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Critical Care Medicine Aug 2023Optimal timing of renal replacement therapy (RRT) initiation in severe acute kidney injury (AKI) remains controversial. Initiation of treatment early in the course of... (Observational Study)
Observational Study
Predicting the Development of Renal Replacement Therapy Indications by Combining the Furosemide Stress Test and Chemokine (C-C Motif) Ligand 14 in a Cohort of Postsurgical Patients.
OBJECTIVES
Optimal timing of renal replacement therapy (RRT) initiation in severe acute kidney injury (AKI) remains controversial. Initiation of treatment early in the course of AKI may lead to some patients undergoing unnecessary RRT, whereas delayed treatment is associated with increased mortality. This study aims to investigate whether the combination of the furosemide stress test (FST) and AKI-associated biomarkers can predict the development of indications for RRT.
DESIGN
Single-center, prospective, observational study.
SETTING
University Hospital of Muenster, Germany.
PATIENTS
Critically ill, postoperative patients with moderate AKI (Kidney Disease: Improving Global Outcomes stage 2) and risk factors for further progression (vasopressors and/or mechanical ventilation) receiving an FST.
INTERVENTIONS
Sample collection and measurement of different biomarkers (chemokine [C-C motif] ligand 14 [CCL14], neutrophil gelatinase-associated lipocalin, dipeptidyl peptidase 3).
MEASUREMENT AND MAIN RESULTS
The primary endpoint was the development of greater than or equal to one predefined RRT indications (hyperkalemia [≥ 6 mmol/L], diuretic-resistant hypervolemia, high urea serum levels [≥ 150 mg/dL], severe metabolic acidosis [pH ≤ 7.15], oliguria [urinary output < 200 mL/12 hr], or anuria). Two hundred eight patients were available for the primary analysis with 108 having a negative FST (urine output < 200 mL in 2 hr following FST). Ninety-eight patients (47%) met the primary endpoint, 82% in the FST negative cohort. At the time of inclusion, the combination of a negative FST test and high urinary CCL14 levels had a significantly higher predictive value for the primary endpoint with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI, 0.82-0.92) compared with FST or CCL14 alone (AUC, 0.79; 95% CI, 0.74-0.85 and AUC, 0.83; 95% CI, 0.77-0.89; p < 0.001, respectively). Other biomarkers showed lower AUCs.
CONCLUSIONS
The combination of the FST with the renal biomarker CCL14 predicts the development of indications for RRT.
Topics: Humans; Furosemide; Prospective Studies; Exercise Test; Ligands; Renal Replacement Therapy; Lipocalin-2; Biomarkers; Acute Kidney Injury; Chemokines
PubMed: 36988335
DOI: 10.1097/CCM.0000000000005849 -
Canadian Journal of Kidney Health and... 2022Nondilated obstructive uropathy (NDOU) is a rare cause of acute renal failure reported in less than 5% of cases of obstructive uropathy. It is typically associated with...
RATIONALE
Nondilated obstructive uropathy (NDOU) is a rare cause of acute renal failure reported in less than 5% of cases of obstructive uropathy. It is typically associated with intrapelvic malignancies and diseases causing retroperitoneal lymphadenopathy and retroperitoneal fibrosis. As these conditions may prevent radiographic dilation of the collecting system, the diagnosis of NDOU may be missed by usual diagnostic testing.
PRESENTING CONCERNS OF THE PATIENT
We present a case of acute anuric renal failure in a middle-aged woman with metastatic breast cancer associated with abdominal and retroperitoneal lymphadenopathy. Acute kidney injury was initially deemed secondary to drug-induced acute tubular necrosis (ATN) from bisphosphonate; however, there remained a high clinical suspicion of NDOU due to the presence of enlarged retroperitoneal lymph nodes on CT abdomen and pelvis with concerns for encasement of bilateral renal pelvic regions and ureters.
DIAGNOSES
The patient underwent a retrograde pyelogram which demonstrated questionable narrowing bilaterally at the level of the renal pelvices. This led to an even stronger clinical suspicion of NDOU and urology service was consulted for evaluation.
INTERVENTION
Bilateral ureteral stents were placed by urology which led to robust urine output and rapid reversal of renal failure over the next 24 to 48 hours.
OUTCOMES
Despite 2 weeks of anuria and hemodialysis, this patient's creatinine came back to her baseline. She was able to discontinue hemodialysis and her creatinine stabilized at 88.4 μmol/L (1 mg/dL).
