Abstract: We appreciate the concerns expressed by Athanasios Chalkias and Theodoros Xanthos about the role of increased intra-abdominal pressure in the pathogenesis of acute kidney injury (AKI), and indeed mention this possibility in our Seminar.1Bellomo R Kellum JA Ronco C Acute kidney injury.Lancet. 2012; 380: 756-766Summary Full Text Full Text PDF PubMed Scopus (1191) Google Scholar However, as shown in a prospective investigation,2Kim IB Prowle J Baldwin I Bellomo R Incidence, risk factors and outcome associations of intra-abdominal hypertension in critically ill patients.Anaesth Intensive Care. 2012; 40: 79-89PubMed Google Scholar although increased intra-abdominal pressure is common in patients in intensive care, its clinical meaning and renal consequences remain unclear in the absence of a full abdominal compartment syndrome. Therefore, we argue that routine measurement of intra-abdominal pressure is not justified unless intra-abdominal compartment syndrome seems clinically likely and renal function is being rapidly lost. Moreover, until randomised trials indicate that patients whose intra-abdominal pressure is routinely monitored achieve or maintain better renal function than do patients assigned standard care, we regard selective measurement of intra-abdominal pressure as a more rational approach. We fully share Alain Rudiger and Mervyn Singer's view that changes in intrarenal blood flow are most likely to be responsible for AKI, especially in sepsis.3Wan L Bagshaw SM Langenberg C Saotome T May C Bellomo R Pathophysiology of septic acute kidney injury: what do we really know?.Crit Care Med. 2008; 36: S198-S203Crossref PubMed Scopus (300) Google Scholar Thus, at least in the early phases, AKI seems to be a disease of the microcirculation. If this is correct, as many observations now suggest, the therapeutic implications are substantial. In particular, the administration of large amounts of fluids in a futile attempt to resuscitate the kidney might well aggravate rather than attenuate AKI.4Bellomo R Cass A Cole L et al.for the RENAL Replacement Therapy Study InvestigatorsAn observational study of fluid balance and patient outcomes in the Randomized Evaluation of Normal vs Augmented Level of Replacement Therapy trial.Crit Care Med. 2012; 40: 1753-1760Crossref PubMed Scopus (128) Google Scholar Such fluid-based therapy remains the unproven and pathophysiologically unjustified cornerstone of AKI treatment in critically ill patients. Accordingly, in our Seminar, we specifically sought to begin the process of formally challenging yet another unproven dogma in medicine. We fear that, until physicians are better informed about these developing insights into the pathogenesis of septic AKI, many patients will suffer from iatrogenic disease induced by flawed pathophysiological paradigms. RB and CR have received consultancy and speaking fees from Alere, Abbott Diagnostics, Gambro, Fresenius, B Braun, and Edwards Lifesciences. JAK has received consultancy and speaking fees from Alere, Abbott Diagnostics, Gambro, Baxter, and Fresenius. Acute kidney injuryThe Seminar on acute kidney injury (AKI) by Rinaldo Bellomo and colleagues (Aug 25, p 756)1 is excellent. AKI is typically diagnosed by the accumulation of end products of nitrogen metabolism, decreased urine output, or both.2 In the presence of decreased urine output, however, the diagnosis of AKI should be established only in the absence of increased intra-abdominal pressure. Full-Text PDF Acute kidney injuryRinaldo Bellomo and colleagues1 express serious concerns about acute tubular necrosis as an underlying mechanism of acute kidney injury. We would like to endorse this view. Full-Text PDF Acute kidney injuryAcute kidney injury (formerly known as acute renal failure) is a syndrome characterised by the rapid loss of the kidney's excretory function and is typically diagnosed by the accumulation of end products of nitrogen metabolism (urea and creatinine) or decreased urine output, or both. It is the clinical manifestation of several disorders that affect the kidney acutely. Acute kidney injury is common in hospital patients and very common in critically ill patients. In these patients, it is most often secondary to extrarenal events. Full-Text PDF
Publication Year: 2012
Publication Date: 2012-12-01
Language: en
Type: article
Indexed In: ['crossref']
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Cited By Count: 3
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