[show abstract][hide abstract] ABSTRACT: Nephrotoxic medication use is common in neonates. In older children, the use of nephrotoxic medication is known to be one of the most common causes of acute kidney injury (AKI) and to be associated with increased morbidity. In critically ill neonates, AKI significantly complicates fluid and electrolyte management and may be an important risk factor for mortality. Better understanding of methods to avoid and detect the presence of nephrotoxicity may lead to more intelligent use of these medications, which could ultimately reduce the incidence of AKI and improve outcomes. In this work, we summarize why neonates are predisposed to drug nephrotoxicity, review the mechanisms and clinical picture of the most common nephrotoxic medications used in neonates (aminoglycosides, vancomycin, amphotericin B, acyclovir, nonsteroidal anti-inflammatory drugs, and radiocontrast agents), and discuss the roles of angiotensin-converting enzyme inhibitors and diuretics in nephrotoxicity. We also suggest ways to avoid and reduce the incidence and complications of neonatal nephrotoxicity.
[show abstract][hide abstract] ABSTRACT: Acute kidney injury and fluid overload (FO) are associated with increased mortality in critically ill patients, including the subset supported with extracorporeal membrane oxygenation (ECMO). The indication for and method of application of renal support therapy (RST) during ECMO is largely unknown beyond single-center experiences. The current study uses a survey design to document practice variation regarding RST, including indication, method of interface with the ECMO circuit, and prescribing practices. Sixty-five international ECMO centers (31%) responded to an online electronic survey regarding RST during ECMO. Nearly a quarter of centers (23%) reported using no RST during ECMO. Among those using the therapy, the predominant mode of therapy applied was convection and included slow continuous ultrafiltration and continuous venovenous hemofiltration. The predominant indication for RST was the treatment (43%) or prevention (16%) of FO. Nephrology rather than critical care medicine is reported as the prescribing service in a majority of centers with a significant difference between US centers and non-US centers. The results of this study identify a wide variation in practice regarding RST during ECMO that will offer multiple important avenues for further research by this group and others regarding the interface of RST and ECMO.
ASAIO journal (American Society for Artificial Internal Organs: 1992) 05/2012; 58(4):407-14. · 1.39 Impact Factor
[show abstract][hide abstract] ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used in neonates, children, and adults with severe, reversible, cardiopulmonary failure. On the basis of single-center studies, the incidence of AKI occurs in 70%-85% of ECMO patients. Those with AKI and those who require renal replacement therapy (RRT) are at high risk for mortality, independent of potentially confounding variables. Fluid overload is common in ECMO patients, and is one of the main indications for RRT. RRT to maintain fluid balance and metabolic control is common in some but not all centers. RRT on ECMO can be performed via an in-line hemofilter or by incorporating a standard continuous renal replacement machine into the ECMO circuit. Both of these methods require specific technical considerations to provide safe and effective RRT. This review summarizes available epidemiologic data and how they apply to our understanding of AKI pathophysiology during ECMO, identifies indications for RRT while on ECMO, reviews technical elements for RRT application in the setting of ECMO, and finally identifies specific research-focused questions that need to be addressed to improve outcomes in this at-risk population.
Clinical Journal of the American Society of Nephrology 04/2012; 7(8):1328-36. · 5.07 Impact Factor