The drama of the continuous increase in end-stage renal failure in patients with type II diabetes mellitus.

PubMed

Rychlík, I; Miltenberger-Miltenyi, G; Ritz, E

1998-01-01

Type II diabetes mellitus has become the leading cause of end-stage renal failure in many countries of Western Europe. In all European countries, even in those with a relatively low prevalence of diabetic nephropathy, the number of patients with type II diabetes mellitus admitted for renal replacement therapy has recently increased continuously. Survival and medical rehabilitation of patients with type II diabetes on renal replacement therapy is significantly worse than in non-diabetic patients. It is obvious that in order to stem the tide, intense efforts are necessary (i) to inform the medical community about the renal risk of type II diabetes and the striking effectiveness of preventive measures, (ii) to provide better care for diabetic patients, and (iii) to reduce the high prevalence of diabetes in the population by modification of the Western life style.

Development of an accurate fluid management system for a pediatric continuous renal replacement therapy device

PubMed Central

SANTHANAKRISHNAN, ARVIND; NESTLE, TRENT T.; MOORE, BRIAN L.; YOGANATHAN, AJIT P.; PADEN, MATTHEW L.

2013-01-01

Acute kidney injury is common in critically ill children and renal replacement therapies provide a life saving therapy to a subset of these children. However, there is no Food and Drug Administration approved device to provide pediatric continuous renal replacement therapy (CRRT). Consequently, clinicians adapt approved adult CRRT devices for use in children due to lack of safer alternatives. Complications occur using adult CRRT devices in children due to inaccurate fluid balance (FB) between the volumes of ultrafiltrate (UF) removed and replacement fluid (RF) delivered. We demonstrate the design and validation of a pediatric fluid management system for obtaining accurate instantaneous and cumulative FB. Fluid transport was achieved via multiple novel pulsatile diaphragm pumps. The conservation of volume principle leveraging the physical property of fluid incompressibility along with mechanical coupling via a crankshaft was used for FB. Accuracy testing was conducted in vitro for 8-hour long continuous operation of the coupled UF and RF pumps. The mean cumulative FB error was <1% across filtration flows from 300 mL/hour to 3000 mL/hour. This approach of FB control in a pediatric specific CRRT device would represent a significant accuracy improvement over currently used clinical implementations. PMID:23644618

Delay in onset of metabolic alkalosis during regional citrate anti-coagulation in continuous renal replacement therapy with calcium-free replacement solution.

PubMed

See, Kay Choong; Lee, Margaret; Mukhopadhyay, Amartya

2009-01-01

Regional citrate anti-coagulation for continuous renal replacement therapy chelates calcium to produce the anti- coagulation effect. We hypothesise that a calcium-free replacement solution will require less citrate and produce fewer metabolic side effects. Fifty patients, in a Medical Intensive Care Unit of a tertiary teaching hospital (25 in each group), received continuous venovenous hemofiltration using either calcium-containing or calcium-free replacement solutions. Both groups had no significant differences in filter life, metabolic alkalosis, hypernatremia, hypocalcemia, and hypercalcemia. However, patients using calcium-containing solution developed metabolic alkalosis earlier, compared to patients using calcium-free solution (mean 24.6 hours,CI 0.8-48.4 vs. 37.2 hours, CI 9.4-65, P = 0.020). When calcium-containing replacement solution was used, more citrate was required (mean 280 ml/h, CI 227.2-332.8 vs. 265 ml/h, CI 203.4-326.6, P = 0.069), but less calcium was infused (mean 21.2 ml/h, CI 1.2-21.2 vs 51.6 ml/h, CI 26.8-76.4, P < or = 0.0001).

Slow continuous renal replacement therapies: an update.

PubMed

Kes, P

2000-01-01

Continuous renal replacement therapies (CRRT) are now being used by nephrologists, intensivists, and anesthesiologists. The various CRRT modalities differ in the kind of vascular access, the application of diffusive or convective clearances (or a combination of both), and in the location where the replacement fluid enters the circuit. CRRTs have certainly made the management of critically ill patients with acute renal failure (ARF) combined with cardiovascular instability, severe fluid overload, hypercatabolism, cerebral edema, adult respiratory distress syndrome, lactic acidosis, sepsis or other inflammatory syndromes, crush syndrome, congestive heart failure, and cardiopulmonary bypass easier. Continuous therapies incorporate several advantages including improved hemodynamic stability, optimal fluid balance, gradual urea removal, elimination of septic mediators, and the possibility of unlimited parenteral nutrition. Major difficulties and unsolved problems of CRRT are the ongoing necessity of continuous anticoagulation, considerable loss of amino acids, vitamins, trace elements, potassium, phosphate, and some drugs, as well as immobilization of the patient. The advantages of CRRT should theoretically translate into improved outcomes of critically ill ARF patients, but the superiority of continuous modalities in terms of outcome is still controversial, despite encouraging results in some clinical trials. Currently used CRRT with sophisticated treatment devices has become more expensive than hemodialysis, but the cost cannot be used as an argument against the continuous treatment modalities.

Understanding cost of care for patients on renal replacement therapy: looking beyond fixed tariffs.

PubMed

Li, Bernadette; Cairns, John A; Fotheringham, James; Tomson, Charles R; Forsythe, John L; Watson, Christopher; Metcalfe, Wendy; Fogarty, Damian G; Draper, Heather; Oniscu, Gabriel C; Dudley, Christopher; Johnson, Rachel J; Roderick, Paul; Leydon, Geraldine; Bradley, J Andrew; Ravanan, Rommel

2015-10-01

In a number of countries, reimbursement to hospitals providing renal dialysis services is set according to a fixed tariff. While the cost of maintenance dialysis and transplant surgery are amenable to a system of fixed tariffs, patients with established renal failure commonly present with comorbid conditions that can lead to variations in the need for hospitalization beyond the provision of renal replacement therapy. Patient-level cost data for incident renal replacement therapy patients in England were obtained as a result of linkage of the Hospital Episodes Statistics dataset to UK Renal Registry data. Regression models were developed to explore variations in hospital costs in relation to treatment modality, number of years on treatment and factors such as age and comorbidities. The final models were then used to predict annual costs for patients with different sets of characteristics. Excluding the cost of renal replacement therapy itself, inpatient costs generally decreased with number of years on treatment for haemodialysis and transplant patients, whereas costs for patients receiving peritoneal dialysis remained constant. Diabetes was associated with higher mean annual costs for all patients irrespective of treatment modality and hospital setting. Age did not have a consistent effect on costs. Combining predicted hospital costs with the fixed costs of renal replacement therapy showed that the total cost differential for a patient continuing on dialysis rather than receiving a transplant is considerable following the first year of renal replacement therapy, thus reinforcing the longer-term economic advantage of transplantation over dialysis for the health service. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

[Ethical and legal issues concerning renal replacement therapy withdrawal or withholding].

PubMed

Radziszewski, Andrzej; Stompór, Tomasz; Gajda, Mariusz; Sułowicz, Władysław

2006-01-01

Rapid and dynamic increase of the number of patients that need different forms of renal replacement therapy can be noticed in the developed countries. This increase is associated with increased number of patients with 'diseases of modern civilization', such as diabetes and hypertension, which lead to kidney complications (e.g. diabetic and hypertensive nephropathy). Improved long-term care (especially diabetic and cardiologic) allows these patients to survive longer and to reach the stage of end-stage renal disease. This leads to increasing age and morbidity of patients treated with dialysis. In many cases, due to extremely advanced level of co-morbidity patients on dialysis are exposed to extreme level of suffering and unacceptably low quality of life. Persistent continuing of renal replacement therapy under such circumstances (with no hope for recovery or improvement) raises also some economical issues, especially in the context of permanent crisis and shortage of resources in health systems of most countries in the world. In this review the current practice concerning withdrawal or withholding of renal replacement therapy as well as some legal and ethical issues of this practice are discussed.

Long-term results with renal autotransplantation for ureteral replacement.

PubMed

Bodie, B; Novick, A C; Rose, M; Straffon, R A

1986-12-01

From 1970 to 1984 renal autotransplantation was performed on 23 patients to replace all or a major portion of the ureter. The conditions necessitating ureteral replacement were postoperative ureteral injury in 16 cases, recurrent renal colic in 4, urinary undiversion in 2 and an atonic ureter in 1. Six patients presented with a solitary kidney and 1 underwent staged bilateral autotransplantation. After autotransplantation urinary continuity was restored by ureteroneocystostomy in 11 patients, pyelovesicostomy in 7, ureteroureterostomy in 2, pyeloureterostomy in 2 and ureterosigmoidostomy in 1. Postoperatively, there was no mortality and all but 1 of the autotransplanted kidneys functioned immediately. Two kidneys required removal postoperatively owing to bleeding. Currently, 20 patients are alive with functioning renal autotransplants at intervals of 1.5 to 14 years. The current serum creatinine level in these patients ranges from 1.1 to 2.2 mg. per dl., which in each case is improved or stable compared to the preoperative determination. Only 1 patient has experienced chronic bacteriuria. We conclude that renal autotransplantation provides excellent long-term treatment for patients who require ureteral replacement.

Therapeutic Plasma Exchange in Critically Ill Children Requiring Intensive Care.

PubMed

Cortina, Gerard; McRae, Rosemary; Chiletti, Roberto; Butt, Warwick

2018-02-01

To characterize the clinical indications, procedural safety, and outcome of critically ill children requiring therapeutic plasma exchange. Retrospective observational study based on a prospective registry. Tertiary and quaternary referral 30-bed PICU. Forty-eight critically ill children who received therapeutic plasma exchange during an 8-year period (2007-2014) were included in the study. Therapeutic plasma exchange. A total of 48 patients underwent 244 therapeutic plasma exchange sessions. Of those, therapeutic plasma exchange was performed as sole procedure in 193 (79%), in combination with continuous renal replacement therapy in 40 (16.4%) and additional extracorporeal membrane oxygenation in 11 (4.6%) sessions. The most common admission diagnoses were hematologic disorders (30%), solid organ transplantation (20%), neurologic disorders (20%), and rheumatologic disorders (15%). Complications associated with the procedure occurred in 50 (21.2%) therapeutic plasma exchange sessions. Overall, patient survival from ICU was 82%. Although patients requiring therapeutic plasma exchange alone (n = 31; 64%) had a survival rate of 97%, those with additional continuous renal replacement therapy (n = 13; 27%) and extracorporeal membrane oxygenation (n = 4; 8%) had survival rates of 69% and 50%, respectively. Factors associated with increased mortality were lower Pediatric Index of Mortality 2 score, need for mechanical ventilation, higher number of failed organs, and longer ICU stay. Our results indicate that, in specialized centers, therapeutic plasma exchange can be performed relatively safely in critically ill children, alone or in combination with continuous renal replacement therapy and extracorporeal membrane oxygenation. Outcome in children requiring therapeutic plasma exchange alone is excellent. However, survival decreases with the number of failed organs and the need for continuous renal replacement therapy and extracorporeal membrane oxygenation.

Early Implementation of Continuous Renal Replacement Therapy Optimizes Casualty Evacuation for Combat-Related Acute Kidney Injury

DTIC Science & Technology

2013-08-01

were Acute Kidney Injury Network (AKIN) 3 and all developed critical hyperkalemia (mean [SD], peak K+ 6.4 [0.4]). The peak plasma creatinine ranged...related acid-base disorders, severe hyperkalemia , and metabolic disorders became apparent. Based on the mounting pressure and internal performance im...with severe hyperkalemia was the most common indication for renal replacement. Validation for critical care evacuation to the Role IV facility mandated a

Acute dialysis and continuous renal replacement: the emergence of new technology involving the nephrologist in the intensive care setting.

PubMed

Yagi, N; Paganini, E P

1997-07-01

The emergence of dialytic support for patients with reversible renal failure was one of the most significant advances in critical care medicine. Supporting a patient with a failed organ till organ recovery has not had the same success with other organ failures. Despite the indispensable nature of the support, dialysis was intermittent at best, and carried its own morbidity. The emergence of a "continuous" dialysis delivery system, originally through an arteriovenous access and later through veno-venous methodology, began to simulate the continuity of the natural kidney, and lifted much of the fluid and drug restrictions imposed by the intermittent nature of standard dialytic therapies. Components of the system were next reviewed for improvement and biocompatability. Differences in patient outcome were documented with various component comparisons, and disparate patient tolerance of delivery modality was also clearly proven. The hemodynamic stability of continuous treatment created utilization to be focused on the more unstable, the more severely compromised patient group. In this context, comparative studies with intermittent delivery methods showed improved hemodynamic stability among patients treated with continuous renal replacement therapies (CRRT), but no clear difference in patient mortality. Patient characteristics and severity scoring have recently been undertaken to better describe the population, and attempts at dialysis dosing is currently being developed for ARF dialysis recipients. Early results seem to point toward a dialysis dose effect on mortality in certain groups of ICU acute renal failure patients. However, the dialytic process is only depurative and artificial. Plastic membrane bio-incompatibility, human physiological responses to foreign material exposure, either in the circuit material itself or introduced from therapy methodology, pose practical and theoretical problems. Recent advances in the field of bio-artificial technology have allowed the development of functioning hybrid "blood processors," which function as a renal tubule and may be able to not only "clean" blood, but also allow for other cellular functions not currently possible with dead membrane technology. Combining living cells with a continuous delivery method may be the next significant step toward a fully functional renal replacement therapy.

Doripenem Treatment during Continuous Renal Replacement Therapy

PubMed Central

Wenisch, J. M.; Maier-Salamon, A.; Fritsch, A.; Saria, K.; Zuba, C.; Jilch, S.; Lemmerer, R.; Unger, M.; Jaehde, U.; Jäger, W.; Thalhammer, F.

2015-01-01

Doripenem is a broad-spectrum parenteral carbapenem with enhanced activity against Pseudomonas aeruginosa. While the initial dosing recommendation for renally competent patients and patients undergoing continuous renal replacement therapy (cRRT) was 500 mg every 8 h (q8h), the dose for renally competent patients was updated to 1 g q8h in June 2012. There are no updated data for the dosing of patients on continuous renal replacement therapy. The original dosing regimen for cRRT patients was based on nonseptic patients, while newer publications chose comparatively low target concentrations for a carbapenem. Thus, there is an urgent need for updated recommendations for dosing during cRRT. In the trial presented here, we included 13 oliguric septic patients undergoing cRRT in an intensive care setting. Five patients each were treated with hemodiafiltration or hemodialysis, while three patients received hemofiltration treatment. All patients received 1 g doripenem every 8 h. Doripenem concentrations in the plasma and ultrafiltrate were measured over 48 h. The mean hemofilter clearance was 36.53 ml/min, and the mean volume of distribution was 59.26 liters. The steady-state trough levels were found at 8.5 mg/liter, with no considerable accumulation. Based on pharmacokinetic and pharmacodynamic considerations, we propose a regimen of 1 g q8h, which may be combined with a loading dose of 1.5 to 2 g for critically ill patients. (This study has been registered with EudraCT under registration no. 2009-018010-18 and at ClinicalTrials.gov under registration no. NCT02018939.) PMID:26711775

Continuous ambulatory peritoneal dialysis is better than automated peritoneal dialysis as first-line treatment in renal replacement therapy.

PubMed

Li, Philip Kam-Tao; Chung, Kwok Yi; Chow, Kai Ming

2007-06-01

This article examines the roles of continuous ambulatory peritoneal dialysis (CAPD) versus automated peritoneal dialysis (APD) as first-line renal replacement therapy. To date, no high-quality large-scale randomized controlled studies have compared CAPD with APD as first-line therapy. However, a discussion on this issue is important so that nephrologists can decide and patients can have a choice of modality on which to start dialysis, especially in the context of health care economics. We review the literature and present Hong Kong as the model of a "CAPD first" policy, an appealing, cost-effective approach for any country. An ideal renal replacement therapy should provide optimal survival, lowest possible risk for comorbidity, highest level of quality of life, and equally important, acceptable cost to society. When we consider this subject in the context that all patients should be started on one first-line modality, the data suggest that a "CAPD first" policy has all these advantages, with APD probably having the edge only with regard to patient preference. The present review highlights preservation of residual renal function, removal and balancing of sodium, incidence of peritonitis, peritoneal membrane transport status, patient rehabilitation, and financial issues in demonstrating that a "CAPD first" policy is the model that should be adopted.

Clinical Validation of Therapeutic Drug Monitoring of Imipenem in Spent Effluent in Critically Ill Patients Receiving Continuous Renal Replacement Therapy: A Pilot Study.

PubMed

Wen, Aiping; Li, Zhe; Yu, Junxian; Li, Ren; Cheng, Sheng; Duan, Meili; Bai, Jing

2016-01-01

The primary objective of this pilot study was to investigate whether the therapeutic drug monitoring of imipenem could be performed with spent effluent instead of blood sampling collected from critically ill patients under continuous renal replacement therapy. A prospective open-label study was conducted in a real clinical setting. Both blood and effluent samples were collected pairwise before imipenem administration and 0.5, 1, 1.5, 2, 3, 4, 6, and 8 h after imipenem administration. Plasma and effluent imipenem concentrations were determined by reversed-phase high-performance liquid chromatography with ultraviolet detection. Pharmacokinetic and pharmacodynamic parameters of blood and effluent samples were calculated. Eighty-three paired plasma and effluent samples were obtained from 10 patients. The Pearson correlation coefficient of the imipenem concentrations in plasma and effluent was 0.950 (P<0.0001). The average plasma-to-effluent imipenem concentration ratio was 1.044 (95% confidence interval, 0.975 to 1.114) with Bland-Altman analysis. No statistically significant difference was found in the pharmacokinetic and pharmacodynamic parameters tested in paired plasma and effluent samples with Wilcoxon test. Spent effluent of continuous renal replacement therapy could be used for therapeutic drug monitoring of imipenem instead of blood sampling in critically ill patients.

A Prospective Observational Study on the Predictive Value of Serum Cystatin C for Successful Weaning from Continuous Renal Replacement Therapy.

