Prevention of acute kidney injury and protection of renal function in the intensive care unit : update 2017

Background: Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. Objectives: To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. Method: A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. Results: We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. Conclusion: The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes

Allostery at opioid receptors: modulation with small molecule ligands

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144601/1/bph13823_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144601/2/bph13823.pd

Dual-Mode Combustion Experiments with an Integrated Aeroramp-Injector/Plasma-Torch Igniter

Results from combustion experiments in a direct-connect supersonic combustor facility are presented. Successful ignition and sustained combustion of both hydrogen and ethylene fuels were achieved using an integrated aeroramp-injector/plasma-torch igniter configuration. A Mach 2 nozzle was used to obtain How simulating Mach approximate to 4 flight conditions at 27 km, at a total temperature of 1000 K and a static pressure of 42 kPa. Combustion was achieved at (global) equivalence ratios between 0.08 and 0.31 for hydrogen and 0.13 and 0.47 for ethylene, with corresponding maximum combustor pressure rises of about a factor of 4.0. One-dimensional performance analysis of the test data indicates combustion efficiencies as high as 75% for both fuels, in the leanest conditions tested. Off-design flight conditions were tested by varying the freestream air total temperature. Supersonic combustion was achieved at total temperatures as low as 530 K with hydrogen and 680 K with ethylene

Dual-Mode Combustion Experiments with an Integrated Aeroramp-Injector/Plasma-Torch Igniter

Results from combustion experiments in a direct-connect supersonic combustor facility are presented. Successful ignition and sustained combustion of both hydrogen and ethylene fuels were achieved using an integrated aeroramp-injector/plasma-torch igniter configuration. A Mach 2 nozzle was used to obtain How simulating Mach approximate to 4 flight conditions at 27 km, at a total temperature of 1000 K and a static pressure of 42 kPa. Combustion was achieved at (global) equivalence ratios between 0.08 and 0.31 for hydrogen and 0.13 and 0.47 for ethylene, with corresponding maximum combustor pressure rises of about a factor of 4.0. One-dimensional performance analysis of the test data indicates combustion efficiencies as high as 75% for both fuels, in the leanest conditions tested. Off-design flight conditions were tested by varying the freestream air total temperature. Supersonic combustion was achieved at total temperatures as low as 530 K with hydrogen and 680 K with ethylene

Acute kidney injury in the critically ill: an updated review on pathophysiology and management.

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

Renal recovery after acute kidney injury

Acute kidney injury (AKI) is a frequent complication of critical illness and carries a significant risk of short-and long-term mortality, chronic kidney disease (CKD) and cardiovascular events. The degree of renal recovery from AKI may substantially affect these long-term endpoints. Therefore maximising recovery of renal function should be the goal of any AKI prevention and treatment strategy. Defining renal recovery is far from straightforward due in part to the limitations of the tests available to assess renal function. Here, we discuss common pitfalls in the evaluation of renal recovery and provide suggestions for improved assessment in the future. We review the epidemiology of renal recovery and of the association between AKI and the development of CKD. Finally, we stress the importance of post-discharge follow-up of AKI patients and make suggestions for its incorporation into clinical practice. Summary key points are that risk factors for non-recovery of AKI are age, CKD, comorbidity, higher severity of AKI and acute disease scores. Second, AKI and CKD are mutually related and seem to have a common denominator. Third, despite its limitations full recovery of AKI may best be defined as the absence of AKI criteria, and partial recovery as a fall in AKI stage. Fourth, after an episode of AKI, serial follow-up measurements of serum creatinine and proteinuria are warranted to diagnose renal impairment and prevent further progression. Measures to promote recovery are similar to those preventing renal harm. Specific interventions promoting repair are still experimental.Peer reviewe