To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.

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KDIGO clinical practice guidelines for acute kidney injury.

To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012”. A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

https://link.springer.com/content/pdf/10.1007%2Fs00134-017-4683-6.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Statistical Analysis with Missing Data

Objective:To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012.”Design:A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

Patients with CKD and ESRD are vulnerable to increased mortality rates and other poor outcomes. Among those with ESRD, their health-related quality of life (HRQOL) is shown little to no improvement as they undergo treatments such as dialysis and providers concurrently manage other health issues that complicate their already vulnerable state. This review synthesizes evidence demonstrating that a focus on measuring and monitoring patient-reported outcomes (PRO) such as pain and depression can improve HRQOL. Patient-centered care has the potential to create an efficient way for clinicians to address specific challenges facing patients. While there is an emerging literature assessing the use of PROs in kidney research, by examining relevant research in other disciplines it is possible to generate better ways to use PROs in this high-risk population. Electronic health records as well as various other electronic methods of communication between the clinician and patient may serve to accelerate the trajectory toward patient-centered care using PROs.

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Using Patient-Reported Measures to Improve Outcomes in Kidney Disease.

exercise program in hemodialysis patients: a randomized controlled study. Complement Ther Med 15(3):164–171, 2007 59. Portenoy RK: Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage 11(4):203–217, 1996 60. Allan L, Hays H, Jensen NH, de Waroux BL, Bolt M, Donald R, Kalso E: Randomised crossover trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain. BMJ 322(7295):1154–1158, 2001 61. Brunet P, Saingra Y, Leonetti F, Vacher-Coponat H, Ramananarivo P, Berland Y: Tolerance of haemodialysis: a randomized cross-over trial of 5-h versus 4-h treatment time. Nephrol Dial Transplant 11(Suppl 8):46–51, 1996 62. Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, Haythornthwaite JA, Jensen MP, Kerns RD, Ader DN, Brandenburg N, Burke LB, Cella D, Chandler J, Cowan P, Dimitrova R, Dionne R, Hertz S, Jadad AR, Katz NP, Kehlet H, Kramer LD, Manning DC, McCormick C, McDermott MP, McQuay HJ, Patel S, Porter L, Quessy S, Rappaport BA, Rauschkolb C, Revicki DA, Rothman M, Schmader KE, Stacey BR, Stauffer JW, von Stein T, White RE, Witter J, Zavisic S: Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 9(2):105–121, 2008 63. Alon US, Allen S, Rameriz Z, Warady BA, Kaplan RA, Harris DJ: Lidocaine for the alleviation of pain associated with subcutaneous erythropoietin injection. J Am Soc Nephrol 5(4):1161–1162, 1994 64. Morris KP, Hughes C, Hardy SP, Matthews JN, Coulthard MG: Pain after subcutaneous injection of recombinant human erythropoietin: does emla cream help? Nephrol Dial Transplant 9(9):1299–1301, 1994 65. Turkmen M, Kavukcu S, Soylu A, Ay N, Sevinc N, Sersan R: Topical anaesthesia in haemodialysis: evaluation of topical anaesthesia with lidocaine during vascular access in children undergoing long-term haemodialysis for chronic renal failure. Int J Nurs Pract 3(2):79–83, 1997 66. Alhani F: The effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis. Pain Manag Nurs 11(2):85–91, 2010 67. Celik G, Ozbek O, Yilmaz M, Duman I, Ozbek S, Apiliogullari S: Vapocoolant spray vs lidocaine ⁄ prilocaine cream for reducing the pain of venipuncture in hemodialysis patients: a randomized, placebo-controlled, crossover study. Int J Med Sci 8(7):623–627, 2011 68. Canzanello VJ, Hylander-Rossner B, Sands RE, Morgan TM, Jordan J, Burkart JM: Comparison of 50% dextrose water, 25% mannitol, and 23.5% saline for the treatment of hemodialysis-associated muscle cramps. ASAIO Trans 37(4):649–652, 1991 69. Roca AO, Jarjoura D, Blend D, Cugino A, Rutecki GW, Nuchikat PS, Whittier FC: Dialysis leg cramps. efficacy of quinine versus vitamin E. ASAIO J 38(3):M481–M485, 1992 70. Che-Yi C, Wen CY, Min-Tsung K, Chiu-Ching H: Acupuncture in haemodialysis patients at the quchi (LI11) acupoint for refractory uraemic pruritus. Nephrol Dial Transplant 20(9):1912–1915, 2005 71. Gunal AI, Ozalp G, Yoldas TK, Gunal SY, Kirciman E, Celiker H: Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial. Nephrol Dial Transplant 19(12):3137–3139, 2004 72. Ashmore SD, Jones CH, Newstead CG, Daly MJ, Chrystyn H: Ondansetron therapy for uremic pruritus in hemodialysis patients. Am J Kidney Dis 35(5):827–831, 2000 73. Breneman DL, Cardone JS, Blumsack RF, Lather RM, Searle EA, Pollack VE: Topical capsaicin for treatment of hemodialysis-related pruritus. J Am Acad Dermatol 26(1):91–94, 1992 74. Tarng DC, Cho YL, Liu HN, Huang TP: Hemodialysis-related pruritus: a double-blind, placebo-controlled, crossover study of capsaicin 0.025% cream. Nephron 72(4):617–622, 1996 75. Tranaeus A: A long-term study of a bicarbonate ⁄ lactate-based peritoneal dialysis solution–clinical benefits. the Bicarbonate ⁄ Lactate study group. Perit Dial Int 20(5):516–523, 2000 76. Fusshoeller A, Plail M, Grabensee B, Plum J: Biocompatibility pattern of a bicarbonate ⁄ lactate-buffered peritoneal dialysis fluid in APD: a prospective, randomized study. Nephrol Dial Transplant 19(8):2101– 2106, 2004 77. Holtta T, Ronnholm K, Holmberg C: Adequacy of dialysis with tidal and continuous cycling peritoneal dialysis in children. Nephrol Dial Transplant 15(9):1438–1442, 2000 78. Sadowski RH, Allred EN, Jabs K: Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol 4(5):1192–1198, 1993 79. Tang HL, Wong SH, Chu KH, Lee W, Cheuk A, Tang CM, Kong IL, Fung KS, Tsang WK, Chan HW, Tong KL: Sodium ramping reduces hypotension and symptoms during haemodialysis. Hong Kong Med J 12(1):10–14, 2006 80. Gerrish M, Little J: The effect of profiling dialysate sodium and ultrafiltration on patient comfort and cardiovascular stability during haemodialysis. EDTNA ERCA J 29(2):61, 65,6, 68-70 passim. 2003 81. Altieri P, Sorba GB, Bolasco PG, Bostrom M, Asproni E, Ferrara R, Bolasco F, Cossu M, Cadinu F, Cabiddu GF, Casu D, Ganadu M, Passaghe M, Pinna M: On-line predilution hemofiltration versus ultrapure high-flux hemodialysis: a multicenter prospective study in 23 patients. sardinian collaborative study group of on-line hemofiltration. Blood Purif 15(3):169–181, 1997 82. Levin NW, Zasuwa G: Relationship between dialyser type and signs and symptoms. Nephrol Dial Transplant 8(Suppl 2):30–39, 1993 83. Singh NP, Bansal R, Thakur A, Kohli R, Bansal RC, Agarwal SK: Effect of membrane composition on cytokine production and clinical symptoms during hemodialysis: a crossover study. Ren Fail 25(3):419– 430, 2003 84. Leski M, Niethammer T, Wyss T: Glucose-enriched dialysate and tolerance to maintenance hemodialysis. Nephron 24(6):271–273, 1979