TEACHING POINTS
Nondilated obstructive uropathy is rare but important diagnosis that requires a high clinical suspicion in the appropriate clinical scenario. The lack of dilatation is believed to be related to encasement of the collecting system by tumor, fibrosis, or as in our case metastatic retroperitoneal lymphadenopathy. As this diagnosis cannot be overlooked, aggressive direct visualization or even intervention with internal or external stenting may be required to both diagnose and treat this condition.
PubMed: 35356536
DOI: 10.1177/20543581221086683 -
Cureus Apr 2024When acute kidney damage occurs during pregnancy, it poses a difficult clinical problem. One of the main causes of maternal and fetal morbidity and death is...
INTRODUCTION
When acute kidney damage occurs during pregnancy, it poses a difficult clinical problem. One of the main causes of maternal and fetal morbidity and death is pregnancy-related acute kidney injury (AKI), a significant obstetric complication characterized by a fast deterioration in renal function and several subsequent clinical problems. The objective of the study is to analyze the etiological factors, clinical manifestations, and maternal and fetal outcomes of AKI during pregnancy.
MATERIALS AND METHODS
This prospective observational research involved patients hospitalized in the General Medicine and Obstetrics and Gynecology departments at Indira Gandhi Institute of Medical Sciences, Patna, for a year (October 2021 to September 2022) due to obstetric difficulties resulting in acute renal damage.
RESULTS
The study included 62 patients with a mean age of 25.08±4.25 years. The majority of patients in our study were aged 18-25 years (38, 61.3%), followed by 26-30 years (19, 30.6%) and >30 years (5, 8.1%). The majority of patients in our study were non-booked (52, 83.9%) and presented as emergency cases, whereas 10 (16.1%) patients had booked. In addition, 34 (54.8%) patients were primigravida, while 28 (45.1%) were multigravida. There were 25 patients in their third trimester (40.3%), 19 who were postpartum (30.6%), 10 who were post-abortion (16.1%), and eight in their second trimester (12.9%). Upon admission, the majority of the patients showed signs of oliguria, accounting for 45 cases (72.6%). This was followed by nine cases of abnormal kidney function (14.5%) and eight cases of anuria (12.9%). Among the other symptoms, fever was observed in 25 cases (40.32%), whereas breathlessness increased to 15 cases (24.19%), edema was present in 14 cases (22.58%), vomiting and altered sensorium were observed in four cases (6.45%), abdominal pain was observed in three cases (4.83%), and burning micturition was observed in two cases (3.22%). The most common causes of AKI in pregnancy in the present study were puerperal sepsis (18 cases, 29.0%), followed by preeclampsia/eclampsia (14 cases, 22.6%), hemorrhagic shock (10 cases, 16.1%), septic abortion (six cases, 9.7%), hyperemesis gravidarum (four cases, 6.5%), acute fatty liver of pregnancy (three cases, 4.8%), disseminated intravascular coagulation (three cases, 4.8%), drug-induced sepsis (two cases, 3.2%), and urosepsis (two cases, 3.2%). Modes of delivery in this study were normal vaginal delivery (32 cases, 51.6%), lower segment cesarean section (21 cases, 33.9%), dilation and evacuation (seven cases, 11.3%), and total hysterectomy (two cases, 3.2%). Hemodialysis was performed in 39 patients (62.9%), and 51 (82.3%) received blood transfusions. The mean systolic and diastolic BP (mmHg) were 111.37±22.60 and 71.40±18.88, respectively. Maternal outcome data revealed that 48 (77.4%) women had fully recovered, eight (12.9%) had not recovered, 43 (69.4%) were lost to follow-up, and two (3.2%) had died. Neonatal outcomes in the present study were as follows: live birth, 43 (69.4%); abortion, eight (12.9%); intrauterine death of the fetus, five (8.1%); and neonatal mortality, six (9.7%).
CONCLUSION
The diagnosis and treatment of AKI during pregnancy is a significant challenge for the treating physician because of the pathophysiological changes that occur during pregnancy, the variability of symptoms, and the fact that clinical and laboratory features may occasionally overlap.
PubMed: 38800254
DOI: 10.7759/cureus.58982 -
Critical Care (London, England) Dec 2019Recent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial... (Observational Study)
Observational Study
BACKGROUND
Recent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial extrapancreatic infection. Limited data are available concerning empirical and documented AIT prescribing practices in patients admitted to the intensive care unit (ICU) for the management of AP.
