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Management of Acute Renal Dysfunction in Sepsis

  • Sepsis (J Russell, Section Editor)
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Abstract

Acute kidney injury (AKI) often complicates sepsis, leading to greater complexity and a worsening prognosis. Advances in the clinical management of sepsis may have secondary benefits with respect to renal outcomes. In critically ill patients, this disorder typically produces multiple organ dysfunction. Among the several disorders encountered in sepsis, AKI is one of the most important because it is a life-threatening condition, increases the complexity and cost of care, and is an independent risk factor for mortality. The potential interventions in sepsis-related AKI consist of effective prevention/protection strategies for the kidney in patients at risk, early recognition and attenuation of renal damage, pathophysiology-driven pharmacologic support, efficient extracorporeal blood purification therapy, and strategies that promote recovery of renal function. Existing and hybrid extracorporeal therapies are being investigated not only as means to replace lost kidney function, but also to modulate the immune response to sepsis.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Parmar A, Langenberg C, Wan L, et al. Epidemiology of septic acute kidney injury. Curr Drug Targets. 2009;10:1169–78.

    Article  PubMed  CAS  Google Scholar 

  2. Fry DE. Sepsis, systemic inflammatory response, and multiple organ dysfunction: the mystery continues. Am Surg. 2012;78:1–8.

    PubMed  Google Scholar 

  3. Parikh A, Shaw A. The economics of renal failure and kidney disease in critically ill patients. Crit Care Clin. 2012;28:99–111.

    Article  PubMed  Google Scholar 

  4. Oppert M, Engel C, Brunkhorst FM, et al. Acute renal failure in patients with severe sepsis and septic shock–a significant independent risk factor for mortality: results from the German Prevalence Study. Nephrol Dial Transplant. 2008;23:904–9.

    Article  PubMed  Google Scholar 

  5. Kellum JA, Levin N, Bouman C, Lameire N. Developing a consensus classification system for acute renal failure. Curr Opin Crit Care. 2002;8:509–14.

    Article  PubMed  Google Scholar 

  6. Bellomo R, Kellum JA, Ronco C. Defining and classifying acute renal failure: from advocacy to consensus and validation of the RIFLE criteria. Intensive Care Med. 2007;33:409–13.

    Article  PubMed  Google Scholar 

  7. Uchino S, Bellomo R, Goldsmith D, et al. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med. 2006;34:1913–7.

    Article  PubMed  Google Scholar 

  8. Bagshaw SM, George C, Dinu I, Bellomo R. A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant. October 25, 2007.

  9. Hoste EA, Clermont G, Kersten A, Venkataraman R, Angus DC, De Bacquer D, Kellum JA. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care. 2006;10:R73.

    Article  PubMed  Google Scholar 

  10. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. Chest. 1992;101:1644–55.

    Article  PubMed  CAS  Google Scholar 

  11. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R. Report of the American-European Consensus conference on acute respiratory distress syndrome: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Consensus Committee. J Crit Care. 1994;9:72–81.

    Article  PubMed  CAS  Google Scholar 

  12. Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney Int. 2008;73(5):538–46.

    Article  PubMed  CAS  Google Scholar 

  13. Bellomo R, Wan L, May C. Managing septic acute renal failure: “fill and spill”? “squeeze and diurese”? or “block Bax to the max”? Crit Care Resusc. 2004;6:12–6.

    PubMed  CAS  Google Scholar 

  14. Hotchkiss RS, Karl IE. The pathophysiology and treatment of sepsis. N Engl J Med. 2003;348:138–50.

    Article  PubMed  CAS  Google Scholar 

  15. Ronco C, Tetta C, Mariano F, et al. Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs. 2003;27:792–801.

    Article  PubMed  Google Scholar 

  16. Liangos O, Perianayagam MC, Vaidya VS, et al. Urinary N-acetyl-beta-(D)-glucosaminidase activity and kidney injury molecule-1 level are associated with adverse outcomes in acute renal failure. J Am Soc Nephrol. 2007;18:904–12.

    Article  PubMed  CAS  Google Scholar 

  17. • Haase M, Devarajan P, Haase-Fielitz A, et al. The outcome of neutrophil gelatinase-associated lipocalin-positive subclinical acute kidney injury: a multicenter pooled analysis of prospective studies. J Am Coll Cardiol. 2011;57:1752–61. This paper highlights the role of N-GAL in the early diagnosis of AKI.

    Article  PubMed  CAS  Google Scholar 

  18. Liangos O. Drugs and AKI. Minerva Urol Nefrol. 2012;64:51–62.

    PubMed  CAS  Google Scholar 

  19. Hilton AK, Bellomo R. A critique of fluid bolus resuscitation in severe sepsis. Crit Care. 2012;16:302.

    Article  PubMed  Google Scholar 

  20. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296–327.

