International criteria for acute kidney injury: advantages and remaining challenges

• Acute Kidney Injury (AKI) is defined using widely accepted international criteria that are based on changes in serum creatinine concentration and degree of oliguria. • AKI, when defined in this way, has a strong association with poor patient outcomes, including high mortality rates and longer hospital admissions with increased resource utilisation and subsequent chronic kidney disease. • The detection of AKI using current criteria can assist with AKI diagnosis and stratification of individual patient risk. • The diagnosis of AKI requires clinical judgement to integrate the definition of AKI with the clinical situation, to determine underlying cause of AKI, and to take account of factors that may affect performance of current definitions

Nitrate regulates floral induction in Arabidopsis, acting independently of light, gibberellin and autonomous pathways

The transition from vegetative growth to reproduction is a major developmental event in plants. To maximise reproductive success, its timing is determined by complex interactions between environmental cues like the photoperiod, temperature and nutrient availability and internal genetic programs. While the photoperiod- and temperature- and gibberellic acid-signalling pathways have been subjected to extensive analysis, little is known about how nutrients regulate floral induction. This is partly because nutrient supply also has large effects on vegetative growth, making it difficult to distinguish primary and secondary influences on flowering. A growth system using glutamine supplementation was established to allow nitrate to be varied without a large effect on amino acid and protein levels, or the rate of growth. Under nitrate-limiting conditions, flowering was more rapid in neutral (12/12) or short (8/16) day conditions in C24, Col-0 and Laer. Low nitrate still accelerated flowering in late-flowering mutants impaired in the photoperiod, temperature, gibberellic acid and autonomous flowering pathways, in the fca co-2 ga1-3 triple mutant and in the ft-7 soc1-1 double mutant, showing that nitrate acts downstream of other known floral induction pathways. Several other abiotic stresses did not trigger flowering in fca co-2 ga1-3, suggesting that nitrate is not acting via general stress pathways. Low nitrate did not further accelerate flowering in long days (16/8) or in 35S::CO lines, and did override the late-flowering phenotype of 35S::FLC lines. We conclude that low nitrate induces flowering via a novel signalling pathway that acts downstream of, but interacts with, the known floral induction pathways

Survival benefit of cardiopulmonary bypass support in bilateral lung transplantation for emphysema patients

Background. This study is designed to examine a possible association of cardiopulmonary bypass (CPB) support and outcome of lung transplantation in a well-balanced group of emphysema patients. Methods. We performed a retrospective analysis of 62 consecutive primary bilateral lung transplantations for emphysema. Risk factors for their possible association with patient survival were analyzed by multivariate logistic regression. Results. The use of CPB support was associated with improved survival (odds ratio=0.25; P=0.038). The actuarial survival at 1 year was 97% for patients treated with CPB and 77% for patients treated without CPB support. In 28 patients (45%), 2 human leukocyte antigen (HLA)-DR mismatches between donor and recipient occurred, whereas 34 patients had 0 or 1 HLA-DR mismatches. The use of CPB support in the group with two HLA-DR mismatches was associated with improved survival (odds ratio=0.06; P=0.020). This association was not present in the group with 0 or 1 HLA-DR mismatches. Conclusions. These results demonstrate a significant survival benefit of CPB support during bilateral lung transplantation in emphysema patients. The difference in survival benefit of CPB support between the patients with 0 or 1 HLA-DR mismatches and the patients with 2 HLA-DR mismatches indicates that the immunosuppressive effect of CPB support might be responsible for this survival benefit. The underlying immunological mechanism might be important in the future treatment of organ transplantation

INCREASING CYANOSIS AFTER TOTAL CAVOPULMONARY CONNECTION TREATED BY BANDING A SEPARATE LIVER VEIN

An increasing right-to-left shunt after a total cavopulmonary connection was treated by banding the separate liver vein. As a variation on a fenestrated total cavopulmonary connection, this liver vein was not connected with the intercaval tunnel. After a few days, the shunt increased to an unacceptable level. This was treated by banding the liver vein, which was connected with the right-sided atrium and turned out to be only part of the venous drainage of the liver.</p

Endotracheal suctioning versus minimally invasive airway suctioning in intubated patients: a prospective randomised controlled trial

Study objective: Endotracheal suctioning in intubated patients is routinely applied in most ICUs but may have negative side effects. We hypothesised that on-demand minimally invasive suctioning would have fewer side effects than routine deep endotracheal suctioning, and would be comparable in duration of intubation, length of stay in the ICU, and ICU mortality. Design: Randomised prospective clinical trial. Setting. In two ICUs at University Hospital Groningen, the Netherlands. Patients: Three hundred and eighty-three patients requiring endotracheal intubation for more than 24 h. Interventions: Routine endotracheal suctioning (n=197) using a 49-cm suction catheter was,compared with on-demand minimally invasive airway suctioning (n=186) using a suction catheter only 29 cm long. Measurements and results: No differences were found between the routine endotracheal suctioning group and the minimally invasive airway suctioning group in duration of intubation [median (range) 4 (1-75) versus 5 (1-101) days], ICU-stay [median (range) 8 (1-133) versus 7 (1-221) days], ICU mortality (15% versus 17%), and incidence of pulmonary infections (14% versus 13%). Suction-related adverse events occurred more frequently with RES interventions than with MIAS interventions; decreased saturation: 2.7% versus 2.0% (P=0.010); increased systolic blood pressure 24.5% versus 16.8% (