METHODS
Using a multicentre, retrospective (2009-2014), observational database of ICU patients admitted for AP, our primary objective was to assess the incidence of AIT prescribing practices during the first 30 days following admission. Secondary objectives were to assess the independent impact of centre characteristics on the incidence of AIT and to identify factors associated with crude hospital mortality in a logistic regression model.
RESULTS
In this cohort of 860 patients, 359 (42%) received AIT on admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free patients on admission received additional AIT, mainly for intra-abdominal and lung infections. A large heterogeneity was observed between centres in terms of the incidence of infections, therapeutic management including AIT and prognosis. Administration of AIT on admission or until day 30 was not associated with an increased mortality rate. Patients receiving AIT on admission had increased rates of complications (septic shock, intra-abdominal and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic) interventions and increased length of ICU stay compared to AIT-free patients. Patients receiving delayed AIT after admission and until day 30 had increased rates of complications (respiratory distress syndrome, intra-abdominal and pulmonary infections), therapeutic interventions and increased length of ICU stay compared to those receiving AIT on admission. Risk factors for hospital mortality assessed on admission were age (adjusted odds ratio [95% confidence interval] 1.03 [1.02-1.05]; p < 0.0001), Balthazar score E (2.26 [1.43-3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82-4.33]; p < 0.0001), vasoactive support (2.83 [1.73-4.62]; p < 0.0001) and mechanical ventilation (1.90 [1.15-3.14]; p = 0.011), but not AIT (0.63 [0.40-1.01]; p = 0.057).
CONCLUSIONS
High proportions of ICU patients admitted for AP receive AIT, both on admission and during their ICU stay. A large heterogeneity was observed between centres in terms of incidence of infections, AIT prescribing practices, therapeutic management and outcome. AIT reflects the initial severity and complications of AP, but is not a risk factor for death.
Topics: Adult; Aged; Anti-Bacterial Agents; Carbapenems; Chi-Square Distribution; Cohort Studies; Female; Hospitalization; Humans; Incidence; Intensive Care Units; Length of Stay; Logistic Models; Male; Middle Aged; Pancreatitis; Prognosis; Retrospective Studies
PubMed: 31805988
DOI: 10.1186/s13054-019-2681-5 -
Trials Dec 2019The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in...
BACKGROUND
The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in critically ill patients was safe and associated with major reduction in RRT initiation compared with an early strategy. The five criteria which mandated RRT initiation in the delayed arm were: severe hyperkalemia, severe acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia, serum urea concentration > 40 mmol/l and oliguria/anuria > 72 h. However, duration of anuria/oliguria and level of blood urea are still criteria open to debate. The objective of the study is to compare the delayed strategy used in AKIKI (now termed "standard") with another in which RRT is further delayed for a longer period (termed "delayed strategy").
METHODS/DESIGN
This is a prospective, multicenter, open-label, two-arm randomized trial. The study is composed of two stages (observational and randomization stages). At any time, the occurrence of a potentially severe condition (severe hyperkalemia, severe metabolic or mixed acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia) suggests immediate RRT initiation. Patients receiving (or who have received) intravenously administered catecholamines and/or invasive mechanical ventilation and presenting with AKI stage 3 of the KDIGO classification and with no potentially severe condition are included in the observational stage. Patients presenting a serum urea concentration > 40 mmol/l and/or an oliguria/anuria for more than 72 h are randomly allocated to a standard (RRT is initiated within 12 h) or a delayed RRT strategy (RRT is initiated only if an above-mentioned potentially severe condition occurs or if the serum urea concentration reaches 50 mmol/l). The primary outcome will be the number of RRT-free days at day 28. One interim analysis is planned. It is expected to include 810 patients in the observational stage and to randomize 270 subjects.
DISCUSSION
The AKIKI2 study should improve the knowledge of RRT initiation criteria in critically ill patients. The potential reduction in RRT use allowed by a delayed RRT strategy might be associated with less invasive care and decreased costs. Enrollment is ongoing. Inclusions are expected to be completed by November 2019.
TRIAL REGISTRATION
ClinicalTrials.gov, ID: NCT03396757. Registered on 11 January 2018.
Topics: Acute Kidney Injury; France; Humans; Kidney; Kidneys, Artificial; Multicenter Studies as Topic; Prospective Studies; Randomized Controlled Trials as Topic; Recovery of Function; Renal Replacement Therapy; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 31843007
DOI: 10.1186/s13063-019-3774-9 -
Case Reports in Neurological Medicine 2022Myelin oligodendrocyte glycoprotein (MOG) antibody disease most commonly presents with optic neuritis, though myelitis is also possible. It is rare in the...
BACKGROUND
Myelin oligodendrocyte glycoprotein (MOG) antibody disease most commonly presents with optic neuritis, though myelitis is also possible. It is rare in the post-infectious and particularly post-COVID-19 setting. . We present the case of a 57-year-old man who tested positive for COVID-19 and experienced respiratory symptoms that completely resolved within one week. About 3 weeks after testing positive, he began experiencing acute onset anuria, followed by lower extremity paresthesia and paraparesis, which progressed to bilateral lower extremity paraplegia, complete loss of sensation of pain, temperature, vibration, and proprioception, and a T4 sensory level. He was initially diagnosed with and treated for acute inflammatory demyelinating polyradiculoneuropathy (AIDP), after which he made minimal clinical improvement. The diagnosis was shifted to longitudinally extensive transverse myelitis, and his CSF tested positive for MOG antibodies. He is being treated with a steroid regimen and extensive outpatient physical therapy.
CONCLUSION
The neurologic manifestations of COVID-19 are still being uncovered. Neurologic symptoms should be included in patient education on symptom monitoring, even after recovery of respiratory illness, so that COVID-19-related CNS pathology can be urgently treated.
PubMed: 35399911
DOI: 10.1155/2022/1068227 -
Journal of Cardiology Cases Jul 2022Cardiorenal syndrome is the term that describes the interaction between the heart and kidney that leads to diuretic resistance and worsening renal function. Prolonged...
Cardiorenal syndrome is the term that describes the interaction between the heart and kidney that leads to diuretic resistance and worsening renal function. Prolonged anuria generally represents irreversible renal failure, and recovery of renal function after prolonged anuria in patients with heart failure has rarely been reported. Moreover, increased central venous pressure including heart failure is associated with impaired renal function. We herein report a rare case of a 46-year-old man with dilated cardiomyopathy who presented with dyspnea and generalized edema. His body weight increased from 90 kg to 128 kg in one year and he was hospitalized. Central venous pressure (CVP) on admission was 33 mmHg. Intravenous catecholamines were not effective; thus, he was started on continuous hemodiafiltration. Anuria occurred after hemodiafiltration due to heart failure, sepsis, and antibiotics use. However, he experienced weight reduction of over 70 kg, under hemodialysis guided by central venous pressure measurement, and renal function recovery after 87 days of anuria. His CVP had improved to 5 mmHg at discharge. This case showed continuous trial to reduce the CVP and raise cardiac output could result in the recovery of impaired renal function even in the presence of prolonged anuria. < We report a rare case of a patient with dilated cardiomyopathy who experienced weight reduction of over 70 kg under hemodialysis guided by central venous pressure (CVP) measurement and renal function recovery after 87 days of anuria due to chronic heart failure. Even in the presence of prolonged anuria, continuous trial to reduce the CVP and raise cardiac output could result in the recovery of impaired renal function.>.
PubMed: 35923529
DOI: 10.1016/j.jccase.2022.01.013 -
Annals of Medicine and Surgery (2012) May 2023Delayed reaction following mass hornet envenomation is associated with various clinical manifestations.
UNLABELLED
Delayed reaction following mass hornet envenomation is associated with various clinical manifestations.
CASE PRESENTATION
The authors present a case of a 24-year-old male from eastern Nepal, who presented following mass envenomation by hornet stings. He had progressive yellowish discoloration of skin and sclera, myalgia, fever, and dizziness. He had passage of tea-coloured urine followed by anuria. Laboratory investigations suggested acute kidney injury, rhabdomyolysis, and acute liver injury. The authors managed the patient with supportive measures and haemodialysis. There was complete recovery of liver and renal function in the patient.
DISCUSSION
The findings in this patient were similar to other cases reported in the literature. These patients must be managed supportively, with few requiring renal replacement therapy. Most of these patients recover completely. In low-middle-income countries like Nepal, delay in seeking care and delay in reaching care is associated with severe clinical manifestations. Delayed presentation can lead to renal shutdown and mortality; hence, early intervention is simple, and, crucial.
