Aproximación al filtrado glomerular en el paciente crítico, ¿seguimos utilizando las fórmulas de estimación basadas en la creatinina sérica?

Acute kidney failure is a problem in the critical care setting with a high frequency of appearance. Evaluating the glomerular filtration rate is necessary to make dosage adjustments for patients with impaired renal function. Serum creatinine and the estimated glomerular filtration rate are used to approximate the glomerular filtration in stable patients. We reviewed the CockCroft-Gault equation, MDRD, and CKD-EPI. These equations require that the serum creatinine concentration be stable and therefore cannot be used to assess renal function in the intensive care unit. We recommend continuous renal function monitoring and a determination of creatinine clearance in urine to adjust dosage in critically ill patients.El fracaso renal agudo es un problema en el ámbito de los cuidados críticos donde su frecuencia de aparición en elevada. El conocimiento de la tasa de filtrado glomerular es necesario para realizar ajustes posológicos para pacientes con función renal deteriorada. Para estimar el filtrado glomerular en pacientes estables y ambulatorios se utiliza la creatinina sérica y la tasa de filtrado glomerular estimada a través de ecuaciones estimativas. Revisamos las ecuaciones CockCroft-Gault, MDRD y CKD-EPI. Estas ecuaciones requieren que la concentración de creatinina en suero sea estable por lo que no pueden utilizarse para valorar la función renal en la Unidad de Cuidados Intensivos. Recomendamos la monitorización de la función renal continua y el cálculo de aclaramiento de creatinina en orina para realizar ajustes posológicos en los pacientes críticos

Estrategias de protección renal en Anestesiología y Cuidados Críticos

In the perioperative setting, acute kidney injury (AKI) is a common complication. By itself, the presence of AKI is associated with adverse outcomes, such as increased risk of chronic kidney disease and mortality. Several risk factors are associated with the appearance of perioperative AKI and identifying them is crucial to initiate renal protective measures. Some renoprotective strategies have been shown to be helpful, others are still under investigation, and others are no longer recommended because they are ineffective or even harmful. The lack of efficacy of these therapies could be due to the fact that the therapy was started too late. The new renal biomarkers allow the identification of kidney damage without loss of function, thus allowing the implementation of preventive measures. The purpose of this review is to present an updated summary of the current evidence about the risk factors and mechanisms that lead to the appearance of AKI in the perioperative and the intensive care unit, as well as the different renoprotective strategies and treatments.En el contexto perioperatorio, el daño renal agudo (acute renal injury o AKI) es una complicación frecuente. Por sí mismo, la presencia de AKI se asocia con resultados adversos, tales como mayor riesgo de enfermedad renal crónica (ERC) y de mortalidad. Varios factores de riesgo están asociados con la aparición de AKI perioperatorio e identificarlos es crucial para iniciar medidas de protección renal.  Algunas estrategias renoprotectoras han demostrado ser útiles, otras se encuentran aún en investigación y otras ya no se recomiendan porque son ineficaces o incluso dañinas. La falta de eficacia de estas terapias podría deberse al hecho de que la terapia se inició demasiado tarde. Los nuevos biomarcadores renales permiten identificar el daño renal sin pérdida de función permitiendo así la implementación de medidas preventivas.  El propósito de esta revisión es mostrar un resumen actualizado de la evidencia actual acerca de los factores de riesgo y los mecanismos que nos conducen a la aparición de AKI perioperatorio y en unidad de cuidados críticos así como las diferentes estrategias y tratamientos renoprotectores

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

Objectives: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). Methods: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. Results: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. Conclusion: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective