Mannitol Reduces the Hydrostatic Pressure in the Proximal Tubule of the Isolated Blood-Perfused Rabbit Kidney during Hypoxic Stress and Improves Its Function
Background/Aims: Hypoxia may play a role in the development of renal failure in donated kidneys. In the present study,... more Background/Aims: Hypoxia may play a role in the development of renal failure in donated kidneys. In the present study, the effects of hypoxia on isolated blood-perfused rabbit kidneys were investigated and the effects of mannitol were explored, giving special attention to intratubular pressure. Methods: Kidneys were perfused with their autologous blood during four 30-min periods (P1–P4). P1 was considered baseline function. In P2, hypoxia was induced either alone or with an infusion of mannitol (15 mg/min) during P2–P4. Reoxygenation was applied after P2. Proximal intratubular pressure was measured in all conditions. Results: During hypoxia, renal blood flow doubled and restored immediately in P3. Urine flow stopped in P2, except in the series with mannitol, but gradually resumed in P3 and P4. Likewise, creatinine clearance recovered slightly (<25%) in P4, except for the series with mannitol, where it still could be measured in P2 and reached a value >50% of P1. Proximal intratubular pressure (mean ± SD) increased from 12 ± 5 in P1 to 24 ± 11 mm Hg during hypoxia and returned to 10 ± 6 mm Hg in P3. This increase was not observed with mannitol. Conclusion: Cellular swelling might be responsible for the suppressed filtration during hypoxia and can be prevented by mannitol.
Perioperative acute kidney injury: risk factors, recognition, management, and outcomes
Borthwick E, Ferguson A
Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Review
Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Review
Perioperative acute kidney injury: risk factors, recognition, management, and outcomes
Emma Borthwick, specialist registrar1, Andrew Ferguson, consultant in intensive care medicine and anaesthesia2
1 Nephrology and Intensive Care Medicine, Belfast City Hospital, Belfast BT12 7BA, 2 Craigavon Area Hospital, Portadown BT63 5QQ
Correspondence to: A Ferguson fergua@yahoo.ca
doi:10.1136/bmj.b2370
Summary points
Perioperative acute kidney injury (AKI) is common but poorly recognised and managed
Perioperative AKI increases surgical mortality and morbidity and increases cost
An apparently successful surgical outcome may not mean a successful renal outcome
Careful and thoughtful preoperative assessment, including identifying patients with existing chronic kidney disease and stopping and avoiding nephrotoxic drugs, will reduce the incidence of perioperative AKI.
Management of AKI centres on optimising fluid status and blood pressure, treating sepsis, and removing nephrotoxic agents where possible
Patients with AKI are often complex to treat, and senior help should be sought at an early stage
Acute kidney injury (AKI), formerly known as "acute renal failure," is associated with increased morbidity, mortality, duration of hospital stay, and healthcare cost.w1 Despite this, published data on perioperative acute kidney injury, occurring between the time of admission for surgery and the time of discharge, are scarce outside the cardiovascular surgery setting. Regardless of the clinical setting, the diagnosis of AKI is often delayed, and treatment is suboptimal in a large proportion of cases.1 To improve diagnosis and treatment, clinicians need to understand the risks and triggers for perioperative AKI, the association of even small transient rises in creatinine concentration with risk of death,2 and what actions they need to take promptly on diagnosis. The term acute kidney injury reflects the importance of thinking of the condition as a spectrum or continuum of disease that may be recognised at an early stage, rather than as an "all or nothing" phenomenon as implied by the term acute renal failure. Recognising earlier stages of renal impairment allows for early appropriate action that may interrupt a process of functional decline.
In this article we recommend the introduction of systems to ensure that changes in creatinine concentration from baseline are urgently highlighted to the clinical team. We outline the risk factors for perioperative AKI and discuss how to recognise the condition, manage it, and improve outcomes, focusing on the non-specialist surgery setting and using evidence from randomised trials, retrospective studies, meta-analyses, and expert reviews, as well as the recommendations of recent guidelines.
407 views
Seen by:
Download (.pdf) A System to Monitor and Improve Medication Safety In the Setting of Acute Kidney Injury: Initial Provider Response
McCoy AB, Peterson JF, Gadd CS, Danciu I, Waitman LR. A System to Improve Medication Safety in the Setting of Acute Kidney Injury: Initial Provider Response. AMIA Annu Symp Proc. 2008.
Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for... more Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.
A Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report
McCoy AB, Waitman LR, Gadd CS, Danciu I, Smith JP, Lewis JB, Schildcrout JS, Peterson JF. A Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report. Am J Kidney Dis. 2010 Nov;56(5):832-41
BACKGROUND: Frequently, prescribers fail to account for changing kidney function when prescribing medications. We... more
BACKGROUND: Frequently, prescribers fail to account for changing kidney function when prescribing medications. We evaluated the use of a computerized provider order entry intervention to improve medication management during acute kidney injury.
STUDY DESIGN: Quality improvement report with time series analyses.
SETTING & PARTICIPANTS: 1,598 adult inpatients with a minimum 0.5-mg/dL increase in serum creatinine level over 48 hours after an order for at least one of 122 nephrotoxic or renally cleared medications. QUALITY IMPROVEMENT PLAN: Passive noninteractive warnings about increasing serum creatinine level appeared within the computerized provider order entry interface and on printed rounding reports. For contraindicated or high-toxicity medications that should be avoided or adjusted, an interruptive alert within the system asked providers to modify or discontinue the targeted orders, mark the current dosing as correct and to remain unchanged, or defer the alert to reappear in the next session.
OUTCOMES & MEASUREMENTS: Intervention effect on drug modification or discontinuation, time to modification or discontinuation, and provider interactions with alerts.
RESULTS: The modification or discontinuation rate per 100 events for medications included in the interruptive alert within 24 hours of increasing creatinine level improved from 35.2 preintervention to 52.6 postintervention (P < 0.001); orders were modified or discontinued more quickly (P < 0.001). During the postintervention period, providers initially deferred 78.1% of interruptive alerts, although 54% of these eventually were modified or discontinued before patient death, discharge, or transfer. The response to passive alerts about medications requiring review did not significantly change compared with baseline.
LIMITATIONS: Single tertiary-care academic medical center; provider actions were not independently adjudicated for appropriateness.
CONCLUSIONS: A computerized provider order entry-based alerting system to support medication management after acute kidney injury significantly increased the rate and timeliness of modification or discontinuation of targeted medications.
Acute Kidney Injury In Tropical Acute Febrile Illness In a Tertiary Care Centre--RIFLE Criteria Validation
by Basu Gopal
Basu G, Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, Thomas K, Abraham AM, John GT.
Source
Department of Nephrology, Christian Medical College, Vellore, India.
Abstract
BACKGROUND:
Acute febrile illnesses are a common cause of tropical acute kidney injury (AKI). The... more
Abstract
BACKGROUND:
Acute febrile illnesses are a common cause of tropical acute kidney injury (AKI). The incidence and severity of AKI in tropical febrile illnesses and validity of RIFLE classification are unclear.
METHODS:
Consecutive adult inpatients of a tertiary hospital in southern India with tropical acute febrile illness between January 2007 and January 2008 were prospectively studied for the incidence and severity of AKI based on RIFLE classification and its association with mortality and dialysis requirement.
RESULTS:
The 367 patients (mean age 39.7±16.9 years; 60% males) with tropical acute febrile illness due to scrub typhus (51.2%), falciparum malaria (10.4%), enteric fever (8.7%), dengue (7.6%), mixed malaria (6.5%), leptospirosis (3.3%), undifferentiated acute febrile illness (8.4%) and others (3.8%) (spotted fever, vivax malaria and Hantaan virus infection) had an overall mortality rate of 12.3%. The incidence of AKI was 41.1%; of which, 17.4%, 9.3% and 14.4% were in the Risk, Injury and Failure classes, respectively. Of the patients, 7.9% required dialysis. Among the Risk, Injury and Failure groups, there was an incremental risk of mortality (OR 6.9, 20.2 and 25.6; P<0.001) and dialysis requirement (OR 3.4, 28.8 and 178.8; P<0.001).
CONCLUSIONS:
The incidence of AKI in the common tropical acute febrile illnesses in our study such as scrub typhus, falciparum malaria, enteric fever, dengue and leptospirosis is 41.1%. RIFLE classification is valid and applicable in AKI related to tropical acute febrile illnesses, with an incremental risk of mortality and dialysis requirement.