Sepsis, Kidney and Multiple Organ Dysfunction: 3rd International Course on Critical Care Nephrology, Vicenza, June 2004: Proceedings (Contributions to Nephrology, Vol. 144)

Severe sepsis is among the most common causes of death in the United States and the most common cause of death in the Intensive Care Units worldwide, and its recognition and treatment remain the most important challenges of critical care medicine. Severe sepsis and septic shock have a profound effect on kidney function and the function of other organs through complex mechanisms, which involve the immune response, multiple pro and anti-inflammatory pathways, intracellular dysfunction and hemodynamic instability. Their optimal management requires complex knowledge of general medicine, immunology, nephrology, extra-corporeal technology, fluid resuscitation and critical care endocrinology. In order to deliver optimal patient care, nephrologists and intensive care medicine specialists need to understand and be highly knowledgeable in the epidemiology of sepsis, the mechanisms of injury which determine outcome and the fundamental aspects of new insights into fluid resuscitation, acid-base physiology and glucose control. They also need to have a clear appreciation of new technical developments in the monitoring of critically ill patients and in the delivery of advanced extra-corporeal blood purification therapies. Experts from the fields of intensive care medicine, nephrology, endocrinology, acid-base physiology, extra-corporeal blood purification technology and immunology have contributed to the present book, providing a cutting edge view of developments in each field which contribute to the care of patients with severe sepsis, acute renal failure and multiple organ failure. The resulting mix of fundamental knowledge and recent developments from clinical trials and laboratory research constitute a valuable tool for all professionals involved in the care of the critically ill patient. Contents......Page 6 Preface......Page 10 Acute Renal Failure in the Critically Ill: Impact on Morbidity and Mortality......Page 14 Volume Overload......Page 15 Acidosis......Page 16 Electrolyte Disorders......Page 17 Drug Prescription......Page 18 Sedatives and Analgetics......Page 19 References......Page 20 Acute Renal Failure in the Intensive Care Unit......Page 25 Acute Morphologic Lesions in Tubules......Page 29 References......Page 31 Pathophysiology of Ischemic Acute Renal Failure......Page 32 Inflammation......Page 33 Protection against Injury by Ischemic Preconditioning......Page 36 Lung-Kidney Cross-Talk......Page 38 Biomarkers......Page 39 Conclusions......Page 40 References......Page 41 Initial Cellular Events of Innate Immunity: Outside-In Signaling......Page 44 Intracellular Inflammatory Events......Page 46 NF-kappaB Activation Biology......Page 49 Heat Shock Proteins and the Stress Response......Page 50 Is Sepsis Characterized by Excessive Pro- and Anti-Inflammatory Activity? Assessment by Inside-Out Signaling......Page 52 References......Page 55 Epidemiology......Page 57 Direct Parenchymal Invasion......Page 58 Immune-Mediated Renal Lesions......Page 59 Hemodynamically Mediated ARF......Page 60 Toxins of Animal Origin......Page 61 Intoxication with Industrial Chemicals......Page 62 Management of Tropical ARF......Page 63 References......Page 64 Pulmonary Effects of Acute Renal Failure......Page 66 Renal Effects of Mechanical Ventilation......Page 69 Conclusion......Page 71 References......Page 72 Mediators of the Systemic Inflammatory Response Syndrome in ARF......Page 76 Ischemic and Nephrotoxic Injury in ARF......Page 77 Human Gene Polymorphism and Biological Diversity......Page 78 Identification of Genes Relevant to Human Disease......Page 79 Tumor Necrosis Factor Locus......Page 80 The Interleukin-10 Gene......Page 82 Down-Regulation of TNF-alpha......Page 83 Summary and Conclusions......Page 84 References......Page 85 Mechanisms of Immunodysregulation in Sepsis......Page 89 Circulating Leukocytes and HLA-DR Expression......Page 90 Neutrophil Functions......Page 91 Ex vivo Cytokine Production......Page 92 Concept of Compartmentalization......Page 93 Desensitizing Agents in Plasma......Page 95 Toll-Like Receptor Expression......Page 96 Nuclear Factor-kappaB......Page 97 Downregulation of TLR-Associated Signaling Pathways......Page 98 References......Page 100 Shock States......Page 107 Goals of Therapy......Page 109 Hemoglobin and the Optimal Hematocrit......Page 110 Fluid Resuscitation......Page 111 Vasopressors......Page 113 Conclusion......Page 114 References......Page 115 Crystalloid Solutions and Acid-Base Balance......Page 118 Acid-Base Analysis Using the Stewart-Figge Methodology......Page 119 The Conventional Ideology......Page 120 The Physiological Consequences of Iatrogenic Acidosis......Page 121 The Controversy......Page 124 Effect of Replacement Fluids and Their Composition......Page 125 High-Volume Hemofiltration......Page 127 References......Page 129 Glucose Regulation in Critical Illness......Page 132 Adverse Effects of Hyperglycemia......Page 133 Intensive Insulin Therapy in the ICU......Page 134 Harmful Effect of Hyperglycemia or Beneficial Effect of Insulin?......Page 136 Role of Hyperglycemia in Critical Illness-Associated Neuropathy......Page 138 Effects of Critical Illness and Insulin on Inflammation and Coagulation......Page 139 Possible Dangers of Intensive Insulin Therapy......Page 140 References......Page 141 Dysnatremias in the Critical Care Setting......Page 145 Pathogenesis of Hyponatremia......Page 146 Diagnostic Approach......Page 147 Hospital Acquired Hyponatremia and Its Prevention......Page 149 Clinical Symptoms......Page 150 Age......Page 151 Hypoxia......Page 152 Hyponatremic Encephalopathy in the Outpatient Setting......Page 153 Syndrome of Inappropriate Vasopressin Production (SIADH)......Page 154 Cerebral Salt Wasting (CSW)......Page 155 Treatment of Hyponatremic Encephalopathy......Page 156 Risk Factors for Developing Cerebral Demyelination......Page 158 Pathogenesis......Page 159 Clinical Manifestations of Hypernatremia......Page 160 Mortality......Page 161 Treatment......Page 162 Hypernatremia in the Edematous Patient......Page 163 Peritoneal Dialysis......Page 164 References......Page 165 Rasburicase Therapy in Acute Hyperuricemic Renal Dysfunction......Page 171 Uric Acid: A New Toxin?......Page 172 Rationale for Rasburicase Therapy......Page 174 References......Page 177 Loop Diuretics in ARF: Experimental Evidence......Page 179 Loop Diuretics in ARF: Clinical Evidence......Page 180 Pathophysiology of ARF......Page 183 How to Explain the Absence of a Beneficial Effect?......Page 185 Toxicity of Loop Diuretics......Page 187 Conclusion......Page 188 References......Page 189 How to Manage Vasopressors in Acute Renal Failure and Septic Shock......Page 195 Sepsis-Induced Circulatory Dysfunction......Page 196 An Hydraulic Point of View......Page 197 Vasopressor Therapy for Septic Shock......Page 200 Strategies for Treatment of Septic Shock......Page 201 References......Page 202 Management of Vascular Catheters for Acute Renal Replacement Therapy......Page 204 Insertion Techniques......Page 205 Catheter-Related Morbidity......Page 206 Immediate Complications......Page 207 Long-Term Complications......Page 208 Thrombotic Occurrences......Page 209 Catheter-Related Infections......Page 210 Catheter Performances and Recirculation......Page 212 Conclusions......Page 214 References......Page 215 Blood Pumping for Extracorporeal Circuits......Page 216 Roller Pumps and Segment Tubing......Page 218 Blood Pumps and Flow Doppler Assessment of Blood Flow......Page 219 Access Catheters......Page 220 Access Site......Page 221 Blood Flow Monitoring......Page 222 Doppler Flow Measurement Unit and Computer Interface......Page 223 Conclusion......Page 224 References......Page 225 Patient Selection for Acute Extracorporeal Renal Support......Page 227 Patient Selection for CRRT in ARF......Page 230 Non-Renal Indications for CRRT......Page 232 References......Page 233 Electrolyte and Acid-Base Disturbances in CRRT Patients......Page 235 Fluids for CRRT......Page 236 Influence of CRRT Prescription......Page 239 References......Page 240 Anticoagulation for Continuous Renal Replacement Therapy......Page 241 Unfractionated Heparin......Page 242 Low-Molecular-Weight Heparins......Page 243 Danaparoid......Page 244 Argatroban......Page 245 Citrate......Page 246 Prostanoids......Page 247 Circuit Design for CRRT......Page 248 References......Page 249 Peritoneal Dialysis in Acute Renal Failure of Adults: The Under-Utilized Modality......Page 252 References......Page 265 CRRT vs. IHD......Page 268 Dialysis Dose......Page 270 Biocompatibility of the Dialysis Membranes......Page 273 References......Page 274 Continuous Renal Replacement Techniques......Page 277 Diffusion......Page 278 Convection......Page 279 CRRT Techniques......Page 280 Continuous Venovenous Hemofiltration (CVVH)......Page 281 Continuous Venovenous Hemodialysis (CVVHD)......Page 282 Continuous Venovenous Hemodiafiltration (CVVHDF)......Page 283 Technical Aspects of CRRT......Page 284 Clinical Indications for CRRT......Page 285 New Horizons......Page 286 Conclusions......Page 287 References......Page 288 Cost Analysis......Page 291 Clearances and Dose Versatility......Page 293 Future Issues in Hybrid Therapies......Page 294 References......Page 295 Pediatric ARF Epidemiology......Page 297 The Critically Ill Pediatric Patient......Page 298 Infants......Page 300 Future Studies......Page 301 References......Page 302 Vascular Access for Extracorporeal Renal Replacement Therapy in the Intensive Care Unit......Page 304 Catheters and Material......Page 305 Femoral Vein......Page 307 Subclavian Vein......Page 308 Internal Jugular Vein......Page 309 Catheter Care and Catheter Maintenance......Page 311 Catheter Performances......Page 312 Catheter Complications......Page 313 Technical Catheter Advances......Page 315 Prevention of Venous Catheter-Related Morbidity......Page 316 References......Page 318 High-Molecular-Weight (HMW) Heparin......Page 321 Low-Molecular-Weight (LMW) Heparin......Page 322 Hirudin......Page 323 Sodium-Citrate......Page 324 References......Page 327 Sterility......Page 330 Electrolyte Composition......Page 332 Acid-Base Balance......Page 335 CRRT Using Citrate Anticoagulation......Page 337 Temperature......Page 338 Conclusions......Page 339 References......Page 340 How Would You Define an Adequate Renal Replacement Therapy?......Page 342 Does Treatment Dose Correlate with Outcome?......Page 343 How Can You Measure Treatment Dose in Different Treatments?......Page 344 Efficiency......Page 345 Efficacy......Page 346 SCUF......Page 348 CVVH......Page 350 Continuous Venovenous Hemodialysis......Page 353 CVVHDF......Page 355 Intermittent Mode......Page 356 References......Page 361 Diagnosis of Sepsis......Page 363 Organ Dysfunction.......Page 364 Infection Control......Page 365 Ventilate......Page 366 Infuse......Page 367 Fluids......Page 368 Transfusion......Page 369 Inotropic Agents......Page 370 Immunomodulatory Therapies......Page 371 Conclusion......Page 372 References......Page 373 High Volume Hemofiltration in Critically Ill Patients: Why, When and How?......Page 375 High Volume Hemofiltration (HVHF): Why?......Page 377 HVHF: When?......Page 381 HVHF: How?......Page 382 References......Page 385 Treatment Rationale: Learning from Past Lessons......Page 389 How Do Sorbents Work?......Page 392 In vitro Experiments......Page 393 Human Clinical Studies......Page 396 Conclusion......Page 397 References......Page 398 Plasmapheresis in Sepsis......Page 400 Description of the Technique and Terminology......Page 401 Laboratory Experiences......Page 402 Clinical Studies......Page 403 Laboratory Experiences......Page 404 References......Page 405 Author Index......Page 408 C......Page 409 F......Page 411 H......Page 412 L......Page 413 P......Page 414 S......Page 415 V......Page 416