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Background: Unlike other viruses, the pathogenicity of human metapneumovirus (hMPV) in adults remains uncertain. To address this question, a retrospective monocentric cohort including all patients admitted to ICU with hMPV infection between January 1, 2010, and June 30, 2018 was performed. The characteristics of hMPV infected patients were studied and compared to matched influenza infected patients. Consecutively, a systematic review and meta-analyses investigating PUBMED, EMBASE and COCHRANE databases was conducted to explore the hMPV infections in adult patients (PROSPERO number: CRD42018106617). Trials, case series, and cohorts published between January 1, 2008 and August 31, 2019 compiling adults presenting hMPV infections were included. Pediatric studies were excluded. Data were extracted from published reports. Primary endpoint was the rate of low respiratory tract infections (LRTIs) among all hMPV infected patients. Results: During the study period, 402 patients were tested positive for hMPV. Among them 26 (6.5%) patients were admitted to the ICU, 19 (4.7%) for acute respiratory failure. Twenty-four (92%) were immunocompromised. Bacterial coinfections were frequent 53.8%. Hospital mortality rate was 30.8%. In the case–control analysis, the clinical and imaging characteristics were not different between hMPV and influenza infected patients. The systematic review identified 156 studies and 69 of them (1849 patients) were eligible for analysis. Although there was heterogeneity between the studies, the rate of hMPV LRTIs was 45% (95% CI 31–60%; I2 = 98%). Intensive care unit (ICU) admission was required for 33% (95% CI 21–45%; I2 = 99%). Hospital mortality rate was 10% (95% CI 7–13%; I2 = 83%) and ICU mortality rate was 23% (95% CI 12–34%; I2 = 65%). Underlying malignancy was independently associated with increased mortality rate. Conclusions: This preliminary work suggested that hMPV may be associated with severe infection and high mortality in patients with underlying malignancies. However, regarding the small size of the cohort and the heterogeneity of the review, more cohort studies are warranted. [ABSTRACT FROM AUTHOR]

Background: Etoposide remains the cornerstone of symptomatic management of critically ill patients with secondary hemophagocytic syndrome (sHS). Risk of healthcare-associated infections (HAIs) in this setting with etoposide has never been assessed. We sought to evaluate the association between etoposide administration, HAIs occurrence and survival in critically ill adult patients with sHS. In this retrospective single-center study conducted in a university hospital ICU between January 2007 and March 2020, all consecutive patients with sHS were included. HAIs were defined as any microbiologically documented infection throughout ICU stay. Competing risk survival analysis was performed to determine factors associated with HAIs. Propensity score-based overlap weighting was performed to adjust for factors associated with etoposide use. Results: 168 patients with a median age of 49 [38, 59] were included. Forty-three (25.6%) patients presented with at least 1 microbiologically documented HAI throughout ICU stay. After adjustment, cumulative incidence of HAI was higher in patients receiving etoposide (p = 0.007), while survival was unaffected by etoposide status (p = 0.824). By multivariable analysis, etoposide treatment was associated with a higher incidence of HAIs (sHR 3.75 [1.05, 6.67]), whereas no association with survival (sHR 0.53 [0.20, 1.98]) was found. Other factors associated with increased mortality after adjustment included age, immunodepression, male sex, SOFA score > 13, and occurrence of HAI. Conclusions: In patients with sHS, etoposide treatment is independently associated with increased occurrence of HAIs, whereas no association with survival was found. Intensivists should be aware of increased infectious risk, to promptly detect and treat infections in this specific setting. Studies to assess benefits from prophylactic anti-infectious agents in this setting are warranted and the lack of benefit of etoposide on survival needs to be interpreted cautiously. [ABSTRACT FROM AUTHOR]

Purpose: Identifying patients who will receive renal replacement therapy (RRT) during intensive care unit (ICU) stay is a major challenge for intensivists. The objective of this study was to evaluate the performance of physicians in predicting the need for RRT at ICU admission and at acute kidney injury (AKI) diagnosis. Methods: Prospective, multicenter study including all adult patients hospitalized in 16 ICUs in October 2020. Physician prediction was estimated at ICU admission and at AKI diagnosis, according to a visual Likert scale. Discrimination, risk stratification and benefit of physician estimation were assessed. Mixed logistic regression models of variables associated with risk of receiving RRT, with and without physician estimation, were compared. Results: Six hundred and forty-nine patients were included, 270 (41.6%) developed AKI and 77 (11.8%) received RRT. At ICU admission and at AKI diagnosis, a model including physician prediction, the experience of the physician, SOFA score, serum creatinine and diuresis to determine need for RRT performed better than a model without physician estimation with an area under the ROC curve of 0.90 [95% CI 0.86–0.94, p < 0.008 (at ICU admission)] and 0.89 [95% CI 0.83–0.93, p = 0.0014 (at AKI diagnosis)]. In multivariate analysis, physician prediction was strongly associated with the need for RRT, independently of creatinine levels, diuresis, SOFA score and the experience of the doctor who made the prediction. Conclusion: As physicians are able to stratify patients at high risk of RRT, physician judgement should be taken into account when designing new randomized studies focusing on RRT initiation during AKI. [ABSTRACT FROM AUTHOR]

