Renal Failure

37th Critical Care Congress:  AN UPDATE ON CRRT 

• Claudio Ronco, MD discusses various RRT strategies toward
   intravascular volume control
• Patrick T. Murray, MD assesses which patients tend to benefit
   most from CRRT
• Hiroyuki Hirasawa, MD examines the evidence on what are the
   strongest endpoints beyond mortality

To hear the complete presentation, click here.

36th Critical Care Congress:  ACUTE RENAL FAILURE DURING CRITICAL ILLNESS

John Kellum, MD, FCCM, discusses epidemiologic, pathophysiologic and consensus definitions of acute kidney injury.  Patrick Murray, MD, illustrates renal protection strategies during critical illness including fluid replacement, decreasing nephrotoxic insults, pharmacotherapies and ICU management techniques. Paul M. Palevsky, MD, discusses the modalities of renal replacement therapy in acute kidney injury, comparing the research data on intermittent and continuous therapies.  Kevin Finkel, MD, discusses multicenter trials of dialysis dosing in acute kidney injury and the impact on patient outcomes. Michael Bentley, PharmD, discusses drug dosing in acute renal failure, pointing out some inconsistencies in renal dosing recommendations and exploring factors such as pharmokinetics, pharmadynamics, metabolism and filter size, all of which influence dosing in the acute renal failure patient.

To hear the complete presentation, click here.

Publications

Fulminant glomerulonephritides due to bacterial endocarditis, lupus erythematosus, staphylococcal septicemia, visceral abscesses, Goodpasture syndrome, or pauci-immune antineutrophil cytoplasmic antibodies (ANCA) associated glomerulonephritis are not infrequent causes of acute renal failure in the ICU.  Once considered, these diagnoses are not difficult to make.  The urinalysis will show hematuria, red blood cell casts, and moderate to heavy proteinuria.  Hypertension is variably present.  Blood cultures, serologic testing (ANCA, hepatitis C antibodies, and antiglomerular basement membrane [Anti-GBM} antibody), and a search for visceral abscess may be rewarding.  Complement levels (C3 and C4) are particularly helpful as they will be decreased in the majority of cases of endocarditis, post-streptococcal and other infection- related glomerulonephritides, cryoglobulinemic GN, and lupus nephritis.  An urgent renal biopsy should be considered whenever acute glomerulonephritides is suspected, as aggressive specific therapy ( e.g., plasma exchange, corticosteroids and/or cyclophosphamide) often is required. 
    
Click here to view the entire chapter of Acute Renal Failure in the Critically Ill.

For more information on caring for the critically ill and injured patients, the publication Multiprofessional Critical Care Review Course is available for purchase from the Society of Critical Care Medicine. Click here for details or to add to your shopping cart.

Pediatrics

Acute Renal Failure and Renal Replacement Therapies.  Pediatric Multiprofessional Critical Care Review. 2006

The evaluation of a patient with ARF can be divided into urgent and routine.  The urgent evaluation consists of checking the volume status as assessed by blood pressure, oxygen requirements, pulmonary edema, and the electrolytes to look for acute hyperkalemia.  Once it can be assured that there is no urgent pulmonary or potassium lethal risk, the rest of the evaluation should ensue.  This evaluation includes an ascertainment of the patient’s volume status as based on blood pressure and fluid status, and electrolyte combination to look at sodium, potassium, bicarbonate, calcium, phosphorous, and albumin.   The purpose of checking phosphorous is to help delineate acute or chronic hyperphosphatemia, which can be found with either acute or chronic renal insufficiency.  Immunologic evaluation including C3, C4, anti-DNA, ANCA, if needed and an anti-GBM if indicated may be in order.

Once the etiology of the cause of ARF is evoked, then one needs to look at the medical therapy as well as nutrition therapy.  Patients who are receiving adequate medical therapy and who are getting full nutrition do not require dialysis.  These patients need to have a very careful and frequent re-evaluation of their electrolytes, BUN, and creatinine as well as their volume status assessed by weights, blood pressure, pulmonary status, and the I’s and O’s to make sure the patient is not becoming  volume excess.

Click here to view the entire chapter of Acute Renal Failure and Renal Replacement Therapies.

For more information on caring for the critically ill and injured patients, the publication Pediatric Multiprofessional Critical Care Review is available for purchase from the Society of Critical Care Medicine. Click here for details or to add to your shopping cart.






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