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      Lung–kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup

      case-report
      1 , , 2 , 3 , 1 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33
      Intensive Care Medicine
      Springer Berlin Heidelberg
      Acute kidney injury, Acute respiratory distress syndrome, Extracorporeal membrane oxygenation, Renal replacement therapy, Water-electrolyte balance

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          Abstract

          Background

          Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO).

          Methods

          A consensus conference on the spectrum of lung–kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function.

          Conclusion

          The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung–kidney interactions to improve care processes and outcomes in critical illness.

          Electronic supplementary material

          The online version of this article (10.1007/s00134-019-05869-7) contains supplementary material, which is available to authorized users.

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          Most cited references93

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          Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score.

          Increasing use of extracorporeal membrane oxygenation (ECMO) for acute respiratory failure may increase resource requirements and hospital costs. Better prediction of survival in these patients may improve resource use, allow risk-adjusted comparison of center-specific outcomes, and help clinicians to target patients most likely to benefit from ECMO.
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            Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial.

            Studies have shown that an inflammatory response may be elicited by mechanical ventilation used for recruitment or derecruitment of collapsed lung units or to overdistend alveolar regions, and that a lung-protective strategy may reduce this response. To test the hypothesis that mechanical ventilation induces a pulmonary and systemic cytokine response that can be minimized by limiting recruitment or derecruitment and overdistention. Randomized controlled trial in the intensive care units of 2 European hospitals from November 1995 to February 1998, with a 28-day follow-up. Forty-four patients (mean [SD] age, 50 [18] years) with acute respiratory distress syndrome were enrolled, 7 of whom were withdrawn due to adverse events. After admission, volume-pressure curves were measured and bronchoalveolar lavage and blood samples were obtained. Patients were randomized to either the control group (n = 19): tidal volume to obtain normal values of arterial carbon dioxide tension (35-40 mm Hg) and positive end-expiratory pressure (PEEP) producing the greatest improvement in arterial oxygen saturation without worsening hemodynamics; or the lung-protective strategy group (n = 18): tidal volume and PEEP based on the volume-pressure curve. Measurements were repeated 24 to 30 and 36 to 40 hours after randomization. Pulmonary and systemic concentrations of inflammatory mediators approximately 36 hours after randomization. Physiological characteristics and cytokine concentrations were similar in both groups at randomization. There were significant differences (mean [SD]) between the control and lung-protective strategy groups in tidal volume (11.1 [1.3] vs 7.6 [1.1] mL/kg), end-inspiratory plateau pressures (31.0 [4.5] vs 24.6 [2.4] cm H2O), and PEEP (6.5 [1.7] vs 14.8 [2.7] cm H2O) (P<.001). Patients in the control group had an increase in bronchoalveolar lavage concentrations of interleukin (IL) 1beta, IL-6, and IL-1 receptor agonist and in both bronchoalveolar lavage and plasma concentrations of tumor necrosis factor (TNF) alpha, IL-6, and TNF-alpha, receptors over 36 hours (P<.05 for all). Patients in the lung-protective strategy group had a reduction in bronchoalveolar lavage concentrations of polymorphonuclear cells, TNF-alpha, IL-1beta, soluble TNF-alpha receptor 55, and IL-8, and in plasma and bronchoalveolar lavage concentrations of IL-6, soluble TNF-alpha receptor 75, and IL-1 receptor antagonist (P<.05). The concentration of the inflammatory mediators 36 hours after randomization was significantly lower in the lung-protective strategy group than in the control group (P<.05). Mechanical ventilation can induce a cytokine response that may be attenuated by a strategy to minimize overdistention and recruitment/derecruitment of the lung. Whether these physiological improvements are associated with improvements in clinical end points should be determined in future studies.
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              Heart failure and kidney dysfunction: epidemiology, mechanisms and management.

              Heart failure (HF) is a major health-care problem and the prognosis of affected patients is poor. HF often coexists with a number of comorbidities of which declining renal function is of particular importance. A loss of glomerular filtration rate, as in acute kidney injury (AKI) or chronic kidney disease (CKD), independently predicts mortality and accelerates the overall progression of cardiovascular disease and HF. Importantly, cardiac and renal diseases interact in a complex bidirectional and interdependent manner in both acute and chronic settings. From a pathophysiological perspective, cardiac and renal diseases share a number of common pathways, including inflammatory and direct, cellular immune-mediated mechanisms; stress-mediated and (neuro)hormonal responses; metabolic and nutritional changes including bone and mineral disorder, altered haemodynamic and acid-base or fluid status; and the development of anaemia. In an effort to better understand the important crosstalk between the two organs, classifications such as the cardio-renal syndromes were developed. This classification might lead to a more precise understanding of the complex interdependent pathophysiology of cardiac and renal diseases. In light of exceptionally high mortality associated with coexisting HF and kidney disease, this Review describes important crosstalk between the heart and kidney, with a focus on HF and kidney disease in the acute and chronic settings. Underlying molecular and cellular pathomechanisms in HF, AKI and CKD are discussed in addition to current and future therapeutic approaches.
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                Author and article information

