Prevention of acute kidney injury in Intensive Care Units.

Acute kidney injury (AKI) is a growing concern in Intensive Care Units. The advanced age of our patients, with the increase in associated morbidity and the complexity of the treatments provided favor the development of AKI. Since no effective treatment for AKI is available, all efforts are aimed at prevention and early detection of the disorder in order to establish secondary preventive measures to impede AKI progression. In critical patients, the most frequent causes are sepsis and situations that result in renal hypoperfusion; preventive measures are therefore directed at securing hydration and correct hemodynamics through fluid perfusion and the use of inotropic or vasoactive drugs, according to the underlying disease condition. Apart from these circumstances, a number of situations could lead to AKI, related to the administration of nephrotoxic drugs, intra-tubular deposits, the administration of iodinated contrast media, liver failure and major surgery (mainly heart surgery). In these cases, in addition to hydration, there are other specific preventive measures adapted to each condition.

Acute kidney injury: Renal disease in the ICU.

Acute kidney injury (AKI) in the ICU frequently requires costly supportive therapies, has high morbidity, and its long-term prognosis is not as good as it has been presumed so far. Consequently, AKI generates a significant burden for the healthcare system. The problem is that AKI lacks an effective treatment and the best approach relies on early secondary prevention. Therefore, to facilitate early diagnosis, a broader definition of AKI should be established, and a marker with more sensitivity and early-detection capacity than serum creatinine - the most common marker of AKI - should be identified. Fortunately, new classification systems (RIFLE, AKIN or KDIGO) have been developed to solve these problems, and the discovery of new biomarkers for kidney injury will hopefully change the way we approach renal patients. As a first step, the concept of renal failure has changed from being a "static" disease to being a "dynamic process" that requires continuous evaluation of kidney function adapted to the reality of the ICU patient.

[Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU]. / Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI.

OBJECTIVE: To detect possible reasons for mortality of critical patients transferred from the ICU to the hospital wards and to analyze the possible attributable causes for such mortality. DESIGN: An observational study of prospectively collected data, analyzed retrospectively. POPULATION: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolution was followed up to hospital discharge or death. PERIOD: From January 2006 to December 2009. METHOD: An analysis was made of differential significance of epidemiological, clinical-care, death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, without limitation of care effort. RESULTS: A total of 907 patients died (SMR=0.9; 95% CI, 0.87-0.93), 202 of whom died after ICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of stay being 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greater mortality was also not found in those re-admitted to the ICU after having been transferred to the ward. It was verified that the cause of death in the ward did not significantly coincide with the cause of admission to the ICU. DISCUSSION: Some mortality after ICU discharge is to be expected. Our data do not allow us to attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceased care in the wards). The reasons for this mortality have a varied and variable explanation. It mostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU.