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Biomedical subjects

C Ronco

Publications and source records attributed to C Ronco.

At least 73 records · Page 4Linked to original sources
PubMed2002

Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST).

Renal replacement therapy (RRT) has evolved from the concept that we need to treat the dysfunction of a single organ (the kidney). As intensive care units have become more and more complex, it has become clear that the majority of patients with acute renal failure often have dysfunction of several other organs. In order to facilitate single organ support in this setting, continuous renal replacement therapy (CRRT) techniques have been developed. However, CRRT has opened the door to the concept that targeting renal support as the only goal of extracorporeal blood purification may be a simplistic view of our therapeutic aims. In this article we argue that it is now time to move from the simple goal of achieving adequate renal support. The proper goal of extracorporeal blood purification in ICU should be multi-organ support therapy (MOST). We explain why MOST represents the most logical future conceptual and practical evolution of CRRT and illustrates the biological rationale, supplying animal and clinical evidence that confirms the need to move rapidly in this direction theoretically, practically and technologically.

Acute Kidney Injury↗
PubMed2002

Results from EuCliD (European Clinical Dialysis Database): impact of shifting treatment modality.

BACKGROUND: The use of biocompatible high-flux membranes is more efficient than low-flux membranes in controlling a number of hemodialysis-related diseases. The aim of this cooperative study was to evaluate the 6-month effect of a switch from low- to high-flux dialysers on patients treated in 39 Spanish dialysis centres. METHODS: The clinical data used in this analysis were prospectively collected by the EuCliD database, developed to monitor the quality of treatment delivered in a large network of European Dialysis Centres. Inclusion criteria for the study were the condition of end-stage renal disease (ESRD) on chronic hemodialysis and low-flux dialysis for at least six months before the switch to high-flux dialysis. Of 1,543 patients enrolled in the study between 2000 and 2001, 1,046 patients were considered for the analysis. 497 patients were excluded because they did not complete the follow-up. Outcome measures were the reduction of pre-dialysis beta-2 microglobulin, the improvement of anemia or reduction in rHu-EPO dose required to maintain best correction of anemia, reduction of inflammatory parameters (CRP), improvement in lipid profile (Total and HDL cholesterol, tryglycerides), maintenance of nutritional status. Albumin and "dry" (post-hemodialysis) body weight were both evaluated as nutritional indexes. RESULTS: During the six months of high-flux hemodialysis, there was a significant increase in hemoglobin (from 11.55 +/- 1.41 to 11.88 +/- 1.43 g/L; p < 0.001). Considering the temporarily untreated patients on a 0 U/week dose, erythropoietin remained stable (from 5,670 +/- 4,199 to 5,657 +/- 4,411 U/week). During the second part of the follow-up, the lipid profile significantly improved (Fig. 3). Total cholesterol and triglycerides decreased significantly (p < 0.001), while HDL cholesterol increased (p = 0.006). Calculated levels of LDL cholesterol also significantly decreased (p = 0.001). Dry body weight remained stable (64.7 +/- 11.9 vs. 64.7 +/- 12.0 kg) as well as in albumin levels (3.93 +/- 0.43 vs. 3.94 +/- 0.43 g/dL) between the two modalities of treatment. The level of beta2-microglobulin significantly decreased during high-flux dialysis (33.5 +/- 14.4 vs. 26.3 +/- 8.6 mg/dL, p < 0.001). CONCLUSION: All above mentioned results may have as a common denominator an improved blood purification from uremic toxins and a reduced level of chronic sub-clinical inflammation. All together, these results seem to confirm the superiority of high-flux dialysis in terms of clinical and physiological outcomes.

Aged↗
PubMed2001

Hirudin versus heparin for anticoagulation in continuous renal replacement therapy.

OBJECTIVE: To compare the efficacy and safety of hirudin and heparin for anticoagulation during continuous renal replacement therapy (CRRT) in critically ill patients. DESIGN: Prospective, randomized controlled pilot study. SETTING: Single centre; interdisciplinary intensive care unit at a university hospital. PATIENTS: Seventeen patients receiving CRRT. INTERVENTIONS: Patients were randomly allocated to two groups. Heparin group (nine patients): continuous administration of 250 IU/h heparin; dose was adjusted in 125 IU/h steps with a targeted activated clotting time (ACT) of 180-210 s. Hirudin group (eight patients): continuous infusion of 10 micrograms/kg/h hirudin, dose was adjusted in 2 micrograms/kg/h steps with a targeted ecarin clotting time (ECT) of 80-100 s. Observation time was 96 h. MEASUREMENTS AND MAIN RESULTS: Measured filter run patency and haemofiltration efficacy did not significantly differ between the two groups. Three bleeding complications were observed in the hirudin group, none in the heparin group (P < 0.01). At the onset of bleeding, which occurred 60 or more hours after the start of therapy, only one patient was still under continuous hirudin administration but levels were either in therapeutic range or below. CONCLUSIONS: Hirudin can be used efficiently for anticoagulation in CRRT. Late bleeding complications may have been caused by possible hirudin accumulation, but this was not evident from hirudin plasma and ECT levels. Since bleeding complications were observed only in the presence of documented coagulation disorders, not only adequate drug monitoring but also the plasmatic and cellular coagulation status of the patient should be taken into consideration for adjusting hirudin dosage.

