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Frank Holden M, Oczachowska-Kulik AE, Fenton RA, Bech JN. Effect of furosemide on body composition and urinary proteins that mediate tubular sodium and sodium transport-A randomized controlled trial. Physiol Rep 2020; 8:e14653. [PMID: 33356004 PMCID: PMC7757674 DOI: 10.14814/phy2.14653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background Furosemide inhibits the sodium potassium chloride cotransporter (NKCC2) in the thick ascending limb of the loop of Henle and increases urinary water and sodium excretion. This study investigates the effect of furosemide on body composition estimated with multifrequency bioimpedance spectroscopy (BIS) technique and urinary proteins from NKCC2. Methods This study is a randomized, placebo‐controlled, crossover study where healthy subjects received either placebo or 40 mg furosemide on two separate occasions, where body composition with BIS, renal function, proteins from tubular proteins that mediate sodium and water transport, and plasma concentrations of vasoactive hormones were measured before and after intervention. Results We observed an expected increased diuresis with a subsequent reduction in bodyweight of (−1.51 ± 0.36 kg, p < .001) and extracellular water (ECW; −1.14 ± 0.23 L, p < .001) after furosemide. We found a positive correlation between the decrease in ECW and a decrease in bodyweight and a negative correlation between the decrease in ECW and the increase in urinary output. Intracellular water (ICW) increased (0.47 ± 0.28 L, p < .001). Urinary excretion of NKCC2 increased after furosemide and the increase in NKCC2 correlated with an increase in urine output and a decrease in ECW. Conclusion We found BIS can detect acute changes in body water content but the method may be limited to estimation of ECW. BIS demonstrated that furosemide increases ICW which might be explained by an extracellular sodium loss. Finally, urinary proteins from NKCC2 increases after furosemide with a good correlation with diuresis end the decrease in ECW.
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Affiliation(s)
- Mose Frank Holden
- University Clinic in Nephrology and Hypertension, Department of Medicine, University of Aarhus and Gødstrup Hospital, Holstebro, Denmark
| | - Anna Ewa Oczachowska-Kulik
- University Clinic in Nephrology and Hypertension, Department of Medicine, University of Aarhus and Gødstrup Hospital, Holstebro, Denmark
| | | | - Jesper Nørgaard Bech
- University Clinic in Nephrology and Hypertension, Department of Medicine, University of Aarhus and Gødstrup Hospital, Holstebro, Denmark
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Liu C, Lu G, Wang D, Lei Y, Mao Z, Hu P, Hu J, Liu R, Han D, Zhou F. Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis. Am J Emerg Med 2019; 37:2072-2078. [DOI: 10.1016/j.ajem.2019.02.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/05/2019] [Accepted: 02/28/2019] [Indexed: 12/18/2022] Open
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Ren H, Ge Y, He X, Li C, Xu B, Gong D, Liu Z. Vascular Access in Patients Treated with Continuous Renal Replacement Therapy: A Report from a Single Center in China. Ther Apher Dial 2019; 23:562-569. [PMID: 30843338 DOI: 10.1111/1744-9987.12799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/02/2019] [Accepted: 03/05/2019] [Indexed: 12/24/2022]
Abstract
Our aim was to analyze the practice pattern of vascular access use and complication rates in patients receiving continuous renal replacement therapy from a large Chinese urban medical center. Patients who had received continuous renal replacement therapy (CRRT) from April to October 2014 in our center were included in this study. Demographic data, primary disease, department for hospitalization, blood pressure, heart rate, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, presence of mechanical ventilation, CRRT modalities, choice of functioning vascular access, site and duration of catheter insertion, presence of recatheterization, cumulative catheter indwelling time, catheter malfunction and catheter-related infections, as well as laboratory test results, were collected. A total of 292 patients were enrolled in our study, including 175 males (59.9%) and 117 females (40.1%), aged 50.8 ± 18.6 years (range, 12 to 94 years). Acute kidney injury, multiple organ dysfunction syndrome, and systemic inflammatory response syndrome were the main indications for treatment with CRRT. Initial vascular access was non-cuffed temporary catheters in 280 patients and was preferentially obtained in the right internal jugular vein (54.3%). There were 32 (11.4%) patients requiring re-catheterization. Catheter malfunction occurred in 7.14% of all patients, and the median time of catheter malfunction was found at the 5th day. By multivariate analysis, it was found that the main risk factors of catheter malfunction were cumulative treatment time of CRRT and the level of hemoglobin. The average time of catheter-related infections was 10.7 days after insertion and the catheter-related infections occurred at a rate of 7.19 per 1000 catheter days. The main risk factors for catheter-related infections were cumulative time of catheterization and the level of serum albumin. In this cohort of critically ill patients, the main risk factors for catheter malfunction were cumulative CRRT time and the level of hemoglobin. In addition, the main risk factors for catheter-related infections were cumulative time of catheterization and the level of serum albumin.
