Prevention of rhabdomyolysis-induced acute kidney injury - A DASAIM/DSIT clinical practice guideline.

BACKGROUND: Rhabdomyolysis-induced acute kidney injury (AKI) is a common and serious condition. We aimed to summarise the available evidence on this topic and provide recommendations according to current standards for trustworthy guidelines. METHODS: This guideline was developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The following preventive interventions were assessed: (a) fluids, (b) diuretics, (c) alkalinisation, (d) antioxidants, and (e) renal replacement therapy. Exclusively patient-important outcomes were assessed. RESULTS: We suggest using early rather than late fluid resuscitation (weak recommendation, very low quality of evidence). We suggest using crystalloids rather than colloids (weak recommendation, low quality of evidence). We suggest against routine use of loop diuretics as compared to none (weak recommendation, very low quality of evidence). We suggest against use of mannitol as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of any diuretic as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of alkalinisation with sodium bicarbonate as compared to none (weak recommendation, low quality of evidence). We suggest against the routine use of any alkalinisation as compared to none (weak recommendation, low quality of evidence). We suggest against routine use of renal replacement therapy as compared to none (weak recommendation, low quality of evidence). For the remaining PICO questions, no recommendations were issued. CONCLUSION: The quantity and quality of evidence supporting preventive interventions for rhabdomyolysis-induced AKI is low/very low. We were able to issue eight weak recommendations and no strong recommendations.

Transesophageal Doppler reliably tracks changes in cardiac output in comparison with intermittent pulmonary artery thermodilution in cardiac surgery patients.

In this study a comparison of cardiac output (CO) measurements obtained with CardioQ transesophageal Doppler (TED) and pulmonary artery catheter (PAC) thermodilution (TD) technique was done in a systematic set-up, with induced changes in preload, afterload and heart rate. Twenty-five patients completed the study. Each patient were placed in the following successive positions: (1) supine, (2) head-down tilt, (3) head-up tilt, (4) supine, (5) supine with phenylephrine administration, (6) pace heart rate 80 beats per minute (bpm), (7) pace heart rate 110 bpm. The agreement of compared data was investigated by Bland-Altman plots, and to assess trending ability a four quadrants plot and a polar plot were constructed. Both methods showed an acceptable precision 6.4 % (PAC TD) and 12.8 % (TED). In comparison with PAC TD, the TED was associated with a mean bias in supine position of -0.30 l min-1 (95 % CI -0.88; 0.27), wide limits of agreement, a percentage error of 69.5 %, and a trending ability with a concordance rate of 92 %, angular bias of 1.1° and a radial sector size of 40.0° corresponding to an acceptable trending ability. In comparison with PAC TD, the CardioQ TED showed a low mean bias, wide limits of agreement and a larger percentage error than should be expected from the precision of the two methods. However, an acceptable trending ability was found. Thus, the CardioQ TED should not replace CO measurements done by PAC TD, but could be a valuable tool in guiding therapy.

[Rhabdomyolysis].

Rhabdomyolysis is the common denomination of conditions with destruction of skeletal muscle tissue. Complications are disturbances in the electrolyte and acid-base balance and circulatory and renal insufficency. The pathophysiology and treatment of these systemic complications is discussed. Different recommendations exist for the prevention of renal failure; of these, only fluid therapy to restore euvolaemia has been shown to be efficient with reasonable certainty, whereas the effect of diuretic therapy, alkalinisation of the urine and haemofiltration of myoglobin remains to be proved.

Right ventricular failure after implantation of a continuous-flow left ventricular assist device: early haemodynamic predictors.

OBJECTIVES: Right ventricular failure (RVF) is a significant complication after implantation of a left ventricular assist device. We aimed to identify haemodynamic changes in the early postoperative phase that predicted subsequent development of RVF in a cohort of HeartMate II (HMII) implanted patients. METHODS: This was a single-centre observational study of consecutive placement of HMII devices at Rigshospitalet, Copenhagen. Preoperative data (right heart catheterization, biochemistry and clinical status) and postoperative readings from the first 72 h after implantation (haemodynamics, inotropic and vasoactive therapy) were included in the analysis. The data set was examined for significant differences between patients who developed RVF (RVF group, n = 11)-defined as need for inotropic or vasodilator therapy >14 days, nitric oxide therapy ≥ 48 h or right ventricular assist device therapy-and those who did not (non-RVF group, n = 22). RESULTS: Preoperative right heart catheterization data were similar in the two groups. Immediately after HMII implantation, the increase in cardiac index (CI) was significantly larger in the non-RVF than in the RVF group (0.96 ± 0.8 vs 0.2 ± 0.5 L/min, respectively; P = 0.018), whereas right ventricular stroke work index (RVSWI) decreased significantly more in the RVF group (-4.3 ± 2.0 vs -0.9 ± 2.0 g m/m(2); P < 0.001). These differences were present in spite of the RVF group receiving larger doses of catecholaminergic agents (P = 0.034). Over the ensuing 72 h, the CI of the RVF group gradually approached that of the non-RVF group; concurrently, however, the differences in inotropic therapy were further enhanced. Pump settings were similar in the two groups. CONCLUSIONS: The haemodynamic alterations characterizing RVF were present already immediately after HMII implantation. RVF development was not related to pump flow and settings.