APACHE↗
PubMed2001

Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid-base balance.

OBJECTIVES: The maintenance of normal serum sodium, potassium and bicarbonate concentrations is a therapeutic goal of renal replacement therapy (RRT) in acute renal failure (ARF). The aim of this study was to determine whether this goal is best achieved with intermittent hemodialysis (IHD) or continuous venovenous hemodiafiltration (CVVHDF). DESIGN: Retrospective controlled study. SETTING: Tertiary intensive care unit. PATIENTS: Consecutive patients with ARF treated with IHD (n = 47) or CVVHDF (n = 49). INTERVENTIONS: Measurement of daily morning sodium, potassium and bicarbonate concentrations after the initiation of RRT for up to 2 weeks of treatment. MEASUREMENTS AND RESULTS: Before RRT, abnormal (high or low) values were frequently observed for sodium (42.6% vs 39.6%; NS) potassium (23.4% vs 45.8%; NS) and bicarbonate (63.2 % vs 54.3 %; NS). After treatment, however, CVVHDF, but not IHD, significantly increased mean sodium concentrations (p = 0.0001). CVVHDF was also more likely to normalize the serum sodium than IHD (76.2 % vs 47.8% p = 0.0001). The mean potassium concentrations of both groups significantly decreased (p = 0.019 vs p = 0.0075, difference: NS). However, CVVHDF more frequently reduced the incidence of hypokalemia (1.9 % vs 7.1%, p = 0.0006). CVVHDF but not IHD significantly increased mean bicarbonate concentrations (p = 0.016) in the first 48 h, and more frequently normalized them (71.5% vs 59.2, p = 0.0073). CONCLUSIONS: Serum sodium and potassium, and arterial bicarbonate, concentrations are frequently abnormal in ARF patients before and during renal replacement. Normalization of these values, however, is achieved more frequently with CVVHDF than with IHD.

APACHE↗
PubMed2001

Blood purification in the intensive care unit: evolving concepts.

Until relatively recently surgeons were familiar with the concept that some of their patients admitted to the intensive care unit require dialysis to deal with the development of severe acute renal failure. Under such circumstances the nephrology team would then attend the patient and take over that aspect of management. More recently, however, this situation has undergone a significant evolution because of the advent of continuous renal replacement therapy (CRRT). First introduced as "last ditch" therapy in the most critically ill patients who were hemodynamically intolerant of hemodialysis, CRRT has become more and more widely used. It is now the dominant form of artificial renal support in Australia and close to being the dominant treatment of the severe acute renal failure of critical illness in most European countries. The use of CRRT in the United States is rapidly growing. The arrival of CRRT has also renewed interest in the wider concept of blood purification during critical illness. Experimental and preliminary human data suggest that such blood purification therapies may indeed have beneficial immunomodulatory effects. Accordingly, CRRT is now being considered as a potential adjuvant treatment of septic shock and has even moved into the operating room as a tool for antiinflammatory therapy and volume control. The intensivist-surgeon and the general surgeon need to be aware of and understand these developments in extracorporeal therapy if they wish to make the full armamentarium of modern treatment available to their sickest patients.

Blood Component Removal↗
PubMed2001

Inflammation and dietary protein intake exert competing effects on serum albumin and creatinine in hemodialysis patients.

BACKGROUND: Cross-sectional studies have shown an inverse correlation between serum C-reactive protein (CRP) and serum albumin concentration in hemodialysis patients. The net effects of inflammation and dietary protein intake on nutritional markers over time are unknown. METHODS: To explore the effects of CRP and normalized protein catabolic rate (nPCR) on serum albumin and creatinine, we analyzed six consecutive months of laboratory data from 364 hemodialysis patients, using a multivariable Mixed model with conservative biases. RESULTS: The overall trend over time in serum albumin was slightly positive (0.039 g/dL/month) and in serum creatinine slightly negative (-0.052 mg/dL/month). With increasing CRP, serum albumin declined significantly (-0.124 g/dL/month per unit increase in log CRP, adjusted for age, gender, race, diabetes, and nPCR, P < 0.0001). Serum albumin increased with increasing nPCR (0.021 g/dL/month per 0.1 g/kg/day, P < 0.0001). The effect of CRP on albumin was attenuated in African Americans and at a higher nPCR. Corresponding values for creatinine mirrored those for albumin. With increasing CRP, creatinine declined significantly [-0.142 mg/dL/month per unit increase in log CRP, adjusted for age, gender, race, diabetes (time since initiation of dialysis; vintage), Kt/V, and nPCR, P = 0.002]. Serum creatinine increased with increasing nPCR (0.183 mg/dL/month per g/kg/day, P < 0.0001). CONCLUSIONS: Proxies of inflammation and dietary protein intake exert competing effects on serum albumin and creatinine in hemodialysis patients. These data provide a rationale for prospective testing of dietary protein supplementation in hemodialysis patients with biochemical evidence of ongoing inflammation and "malnutrition."