Background: CAR-T cell (chimeric antigen receptor T) therapy has emerged as an effective treatment of refractory hematological malignancies. Intensive care management is intrinsic to CAR-T cell therapy. We aim to describe and to assess outcomes in critically ill CAR-T cell recipients. Study design and methods: Hospital-wide retrospective study. Consecutive CAR-T cell recipients requiring ICU admission from July 2017 and December 2020 were included. Results: 71 patients (median age 60 years [37–68]) were admitted to the ICU 6 days [4–7] after CAR-T cell infusion. Underlying malignancies included diffuse large B cell lymphoma (n = 53, 75%), acute lymphoblastic leukemia (17 patients, 24%) and multiple myeloma (n = 1, 1.45%). Performance status (PS) was 1 [1–2]. Shock was the main reason for ICU admission (n = 40, 48%). Isolated cytokine release syndrome (CRS) was the most common complication (n = 33, 46%), while 21 patients (30%) had microbiologically documented bacterial infection (chiefly catheter-related infection). Immune effector cell-associated neurotoxicity syndrome was reported in 26 (37%) patients. At ICU admission, vasopressors were required in 18 patients (25%) and invasive mechanical ventilation in two. Overall, 49 (69%) and 40 patients (56%) received tocilizumab or steroids, respectively. Determinant of mortality were the reason for ICU admission (disease progression vs. sepsis or CRS (HR 4.02 [95%CI 1.10–14.65]), Performance status (HR 1.97/point [95%CI 1.14–3.41]) and SOFA score (HR 1.16/point [95%CI 1.01–1.33]). Conclusions: Meaningful survival could be achieved in up to half the CAR-T cell recipients. The severity of organ dysfunction is a major determinant of death, especially in patients with altered performance status or disease progression. [ABSTRACT FROM AUTHOR]

Background. The objectives of this study were (1) to determine factors associated with impaired sleep and (2) to evaluate the relationship between impaired sleep and the outcome. Methods. Secondary analysis of a prospective observational cohort study in 54 intensive care units in France and Belgium. Sleep quality was quantified by the patients with a semi-quantitative scale. Results. Among the 389 patients included, 40% reported poor sleep during the first night in the ICU and the median (interquartile) total sleep time was 4 h (2–5). Factors independently associated with poor sleep quality were the SOFA score (odds ratio [OR] 0.90, p = 0.037), anxiety (OR 0.43, p = 0.001) and the presence of air leaks (OR 0.52, p = 0.013). Factors independently associated with short-estimated sleep duration (<4 h) were the SOFA score (1.13, p = 0.005), dyspnea on admission (1.13, p = 0.031) and the presence of air leaks (1.92, p = 0.008). Non-invasive ventilation failure was independently associated with poor sleep quality (OR 3.02, p = 0.021) and short sleep duration (OR 0.77, p = 0.001). Sleep quality and duration were not associated with an increase in mortality or length of stay. Conclusions. The sleep of patients with ARF requiring NIV is impaired and is associated with a high rate of NIV failure. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) remains associated with short- and long-term mortality and morbidity. Doppler-based renal resistive index (RI) is a rapid and non-invasive tool that was proposed to assess renal perfusion, identify early risk of AKI, or predict renal recovery course. Central venous pressure and mean perfusion pressure have been associated with risk of AKI in observational studies but may reflect macrovascular perfusion and congestion rather than intra-renal hemodynamic dysregulation [[1]]. Although magnetic resonance imaging (MRI) may assess renal perfusion and oxygenation changes, relevancy of this technique at bedside for critically ill patients is debatable [[3]]. [Extracted from the article]

Many patients develop acute kidney injury (AKI), the causes of which may be directly related to the cancer, its associated therapies, or non-cancer related factors [[3]] (Fig. Thus, the complex issues that arise in critically ill patients with underlying cancer require multidisciplinary care with a focus on patient-centered outcomes. Malignancy associated AKI Although the main risk factors for AKI in the ICU setting are common to the general ICU population, several causes related to malignancy are relatively unique. AKI is common in patients with tumor lysis syndrome (TLS), (> 80%) and in critically ill patients with myeloma (80-90%) [[5]]. [Extracted from the article]

Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient's long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed. [ABSTRACT FROM AUTHOR]

Background: While acute kidney injury (AKI) is frequent in severe SARS-CoV2-related pneumonia ICU patients, few data are still available about its risk factors. Methods: Retrospective observational study performed in four university affiliated hospitals in Paris. AKI was defined according to the KIDGO guidelines. Factors associated with AKI were picked up using multivariable mixed-effects logistic regression. Independent risk factors of day 28 mortality were assessed using Cox model. Results: 379 patients (median age 62 [53,69], 77% of male) were included. Half of the patients had AKI (n = 195, 52%) including 58 patients (15%) with AKI stage 1, 44 patients (12%) with AKI stage 2, and 93 patients (25% with AKI stage 3). Chronic kidney disease (OR 7.41; 95% CI 2.98–18.4), need for invasive mechanical ventilation at day 1 (OR 4.83; 95% CI 2.26–10.3), need for vasopressors at day 1 (OR 2.1; 95% CI 1.05–4.21) were associated with increased risk of AKI. Day 28 mortality in the cohort was 26.4% and was higher in patients with AKI (37.4 vs. 14.7%, P < 0.001). Neither AKI (HR 1.35; 95% CI 0.78–2.32) nor AKI stage were associated with mortality (HR [95% CI] for stage 1, 2 and 3 when compared to no AKI of, respectively, 1.02 [0.49–2.10], 1.73 [0.81–3.68] and 1.42 [0.78–2.58]). Conclusion: In this large cohort of SARS-CoV2-related pneumonia patients admitted to the ICU, AKI was frequent, mostly driven by preexisting chronic kidney disease and life sustaining therapies, with unclear adjusted relationship with day 28 outcome. [ABSTRACT FROM AUTHOR]

Respiratory complications of solid organ transplant (SOT) are a diagnostic and therapeutic challenge when requiring intensive care unit (ICU) admission. We aimed at describing this challenge in a prospective cohort of SOT recipients admitted in the ICU. In this post hoc analysis of an international cohort of immunocompromised patients admitted in the ICU for an acute respiratory failure, we analyzed all SOT recipients and compared their severity, etiologic diagnosis, prognosis, and outcome according to the performance of an invasive diagnostic strategy (encompassing a fiber-optic bronchoscopy and bronchoalveolar lavage), the type of transplanted organ, and the need of invasive ventilation at day 1. Among 1611 patients included in the primary study, 142 were SOT recipients (kidney, n = 73; 51.4%; lung, n = 33; 23.2%; liver, n = 29; 20.4%; heart, n = 7; 4.9%). Lung transplant recipients were younger than other SOT recipients, and severity did not differ across type of received organ. An invasive diagnostic strategy was more frequently performed in lung transplant recipients with a trend toward a higher rate of bacterial etiology in lung than kidney transplant recipients. Overall ICU survival of SOT recipients was 75.4%. Invasive diagnostic strategy, type of transplanted organ, and need of invasive mechanical ventilation at day 1 did not affect ICU prognosis. ICU management of hypoxemic acute respiratory failure in SOT recipients translated into a low ICU mortality rate, whatever the transplanted organ or the acute respiratory failure cause. The post-ICU burden of acute respiratory failure SOT recipients remains to be investigated. [ABSTRACT FROM AUTHOR]

The article highlights several tips to manage renal transplant patients in intensive care unit (ICU.) It includes recommendation for diagnosis and treatment of sepsis such as acute bacterial graft pyelonephritis; management of immunosuppressive drugs in the ICU during critical illness; and differential diagnosis of acute kidney injury (AKI) in patients with lower levels of transplant function.

Purpose: The Doppler-based resistive index (RI) and semi-quantitative evaluation of renal perfusion using color Doppler (SQP) have shown promising results for predicting persistent acute kidney injury (AKI) in preliminary studies. This study aimed at evaluating the performance of RI and SQP to predict short-term renal prognosis in critically ill patients.Methods: Prospective multicenter cohort study including unselected critically ill patients. Renal Doppler was performed at admission to the intensive care unit. The diagnostic performance of RI and SQP to predict persistent AKI at day 3 was evaluated.Results: Overall, 371 patients were included, of whom 351 could be assessed for short-term renal recovery. Two thirds of the included patients had AKI (n = 233; 66.3%), of whom 136 had persistent AKI (58.4%). Doppler-based RI was higher and SQP lower in AKI patients and according to AKI recovery. Overall performance in predicting persistent AKI was however poor with area under ROC curve of respectively 0.58 (95% CI 0.52-0.64) and 0.59 (95% CI 0.54-0.65) for RI and SQP. Optimal cutoff was respectively 0.71 and 2 for RI and SQP. At optimal cutoff, sensitivity and specificity were 50% (95% CI 41-58%) and 68% (62-74%) for RI and 39% (32-45%) and 75% (66-82%) for SQP.Conclusion: Although statistically associated with AKI occurrence, RI and SQP perform poorly in predicting persistent AKI at day 3. Further studies are needed to adequately describe factors influencing Doppler-based assessment of renal perfusion and to delineate whether these indicators may be useful at the bedside. CLINICALTRIAL.GOV: NCT02355314. [ABSTRACT FROM AUTHOR]

Purpose: Conflict of interest (COI) may compromise, or have the appearance of compromising, a researcher's judgment or integrity in conducting or reporting research. We sought to assess time trends of COI and funding statement reporting in the critical care literature.Methods: PubMed was searched by using Medical Subject Headings and the appropriate corresponding keywords: "INTENSIVE CARE UNIT" or "ICU" as a major topic. Four years in a 15-year time period (2001-2016) were arbitrarily chosen and one study month was randomly selected for each study period. Studies published during the selected months were included in the analysis.Results: Three hundred and seventy-four studies were evaluated, including five reviews (1.3%) and ten randomized clinical trials (RCTs) (2.7%). COI statements were available in 65% of the studies and 8% had declared COI. COI statement rate, declared COI and funding statements increased over time, while the number of authors affiliated with industry and the discordance between the lack of COI statement and affiliation with industry decreased. Declared COI were more frequent in 2011-2016 as compared to 2001-2010 (OR 4.06; 95% CI 1.15-25.79) and in the higher quartile of a journal's impact factor (OR of 16.73; 95% CI 3.28-306.20). Surprisingly, focus of the study, country of the first author and/or endorsement of the study by a trial group were not associated with COI statements.Conclusion: Our study suggests COI reporting to have been unintuitive to most investigators and unreliable before ICMJE statements, and that strong incentives are needed to implement adequate reporting of COI. [ABSTRACT FROM AUTHOR]

Acute kidney injury, interaction with distant organs, metabolic disturbances and renal replacement therapy (RRT) encompass vast areas of research. Acute kidney injury Acute kidney injury (AKI) can be viewed as a syndrome encompassing various pathophysiological mechanisms and variable degrees of renal dysfunction. Although AKI and AKI severity were strongly associated with outcome, a lack of data regarding long-term prognosis and resource consumption was noted by the authors [[4]]. [Extracted from the article]

An increasing number of practices in the Intensive Care Unit (ICU) have recently been challenged. Instead, a careful assessment of the benefit/risk ratio and the balance between beneficence and non-maleficence, summarized as "The patient's interests always come first" may more precisely reflect the spirit of this ethical principle [[1]]. As such, multiplication of intervention or drug is likely to increase risk of cumulative toxicity further disfavouring the risk-benefit ratio of interventions that have limited benefit, unknown benefits and/or limited data regarding side effects. Debated toxicity remains a potential toxicity. [Extracted from the article]

The article discusses the acute kidney injury (AKI) and acute lung injury (ALI). Particular focus is given to the significance of lung-kidney interactions, the various risk factors of respiratory distress syndrome, and the need for proper ventilation. Other topics discussed are information on bilateral nephrectomy performed on animals.

The article focuses on facts and complications related to renal replacement. Topics discussed include renal replacement causing unwanted losses of electrolytes, nutrients and drugs; treating end-stage renal disease through organ transplantation and replicating renal functions including glomerular, immunoregulatory and endocrine functions by renal replacement therapy.

Acute kidney injury (AKI) is associated with incremental risk for death and chronic kidney disease and represents a mounting clinical challenge for healthcare professionals. Renal replacement therapy (RRT) use in ICU settings is rising, likely in response to similar trends in AKI, taken together with an ageing population burdened by high prevalence of multi-morbidity and high illness acuity. Numerous features of RRT prescription and delivery are not standardized, nor are they supported from high-quality evidence derived from randomized trials. Despite the publication of rigorous clinical practice guidelines focused on RRT for AKI that are intended to optimize the quality and reliability of RRT in ICU settings, practice patterns and outcomes continue to show significant variability. In this concise review, we aim to summarize new knowledge and recent advances for the provision of RRT for critically ill patients with AKI. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is common in critically ill patients and associated with grim short- and long-term outcome. Although in the vast majority of cases AKI is multifactorial, with sepsis, shock and nephrotoxicity accounting for most episodes, specific causes of AKI are not uncommon. Despite remaining uncertainties regarding their prevalence in the ICU, prompt recognition of specific aetiologies of AKI is likely to ensure timely management, limit worsening of renal dysfunction, and ultimately limit renal and systemic consequences of AKI. The ability to recognize conditions that may be associated with specific aetiologies and the appropriate use of clinical imaging, biological and immunological tests, along with optimal assessment of the need for renal biopsies, should be part of routine ICU care. In this review, we summarize uncertainties, current knowledge and recent advances regarding specific types of AKI. We describe the most common specific causes as well as rare aetiologies requiring urgent management, and outline available tools that may be used during the diagnostic work-up along with their limitations. [ABSTRACT FROM AUTHOR]

Purpose: The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis.Methods: Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency.Results: Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge.Conclusion: Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure. [ABSTRACT FROM AUTHOR]

An editorial is presented on the advances in the treatment options and the research in the medical care field to improve patient management. It talks about the medical care provided for the management of thrombotic thrombocytopenic purpura (TTP) in the patients. It tells about the results from the clinical trial determining the risk associated with blood transfusion in patients being administered alloimmunization.

The authors talk about the assessment of outcomes in critical care medicine, discussing evaluation of patients' nutritional status. Topics discussed include the assessment of the level of creatinine in patient's urine; the use of creatinine assessment to evaluate patient's muscle mass; and the body mass index (BMI) of the patients.

Background: Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training.Methods: Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods.Results: More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process.Conclusions: Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations. [ABSTRACT FROM AUTHOR]

Background. Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high morbidity and mortality. We sought to appraise the incidence, risk factors, and outcome of AKI in a large multicentre cohort study of critically ill patients with haematological malignancies. Methods. We used a retrospective analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centres in France and Belgium between 2010 and 2012. AKI was defined according to the Acute Kidney Injury Network (AKIN) definition. Results. Of the 1011 patients admitted into the intensive care unit (ICU) during the study period, 1009 were included in this study. According to the AKIN definition, 671 patients (66.5%) developed an AKI during their ICU stay, of which 258 patients (38.4%) were AKI stage 1, 75 patients (11.2%) AKI stage 2 and 338 patients (50.4%) AKI stage 3. After adjustment for confounders, main adverse risk factors of AKI were older age, severity [non-renal Sequential Organ Failure Assessment (SOFA)], history of hypertension, tumour lysis syndrome, exposure to nephrotoxic agents and myeloma. Hospital mortality was 44.3% in patients with AKI and 25.4% in patients without AKI (P < 0.0001). After adjustment for confounders, AKI was independently associated with hospital mortality [OR 1.65 (95% CI 1.19-2.29)]. Overall, 271 patients required renal replacement therapy (RRT), of whom 57.2% died during their hospital stay as compared with 31.2% (P < 0.0001) in those not requiring RRT. Conclusion. Two-thirds of critically ill patients with haematological malignancies developed AKI. Hospital mortality in this population of patients developing AKI or requiring RRT is close to that in general ICU population. [ABSTRACT FROM AUTHOR]

The article offers information about cardiorenal syndrome (CRS), a bidirectional disorder in which heart and kidney may induce or perpetuate disease in the other organ. Topics discussed include subtypes reflecting the primary dysfunction and its chronicity; pathophysiological mechanisms underlying CRS type 1 include renal hypoperfusion; and significance of worsening renal function and role of biomarkers.

The article focus on immunocompromised patients. Topics discussed include neutropenic enterocolitis as a factor independently associated with survival identified in study by Mokart et al, assessment of incidence of acute respiratory distress syndrome (ARDS) within 6 months of renal transplantation by Wan et al and study by Mokart et al. revealing patients receiving both non-invasive ventilation (NIV) and high-flow nasal cannula oxygen therapy (HFNC) have a lower mortality.

Purpose: Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock. Methods: In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics. Results: We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day. Conclusion: In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk. [ABSTRACT FROM AUTHOR]

The authors discuss the advantages of consulting a nephrologist in cases of acute kidney injury (AKI) in the intensive care unit (ICU). Nephrologists can assess residual function, identify high-risk patients, participate in ICU multidisciplinary daily rounds to help increase quality and safety and arrange for a proper follow-up after the patient's discharge from the ICU or the hospital. Barriers to nephrology consultation in AKI patients include cost concerns and healthcare system priorities.

The authors examine difficulties in identifying patients at high risk of developing acute kidney injury (AKI ) and diagnosing the disease early. They describe factors behind the shortcomings and limited utility of most AKI biomarkers. They also discuss the results of a study which developed an electronic AKI prediction calculator to predict the onset of AKI during the first seven days in the intensive care unit.

In tumour lysis syndrome ( TLS), metabolic alterations caused by the destruction of malignant cells manifest as laboratory abnormalities with (clinical TLS) or without (laboratory TLS) organ dysfunction. This prospective multicentre cohort study included 153 consecutive patients with malignancies at high risk for TLS (median age 54 years (interquartile range, 38-66). Underlying malignancies were acute leukaemia (58%), aggressive non-Hodgkin lymphoma (29.5%), and Burkitt leukaemia/lymphoma (12.5%). Laboratory TLS developed in 17 (11.1%) patients and clinical TLS with acute kidney injury ( AKI) in 30 (19.6%) patients. After adjustment for confounders, admission phosphates level (odds ratio [ OR] per mmol/l, 5.3; 95% confidence interval [95% CI], 1.5-18.3), lactic dehydrogenase ( OR per x normal, 1.1; 95% CI, 1.005-1.25), and disseminated intravascular coagulation ( OR, 4.1; 95% CI, 1.4-12.3) were associated with clinical TLS; and TLS was associated with day-90 mortality ( OR, 2.45; 95% CI, 1.09-5.50; P = 0.03). In this study, TLS occurred in 30.7% of high-risk patients. One third of all patients experienced AKI, for which TLS was an independent risk factor. TLS was associated with increased mortality, indicating a need for interventional studies aimed at decreasing early TLS-related deaths in this setting. [ABSTRACT FROM AUTHOR]