Patient recollection of airway suctioning in the ICU:routine versus a minimally invasive procedure

Objective: Many patients have an unpleasant recollection of routine endotracheal suctioning after discharge from the Intensive Care Unit (ICU). We hypothesized that through minimally invasive airway suctioning discomfort and stress may be prevented, resulting in less recollection. Design: A prospective randomized clinical trial. Setting: Two ICUs at the University Hospital of Groningen, the Netherlands. Patients and participants: Adult patients with an intubation period exceeding 24 h were included. Interventions: Patients received either routine endotracheal suctioning (RES) or minimally invasive airway suctioning (MIAS) during the duration of intubation. Measurements and results: Within 3 days after ICU discharge all patients were interviewed, regarding recollection and discomfort of suctioning. The level of discomfort was quantified on a visual analogue scale (VAS). We analyzed data from 208 patients (RES: n=113 ,and MIAS: n=95). A significantly lower prevalence of recollection of airway suctioning was found in the MIAS group (20%) compared to the RES group (41%) (P-value =0.001). No significant difference in level of discomfort was found between the RES and the MIAS group (P-value =0.136). Conclusions: Minimally invasive airway suctioning results in a lower prevalence of recollection of airway suction than in RES, but not in discomfort

To ventilate or not after minimally invasive direct coronary artery bypass surgery:The role of epidural anesthesia

Objective: To evaluate the effect of immediate postoperative extubation and postoperative ventilation after minimally invasive direct coronary artery bypass (MIDCAB) surgery and to assess the role of epidural anesthesia. Design: Randomized prospective study. Setting: University hospital, single institution. Participants: Patients (n = 90) scheduled for elective MIDCAB surgery. Interventions: Patients were divided into 3 groups: 30 patients had general anesthesia and were extubated immediately after surgery (extubated group), 30 patients had a thoracic epidural and general anesthesia and were extubated immediately after surgery (epidural group), and 30 patients had general anesthesia and were ventilated after surgery (intubated group). Measurements and Main Results. With a similar cardiac Index and less vasoactive medication, mean arterial blood pressure (77 +/- 8 mmHg [mean +/- SD]) and heart rate (76 +/- 10 beats/min) in the epidural group were lower on the first postoperative day than in the intubated group (83 10 mmHg and 81 +/- 13 beats/min) and the extubated group (86 +/- 10 mmHg and 83 +/- 13) (p = 0.01 and p = 0.09). Oxygenation on the first postoperative day was better in the epidural group than in the intubated group (14.8 +/- 3.8 kPa v 12.6 +/- 3.2 kPa; p = 0.05). The epidural group and the extubated group had a transient respiratory acidosis postoperatively. Pain score in the epidural group was lower on the first postoperative day than in the extubated group with general anesthesia (3.0 +/- 1.6 visual analog scale v 4.6 +/- 1.8 visual analog scale; p = 0.01). Hospital stay was shorter in the epidural group than in the ventilated group (5.9 +/- 2.4 days v 8.1 +/- 5.3 days; p = 0.05) Conclusion: Immediate postoperative extubation in patients with thoracic epidural anesthesia and supplemental general anesthesia provides the most favorable clinical circumstances after MIDCAB surgery. Copyright 2002, Elsevier Science (USA). All rights reserved

Off-pump coronary revascularization attenuates transient renal damage compared with on-pump coronary revascularization

Study objectives: Cardiopulmonary bypass (CPB) represents a specific risk factor for renal damage during coronary, revascularization. The purpose of this study, was to compare the perioperative renal damage in patients undergoing on-pump and off-pump Coronary, surgery.. Design and patients: The progress and extent of renal damage was prospectively studied in two groups of patients undergoing cardiac surgery without concomitant morbidity, undergoing elective coronary revascularization with (n = 12; and without (n = 10) CPB. Markers of glomerular function (creatinine clearance) and damage (microalbuminuria), and markers of tubular function (fractional excretion of sodium [FENa] and free water clearance) and damage (N-acetyl-beta-D glucosaminidase [NAG]) were evaluated. Measuring plasma concentrations of free hemoglobin assessed hemolysis. Plasma and urinary specimens were obtained at the following points: (1) baseline; (2) heparinization; (3) the end of CPB or completing graft for off-pump surgery; (4) skin closure; (5) the sixth hour in the ICU; and (6) the second postoperative day,. Free water and creatinine clearances, FENa, and the urinary excretion of microalbumin and NAG were calculated for the corresponding time intervals. Setting: University hospital. Results: We found that off-pump coronary revascularization induced significantly less changes in microalbuminuria, FENa, free water clearance, NAG, and free hemoglobin as compared with operations with CPB. Markers returned to baseline within 2 days after the operation, and there was no clinical or laboratory evidence of overt renal dysfunction in both groups. Conclusion: Off-pump coronary surgery attenuates transient renal injury compared with traditional on-pump coronary, artery, bypass grafting