    Article  PubMed  Google Scholar 

  21. •• SAFE Study Investigators. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med. 2011;37:86–96. This paper is important since it provides very important information about the fluids theraphy of sepsis.

    Article  Google Scholar 

  22. Friedman G, Jankowski S, Shahla M, Gomez J, Vincent JL. Hemodynamic effect of 6 % and 10 % hydroxyethyl starch solutions versus 4 % albumin solution in septic patients. J Clin Anesth. 2008;20:528–33.

    Article  PubMed  CAS  Google Scholar 

  23. Fang ZX, Li YF, Zhou XQ, Zhang Z, Zhang JS, Xia HM, Xing GP, Shu WP, Shen L, Yin GQ. Effects of resuscitation with crystalloud fluids on cardiac function in patients with severe sepsis. BMC Infect Dis. 2008;8:50.

    Article  PubMed  Google Scholar 

  24. Hartog CS, Brunkhorst FM, Engel C, et al. Are renal adverse effects of hydroxyethyl starches merely a consequence of their incorrect use? Wien Klin Wochenschr. 2011;123:145–55.

    Article  PubMed  CAS  Google Scholar 

  25. Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev. 2010;20:CD007594.

    Google Scholar 

  26. Rivers E, Nguyen B, Havstad S, et al. Early Goal-Directed Therapy Collaborative Group: early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.

    Article  PubMed  CAS  Google Scholar 

  27. Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med. 1995;333:1025–32.

    Article  PubMed  CAS  Google Scholar 

  28. Di Giantomasso D, May CN, Bellomo R. Norepinephrine and vital organ blood flow during experimental hyperdynamic sepsis. Intensive Care Med. 2003;29:1774–81.

    Article  PubMed  Google Scholar 

  29. Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008;358:877–87.

    Article  PubMed  CAS  Google Scholar 

  30. Gordon AC, Russell JA, Walley KR, et al. The effects of vasopressin on acute kidney injury in septic shock. Intensive Care Med. 2010;36:83–91.

    Article  PubMed  CAS  Google Scholar 

  31. Morelli A, Ricci Z, Bellomo R, et al. Prophylactic fenoldopam for renal protection in sepsis: a randomized, double-blind, placebo-controlled pilot trial. Crit Care Med. 2005;33:2451–6.

    Article  PubMed  CAS  Google Scholar 

  32. •• Lentini P, de Cal M, Clementi A, et al. Sepsis and AKI in ICU Patients: The Role of Plasma Biomarkers. Crit Care Res Pract. 2012;2012:856401. This paper is important since provide some important informations about some interesting biomarkers to early diagnose AKI.

    PubMed  Google Scholar 

  33. Goldstein SL. Acute kidney injury biomarkers: renal angina and the need for a renal troponin I. BMC Med. 2011;9:135.

    Article  PubMed  Google Scholar 

  34. Bellomo R. How to feed patients with renal dysfunction. Blood Purif. 2002;20:296–303.

    Article  PubMed  CAS  Google Scholar 

  35. Lipcsey M, Bellomo R. Septic acute kidney injury: hemodynamic syndrome, inflammatory disorder, or both? Crit Care. 2011;15:1008.

    Article  PubMed  Google Scholar 

  36. Langenberg C, Bellomo R, May C, Wan L, Egi M, Morgera S. Renal blood flow in sepsis. Crit Care. 2005;9:R363–74.

    Article  PubMed  Google Scholar 

  37. Ishikawa K, Bellomo R, May CN. The impact of intrarenal nitric oxide synthase inhibition on renal blood flow and function in mild and severe hyperdynamic sepsis. Crit Care Med. 2011;39:770–6.

    Article  PubMed  CAS  Google Scholar 

  38. Benes J, Chvojka J, Sykora R, Radej J, Krouzecky A, Novak I, Matejovic M. Searching for mechanisms that matter in early septic acute kidney injury: an experimental study. Crit Care. 2011;15:R256.

    Article  PubMed  Google Scholar 

  39. •• Ricci Z, Polito A, Polito A, Ronco C. The implications and management of septic acute kidney injury. Nat Rev Nephrol. 2011;7:218–25. This paper hightlights the management of AKI in septic patients and provide important information for the treatments of sepsis related kidney injury.

    Article  PubMed  CAS  Google Scholar 

  40. Mehta RL, Pascual MT, Soroko S, Chertow GM, PICARD Study Group. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA. 2002;288:2547–53.

    Article  PubMed  CAS  Google Scholar 

  41. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol. 2011;6:966–73.

    Article  PubMed  Google Scholar 

  42. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564–75.