PubMed

Kim, Chang Seong; Bae, Eun Hui; Ma, Seong Kwon; Kim, Soo Wan

2018-05-30

There is a paucity of literature that investigates a biomarker associated with successful renal recovery following continuous renal replacement therapy (CRRT). Our study aimed to identify potential renal biomarkers or clinical indicators that could predict the successful weaning from CRRT. We conducted a prospective, observational study of 110 patients who had received CRRT and were weaned after renal recovery. Patients were considered to have successfully weaned from CRRT once there was no need for renal replacement therapy (RRT) for at least 14 days. For patients who had to restart dialysis within 14 days were considered unsuccessful. Of the 110 patients evaluated, 89 (80.9%) were successfully weaned from CRRT. These patients had lower serum cystatin C (CysC) levels and higher urine output than the group that restarted RRT at the time of CRRT cessation. However, the levels of serum creatinine and neutrophil gelatinase-associated lipocalin were not significantly lower in the successful group compared to the restart-RRT group. A multivariable logistic regression showed that serum CysC was an independent predictor for the successful weaning from CRRT. Furthermore, in a multivariable Cox proportional hazards analysis, the group that was successfully weaned from CRRT had a lower in-hospital mortality compared to the restarted RRT group. Serum CysC, at the time of CRRT cessation, is an independent predictor of the successful weaning from CRRT in critically ill patients with acute kidney injury. © 2018 The Author(s). Published by S. Karger AG, Basel.

[Long-term outcomes of children treated with continuous renal replacement therapy].

PubMed

Almarza, S; Bialobrzeska, K; Casellas, M M; Santiago, M J; López-Herce, J; Toledo, B; Carrillo, Á

2015-12-01

The objective of this study is to analyze long-term outcomes and kidney function in children requiring continuous renal replacement therapy (CRRT) after an acute kidney injury episode. A retrospective observational study was performed using a prospective database of 128 patients who required CRRT admitted to the pediatric intensive care unit between years 2006 and 2012. The subsequent outcomes were assessed in those surviving at hospital discharge. Of the 128 children who required RRT in the pediatric intensive care unit, 71 survived at hospital discharge (54.4%), of whom 66 (92.9%) were followed up. Three patients had chronic renal failure prior to admission to the NICU. Of the 63 remaining patients, 6 had prolonged or relapses of renal function disturbances, but only one patient with atypical Hemolytic Uremic Syndrome developed end-stage renal failure. The rest had normal kidney function at the last check-up. Most of surviving children that required CRRT have a positive outcome later on, presenting low mortality rates and recovery of kidney function in the medium term. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

In vivo validation of the adequacy calculator for continuous renal replacement therapies

PubMed Central

Ricci, Zaccaria; Salvatori, Gabriella; Bonello, Monica; Pisitkun, Tirak; Bolgan, Irene; D'Amico, Giuseppe; Dan, Maurizio; Piccinni, Pasquale; Ronco, Claudio

2005-01-01

Introduction The study was conducted to validate in vivo the Adequacy Calculator, a Microsoft Excel-based program, designed to assess the prescription and delivery of renal replacement therapy in the critical care setting. Methods The design was a prospective cohort study, set in two intensive care units of teaching hospitals. The participants were 30 consecutive critically ill patients with acute renal failure treated with 106 continuous renal replacement therapies (CRRT). Urea clearance computation was performed with the Adequacy Calculator (KCALC). Simultaneous blood and effluent urea samples were collected to measure the effectively delivered urea clearance (KDEL) at the beginning of each treatment and, during 73 treatments, between the 18th and 24th treatment hour. The correlation between 179 computed and 179 measured clearances was assessed. Fractional clearances for urea were calculated as spKt/V (where sp represents single pool, K is clearance, t is time, and V is urea volume of distribution) obtained from software prescription and compared with the delivered spKt/V obtained from empirical data. Results We found that the value of clearance predicted by the calculator was strongly correlated with the value obtained from computation on blood and dialysate determination (r = 0.97) during the first 24 treatment hours, regardless of the renal replacement modality used. The delivered spKt/V (1.25) was less than prescribed (1.4) from the Adequacy Calculator by 10.7%, owing to therapy downtime. Conclusion The Adequacy Calculator is a simple tool for prescribing CRRT and for predicting the delivered dose. The calculator might be a helpful tool for standardizing therapy and for comparing disparate treatments, making it possible to perform large multi-centre studies on CRRT. PMID:15987400

[Oliguria and acute renal dysfunction in a six-month-old infant].

PubMed

Cui, Ya-Jie; Song, Chun-Lan; Cheng, Yi-Bing

2017-02-01

The infant (a girl aged 6 months) was admitted to the hospital because of oliguria and acute renal dysfunction. The laboratory examination results showed serious metabolic acidosis and increased blood urea nitrogen and serum creatinine levels. The patient continued to be anuric after 10 days of treatment with continuous renal replacement therapy (CRRT). she died a day later. The family history showed that the patient's sister died of acute renal failure 6 months after birth. The genomic sequencing results showed AGXT mutation in the patient and confirmed the diagnosis of primary hyperoxaluria type 1 (PH1). Her parents were heterozygous carriers. PH1 should be considered when the children have abnormal renal function or recurrent renal calculi or have a family history of these symptoms. AGXT gene analysis is an important method for PH1 diagnosis.

End-stage renal failure in type 2 diabetes: A medical catastrophe of worldwide dimensions.

PubMed

Ritz, E; Rychlík, I; Locatelli, F; Halimi, S

1999-11-01

The incidence of patients with end-stage renal failure and diabetes mellitus type 2 as a comorbid condition has increased progressively in the past decades, first in the United States and Japan, but subsequently in all countries with a western lifestyle. Although there are explanations for this increase, the major factor is presumably diminishing mortality from hypertension and cardiovascular causes, so that patients survive long enough to develop nephropathy and end-stage renal failure. This review summarizes the striking differences between countries against the background of a similar tendency of an increasing incidence in all countries. Survival on renal replacement therapy continues to be substantially worse for patients with type 2 diabetes. A major reason for this observation is that patients enter renal replacement programs with cardiovascular morbidity acquired in the preterminal phase of renal failure. It is argued that the challenge for the future will be better patient management in earlier phases of diabetic nephropathy to attenuate or prevent progression, as well as cardiovascular complications.

Femoral Access and Delivery of Continuous Renal Replacement Therapy Dose.

PubMed

Bellomo, Rinaldo; Mårtensson, Johan; Lo, Serigne; Kaukonen, Kirsi-Maija; Cass, Alan; Gallagher, Martin

2016-01-01

The study aims to describe the use of dialysis catheters in critically ill patients treated with continuous renal replacement therapy (CRRT) and to study the impact of femoral versus non-femoral access on CRRT dose. Statistical analysis and predictive modelling of data from the Randomized Evaluation of Normal vs. Augmented Level renal replacement therapy trial. The femoral vein was the first access site in 937 (67%) of 1,399 patients. These patients had higher Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores (p = 0.009) and lower pH (p < 0.001) but similar mortality to patients with non-femoral access (44 vs. 45%; p = 0.63). Lower body weight was independently associated with femoral access placement (OR 0.97, 95% CI 0.96-0.98). Femoral access was associated with a 1.03% lower CRRT dose (p = 0.05), but a 4.20% higher dose was achieved with 13.5 Fr catheters (p = 0.03). Femoral access was preferred in lighter and sicker patients. Catheter gauge had greater impact than catheter site in CRRT dose delivery. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=439581. © 2015 S. Karger AG, Basel.

Combination of continuous renal replacement therapies (CRRT) and extracorporeal membrane oxygenation (ECMO) for advanced cardiac patients.

PubMed

Yap, Hon-Jek; Chen, Yung-Chang; Fang, Ji-Tseng; Huang, Chiu-Ching

2003-03-01

The critically ill patients may require mechanical ventilation, cardiac mechanical support, and other types of critical support. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides good cardiopulmonary and end-organ support. Continuous renal replacement therapies (CRRT) exhibit important advantages in terms of clinical tolerance and blood purification. This investigation aims to evaluate the acute renal failure in cardiac patients under ECMO, and assess the effect of combining these two technologies, ECMO and CRRT. Between December 1998 and June 2001, 10 adult cardiac patients were treated on ECMO. Five of them were treated with both ECMO and CRRT. The clinical outcomes were retrospectively analyzed. Of the 10 patients studied, five were men and five were women. The mean age of survivors and non-survivors was 37.00 +/- 14.54 years and 46.17 +/- 7.41 years, respectively. The overall mortality rate was 60%. Survivors did not differ significantly from non-survivors in age or gender. The APACHE II scores on the first day of ECMO support between survival and non-survival were 19.00 +/- 9.38 and 24.67 +/- 3.50 (P value = 0.392) (Table 2), which demonstrates no significant differences too. The cause of death in most patients was related to organ system failure during the 24 h immediately before ECMO started. Five patients with acute renal failure treated by CRRT were eventually died. The median and mean survival in this group on CRRT was 40.50 +/- 18.07 h and 92.60 +/- 60.50 h. We conclude that mortality rate for acute renal failure in cardiac patients under ECMO continues to be high. Our data suggest that acute renal failure is generally a part of multiorgan failure. This unique form of acute renal failure, causes generalized edema and fluid overload despite still low serum creatinine and azotemia, and deteriorates rapidly to death. From this study shows, advanced cardiac failure may need more aggressive and early initiation of ECMO support before acute renal failure develops. Acute renal failure in advanced heart failure under ECMO support means a grave sign, need aggressive heart transplantation therapy as soon as possible. Combination of CRRT and ECMO might serve an alternative therapy bridging the temporary replacement treatment and heart transplantation in advanced cardiac patients.

Massive naproxen overdose with serial serum levels.

PubMed

Al-Abri, Suad A; Anderson, Ilene B; Pedram, Fatehi; Colby, Jennifer M; Olson, Kent R

2015-03-01

Massive naproxen overdose is not commonly reported. Severe metabolic acidosis and seizure have been described, but the use of renal replacement therapy has not been studied in the context of overdose. A 28-year-old man ingested 70 g of naproxen along with an unknown amount of alcohol in a suicidal attempt. On examination in the emergency department 90 min later, he was drowsy but had normal vital signs apart from sinus tachycardia. Serum naproxen level 90 min after ingestion was 1,580 mg/L (therapeutic range 25-75 mg/L). He developed metabolic acidosis requiring renal replacement therapy using sustained low efficiency dialysis (SLED) and continuous venovenous hemofiltration (CVVH) and had recurrent seizure activity requiring intubation within 4 h from ingestion. He recovered after 48 h. Massive naproxen overdose can present with serious toxicity including seizures, altered mental status, and metabolic acidosis. Hemodialysis and renal replacement therapy may correct the acid base disturbance and provide support in cases of renal impairment in context of naproxen overdose, but further studies are needed to determine the extraction of naproxen.

Clinical Validation of Therapeutic Drug Monitoring of Imipenem in Spent Effluent in Critically Ill Patients Receiving Continuous Renal Replacement Therapy: A Pilot Study

PubMed Central

Wen, Aiping; Li, Zhe; Yu, Junxian; Li, Ren; Cheng, Sheng; Duan, Meili; Bai, Jing

2016-01-01

Objectives The primary objective of this pilot study was to investigate whether the therapeutic drug monitoring of imipenem could be performed with spent effluent instead of blood sampling collected from critically ill patients under continuous renal replacement therapy. Methods A prospective open-label study was conducted in a real clinical setting. Both blood and effluent samples were collected pairwise before imipenem administration and 0.5, 1, 1.5, 2, 3, 4, 6, and 8 h after imipenem administration. Plasma and effluent imipenem concentrations were determined by reversed-phase high-performance liquid chromatography with ultraviolet detection. Pharmacokinetic and pharmacodynamic parameters of blood and effluent samples were calculated. Results Eighty-three paired plasma and effluent samples were obtained from 10 patients. The Pearson correlation coefficient of the imipenem concentrations in plasma and effluent was 0.950 (P<0.0001). The average plasma-to-effluent imipenem concentration ratio was 1.044 (95% confidence interval, 0.975 to 1.114) with Bland-Altman analysis. No statistically significant difference was found in the pharmacokinetic and pharmacodynamic parameters tested in paired plasma and effluent samples with Wilcoxon test. Conclusion Spent effluent of continuous renal replacement therapy could be used for therapeutic drug monitoring of imipenem instead of blood sampling in critically ill patients. PMID:27093294

Accuracy of intravenous infusion pumps in continuous renal replacement therapies.

PubMed

Jenkins, R; Harrison, H; Chen, B; Arnold, D; Funk, J

1992-01-01

Most extracorporeal continuous renal replacement therapies (CRRT) require inflow pumping of either dialysate, filtrate replacement solution, or both. Outflow of spent dialysate and ultrafiltrate can be accomplished by gravity drainage or pump. Intravenous infusion pumps have been commonly used for these purposes, although little is known about the accuracy of these pumps. To evaluate accuracy of two different types of intravenous infusion pumps used in CRRT, we studied flow rates at nine different pressure variations in three piston type and three linear peristaltic pumps. The results showed that error of either pump was not different for flow rates of 4 and 16 ml/min. Both types of pumps were affected by fluid circuit pressures, although pressure conditions under which error was low were different for each pump type. The linear peristaltic pumps were most accurate under conditions of low pump inlet pressure, whereas piston pumps were most accurate under conditions of low pump pressure gradient (outlet minus inlet) of 0 or -100 mmHg. The magnitude of error outside these conditions was substantial, reaching 12.5% for the linear peristaltic pump when inlet pressure was -100 mmHg and outlet pressure was 100 mmHg. Error may be minimized in the clinical setting by choosing the pump type best suited for the pressure conditions expected for the renal replacement modality in use.

Update on Renal Replacement Therapy: Implantable Artificial Devices and Bioengineered Organs.

PubMed

Attanasio, Chiara; Latancia, Marcela T; Otterbein, Leo E; Netti, Paolo A

2016-08-01

Recent advances in the fields of artificial organs and regenerative medicine are now joining forces in the areas of organ transplantation and bioengineering to solve continued challenges for patients with end-stage renal disease. The waiting lists for those needing a transplant continue to exceed demand. Dialysis, while effective, brings different challenges, including quality of life and susceptibility to infection. Unfortunately, the majority of research outputs are far from delivering satisfactory solutions. Current efforts are focused on providing a self-standing device able to recapitulate kidney function. In this review, we focus on two remarkable innovations that may offer significant clinical impact in the field of renal replacement therapy: the implantable artificial renal assist device (RAD) and the transplantable bioengineered kidney. The artificial RAD strategy utilizes micromachining techniques to fabricate a biohybrid system able to mimic renal morphology and function. The current trend in kidney bioengineering exploits the structure of the native organ to produce a kidney that is ready to be transplanted. Although these two systems stem from different technological approaches, they are both designed to be implantable, long lasting, and free standing to allow patients with kidney failure to be autonomous. However, for both of them, there are relevant issues that must be addressed before translation into clinical use and these are discussed in this review.

[Epidemiology of severe acute renal failure in Metropolitan Santiago].

PubMed

Vukusich, Antonio; Alvear, Felipe; Villanueva, Pablo; González, Claudio; Francisco, Olivari; Alvarado, Nelly; Zehnder, Carlos

2004-11-01

There is a paucity of information about the epidemiology of acute renal failure in Chile. To perform a prospective multicentric survey of severe acute renal failure in Chile. All patients admitted to ten hospitals in Metropolitan Santiago, during a period of six months with severe acute renal failure, were studied. The criteria for severity was the requirement of renal replacement therapy. All patients information was gathered in special forms and the type of renal replacement therapy and evolution was registeres. One hundred fourteen patients were studied (65 males, age range 18 to 87 years). The calculated incidence of acute renal failure was 1.03 cases per 1000 hospital discharges. The onset was nosocomial in 79 subjects (69%) and community acquired in the rest. Renal failure was oliguric in 64 cases (56%) and in 60% of patients it had two or more causative factors. Sepsis, isolated or combined with other causes, was present in 51 of patients. Other causes included ischemia in 47%, surgery in 26%, exogenous toxicity in 25%, endocenous toxicity in 11%, acute glomerular damage in 6% and obstructive uropathy in 6%. Cardiac surgery was responsible for 47% of post operative cases of acute renal failure. Intermittent conventional hemodialysis, continuous renal replacement techniques and daily prolonged hemodialysis were used in 66%, 29% and 2% of patients, respectively. Overall mortality was 45% and it was higher in oliguric patients. Gender, age, cause or the type of therapy did not influence survival. Nine percent of surviving patients had some degree of kidney dysfunction at discharge. There is still a great space for prevention of severe acute renal failure in Chile, considering the main etiologies found in this study.

UK Renal Registry 16th annual report: chapter 11 blood pressure profile of prevalent patients receiving renal replacement therapy in 2012: national and centre-specific analyses.

PubMed

Rao, Anirudh; Pitcher, David; Farrington, Ken

2013-01-01

There continues to be uncertainty in the literature about which blood pressure (BP) recordings in which time period associate best with long-term patient outcomes and therefore optimal target ranges. Patients receiving renal replacement therapy (RRT) on 31st December 2012 with a BP reading in either the fourth or third quarter of 2012 were included. Summary statistics were calculated for each renal centre and country. Data completeness for BP measurements submitted to the UK Renal Registry (UKRR) for all modalities were improved from previous years: it was better for haemodialysis (HD) patients (75% for pre-HD measurements) than for peritoneal dialysis (PD) patients (51%) or transplant recipients (41%). In 2012, the median pre- and post-HD systolic blood pressures (SBPs) were 140 mmHg and 128 mmHg respectively. The median SBP of patients on PD was 137 mmHg. Transplant recipients had a median SBP of 134 mmHg. Median diastolic blood pressures (DBPs) were 71 mmHg (pre-HD), 67 mmHg (post-HD), 78 mmHg (PD) and 79 mmHg (transplant). Only 26% of PD patients achieved the Renal Association guideline of SBP <130 mmHg and DBP <80 mmHg. Amongst transplant patients, 27% achieved the Renal Association guideline of SBP <130 mmHg and DBP <80 mmHg. In 2012 there continued to be significant variation in the achievement of BP standards between UK renal centres. © 2014 S. Karger AG, Basel.

[Diuretics in acute kidney failure: useful or harmful?].

PubMed

Tataw, J; Saudan, P

2011-03-02

Loop diuretics are commonly prescribed within different clinical settings to prevent and or to treat acute renal failure. In most cases they facilitate fluid management following an increased urine output. Experimental models in animals revealed protective effects of loop diuretics in acute renal failure. Several clinical trials have failed to outline better outcomes associated with the use of diuretics in acute renal failure as there was no recovery in renal function nor a reduction in the number of dialysis sessions required. Glomerular filtration rate did not improve with the administration of loop diuretics after continuous renal replacement therapy. The administration of loop diuretics in the management of acute renal failure should be mainly restricted to patients with hypervolemia.