                Contributors
                michael.joannidis@i-med.ac.at
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0342-4642
                1432-1238
                9 December 2019
                9 December 2019
                2020
                : 46
                : 4
                : 654-672
                Affiliations
                [1 ]GRID grid.5361.1, ISNI 0000 0000 8853 2677, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, , Medical University Innsbruck, ; Anichstrasse 35, 6020 Innsbruck, Austria
                [2 ]GRID grid.5475.3, ISNI 0000 0004 0407 4824, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, , University of Surrey, ; Guildford, UK
                [3 ]GRID grid.412946.c, ISNI 0000 0001 0372 6120, Intensive Care Unit, , Royal Surrey County Hospital NHS Foundation Trust, ; Guildford, UK
                [4 ]GRID grid.5771.4, ISNI 0000 0001 2151 8122, Doctoral College Medical Law and Healthcare, Faculty of Law, , University Innsbruck, ; Innsbruck, Austria
                [5 ]GRID grid.411371.1, ISNI 0000 0004 0469 8354, Department of Intensive Care Medicine, , CHU Brugmann University Hospital, ; Brussels, Belgium
                [6 ]GRID grid.66875.3a, ISNI 0000 0004 0459 167X, Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, , Mayo Clinic, ; Rochester, MN USA
                [7 ]GRID grid.425213.3, Department of Critical Care, King’s College London, , Guy’s and St Thomas’ Hospital, ; London, UK
                [8 ]GRID grid.416041.6, ISNI 0000 0001 0738 5466, Adult Critical Care Unit, , The Royal London Hospital, Barts Health NHS Trust, ; London, UK
                [9 ]GRID grid.4868.2, ISNI 0000 0001 2171 1133, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, , Queen Mary University of London, ; London, UK
                [10 ]GRID grid.17089.37, Department of Critical Care Medicine, Faculty of Medicine and Dentistry, , University of Alberta, ; Edmonton, Canada
                [11 ]Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont “A. Avogadro”, Maggiore della Carità University Hospital, Novara, Italy
                [12 ]GRID grid.413328.f, ISNI 0000 0001 2300 6614, Medical ICU, , Saint-Louis University Hospital, AP-HP, ; Paris, France
                [13 ]GRID grid.7452.4, ISNI 0000 0001 2217 0017, Faculté de Médecine, , Université Paris-Diderot, Sorbonne-Paris-Cité, ; Paris, France
                [14 ]GRID grid.7429.8, ISNI 0000000121866389, ECSTRA Team, Biostatistics and Clinical Epidemiology, , UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, ; Paris, France
                [15 ]GRID grid.8547.e, ISNI 0000 0001 0125 2443, Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, , Fudan University, ; Shanghai, China
                [16 ]GRID grid.13648.38, ISNI 0000 0001 2180 3484, Department of Intensive Care Medicine, , University Medical Center Hamburg-Eppendorf, ; Hamburg, Germany
                [17 ]GRID grid.5949.1, ISNI 0000 0001 2172 9288, Department of Medicine B, , University Muenster, ; Muenster, Germany
                [18 ]GRID grid.410566.0, ISNI 0000 0004 0626 3303, ICU, , Ghent University Hospital, ; Ghent, Belgium
                [19 ]GRID grid.434261.6, ISNI 0000 0000 8597 7208, Research Fund-Flanders (FWO), ; Brussels, Belgium
                [20 ]GRID grid.411067.5, ISNI 0000 0000 8584 9230, Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, , University Hospital Giessen and Marburg, ; Giessen, Germany
                [21 ]GRID grid.411941.8, ISNI 0000 0000 9194 7179, Department of Cardiology, Pulmonary and Critical Care Medicine, , University Hospital Regensburg, ; Regensburg, Germany
                [22 ]GRID grid.412004.3, ISNI 0000 0004 0478 9977, Medical Intensive Care Unit, Institute for Intensive Care Medicine, , University Hospital Zurich, ; Zurich, Switzerland
                [23 ]GRID grid.16149.3b, ISNI 0000 0004 0551 4246, Department of Anesthesiology, Intensive Care and Pain Medicine, , University Hospital Muenster, ; Muenster, Germany
                [24 ]GRID grid.7886.1, ISNI 0000 0001 0768 2743, School of Medicine, , University College Dublin, ; Dublin, Ireland
                [25 ]GRID grid.7886.1, ISNI 0000 0001 0768 2743, UCD Catherine McAuley Education and Research Centre, ; Dublin, Ireland
                [26 ]GRID grid.414125.7, ISNI 0000 0001 0727 6809, Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, , Bambino Gesù Children’s Hospital, IRCCS, ; Rome, Italy
                [27 ]GRID grid.417468.8, ISNI 0000 0000 8875 6339, Department of Critical Care Medicine, , Mayo Clinic, ; Phoenix, AZ USA
                [28 ]Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
                [29 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Klinik für Pneumologie, Medizinische Hochschule Hannover, ; Hannover, Germany
                [30 ]GRID grid.5608.b, ISNI 0000 0004 1757 3470, Department of Medicine, , University of Padova, ; Padua, Italy
                [31 ]GRID grid.416303.3, ISNI 0000 0004 1758 2035, International Renal Research Institute of Vicenza, , San Bortolo Hospital, ; Vicenza, Italy
                [32 ]GRID grid.416303.3, ISNI 0000 0004 1758 2035, Department of Nephrology, Dialysis and Transplantation, , San Bortolo Hospital, ; Vicenza, Italy
                [33 ]GRID grid.21925.3d, ISNI 0000 0004 1936 9000, Center for Critical Care Nephrology, , University of Pittsburgh, ; Pittsburgh, PA USA
                Author information
                http://orcid.org/0000-0002-6996-0881
                Article
                5869
                10.1007/s00134-019-05869-7
                7103017
                31820034
                31708e6a-1a1b-471c-98dc-af39cb86a5f3
                © The Author(s) 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 9 September 2019
                : 13 November 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100009777, Astute Medical;
                Funded by: Baxter
                Funded by: CLS Behring
                Funded by: Cytosorb
                Funded by: HepaWash
                Funded by: NxStage
                Categories
                Conference Reports and Expert Panel
                Custom metadata
                © Springer-Verlag GmbH Germany, part of Springer Nature 2020

                Emergency medicine & Trauma
                acute kidney injury,acute respiratory distress syndrome,extracorporeal membrane oxygenation,renal replacement therapy,water-electrolyte balance

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