[Electronic alerts for acute kidney injury: Opportunities and limits]. / Elektronische Frühwarnsysteme für die akute Nierenschädigung: Chancen und Grenzen.

BACKGROUND: Acute kidney injury (previously: acute renal failure) is a frequent disorder of hospitalized patients with serious complications contributing to worse prognosis as seen in patients with acute myocardial infarction. Acute kidney injury carries a high economic health burden. Early diagnosis and treatment and outpatient care may avoid complications such as development or progression of chronic kidney disease. OBJECTIVES: The opportunities and limits of electronic alert systems for acute kidney injury were evaluated. MATERIALS AND METHODS: Narrative review. RESULTS: In accordance with the literature, more than 95% of affected patients are treated by nonrenal specialties. Results from such systems established in the UK are promising. Patients with acute kidney injury are reliably and early detected by electronic alert systems. Quality of care is improved by hospital-wide electronic alert systems for acute kidney injury. Also, early initiated treatment seems to contribute to favorable patient-related outcome and to reduce mortality. CONCLUSIONS: Implementation of hospital-wide electronic alert systems for acute kidney injury should be seriously considered.

[Acute kidney injury after cardiac surgery : early diagnosis with neutrophil gelatinase-associated lipocalin]. / Akute Nierenschädigung nach Herzchirurgie : Frühdiagnose mit Neutrophilen-Gelatinase-assoziiertem Lipocalin.

In current clinical practice, the diagnosis of acute kidney injury (AKI) is based on markers of renal function, e.g., an increase in serum creatinine or a decrease in urine output. Biomarkers for the early detection of structural renal damage are still not available. This dilemma may have considerably contributed to the delayed development of effective therapies and poor prognosis for the affected patients. The measurement of novel renal damage biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL), enables a 24 to 48-hour earlier diagnosis of AKI after cardiac surgical procedures. Based on the presence of a biomarker, potentially effective treatments may be initiated or nephrotoxins withdrawn. In addition, NGAL may also provide valuable information for patient management. Currently, no clear NGAL cut-off has been established, thus, impeding its clinical implementation. Prior to a change of guidelines, multicenter randomized studies, using NGAL as an entry criterion, should prove a benefit for the patients or a favorable cost-benefit ratio.

The effect of three different miniaturized blood purification devices on plasma cytokine concentration in an ex vivo model of endotoxinemia.

PURPOSE: A novel type of adsorptive plasma filtering device (ETX-A) capable of removing endotoxin from blood in a single step has recently been developed using nanotechnology. METHODS: In a miniaturized, ex vivo model of extracorporeal circuits, we tested the capacity to reduce plasma cytokine concentration of ETX-A filters in comparison to standard high-flux (HF) filters, high cut-off (HCO) filters and a control. Blood from six healthy volunteers was spiked with endotoxin and then circulated through closed (ETX-A, control) or open (HF, HCO) circuits. Blood flow was set at 16 ml/min and filtration flow at 1 ml/min. Samples for measurement of IL-1ra and IL-6 were taken at baseline and at 4 hours. RESULTS: Compared to control (703.3 [850.6] pg/mL), in HCO (383.5 [1144.1] pg/mL) and ETX-A (490.1 [683.2] pg/mL) filters, plasma IL-1ra pooled pre- and postfilter concentrations were lower at the end of the experiment (P=0.002; P=0.050, respectively) whereas, in standard HF filters, IL-1ra concentration was higher than control. HCO showed a trend toward a reduced relative increase in IL-6 concentration from commencement to end of experiment compared to control (P=0.07). After pooling end-of-experiment plasma cytokine values of novel blood purification devices, we found HCO + ETX-A superior to H with regard to reduction of IL-1ra (-27.0 [-20.5]% vs. 8.1 [18.9]%; p<0.001) and IL-6 (-18.0 [38.3]% vs. -1.1 [24.3]%; P=0.050) compared to control. CONCLUSIONS: HCO and ETX-A appeared to significantly reduce plasma IL-1ra and, when combined, plasma IL-6 concentration as well. It appears desirable to manufacture full-size blood purification devices using this technology and to explore their effect on cytokine removal.

Beta2-microglobulin removal and plasma albumin levels with high cut-off hemodialysis.

PURPOSE: beta2-microglobulin (beta2MG) is pivotal to the pathogenesis of dialysis-related amyloidosis. We compared the effects of high cut-off hemodialysis (HCO-HD) with those of standard high-flux hemodialysis (HF-HD) regarding the concentration and clearance of beta2MG and albumin. DESIGN: We enrolled ten patients with acute renal failure in a double-blind, cross-over, randomized controlled trial. PROCEDURES: Each patient received four hours of HCO-HD (estimated in vivo cutoff 50-60 kDa) and four hours of HF-HD (estimated in vivo cutoff 15-20 kDa) in random order. Statistical methods and outcome measures: As data lacked normal distribution, we used nonparametric statistical analysis. Plasma and dialysate concentrations of beta2MG and albumin were measured at baseline and after four hours of each study treatment. MAIN FINDINGS: We found significantly greater diffusive beta2MG clearances for HCO-HD compared to HF-HD (at the start: 71.8 ml/min vs. 5.1 ml/min; P=0.008 and at the end: 68.8 ml/min vs. 5.7 ml/min; P=0.008). We found a reduction in plasma beta2MG concentrations of -31.6% during HCO-HD compared to an increase by 25.7% during HF-HD; P=0.008. At baseline (HCO-HD: 26.0 g/L vs. HF-HD: 26.5 g/L), and at the end of both treatments, plasma albumin concentrations were comparable (HCO-HD: 25.5 g/L vs. HF-HD: 26.5 g/L; P=0.25). During HCO-HD, albumin clearance was 1.9 ml/min at the start and decreased significantly to 0.8 ml/min at the end; P=0.008. HF-HD had an albumin clearance of 0.01 ml/min. CONCLUSIONS: HCO-HD was more effective in decreasing plasma beta2MG concentrations than standard HF-HD and did not reduce plasma albumin levels. Further studies of HCO-HD in the treatment of dialysis-related beta2MG accumulation appear warranted.