Efficacy of cellulose triacetate dialyzer and polysulfone synthetic hemofilter for continuous venovenous hemofiltration in acute renal failure.

PubMed

Pichaiwong, Warangkana; Leelahavanichkul, Asada; Eiam-ong, Somchai

2006-08-01

To compare the clearance performances and biocompatibility between the modified cellulose membrane and the standard synthetic membrane in continuous renal replacement therapy (CRRT). Seventeen patients with acute renal failure (ARF) were treated with separated continuous veno venous hemofiltration (CVVH) system conducted with the pre-dilution mode. The modified cellulose used was a Sureflux150E (cellulose triacetate) and the standard synthetic membranes used was an AV-400. Blood and replacement flow rate were kept at 100 and 20 mL/min, respectively. Ultrafiltraion rate was 1,200 mL/hr. Samplings of blood and ultrafiltrate were collected at baseline, 2, 8, 16, and 24 hr. Patients in both methods could similarly tolerate CRRT with only minor complications. Sureflux 150E and AV-400 provided comparable values of sieving coefficients and clearances of small solutes. The albumin loss in ultrafiltrate by Sureflux 150E was greater than AV-400. The values of life span and biocompatability of both hemofilters were not different. Because of the excellent efficacy and the much cheaper cost, the modified cellulose membrane could be an appropriate alternative to standard synthetic membrane in CRRT.

Development and application of novelty pretreatment method for the concurrent quantitation of eleven water-soluble B vitamins in ultrafiltrates after renal replacement therapy.

PubMed

Wirkus, Dorota; Jakubus, Aleksandra; Owczuk, Radosław; Stepnowski, Piotr; Paszkiewicz, Monika

2017-02-01

Continous renal replacement therapy (CRRT) is particularly recommended for septic shock patients in intensive care units. The CRRT technique used most frequently is high volume continuous veno-venous haemofiltration. It provides a high rate of clearance of uremic toxins and inflammatory cytokines. However, it should also be taken into account that substances important for homeostasis may be concurrently unintentionally removed. Accordingly, water-soluble vitamins can be removed during continuous renal replacement therapy, and the estimate of the loss is critical to ensure appropriate supplementation. The aim of this work was to develop a simple methodology for a purification step prior to the LC-MS/MS determination of water-soluble vitamins in ultrafiltrate samples. For this purpose, two types of resin and a mix of resins were used as sorbents for the purification step. Moreover, parameters such as the amount of resin and the extraction time were optimized. The LC-MS/MS method was developed and validated for final determination of 11 vitamins. The results demonstrated the high purification capability of DEAE Sephadex resin with recoveries between 65 and 101% for water-soluble vitamins from ultrafiltrate samples. An optimized method was applied to assess the loss of B-group vitamins in patients after 24h of renal replacement therapy. The loss of vitamins B2, B6 pyridoxamine, B6 pyridoxal, B7, B1, and B5 in ultrafiltrates was similar in all patients. In the native ultrafiltrates, vitamins B6 pyridoxine, B9 and B12 were not detected. Copyright © 2016 Elsevier B.V. All rights reserved.

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

PubMed Central

2008-01-01

BACKGROUND The optimal intensity of renal-replacement therapy in critically ill patients with acute kidney injury is controversial. METHODS We randomly assigned critically ill patients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained low-efficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour. RESULTS Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P = 0.47). There was no significant difference between the two groups in the duration of renalreplacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups. CONCLUSIONS Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.) PMID:18492867

Teaching and training acute renal replacement therapy in children.

PubMed

López-Herce, Jesús; Ferrero, Luis; Mencía, Santiago; Antón, Montserrat; Rodríguez-Núñez, Antonio; Rey, Corsino; Rodríguez, Luis

2012-05-01

The objective of this study is to describe and analyse the initial experience in paediatric acute renal replacement therapy (ARRT) education by means of specific courses. Three paediatric ARRT courses were run. The course programme included initial and final multiple-choice question (MCQ) exams, short lectures, practical workshops [in vitro peritoneal dialysis (PD) and continuous renal replacement therapy (CRRT) machines skill stations, real-time PD and CRRT in paediatric animal models and paediatric CRRT advanced simulation scenarios based on real cases) and an anonymous survey on the perceived value of the course (score from 0: very bad to 10: perfect). Number of students per workshop was six to eight. Continuous assessment of participants' performance was done. In the initial MCQ, only 11% of students answered correctly at least 70% of questions, while in the final test, 90.5% hit this target (P < 0.001). In the performance assessments, all of the students demonstrated sufficient acquisition of practical skills. In the perceived value survey, the course methodology was rated at 9.3, organization 9.9, teaching staff 9.6, lectures 9 and practical sessions 9.1. Specifically designed CRRT and PD courses are adequate for teaching the theoretical aspects and training these procedures. The combination of laboratory, training with animals and advanced simulation scenarios might have a synergistic effect on learning.

Long-term outcome on renal replacement therapy in patients who previously received a keto acid-supplemented very-low-protein diet.

PubMed

Chauveau, Philippe; Couzi, Lionel; Vendrely, Benoit; de Précigout, Valérie; Combe, Christian; Fouque, Denis; Aparicio, Michel

2009-10-01

The consequences of a supplemented very-low-protein diet remain a matter of debate with regard to patient outcome before or after the onset of renal replacement therapy. We evaluated the long-term clinical outcome during maintenance dialysis and/or transplantation in patients who previously received a supplemented very-low-protein diet. We assessed the outcome of 203 patients who received a supplemented very-low-protein diet for >3 mo (inclusion period: 1985-2000) and started dialysis after a mean diet duration of 33.1 mo (4-230 mo). The survival rate in the whole cohort was 79% and 63% at 5 and 10 y, respectively. One hundred two patients continued with chronic dialysis during the entire follow-up, and 101 patients were grafted at least once. Patient outcomes were similar to those of the French Dialysis Registry patients for the dialysis group and similar to the 865 patients who were transplanted in Bordeaux during the same period for the transplant group. There was no correlation between death rate and duration of diet. The lack of correlation between death rate and duration of diet and the moderate mortality rate observed during the first 10 y of renal replacement therapy confirm that a supplemented very-low-protein diet has no detrimental effect on the outcome of patients with chronic kidney disease who receive renal replacement therapy.

Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease.

PubMed

Hussain, Jamilla A; Mooney, Andrew; Russon, Lynne

2013-10-01

There are limited data on the outcomes of elderly patients with chronic kidney disease undergoing renal replacement therapy or conservative management. We aimed to compare survival, hospital admissions and palliative care access of patients aged over 70 years with chronic kidney disease stage 5 according to whether they chose renal replacement therapy or conservative management. Retrospective observational study. Patients aged over 70 years attending pre-dialysis clinic. In total, 172 patients chose conservative management and 269 chose renal replacement therapy. The renal replacement therapy group survived for longer when survival was taken from the time estimated glomerular filtration rate <20 mL/min (p < 0.0001), <15 mL/min (p < 0.0001) and <12 mL/min (p = 0.002). When factors influencing survival were stratified for both groups independently, renal replacement therapy failed to show a survival advantage over conservative management, in patients older than 80 years or with a World Health Organization performance score of 3 or more. There was also a significant reduction in the effect of renal replacement therapy on survival in patients with high Charlson's Comorbidity Index scores. The relative risk of an acute hospital admission (renal replacement therapy vs conservative management) was 1.6 (p < 0.05; 95% confidence interval = 1.14-2.13). A total of 47% of conservative management patients died in hospital, compared to 69% undergoing renal replacement therapy (Renal Registry data). Seventy-six percent of the conservative management group accessed community palliative care services compared to 0% of renal replacement therapy patients. For patients aged over 80 years, with a poor performance status or high co-morbidity scores, the survival advantage of renal replacement therapy over conservative management was lost at all levels of disease severity. Those accessing a conservative management pathway had greater access to palliative care services and were less likely to be admitted to or die in hospital.

Stressful ethical issues in uremia therapy.

PubMed

Friedman, Eli A

2010-08-01

The objectives of this review are to introduce and explore the following representative ethical problems generated by modern renal replacement therapy: (1) reviewing the historical origin of medical ethics with specific reference to nephrology; (2) recognizing the complex stresses surrounding assignment of a deceased donor renal transplant to a geriatric patient while young patients continue waiting for a donor kidney; and (3) appreciating the concept of futility and support for a uremic patient opting for death rather than further uremia therapy as the best in choice in coping with renal failure.

Colistin Pharmacokinetics in Burn Patients during Continuous Venovenous Hemofiltration

PubMed Central

Rowan, Matthew P.; Niece, Krista L.; Stewart, Ian J.; Mende, Katrin; Cota, Jason M.; Murray, Clinton K.; Chung, Kevin K.

2014-01-01

While colistin is considered a last resort for the treatment of multidrug-resistant Gram-negative bacterial infections, there has been an increase in its use due to the increasing prevalence of drug-resistant infections worldwide. The pharmacology of colistin is complex, and pharmacokinetic data are limited, especially in patients requiring renal replacement therapy. As a result, dosing for patients who require renal replacement remains a challenge. Here, we present pharmacokinetic data for colistin from two burn patients (37 and 68 years old) infected with colistin-susceptible isoclonal Acinetobacter baumannii and receiving continuous venovenous hemofiltration (CVVH). To our knowledge, we are the first to examine data from before and during CVVH (for one patient), allowing analysis of the effect of CVVH on colistin pharmacokinetics. Pharmacokinetic/pharmacodynamic analysis indicated that a dose increase from 1.5 to 2.2 mg/kg of body weight colistin base activity on CVVH was insufficient to satisfy the target parameter of an AUC24/MIC (area under the concentration-time curve over 24 h in the steady state divided by the MIC) of ≥60 at an MIC of ≥1 μg/ml in one patient with residual endogenous renal function. Plasma concentrations of colistin ranged from 0 to 15 μg/ml, with free colistin levels ranging from 0.4 to 2.2 μg/ml. While both patients resolved their clinical infections and survived to discharge, colistin-resistant colonizing isolates resulted from therapy in one patient. The variabilities observed in colistin concentrations and pharmacokinetic characteristics highlight the importance of pharmacokinetic monitoring of antibiotics in patients undergoing renal replacement therapy. PMID:25313211

Micafungin Plasma Levels Are Not Affected by Continuous Renal Replacement Therapy: Experience in Critically Ill Patients.

PubMed

Vossen, M G; Knafl, D; Haidinger, M; Lemmerer, R; Unger, M; Pferschy, S; Lamm, W; Maier-Salamon, A; Jäger, W; Thalhammer, F

2017-08-01

Critically ill patients often experience acute kidney injury and the need for renal replacement therapy in the course of their treatment in an intensive care unit (ICU). These patients are at an increased risk for candidiasis. Although there have been several reports of micafungin disposition during renal replacement therapy, to this date there are no data describing the elimination of micafungin during high-dose continuous venovenous hemodiafiltration with modified AN69 membranes. The aim of this prospective open-label pharmacokinetic study was to assess whether micafungin plasma levels are affected by continuous hemodiafiltration in critical ill patients using the commonly employed AN69 membrane. A total of 10 critically ill patients with micafungin treatment due to suspected or proven candidemia were included in this trial. Prefilter/postfilter micafungin clearance was measured to be 46.0 ml/min (±21.7 ml/min; n = 75 individual time points), while hemofilter clearance calculated by the sieving coefficient was 0.0038 ml/min (±0.002 ml/min; n = 75 individual time points). Total body clearance was measured to be 14.0 ml/min (±7.0 ml/min; n = 12). The population area under the curve from 0 to 24 h (AUC 0-24 ) was calculated as 158.5 mg · h/liter (±79.5 mg · h/liter; n = 13). In spite of high protein binding, no dose modification is necessary in patients receiving continuous venovenous hemodiafiltration with AN69 membranes. A dose elevation may, however, be justified in certain cases. (This study has been registered at ClinicalTrials.gov under identifier NCT02651038.). Copyright © 2017 American Society for Microbiology.

Therapeutic drug monitoring of antitubercular agents for disseminated Mycobacterium tuberculosis during intermittent haemodialysis and continuous venovenous haemofiltration.

PubMed

Sin, J H; Elshaboury, R H; Hurtado, R M; Letourneau, A R; Gandhi, R G

2018-04-01

There is a lack of data regarding therapeutic drug monitoring (TDM) of antitubercular agents in the setting of continuous venovenous haemofiltration (CVVH). We describe TDM results of numerous antitubercular agents in a critically ill patient during CVVH and haemodialysis. A 49-year-old man was initiated on treatment for disseminated Mycobacterium tuberculosis. During hospital admission, the patient developed critical illness and required renal replacement therapy. TDM results and pharmacokinetic calculations showed adequate serum concentrations of rifampin, ethambutol and amikacin during CVVH and of rifampin, pyrazinamide, ethambutol and levofloxacin during intermittent haemodialysis. The presence of critical illness and renal replacement therapy can induce pharmacokinetic changes that may warrant vigilant TDM to ensure optimal therapy. To our knowledge, this is the first report to describe TDM for several antitubercular agents during CVVH in a critically patient with disseminated M. tuberculosis. © 2017 John Wiley & Sons Ltd.

Precision Fluid Management in Continuous Renal Replacement Therapy.

PubMed

Murugan, Raghavan; Hoste, Eric; Mehta, Ravindra L; Samoni, Sara; Ding, Xiaoqiang; Rosner, Mitchell H; Kellum, John A; Ronco, Claudio

2016-01-01

Fluid management during continuous renal replacement therapy (CRRT) in critically ill patients is a dynamic process that encompasses 3 inter-related goals: maintenance of the patency of the CRRT circuit, maintenance of plasma electrolyte and acid-base homeostasis and regulation of patient fluid balance. In this article, we report the consensus recommendations of the 2016 Acute Disease Quality Initiative XVII conference on 'Precision Fluid Management in CRRT'. We discuss the principles of fluid management, describe various prescription methods to achieve circuit integrity and introduce the concept of integrated fluid balance for tailoring fluid balance to the needs of the individual patient. We suggest that these recommendations could serve to develop the best clinical practice and standards of care for fluid management in patients undergoing CRRT. Finally, we identify and highlight areas of uncertainty in fluid management and set an agenda for future research. © 2016 S. Karger AG, Basel.

Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy.

PubMed

Kunka, Megan E; Cady, Elizabeth A; Woo, Heejung C; Thompson Bastin, Melissa L

2015-01-01

Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient's actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure.

Incidence and Patient Outcomes in Renal Replacement Therapy After Orthotopic Liver Transplant.

PubMed

Ayhan, Asude; Ersoy, Zeynep; Ulas, Aydin; Zeyneloglu, Pinar; Pirat, Arash; Haberal, Mehmet

2017-02-01

Our objective was to evaluate the incidence of renal replacement therapy after orthotopic liver transplant and to evaluate and analyze patient outcomes. We performed a retrospective analysis of 177 consecutive patients at a tertiary care unit who underwent orthotopic liver transplant between January 2010 and June 2016. Patients who were admitted to the intensive care unit after orthotopic liver transplant and who required renal replacement therapy were included. A total of 177 (79 adult, 98 pediatric) orthotopic liver transplants were performed during the study period. Of these, 35 patients (19%) required renal replacement therapy during the early posttransplantation period. After excluding 5 patients with previous chronic renal failure, 30 patients (17%; 20 adult [25% ], 10 pediatric [10% ]) with acute kidney injury required renal replacement therapy. The mean patient age was 31.1 ± 20.0 years, with a mean Model for End-stage Liver Disease score of 16.7 ± 12.3. Of the patients with acute kidney injury who underwent renal replacement therapy, in-hospital mortality was 23.3% (7 of 30 patients), and 40% remained on dialysis. No significant difference was seen in mortality between early versus delayed initiation of renal replacement therapy in patients with stage 3 acute kidney injury (P = .17). Of liver transplant recipients who present with acute kidney injury, 19% require renal replacement therapy, and in-hospital mortality is 20% in the early postoperative period.

Preventing Continuous Renal Replacement Therapy-Induced Hypophosphatemia: An Extended Clinical Experience with a Phosphate-Containing Solution in the Setting of Regional Citrate Anticoagulation.

PubMed

Pistolesi, Valentina; Zeppilli, Laura; Polistena, Francesca; Sacco, Maria Itala; Pierucci, Alessandro; Tritapepe, Luigi; Regolisti, Giuseppe; Fiaccadori, Enrico; Morabito, Santo

2017-01-01

To evaluate the efficacy and safety of a commercially available phosphate-containing solution for continuous renal replacement therapy (CRRT) in preventing CRRT-related hypophosphatemia. In heart surgery patients undergoing continuous veno-venous haemodiafiltration (CVVHDF) with regional citrate anticoagulation (RCA), we combined an 18 mmol/l citrate solution with a phosphate-containing (1.2 mmol/l) dialysate/replacement fluid evaluating the incidence of hypophosphatemia and the need for parenteral phosphorus supplementation. In 75 patients on RCA-CVVHDF, the mean filter life was 53.9 ± 33.6 h. Regardless of baseline levels, phosphoremia was progressively corrected and maintained in a narrow normality range throughout RCA-CRRT days (after 72 h: 1.14 ± 0.25 mmol/l). Considering the whole CRRT period, 45 out of 975 (4.6%) serum phosphorus determinations met the criteria for mild (<0.81 mmol/l) or moderate (<0.61 mmol/l) hypophosphatemia; severe hypophosphatemia (<0.32 mmol/l) never occurred. After 72 h 88% of the patients were normophosphatemic, 9% hyperphosphatemic and 3% hypophosphatemic. RCA-CVVHDF with a phosphate-containing solution enabled the maintenance of phosphorus levels within normophosphatemic range in most of the patients, minimizing the occurrence of CRRT-related hypophosphatemia. © 2017 S. Karger AG, Basel.

Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala

PubMed Central

Moore, Jillian; Garcia, Pablo; Flood, David

2018-01-01

A 42-year-old indigenous Maya man presented to a non-profit clinic in rural Guatemala with signs, symptoms and laboratory values consistent with uncontrolled diabetes. Despite appropriate treatment, approximately 18 months after presentation, he was found to have irreversible end-stage renal disease (ESRD) of uncertain aetiology. He was referred to the national public nephrology clinic and subsequently initiated home-based continuous ambulatory peritoneal dialysis. With primary care provided by the non-profit clinic, his clinical status improved on dialysis, but socioeconomic and psychological challenges persisted for the patient and his family. This case shows how care for people with ESRD in low- and middle-income countries requires scaling up renal replacement therapy and ensuring access to primary care, mental healthcare and social work services. PMID:29705734

Phosphate-containing dialysis solution prevents hypophosphatemia during continuous renal replacement therapy

PubMed Central

BROMAN, M; CARLSSON, O; FRIBERG, H; WIESLANDER, A; GODALY, G

2011-01-01

Background Hypophosphatemia occurs in up to 80% of the patients during continuous renal replacement therapy (CRRT). Phosphate supplementation is time-consuming and the phosphate level might be dangerously low before normophosphatemia is re-established. This study evaluated the possibility to prevent hypophosphatemia during CRRT treatment by using a new commercially available phosphate-containing dialysis fluid. Methods Forty-two heterogeneous intensive care unit patients, admitted between January 2007 and July 2008, undergoing hemodiafiltration, were treated with a new Gambro dialysis solution with 1.2 mM phosphate (Phoxilium) or with standard medical treatment (Hemosol B0). The patients were divided into three groups: group 1 (n=14) receiving standard medical treatment and intravenous phosphate supplementation as required, group 2 (n=14) receiving the phosphate solution as dialysate solution and Hemosol B0 as replacement solution and group 3 (n=14) receiving the phosphate-containing solution as both dialysate and replacement solutions. Results Standard medical treatment resulted in hypophosphatemia in 11 of 14 of the patients (group 1) compared with five of 14 in the patients receiving phosphate solution as the dialysate solution and Hemosol B0 as the replacement solution (group 2). Patients treated with the phosphate-containing dialysis solution (group 3) experienced stable serum phosphate levels throughout the study. Potassium, ionized calcium, magnesium, pH, pCO2 and bicarbonate remained unchanged throughout the study. Conclusion The new phosphate-containing replacement and dialysis solution reduces the variability of serum phosphate levels during CRRT and eliminates the incidence of hypophosphatemia. PMID:21039362

MRI appearance of massive renal replacement lipomatosis in the absence of renal calculus disease

PubMed Central

Fitzgerald, E; Melamed, J; Taneja, S S; Rosenkrantz, A B

2011-01-01

Renal replacement lipomatosis is a rare benign entity in which extensive fibrofatty proliferation of the renal sinus is associated with marked renal atrophy. In this report, we present a case of massive renal replacement lipomatosis demonstrated on MRI. The presentation was atypical given an absence of associated renal calculus disease, and an initial CT scan was interpreted as suspicious for a liposarcoma. The differential diagnosis and key MRI findings that served to establish this specific diagnosis are reviewed. Histopathological correlation is also presented, as the patient underwent nephroureterectomy. PMID:21257835

Robotic Versus Open Renal Transplantation in Obese Patients: Protocol for a Cost-Benefit Markov Model Analysis

PubMed Central

Puttarajappa, Chethan; Wijkstrom, Martin; Ganoza, Armando; Lopez, Roberto; Tevar, Amit

2018-01-01

Background Recent studies have reported a significant decrease in wound problems and hospital stay in obese patients undergoing renal transplantation by robotic-assisted minimally invasive techniques with no difference in graft function. Objective Due to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, the primary aim of our study is to develop a Markov model to analyze the cost-benefit of robotic surgery versus open traditional surgery in obese patients in need of a renal transplant. Methods Electronic searches will be conducted to identify studies comparing open renal transplantation versus robotic-assisted renal transplantation. Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations. A decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: (1) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity, (2) transplant recipients undergoing open transplant surgery, and (3) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1 TreeAge Software, Williamstown, MA, USA) will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions. Results The model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients' death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients' age at the time of randomization to determine if age is a critical variable for cost-benefit analysis or cost-effectiveness analysis comparing renal replacement therapy, robotic-assisted surgery or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. Conclusions After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. PMID:29519780

Nursing essential principles: continuous renal replacement therapy.

PubMed

Richardson, Annette; Whatmore, Jayne

2015-01-01

This article aims to guide critical care nurses with the care and management of patients on continuous renal replacement therapy (CRRT). CRRT, a highly specialized therapy involving complex nursing care, is used widely in the intensive care unit to treat patients with acute kidney injury. A literature search was conducted using CINAHL, Medline from PubMed and BNI using the search terms CRRT or continuous veno-venous haemofiltration and nursing or nurses from 2000 onwards and limited to the English language. The appraised evidence and expert opinion is used in this article. Four essential nursing principles for CRRT are reviewed (1) the importance of continuous assessment of the indications to influence the appropriate mode; (2) ensuring good vascular access; (3) the avoidance of unnecessary interruptions and (4) the prevention of complications. The identified four essential nursing principles provide guidance on this complex aspects of nursing practice. Specific nursing research to guide the care and management of this therapy is limited so should be explored in the future. Critical care nurses caring for and managing patients on CRRT require an understanding of how to deliver safe CRRT. © 2014 British Association of Critical Care Nurses.

Regional citrate anticoagulation for continuous renal replacement therapy in severe burns-a retrospective analysis of a protocol-guided approach.

PubMed

Gille, Jochen; Sablotzki, Armin; Malcharek, Michael; Raff, Thomas; Mogk, Martin; Parentin, Torsten

2014-12-01

For critically ill patients, the use of regional citrate anticoagulation as part of continuous renal replacement therapy (CRRT) has become increasingly common in recent years. However, there are scarce data on the use of this technique in patients with burns. The aim of this study was to examine the effectiveness, feasibility and complications of regional citrate anticoagulation for CRRT in burn patients, as well as the effects on coagulation and the electrolyte and acid-base balance. This retrospective study included all patients who received renal replacement therapy with citrate anticoagulation to treat acute kidney injury (AKI) between January 1, 2004 and December 31, 2009 at the burn unit of St. Georg Hospital GmbH in Leipzig. During the examination period, 18 patients were treated using CRRT with regional citrate anticoagulation (CVVHDF in the pre-dilution mode). The median patient age was 64 years (49.5; 71), with a median TBSA of 42.5% (33.25; 52.5) and a median ABSI score of 10 (9; 10). The CRRT was initiated on a median of 6 days (4; 8.75) after admission to the hospital and continued for a median duration of 7 days (5; 8). The median dialysis dose was 38.2mlkgBW(-1)h(-1) (31.8; 42.1). The median effective filter operation time was 67h (46; 72). No relevant disorders associated with acid-base balance, electrolytes or coagulation occurred, and there were no bleeding complications. In terms of bleeding risk and electrolyte and acid-base balance, regional citrate anticoagulation may be considered to be an effective, safe and user-friendly procedure for patients with severe burns and AKI. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

How perceived feelings of "wellness" influence the decision-making of people with predialysis chronic kidney disease.

PubMed

Campbell-Crofts, Sandra; Stewart, Glenn

2018-04-01

To identify the subjective meanings attached to decisions made by people living with chronic kidney disease as they consider their transition to renal replacement therapy. Within the challenging world of chronic illness, people draw upon their temporal life experiences to help them make the best or most balanced primary healthcare decisions. Understanding the risks and benefits associated with these decisions has been an area of intense interest in health research. An exploratory qualitative descriptive design. A convenience sample of twelve people, at stages 3B to 5 of chronic kidney disease, attending two predialysis renal clinics in Sydney, Australia, consented to be interviewed. The semi-structured interviews centred on their decision-making experiences as they considered their transition to renal replacement therapy. Three themes emerged from participant narratives which have been framed into the following questions: (i) Do I need renal replacement therapy? (ii) What is the "right" renal replacement therapy for me? and (iii) When should I start renal replacement therapy? Decisions about the transition to renal replacement therapy were impacted upon by the participants' perceived feelings of wellness and the belief that renal replacement therapy would not be needed at any time in the foreseeable future. This study highlights the importance of optimising person-centred care and raises important issues for the education and management of people with chronic kidney disease in the predialysis stages of the illness. In order to facilitate the transition to renal replacement therapy, renal clinicians have a responsibility to more fully understand the patient journey during the predialysis stages of chronic kidney disease. A clearer understanding of patients' perceptions and decision-making experiences creates a space for mutual understanding. This is essential for the future development and implementation of collaborative, person-centred educational strategies and long-term renal healthcare outcomes. © 2017 John Wiley & Sons Ltd.

Exsanguination Shock: The Next Frontier in Prevention of Battlefield Mortality

DTIC Science & Technology

2011-07-01

and various forms of organ support such as extracorporeal membrane oxygenation/continuous renal replacement therapy.19–23 Given this population of...patient died as a result of near exsanguina- tion but expired with adequate circulating blood volume and indicators of improving physiology

Suicidal intoxication with potassium chlorate successfully treated with renal replacement therapy and extracorporeal liver support.

PubMed

Sein Anand, Jacek; Barwina, Małgorzata; Zajac, Maciej; Kaletha, Krystian

2012-01-01

We present a case of a 22-year-old male who, in a suicide attempt, ingested approximately 200 g of potassium chlorate. Upon admission to the hospital, he presented in full respiratory failure with cyanosis. Methylene blue antidote was given but found to be ineffective. The patient was intubated and mechanical ventilation was initiated. Because of renal failure with anuria, intermittent haemodialysis (iHD) followed by continuous venovenous hemodiafiltration (CVVHDF) was performed. His hospital stay was also complicated by hemolysis, disseminated intravascular coagulation, and atrial fibrillation. Transfusions of packed red blood cells, platelets, and fresh frozen plasma were necessary to correct the deficits. He also developed liver failure and required two sessions of molecular adsorbent recirculating system (MARS) therapy. On day 14 of his hospitalization, he regained consciousness, as well as full respiratory and circulatory function. There are no controlled studies addressing management of potassium chlorate poisoning. We suggest that early renal replacement therapy should be strongly considered.

[Mobile single-pass batch hemodialysis system in intensive care medicine. Reduction of costs and workload in renal replacement therapy].

PubMed

Hopf, H-B; Hochscherf, M; Jehmlich, M; Leischik, M; Ritter, J

2007-07-01

This paper describes the introduction of a single-pass batch hemodialysis system for renal replacement therapy in a 14 bed intensive care unit. The goals were to reduce the workload of intensive care unit physicians using an alternative and simpler method compared to continuous veno-venous hemodiafiltration (CVVHDF) and to reduce the costs of hemofiltrate solutions (80,650 EUR per year in our clinic in 2005). We describe and evaluate the process of implementation of the system as well as the achieved and prospective savings. We conclude that a close cooperation of all participants (physicians, nurses, economists, technicians) of a hospital can achieve substantial benefits for patients and employees as well as reduce the economic burden of a hospital.

Acute coronary syndromes in patients with renal failure.

PubMed

McCullough, Peter A

2003-07-01

As the rates of obesity and diabetes continue to rise sharply in the United States, there is a secondary epidemic of diabetic nephropathy, chronic kidney disease, and end-stage renal disease requiring renal replacement therapy. Cardiovascular disease is the leading cause of death in patients with renal disease. Many sources of information support the concept that the metabolic condition caused by renal failure is an independent cardiac risk factor with a direct relationship to the pathogenesis of atherosclerosis, acute coronary syndromes (ACS), heart failure, and arrhythmias. An estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) has consistently been shown to be the most powerful predictor of adverse outcomes in ACS. This paper focuses on ACS and highlights the major issues with respect to diagnosis and treatment in patients with underlying renal failure. Because patients with renal disease are routinely excluded from clinical trials of ACS, we draw upon a variety of clinical data sets to gather an evidenced-based approach to this important and growing population of patients.

Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II.

PubMed

Tumlin, James A; Murugan, Raghavan; Deane, Adam M; Ostermann, Marlies; Busse, Laurence W; Ham, Kealy R; Kashani, Kianoush; Szerlip, Harold M; Prowle, John R; Bihorac, Azra; Finkel, Kevin W; Zarbock, Alexander; Forni, Lui G; Lynch, Shannan J; Jensen, Jeff; Kroll, Stew; Chawla, Lakhmir S; Tidmarsh, George F; Bellomo, Rinaldo

2018-06-01

Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. ICUs. Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively). IV angiotensin II or placebo. Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%-67%) and 30% (95% CI, 19%-41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%-54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%-27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%-68%) and 22% (95% CI, 12%-34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively. In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.

Standard versus accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI): study protocol for a randomized controlled trial.

PubMed

Smith, Orla M; Wald, Ron; Adhikari, Neill K J; Pope, Karen; Weir, Matthew A; Bagshaw, Sean M

2013-10-05

Acute kidney injury is a common and devastating complication of critical illness, for which renal replacement therapy is frequently needed to manage severe cases. While a recent systematic review suggested that "earlier" initiation of renal replacement therapy improves survival, completed trials are limited due to small size, single-centre status, and use of variable definitions to define "early" renal replacement therapy initiation. This is an open-label pilot randomized controlled trial. One hundred critically ill patients with severe acute kidney injury will be randomly allocated 1:1 to receive "accelerated" initiation of renal replacement therapy or "standard" initiation at 12 centers across Canada. In the accelerated arm, participants will have a venous catheter placed and renal replacement therapy will be initiated within 12 hours of fulfilling eligibility. In the standard initiation arm, participants will be monitored over 7 days to identify indications for renal replacement therapy. For participants in the standard arm with persistent acute kidney injury, defined as a serum creatinine not declining >50% from the value at the time of eligibility, the initiation of RRT will be discouraged unless one or more of the following criteria are fulfilled: serum potassium ≥6.0 mmol/L; serum bicarbonate ≤10 mmol/L; severe respiratory failure (PaO₂/FiO₂<200) or persisting acute kidney injury for ≥72 hours after fulfilling eligibility. The inclusion criteria are designed to identify a population of critically ill adults with severe acute kidney injury who are likely to need renal replacement therapy during their hospitalization, but not immediately. The primary outcome is protocol adherence (>90%). Secondary outcomes include measures of feasibility (proportion of eligible patients enrolled in the trial, proportion of enrolled patients followed to 90 days for assessment of vital status and the need for renal replacement therapy) and safety (occurrence of adverse events). The optimal timing of renal replacement therapy initiation in patients with severe acute kidney injury remains uncertain, representing an important knowledge gap and a priority for high-quality research. This pilot trial is necessary to establish protocol feasibility, confirm the safety of participants and obtain estimated events rates for design of a large definitive trial. NCT01557361.

Argatroban versus Lepirudin in critically ill patients (ALicia): a randomized controlled trial.

PubMed

Treschan, Tanja A; Schaefer, Maximilian S; Geib, Johann; Bahlmann, Astrid; Brezina, Tobias; Werner, Patrick; Golla, Elisabeth; Greinacher, Andreas; Pannen, Benedikt; Kindgen-Milles, Detlef; Kienbaum, Peter; Beiderlinden, Martin

2014-10-25

Critically ill patients often require renal replacement therapy accompanied by thrombocytopenia. Thrombocytopenia during heparin anticoagulation may be due to heparin-induced thrombocytopenia with need for alternative anticoagulation. Therefore, we compared argatroban and lepirudin in critically ill surgical patients. Following institutional review board approval and written informed consent, critically ill surgical patients more than or equal to 18 years with suspected heparin-induced thrombocytopenia, were randomly assigned to receive double-blind argatroban or lepirudin anticoagulation targeting an activated Partial Thromboplastin Time (aPTT) of 1.5 to 2 times baseline. In patients requiring continuous renal replacement therapy we compared the life-time of hemodialysis filters. We evaluated in all patients the incidence of bleeding and thrombembolic events. We identified 66 patients with suspected heparin-induced thrombocytopenia, including 28 requiring renal replacement therapy. Mean filter lifetimes did not differ between groups (argatroban 32 ± 25 hours (n = 12) versus lepirudin 27 ± 21 hours (n = 16), mean difference 5 hours, 95% CI -13 to 23, P = 0.227). Among all 66 patients, relevant bleeding occurred in four argatroban- versus eleven lepirudin-patients (OR 3.9, 95% CI 1.1 to 14.0, P = 0.040). In the argatroban-group, three thromboembolic events occurred compared to two in the lepirudin group (OR 0.7, 95% CI 0.1 to 4.4, P = 0.639). The incidence of confirmed heparin-induced thrombocytopenia was 23% (n = 15) in our study population. This first randomized controlled double-blind trial comparing two direct thrombin inhibitors showed comparable effectiveness for renal replacement therapy, but suggests fewer bleeds in surgical patients with argatroban anticoagulation. Clinical Trials.gov NCT00798525. Registered 25 November 2008.

Mortality risk disparities in children receiving chronic renal replacement therapy for the treatment of end-stage renal disease across Europe: an ESPN-ERA/EDTA registry analysis.

PubMed

Chesnaye, Nicholas C; Schaefer, Franz; Bonthuis, Marjolein; Holman, Rebecca; Baiko, Sergey; Baskın, Esra; Bjerre, Anna; Cloarec, Sylvie; Cornelissen, Elisabeth A M; Espinosa, Laura; Heaf, James; Stone, Rosário; Shtiza, Diamant; Zagozdzon, Ilona; Harambat, Jérôme; Jager, Kitty J; Groothoff, Jaap W; van Stralen, Karlijn J

2017-05-27

We explored the variation in country mortality rates in the paediatric population receiving renal replacement therapy across Europe, and estimated how much of this variation could be explained by patient-level and country-level factors. In this registry analysis, we extracted patient data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry for 32 European countries. We included incident patients younger than 19 years receiving renal replacement therapy. Adjusted hazard ratios (aHR) and the explained variation were modelled for patient-level and country-level factors with multilevel Cox regression. The primary outcome studied was all-cause mortality while on renal replacement therapy. Between Jan 1, 2000, and Dec 31, 2013, the overall 5 year renal replacement therapy mortality rate was 15·8 deaths per 1000 patient-years (IQR 6·4-16·4). France had a mortality rate (9·2) of more than 3 SDs better, and Russia (35·2), Poland (39·9), Romania (47·4), and Bulgaria (68·6) had mortality rates more than 3 SDs worse than the European average. Public health expenditure was inversely associated with mortality risk (per SD increase, aHR 0·69, 95% CI 0·52-0·91) and explained 67% of the variation in renal replacement therapy mortality rates between countries. Child mortality rates showed a significant association with renal replacement therapy mortality, albeit mediated by macroeconomics (eg, neonatal mortality reduced from 1·31 [95% CI 1·13-1·53], p=0·0005, to 1·21 [0·97-1·51], p=0·10). After accounting for country distributions of patient age, the variation in renal replacement therapy mortality rates between countries increased by 21%. Substantial international variation exists in paediatric renal replacement therapy mortality rates across Europe, most of which was explained by disparities in public health expenditure, which seems to limit the availability and quality of paediatric renal care. Differences between countries in their ability to accept and treat the youngest patients, who are the most complex and costly to treat, form an important source of disparity within this population. Our findings can be used by policy makers and health-care providers to explore potential strategies to help reduce these health disparities. ERA-EDTA and ESPN. Copyright © 2017 Elsevier Ltd. All rights reserved.

