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Intensive Care Nephrology

Technische Universität Dresden, Dresden, Germany.

Correspondence to Dr. Peter Gross, Professor of Medicine and Nephrology, Universitätsklinikum Carl Gustav Carus, Fetscherstrasse 74, D-01307 Dresden, Germany. Phone: 49-351-458-2645; Fax: 49-351-458-5333; E-mail: peter.gross{at}mailbox.tu-dresden.de

The past 3 yr have witnessed a further increase of the nephrologist's involvement in critical care. This has been due to novel treatments such as bone marrow transplantation, the use of "marginal donors" in kidney transplantation, the introduction of supportive treatments for terminal liver failure, and an increasing use of immune-absorption and plasmapheresis in general, to cite just a few examples. To discuss the progress achieved, our university again arranged an international symposium, Intensive Care Nephrology, which was held in May 2000 in Dresden, Germany (the first symposium was in May 1997 (1). A unique aspect of both symposia was that they provided an opportunity for nephrologists to have direct discussions with intensivists. It is a privilege that the Journal of the American Society of Nephrology agreed to document the proceedings of the recent symposium in the form of condensed reports as published here.

The first section of the symposium dealt with new aspects of electrolyte abnormalities. In his discussion entitled "Hypercalcemic Crisis," L. Ziegler (Heidelberg, Germany) emphasized the life-threatening nature of hypercalcemic crisis. Most cases of hypercalcemic crisis eventually are attributable to primary hyperparathyroidism. Potent biphosphonates are highly effective in lowering the serum calcium concentration in most circumstances. However, physicians are well advised to act fast in hypercalcemic crisis. The subject of severe hyponatremia was considered by P. Gross et al. (Dresden, Germany). According to their reasoning, acute severe symptomatic hyponatremia often is a sign of cerebral edema and requires rapid correction. Conversely, chronic oligosymptomatic severe hyponatremia may be corrected slowly. In severe hyponatremia of unknown duration, the authors recommended obtaining imaging studies of the brain to guide the corrective therapy. In the near future, clinically available V₂ and V _1/2 competitive vasopressin receptor antagonists—now in clinical testing—will help to make the treatment of hyponatremia easier, more specific, and more predictable. F. Luft (Berlin, Germany) gave an update on lactic acidosis. He addressed several issues; the risk for lactic acidosis caused by metformin is considerably less than with phenformin. He was critical of using NaHCO₃, carbicarb, and dichloroacetate in the treatment of lactic acidosis. He indicated that treating effectively the underlying disorder perhaps combined with using hemofiltration was a reasonable approach.

Another section of the symposium concentrated on acute renal failure and its treatments. N. Lameire and R. Vanholder (Gent, Belgium) discussed current concepts of acute tubular necrosis. Their almost encyclopedic listing of contributory mechanisms was in stark contrast to the paucity of proven therapeutic interventions. In fact, even nowadays therapy is largely supportive. Nonetheless, they proposed to use in the future experimental models that reflect the multifactorial causes of clinical acute renal failure. M. J. R. Ragaller et al. (Dresden, Germany) discussed volume replacement in critically ill patients. Although crystalloid solutions are considered the best immediate treatment to correct deficits, colloidal solutions are required in circumstances of more severe volume loss. Ragaller et al. presented reasons that synthetic colloids such as hydroxyethyl-starch seem to be advantageous in comparison with other colloids, including albumin. R. Vanholder et al. (Gent, Belgium) discussed the renal replacement method of choice in the intensive care patient. The authors made a case for the use of slow low efficient daily dialysis, a new method.

Severe renal parenchymal disorders were another focus of the symposium. A. Schwarz (Hannover, Germany) focused on new aspects in the treatment of nephrotic syndrome. She was able to extract from the literature a number of interesting suggestions on the use of novel immunosuppressive agents, other modalities, and immunoabsorption. H. A. Bock (Aarau, Switzerland) considered the issue of steroid-resistant kidney transplant rejection. He stressed that rejection should always be diagnosed by biopsy. He favored an increase of the patient's basic immunosuppressive treatment after an episode of rejection. There are now a number of maneuvers that can be used in the circumstance of steroid-resistant rejection, permitting an individualized approach in such patients. Not surprising, sepsis was a big issue of the symposium. T. Koch et al. (Dresden, Germany) considered suggestions for monitoring organ dysfunction in sepsis. She discussed the use of novel strategies such as measurements of microcirculatory disturbances. However, she was unable to say whether such suggestions would improve eventual outcome. F. Stüber (Bonn, Germany) indicated that genetically determined molecular mechanisms may determine the outcome of sepsis in individual cases. Thus, homozygotes for the allele TNF-2 and carriers of homozygosity for the allele A2 of the IL-1 receptor antagonist may have a poor outcome of sepsis, whereas the toll-like receptor IV gene and gene product may confer some protection from a poor outcome in sepsis. A. Meier-Hellmann et al. (Jena, Germany) indicated that early enteral nutrition is a preventive strategy in sepsis. J. Briegel et al. (Munich, Germany) provided new evidence that "stress doses" of hydrocortisone may be a valuable immunomodulatory therapy for septic shock. Their data demonstrate differential regulation by hydrocortisone of IL-IV and IL-VIII as opposed to IL-VI, IL-X, and TNF.

S. R. Mitzner et al. (Rostock, Germany) have worked with extracorporeal detoxification using dialysis against albumin with the MARS system in critically ill patients with liver failure. They present a review of observations in more than 200 treated patients. Treatment resulted in decreased encephalopathy, increased mean arterial BP, and improvement of liver function. A randomized trial of patients with hepatorenal syndrome indicated prolongation of survival with MARS treatment. Finally, R. Fretschner et al. (Tübingen, Germany) considered the use of systems for patient data management in critical care.

It is hoped that the documentation of the Symposium on Intensive Care Nephrology contained in this supplement of the Journal of the American Society of Nephrology provides useful information and stimulation to nephrologists elsewhere who are faced with similar problems to those discussed here.

References

1. Kidney Int 53[Suppl 64]: S1-S90, 1997

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