An experimental, simplified method for intradialytic cardiac output measurement.

Hypotension during hemodialysis (HD) is a frequent and troublesome treatment complication. A decrease in the cardiac output (CO) due to an imbalance in the rates of fluid ultrafiltration vs. tissue reabsorption is a major cause of such episodes; thus, routine repeated measurements of CO during HD sessions could be of use in preventing its occurrence. We tested an experimental method (EXP) for measuring CO during HD using hardware already supplied with current Gambro dialysis machines. In 12 HD patients, CO was measured twice during dialysis by injecting a small (2 mL) bolus of highly concentrated saline into the patient's bloodstream and measuring the subsequent increase in dialysate conductivity using the Diascan technology. CO was calculated with the Stewart-Hamilton method using the area under the conductivity curve, measured dialysate flow rate, and dialyzer clearance. Compared with ultrasound hemodilution measurements, the EXP showed no bias and limits of agreement of ±34.6%. The intradialytic trend correlated well between the two methods (r(2) = 0.63, concordance rate 100%). We propose that with further development and refining, reliable measurements of CO could be performed easily during routine HD treatment using this new methodology.

Pulse contour-derived cardiac output in hemodialysis patients.

Reliable methods for cardiac output determination are essential for studying the pathophysiology of intradialytic hypotension. Use of the current gold standard, the Transonic monitor, requires an arteriovenous fistula. We wished to verify the accuracy of a method based on finger pulse contour analysis, namely the Finometer monitor (FNM) for further use on patients dialyzing on a central vascular catheter. Fifty simultaneous cardiac output measurements were obtained during hemodialysis sessions in 25 patients. The internal variability of the FNM measurements was assessed by comparing 24 pairs of immediately successive measurements. The variability of successive FNM measurements was small (bias 0.28%, SD +/- 6.1%; NS). The absolute cardiac output values reported by the FNM were unreliable (bias 20.1%, SD +/- 35.3%; P<0.001) as were the relative intradialytic changes (r(2)=0.01). Excluding participants from the analysis due to old age, high dialysis vintage or a suspicion of atherosclerosis did not improve the results. Our findings do not support the use of pulse contour analysis for measuring cardiac output in hemodialysis patients. Uremic vascular disease may be the cause of the observed inaccuracy.

[Acute hyperphosphatemia in a dialysis patient after administration of sodium phosphate]. / Akut hyperfosfataemi hos en dialysepatient efter indgift af fosfatklyx.

We describe a case of severe hyperphosphatemia due to phosphate-based enema for the preparation of coloscopy. A 39-year-old man with end-stage renal failure was admitted with bloody diarrhoea. After administration of a phosphate-based enema, he was seized with general convulsions due to severe hyperphosphatemia and subsequent hypocalcaemia. The patient recovered after daily dialysis and administration of intravenous calcium. The case demonstrates the need to avoid using phosphate-based laxatives in patients with impaired renal function.

Central venous oxygen saturation and thoracic admittance during dialysis: new approaches to hemodynamic monitoring.

Intradialytic hypotension (IDH) is one of the most important short-term complications to hemodialysis (HD). Inadequate cardiac filling due to a reduction in the central blood volume is believed to be a major etiological factor. The aim of this study was to evaluate whether these pathophysiologic events are reflected in the central venous oxygen saturation (ScO(2)) and thoracic admittance (TA) during dialysis. Twenty ambulatory HD patients, 11 hypotension prone (HP) and 9 hypotension resistant, with central vascular access, were monitored during 3 HD sessions each. ScO(2), TA, finger blood pressure (BP), and relative change in blood volume (DeltaBV) were measured and sampled continuously. The relative TA decrease and DeltaBV were both largest in the HP group (p<0.05 for both), whereas ScO(2) decreased only in HP patients (p<0.001). Baseline TA was lower in the HP group (p<0.01). Changes in ScO(2) and TA correlated much closer than did changes in ScO(2) and DeltaBV (r=0.43 and 0.18, respectively). Our results suggest that an intradialytic decrease in cardiac output, as reflected by a fall in ScO(2), is a common feature to HD patients prone to IDH. In patients using a central vascular access, ScO(2) and TA measurements may be more specific to the pathophysiologic events preceding IDH than DeltaBV-the current standard monitoring method.

[Cardiovascular risk factors in hemodialysis patients--reverse epidemiology]. / Kardiovaskulaere risikofaktorer hos patienter i haemodialyse--revers epidemiologi.

Cardiovascular Disease (CVD) is very common among hemodialysis (HD) patients. As the relation to the traditional risk factors is uncertain, strategies for preventing CVD in these patients cannot be uncritically extrapolated from the general population. In this review, data from epidemiological studies on HD patients are presented. We conclude that further research in the pathogenesis of CVD in HD patients is required for specific clinical interventional trials to be carried out and evidence based treatment strategies to be established.

Disseminated Ureaplasma urealyticum infection in a hypo-gammaglobulinaemic renal transplant patient.

We report of a case of severe disseminated U. urealyticum infection in a 35-y-old kidney transplanted patient with CVID. Routine microbiological tests were negative. Six weeks after admission, abscess material was grown on Mycoplasma culture medium yielding U. urealyticum in high titres. The patient responded promptly to appropriate antibiotics.