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Environment, Smoking, Obesity, and the Kidney

Objectives This chapter will: 1. Review the effects of environment injury, smoking, and obesity in the critical ill. 2. Unravel the main pathophysiologic mechanisms of these effects. 3. Suggest preventive and therapeutic measures. Environment The kidney is especially vulnerable to toxic injury because it receives about one quarter of the cardiac output and it transports and concentrates potentially toxic compounds within its parenchyma. The main mechanisms…

Alternative Medicine and Chinese Herbs and the Kidney

Objectives This chapter will: 1. Define complementary and alternative medicine. 2. Present general treatment principles of Chinese herbal medicine. 3. Provide an overview of mechanisms of nephrotoxicity with exposure to alternative medicine, with specific examples of herb-related nephrotoxicity. 4. Discuss possible therapeutic roles of alternative medicines in renal disease. Definitions Complementary and alternative medicine (CAM) involves therapies that usually are not taught in Western medical schools.…

Calcineurin Inhibitors and Other Immunosuppressive Drugs and the Kidney

Objectives This chapter will: 1. Define potential mechanisms underlying the nephrotoxicity of immunosuppressive drugs in the intensive care unit (ICU). 2. Analyze pharmacologic interactions among immunosuppressive agents and other drugs used in ICU patients. 3. Evaluate clinical outcomes after adjustments or reductions in the immunosuppressive regimen. Drug-induced nephrotoxicity can cause acute kidney injury (AKI) in patients in the intensive care unit (ICU). Drug toxicity may cause…

Antiinflammatory Drugs and the Kidney

Objectives This chapter will: 1. Identify the mechanisms of renal damage induced by nonsteroidal antiinflammatory drugs (NSAIDs) and coxibs. 2. Describe the incidence and epidemiology of NSAID-induced acute kidney injury. 3. Describe the risk factors for NSAID-induced acute vasomotor renal injury and NSAID-induced nephrotoxicity. Nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed widely in clinical practice and are available without a prescription. NSAIDs, including the more selective inhibitors…

Anticancer Drugs and the Kidney

Objectives This chapter will: 1. Characterize major nephrotoxic chemotherapy agents and their effect on kidney function and electrolyte homeostasis. 2. Describe strategies aimed at preventing and alleviating chemotherapy-induced acute kidney injury. 3. Provide guidelines for administration of chemotherapeutic agents to patients undergoing renal replacement therapy. The kidneys represent the major elimination pathway for many chemotherapeutic agents and are vulnerable to toxic effects of chemotherapy. Antineoplastic agents…

Diagnosis and Management of Acute Kidney Injury in the Emergency Department

Objectives This chapter will: 1. Describe the importance of timely acute kidney injury (AKI) diagnosis according to available guidelines. 2. Discuss the importance of early diagnosis of AKI in the emergency department (ED) and how physicians should manage the patients with AKI in the ED properly. The diagnosis of acute kidney injury includes an acute and broad condition of kidney dysfunction detected by serum creatinine (SCr)…

Management of Patients with Diabetes in the Intensive Care Unit

Objectives This chapter will: 1. Describe the epidemiology of diabetic kidney disease and the burden of illness in the intensive care unit (ICU) setting. 2. Illustrate the spectrum of renal disease observed in patients with diabetes in the ICU. 3. Describe the metabolic abnormalities observed in patients with diabetes in the ICU. 4. Review the evolution of glycemic targets in the ICU. 5. Recommend treatment strategies…

Management of Chronic Kidney Disease and End-Stage Kidney Disease Patients in the Intensive Care Unit

Objectives This chapter will: 1. Describe the pathophysiologic mechanisms underlying the development of acute-on-chronic (AoC) kidney dysfunction and its role in the progression toward end-stage kidney disease (ESKD). 2. Identify the most common clinical presentations of critical illness among chronic kidney disease (CKD)/ESKD patients. 3. Detail the continuum of care for CKD/ESKD patients from maintenance hemodialysis/peritoneal dialysis to acute renal replacement therapy performed in an intensive…

Acute Renal Failure in Kidney Transplant Recipients

Objectives This chapter will: 1. Discuss the causes and risk factors of delayed graft function (DGF). 2. Describe the pathophysiology of ischemia/reperfusion damage. 3. Address the question of whether DGF is associated with an increased risk of acute rejection and long-term graft dysfunction. 4. Discuss allograft acute kidney injury (AKI) as a template for studying mechanistic aspects of AKI. 5. Discuss strategies to prevent ischemia/reperfusion injury…

Kidney Support and Perioperative Care in Kidney Transplantation

Objectives This chapter will: 1. Discuss the period from renal transplantation to the first week after surgery. 2. Describe the evaluation of patients immediately before transplantation. 3. Discuss the evaluation and management of patients immediately after surgery. 4. Address techniques for management of hypertension and mineral and electrolyte problems after surgery. 5. Describe identification and management of surgical complications in the perioperative period. 6. Identify specific…

Patient Selection and Pretransplantation Care for Kidney Transplant Recipients

Objectives This chapter will: 1. Outline an overall approach to evaluating renal transplant recipients. 2. Identify risk factors for graft loss and death after transplantation. 3. Identify renal diseases known to recur after transplantation. 4. Identify the basic cardiac evaluation for transplant recipients. 5. Identify appropriate waiting periods for patients with malignancies before transplantation. Innovations in transplantation have led to progressive improvement in patient and graft…

Antibiotics in Critically Ill Newborns and Children: Nephrotoxicity and Management During Renal Replacement Therapy

Objectives This chapter will: 1. Discuss the use of antibiotics in newborns admitted to intensive care units because of prematurity or severe diseases. 2. Discuss the choice of the proper antibiotic according to the clinical situation and the potential renal effects of antibiotics in premature children according to the currently available data based on guidelines, recommendations, and institutional experience. 3. Describe the dose adaptation according to…

Techniques and Machines for Pediatric Renal Replacement Therapy

Objectives This chapter will: 1. Describe the current modalities currently available for pediatric continuous renal replacement therapy, giving context to the differences and indications for peritoneal dialysis and extracorporeal dialysis. 2. Present some general rules to follow to rationally prescribe acute dialysis in children, considering that very little literature is available in this field. 3. Provide some recent updates on recent pediatric monitors described for the…

Modified Ultrafiltration in Pediatric Heart Surgery

Objectives This chapter will: 1. Present a rationale for use of modified ultrafiltration in pediatric cardiac surgery. 2. Review the pathophysiologic changes leading to the systemic inflammatory response syndrome with use of cardiopulmonary bypass. 3. Summarize the benefits of modified ultrafiltration for pediatric cardiac surgery. 4. Provide guidelines for the modified ultrafiltration procedure based on clinical experience. Pediatric heart surgery is an area with consolidated excellent…

Neonatal Hyperammonemia and Continuous Renal Replacement Therapy

Objectives This chapter will: 1. Review the rationale for use of continuous renal replacement therapy (CRRT) in the management of inborn errors of metabolism. 2. Outline the practical considerations for use of CRRT in neonatal hyperammonemia as well as technical considerations and challenges in providing therapy. Neonatal hyperammonemia (NH) is a life-threatening medical emergency. NH should be suspected if the plasma ammonium level is greater than…

Renal Replacement Therapy for the Critically Ill Infant

Objectives This chapter will: 1. Explain special issues related to use of renal replacement therapy for infants. 2. Identify specific risks and complications of renal replacement therapy in infants. 3. Highlight advantages and disadvantages of different renal replacement modalities for the critically ill infant. The expanding role of renal replacement therapy (RRT) in the care of critically ill children extends to the smallest pediatric patients. Infants…

Outcome of Pediatric Acute Kidney Injury

Objectives This chapter will: 1. Compare mortality rates observed in various critically ill pediatric populations in which acute kidney injury develops. 2. Analyze outcomes for children who acquire acute kidney injury in terms of need for renal replacement therapy. 3. Identify clinical variables associated with increased mortality in critically ill children with acute kidney injury who receive renal replacement therapy. 4. Review long-term sequelae in children…

Nutrition of Critically Ill Children With Acute Renal Failure

Objectives This chapter will: 1. Describe the importance of providing adequate nutrition in critically ill children with acute kidney injury (AKI). 2. Provide an approach to assessment and monitoring of nutritional status in children with AKI and those treated with renal replacement therapy (RRT). 3. Outline energy, protein, and other nutritional requirements in patients with AKI and those treated with RRT. Malnutrition and protein energy wasting…

Drug Dosing in Pediatric Acute Kidney Insufficiency and Renal Replacement Therapy

Objectives This chapter will: 1. Describe the pharmacokinetic alterations that occur in critically ill children with acute kidney insufficiency that may affect drug dosing. 2. Review the limitations of the various methods used to calculate drug doses in children receiving continuous renal replacement therapy. 3. Identify the factors that influence drug removal through continuous renal replacement therapy. 4. Identify the factors that influence drug removal through…

Multiple Organ Dysfunction in the Pediatric Intensive Care Unit

Objectives This chapter will: 1. Describe the clinical manifestation of pediatric multiple organ dysfunction syndrome (MODS), including pathogenetic pathways and specific pediatric MODS causes. 2. Detail theoretic mechanisms of organ damage and current literature available in this field. 3. Present available therapeutic strategies for pediatric MODS management. Multiple organ dysfunction syndrome (MODS), initially described as multiple systems organ failure in adult patients in 1960, represents a…