Purpose: The optimal management of renal replacement therapy (RRT) in critically ill patients remains a matter of debate, although insights have arisen from recent large trials. Nonetheless, little is known about the current practices and beliefs of intensivists. The goal of this study was to record current practices in RRT management among an international panel of intensivists. Methods: An online questionnaire that included questions about RRT management in critically ill patients with acute kidney injury was sent to European Society of Intensive Care Medicine members in 2010. Results: Two hundred and seventy-three intensivists from 50 countries responded. The respondents had an average of 12 (7-20) years of experience in ICUs, and most of them worked in mixed ICUs. Most of the intensivists were responsible for prescribing RRT (92.6 %). Half of the respondents reported using both intermittent haemodialysis and continuous renal replacement therapy techniques (CRRT), but most preferred using CRRT. The reasons for preferring CRRT were the perception of better haemodynamic stability, better therapeutic effect resulting from cytokine removal and easier fluid balance control. The intensivists used higher RRT doses in septic patients than in non-septic patients ( p = 0.03). Finally, we observed an increasing inclination towards the early use of RRT among the intensivists. Conclusion: CRRT remains the preferred technique for most intensivists in Europe, and a large proportion of the participating intensivists used RRT prescription doses similar to those proposed a decade ago. Our results provide insights into the motivations of intensivists while presenting the technique that may help in selecting control groups for future trials. [ABSTRACT FROM AUTHOR]

Purpose: To describe the method and significance of Doppler-based resistive index (RI) and to provide an updated description of its interest with a special focus on the critically ill. Methods: Review of selected studies on RI found in the PubMed, Ovid and Cochrane databases. Additional references were retrieved from the selected studies. Results: An increasing body of evidence suggests that renal Doppler may help to assess perfusion of native or transplanted kidneys. In addition, recent studies suggest that it may be useful in critically ill patients. The RI is a parameter derived from Doppler examination that is calculated as follows: $$ {\text{RI}} = \left[ {\text{peak systolic shift}}\,-\,{\text{minimum diastolic shift}} \right]/{\text{peak systolic shift}} $$. Renal Doppler has proven to be valuable for assessing large arterial or venous abnormalities and has been suggested to assess renal perfusion and to predict acute kidney injury (AKI) in critically ill patients. However, numerous factors have been shown to influence renal Doppler and may constitute potential confounding factors. Moreover, experience with critically ill patients is scant and our understanding of factors influencing RI in this setting is limited. Conclusion: Doppler-based RI seems to be a promising tool in the critically ill to assess the risk of AKI, help in differentiating persistent from transient AKI, or assess changes in renal perfusion as consequences of therapeutic intervention. However, we still lack large, adequately powered studies in non-selected populations of patients before implementing this technique in clinical practice. In addition, the impact of several factors that may influence this parameter remains to be evaluated. [ABSTRACT FROM AUTHOR]

Objectives: Diagnosing persistent acute kidney injury (AKI) as opposed to transient AKI in critically ill patients may help physicians in making treatment decisions. This diagnosis relies chiefly on urinary indices, which may be of limited value or difficult to obtain. We assessed the performance of the Doppler renal resistive index (RI) in diagnosing persistent AKI. Design: Prospective observational study. Setting: Twenty-four-bed medical intensive care unit in a university hospital. Patients: Consecutive patients requiring mechanical ventilation, without severe chronic renal dysfunction or receiving diuretic therapy. Definitions: Persistent AKI was defined as AKI lasting longer than 3 days. AKI resolving within 3 days in a patient with a cause of renal hypoperfusion was considered to be transient AKI. Results are reported as median values with interquartile range (IQR). Measurements and main results: Of the 51 patients enrolled in the study, 16 had no AKI, 13 had transient AKI, and 22 had persistent AKI. The RI was 0.71 (0.66-0.77) in the no-AKI group, 0.71 (0.62-0.77) in the transient AKI group, and 0.82 (0.80-0.89) in the persistent AKI group ( P < 0.0001). The RI was better than urinary indices for diagnosing persistent AKI. The area under the RI ROC curve was 0.91 [95% confidence interval (95% CI) 0.83-0.99; P < 0.0001]. An RI > 0.795 had a 92% sensitivity and 85% specificity for persistent AKI. Logistic regression analysis revealed that an RI > 0.795 [odds ratio (OR) 28.2; 95% CI 4.0-198] and a higher logistic organ dysfunction score (OR 1.85/point; 95% CI 1.20-2.85) predicted persistent AKI. Conclusion: These preliminary results suggest that Doppler renal RI may be a promising tool for predicting the reversibility of AKI in critically ill patients. [ABSTRACT FROM AUTHOR]

