The present investigation provides no evidence for a survival benefit of continuous vs intermittent RRT in ICU patients with ARF.

No abstract

Fifty-seven patients receiving chronic high-flux hemodialysis began receiving recombinant alpha-human erythropoietin (rHuEPO). The mean initial rHuEPO dose used in 54 evaluable patients was 9963 +/- 4364 U/week; the final dose was 8972 +/- 4058 U/week. Treatment over a mean period of 154 +/- 40 days (84 to 224 days) resulted in an average increase in hematocrit from 24.7% +/- 3.7% to 32.5% +/- 4.4%. We present a model for these data that describes changes in hematocrit during rHuEPO therapy and that allows simultaneous estimation of red blood cell lifespan and rHuEPO-induced increases in red blood cell production rate. Analysis of the hematocrit values of the patients with the model, by use of NONMEM, a computer program for analysis of population data, reveals a nonlinear dose-response relationship with large interindividual variability (coefficient of variation) of about 50%. The estimated mean red blood cell lifespan is 64 days, with interindividual variability of about 30% (coefficient of variation). The intraindividual random variability in hematocrit about its prediction is +/- 5% of the prediction. For clinical dose adjustment, we present a method that uses only simple calculations.

Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.

Since mammalian atria were recently found to contain vasoactive and natriuretic peptides, we investigated the following in normal humans: plasma human atrial natriuretic peptide concentrations, effective renal plasma flow (ERPF), glomerular filtration rate (GFR), urinary water and electrolyte excretion, blood pressure (BP), and catecholamine, antidiuretic hormone (ADH), angiotensin II, and aldosterone levels before, during, and after intravenous administration of the newly synthetized alpha-human atrial natriuretic peptide (ahANP).In 10 subjects ahANP given as an initial bolus of 50 Ag followed by a 45-min maintenance infusion at 6.25 jig/min (a) increased plasma ahANP from 58±12 to 625±87 (mean±SEM) pg/ml; (b) caused an acute fall in diastolic BP (-12%, P < 0.001) and a hemoconcentration (hematocrit +7%, P < 0.01) not fully explained by a negative body fluid balance; (c) increased GFR (+15%, P < 0.05) despite unchanged or decreased ERPF (filtration fraction +37%, P < 0.001); (d) augmented (P < 0.05-< 0.001) urinary chloride (+317%), sodium (+224%), calcium (+158%), magnesium (+110%), phosphate excretion (+88%), and free water clearance (from -0.76 to +2.23 ml/min, P < 0.001) with only little change in potassium excretion; and (e) increased plasma norepinephrine (P < 0.001) while plasma and urinary epinephrine and dopamine, and plasma ADH, angiotensin II, and aldosterone levels were unchanged. The magnitude and pattern of electrolyte and water excretion during ahANP infusion could not be accounted for by increased GFR alone.Therefore, in normal man, endogenous ahANP seems to circulate in blood. ahANP can cause a BP reduction and hemoconcentration which occur, at least in part, independently of diuresis and are accompanied by sympathetic activation. An increase in GFR that occurs in the presence of unchanged or even decreased total renal blood flow is an important but not sole mechanism of natriuresis and diuresis induced by ahANP in man.

Early diagnosis of acute kidney injury (AKI) and accurate prognostic stratification is a prerequisite for optimal medical management. To identify novel prognostic markers of AKI, urine was collected on the first day of AKI in critically ill patients. Twelve patients with early recovery and 12 matching patients with late/non-recovery were selected and their proteome analyzed by gel electrophoresis and mass spectrometry. We identified eight prognostic candidates including α-1 microglobulin, α-1 antitrypsin, apolipoprotein D, calreticulin, cathepsin D, CD59, insulin-like growth factor-binding protein 7 (IGFBP-7), and neutrophil gelatinase-associated lipocalin (NGAL). Subsequent quantification by ELISA showed that IGFBP-7 was the most potent predictor of renal recovery. IGFBP-7 and NGAL were then chosen for further analyses in an independent verification group of 28 patients with and 12 control patients without AKI. IGFBP-7 and NGAL discriminated between early and late/non-recovery patients and patients with and without AKI. Significant upregulation of the urinary markers predicted mortality (IGFBP-7: AUC 0.68; NGAL: AUC 0.81), recovery (IGFBP-7: AUC 0.74; NGAL: AUC 0.70), and severity of AKI (IGFBP-7: AUC 0.77; NGAL: AUC 0.69), and were associated with the duration of AKI. IGFBP-7 was a more accurate predictor of renal outcome than NGAL. Thus, IGFBP-7 is a novel prognostic urinary marker that warrants further investigation.

Chloride is the principal anion of the extracellular fluid and vital for both serum electroneutrality and acid-base homeostasis. The aim of this review is to investigate the relevance of dyschloremia in the critically ill.An extensive literature research was conducted on www.pubmed.org. In addition, the references of included articles were searched for further possible investigation regarding chloride.Articles investigating the relevance of dyschloremia in the critically ill were included.All articles were screened in regard to dyschloremia in the critically ill.Chloride is essential for blood pressure control, decarboxylation/gas transport, renal function, and gastrointestinal homeostasis. “Dyschloremia,” i.e., serum chloride levels not within the limits of normal, may commonly be observed on ICUs and appear mainly induced by iatrogenic measures (i.e., infusion of chloride-rich fluids). Hypo- and hyperchloremia appear linked to increased mortality in defined ICU populations, but evidence is sparse. Data show that hyperchloremia may not only be linked to hyperchloremic metabolic acidosis, but also to increased hemodynamic instability and vasopressor need (e.g., in patients after major surgery). Nevertheless, it is currently unknown whether such effects would be directly or indirectly mediated. Moreover, recent evidence points to an increased incidence of acute kidney injury and need for renal replacement therapy in patients with advanced hyperchloremia.Current knowledge on chloride is largely limited by heterogeneous trial design and mostly abundant data on specific fluid replacement strategies. The aim of this review is to summarize key consequences of chloride in critical illness and to discuss implications for daily clinical practice and future research.

Background. Randomized, controlled comparisons between home haemodialysis (HHD) and centre haemodialysis (CHD) have not been performed to date. Reported survival benefits of HHD as compared with CHD from uncontrolled studies have been attributed largely to patient selection. Methods. In order to minimize a selection bias, we have compared the outcome of our HHD and CHD patients with a nested case-cohort study. For each patient trained for HHD at our dialysis centre between 1970 and 1995 (n ¼ 103), a corresponding match was searched from the CHD patients by retrospective chart analysis. The pairs were matched for sex, age (±5 years), time of dialysis therapy onset (±2 years) and renal disease category. For 58 of the 103 HHD patients, a corresponding matched CHD patient was identified. Both treatment groups had the same mean age (50±13 years) at dialysis onset and were comparable with respect to the Khan comorbidity index, prevalence and duration of hypertension, smoking habits, history of myocardial infarction, stroke and peripheral vascular disease. In both groups, 50% of the patients were transplanted during the observation period. Results. HHD patients were hospitalized less often and tended to have fewer operations as compared with CHD patients. Survival was significantly longer in HHD as compared with CHD. Five, 10 and 20 year survival rates were 93 (n ¼ 55 patients at risk), 72 (41) and 34% (11) with HHD and 64 (38), 48 (26) and 23% (4) with CHD, respectively. This survival difference persisted after adjusting for predictors of mortality, i.e. age at onset of dialysis, year of start of dialysis therapy and Khan comorbidity index. Conclusions. HHD offers a cheap and valuable alternative to CHD, with no apparent disadvantages.