Current practice in continuous renal replacement therapy: An epidemiological multicenter study.

PubMed

Tomasa Irriguible, T M; Sabater Riera, J; Poch López de Briñas, E; Fort Ros, J; Lloret Cora, M J; Roca Antònio, J; Navas Pérez, A; Ortiz Ballujera, P; Servià Goixart, L; González de Molina Ortiz, F J; Rovira Anglès, C; Rodríguez López, M; Roglan Piqueras, A

2017-05-01

The aim of the study is to ascertain the most relevant aspects of the current management of renal replacement therapy (RRT) in critically ill patients, and to analyze renal function recovery and mortality in patients undergoing RRT. A non-interventional three-month observational study was made in 2012, with a follow-up period of 90 days, in 21 centers in Catalonia (Spain). Demographic information, severity scores and clinical data were obtained, as well as RRT parameters. patients aged ≥ 16 years admitted to Intensive Care Units (ICUs) and subjected to RRT. A total of 261 critically ill patients were recruited, of which 35% had renal dysfunction prior to admission. The main reason for starting RRT was oliguria; the most widely used RRT modality was hemodiafiltration; and the median prescribed dose at baseline was 35mL/kg/h. The median time of RRT onset from ICU admission was one day. The mortality rate at 30 and 90 days was 46% and 54%, respectively, and was associated to greater severity scores and a later onset of RRT. At discharge, 85% of the survivors had recovered renal function. Current practice in RRT in Catalonia abides with the current clinical practice guidelines. Mortality related to RRT is associated to later onset of such therapy. The renal function recovery rate at hospital discharge was 85% among the patients subjected to RRT. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

[Dialysis dose quantification in critically ill patients].

PubMed

Casino, Francesco Gaetano

2010-01-01

Acute kidney injury affects about 35% of intensive care unit patients. Renal replacement therapy is required in about 5% of such patients and is associated with a mortality rate as high as 50% to 80%. The latter is likely more related to the failure of extrarenal organs than to an insufficient dialysis dose. This could explain, at least in part, the findings of 2 recent trials (VA/ NIH and RENAL) where the expected dose-outcome relationship was not confirmed. These results cannot be taken to infer that assessing the dialysis dose is no longer required. The contrary is true, in that the common finding of large differences between prescribed and delivered doses calls for accurate dose assessment, at least to avoid underdialysis. The minimum adequate levels are now a Kt/V urea of 1.2 to 1.4 three times a week (3x/wk) on intermittent hemodialysis (IHD), and an effluent of 20 mL/kg/h for 85% of the time on continuous renal replacement therapy (CRTT). Both these parameters can be easily measured but are far from ideal indices because they account neither for residual renal function nor for irregular dose delivery. The equivalent renal urea clearance (EKRjc), by expressing the averaged renal+dialytic urea clearance over the whole treatment period, is able to account for the above factors. Although assessing EKRjc is quite complex, for regular 3x/wk IHD one could use the formula EKRjc=10 Kt/V+1 to compute that a Kt/V of 1.2 and 1.4 corresponds to an EKRjc of 13 and 15 mL/min, respectively. On the other hand, the hourly effluent per kg is numerically similar to EKRjc. On this basis it can be calculated that in non-prediluted really continuous treatment, the recommended CRRT dose (EKRjc=20 mL/min) is 33% higher than the EKRjc of 15 mL/min, corresponding to the recommended Kt/V of 1.4 on 3x/wk IHD.

Enteral nutrition in patients with acute renal failure.

PubMed

Fiaccadori, Enrico; Maggiore, Umberto; Giacosa, Roberto; Rotelli, Carlo; Picetti, Edoardo; Sagripanti, Sibilla; Melfa, Luigi; Meschi, Tiziana; Borghi, Loris; Cabassi, Aderville

2004-03-01

Systematic studies on safety and efficacy of enteral nutrition in patients with acute renal failure (ARF) are lacking. We studied enteral nutrition-related complications and adequacy of nutrient administration during 2525 days of artificial nutrition in 247 consecutive patients fed exclusively by the enteral route: 65 had normal renal function, 68 had ARF not requiring renal replacement therapy, and 114 required renal replacement therapy. No difference was found in gastrointestinal or mechanical complications between ARF patients and patients with normal renal function, except for high gastric residual volumes, which occurred in 3.1% of patients with normal renal function, 7.3% of patients with ARF not requiring renal replacement therapy, 13.2% of patients with ARF on renal replacement therapy (P= 0.02 for trend), and for nasogastric tube obstruction: 0.0%, 5.9%, 14%, respectively (P < 0.001). Gastrointestinal complications were the most frequent cause of suboptimal delivery; the ratio of administered to prescribed daily volume was well above 90% in all the three groups. Definitive withdrawal of enteral nutrition due to complications was documented in 6.1%, 13.2%. and 14.9% of patients, respectively (P= 0.09 for trend). At regimen, mean delivered nonprotein calories were 19.8 kcal/kg (SD 4.6), 22.6 kcal/kg (8.4), 23.4 kcal/kg (6.5); protein intake was 0.92 g/kg (0.21), 0.87 g/kg (0.25), and 0.92 g/kg (0.21), the latter value being below that currently recommended for ARF patients on renal replacement therapy. Median fluid intake with enteral nutrition was 1440 mL (range 720 to 1960), 1200 (720 to 2400), and 960 (360 to 1920). Enteral nutrition is a safe and effective nutritional technique to deliver artificial nutrition in ARF patients. Parenteral amino acid supplementation may be required, especially in patients with ARF needing renal replacement therapy.

Fasciotomy Rates in Operations Enduring Freedom and Iraqi Freedom: Association with Injury Severity and Tourniquet Use

DTIC Science & Technology

2011-03-01

civilian trauma care, more evidence supports their use for hemorrhage control in combat casualties.7–9 With the recent widespread reintroduction of...KK, Juncos LA, Wolf SE, et al. Continuous renal replacement therapy improves survival in severely burned military casualties with acute kidney injury

Progressive renal failure despite long-term biweekly enzyme replacement therapy in a patient with Fabry disease secondary to a new α-galactosidase mutation of Leu311Arg (L311R).

PubMed

Suzuki, Keisuke; Miura, Naoto; Kitagawa, Wataru; Suzuki, Shinkichi; Komatsuda, Atsushi; Nishikawa, Kazuhiro; Watanabe, Daisuke; Imai, Hirokazu

2011-12-01

A 37-year-old Japanese man affected by Fabry disease secondary to a novel mutation of Leu311Arg (L311R) in α-galactosidase demonstrated progressive renal failure despite biweekly enzyme replacement therapy (ERT) for approximately 10 years. Kidney biopsy revealed foamy glomerular epithelial cells, compatible with the typical pathologic features of Fabry disease. The patient entered a phase III study of Replagal (agalsidase alfa) in 2001, allowing him to continue ERT with biweekly dosing for almost 10 years. During 2 years of that period, he was continued on Fabrazyme (agalsidase beta) biweekly dosing. His estimated GFR was calculated to decrease by 9.9 mL/min/1.73 m(2) per year. Patients with Fabry disease have been reported to have a mean decrease in GFR of 12.2 ± 8.1 mL/min/1.73 m(2) per year. This result suggests that biweekly ERT is only mildly effective at preventing loss of kidney function.

[Echinocandins: searching for differences. The example of their use in patients requiring continuous renal replacement therapy].

PubMed

de la Llama-Celis, Natalia; Huarte-Lacunza, Rafael; Gómez-Baraza, Cristina; Cañamares-Orbis, Iciar; Sebastián-Aldeanueva, Manuel; Arrieta-Navarro, Raquel

2012-12-01

The echinocandins have a growing role in the treatment of fungal infections because of their novel mechanism of action. This is reflected in recently published management guidelines, but available in vitro data, animal studies, and clinical studies do not clearly differentiate the three agents in class. Comparative clinical efficacy among agents within the class, pharmacokinetic profiles in special populations, pharmacoeconomics justifications, and place in therapy have been largely unanswered. They share many common properties but marketing strategies of drug manufacturers are engaged in product differentiation. Although exist similarities in the pharmacokinetic (PK) profiles of the echinocandins, limited data have been published regarding their pharmacokinetics in continuous renal replacement therapy (CRRT) patients. The pharmacokinetics of drug removal in critically ill patients receiving CRRT is very complex, with multiple variables affecting clearance. This review outlines the basic principles that determine whether a dose adjustment is required. Two studies with data on PK parameters of micafungin and anidulafungin in CRRT patients have been published and are compared following that basic principles in the review.

Bioengineering in renal transplantation: technological advances and novel options.

PubMed

Yeo, Wee-Song; Zhang, Yao-Chun

2017-06-06

End-stage kidney disease (ESKD) is one of the most prevalent diseases in the world with significant morbidity and mortality. Current modes of renal replacement therapy include dialysis and renal transplantation. Although dialysis is an acceptable mode of renal replacement therapy, it does have its shortcomings, which include poorer life expectancy compared with renal transplantation, risk of infections and vascular thrombosis, lack of vascular access and absence of biosynthetic functions of the kidney. Renal transplantation, in contrast, is the preferred option of renal replacement therapy, with improved morbidity and mortality rates and quality of life, compared with dialysis. Renal transplantation, however, may not be available to all patients with ESKD. Some of the key factors limiting the availability and efficiency of renal transplantation include shortage of donor organs and the constant risk of rejection with complications associated with over-immunosuppression respectively. This review focuses chiefly on the potential roles of bioengineering in overcoming limitations in renal transplantation via the development of cell-based bioartificial dialysis devices as bridging options before renal transplantation, and the development of new sources of organs utilizing cell and organ engineering.

Association between mortality and replacement solution bicarbonate concentration in continuous renal replacement therapy: A propensity-matched cohort study.

PubMed

Kashani, Kianoush; Thongprayoon, Charat; Cheungpasitporn, Wisit; Iacovella, Gina M; Akhoundi, Abbasali; Albright, Robert C

2017-01-01

Given the known deleterious effects seen with bicarbonate supplementation for acidemia, we hypothesized that utilizing high bicarbonate concentration replacement solution in continuous venovenous hemofiltration (CVVH) would be independently associated with higher mortality. In a propensity score-matched historical cohort study conducted at a single tertiary care center from December 9, 2006, through December 31, 2009, a total of 287consecutive adult critically ill patients with Stage III acute kidney injury (AKI) requiring CVVH were enrolled. We excluded patients on maintenance dialysis, those who received other modalities of continuous renal replacement therapies, and patients that received a mixed of 22 and 32 mEq/L bicarbonate solution pre- and post-filter. The primary outcome was in-hospital and 90-day mortality rates. Among enrollees, 68 were used 32 mEq/L bicarbonate solution, and 219 received 22mEq/L bicarbonate solution for CVVH. Patients on 32 mEq/L bicarbonate solution were more often non-surgical, had lower pH and bicarbonate level but had higher blood potassium and phosphorus levels in comparison with those on 22 mEq/L bicarbonate solution. After adjustment for the baseline characteristics, the use of 32 bicarbonate solution was significantly associated with increased in-hospital (HR = 1.94; 95% CI 1.02-3.79) and 90-day mortality (HR = 1.50; 95% CI 1.03-2.14). There was a significant increase in the hospital (p = .03) and 90-day (p = .04) mortality between the 22 vs. 32 mEq/L bicarbonate solution groups following propensity matching. Our data showed there is a strong association between using high bicarbonate solution and mortality independent of severity of illness and comorbid conditions. These findings need to be evaluated further in prospective studies.

The use of renal replacement therapy in acute decompensated heart failure.

PubMed

Udani, Suneel M; Murray, Patrick T

2009-01-01

The worsening of renal function in the context of decompensated heart failure is an increasingly common clinical scenario, dubbed the cardiorenal syndrome. Its development is not completely understood; however, it results from the hemodynamic and neurohumoral alterations that occur in the setting of left ventricular pressure and volume overload with poor cardiac output. Diuretics have been the mainstay of treatment; however, they are often unsuccessful in reversing the vicious cycle of volume overload, worsening cardiac function, and azotemia. Renal replacement therapy (RRT) in the form of isolated or continuous ultrafiltration (UF) with or without a component of solute clearance (hemofiltration or hemodialysis) has been increasingly utilized as a therapeutic tool in this setting. Initial clinical trial data on the use of UF have demonstrated promising cardiac outcomes with regard to fluid removal and symptom relief without worsening renal function. The addition of a component of solute clearance may provide additional benefits in these patients with varying degrees of renal impairment. The exact clinical setting in which the various forms of RRT should be applied as initial or early therapy for acute decompensated heart failure (ADHF) remains unknown. More research examining the use of RRT in ADHF is necessary; however, it appears that the patients with the most severe clinical presentations have the best chance of benefiting from the early application of RRT.

Family clustering of secondary chronic kidney disease with hypertension or diabetes mellitus. A case-control study.

PubMed

de Almeida, Fernando Antonio; Ciambelli, Giuliano Serafino; Bertoco, André Luz; Jurado, Marcelo Mai; Siqueira, Guilherme Vasconcelos; Bernardo, Eder Augusto; Pavan, Maria Valeria; Gianini, Reinaldo José

2015-02-01

In Brazil hypertension and type 2 diabetes mellitus are responsible for 60% of cases of end-stage renal disease in renal replacement therapy. In the United States studies have identified family clustering of chronic kidney disease, predominantly in African-Americans. A single Brazilian study observed family clustering among patients with chronic kidney disease when compared with hospitalized patients with normal renal function. This article aims to assess whether there is family clustering of chronic kidney disease in relatives of individuals in renal replacement therapy caused by hypertension and/or diabetes mellitus. A case-control study with 336 patients in renal replacement therapy with diabetes mellitus or hypertension for at least 5 years (cases) and a control matched sample group of individuals with hypertension or diabetes mellitus and normal renal function (n = 389). Individuals in renal replacement therapy (cases) had a ratio of 2.35 (95% CI 1.42-3.89, p < 0.001) versus the control group in having relatives with chronic renal disease, irrespective of race or causative illness. There is family clustering of chronic kidney disease in the sample studied, and this predisposition is irrespective of race and underlying disease (hypertension or diabetes mellitus).

[Critical care nurse learning of continuous renal replacement therapy: the efficacy of a self-learning manual].

PubMed

Huang, Yi-Chen; Hsu, Li-Ling

2011-02-01

Many nurses have difficulty learning to use the complex, non-traditional, and regularly-updated critical care equipment. Failure to use such equipment properly can seriously compromise treatment and endanger patient health and lives. New self-learning materials for novice nurses are necessary to provide essential and effective guidance as a part of formal nursing training. Such materials can enhance the capabilities of critical care nurses and, thus, improve the general quality of critical care. The purpose of this research was to develop a continuous renal replacement therapy (CRRT)-themed self-learning manual that would provide easily absorbed and understood knowledge in an easy-to-carry format for ICU nursing staff. This study also investigated CCRT skill learning efficacy. This study adopted a quasi-experimental design with pretests and posttests. Purposive sampling generated a sample of 66 critical care nurses currently working at one hospital in Taipei City. Participants submitted a completed self-assessment survey that rated their command of continuous renal replacement therapy before and after the self-learning manual intervention. Survey data were analyzed using SPSS Version 17.0 for Windows. The two major findings derived from the study included: (1) The mean response score from the self-assessment survey filled out after the intervention was 91.06 and 79.75 (SD = 9.49 and 11.65), respectively, for experimental and control groups. Such demonstrated significant difference. (2) The mean posttest score after the intervention for the experimental group was 91.06 ± 9.49. This represents a significant increase of 10.35 ± 10.35 over their mean pretest score (80.71 ± 11.82). The experimental group showed other significant differences in terms of the CRRT self-assessment survey posttest. Self-learning manuals may be introduced in nursing education as useful aids and catalysts to achieve more effective and satisfying learning experiences.

Circuit lifespan during continuous renal replacement therapy for combined liver and kidney failure.

PubMed

Chua, Horng-Ruey; Baldwin, Ian; Bailey, Michael; Subramaniam, Ashwin; Bellomo, Rinaldo

2012-12-01

To evaluate circuit lifespan (CL) and bleeding risk during continuous renal replacement therapy (CRRT), in combined liver and renal failure. Single-center retrospective analysis of adults with acute liver failure or decompensated cirrhosis who received CRRT, without anticoagulation or with heparinization in intensive care unit. Seventy-one patients with 539 CRRT circuits were evaluated. Median overall CL was 9 (6-16) hours. CL was 12 (7-24) hours in 51 patients never anticoagulated for CRRT. In 20 patients who subsequently received heparinization, CL was 7 (5-11) hours without anticoagulation, which did not improve with systemic or regional heparinization (P = .231), despite higher peri-circuit activated partial thromboplastin time (APTT) and heparin dose. Using multivariate linear regression, patients with higher baseline APTT or serum bilirubin, or who were not mechanically ventilated, had longer CL (P < .05). Additionally, peri-circuit thrombocytopenia (P < .0001) or higher international normalized ratio (P < .05) predicted longer CL. Of 71 patients, 33 had significant bleeding events. Using multivariate logistic regression, patients with higher baseline APTT, vasoactive drug use >24 hours, or thrombocytopenia, had more bleeding complications (P < .05). Decreasing platelet counts (especially <50 × 10(9)/mm(3)) had an incremental effect on CL (P < .0001). CRRT CL is short in patients with liver failure despite apparent coagulopathy. Thrombocytopenia predicts longer CL and bleeding complications. Copyright © 2012 Elsevier Inc. All rights reserved.

Predictors of Mortality in the Critically Ill Cirrhotic Patient: Is the Model for End-Stage Liver Disease Enough?

