Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients

Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.

Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients

Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.

A Case of Osmotic Demyelination Presenting with Severe Hypernatremia

Osmotic demyelination syndrome is a demyelinating disorder associated with rapid correction of hyponatremia. But, it rarely occurs in acute hypernatremia, and it leads to permanent neurologic symptoms and is associated with high mortality. A 44-year-old woman treated with alternative medicine was admitted with a history of drowsy mental status. Severe hypernatremia (197mEq/L) with hyperosmolality (415mOsm/kgH2O) was evident initially and magnetic resonance imaging revealed a high signal intensity lesion in the pons, consistent with central pontine myelinolysis. She was treated with 0.45% saline and 5% dextrose water and intravenous corticosteroids. Serum sodium normalized and her clinical course gradually improved. Brain lesion of myelinolysis also improved in a follow-up imaging study. This is the first report of a successful treatment of hypernatremia caused by iatrogenic salt intake, and it confirms the importance of adequate fluid supplementation in severe hypernatremia.

A Case of Acute Kidney Injury Associated with Rhabdomyolysis after Liposuction / 대한내과학회지

Rhabdomyolysis is defined as a skeletal muscle injury with release of muscle cell constituents into the plasma. It can occur in various diseases and conditions, including muscle strain, drug or alcohol abuse, connective tissue disease, excess exercise, or following surgery. Only one case of rhabdomyolysis has ever been associated with liposuction in Korea. We experienced a case of rhabdomyolysis that developed after liposuction surgery. The patient was a 39-year-old woman presenting with abdominal pain 1 day after liposuction. She was treated with general supportive care, including massive hydration and absolute bed rest. Renal replacement therapy was performed due to pulmonary edema. She, finally, recovered fully. Acute kidney injury caused by liposuction-induced rhabdomyolysis is a rare disease. Therefore, we present this case with a review of the literature.

Rituximab for Rheumatoid Arthritis Following TNF-alpha Inhibitor Associated Splenic Tuberculosis

One of the most important adverse effects of a tumor necrosis factor (TNF)-alpha inhibitor is the reactivation of tuberculosis. Most of them occur in the lung, but sometimes they can be found in other organs. Moreover, the proper management of active rheumatoid arthritis (RA) in patients with anti-TNF-alpha associated tuberculosis is still in debate. We present the case of a seropositive RA patient who showed good response with rituximab, an anti-CD20 monoclonal antibody, after developing splenic tuberuculosis, following treatment with TNF-alpha inhibitor. Confirming a diagnosis of splenic tuberculosis is difficult and can be delayed due to its nonspecific symptoms and rare occurrence. This case suggests that splenic tuberculosis should be doubted in RA patients treated with TNF-alpha inhibitor, and that rituximab may be considered as an alternative treatment option in RA patients with anti-TNF-alpha associated tuberculosis.

Clinical Significance of Acute Kidney Injury in Patients with Colistin Treatment / 대한신장학회지

PURPOSE: Colistin (colistimethate sodium) became available for clinical use in 1959 and was used until the early 1980s to treat infections caused by Gram-negative rods. It was abandoned during the last two decades mainly due to its significant nephrotoxicity. However, the emergence of multidrug-resistant (MDR) bacteria such as Pseudomonas aeruginosa and Acinetobacter baumanii has resulted in significantly increased use of intravenous colistin. This study was designed to investigate the incidence and risk factors of acute kidney injury (AKI) associated with intravenous colistin (colistimethate sodium) treatment. METHODS: We retrospectively collected the data from patients who were admitted to Chung-Ang University Hospital and treated with colistin from May 2007 to June 2009. Among these, we excluded the patients with baseline glomerular filtration rate (GFR) less than 15 ml/min/1.73m2. AKI was defined as an increase of creatinine more than 150% from the baseline, according to RIFLE criteria. RESULTS: A total of 92 patients met the inclusion criteria and were included in the analysis. AKI occurred in 43 (47%) of the 92 patients. The cumulative doses (2.51+/-1.89 vs. 1.75+/-1.35 g, p=0.032) of colistin were significantly greater in the AKI group than in the normal kidney function (NKF) group. Serum creatinine level showed a significant increase in the AKI group, from day 3 (1.6+/-1.1 vs. 0.9+/-0.5 mg/dL, p=0.001) to day 90 (2.1+/-1.9 vs. 0.7+/-0.2 mg/dL, p=0.033). Furthermore, the occurrence of AKI at day 3 was a significant predictor of shorter survival (Log rank test p=0.031). CONCLUSION: AKI was a relatively common side effect of colistin. The cumulative dose was critical, rather than the daily dose or duration of treatment. Early acute kidney injury may predict shorter cumulative survival in patients undergoing colistin treatment.

Role of IL-1alpha in Cisplatin-Induced Acute Renal Failure in Mice

BACKGROUND/AIMS: For unknown reasons, caspase-1 -/- mice, protected against cisplatin-induced acute renal failure (ARF), are deficient in interleukin (IL)-1alpha. We thus asked whether IL-1alpha deficiency underlies the mechanism of protection against cisplatin-induced ARF in these mice. METHODS: Cisplatin (30 mg/kg) was injected intraperitoneally into wild-type C57BL/6 mice to produce a cisplatin-induced model of ARF. IL-1alpha was measured in control vehicle- and cisplatin-treated wild-type animals. We also examined whether IL-1alpha -/- mice were similarly protected against cisplatin-induced ARF. Additionally, infiltration of CD11b- and CD49b-positive cells, as markers of macrophages, natural killer, and natural killer T cells (pan-NK cells), was investigated in wild-type and IL-1alpha -/- mice. RESULTS: Compared with vehicle-treated mice, renal IL-1alpha increased in cisplatin-treated wild-type mice beginning on day 1. IL-1alpha -/- mice were shown to be protected against cisplatin-induced ARF. No significant difference in the infiltration of neutrophils or CD11b- and CD49b-positive cells were observed between wild-type and IL-1alpha -/- mice. CONCLUSIONS: Mice deficient in IL-1alpha are protected against cisplatin-induced ARF. The lack of IL-1alpha may explain, at least in part, the protection against cisplatin-induced ARF observed in caspase-1 -/- mice. Investigation of the protective mechanism (s) in IL-1alpha -/- mice in cisplatin-induced ARF merits further study.