    Article  Google Scholar 

  43. Bagshaw SM, Gibney RT, McAlister FA, Bellomo R. The SPARK Study: a phase II randomized blinded controlled trial of the effect of furosemide in critically ill patients with early acute kidney injury. Trials. 2010;11:50.

    Article  PubMed  Google Scholar 

  44. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet. 2000;356:2139–43.

    Article  PubMed  CAS  Google Scholar 

  45. Hirschberg R, Kopple J, Lipsett P, et al. Multicenter clinical trial of recombinant human insulin- like growth factor I in patients with acute renal failure. Kidney Int. 1999;55:2423–32.

    Article  PubMed  CAS  Google Scholar 

  46. Mitka M. Drug for severe sepsis is withdrawn from market, fails to reduce mortality. JAMA. 2011;306:2439–40.

    Article  PubMed  CAS  Google Scholar 

  47. Jo SK, Rosner MH, Okusa MD. Pharmacologic treatment of acute kidney injury: why drugs haven't worked and what is on the horizon. Clin J Am Soc Nephrol. 2007;2:356–65.

    Article  PubMed  Google Scholar 

  48. Pickkers P, Heemskerk S, Schouten J, et al. Alkaline phosphatase for treatment of sepsis-induced acute kidney injury: a prospective randomized double-blind placebo-controlled trial. Crit Care. 2012;16:R14.

    Article  PubMed  Google Scholar 

  49. Gotloib L, Barzilay E, Shustak A, Lev A. Sequential hemofiltration in nonoliguric high capillary permeability pulmonary edema of severe sepsis: preliminary report. Crit Care Med. 1984;12:997–1000.

    Article  PubMed  CAS  Google Scholar 

  50. De Vriese AS, Colardyn FA, Philippe JJ, et al. Cytokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol. 1999;10:846–53.

    PubMed  Google Scholar 

  51. De Vriese AS, Vanholder RC, Pascual M, et al. Can inflammatory cytokines be removed efficiently by continuous renal replacement therapies? Intensive Care Med. 1999;25:903–10.

    Article  PubMed  Google Scholar 

  52. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000;356:26–30.

    Article  PubMed  CAS  Google Scholar 

  53. Huang H, Yao T, Wang W, et al. Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass. Ann Thorac Surg. 2003;76:136–40.

    Article  PubMed  Google Scholar 

  54. Davenport A. Renal replacement therapy in the patient with acute brain injury. Am J Kidney Dis. 2001;37:457–66.

    Article  PubMed  CAS  Google Scholar 

  55. Yekebas EF, Eisenberger CF, Ohnesorge H, et al. Attenuation of sepsis-related immunoparalysis by continuous veno-venous hemofiltration in experimental porcine pancreatitis. Crit Care Med. 2001;29:1423–30.

    Article  PubMed  CAS  Google Scholar 

  56. Righetti M, Ferrario GM, Milani S, et al. A single centre study about the effects of HFR on anemia. G Ital Nefrol. 2004;21 Suppl 30:S168–71.

    PubMed  Google Scholar 

  57. Tarakcioglu M, Erbagci AB, Usalan C, et al. Acute effect of hemodialysis on serum levels of the proinflammatory cytokines. Mediat Inflamm. 2003;12:15–9.

    Article  CAS  Google Scholar 

  58. Fiaccadori E, Maggiore U, Parenti E, et al. Sustained low-efficiency dialysis (SLED) with prostacyclin in critically ill patients with acute renal failure. Nephrol Dial Transplant. 2007;22:529–37.

    Article  PubMed  CAS  Google Scholar 

  59. Marshall MR, Golper TA, Shaver MJ, et al. Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis. 2002;39:556–70.

    Article  PubMed  CAS  Google Scholar 

  60. Van Biesen W, Veys N, Vanholder R. Intermittent hemodialysis for renal replacement therapy in intensive care: new evidence for old truths. Contrib Nephrol. 2007;156:304–8.

    Article  PubMed  Google Scholar 

  61. Lonnemann G, Bechstein M, Linnenweber S, et al. Tumor necrosis factor-alpha during continuous high-flux hemodialysis in sepsis with acute renal failure. Kidney Int Suppl. 1999;(72):S84–S87.

  62. Brunet S, Leblanc M, Geadah D, et al. Diffusive and convective solute clearances during continuous renal replacement therapy at various dialysate and ultrafiltration flow rates. Am J Kidney Dis. 1999;34:486–92.

    Article  PubMed  CAS  Google Scholar 

  63. Bouman CS, Oudemans-van Straaten HM, et al. Hemofiltration in sepsis and systemic inflammatory response syndrome: the role of dosing and timing. J Crit Care. 2007;22:1–12.

    Article  PubMed  Google Scholar 

  64. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000;356:26–30.

