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1.
Blood Purif ; 52(11-12): 857-879, 2023.
Article in English | MEDLINE | ID: mdl-37742622

ABSTRACT

In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.


Subject(s)
Acute Kidney Injury , Continuous Renal Replacement Therapy , Heart Failure , Hemodynamic Monitoring , Water-Electrolyte Imbalance , Humans , Continuous Renal Replacement Therapy/adverse effects , Prospective Studies , Hemodynamic Monitoring/adverse effects , Pandemics , Acute Kidney Injury/therapy , Acute Kidney Injury/etiology , Renal Replacement Therapy/adverse effects , Water-Electrolyte Imbalance/complications , Heart Failure/complications , Cell Proliferation
2.
Clin J Am Soc Nephrol ; 17(6): 890-901, 2022 06.
Article in English | MEDLINE | ID: mdl-35595531

ABSTRACT

Mechanical life support therapies exist in many forms to temporarily replace the function of vital organs. Generally speaking, these tools are supportive therapy to allow for organ recovery but, at times, require transition to long-term mechanical support. This review will examine nonrenal extracorporeal life support for cardiac and pulmonary support as well as other mechanical circulatory support options. This is intended as a general primer and overview to assist nephrologist consultants participating in the care of these critically ill patients who often experience acute renal injury as a result of cardiopulmonary shock and from their exposure to mechanical circulatory support.


Subject(s)
Acute Kidney Injury , Extracorporeal Membrane Oxygenation , Heart Failure , Heart-Assist Devices , Acute Kidney Injury/therapy , Consultants , Critical Illness , Extracorporeal Membrane Oxygenation/adverse effects , Heart Failure/therapy , Humans
3.
Adv Chronic Kidney Dis ; 28(1): 29-36, 2021 01.
Article in English | MEDLINE | ID: mdl-34389134

ABSTRACT

The number of patients using critical care is increasing as our populations live longer thanks to advances in medical therapies. This is reflected by an increase in both usage and number of critical care beds as compared with total hospital beds across the United States. As this aging population suffers more and more from multiorgan dysfunction, including but not limited to respiratory failure, cardiac failure, and acute kidney injury, technologies are used to facilitate recovery in those that would have assuredly passed away years ago. Some of these advancements include extracorporeal membrane oxygenation and continuous kidney replacement therapy. In this article, we review the literature regarding the history, technology, indications, and outcomes of synchronous extracorporeal membrane oxygenation and kidney replacement therapy.


Subject(s)
Acute Kidney Injury , Extracorporeal Membrane Oxygenation , Respiratory Insufficiency , Acute Kidney Injury/therapy , Aged , Humans , Renal Replacement Therapy , Respiratory Insufficiency/therapy , Technology
4.
Adv Chronic Kidney Dis ; 27(4): 328-335.e1, 2020 07.
Article in English | MEDLINE | ID: mdl-33131646

ABSTRACT

The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field.


Subject(s)
Critical Care , Nephrologists/education , Nephrologists/statistics & numerical data , Nephrology/statistics & numerical data , Physician's Role , Adult , Career Choice , Emigrants and Immigrants/statistics & numerical data , Female , Health Services Needs and Demand , Health Workforce , Humans , Job Satisfaction , Kidney Diseases/therapy , Male , Nephrology/education , Professional Practice Location/statistics & numerical data , Salaries and Fringe Benefits/statistics & numerical data , Scope of Practice , Surveys and Questionnaires
5.
Clin Transl Med ; 10(2): e44, 2020 Jun.
Article in English | MEDLINE | ID: mdl-32508062

ABSTRACT

Patients with severe COVID-19 disease have been characterized as having the acute respiratory distress syndrome (ARDS). Critically ill COVID-19 patients have relatively well-preserved lung mechanics despite severe gas exchange abnormalities, a feature not consistent with classical ARDS but more consistent with pulmonary vascular disease. Many patients with severe COVID-19 also demonstrate markedly abnormal coagulation, with elevated d-dimers and higher rates of venous thromboembolism. We present four cases of patients with severe COVID-19 pneumonia with severe respiratory failure and shock, with evidence of markedly elevated dead-space ventilation who received tPA. All showed post treatment immediate improvements in gas exchange and/or hemodynamics. We suspect that severe COVID-19 pneumonia causes respiratory failure via pulmonary microthrombi and endothelial dysfunction. Treatment for COVID-19 pneumonia may warrant anticoagulation for milder cases and thrombolysis for more severe disease.

6.
medRxiv ; 2020 Apr 21.
Article in English | MEDLINE | ID: mdl-32511632

ABSTRACT

Patients with severe COVID-19 disease have been characterized as having the acute respiratory distress syndrome (ARDS). Critically ill COVID-19 patients have relatively well-preserved lung mechanics despite severe gas exchange abnormalities, a feature not consistent with classical ARDS but more consistent with pulmonary vascular disease. Patients with severe COVID-19 also demonstrate markedly abnormal coagulation, with elevated D-dimers and higher rates of venous thromboembolism. We present five cases of patients with severe COVID-19 pneumonia with severe respiratory failure and shock, with evidence of markedly elevated dead-space ventilation who received tPA. All showed post treatment immediate improvements in gas exchange and/or hemodynamics. We suspect that severe COVID-19 pneumonia causes respiratory failure via pulmonary microthrombi and endothelial dysfunction. Treatment for COVID-19 pneumonia may warrant anticoagulation for milder cases and thrombolysis for more severe disease.

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