PubMed

Annamalai, Alagappan; Harada, Megan Y; Chen, Melissa; Tran, Tram; Ko, Ara; Ley, Eric J; Nuno, Miriam; Klein, Andrew; Nissen, Nicholas; Noureddin, Mazen

2017-03-01

Critically ill cirrhotics require liver transplantation urgently, but are at high risk for perioperative mortality. The Model for End-stage Liver Disease (MELD) score, recently updated to incorporate serum sodium, estimates survival probability in patients with cirrhosis, but needs additional evaluation in the critically ill. The purpose of this study was to evaluate the predictive power of ICU admission MELD scores and identify clinical risk factors associated with increased mortality. This was a retrospective review of cirrhotic patients admitted to the ICU between January 2011 and December 2014. Patients who were discharged or underwent transplantation (survivors) were compared with those who died (nonsurvivors). Demographic characteristics, admission MELD scores, and clinical risk factors were recorded. Multivariate regression was used to identify independent predictors of mortality, and measures of model performance were assessed to determine predictive accuracy. Of 276 patients who met inclusion criteria, 153 were considered survivors and 123 were nonsurvivors. Survivor and nonsurvivor cohorts had similar demographic characteristics. Nonsurvivors had increased MELD, gastrointestinal bleeding, infection, mechanical ventilation, encephalopathy, vasopressors, dialysis, renal replacement therapy, requirement of blood products, and ICU length of stay. The MELD demonstrated low predictive power (c-statistic 0.73). Multivariate analysis identified MELD score (adjusted odds ratio [AOR] = 1.05), mechanical ventilation (AOR = 4.55), vasopressors (AOR = 3.87), and continuous renal replacement therapy (AOR = 2.43) as independent predictors of mortality, with stronger predictive accuracy (c-statistic 0.87). The MELD demonstrated relatively poor predictive accuracy in critically ill patients with cirrhosis and might not be the best indicator for prognosis in the ICU population. Prognostic accuracy is significantly improved when variables indicating organ support (mechanical ventilation, vasopressors, and continuous renal replacement therapy) are included in the model. Copyright © 2016. Published by Elsevier Inc.

Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Study

PubMed Central

2010-01-01

Introduction Severe acute kidney injury (AKI) can be treated with either continuous renal replacement therapy (CRRT) or intermittent renal replacement therapy (IRRT). Limited evidence from existing studies does not support an outcome advantage of one modality versus the other, and most centers around the word use both modalities according to patient needs. However, cost estimates involve multiple factors that may not be generalizable to other sites, and, to date, only single-center cost studies have been performed. The aim of this study was to estimate the cost difference between CRRT and IRRT in the intensive care unit (ICU). Methods We performed a post hoc analysis of a prospective observational study among 53 centers from 23 countries, from September 2000 to December 2001. We estimated costs based on staffing, as well as dialysate and replacement fluid, anticoagulation and extracorporeal circuit. Results We found that the theoretic range of costs were from $3,629.80/day more with CRRT to $378.60/day more with IRRT. The median difference in cost between CRRT and IRRT was $289.60 (IQR 830.8-116.8) per day (greater with CRRT). Costs also varied greatly by region. Reducing replacement fluid volumes in CRRT to ≤ 25 ml/min (approximately 25 ml/kg/hr) would result in $67.20/day (23.2%) mean savings. Conclusions Cost considerations with RRT are important and vary substantially among centers. We identified the relative impact of four cost domains (nurse staffing, fluid, anticoagulation, and extracorporeal circuit) on overall cost differences, and hospitals can look to these areas to reduce costs associated with RRT. PMID:20346163

Using continuous renal replacement therapy to manage patients of shock and acute renal failure

PubMed Central

Soni, Sachin S; Nagarik, Amit P; Adikey, Gopal Kishan; Raman, Anuradha

2009-01-01

Background: The incidence of acute renal failure (ARF) in the hospital setting is increasing. It portends excessive morbidity and mortality and a considerable burden on hospital resources. Extracorporeal therapies show promise in the management of patients with shock and ARF. It is said that the potential of such therapy goes beyond just providing renal support. The aim of our study was to analyze the clinical setting and outcomes of critically ill ARF patients managed with continuous renal replacement therapy (CRRT). Patients and Methods: Ours was a retrospective study of 50 patients treated between January 2004 and November 2005. These 50 patients were in clinical shock and had concomitant ARF. All of these patients underwent CVVHDF (continuous veno-venous hemodiafiltration) in the intensive care unit. For the purpose of this study, shock was defined as systolic BP < 100 mm Hg in spite of administration of one or more inotropic agents. SOFA (Sequential Organ Failure Assessment) score before initiation of dialysis support was recorded in all cases. CVVHDF was performed using the Diapact® (Braun) CRRT machine. The vascular access used was as follows: femoral in 32, internal jugular in 8, arteriovenous fistula (AVF) in 4, and subclavian in 6 patients. We used 0.9% or 0.45% (half-normal) saline as a prefilter replacement, with addition of 10% calcium gluconate, magnesium sulphate, sodium bicarbonate, and potassium chloride in separate units, while maintaining careful monitoring of electrolytes. Anticoagulation of the extracorporeal circuit was achieved with systemic heparin in 26 patients; frequent saline flushes were used in the other 24 patients. Results: Of the 50 patients studied, 29 were males and 21 females (1.4:1). The average age was 52.88 years (range: 20–75 years). Causes of ARF included sepsis in 24 (48%), hemodynamically mediated renal failure (HMRF) in 18 (36%), and acute over chronic kidney disease in 8 (16%) patients. The overall mortality was 74%. The average SOFA score was 14.31. The variables influencing mortality on multivariate analysis were: age [odds ratio (OR):1.65; 95% CI: 1.35 to 1.92; P = 0.04], serum creatinine (OR:1.68; 95% CI: 1.44 to 1.86; P = 0.03), and serum bicarbonate (OR: 0.76; 95% CI: 0.55 to 0.94; P = 0.01). On univariate analysis the SOFA score was found to be a useful predictor of mortality. Conclusions: Despite advances in treating critically ill patients with newer extracorporeal therapies, mortality is dismally high. Multiorgan dysfunction adversely affects outcome of CRRT. Older age, level of azotemia, and severity of metabolic acidosis are important predictors of adverse outcome. PMID:19561951

Automated electronic monitoring of circuit pressures during continuous renal replacement therapy: a technical report.

PubMed

Zhang, Ling; Baldwin, Ian; Zhu, Guijun; Tanaka, Aiko; Bellomo, Rinaldo

2015-03-01

Automated electronic monitoring and analysis of circuit pressures during continuous renal replacement therapy (CRRT) has the potential to predict failure and allow intervention to optimise function. Current CRRT machines can measure and store pressure readings for downloading into databases and for analysis. We developed a procedure to obtain such data at intervals of 1 minute and analyse them using the Prismaflex CRRT machine, and we present an example of such analysis. We obtained data on pressures obtained at intervals of 1 minute in a patient with acute kidney injury and sepsis treated with continuous haemofiltration at 2 L/hour of ultrafiltration and a blood flow of 200 mL/minute. Data analysis identified progressive increases in transmembrane pressure (TMP) and prefilter pressure (PFP) from time 0 until 33 hours or clotting. TMP increased from 104 mmHg to 313 mmHg and PFP increased from from 131 mmHg to 185 mmHg. Effluent pressure showed a progressive increase in the negative pressure applied to achieve ultrafiltration from 0 mmHg to -168 mmHg. The inflection point for such changes was also identified. Blood pathway pressures for access and return remained unchanged throughout. Automated electronic monitoring of circuit pressure during CRRT is possible and provides useful information on the evolution of circuit clotting.

Open heart surgery after renal transplantation.

PubMed

Yamamura, Mitsuhiro; Miyamoto, Yuji; Mitsuno, Masataka; Tanaka, Hiroe; Ryomoto, Masaaki; Fukui, Shinya; Tsujiya, Noriko; Kajiyama, Tetsuya; Nojima, Michio

2014-09-01

to evaluate the strategy for open heart surgery after renal transplantation performed in a single institution in Japan. we reviewed 6 open heart surgeries after renal transplantation in 5 patients, performed between January 1992 and December 2012. The patients were 3 men and 2 women with a mean age of 60 ± 11 years (range 46-68 years). They had old myocardial infarction and unstable angina, aortic and mitral stenosis, left arterial myxoma, aortic stenosis, and native valve endocarditis followed by prosthetic valve endocarditis. Operative procedures included coronary artery bypass grafting, double-valve replacement, resection of left arterial myxoma, 2 aortic valve replacements, and a double-valve replacement. Renal protection consisted of steroid cover (hydrocortisone 100-500 mg or methylprednisolone 1000 mg) and intravenous immunosuppressant infusion (cyclosporine 30-40 mg day(-1) or tacrolimus 1.0 mg day(-1)). 5 cases were uneventful and good renal graft function was maintained at discharge (serum creatinine 2.1 ± 0.5 mg dL(-1)). There was one operative death after emergency double-valve replacement for methicillin-resistant Staphylococcus aureus-associated prosthetic valve endocarditis. Although the endocarditis improved after valve replacement, the patient died of postoperative pneumonia on postoperative day 45. careful perioperative management can allow successful open heart surgery after renal transplantation. However, severe complications, especially methicillin-resistant Staphylococcus aureus infection, may cause renal graft loss. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

[Residual renal function and nutritional status in patients on continuous ambulatory peritoneal dialysis].

PubMed

Jovanović, Natasa; Lausević, Mirjana; Stojimirović, Biljana

2005-01-01

During the last years, an increasing number of patients with end-stage renal failure caused by various underlying diseases, all over the world, is treated by renal replacement therapy. NUTRITIONAL STATUS: Malnutrition is often found in patients affected by renal failure; it is caused by reduced intake of nutritional substances due to anorexia and dietary restrictions hormonal and metabolic disorders, comorbid conditions and loss of proteins, amino-acids, and vitamins during the dialysis procedure itself. Nutritional status significantly affects the outcome of patients on chronic dialysis treatment. Recent epiodemiological trials have proved that survival on chronic continuous ambulatory peritoneal dialysis program depends more on residual renal function (RRF) than on peritoneal clearances of urea and creatinine. The aim of the study was to analyze the influence of RRF on common biochemical and anthropometric markers of nutrition in 32 patients with end-stage renal failure with various underlying diseases during the first 6 months on continuous ambulatory peritoneal dialysis (CAPD). The mean residual creatinine clearance was 8,3 ml/min and the mean RRF was 16,24 l/week in our patients at the beginning of the chronic peritoneal dialysis treatment. During the follow-up, the RRF slightly decreased, while the nutritional status of patients significantly improved. Gender and age, as well as the leading disease and peritonitis didn't influence the RRF during the first 6 months of CAPD treatment. We found several positive correlations between RRF and laboratory and anthropometric markers of nutrition during the follow-up, proving the positive influence of RRF on nutritional status of patients on chronic peritoneal dialysis.

Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study.

PubMed

Verma, Sean; Bassily, Emmanuel; Leighton, Shane; Mhaskar, Rahul; Sunjic, Igor; Martin, Angel; Rihana, Nancy; Jarmi, Tambi; Bassil, Claude

2017-07-01

Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated. In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer's exact at the significance level of 0.05. Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001). Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period.

The use of the RenalGuard system in cardiac surgery with cardiopulmonary bypass: a first in man prospective, observational, feasibility pilot study

PubMed Central

Giri, Ramesh; Wrigley, Benmjamin; Hennessy, Anne-Marie; Nicholas, Johann; Nevill, Alan

2017-01-01

Objectives As proof of concept, this prospective, observational study assessed the feasibility and early clinical outcomes of performing on-pump cardiac surgery with the RenalGuard system. Background Acute kidney injury (AKI) is reported in up to 30% of patients undergoing cardiac surgery and is a recognised independent predictor of both morbidity and mortality. Forced diuresis with the RenalGuard system reduces the incidence of AKI during percutaneous coronary intervention procedures but its use in cardiac surgery has not been explored. Methods Ten consecutive patients who were at risk of developing AKI during cardiac surgery were selected. The RenalGuard system was used to facilitate forced diuresis using weight-adjusted intravenous furosemide while maintaining neutral fluid balance by matched intravenous fluid replacement. This regimen was initiated preoperatively in all patients and continued for 6–12 hours postoperatively. Serum creatinine, electrolytes and need for renal replacement were documented in all patients. Results The RenalGuard system functioned successfully in all patients and facilitated high perioperative urine outputs, even when patients were placed on cardiopulmonary bypass (CPB). There were no incidences of significant (A) electrolyte imbalance, (B) changes in haemoglobin levels or (C) pulmonary oedema. No patients developed AKI within 36 hours of surgery despite one patient developing cardiac tamponade 8 hours postoperatively and one patient developing paralytic ileus. One patient, however, was ‘electively’ haemofiltered on day 2 after developing acute right ventricular failure. The median intensive care stay was 1.5 (1, 5) days. Conclusion The RenalGuard system can be used successfully in patients undergoing cardiac surgery with CPB and may reduce the incidence of AKI in at-risk patients. Trial registration NCT02974946; Pre-results. PMID:29071091

The use of the RenalGuard system in cardiac surgery with cardiopulmonary bypass: a first in man prospective, observational, feasibility pilot study.

PubMed

Luckraz, Heyman; Giri, Ramesh; Wrigley, Benmjamin; Hennessy, Anne-Marie; Nicholas, Johann; Nevill, Alan

2017-01-01

As proof of concept, this prospective, observational study assessed the feasibility and early clinical outcomes of performing on-pump cardiac surgery with the RenalGuard system. Acute kidney injury (AKI) is reported in up to 30% of patients undergoing cardiac surgery and is a recognised independent predictor of both morbidity and mortality. Forced diuresis with the RenalGuard system reduces the incidence of AKI during percutaneous coronary intervention procedures but its use in cardiac surgery has not been explored. Ten consecutive patients who were at risk of developing AKI during cardiac surgery were selected. The RenalGuard system was used to facilitate forced diuresis using weight-adjusted intravenous furosemide while maintaining neutral fluid balance by matched intravenous fluid replacement. This regimen was initiated preoperatively in all patients and continued for 6-12 hours postoperatively. Serum creatinine, electrolytes and need for renal replacement were documented in all patients. The RenalGuard system functioned successfully in all patients and facilitated high perioperative urine outputs, even when patients were placed on cardiopulmonary bypass (CPB). There were no incidences of significant (A) electrolyte imbalance, (B) changes in haemoglobin levels or (C) pulmonary oedema. No patients developed AKI within 36 hours of surgery despite one patient developing cardiac tamponade 8 hours postoperatively and one patient developing paralytic ileus. One patient, however, was 'electively' haemofiltered on day 2 after developing acute right ventricular failure. The median intensive care stay was 1.5 (1, 5) days. The RenalGuard system can be used successfully in patients undergoing cardiac surgery with CPB and may reduce the incidence of AKI in at-risk patients. NCT02974946; Pre-results.

[Assisted peritoneal dialysis: home-based renal replacement therapy for the elderly patient].

PubMed

Wiesholzer, Martin

2013-06-01

The number of elderly patients with end stage renal disease is constantly increasing. Conventional hämodiaylsis as the mainstay of renal replacement therapy is often poorly tolerated by frail eldery patients with multiple comorbidities. Although many of these patients would prefer a home based dialysis treatment, the number of elderly patients using peritoneal dialysis (PD) is still low. Impaired physical and cognitive function often generates insurmountable barriers for self care peritoneal dialysis. Assisted peritoneal dialysis can overcome many of these barriers and give elderly patients the ability of a renal replacement therapy in their own homes respecting their needs.

Risk factors for renal dysfunction after total knee joint replacement.

PubMed

Hassan, Basim K; Sahlström, Arne; Dessau, Ram B

2015-12-01

Renal injury and dysfunction are serious complications after major surgery, which may lead to increased morbidity and mortality. The objective of our study was to identify the possible risk factors for renal dysfunction after total knee joint replacement. A retrospective study was conducted among 702 consecutive primary knee joint replacements performed between January 2009 and December 2012 in our department. Increased postoperative serum creatinine was considered indicative of postoperative renal injury according to RIFLE criteria. Sixty three patients (9.7%) had significant moderate or severe postoperative renal dysfunction in which 8 patients (1.2%) ended with severe and permanent renal impairment. Advanced age, low intraoperative blood pressure, hypertension, general anaesthesia, and prophylactic dicloxacillin were identified as significant risk factors. Male gender and BMI were independent risk factors for postoperative increase in serum creatinine. Smoking, female gender, diabetes mellitus and duration of surgery were not identified as significant risk factors.

Age-related differences in the quality of life in end-stage renal disease in patients enrolled in hemodialysis or continuous peritoneal dialysis.

PubMed

Laudański, Krzysztof; Nowak, Zbigniew; Niemczyk, Stanisław

2013-05-20

The aim of the present study was to compare the experience elderly and younger patients in terms of emotional status, disease perception, methods of coping with the end-stage renal disease (ESRD) stress, and health-related quality of life in 2 different settings of renal replacement therapy: hemodialysis (HD) and continuous ambulatory peritoneal dialysis programs (CAPD). Specifically, we hypothesized that younger people will more frequently use goal-oriented strategies to cope with illness-related stress and elderly patients will use more strategies related to the control of emotion. A total of 69 HD patients, 40 CAPD patients, and 89 healthy volunteers were analyzed. The Situation and Trait Anxiety Inventory, the Profile of Mood States, the Cognitive Stress Appraisal Questionnaire, and the Nottingham Health Profile were used to assess anxiety, long-term emotional status, coping mechanisms, and health-related quality of life. Data were collected on several biochemical and demographic variables. Our study revealed that younger and elderly people on dialysis faced quite different problems. Younger people in both RRT groups had statistically higher assessment of ESRD as loss or challenge and they more frequently used distractive and emotional preoccupation coping strategies. Depression, confusion, and bewilderment dominate the emotional status of both patient populations, especially in the younger cohort. Both HD(young) and CAPD(young) patients complained more about lack of energy, mobility limitations, and sleep disturbances as compared to their elderly HD and CAPD counterparts. There are different needs and problems in younger and elderly patients on renal replacement therapy. Younger people required more ESRD-oriented support to relieve their health-related complaints to the level observed in their peers and needed extensive psychological assistance in order to cope with negative emotions related to their disease.

Low-flow CO₂ removal integrated into a renal-replacement circuit can reduce acidosis and decrease vasopressor requirements.