    Article  PubMed  CAS  Google Scholar 

  65. Cruz DN, Bellomo R, Ronco C. Clinical effects of polymyxin B-immobilized fiber column in septic patients. Contrib Nephrol. 2007;156:444–51.

    Article  PubMed  Google Scholar 

  66. Cruz DN, Perazella MA, Bellomo R, et al. Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review. Crit Care. 2007;11:R47.

    Article  PubMed  Google Scholar 

  67. • Antonelli M, Fumagalli R, Cruz DN, EUPHAS Study Group, et al. PMX endotoxin removal in the clinical practice: results from the EUPHAS trial. Contrib Nephrol. 2010;167:83–90. Epub 2010 Jun 1. This paper highlight the role of PMX in endotoxin removal and the interesting results in using this device to treat patients with Sepsis from Gram negative bacteria.

    Article  PubMed  CAS  Google Scholar 

  68. Uchino S, Bellomo R, Goldsmith D, et al. A new technique for cytokine removal. Intensive Care Med. 2002;28:651–5.

    Article  PubMed  CAS  Google Scholar 

  69. Lee PA, Weger GW, Pryor RW, Matson JR. Effects of filter pore size on efficacy of continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicemia in immature swine. Crit Care Med. 1998;26:730–7.

    Article  PubMed  CAS  Google Scholar 

  70. Morgera S, Haase M, Rocktaschel J, et al. High permeability haemofiltration improves peripheral blood mononuclear cell proliferation in septic patients with acute renal failure. Nephrol Dial Transplant. 2003;18:2570–6.

    Article  PubMed  Google Scholar 

  71. Morgera S, Haase M, Kuss T, et al. Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure. Crit Care Med. 2006;34:2099–104.

    Article  PubMed  CAS  Google Scholar 

  72. Haase M, Bellomo R, Baldwin I, et al. Hemodialysis membrane with a high-molecular-weight cutoff and cytokine levels in sepsis complicated by acute renal failure: a phase 1 randomized trial. Am J Kidney Dis. 2007;50:296–304.

    Article  PubMed  CAS  Google Scholar 

  73. Peng ZY, Kiss JE, Cortese-Hasset A, et al. Plasma filtration on mediators of thrombotic microangiopathy: an in vitro study. Int J Artif Organs. 2007;30:401–6.

    PubMed  CAS  Google Scholar 

  74. Formica M, Inguaggiato P, Bainotti S, Wratten ML. Coupled plasma filtration adsorption. Contrib Nephrol. 2007;156:405–10.

    Article  PubMed  Google Scholar 

  75. Bellomo R, Tetta C, Ronco C. Coupled plasma filtration adsorption. Intensive Care Med. 2003;29:1222–8.

    Article  PubMed  Google Scholar 

  76. Ronco C, Brendolan A, Lonnemann G, et al. A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med. 2002;30:1250–5.

    Article  PubMed  Google Scholar 

  77. Uchino S, Bellomo R, Morimatsu H, et al. A worldwide practice survey—The Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators. Intensive Care Med. 2007;33:1563–70.

    Article  PubMed  Google Scholar 

  78. Uchino S, Bellomo R, Kellum JA, et al. Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators Writing Committee: patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Artif Organs. 2007;30:281–92.

    PubMed  CAS  Google Scholar 

  79. Van Wert R, Friedrich JO, Scales DC, University of Toronto Acute Kidney Injury Research Group, et al. High-dose renal replacement therapy for acute kidney injury: systematic review and meta-analysis. Crit Care Med. 2010;38:1360–9.

    PubMed  Google Scholar 

  80. RENAL Study Investigators, Bellomo R, Cass A, Cole L, et al. Design and challenges of the Randomized Evaluation of Normal versus Augmented Level Replacement Therapy (RENAL) Trial: high-dose versus standard-dose hemofiltration in acute renalfailure. Blood Purif. 2008;26(5):407–16. Review.

    Article  PubMed  Google Scholar 

  81. Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators. Intensive Care Med. 2007;33(9):1563–70.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy

    Federico Nalesso & Claudio Ronco

  2. Department of Pediatric Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy

    Zaccaria Ricci

  3. IRRIV, Internatinal Renal Reserch Institute Vicenza, Vicenza, Italy

    Federico Nalesso & Claudio Ronco

  4. Department of Nephrology, Dialysis and Transplant, San Bortolo Hospital, via Rodolfi 37, 36100, Vicenza, Italy

    Federico Nalesso

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  1. Federico Nalesso
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  2. Zaccaria Ricci
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  3. Claudio Ronco
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Correspondence to Federico Nalesso.

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Nalesso, F., Ricci, Z. & Ronco, C. Management of Acute Renal Dysfunction in Sepsis. Curr Infect Dis Rep 14, 462–473 (2012). https://doi.org/10.1007/s11908-012-0274-4

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