous renal replacement therapy in children with fluid overload.
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White LE, Chaudhary R, Moore LJ, Moore FA, Hassoun HT. Surgical sepsis and organ crosstalk: the role of the kidney. J Surg Res 2010; 167:306-15. [PMID: 21324390 DOI: 10.1016/j.jss.2010.11.923] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/19/2010] [Accepted: 11/29/2010] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a common complication of hospitalized patients, and clinical outcomes remain poor despite advances in renal replacement therapy. The accepted pathophysiology of AKI in the setting of sepsis has evolved from one of simple decreased renal blood flow to one that involves a more complex interaction of intra-glomerular microcirculatory vasodilation combined with the local release of inflammatory mediators and apoptosis. Evidence from preclinical AKI models suggests that crosstalk occurs between kidneys and other organ systems via soluble and cellular inflammatory mediators and that this involves both the innate and adaptive immune systems. These interactions are reflected by genomic changes and abnormal rates of cellular apoptosis in distant organs including the lungs, heart, gut, liver, and central nervous system. The purpose of this article is to review the influence of AKI, particularly sepsis-associated AKI, on inter-organ crosstalk in the context of systemic inflammation and multiple organ failure (MOF).
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Affiliation(s)
- Laura E White
- Department of Surgery, The Methodist Hospital and Research Institute, Houston Texas, USA
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Matejovic M, Radermacher P. Pulmonary and renal protection: targeting PARP to ventilator-induced lung and kidney injury? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:147. [PMID: 20459596 PMCID: PMC2911694 DOI: 10.1186/cc8982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Both acute lung injury and acute kidney injury (AKI) are frequent and serious problems in intensive care medicine. Therefore, the avoiding of any iatrogenic insult to these organs is of great importance. While an increasing body of evidence suggests that mechanical ventilation is capable of inducing lung and distant organ injury, the complex underlying molecular mechanisms remain insufficiently understood. In the previous issue of Critical Care, Vaschetto and colleagues reported the results of an experimental study designed to further explore pathways linking injurious ventilation with AKI. The authors demonstrated that scavenging of peroxynitrite or inhibiting poly(ADP-ribose) polymerase (PARP) afforded protection against AKI induced by double-hit lung injury. Although PARP inhibition or peroxynitrite detoxification or both may become viable candidates for a protective strategy in this setting, the implementation of a lung-protective ventilatory strategy remains the only clinical tool to mitigate the lung biotrauma and its systemic consequences.
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Affiliation(s)
- Martin Matejovic
- 1st Medical Department, Charles University Medical School and Teaching Hospital, alej Svobody 80, 304 60 Plzen, Czech Republic.
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