Critical Care Nephrology: Core Curriculum 2020

Publication date: Available online 22 January 2020Source: American Journal of Kidney DiseasesAuthor(s): Benjamin R. Griffin, Kathleen D. Liu, J. Pedro TeixeiraThe intensive care unit (ICU) is a common source of high-acuity nephrology consultations. Although advanced chronic kidney disease is associated with increased ICU mortality, the prognosis of acute kidney injury (AKI) requiring renal replacement therapy is far worse, with short-term mortality rates that often exceed 50%. As such, it is essential that practicing nephrologists be comfortable caring for critically ill patients. This Core Curriculum article emphasizes the developments of the last decade since the last Core Curriculum installment on this topic in 2009. We focus on some of the most common causes of AKI in the critical care setting and use these AKI causes to delve into specific topics most relevant to critical care nephrology, including acute respiratory distress syndrome, extracorporeal membrane oxygenation, evolving concepts in fluid management, and shock. We conclude by reviewing the basics of palliative care nephrology and dialysis decision making in the ICU.
Source: American Journal of Kidney Diseases - Category: Urology & Nephrology Source Type: research

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Purpose of review Renal replacement therapies, such as hemodialysis are invasive and impose significant financial burden as well as burden on quality of life. Conservative and ‘gentler’ forms of renal replacement therapy for the frail and palliative care patient is an unmet medical need. Recent findings The treatment of uremia using the gut as a substitute for the kidney has been proposed but is not practiced widely because of proven lack of long-term mortality benefit coupled with complications like edema and hyperchloremia. Mounting evidence showed that endotoxins from gastrointestinal tract are a major ...
Source: Current Opinion in Nephrology and Hypertension - Category: Urology & Nephrology Tags: NOVEL THERAPEUTIC APPROACHES IN NEPHROLOGY AND HYPERTENSION: Edited by Kamyar Kalantar-Zadeh and Ekamol Tantisattamo Source Type: research
Purpose of review Dialysis has been the prevailing treatment paradigm in advanced chronic kidney disease (CKD) for patients ineligible for or unlikely to receive kidney transplantation. As dialysis may neither offer survival benefit nor improved quality of life in certain groups, there has been increasing interest in conservative management as an alternative approach. Recent findings Experts and workgroups suggest the main goals of conservative management are to optimize quality of life, treat symptoms of end-stage renal disease without dialysis or transplant, and improve survival and cardiovascular health. Given the ...
Source: Current Opinion in Nephrology and Hypertension - Category: Urology & Nephrology Tags: NOVEL THERAPEUTIC APPROACHES IN NEPHROLOGY AND HYPERTENSION: Edited by Kamyar Kalantar-Zadeh and Ekamol Tantisattamo Source Type: research
CONCLUSION: Patients' decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies. PMID: 31775149 [PubMed - as supplied by publisher]
Source: American Journal of Nephrology - Category: Urology & Nephrology Authors: Tags: Am J Nephrol Source Type: research
Authors: Sowa PM, Purtell L, Hoy WE, Healy HG, Bonner A, Connelly LB Abstract Kidney supportive care (KSC) is a patient-centered model of multidisciplinary care designed for patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Our goal was to characterize the types, frequencies, and costs of services accessed by patients enrolled in a KSC program. We analyzed health care utilization data prospectively collected from 102 patients who enrolled in the KSC program during the first 52 weeks of its existence. The data comprised program appointments, emergency department presentations, ...
Source: Journal of Palliative Care - Category: Palliative Care Tags: J Palliat Care Source Type: research
CONCLUSION:: Our model could justify the creation of a novel palliative care introduction trigger, as patients with medium demand for care may benefit from additional palliative care evaluation. The trigger could facilitate the uniformization of conservative treatment preparations. It could prompt messages to a managing physician when a patient crosses the threshold between low and medium appointment utilization. It may also aid in system-level policy development. Furthermore, our results highlight the benefit of significant appointment utilization among high-risk patients. PMID: 30747040 [PubMed - as supplied by publisher]
Source: Palliative Medicine - Category: Palliative Care Authors: Tags: Palliat Med Source Type: research
As multiple different studies and surveys continue to illustrate, palliative and hospice medicine has failed to have an appropriate impact on the quality of life for the end-stage renal disease (ESRD) population. People with Chronic Kidney Disease (CKD) remain less likely to die at home, spend more time in the hospital and at higher costs in the last 3 months of life. (Kerr M et al, NDT, 2016).
Source: Journal of Pain and Symptom Management - Category: Palliative Care Authors: Source Type: research
As chronic kidney disease progresses to end-stage renal disease (ESRD), important discussions regarding when and if to initiate dialysis occur. ESRD affects more than 660,000 Americans, less than 10,000 (1.5%) of those are pediatric patients whose time on dialysis is typically meant as a bridge to transplant. In rare circumstances, comorbidities, such as multiorgan failure, progression of other life-threating medical conditions, congenital anomalies, and size restrictions limit pediatric candidates ’ access to transplant.
Source: Journal of Pain and Symptom Management - Category: Palliative Care Authors: Source Type: research
Abstract This evidence-based quality initiative project was designed to increase advance care planning and palliative care referrals, thus improving quality of life for patients with chronic kidney disease by increasing nephrology providers' knowledge of the Renal Physicians Association guidelines on "Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis." Thirteen nephrology providers and nurses received the educational intervention. Post-intervention outcomes included four renal palliative care referrals and 21 advance care plans over four months from a baseline of zero/u...
Source: Nephrology Nursing Journal - Category: Nursing Authors: Tags: Nephrol Nurs J Source Type: research
CONCLUSION: Such ethical dilemmas are challenging for parents and physicians. They can only be overcome by taking into account both concrete on the ground realities and general principles and values acknowledged to be a basis for respecting the individual. In this way, it ensures humaneness and humanization of a practice that must meet a variety of challenges, one by one. The answer is not simple; it is always unique to each child and can only be approached by a multidisciplinary, time-consuming, open discussion, which will never totally erase uncertainty. PMID: 30143372 [PubMed - as supplied by publisher]
Source: Archives de Pediatrie - Category: Pediatrics Authors: Tags: Arch Pediatr Source Type: research
Authors: Castro MCM Abstract Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations an...
Source: Jornal Brasileiro de Nefrologia - Category: Urology & Nephrology Tags: J Bras Nefrol Source Type: research
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