CONCLUSION
This case highlights the occurrence of delayed reaction following mass envenomation by hornets. Also, the authors show an approach to managing such patients, similar to managing any other case with acute kidney injury. In these cases, an early simple intervention can prevent mortality. It is crucial to train healthcare workers regarding toxin induced acute kidney injury and the importance of early identification and intervention.
PubMed: 37228939
DOI: 10.1097/MS9.0000000000000453 -
Indian Journal of Nephrology 2020Renal failure occurring in the setting of cirrhosis increases mortality by more than threefold. Serum creatinine, the conventional marker for renal dysfunction has...
BACKGROUND AND AIMS
Renal failure occurring in the setting of cirrhosis increases mortality by more than threefold. Serum creatinine, the conventional marker for renal dysfunction has inherent limitations in identifying and categorizing renal dysfunction in patients with chronic liver disease (CLD). Neutrophil gelatinase associated lipocalin (NGAL) is a novel biomarker which gets upregulated as early as 2-6 hours following the insult to renal tubules. In this study, we aim to check the utility of uNGAL to identify the different phenotypes of renal dysfunction in patients with CLD. We also intend to assess the utility of NGAL to predict 90-day transplant-free survival in patients with CLD.
METHODS
A total number of 120 adult patients, with cirrhosis of liver were recruited. Those with pre-existing renal parenchymal disease, receiving nephrotoxic medications, spontaneous bacterial peritonitis, septic shock, proteinuria, hematuria, urinary tract infection and anuria were excluded. Urine samples for NGAL was measured at admission and at 48 hours thereafter. Patients were followed up for 90 days post admission.
RESULTS
Among the study population, 16 patients (13.3%) had normal kidney function, 43 (35.8%) had prerenal azotemia and 54 (45%) had Hepatorenal Syndrome (HRS - AKI) and 7 (5.8%) had acute tubular necrosis (ATN). Urinary NGAL (uNGAL) levels were considerably lower in patients with normal kidney function and prerenal azotemia. An uNGAL level of 124 ng/ml on admission could distinguish severe forms of renal injury, with a sensitivity of 86% and specificity of 84%. The non survivors had higher uNGAL levels at admission [209.6 ng/ml (118.7-376.8) vs. 123 (33.6-344.3); = 0.013].The receiver operated curves for uNGAL and serum creatinine at admission did not show any significant difference for predicting 90 day mortality (AUC for uNGAL: 0.632 vs 0.580 for serum creatinine; difference in AUC 0.053, value 0.17).
CONCLUSION
uNGAL levels are elevated in patients with HRS-AKI and ATN. A higher uNGAL level at admission was suggestive of severe renal dysfunction. An elevated uNGAL on admission is associated with inferior survival. However, uNGAL is not superior to serum creatinine in predicting 90-day mortality.
PubMed: 33840958
DOI: 10.4103/ijn.IJN_254_19 -
Annals of Medicine and Surgery (2012) Aug 2021Peganum harmala L. is a cosmopolitan plant within the Mediterranean region. It's normally employed in ancient drugs in Morocco as sedative and abortifacient however...
INTRODUCTION
Peganum harmala L. is a cosmopolitan plant within the Mediterranean region. It's normally employed in ancient drugs in Morocco as sedative and abortifacient however exposes users to the danger of dose and poisoning. The medical specialty active compounds of this plant embody variety of carboline and quinazoline alkaloids accountable of its pharmacological and medical effects.
CASE REPORT
We tend to report the case of a 20-year-old woman, intoxicated with the Peganum harmala L. On admission, she was shocked with agitation vomittiong and disturbances of consciousness. Laboratory tests showed anemia, thrombocytopenia, acute kidney disease, increase in transaminases and a positive plasma bHCG. Cerebral CT disclosed multiple areas of cerebral ischemia with subarachnoid hemorrhage, thoraco-abdominal-pelvic CT scan showed an enlarged uterus, the location of an interior hemorrhage while not physiological condition sac and inhalation pneumonia. Early treatment was given, she was intubated, ventilated artificially and sedated, symptomatic treatment was received. Hemodialysis was needed for her renal failure and anuria. She was extubated after six days and discharged from the hospital after one month and a half.
CONCLUSION
Doctors operating in areas where P. harmala is prescribed or used as an ancient medicine should recognize the signs and symptoms of its toxicity in order to treat and initiate prompt and adequate management. The prognosis is generally favorable, excessive use of high doses of P. Harmala L. can lead to fatal evolution.
PubMed: 34401132
DOI: 10.1016/j.amsu.2021.102649