Renal kallikrein excretion and epigenetics in human acute kidney injury: expression, mechanisms and consequences.

Background: Renal kallikrein (KLK1) synthesis and urinary excretion are reportedly diminished during AKI (acute kidney injury) in animal models, and provision of kallikrein abrogates renal injury in this setting, but data in human AKI is limited. Therefore we first examined KLK1 renal excretion in human AKI, and then probed potential endocrine and epigenetic mechanisms for its alterations.

Methods: KLK1 enzymatic activity excretion was evaluated in urine from patients with established or incipient AKI, versus healthy/non-hospital as well as ICU controls.

Baseline values of candidate urine acute kidney injury biomarkers vary by gestational age in premature infants.

Acute kidney injury (AKI) is common in premature infants and is associated with poor outcomes. Novel biomarkers can detect AKI promptly. Because premature infants are born with underdeveloped kidneys, baseline biomarker values may differ.

Withholding and withdrawing renal support in acute kidney injury.

Management of critically ill patients with acute kidney injury (AKI) is mainly limited to supportive therapy, with dialysis as one of the main components. Whether or not to offer dialysis and when to withdraw dialysis is a one of the many choices physicians face in daily clinical practice. Withholding or withdrawing renal replacement therapy is a complex decision and depends on many interacting factors, which are unique for each patient and their families and for the care team.

Assessing and delivering dialysis dose in acute kidney injury.

Assessing and delivering dialysis dose in acute kidney injury (AKI) has emerged as an important issue in the management of critically ill patients. There is ongoing debate on how dose of dialysis should be expressed and measured. Most studies have focused on clearance of small molecules (blood urea nitrogen) as a marker of delivered dose and for establishing dose-outcome relationships.

When should renal replacement therapy be initiated for acute kidney injury?

Acute kidney injury (AKI) is now well recognized as an independent risk factor for increased morbidity and mortality particularly when dialysis is needed. Although renal replacement therapy (RRT) has been used in AKI for more than five decades, there is no standard methodology to predict which AKI patients will need dialysis and who will recover renal function without requiring dialysis. The lack of consensus on what parameters should guide the decision to start dialysis has led to a wide variation in dialysis utilization.

Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease.

Purpose: Sepsis commonly contributes to acute kidney injury (AKI); however, the frequency with which sepsis develops as a complication of AKI and the clinical consequences of this sepsis are unknown. This study examined the incidence of, and outcomes associated with, sepsis developing after AKI.

Methods: We analyzed data from 618 critically ill patients enrolled in a multicenter observational study of AKI (PICARD).

Effluent volume in continuous renal replacement therapy overestimates the delivered dose of dialysis.

Background And Objectives: Studies examining dose of continuous renal replacement therapy (CRRT) and outcomes have yielded conflicting results. Most studies considered the prescribed dose as the effluent rate represented by ml/kg per hour and reported this volume as a surrogate of solute removal. Because filter fouling can reduce the efficacy of solute clearance, the actual delivered dose may be substantially lower than the observed effluent rate.

In-center hemodialysis six times per week versus three times per week.

Background: In this randomized clinical trial, we aimed to determine whether increasing the frequency of in-center hemodialysis would result in beneficial changes in left ventricular mass, self-reported physical health, and other intermediate outcomes among patients undergoing maintenance hemodialysis.

Methods: Patients were randomly assigned to undergo hemodialysis six times per week (frequent hemodialysis, 125 patients) or three times per week (conventional hemodialysis, 120 patients) for 12 months. The two coprimary composite outcomes were death or change (from baseline to 12 months) in left ventricular mass, as assessed by cardiac magnetic resonance imaging, and death or change in the physical-health composite score of the RAND 36-item health survey.

Urinary biomarkers to detect acute kidney injury in the pediatric emergency center.

We conducted a prospective study in pediatric patients presenting to an emergency center (EC) to (1) test the ability of urinary acute kidney injury (AKI) biomarkers to predict AKI presence and severity and (2) determine if these biomarkers offer similar precision in patients with versus without a known baseline SCr. The accuracy of five putative urinary biomarkers to detect AKI presence and severity was evaluated in 252 children presenting to our EC. AKI was defined by the modified pediatric RIFLE (pRIFLE) system.

Review article: Acute kidney injury in critical illness.

Purpose: This review provides a focused and comprehensive update on emerging evidence related to acute kidney injury (AKI).

