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Clinical Journal of the American... Dec 2018Patients are exposed to numerous prescribed and over-the-counter medications. Unfortunately, drugs remain a relatively common cause of acute and chronic kidney injury. A... (Review)
Review
Patients are exposed to numerous prescribed and over-the-counter medications. Unfortunately, drugs remain a relatively common cause of acute and chronic kidney injury. A combination of factors including the innate nephrotoxicity of drugs, underlying patient characteristics that increase their risk for kidney injury, and the metabolism and pathway of excretion by the kidneys of the various agents administered enhance risk for drug-induced nephrotoxicity. This paper will review these clinically relevant aspects of drug-induced nephrotoxicity for the clinical nephrologist.
Topics: Drug-Related Side Effects and Adverse Reactions; Humans; Kidney; Kidney Diseases; Prescription Drugs
PubMed: 29622670
DOI: 10.2215/CJN.00150118 -
JPMA. the Journal of the Pakistan... Jun 2022
Topics: Hematologic Neoplasms; Humans; Nephrologists
PubMed: 35751300
DOI: 10.47391/JPMA.22-69 -
Kidney360 Aug 2021The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid... (Review)
Review
The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-care ultrasonography (POCUS) is emerging as a valuable, noninvasive, bedside diagnostic tool for objective evaluation of physiologic and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function and quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography, provides additional quantitative information, including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage, adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient's hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function and pulmonary and venous congestion using POCUS and review relevant literature.
Topics: Humans; Nephrologists; Point-of-Care Systems; Ultrasonography; Ultrasonography, Doppler; Water-Electrolyte Imbalance
PubMed: 35369665
DOI: 10.34067/KID.0006482020 -
Medicine Jun 2023Chronic kidney disease (CKD) is a prevalent and progressive condition affecting millions worldwide. It is a long-term condition characterized by gradual loss of kidney... (Review)
Review
Chronic kidney disease (CKD) is a prevalent and progressive condition affecting millions worldwide. It is a long-term condition characterized by gradual loss of kidney function over time. The management of CKD is complex and requires a multidisciplinary approach. This review aims to outline the current management guidelines for CKD. The study included a comprehensive search of various PubMed, Embase, and the Cochrane Library databases for articles published between 2010 and 2023. The search terms used were "chronic kidney disease," "management," and "guidelines." The inclusion criteria were articles that provided management guidelines for patients with CKD. A total of 23 articles were included in the review. Most articles were based on the Kidney Disease Improving Global Outcomes guidelines, the most widely recognized and used guidelines for managing CKD. The study found that the guidelines emphasize the importance of early detection and management of CKD and the need for an approach that involves multiple disciplines in its management. The guidelines recommend several interventions to slow the progression of CKD, including blood pressure control, glycemic control in diabetic patients, and reduce proteinuria. Other interventions include lifestyle modifications such as dietary changes, physical activity, and smoking cessation. The guidelines also recommend regular monitoring of kidney function and referral to a nephrologist for patients with advanced CKD or other complications. Overall, the current management guidelines for CKD emphasize the importance of early detection and a multidisciplinary approach to its management.
Topics: Humans; Renal Insufficiency, Chronic; Delivery of Health Care; Exercise; Nephrologists; Referral and Consultation; Chronic Disease
PubMed: 37335639
DOI: 10.1097/MD.0000000000033984 -
Clinical Journal of the American... Dec 2020The American Society of Nephrology has established a new initiative, , with the goal of promoting excellence in the prevention and treatment of AKI by building a...
The American Society of Nephrology has established a new initiative, , with the goal of promoting excellence in the prevention and treatment of AKI by building a foundational program that transforms education and delivery of AKI care, aiming to reduce morbidity and associated mortality and to improve long-term outcomes. In this article, we describe our current efforts to improve early recognition and management involving inclusive interdisciplinary collaboration between providers, patients, and their families; discuss the ongoing need to change some of our current AKI paradigms and diagnostic methods; and provide specific recommendations to improve AKI recognition and care. In the hospital and the community, AKI is a common and increasingly frequent condition that generates risks of adverse events and high costs. Unfortunately, patients with AKI may frequently have received less than optimal quality of care. New classifications have facilitated understanding of AKI incidence and its impact on outcomes, but they are not always well aligned with AKI pathophysiology. Despite ongoing research efforts, treatments to promote or hasten kidney recovery remain ineffective. To avoid progression, the current approach to AKI emphasizes the promotion of early recognition and timely response. However, a lack of awareness of the importance of early recognition and treatment among health care team members and the heterogeneity of approaches within the health care teams assessing the patient remains a major challenge. Early identification is further complicated by differences in settings where AKI occurs (the community or the hospital), and by differences in patient populations and cultures between the intensive care unit and ward environments. To address these obstacles, we discuss the need to improve education at all levels of care and to generate specific guidance on AKI evaluation and management, including the development of a widely applicable education and an AKI management toolkit, engaging hospital administrators to incorporate AKI as a quality initiative, and raising awareness of AKI as a complication of other disease processes.
Topics: Acute Kidney Injury; Attitude of Health Personnel; Clinical Competence; Early Diagnosis; Health Knowledge, Attitudes, Practice; Health Promotion; Humans; Nephrologists; Nephrology; Patient Education as Topic; Practice Patterns, Physicians'; Quality Improvement; Quality Indicators, Health Care; Time-to-Treatment
PubMed: 32317329
DOI: 10.2215/CJN.15611219 -
Jornal Brasileiro de Nefrologia 2019Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis...
Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis patients has been a permanent quest by nephrologists summarized by the 'dry weight' probing approach. Although this clinical approach has been associated with benefits on cardiovascular outcome, it is now challenged by recent studies showing that intensity or aggressiveness to remove fluid during intermittent dialysis is associated with cardiovascular stress and potential organ damage. A more precise approach is required to improve cardiovascular outcome in this high-risk population. Fluid status assessment and monitoring rely on four components: clinical assessment, non-invasive instrumental tools (e.g., US, bioimpedance, blood volume monitoring), cardiac biomarkers (e.g. natriuretic peptides), and algorithm and sodium modeling to estimate mass transfer. Optimal management of fluid and sodium imbalance in dialysis patients consist in adjusting salt and fluid removal by dialysis (ultrafiltration, dialysate sodium) and by restricting salt intake and fluid gain between dialysis sessions. Modern technology using biosensors and feedback control tools embarked on dialysis machine, with sophisticated analytics will provide direct handling of sodium and water in a more precise and personalized way. It is envisaged in the near future that these tools will support physician decision making with high potential of improving cardiovascular outcome.
Topics: Algorithms; Biomarkers; Blood Pressure; Cardiovascular Deconditioning; Cardiovascular System; Dialysis Solutions; Hemodynamics; Homeostasis; Humans; Kidney Failure, Chronic; Nephrologists; Renal Dialysis; Sodium; Treatment Outcome; Water-Electrolyte Balance
PubMed: 31661543
DOI: 10.1590/2175-8239-JBN-2019-0135 -
Jornal Brasileiro de Nefrologia 2020The pregnancy rate of women on dialysis is still very low when compared to that of the remaining population. However, recent years have seen an increase in the success... (Review)
Review
The pregnancy rate of women on dialysis is still very low when compared to that of the remaining population. However, recent years have seen an increase in the success rates of these pregnancies. Among the main precautions that must be taken with pregnant women on dialysis are the maintenance of low levels of pre-dialysis urea, the adequacy of the tension profile, the control of anemia and care to avoid infections, nutritional deficits, changes in phosphorus-calcium metabolism and electrolytic fluctuations. It is also necessary to strictly monitor fetal growth and development. Pregnant women on dialysis have a higher probability of maternal and fetal complications; thus the importance of a multidisciplinary approach among nephrologists, obstetricians and pediatricians. The main objective of this study was to review the literature evidence available on pregnancy on dialysis, on the basic principles of the pathophysiology of pregnant women and their particularities in kidney disease. We will address available treatment options, benefits and risks, anticipating possible future challenges. At the end, we will present a clinical case to illustrate the topic.
Topics: Anemia; Dialysis; Female; Humans; Nephrologists; Pregnancy; Pregnancy Complications; Renal Dialysis
PubMed: 32776086
DOI: 10.1590/2175-8239-JBN-2020-0028 -
The National Medical Journal of India 2017
Topics: History, 20th Century; History, 21st Century; Humans; India; Mentoring; Nephrologists; Nephrology; Quality of Health Care; Universities
PubMed: 29916435
DOI: 10.4103/0970-258X.234401 -
Clinical Journal of the American... Feb 2016Immunosuppressive agents are commonly used in the nephrologist's practice in the treatment of autoimmune and immune-mediated diseases and transplantation, and they are... (Review)
Review
Immunosuppressive agents are commonly used in the nephrologist's practice in the treatment of autoimmune and immune-mediated diseases and transplantation, and they are investigational in the treatment of AKI and ESRD. Drug development has been rapid over the past decades as mechanisms of the immune response have been better defined both by serendipity (the discovery of agents with immunosuppressive activity that led to greater understanding of the immune response) and through mechanistic study (the study of immune deficiencies and autoimmune diseases and the critical pathways or mutations that contribute to disease). Toxicities of early immunosuppressive agents, such as corticosteroids, azathioprine, and cyclophosphamide, stimulated intense investigation for agents with more specificity and less harmful effects. Because the mechanisms of the immune response were better delineated over the past 30 years, this specialty is now bestowed with a multitude of therapeutic options that have reduced rejection rates and improved graft survival in kidney transplantation, provided alternatives to cytotoxic therapy in immune-mediated diseases, and opened new opportunities for intervention in diseases both common (AKI) and rare (atypical hemolytic syndrome). Rather than summarizing clinical indications and clinical trials for all currently available immunosuppressive medications, the purpose of this review is to place these agents into mechanistic context together with a brief discussion of unique features of development and use that are of interest to the nephrologist.
Topics: Animals; Antibodies, Monoclonal; Autoimmune Diseases; B-Lymphocytes; Graft Rejection; Graft Survival; Humans; Immunosuppressive Agents; Kidney Diseases; Kidney Transplantation; Molecular Targeted Therapy; Signal Transduction; T-Lymphocytes; Treatment Outcome
PubMed: 26170177
DOI: 10.2215/CJN.08570814 -
Clinical Journal of the American... Jun 2022The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion... (Review)
Review
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
Topics: Fluid Therapy; Humans; Lactic Acid; Nephrologists; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 35551069
DOI: 10.2215/CJN.14381121