Background. The aim of this study is to describe the prevalence and outcomes of intensive care unit (ICU)-acquired hypernatraemia (IAH). [ABSTRACT FROM PUBLISHER]

Acute tumor lysis syndrome (ATLS) caused by the destruction of malignant cells leads to metabolic abnormalities, which may either remain isolated (biological ATLS) or subsequently lead to renal dysfunction (clinical ATLS). We compared hospital and 6-month survival in patients with ATLS with hematological malignancies with or without acute renal injury. Sixty-three patients (median age, 50 years; range, 32–64) were included with ATLS. Twenty-eight had no ARI (including 17 (61%) who subsequently required dialysis) whereas 35 had an ATLS-related ARI (including 31 (89%) who required dialysis). Acute leukemia ( n = 28) and lymphoma ( n = 30) were the main malignancies. All patients had high tumor burdens. Hospital and 6-month mortality rates were significantly lower in patients without ARI (7% and 21%, respectively) than in the ATLS-related renal injury group (51% and 66%). After adjustment for acute disease severity, presence of ARI at ICU admission was associated with higher hospital mortality (odds ratio, 10.41; 95% confidence interval, 2.01–19.170; p = 0.005) and 6-month mortality (odds ratio, 5.61; 95% confidence interval, 1.64–54.66; p = 0.006), compared to patients without renal injury. Our study suggests that in patients with ATLS, ICU management when acute renal injury is present is associated with higher short- and long-term mortality. [ABSTRACT FROM AUTHOR]

The authors reflect on the findings associated with the diagnosis, epidemiology, and extracorporeal treatment for an acute deterioration of kidney function, also known as acute kidney injury (AKI). Topics discussed include assessment of renal prognosis and renal function, the gold standard for the determination of glomerular filtration rate (GFR), and fluid resuscitation on kidney function.

Short-term hypoxemia affects diuresis and natriuresis in healthy individuals. No data are available on the impact of the mild hypoxemia levels usually tolerated in critically ill patients receiving mechanical ventilation. To assess the renal effects of mild hypoxemia during mechanical ventilation for acute lung injury (ALI). Prospective, physiological study in 12 mechanically ventilated patients with ALI. Patients were studied at baseline with an arterial saturation (SaO2) of 96% [94–98] then a comparison was performed between SaO2 values of 88–90% (mild hypoxemia) and 98–99% (high oxygenation). FiO2 was set at 0.25 [0.23–0.32] and 0.7 [0.63–0.8], respectively, to obtain SaO2 of 89 [89–90] and 99% [98–99]. Hemodynamic or respiratory parameters were not significantly affected by FiO2 levels. Compared with high oxygenation level, mild hypoxemia using low FiO2 was associated with increase in diuresis (median [interquartile range], 67 [55–105] vs. 55 [45–60] ml/h; P = 0.003) and in doppler-based renal resistive index (RI) (0.78 [0.66–0.85] vs. 0.72 [0.60–0.78]; P = 0.003). The 2-h calculated creatinine clearance also increased (63 [46–103] vs. 35 [30–85] ml/min; P = 0.005) without change in urinary creatinine ( P = 0.13). No significant change in natriuresis was observed. Half of the patients were under norepinephrine infusion and the renal response did not differ according to the presence of vasopressors. In patients with ALI, mild hypoxemia related to short-term low FiO2 induce increases in diuresis and in renal RI. This latter point suggests intra-renal mechanisms that need to be further investigated. [ABSTRACT FROM AUTHOR]

The authors reflect on the importance of determining the cases of acute kidney injury (AKI) worldwide in order to inform clinicians, scientists and politicians for the efficient use of health care resources. Also cited are the definitions of AKI based on the Acute Dialysis Quality Initiative (RIFLE), the Acute Kidney Injury Network (AKIN), and the Kidney Disease Improving Global Outcomes (KDIGO), as well as the Modification of Diet in Renal Disease (MDRD) back-calculated baseline.

Objectives: Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high mortality when renal replacement therapy is required. Because physicians might be reluctant to offer dialysis to patients with malignancies, we sought to appraise outcomes in critically ill cancer patients (mainly with hematological malignancies) who received renal replacement therapy for AKI complicating cancer management.Design: Cohort study including consecutive patients who received renal replacement therapy for AKI complicating cancer management, over a 42-month period. Their mortality was compared with that of non-cancer patients who received renal replacement therapy in the same center over the same study period (control group).Setting: A 12-bed medical intensive care unit in a university hospital.Results: 94 critically-ill cancer patients met the inclusion criteria. Median SAPS II was 53 (IQR 40-75) and median Logistic Organ Dysfunction score was 7 (IQR 5-10). The etiology of AKI was multiple in most patients (248 identified factors in 93 patients). Hospital mortality was 51.1%. Two variables were independently associated with hospital mortality: the severity of associated organ failures at ICU admission (OR, 1.33; 95% CI, 1.11-1.59; per point) and renal function deterioration after ICU admission (OR, 5.42; 95% CI, 1.62-18.11). Characteristics of the malignancy were not associated with hospital mortality. The presence of cancer had no detectable influence on hospital mortality after adjustment for gender, age, acute severity as assessed by the SAPS II score, and chronic health status [OR 1.2, 95% CI 0.63-2.27; p=0.57].Conclusion: ICU admission should be considered in selected critically ill cancer patients with AKI requiring renal replacement therapy. [ABSTRACT FROM AUTHOR]