Principal Findings: Acute kidney injury is a significant clinical problem that increasingly complicates the course of hospitalization and portends worse clinical outcome for sick hospitalized patients. The recent introduction of consensus criteria for the diagnosis of AKI (i.

Review article: Renal support in critical illness.

Purpose: This review provides a focused and comprehensive update on established and emerging evidence in acute renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI).

Principal Findings: There have been considerable technological innovations in the methods and techniques for provision of extracorporeal RRT in critical illness. These have greatly expanded our capability to provide both renal and non-renal life-sustaining organ support for critically ill patients.

Clinical profile of ocular sarcoidosis in a South Indian patient population.

Aim: To report the ocular and systemic features in patients with definite and presumed sarcoidosis presenting to a tertiary referral eye center in south India.

Materials And Methods: Retrospective observational case series. Records of 51 patients with diagnosis of sarcoidosis were retrieved.

Prevalence and correlates of cognitive impairment in hemodialysis patients: the Frequent Hemodialysis Network trials.

Background And Objectives: Cognitive impairment is common among persons with ESRD, but the underlying mechanisms are unknown. This study evaluated the prevalence of cognitive impairment and association with modifiable ESRD- and dialysis-associated factors in a large group of hemodialysis patients.

Design, Setting, Participants, & Measurements: Cross-sectional analyses were conducted on baseline data collected from 383 subjects participating in the Frequent Hemodialysis Network trials.

Defining urine output criterion for acute kidney injury in critically ill patients.

Background: The widespread use of RIFLE and AKIN classification systems for acute kidney injury (AKI) diagnosis and staging has established the association between AKI severity and adverse outcomes. However, as a result of the difficulties in measuring and recording the urine output every hour, a few prospective studies have validated the urine output criterion as stated in these classification systems. We assessed hourly urine output in ICU patients using an automated and accurate device to determine if changes in urine flow and volume could be a sensitive marker of AKI.

Scleral nodule and bilateral disc edema as a presenting manifestation of systemic sarcoidosis.

Aim: To report a rare presentation of a large scleral nodule with bilateral disc edema as the initial manifestation of sarcoidosis.

Materials And Methods: Retrospective interventional case report.

Results: A 58-year-old woman was referred for evaluation of nodular scleritis.

Timed and targeted therapy for acute kidney injury: a glimpse of the future.

Whether and when to intervene and with which therapeutic agent are key questions physicians face daily in managing patients. Biomarkers are emerging to define the course of acute kidney injury and offer an opportunity to provide targeted interventions. The EARLYARF study by Endre et al.

Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients.

Introduction: Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI.

Methods: In 253 patients recruited from a prospective observational study of critically-ill patients with AKI, we calculated cumulative fluid balance and computed a fluid-adjusted sCr concentration reflecting the effect of volume of distribution during the development phase of AKI.

Prerenal azotemia in congestive heart failure.

Prerenal failure is used to designate a reversible form of acute renal dysfunction. However, the terminology encompasses different conditions that vary considerably. The Acute Kidney Injury Network group has recently standardized the acute kidney injury (AKI) definition and classification system; however, these criteria have not determined specific diagnostic criteria to classify prerenal conditions.

Fluid balance issues in the critically ill patient.

In critically ill patients, fluid balance management is an integral part of the process of care. In patients in shock or severe sepsis, aggressive initial fluid resuscitation has been shown to improve overall prognosis. However, in critically ill patients, cumulative fluid accumulation is recognized as a potential contributing factor to increased morbidity and mortality.

Early vs late start of dialysis: it's all about timing.

Acute kidney injury (AKI) is now well recognized as an independent risk factor for increased morbidity and mortality, particularly when dialysis is needed. The wide variation in dialysis utilization contributes to a lack of consensus on what parameters should guide the decision to start dialysis. While the association of early initiation of dialysis with survival benefit was first demonstrated four decades ago, few studies in the modern era of dialysis have addressed time of dialysis initiation.

Dosing of renal replacement therapy in acute kidney injury: lessons learned from clinical trials.

Prescribing dialysis to manage acute kidney injury (AKI) is common and recently has become a controversial area for physicians. The concept of dialysis "dose" initially was developed for end-stage renal disease and has been extended to AKI in the last decade. Urea kinetic modeling has been the mainstay of dose quantification in end-stage renal disease.