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Affiliation(s)
- Hongqi Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,Department of Nephrology, Huaihai Hospital affiliated with Xuzhou Medical University, Xuzhou, China
| | - Yongchun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xu He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Chuan Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Fülöp T, Zsom L, Rodríguez RD, Chabrier-Rosello JO, Hamrahian M, Koch CA. Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure. Rev Endocr Metab Disord 2019; 20:65-75. [PMID: 30848433 DOI: 10.1007/s11154-019-09483-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155 mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specifically discussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.
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Affiliation(s)
- Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
| | - Lajos Zsom
- Fresenius Medical Care Hungary Kft, Cegléd, Hungary
| | - Rafael D Rodríguez
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Jorge O Chabrier-Rosello
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Mehrdad Hamrahian
- Department of Medicine - Division of Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christian A Koch
- Medicover GmbH, Berlin, Germany.
- Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Tennessee Health Science Center, Memphis, TN, USA.
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Fülöp T. Greetings to the readers. Ren Fail 2019. [PMCID: PMC6374929 DOI: 10.1080/0886022x.2019.1573499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
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Abstract
BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration among critically ill adults. Which results in better clinical outcomes remains unknown. METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A®), according to the randomization of the unit to which they were admitted. The primary outcome was Major Adverse Kidney Events within 30 days (MAKE30), i.e., the composite of death, new renal replacement therapy, or persistent creatinine elevation ≥ 200% of baseline – all censored at the first of hospital discharge or 30 days. RESULTS: In the balanced crystalloid group, 1,139 patients (14.3%) experienced MAKE30, compared to 1,211 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval, 0.84–0.99; conditional odds ratio, 0.90; 95% confidence interval, 0.82–0.99; P=0.04). Thirty-day in-hospital mortality was 10.3% in the balanced crystalloid group and 11.1% in the saline group (P=0.06). The incidence of new renal replacement therapy was 2.5% and 2.9% respectively (P=0.08), and the incidence of persistent creatinine elevation was 6.4% and 6.6% respectively (P=0.60). CONCLUSIONS: Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration appeared to reduce the composite outcome of in-hospital mortality, new renal replacement therapy, and persistent renal dysfunction compared with the use of saline. (SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779.)
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Affiliation(s)
| | | | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN
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Peritoneal dialysis: The unique features by compartmental delivery of renal replacement therapy. Med Hypotheses 2017; 108:128-132. [PMID: 29055386 DOI: 10.1016/j.mehy.2017.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/06/2017] [Indexed: 11/23/2022]
Abstract
Despite decades of research, the clinical efficacy of peritoneal dialysis (PD) remains enigmatic. We may wonder why the modality fail in some patients but perhaps the more proper question would be, why it works in so many? We know that the contribution of residual renal function (RRF), more so than in hemodialysis, is critically important to the well-being of many of the patients. Unique features of the modality include the relatively low volume of dialysate fluid needed to provide effective uremic control and the disproportionate tendency for both hypokalemia and hypoalbuminemia, when compared to hemodialysis. It is currently believed that most uremic toxins are generated on the interface of human and bacterial structures in the gastrointestinal tract, the intestinal biota. PD offers disproportionate removal of these toxins upon "first-pass", i.e., via PD fluid exchanges before reaching the systemic circulation beyond the gastrointestinal compartment. Studies examining the net removal gradient of protein-bound uremic toxins during PD are scarce, whereas RRF receives considerably more attention without effective interventions being developed to preserve it. We propose an alternative view on PD, emphasizing the modality's compartmental nature, both for its benefits and the limitations.
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Impairment of Thyroid Function in Critically Ill Patients in the Intensive Care Units. Am J Med Sci 2017; 355:281-285. [PMID: 29549931 DOI: 10.1016/j.amjms.2017.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/02/2017] [Accepted: 06/28/2017] [Indexed: 11/22/2022]
Abstract
Unexplained hypotension in the intensive care unit is commonly attributed to volume depletion, cardiorespiratory failure, sepsis, or relative adrenal insufficiency. In these acute conditions, thyroid hormone levels measured in blood, serum or plasma are often altered and solely attributed to critical illness. We report a series of 3 critically ill patients with prolonged respiratory failure, suppressed mental status and unexplained hypotension. Thyroid stimulating hormone levels ranged from normal to mildly elevated (2.36-7.65IU/mL; normal: 0.27-4.20), but free thyroxin was markedly suppressed (0.239-0.66ng/dL; normal: 0.93-1.70). After initiation of intravenous levothyroxine (75-100μg/day), the patients could be weaned off vasopressors and were successfully extubated shortly thereafter. These cases demonstrate that hypothyroid intensive care unit patients may exhibit even seemingly normal or mildly abnormal thyroid stimulating hormone values. Early recognition and treatment of a hypothyroid state superimposed on critical illness may contribute to recovery from hypotension or the need for mechanical ventilation.
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