Michael Joannidis

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

Treatment of refractory cholestatic pruritus after liver transplantation with albumin dialysis

Albumin dialysis has been shown to improve the outcome in patients with cholestatic liver failure caused by chronic liver disease. This study reports 7 liver transplant recipients who were treated with albumin dialysis for intractable pruritus of different origin (ductopenic graft rejection, non‐anastomotic strictures, and recurrence of hepatitis C). Treatment with histamine (H1) blockers, opioid antagonists, and cholestyramine had not been effective. The Molecular Adsorbent Recirculating System (MARS; Teraklin, Rostock, Germany) was used for albumin dialysis. All patients presented with numerous scratch marks, 6 of whom had a pronounced icterus. Six patients (86%) responded to 3 consecutive treatments with significant reduction of pruritus. The mean pruritus score, which was quantified by a visual analog scale (VAS), decreased from 9.7 ± 0.5 to 3.7 ± 0.8 (SD). The mean duration of 1 treatment was 15.6 hours. The procedure was well tolerated by all patients. The mean total serum bilirubin in patients who responded to therapy declined from 19.11 ± 16.96 mg/dL (SD) before MARS therapy to 9.24 ± 3.52 mg/dL after treatment. The mean serum concentration of 3α‐hydroxy bile acids decreased from 192.67 ± 58.12 μmol/L (SD) to 42.33 ± 31.58 μmol/L (SD). Follow‐up in 3 cases showed sustained improvement of pruritus lasting for more than 3 months. In 3 patients, however, pruritus relapsed. One patient, who showed severe pruritus, without relevant elevation of serum bile acids before treatment, did not respond to albumin dialysis. Our data indicate that MARS is an effective therapeutic option for patients with intractable cholestatic pruritus. (Liver Transpl 2004;10:107–114.)

Improving outcomes from acute kidney injury: report of an initiative

Acute kidney injury (AKI) is a clinical condition characterized by acute decline in renal function, with manifestations ranging from minimal elevation of serum creatinine concentration to anuric renal failure. Keeping in view that acquisition of knowledge and research in this important area requires multi-disciplinary collaboration, a group representing members of the Acute Dialysis Quality Initiative and nephrology and critical care societies has established the Acute Kidney Injury Network (AKIN). The First Consensus Conference of this network focused on defining diagnostic and staging criteria for AKI. Changes in serum creatinine levels and urine output were used to define and stage three levels of renal dysfunction. These criteria require evaluation and validation in prospective clinical studies and, perhaps, modifications as more sensitive markers of kidney injury are identified. Other issues that need to be examined include global epidemiology and outcome of AKI and development of strategies to improve outcomes. The vital role of multi-disciplinary conferences for disseminating knowledge and clarifying issues in clinical practice was recognized.

Plasma Levels of Troponin T After Electrical Cardioversion of Atrial Fibrillation and Flutter

To establish possible myocardial damage by direct-current countershock, we measured plasma levels of troponin T after electrical cardioversion in 33 nonselected patients with atrial fibrillation or flutter. Unchanged normal levels of troponin T indicate that significant myocardial cell injury by shocks in the usual dosage is unlikely to occur.

Plasma levels of procalcitonin and interleukin-6 in acute myocardial infarction.

Estimation of cardiac morbidity in patients after major surgery is a difficult problem. In addition, infectious complications seriously decrease potential beneficial outcome after cardiovascular surgery. The present study assessed the use of a newer marker of the inflammatory response, procalcitonin, in the field of myocardial infarction, in conjunction with measurements of interleukin-6. Forty-four consecutive cases with acute myocardial infarction were included in the study 4 ± 1.3 h after the onset of symptoms. Plasma levels of procalcitonin and interleukin-6 were obtained at admission, and after 3, 6, 12, 18, 24 and 48 h, using commercially available test kits. The range of levels of interleukin-6 and procalcitonin was about normal at admission. Interleukin-6 levels increased significantly following myocardial infarction, whereas procalcitonin were essentially unchanged, i.e. remained close to the normal level threshold of 0.5 ng/ml; only minor variability occurred with a mean peak level of procalcitonin of 1 ± 0.4 ng/ml. Data demonstrate that, in contrast to the acute phase reactant interleukin-6, plasma levels procalcitonin are not significantly elevated during uncomplicated acute myocardial infarction. This observation may support the role of procalcitonin measurements in the differential diagnosis of infectious and cardiovascular complications after major surgery.

Morphological and Biochemical Changes of LLC-PK1Cells during Adaptation to Glucose-Free Culture Conditions

