As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.

Extracorporeal membrane oxygenation (ECMO) is an established therapy in the management of patients with refractory cardiogenic shock or acute respiratory failure.In this report, we describe the rapid development and implementation of an organized ECMO program at a facility that previously provided ad hoc support. The program provides care for patients within the Emory Healthcare system and throughout the Southeastern United States.From September 2014 to February 2015, 16 patients were treated with either venovenous or venoarterial ECMO with a survival to decannulation of 53.3% and survival to ICU discharge of 40%. 10/16 patients were transfers from outside facilities of which 2 were remotely cannulated and initiated on ECMO support by our ECMO transport team. Complications included intracerebral hemorrhage, bleeding from other sites, and limb ischemia.The results suggest that a rapidly developed ECMO program can provide safe transport services and provide outcomes similar to those in the existing literature. Key components appear to be institutional commitment, a physician champion, multidisciplinary leadership, and organized training. Further study is required to determine if outcomes will continue to improve.

Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional ‘surges’ in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.

Objective: This report describes three patients with Ebola virus disease who were treated in the United States and developed for severe critical illness and multiple organ failure secondary to Ebola virus infection. The patients received mechanical ventilation, renal replacement therapy, invasive monitoring, vasopressor support, and investigational therapies for Ebola virus disease. Data Sources: Patient medical records from three tertiary care centers (Emory University Hospital, University of Nebraska Medical Center, and Texas Health Presbyterian Dallas Hospital). Study Selection: Not applicable. Data Extraction: Not applicable. Data Synthesis: Not applicable. Conclusion: In the severe form, patients with Ebola virus disease may require life-sustaining therapy, including mechanical ventilation and renal replacement therapy. In conjunction with other reported cases, this series suggests that respiratory and renal failure may occur in severe Ebola virus disease, especially in patients burdened with high viral loads. Ebola virus disease complicated by multiple organ failure can be survivable with the application of advanced life support measures. This collective, multicenter experience is presented with the hope that it may inform future treatment of patients with Ebola virus disease requiring critical care treatment.

Refractory ascites is a common cause of hospitalization in patients with cirrhosis and is associated with high morbidity and mortality.1,2 Therapeutic paracentesis is routinely used to manage refractory ascites. However, in patients hospitalized with decompensated liver disease, therapeutic paracentesis is often delayed, inadequately performed, or avoided altogether due to concern about precipitating acute kidney injury (AKI) from fluid shifts and altered hemodynamics.3 This practice could have negative effects on symptom burden and quality of life.2 Few studies have rigorously examined the incidence and risk factors for AKI following paracentesis among inpatients with cirrhosis. We evaluated the effect of paracentesis on kidney function in a large cohort of patients admitted at an academic liver transplant medical center.

The devastating and rapidly spreading coronavirus disease 2019 (COVID-19) pandemic has challenged the health care system worldwide. COVID-19 primarily affects the lungs and is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); however, multiple other organ systems also may be affected, including kidneys, blood (hypercoagulability), brain, and heart. The incidence of acute kidney injury secondary to COVID-19 is estimated at approximately 15% to 25%,1, 2 and requirement of kidney replacement therapy (KRT) has been variably reported, with many large centers describing an incidence of up to 30% in critically ill patients.3, 4 Further, emerging observations have described 2 phenotypes of COVID-19 pneumonia that may require a more individualized approach of KRT.5 One phenotype has higher lung compliance, ventilation perfusion mismatch, and low lung recruitability (type-L), whereas the other has lower lung compliance, higher right to left shunt, and higher lung recruitability, mimicking acute respiratory distress syndrome (type-H). Therefore, it is possible that patients with type-L are more susceptible to hypovolemia due to dysregulation in pulmonary perfusion, whereas patients with type-H may benefit from timely KRT for fluid management if severe acute kidney injury develops and there is lack of response to diuretics. In this perspectives piece, we complement prior contingency planning recommendations by Burgner et al.,6 with some specific considerations for KRT preparedness in the intensive care unit (ICU) under a model including vulnerability assessment, crisis planning, and crisis challenges.

Objective: We present a case of acute intermittent porphyria with accompanying euvolemic hyponatremia from elevated ADH triggered by an implanted hormonal contraceptive device. Case description: A 19-year-old African-American female with history of childbirth two months prior presented to the emergency department of Grady Memorial Hospital with vague but severe back pain and found with marked hyponatremia of 125mEq/L. Serum sodium level decreased to 113mEq/L after volume resuscitation with 0.9% sodium chloride. The patient experienced progressive decline in mental status and a single generalized tonic clonic seizure. Patient was admitted to intensive care unit and improved with administration of 3% sodium chloride. Extensive evaluation for etiology of euvolemic hyponatremia was initially unremarkable, and patient was managed with free water restriction, hypertonic sodium chloride, vasopressin receptor antagonists, and antihypertensive medications. Empiric removal of a recently inserted etonogestrel implant was performed with resolution of patient’s symptoms. Approximately 2 weeks following hospital discharge, the send-out lab for urine porphobilinogen was found to be notably elevated. Conclusion: We stress the importance of considering the diagnosis of AIP in patients presenting with back or abdominal pain, hyponatremia and altered mental status who are reproductive age females and using implanted hormonal contraceptive devices. Appropriate supportive treatment and removal of the implant is required to prevent morbidity and life-threatening consequences.

Background Recent data suggests an association between blood hyperviscosity and both propensity for thrombosis and disease severity in patients with COVID‐19. This raises the possibility that increased viscosity may contribute to endothelial damage and multiorgan failure in COVID‐19, and that therapeutic plasma exchange (TPE) to decrease viscosity may improve patient outcomes. Here we sought to share our experience using TPE in the first 6 patients treated for COVID‐19‐associated hyperviscosity. Study Design and Methods Six critically ill COVID‐19 patients with plasma viscosity levels ranging from 2.6 to 4.2 centipoise (cP; normal range, 1.4‐1.8 cP) underwent daily TPE for 2‐3 treatments. Results TPE decreased plasma viscosity in all six patients (Pre‐TPE median 3.75 cP, range 2.6‐4.2 cP; Post‐TPE median 1.6 cP, range 1.5‐1.9 cP). TPE also decreased fibrinogen levels in all five patients for whom results were available (Pre‐TPE median 739 mg/dL, range 601‐1188 mg/dL; Post‐TPE median 359 mg/dL, range 235‐461 mg/dL); D‐dimer levels in all six patients (Pre‐TPE median 5921 ng/mL, range 1134‐60 000 ng/mL; Post‐TPE median 4893 ng/mL, range 620‐7518 ng/mL); and CRP levels in five of six patients (Pre‐TPE median 292 mg/L, range 136‐329 mg/L; Post‐TPE median 84 mg/L, range 31‐211 mg/L). While the two sickest patients died, significant improvement in clinical status was observed in four of six patients shortly after TPE. Conclusions This series demonstrates the utility of TPE to rapidly correct increased blood viscosity in patients with COVID‐19‐associated hyperviscosity. Large randomized trials are needed to determine whether TPE may improve clinical outcomes for patients with COVID‐19.

In the version of this article that was originally published online, the text in the red boxes (crisis stage) of Figure 3 was a duplication of the text in the yellow boxes (response stage). This error has been corrected in the HTML and PDF versions of the manuscript.