Recognition and treatment of obstructive sleep apnea.

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Electronic health records implementation: can the European Union learn from the United States?

The prevalence rate of sleep apnea in the hemodialysis (HD) patient population is >50% [1, 2] as compared to only 2–4% in the general population [3]. Not only does sleep apnea contribute to hypertension (HTN) and increased cardiovascular morbidity and mortality in the end-stage renal disease (ESRD) population, but it also significantly impairs their quality of life. However, large gaps in knowledge exist in our understanding of the potential mechanisms for increased sleep apnea in this vulnerable population. Traditional risk factors such as age and body mass index (BMI) do not fully account for the significant increased risk of sleep apnea in these patients [4]. As HTN and fluid overload occur almost universally in HD patients, it is possible that fluid retention may increase the risk of developing obstructive sleep apnea (OSA). If, indeed, fluid overload contributes to sleep apnea and poor sleep efficiency in HD patients, then the treatment of sleep apnea among those with ESRD could be targeted to improving volume control rather than using continuous positive airway pressure (CPAP) or an oral device, which many patients are unable to tolerate or comply with. In this issue of Nephrology Dialysis Transplantation, Elias et al. [5] addresses this important issue in their study evaluating the relationship of rostral fluid shift with OSA 1291

Volume overload as a mechanism for obstructive sleep apnea in CKD

OBJECTIVE: Describe the prevalence of hypertension. DESIGN: Population based cross-sectional survey. SETTING: Six Nicaraguan communities with varying economies. PARTICIPANTS: 1,355 adults aged 20-60 years who completed both self-reported and quantitative measures of health. MAIN OUTCOME MEASURES: Prevalence of hypertension (systolic > or = 140 mm Hg, diastolic > or = 90 mm Hg, or self-reported medical history with diagnosis by a health care professional), uncontrolled hypertension (systolic > or = 140 mm Hg or diastolic > or = 90 mm Hg), diabetes (urinary glucose excretion > or = 100 mg/ dL or self-reported medical history diagnosed by a health care professional), and uncontrolled diabetes (urinary glucose excretion > or =100 mg/dL only). RESULTS: The prevalence of hypertension was 22.0% (19.2% in men, 24.2% in women). Blood pressure was controlled in 31.0% of male hypertensives and 55.1% of female hypertensives (odds ratio [OR] 2.86; 95% confidence interval [Cl] 1.74-4.69). Older age and higher body mass index were strongly associated with hypertension. Women who completed primary school had a lower risk of hypertension (OR .40; 95% Cl .19-.85) compared to those with no formal education. A history of living in both urban and rural settings was associated with lower prevalence of hypertension (OR .52; 95% CI .34-.79). Diabetes mellitus was found in 1.2% of men and 4.3% of women. Male sex was independently associated with decreased risk of diabetes (OR .31; 95% Cl .11-.86). CONCLUSIONS: At least one cardiovascular risk factor was found in half of this Nicaraguan sample. Cardiovascular risk factors should be the target of educational efforts, screening, and treatment. Ethn Dis . 2012 Spring;22(2):129-35.

Mark Unruh

Papers

Using Patient-Reported Measures to Improve Outcomes in Kidney Disease.

Recognition and treatment of obstructive sleep apnea.

Electronic health records implementation: can the European Union learn from the United States?

Volume overload as a mechanism for obstructive sleep apnea in CKD

Prevalence of hypertension and associated risk factors in six Nicaraguan communities.