PubMed

Forster, Christian; Schriewer, Jens; John, Stefan; Eckardt, Kai-Uwe; Willam, Carsten

2013-07-24

Lung-protective ventilation in patients with ARDS and multiorgan failure, including renal failure, is often paralleled with a combined respiratory and metabolic acidosis. We assessed the effectiveness of a hollow-fiber gas exchanger integrated into a conventional renal-replacement circuit on CO₂ removal, acidosis, and hemodynamics. In ten ventilated critically ill patients with ARDS and AKI undergoing renal- and respiratory-replacement therapy, effects of low-flow CO₂ removal on respiratory acidosis compensation were tested by using a hollow-fiber gas exchanger added to the renal-replacement circuit. This was an observational study on safety, CO₂-removal capacity, effects on pH, ventilator settings, and hemodynamics. CO₂ elimination in the low-flow circuit was safe and was well tolerated by all patients. After 4 hours of treatment, a mean reduction of 17.3 mm Hg (-28.1%) pCO₂ was observed, in line with an increase in pH. In hemodynamically instable patients, low-flow CO₂ elimination was paralleled by hemodynamic improvement, with an average reduction of vasopressors of 65% in five of six catecholamine-dependent patients during the first 24 hours. Because no further catheters are needed, besides those for renal replacement, the implementation of a hollow-fiber gas exchanger in a renal circuit could be an attractive therapeutic tool with only a little additional trauma for patients with mild to moderate ARDS undergoing invasive ventilation with concomitant respiratory acidosis, as long as no severe oxygenation defects indicate ECMO therapy.

Kidney transplantation does not increase the level of basic hope or life satisfaction compared with hemodialysis in patients with chronic kidney disease.

PubMed

Zegarow, P; Jankowska, M; Sańko-Resmer, J; Durlik, M; Grzeszczyk, M; Pączek, L

2014-10-01

Although renal replacement therapy can lead to improved health, it also can cause emotional disturbances in patients. It is believed that the success of renal replacement therapy hinges not only on medical parameters, but also on psychosocial factors, which is why modern medicine provides an ever-increasing role in the improvement of patients' quality of life. The purpose of this study was to compare the level of life satisfaction, purpose in life, and basic hope in patients who had received renal replacement due to chronic kidney disease. We also tested whether the specific type of renal replacement therapy and kidney function parameters were influential factors on the above variables. Sixty-one adult patients treated via renal replacement for chronic kidney disease took part in the study. Patients were divided into two groups: 31 hemodialysis patients (15 women and 16 men, ages 23-77 years, mean 51.19 years, SD 14.53 years) and 30 patients who had undergone kidney transplantation (14 women and 16 men, ages 22-69 years, mean 48.40 years, SD 12.64 years). The following research tools were used for analysis: Satisfaction With Life Scale (SWLS), Purpose in Life Test (PIL), and Basic Hope Inventory (BHI-12). There were no statistical differences in the level of satisfaction with life between hemodialysis patients and postkidney transplant patients. The results for the SWLS obtained from both groups fell within the normal range. The average SWLS for hemodialysis patients remained 20.61, SD = 5.79; for postkidney transplant patients, it was 22.57, SD = 5.16. The PIL level in the group of hemodialysis patients (101.5, SD = 15.64) was significantly lower than in the group of postkidney transplant patients (109.7, SD = 15.54). The average BHI-12 level was similar in both groups. The average BHI-12 result for hemodialysis patients was 29.00 (SD = 5.06), and for postkidney transplant patients 29.93 (SD = 3.55). The correlations between the psychological variables and selected biochemical parameters are worthy of particular attention. Among hemodialysis patients, there was an additional correlation between SWLS and hematocrit; whereas for postkidney transplant patients, there was an additional correlation of PIL and eGFR. Our data show that satisfaction with life and basic hope do not increase in patients after renal replacement therapy. The form of renal replacement therapy (hemodialysis or kidney transplantation) does not change the above variables. Patients treated via renal replacement require specialized psychological support to improve the efficacy of renal replacement therapy.

Building and validation of a prognostic model for predicting extracorporeal circuit clotting in patients with continuous renal replacement therapy.

PubMed

Fu, Xia; Liang, Xinling; Song, Li; Huang, Huigen; Wang, Jing; Chen, Yuanhan; Zhang, Li; Quan, Zilin; Shi, Wei

2014-04-01

To develop a predictive model for circuit clotting in patients with continuous renal replacement therapy (CRRT). A total of 425 cases were selected. 302 cases were used to develop a predictive model of extracorporeal circuit life span during CRRT without citrate anticoagulation in 24 h, and 123 cases were used to validate the model. The prediction formula was developed using multivariate Cox proportional-hazards regression analysis, from which a risk score was assigned. The mean survival time of the circuit was 15.0 ± 1.3 h, and the rate of circuit clotting was 66.6 % during 24 h of CRRT. Five significant variables were assigned a predicting score according to the regression coefficient: insufficient blood flow, no anticoagulation, hematocrit ≥0.37, lactic acid of arterial blood gas analysis ≤3 mmol/L and APTT < 44.2 s. The Hosmer-Lemeshow test showed no significant difference between the predicted and actual circuit clotting (R (2) = 0.232; P = 0.301). A risk score that includes the five above-mentioned variables can be used to predict the likelihood of extracorporeal circuit clotting in patients undergoing CRRT.

Status of renal replacement therapy and peritoneal dialysis in Mexico.

PubMed

Cueto-Manzano, Alfonso M; Rojas-Campos, Enrique

2007-01-01

Mexico is struggling to gain a place among developed countries; however, there are many socioeconomic and health problems still waiting for resolution. While Mexico has the twelfth largest economy in the world, a large portion of its population is impoverished. Treatment for end-stage renal disease (377 patients per million population) is determined by the individual's access to resources such as private medical care (approximately 3%) and public sources (Social Security System: approximately 40%; Health Secretariat: approximately 57%). With only 6% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico is still the country with the largest utilization of peritoneal dialysis (PD) in the world, with 18% on automated PD, 56% on continuous ambulatory PD (CAPD), and 26% on hemodialysis. Results of PD (patient morbi-mortality, peritonitis rate, and technique survival) in Mexico are comparable to other countries. However, malnutrition and diabetes mellitus are highly prevalent in Mexican patients on CAPD programs, and these conditions are among the most important risk factors for a poor outcome in our setting.

Biotechnological challenges of bioartificial kidney engineering.

PubMed

Jansen, J; Fedecostante, M; Wilmer, M J; van den Heuvel, L P; Hoenderop, J G; Masereeuw, R

2014-11-15

With the world-wide increase of patients with renal failure, the development of functional renal replacement therapies have gained significant interest and novel technologies are rapidly evolving. Currently used renal replacement therapies insufficiently remove accumulating waste products, resulting in the uremic syndrome. A more preferred treatment option is kidney transplantation, but the shortage of donor organs and the increasing number of patients waiting for a transplant warrant the development of novel technologies. The bioartificial kidney (BAK) is such promising biotechnological approach to replace essential renal functions together with the active secretion of waste products. The development of the BAK requires a multidisciplinary approach and evolves at the intersection of regenerative medicine and renal replacement therapy. Here we provide a concise review embracing a compact historical overview of bioartificial kidney development and highlighting the current state-of-the-art, including implementation of living-membranes and the relevance of extracellular matrices. We focus further on the choice of relevant renal epithelial cell lines versus the use of stem cells and co-cultures that need to be implemented in a suitable device. Moreover, the future of the BAK in regenerative nephrology is discussed. Copyright © 2014 Elsevier Inc. All rights reserved.

Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study

PubMed Central

Verma, Sean; Bassily, Emmanuel; Leighton, Shane; Mhaskar, Rahul; Sunjic, Igor; Martin, Angel; Rihana, Nancy; Jarmi, Tambi; Bassil, Claude

2017-01-01

Background Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated. Methods In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer’s exact at the significance level of 0.05. Results Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001). Conclusion Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period. PMID:28611860

Acute kidney injury: not just acute renal failure anymore?

PubMed

Dirkes, Susan

2011-02-01

Until recently, no uniform standard existed for diagnosing and classifying acute renal failure. To clarify diagnosis, the Acute Dialysis Quality Initiative group stated its consensus on the need for a clear definition and classification system of renal dysfunction with measurable criteria. Today the term acute kidney injury has replaced the term acute renal failure, with an understanding that such injury is a common clinical problem in critically ill patients and typically is predictive of an increase in morbidity and mortality. A classification system, known as RIFLE (risk of injury, injury, failure, loss of function, and end-stage renal failure), includes specific goals for preventing acute kidney injury: adequate hydration, maintenance of renal perfusion, limiting exposure to nephrotoxins, drug protective strategies, and the use of renal replacement therapies that reduce renal injury.

Dialysis for end stage renal disease financed through the Brazilian National Health System, 2000 to 2012

PubMed Central

2014-01-01

Background Chronic kidney disease has become a public health problem worldwide. Its terminal stage requires renal replacement therapy – dialysis or transplantation – for the maintenance of life, resulting in high economic and social costs. Though the number of patients with end-stage renal disease treated by dialysis in Brazil is among the highest in the world, current estimates of incidence and prevalence are imprecise. Our aim is to describe incidence and prevalence trends and the epidemiologic profile of end-stage renal disease patients receiving publically-financed dialysis in Brazil between 2000 and 2012. Methods We internally linked records of the High Complexity Procedure Authorization/Renal Replacement Therapy (APAC/TRS) system so as to permit analyses of incidence and prevalence of dialysis over the period 2000-2012. We characterized temporal variations in the incidence and prevalence using Joinpoint regression. Results Over the period, 280,667 patients received publically-financed dialysis, 57.2% of these being male. The underlying disease causes listed were hypertension (20.8%), diabetes (12.0%) and glomerulonephritis (7.7%); for 42.3%, no specific cause was recorded. Hemodialysis was the therapeutic modality in 90.1%. Over this period, prevalence increased 47%, rising 3.6% (95% CI 3.2% - 4.0%)/year. Incidence increased 20%, or 1.8% (1.1% – 2.5%)/year. Incidence increased in both sexes, in all regions of the country and particularly in older age groups. Conclusions Incidence and prevalence of end-stage renal disease receiving publically-financed dialysis treatment has increased notably. The linkage approach developed will permit continuous future monitoring of these indicators. PMID:25008169

Metformin associated lactic acidosis (MALA): clinical profiling and management.

PubMed

Moioli, Alessandra; Maresca, Barbara; Manzione, Andrea; Napoletano, Antonello Maria; Coclite, Daniela; Pirozzi, Nicola; Punzo, Giorgio; Menè, Paolo

2016-12-01

Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.

Iodinated contrast media and the role of renal replacement therapy.

PubMed

Weisbord, Steven D; Palevsky, Paul M

2011-05-01

Iodinated contrast media are among the most commonly used pharmacologic agents in medicine. Although generally highly safe, iodinated contrast media are associated with several adverse effects, most significantly the risk of acute kidney injury, particularly in patients with underlying renal dysfunction. By virtue of their pharmacokinetic characteristics, these contrast agents are efficiently cleared by hemodialysis and to a lesser extent, hemofiltration. This has led to research into the capacity for renal replacement therapies to prevent certain adverse effects of iodinated contrast. This review examines the molecular and pharmacokinetic characteristics of iodinated contrast media and critically analyzes data from past studies on the role of renal replacement therapy to prevent adverse effects of these diagnostic agents. Published by Elsevier Inc.

Renal replacement therapy in Latin American end-stage renal disease

PubMed Central

Rosa-Diez, Guillermo; Gonzalez-Bedat, Maria; Pecoits-Filho, Roberto; Marinovich, Sergio; Fernandez, Sdenka; Lugon, Jocemir; Poblete-Badal, Hugo; Elgueta-Miranda, Susana; Gomez, Rafael; Cerdas-Calderon, Manuel; Almaguer-Lopez, Miguel; Freire, Nelly; Leiva-Merino, Ricardo; Rodriguez, Gaspar; Luna-Guerra, Jorge; Bochicchio, Tomasso; Garcia-Garcia, Guillermo; Cano, Nuria; Iron, Norman; Cuero, Cesar; Cuevas, Dario; Tapia, Carlos; Cangiano, Jose; Rodriguez, Sandra; Gonzalez, Haydee; Duro-Garcia, Valter

2014-01-01

The Latin American Dialysis and Renal Transplant Registry (RLADTR) was founded in 1991; it collects data from 20 countries which are members of Sociedad Latinoamericana de Nefrología e Hipertension. This paper presents the results corresponding to the year 2010. This study is an annual survey requesting data on incident and prevalent patients undergoing renal replacement treatment (RRT) in all modalities: hemodialysis (HD), peritoneal dialysis (PD) and living with a functioning graft (LFG), etc. Prevalence and incidence were compared with previous years. The type of renal replacement therapy was analyzed, with special emphasis on PD and transplant (Tx). These variables were correlated with the gross national income (GNI) and the life expectancy at birth. Twenty countries participed in the surveys, covering 99% of the Latin American. The prevalence of end stage renal disease (ESRD) under RRT in Latin America (LA) increased from 119 patients per million population (pmp) in 1991 to 660 pmp in 2010 (HD 413 pmp, PD 135 pmp and LFG 111 pmp). HD proportionally increased more than PD, and Tx HD continues to be the treatment of choice in the region (75%). The kidney Tx rate increased from 3.7 pmp in 1987 to 6.9 pmp in 1991 and to 19.1 in 2010. The total number of Tx's in 2010 was 10 397, with 58% deceased donors. The total RRT prevalence correlated positively with GNI (r2 0.86; P < 0.05) and life expectancy at birth (r2 0.58; P < 0.05). The HD prevalence and the kidney Tx rate correlated significantly with the same indexes, whereas the PD rate showed no correlation with these variables. A tendency to rate stabilization/little growth was reported in the most regional countries. As in previous reports, the global incidence rate correlated significantly only with GNI (r2 0.63; P < 0.05). Diabetes remained the leading cause of ESRD. The most frequent causes of death were cardiovascular (45%) and infections (22%). Neoplasms accounted for 10% of the causes of death. The prevalence of RRT continues to increase, particularly in countries with 100% public health or insurance coverage for RRT, where it approaches rates comparable to those displayed by developed countries with a better GNI. The incidence also continues to increase in both countries that have not yet extended its coverage to 100% of the population as well as in those that have an adequate program for timely detection and treatment of chronic kidney disease (CKD) and its associated risk factors. PD is still an underutilized strategy for RRT in the region. Even though renal Tx is feasible, its growth rate is still not as fast as it should be in order to compensate for the increased prevalence of patients on waiting lists. Diagnostic and prevention programs for hypertension and diabetes, appropriate policies promoting the expansion of PD and organ procurement as well as transplantation as cost-effective forms of RRT are needed in the region. Regional cooperation among Latin American countries, allowing the more developed to guide and train others in starting registries and CKD programs, may be one of the key initiatives to address this deficit. PMID:25349696

Association between mortality and replacement solution bicarbonate concentration in continuous renal replacement therapy: A propensity-matched cohort study

PubMed Central

Thongprayoon, Charat; Cheungpasitporn, Wisit; Iacovella, Gina M.; Akhoundi, Abbasali; Albright, Robert C.

2017-01-01

Background Given the known deleterious effects seen with bicarbonate supplementation for acidemia, we hypothesized that utilizing high bicarbonate concentration replacement solution in continuous venovenous hemofiltration (CVVH) would be independently associated with higher mortality. Methods In a propensity score-matched historical cohort study conducted at a single tertiary care center from December 9, 2006, through December 31, 2009, a total of 287consecutive adult critically ill patients with Stage III acute kidney injury (AKI) requiring CVVH were enrolled. We excluded patients on maintenance dialysis, those who received other modalities of continuous renal replacement therapies, and patients that received a mixed of 22 and 32 mEq/L bicarbonate solution pre- and post-filter. The primary outcome was in-hospital and 90-day mortality rates. Results Among enrollees, 68 were used 32 mEq/L bicarbonate solution, and 219 received 22mEq/L bicarbonate solution for CVVH. Patients on 32 mEq/L bicarbonate solution were more often non-surgical, had lower pH and bicarbonate level but had higher blood potassium and phosphorus levels in comparison with those on 22 mEq/L bicarbonate solution. After adjustment for the baseline characteristics, the use of 32 bicarbonate solution was significantly associated with increased in-hospital (HR = 1.94; 95% CI 1.02–3.79) and 90-day mortality (HR = 1.50; 95% CI 1.03–2.14). There was a significant increase in the hospital (p = .03) and 90-day (p = .04) mortality between the 22 vs. 32 mEq/L bicarbonate solution groups following propensity matching. Conclusion Our data showed there is a strong association between using high bicarbonate solution and mortality independent of severity of illness and comorbid conditions. These findings need to be evaluated further in prospective studies. PMID:28957333

Epidemiology of RBC Transfusions in Patients With Severe Acute Kidney Injury: Analysis From the Randomized Evaluation of Normal Versus Augmented Level Study.

PubMed

Bellomo, Rinaldo; Mårtensson, Johan; Kaukonen, Kirsi-Maija; Lo, Serigne; Gallagher, Martin; Cass, Alan; Myburgh, John; Finfer, Simon

2016-05-01

To assess the epidemiology and outcomes associated with RBC transfusion in patients with severe acute kidney injury requiring continuous renal replacement therapy. Post hoc analysis of data from a multicenter, randomized, controlled trial. Thirty-five ICUs in Australia and New Zealand. Cohort of 1,465 patients enrolled in the Randomized Evaluation of Normal versus Augmented Level replacement therapy study. Daily information on morning hemoglobin level and amount of RBC transfused were prospectively collected in the Randomized Evaluation of Normal versus Augmented Level study. We analyzed the epidemiology of such transfusions and their association with clinical outcomes. Overall, 977 patients(66.7%) received a total of 1,192 RBC units. By day 5, 785 of 977 transfused patients (80.4%) had received at least one RBC transfusion. Hemoglobin at randomization was lower in transfused than in nontransfused patients (94 vs 111 g/L; p < 0.001). Mean daily hemoglobin was 88 ± 7 and 99 ± 12 g/L in transfused and nontransfused patients. Among transfused patients, 228 (46.7%) had died by day 90 when compared with 426 (43.6%) of nontransfused patients (p = 0.27). Survivors received on average 316 ± 261 mL of RBC, whereas nonsurvivors received 302 ± 362 mL (p = 0.42). On multivariate Cox regression analysis, RBC transfusion was independently associated with lower 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38-0.79). However, we found no independent association between RBC transfusions and mortality when the analyses were restricted to patients surviving at least 5 days (hazard ratio, 1.29; 95% CI, 0.90-1.85). We found no independent association between RBC transfusion and renal replacement therapy-free days, mechanical ventilator-free days, or length of stay in ICU or hospital. In patients with severe acute kidney injury treated with continuous renal replacement therapy, we found no association of RBC transfusion with 90-day mortality or other patient-centered outcomes. The optimal hemoglobin threshold for RBC transfusion in such patients needs to be determined in future randomized controlled trials.