Background: The management of patients with lung cancer has improved recently, and many of them will require admission to the ICU. The aims of this study were to determine hospital mortality and to identify risk factors for death in a large cohort of critically ill patients.Methods: Cohort study in two ICUs specialized in the management of patients with cancer, in France and Brazil.Results: Of the 143 patients (mean age, 61.6 +/- 9.9 years [+/- SD]), 25 patients (17%) had small cell lung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICU admission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) was used in 100 patients (70%), including 38 patients in whom lung cancer was considered a reason for MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariate logistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancer recurrence or progression, and severity of comorbidities were associated with increased mortality.Conclusions: The improved survival previously reported in patients with cancer admitted to the ICU seems to extend to patients with lung cancer, including those who need MV. Mortality increased with the number of organ failures, severity of comorbidities, and presence of respiratory failure due to cancer progression. The type of the cancer per se was not associated with mortality and, therefore, should not be factored into ICU triage decisions. [ABSTRACT FROM AUTHOR]

Tumour Lysis syndrome (TLS) is characterized by the massive destruction of tumoral cells and the release in the extracellular space of their content. While TLS may occur spontaneously before treatment, it usually develops shortly after the initiation of cytotoxic chemotherapy. These metabolites can overwhelm the homeostatic mechanisms and cause hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia. Moreover, TLS may lead to an acute renal failure (ARF). In addition to the hospital mortality induced by the acute renal failure itself, development of an ARF may preclude optimal cancer treatment. Therefore, prevention of the acute renal failure during acute tumor lysis syndrome is mandatory. The objective of this review is to describe pathophysiological mechanisms leading to acute tumor lysis syndrome, clinical and biological consequences of this syndrome and to provide up-to-date guidelines to ensure prevention and prompt management of this syndrome. [ABSTRACT FROM AUTHOR]

Over the last 15 years, the management of critically ill cancer patients requiring intensive care unit admission has substantially changed. High mortality rates (75–85%) were reported 10–20 years ago in cancer patients requiring life sustaining treatments. Because of these high mortality rates, the high costs, and the moral burden for patients and their families, ICU admission of cancer patients became controversial, or even clearly discouraged by some. As a result, the reluctance of intensivists regarding cancer patients has led to frequent refusal admission in the ICU. However, prognosis of critically ill cancer patients has been improved over the past 10 years leading to an urgent need to reappraise this reluctance. In this review, the authors sought to highlight that critical care management, including mechanical ventilation and other life sustaining therapies, may benefit to cancer patients. In addition, criteria for ICU admission are discussed, with a particular emphasis to potential benefits of early ICU-admission. [ABSTRACT FROM AUTHOR]

The patient meeting criteria of clinical tumor lysis syndrome (TLS) received intravenous hyperhydration and recombinant urate oxydase. This case illustrates the poor specificity of tumor lysis syndrome criteria and the need for extensive diagnostic work-up in hematological patients with suspected TLS. [Extracted from the article]

The author focuses on a study which suggested how extracorporeal blood purification can provide an adjunct treatment of severe sepsis through removal of harmful inflammatory mediators from plasma. Topics discussed include data from the Protocol-Based Care for Early Septic Shock (ProCESS) study, the subsequent improvements with the use of hemofiltration, and the use of therapeutic plasma exchange (TPE) to modulate circulating levels of inflammatory cytokines, coagulation factors and endotoxin.

The authors commend on the use of biomarkers for the diagnosis and treatment of acute kidney injury (AKI). Topics discussed include the basis for diagnosing AKI, which is still based on oliguria and/or an increase in serum creatinine, how biomarkers changed the medical perception of AKI and progress in critical care nephrology and the need for a diagnostic tool that may allow an assessment of renal prognosis or the need for renal replacement therapy.

Purpose: To identify key components and variations in family-centered care practices. Methods: A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate. Results: The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6–8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness. Conclusions: This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness. [ABSTRACT FROM AUTHOR]

In this article, the authors offer information on acute kidney injury (AKI) and neutrophil gelatinase-associated lipocalin (NGAL). They inform that the NGAL belongs to the lipocalin superfamily secreted by immune cells, hepatocytes and renal tubular cells and mention that the NGAL can act as growth and differentiation factors. They also mention a study by researcher J. Martensson et al., according to which the NGAL level increases before the AKI and then decreases during diagnosis.