Adult↗
PubMed2001

Practice pattern and treatment options for kidney patients in a single North Italian nephrology center.

The experience and the current practice of a single center located in northern Italy is reported. The center of Vicenza is a self-standing nephrologic unit serving a population of about 300,000 individuals. The overall province counts approximately 800,000 individuals and some of them are referred to our center from peripheral hospitals for renal transplantation and/or particular pathologic conditions. The center offers an integrated approach to the treatment of uremia including hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation. In HD and PD, the most peculiar aspect is the treatment personalization that leads to numerous types of applied therapies and technologies. The policy of the center is based on the belief that the nephrology team has a substantial influence on the outcomes of dialysis patients. A large number of treatment options are available. Special care is placed on the delivery of an adequate amount of dialysis, but the fractional clearance of urea in relation to volume (Kt/V) is seen as a prerequisite and other factors are considered important. Reduction in mortality and morbidity is largely dependent on beginning therapy early in the course of renal treatment. The attainment of appropriate hemoglobin concentrations, good nutrition, good control of calcium and phosphorus metabolism, lipids, and blood pressure, is considered of great importance. Beyond all these factors the time spent by the physician with the patient is considered one of the major factors influencing quality of care. The particularly low mortality of the center (6%/yr) may also be ascribed to a lower incidence of diabetes and other comorbidities.

Delivery of Health Care↗
PubMed2001

Determinants of haemodialyser performance and the potential effect on clinical outcome.

The performance of a dialyser is determined by several factors. Many of these factors relate to the dialyser membrane, including mean pore size, pore size distribution, wall thickness, surface area, and adsorptivity. In this article, several of these factors are reviewed. The potential impact of these factors on the clinical outcome of chronic haemodialysis patients is also discussed.

Diffusion↗
PubMed2001

Continuous renal replacement therapy in critically ill patients.

Acute renal failure is an evolving syndrome in which new pathogenetic mechanisms have recently been elucidated. The evolution of the field of haemodialysis has led to a parallel development in the therapeutic approach to patients suffering from this syndrome. In particular, acute renal failure is more frequently seen as part of a more complex syndrome, defined as multiple organ failure. In this clinical setting, patients are almost inevitably confined to intensive care units and sepsis is a frequent underlying mechanism of organ failure. The use of new devices and new machines, together with a better understanding of the underlying mechanisms of solute and water removal, have allowed us to achieve higher levels of efficiency and clinical tolerance during artificial renal replacement therapy. The first objective has been reached by increasing the automation of the extracorporeal circuits and the operational levels of the different techniques; the second has been achieved by means of a new generation of monitoring techniques and new machines equipped with specific interfaces and alarms. This progress has made continuous forms of renal replacement (CRRT) possible and easy to perform without major problems or complications. The most promising and effective options for treating acute renal failure in critically ill patients are today offered by continuous renal replacement therapies. Classic indications, but also alternative non-renal indications, have been proposed for these techniques. The most advanced indication is the multiple organ dysfunction occurring in septic patients. The possible removal of proinflammatory mediators may permit a blockade of the systemic inflammation, a modulation of the altered immune response in these patients, and it may lead to a partial or total restoration of the lost homeostasis.

Acute Kidney Injury↗
PubMed2001

Importance of increased ultrafiltration volume and impact on mortality: sepsis and cytokine story and the role of continuous veno-venous haemofiltration.

While in end-stage renal disease dialysis dose correlates with morbidity and mortality, this correlation is less evident in acute renal failure. In spite of a poor literature in the field, a few recent papers seem to suggest that an increase in treatment dose may result in an improved outcome of critically ill patients affected by acute renal failure. This improvement appears to plateau at a certain level of dialysis dose in the general population while, in septic patients, the correlation between treatment dose and outcome continues linearly. These results suggest that, while the 'renal dose' of renal replacement therapy has a threshold beyond which further improvements cannot be expected, the 'septic dose' of renal replacement therapy is probably higher and may provide benefits beyond simple blood purification from uremic toxins. This approach is in agreement with the recently proposed 'peak concentration hypothesis', which suggests that sepsis may derive from a complete derangement of the immunological response, featuring simultaneous peaks of pro- and anti-inflammatory mediators. This would explain the systemic inflammatory syndrome and the cell hyporesponsiveness of the septic patient and, at the same time, would explain the beneficial effects of new therapies such as high volume hemofiltration, coupled plasmafiltration adsorption and dialysis with hyperpermeable membranes. These therapies could be able to reduce the peaks of the pro- and anti-inflammatory substances circulating during the syndrome, leading to a less severe degree of inflammation and immunodepression.

Critical Illness↗