Acute Kidney Injury and Sepsis in Intensive Care Unit: Clinical, Biochemical, Instrumental Evaluation and the role of Emerging treatments

Sepsis is a primary cause of morbidity and mortality in intensive care unit (ICU) and critically ill patients. Acute Kidney Injury (AKI), a frequent complication in critically ill septic patients, occurs in 35-65% of ICU admissions and is an independent risk factor for increased mortality. Sepsis is also a contributing factor in more than 20% of cases of AKI in ICU patients, with cases severe enough to require renal replacement therapy. The higher mortality of these patients required an accurate and early diagnosis of AKI-Septic status as soon as an accurate prevention of kidney failure main complications: fluid overload and acidosis. At the same time we need new extracorporeal treatments not only by offering renal replacement with AKI-related treatments, but also by providing multi-organ support therapies for other organs involved in septic shock. We conduct a series of studies to investigate the role of new technologies for clinical, instrumental and biochemical evaluation in Septic and Non septic-AKI patients; we also analyzed which extracorporeal treatments can allow improve patients clinical patterns and outcome. Biochemical Markers of Acute Kidney Injury We investigate the possible correlation between serum biochemical markers of organ damage, such as Neutrophil Gelatinase-Associated Lipocalin (NGAL), Advanced Oxidation Protein Products (AOPP) and Brain Natriuretic Peptide (BNP) in ICU-AKI patients with or without sepsis. Ninety-eight consecutive adult patients admitted to ICU, divided in two groups depending on the presence of sepsis were enrolled. In Ninety-eight adult patients admitted to ICU the levels of NGAL, BNP and AOPP were significantly higher among septic patients compared with non septic subjects (p<0.001). Among septic patients, subjects who developed AKI showed significant higher levels of NGAL and AOPP (p=0.0425), and BNP (p=0.0327). Fluid status management: BIVA and SVV Bioelectrical Impedance Vector Analysis (BIVA) could be useful the assessment of tissue hydration status in critically patients. A cross-sectional study of 34 patients admitted to the Intensive Care Unit on mechanical ventilation was performed: patients were classified by resistance(Rz) / height(H) ratio (Ω/m): >200Ω/m = dry, ≤200Ω/m = wet . Patients categorized by Rz/H as wet showed a weak but clinically congruent association with a higher CVP (13.0 vs 9.9 mmHg, p=0.065) and higher BNP (882 vs 352 pg/ml, p=0.083). Stroke Volume Variations (SVV) is a dynamic cardiac preload parameter, and its wide variations are described in the literature as a predictor of volume responsiveness in several populations of mechanically ventilated patients. We conducted a pilot study in patients who undergo surgical interventions of abdominal aortic aneurysm (AAA) surgery to assess if with wide variations of SVV before and after clamping of the aorta are correlated with an higher risk of AKI development than those with lesser variations. As compared to patients without AKI, AKI patients had a significantly larger SVV after aortic clamping (13.25 vs. 24.5, p=0.01). The increase in SVV at aortic declamping time, as compared to SSV at clamping time, was also significantly higher in AKI patients (-3.75 vs. 12.5, p=0.04). Management and Detection Of Acidosis Acid-base disorders are common in the ICU and are indications for Renal Replacement Therapies (RRT). The Stewart Approach may be superior for acid-base analysis in the critically ill. We enrolled 19 consecutive adult patients on CVVH and mechanical ventilation. We calculated [HCO-3] and SBE with the Henderson- Hasselbach and Siggaard-Andersen equations. Physicochemical analysis was performed using the Stewart equations modified by Figge et al. The apparent strong ion difference (SIDa) and the effective strong ion difference (SIDe) were then calculated. The prevalence of acidosis after CVVH, as assessed by pH vs. SIDe, was [36.8% vs. 94.7% (p<0.001)] at 6h, 21.1% vs. 73.7% (p<0.05)] at 12h, and [21.1% vs. 98.6% (p<0.001)] at 24h. The prevalence of acidosis after CVVH, as assessed by SBE vs.SIDe, was [57.9%vs.94.7%(p<0.05)] at 6h,[63.2% vs.73.7% (p=NS)]at 12 h,and [63.2% vs.98.6%(p<0.05] at 24h. News Extracorporeal Treatments for AKI and Sepsis High Volume Hemofiltration (HVHF) and Coupled Plasma Filtration Adsorption (CPFA) have shown potential improvements in septic animals, but actually there are no studies that compare these two types of treatments in human. Our aim was to compare the hemodynamic effects of HVHF and CPFA in septic shock patients with Acute Kidney Injury (AKI) undergoing Continuous Renal Replacement therapies(CRRT). We performed a cross-over study enrolling patients with septic shock and AKI who were receiving CRRT. The primary endpoints were changes in mean arterial pressure, vasopressors requirement (expressed as Vasopressor Score, VS) and changes in noradrenaline dose after pHVHF and CPFA. There was a trend for reduction in VS with HVHF and CPFA (HVHF p= 0.13, CPFA p< 0.05) There was not a significant difference between the two treatments in terms of percentage change in VS score (p=0.22). New Technologies, New Biochemical parameters and new treatments can improve early diagnosis, monitoring and treatment in AKI septic and Non-Septic patients