The established renal epithelial cell line LLC-PK1 retained in tissue culture several differentiated properties of renal proximal tubular cells. By adapting LLC-PK1 cells to glucose-free culture conditions, we recently succeeded in isolating a gluconeogenic strain of LLC-PK1 cells capable of growing in the absence of hexoses. In contrast to the parental wild type, the isolated strain expressed fructose-1,6-bisphosphatase activity and was, therefore, designated LLC-PK1-FBPase+. Besides the differences in glucose metabolism, the isolated gluconeogenic substrain differs form the parental wild type with respect to morphological appearance and the expression of apical membrane marker enzymes. LLC-PK1-FBPase+ cells display a drastic accumulation of autophagic vacuoles, disappearance of apical membrane alkaline phosphatase activity, and increased gamma-glutamyltranspeptidase activity. In order to find out whether or not a low alkaline phosphatase activity in combination with the enhanced formation of autophagic vacuoles is related to a change in apical membrane surface, we utilized a combined light and electron microscopic morphometric procedure to determine the absolute amount of organelle volumes and membrane surface areas. This stereologic approach shows that LLC-PK1-FBPase+ cells display a tenfold increase in the volume of autophagic vacuoles and the lysosomal compartment. Analysis of lysosomal enzyme activities, however, revealed no changes as compared to wild-type cells. The apical membrane surface of gluconeogenic cells was found to be increased by 80%. Karyotype analysis revealed that LLC-PK1 wild-type cells were diploid, whereas FBPase+ cells exhibited polyploidy with a high percentage of tetraploid nuclei. Culturing LLC-PK1-FBPase+ cells in the presence of 5 mM glucose does not abolish the morphological and biochemical changes described, indicating the stability of the FBPase+ strain.

Comparison of different scoring methods for assessing the nutritional status of hospitalised patients.

SummaryOBJECTIVE: Despite intense clinical research, no commonly accepted diagnostic tool for assessment of nutritional status is yet available. In this study a comparison of four different methods for diagnosis of the nutritional status of patients admitted to a university hospital in Austria is presented. PATIENTS AND METHODS: Clinical data of 640 hospitalised patients were analysed in a prospective-descriptive study design. Four recommended methods, the Innsbruck nutrition score (INS), the Prideaux nutritional risk assessment (PNRA), the well established nutrition risk index (NRI), and the body mass index (BMI) were used to analyse nutritional status. RESULTS: The BMI showed 90.2% of the patients evaluated to have normal nutritional status, whereas the PNRA identified 48.9%, the NRI 40% and the INS 58.6% as well nourished. Patients were variously diagnosed with moderate malnutrition: 9% (BMI), 42% (PNRA), 54.8% (NRI) and 30% (INS). Severe malnutrition was detected in 0.5% (BMI), 9.1% (PNRA), 5.2% (NRI) and 11.4% (INS) of the patients evaluated. Cancer patients had the worst nutritional status. CONCLUSION: Malnutrition seems to be a common diagnosis among hospitalised patients in Austria. Screening and assessment of nutritional status should be integrated into clinical routine. The methods tested scored malnutrition at different frequencies. BMI seemed to underestimate the prevalence of malnutrition. The PNRA provided some information on clinical outcome, whereas the NRI had the best relationship between the degree of malnutrition and length of stay. Calculation of the INS may give correct diagnosis of severe malnutrition. Further prospective clinical studies are needed to validate the scoring systems used in this study and to provide accurate clinical diagnosis of malnutrition.

Year in review in Intensive Care Medicine 2013: I. Acute kidney injury, ultrasound, hemodynamics, cardiac arrest, transfusion, neurocritical care, and nutrition

Jan Bakker Matteo Bassetti Dominique Benoit Maurizio Cecconi J. Randall Curtis Glenn Hernandez Margaret Herridge Samir Jaber Michael Joannidis Laurent Papazian Mark Peters Pierre Singer Martin Smith Marcio Soares Antoni Torres Antoine Vieillard-Baron Jean-Francois Timsit Elie Azoulay Year in review in Intensive Care Medicine 2013: I. Acute kidney injury, ultrasound, hemodynamics, cardiac arrest, transfusion, neurocritical care, and nutrition

Year in review in Intensive Care Medicine 2014: III. Severe infections, septic shock, healthcare-associated infections, highly resistant bacteria, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics

This third article for the 2014 Year in Review will report publications from intensive care on severe infections (including endocarditis and peritonitis), septic shock, healthcare and ventilator associated pneumonia, highly resistant bacteria, antimicrobial therapy (including antibiotic stewardship, therapeutic drug monitoring and de-escalation), invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics.

Defining the characteristics and expectations of fluid bolus therapy: A worldwide perspective

PURPOSE The purpose of the study is to understand what clinicians believe defines fluid bolus therapy (FBT) and the expected response to such intervention. METHODS We asked intensive care specialists in 30 countries to participate in an electronic questionnaire of their practice, definition, and expectations of FBT. RESULTS We obtained 3138 responses. Despite much variation, more than 80% of respondents felt that more than 250 mL of either colloid or crystalloid fluid given over less than 30 minutes defined FBT, with crystalloids most acceptable. The most acceptable crystalloid and colloid for use as FBT were 0.9% saline and 4% albumin solution, respectively. Most respondents believed that one or more of the following physiological changes indicates a response to FBT: a mean arterial pressure increase greater than 10 mm Hg, a heart rate decrease greater than 10 beats per minute, an increase in urinary output by more than 10 mL/h, an increase in central venous oxygen saturation greater than 4%, or a lactate decrease greater than 1 mmol/L. CONCLUSIONS Despite wide variability between individuals and countries, clear majority views emerged to describe practice, define FBT, and identify a response to it. Further investigation is now required to describe actual FBT practice and to identify the magnitude and duration of the physiological response to FBT and its relationship to patient-centered outcomes.