Serum Vancomycin Levels Resulting from Continuous or Intermittent Infusion in Critically Ill Burn Patients With or Without Continuous Renal Replacement Therapy

DTIC Science & Technology

2012-12-01

associated with higher vancomycin levels in gen- eral and fewer levels of ᝺ μg/mL, significant nephrotoxicity or neutropenia was not observed. Fifty...therapeutic course. An absolute neutrophil count (ANC) of ≤500 cells/μL was used to define neutropenia .11 As a standardized definition for drug-induced...150,000 plate- lets/μL (Table 3, data not shown). The lowest ANC at the end of therapy was 1800 cells/μL. No patients had neutropenia (defined as 

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation.

PubMed

Andreoli, Maria Claudia Cruz; Souza, Nádia Karina Guimarães de; Ammirati, Adriano Luiz; Matsui, Thais Nemoto; Carneiro, Fabiana Dias; Ramos, Ana Claudia Mallet de Souza; Iizuca, Ilson Jorge; Coelho, Maria Paula Vilela; Afonso, Rogério Carballo; Ferraz-Neto, Ben-Hur; Almeida, Marcio Dias de; Durão, Marcelino; Batista, Marcelo Costa; Monte, Julio Cesar; Pereira, Virgílio Gonçalves; Santos, Oscar Pavão Dos; Santos, Bento Cardoso Dos

2017-01-01

Renal dysfunction frequently occurs during the periods preceding and following orthotopic liver transplantation (OLT), and in many cases, renal replacement therapy (RRT) is required. Information regarding the duration of RRT and the rate of kidney function recovery after OLT is crucial for transplant program management. We evaluated a sample of 155 stable patients undergoing post-intensive care hemodialysis (HD) from a patient population of 908 adults who underwent OLT. We investigated the average time to renal function recovery (duration of RRT required) and determined the risk factors for remaining on dialysis > 90 days after OLT. Log-rank tests were used for univariate analysis, and Cox proportional hazards models were used to identify factors associated with the risk of remaining on HD. The results of our analysis showed that of the 155 patients, 28% had pre-OLT diabetes mellitus, 21% had pre-OLT hypertension, and 40% had viral hepatitis. Among the patients, the median MELD (Model for End-Stage Liver Disease) score was 27 (interquartile range [IQR] 22-35). When they were listed for liver transplantation, 32% of the patients had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD, and 50% had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD at the time of OLT. Of the transplanted patients, 25% underwent pre-OLT intermittent HD, and 14% and 41% underwent continuous renal replacement therapy (CRRT) pre-OLT and post-OLT, respectively. At 90 days post-OLT, 118 (76%) patients had been taken off dialysis, and 16 (10%) patients had died while undergoing HD. The median recovery time of these post-OLT patients was 33 (IQR 27-39) days. In the multivariate analysis, fulminant hepatic failure as the cause of liver disease (p<0.001), the absence of pre-OLT hypertension (p = 0.016), a lower intraoperative fresh-frozen plasma (FFP) transfusion volume (p = 0.019) and not undergoing pre-OLT intermittent HD (p = 0.032) were associated with performing RRT for less than 90 days. Therefore, a high proportion of OLT patients showed improved renal function after OLT, and those who were diagnosed with fulminant hepatic failure, had no pre-OLT hypertension, received a lower transfused volume of intraoperative FFP and did not undergo pre-OLT intermittent HD had a higher probability of recovery.

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation

PubMed Central

de Souza, Nádia Karina Guimarães; Ammirati, Adriano Luiz; Matsui, Thais Nemoto; Carneiro, Fabiana Dias; Ramos, Ana Claudia Mallet de Souza; Iizuca, Ilson Jorge; Afonso, Rogério Carballo; Ferraz-Neto, Ben-Hur; de Almeida, Marcio Dias; Durão, Marcelino; Batista, Marcelo Costa; Monte, Julio Cesar; Pereira, Virgílio Gonçalves; dos Santos, Oscar Pavão

2017-01-01

Renal dysfunction frequently occurs during the periods preceding and following orthotopic liver transplantation (OLT), and in many cases, renal replacement therapy (RRT) is required. Information regarding the duration of RRT and the rate of kidney function recovery after OLT is crucial for transplant program management. We evaluated a sample of 155 stable patients undergoing post-intensive care hemodialysis (HD) from a patient population of 908 adults who underwent OLT. We investigated the average time to renal function recovery (duration of RRT required) and determined the risk factors for remaining on dialysis > 90 days after OLT. Log-rank tests were used for univariate analysis, and Cox proportional hazards models were used to identify factors associated with the risk of remaining on HD. The results of our analysis showed that of the 155 patients, 28% had pre-OLT diabetes mellitus, 21% had pre-OLT hypertension, and 40% had viral hepatitis. Among the patients, the median MELD (Model for End-Stage Liver Disease) score was 27 (interquartile range [IQR] 22-35). When they were listed for liver transplantation, 32% of the patients had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD, and 50% had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD at the time of OLT. Of the transplanted patients, 25% underwent pre-OLT intermittent HD, and 14% and 41% underwent continuous renal replacement therapy (CRRT) pre-OLT and post-OLT, respectively. At 90 days post-OLT, 118 (76%) patients had been taken off dialysis, and 16 (10%) patients had died while undergoing HD. The median recovery time of these post-OLT patients was 33 (IQR 27–39) days. In the multivariate analysis, fulminant hepatic failure as the cause of liver disease (p<0.001), the absence of pre-OLT hypertension (p = 0.016), a lower intraoperative fresh-frozen plasma (FFP) transfusion volume (p = 0.019) and not undergoing pre-OLT intermittent HD (p = 0.032) were associated with performing RRT for less than 90 days. Therefore, a high proportion of OLT patients showed improved renal function after OLT, and those who were diagnosed with fulminant hepatic failure, had no pre-OLT hypertension, received a lower transfused volume of intraoperative FFP and did not undergo pre-OLT intermittent HD had a higher probability of recovery. PMID:28574999

A feasible strategy for preventing blood clots in critically ill patients with acute kidney injury (FBI): study protocol for a randomized controlled trial.

PubMed

Robinson, Sian; Zincuk, Aleksander; Larsen, Ulla Lei; Ekstrøm, Claus; Toft, Palle

2014-06-13

Previous pharmacokinetic trials suggested that 40 mg subcutaneous enoxaparin once daily provided inadequate thromboprophylaxis for intensive care unit patients. Critically ill patients with acute kidney injury are at increased risk of venous thromboembolism and yet are often excluded from these trials. We hypothesized that for critically ill patients with acute kidney injury receiving continuous renal replacement therapy, a dose of 1 mg/kg enoxaparin subcutaneously once daily would improve thromboprophylaxis without increasing the risk of bleeding. In addition, we seek to utilize urine output prior to discontinuing dialysis, and low neutrophil gelatinase-associated lipocalin in dialysis-free intervals, as markers of renal recovery. In a multicenter, double-blind randomized controlled trial in progress at three intensive care units across Denmark, we randomly assign eligible critically ill adults with acute kidney injury into a treatment (1 mg/kg enoxaparin subcutaneously once daily) or control arm (40 mg enoxaparin subcutaneously once daily) upon commencement of continuous renal replacement therapy.We calculated that with 133 patients in each group, the study would have 80% power to show a 40% reduction in the relative risk of venous thromboembolism with 1 mg/kg enoxaparin, at a two-sided alpha level of 0.05. An interim analysis will be conducted after the first 67 patients have been included in each group.Enrolment began in March 2013, and will continue for two years. The primary outcome is the occurrence of venous thromboembolism. Secondary outcomes include anti-factor Xa activity, bleeding, heparin-induced thrombocytopenia, filter lifespan, length of stay, ventilator free days, and mortality. We will also monitor neutrophil gelatinase-associated lipocalin and urine volume to determine whether they can be used as prognostic factors for renal recovery. Critically ill unit patients with acute kidney injury present a particular challenge in the provision of thromboprophylaxis. This study hopes to add to the growing evidence that the existing recommendation of 40 mg enoxaparin is inadequate and that 1 mg/kg is both safe and effective for thromboprophylaxis.In addition, the study seeks to identify predictors of renal recovery allowing for the proper utilization of resources. EU Clinical Trials Register: EudraCT number: 2012-004368-23, 25 September 2012.

Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study.

PubMed

Chung, Kevin K; Coates, Elsa C; Hickerson, William L; Arnold-Ross, Angela L; Caruso, Daniel M; Albrecht, Marlene; Arnoldo, Brett D; Howard, Christina; Johnson, Laura S; McLawhorn, Melissa M; Friedman, Bruce; Sprague, Amy M; Mosier, Michael J; Conrad, Peggie F; Smith, David J; Karlnoski, Rachel A; Aden, James K; Mann-Salinas, Elizabeth A; Wolf, Steven E

2018-06-20

Acute kidney injury (AKI) after severe burns is historically associated with a high mortality. Over the past two decades, various modes of renal replacement therapy (RRT) have been utilized in this population. The purpose of this multicenter study was to evaluate demographic, treatment and outcomes data among severe burn patients treated with RRT collectively at various burn centers around the United States. After institutional review board approval, a multicenter observational study was conducted. All adult patients 18 or older, admitted with severe burns who were placed on RRT for acute indications but not randomized into a concurrently enrolling interventional trial were included. Across 8 participating burn centers, 171 subjects were enrolled during a 4 year period. Complete data was available in 170 subjects with a mean age of 51±17, percent total body surface area (TBSA) burn of 38±26% and Injury Severity Score of 27±21. 80% of subjects were male and 34% were diagnosed with smoke inhalation injury. The preferred mode of therapy was continuous venovenous hemofiltration at a mean delivered dose of 37±19 (mL/kg/hr) and a treatment duration of 13±24 days. Overall, in hospital mortality was 50%. Among survivors, 21% required RRT upon discharge from the hospital while 9% continued to require RRT 6 months after discharge. This is the first multi-center cohort of burn patients who underwent RRT reported to date. Overall mortality is comparable to other critically ill populations who undergo RRT. Most patients who survive to discharge eventually recover renal function.

The impact of changes in LVEF and renal function on the prognosis of ICD patients after elective device replacement.

PubMed

Vandenberk, Bert; Robyns, Tomas; Garweg, Christophe; Floré, Vincent; Foulon, Stefaan; Voros, Gabor; Ector, Joris; Willems, Rik

2017-10-01

A proportion of patients with an implantable cardioverter-defibrillator (ICD) in prevention of sudden cardiac death will only receive their first appropriate ICD therapy (AT) after device replacement. Clinical reassessment at the time of replacement could be helpful to guide the decision to replace or not in the future. All patients with an ICD for primary or secondary prevention in ischemic (ICM) or nonischemic cardiomyopathy were included in a single-center retrospective registry. The association of changes in left ventricular ejection fraction (LVEF; cut-off at 35%), worsening renal function (decrease in estimated glomerular filtration rate > 15 mL/min), and worsening New York Heart Association class at elective device replacement with mortality and AT was analyzed using adjusted Cox regression analysis. A total of 238 (33%) out of 727 patients received elective device replacement (86.1% male, 74.4% ICM, 42.9% primary prevention). During this replacement 20.2% received a device upgrade. The mean time to replacement was 6.4 ± 2.0 years and mean follow-up after replacement was 3.4 ± 3.0 years. Of patients who did not receive AT before replacement 23.1% received their first AT after replacement. Worsening renal function (hazard ratio [HR] 2.79, 95% confidence interval [CI] 1.50-5.18) and a consistently LVEF ≤35% compared to a consistently LVEF >35% (HR 2.15, 95% CI 1.10-4.19) at the time of replacement were independent predictors of mortality. Independent predictors of first AT after replacement could not be identified. Although reassessment of LVEF and renal function at replacement can be helpful in predicting total mortality, the clinical utility to guide reimplantation seemed limited. Our experience indicates that approximately 25% of patients received their first AT only after replacement. © 2017 Wiley Periodicals, Inc.

Residual Renal Function in Children Treated with Chronic Peritoneal Dialysis

PubMed Central

Roszkowska-Blaim, Maria

2013-01-01

Residual renal function (RRF) in patients with end-stage renal disease (ESRD) receiving renal replacement therapy is defined as the ability of native kidneys to eliminate water and uremic toxins. Preserved RRF improves survival and quality of life in adult ESRD patients treated with peritoneal dialysis. In children, RRF was shown not only to help preserve adequacy of renal replacement therapy but also to accelerate growth rate, improve nutrition and blood pressure control, reduce the risk of adverse myocardial changes, facilitate treatment of anemia and calcium-phosphorus balance abnormalities, and result in reduced serum and dialysate fluid levels of advanced glycation end-products. Factors contributing to RRF loss in children treated with peritoneal dialysis include the underlying renal disease such as hemolytic-uremic syndrome and hereditary nephropathy, small urine volume, severe proteinuria at the initiation of renal replacement therapy, and hypertension. Several approaches can be suggested to decrease the rate of RRF loss in pediatric patients treated with chronic peritoneal dialysis: potentially nephrotoxic drugs (e.g., aminoglycosides), episodes of hypotension, and uncontrolled hypertension should be avoided, urinary tract infections should be treated promptly, and loop diuretics may be used to increase salt and water excretion. PMID:24376376

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants.

PubMed

Shrestha, Pratyush; Thapa, Shalima; Shrestha, Shikher; Lohani, Subash; Bk, Suresh; MacCormac, Oscar; Thapa, Lekhjung; Devkota, Upendra Prasad

2017-01-01

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2 . Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2 ) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.027). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion : Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes.  The impairment, however, is transient and rarely requires renal replacement therapy.

Extending the benefits of early mobility to critically ill patients undergoing continuous renal replacement therapy: the Michigan experience.

PubMed

Talley, Cheryl L; Wonnacott, Robert O; Schuette, Janice K; Jamieson, Jill; Heung, Michael

2013-01-01

Evidence to support improved outcomes with early ambulation is strong in medical literature. Yet, critically ill continuous renal replacement therapy (CRRT) patients remain tethered to their beds by devices delivering supportive therapy. The University of Michigan Adult CRRT Committee identified this deficiency and sought to change it. There was no guidance in the literature to support mobilizing this population; therefore, we reviewed literature from devices with similar technological profiles. Revision of our institutional mobility protocol for the CRRT population included a simple safety acronym, ASK. The acronym addresses appropriate candidacy; secured, appropriate access; and potential device and patient complications as a memorable aid to help nursing staff determine whether their CRRT patients are candidates for early mobility. After implementing our CRRT mobility standard, a preliminary study of 109 CRRT patients and a review of incident reports related to CRRT demonstrated no significant adverse patient events or falls and no access complications related to mobility. This deliberate intervention allows CRRT patients to safely engage in mobility activities to improve this population's outcomes. A simple mobility protocol and safety acronym partnered with strong clinical leadership has permitted the University of Michigan to add CRRT patients to the body of early mobility literature.

Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

PubMed

Sanchez-Izquierdo-Riera, Jose Angel; Molano-Alvarez, Esteban; Saez-de la Fuente, Ignacio; Maynar-Moliner, Javier; Marín-Mateos, Helena; Chacón-Alves, Silvia

2016-01-01

The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

Hepatic and renal function with successful long-term support on a continuous flow left ventricular assist device.

PubMed

Deo, Salil V; Sharma, Vikas; Altarabsheh, Salah E; Hasin, Tal; Dillon, John; Shah, Ishan K; Durham, Lucian A; Stulak, John M; Daly, Richard C; Joyce, Lyle D; Park, Soon J

2014-03-01

Data regarding the long-term clinical effects of a continuous flow left ventricular assist device (CF-LVAD) on hepato-renal function is limited. Hence our aim was to assess changes in hepato-renal function over a one-year period in patients supported on a CF-LVAD. During the study period 126 patients underwent CF-LVAD implant. Changes in hepato-renal laboratory parameters were studied in 61/126 patients successfully supported on a CF-LVAD for period of one year. A separate cohort of a high-risk group (HCrB) of patients (56/126) with a serum creat>1.9 mg/dL (168 μmol/L) (75th percentile) or a serum bil>1.5 mg/dL (25.65 μmol/L) (75th percentile) was created. Changes in serum creatinine and bilirubin were analysed at regular intervals for this group along with the need for renal replacement therapy. Baseline creatinine and blood urea nitrogen (BUN) for the entire cohort was 1.4[1.2,1.9 mg/dL] [123.7(106,168) μmol/L) and 27[20,39.5 mg/dL] [9.6(7.1,14.1) mmol/L] respectively. After an initial reduction at the end of one month [1(0.8,1.2) mg/dL; 88(70,105) μmol/L] (p<0.0001), a gradual increase was noted over the study period to reach (1.25[1.1,1.5] mg/dL; 106(97.2,132.6) μmol/L] (p=0.0003). The serum bilirubin normalised from a [1(0.7,1.55) mg/dL] [17(18.8,25.7) μmol/L) to 0.9(0.6,1.2)mg/dL [15.4(10.2,20.5) μmol/L] (p=0.0005) and continued to decline over one year. Improvement in the synthetic function of the liver was demonstrated by a rise in the serum albumin levels to reach 4.3[4.1,4.5] [43(41,45) gm/L] at the end of one year (p<0.0001). The baseline serum creatinine and bilirubin for the high-risk cohort (HCrB) was 1.9(1.3,2.4) mg/dL [168(115,212) μmol/L] and 1.7(1.00,2.4) mg/dL [29(17.1,68.4) μmol/L] respectively. The high-risk cohort (HCrB) demonstrated a trend towards higher 30-day mortality (p=0.06). While the need for temporary renal replacement therapy was higher in this cohort (16% vs. 4%; p=0.03), only 3% need it permanently. A significant reduction in creatinine was apparent at the end of one month [1.1(0.8,1.4) mg/dL; 97(70.7,123.7) μmol/L] (p<0.0001) and then remained stable at [1.3(1.1,1.5) mg/dL; 115(97,132.6) μmol/L]. Bilirubin demonstrated a 30% decline over one month and then remained low at [0.7(0.5,0.8) mg/dL; 62(44,70) μmol/L] p=0.0005 compared to the pre-operative baseline. Hepato-renal function demonstrates early improvement and then remains stable in the majority of patients on continuous flow left ventricular assist device support for one year. High-risk patients demonstrate a higher 30-day mortality and temporary need for renal replacement therapy. Yet even in this cohort, improvement is present over a period of one year on the device, with a minimal need for permanent haemodialysis. Copyright © 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

[Management of patients with chronic renal failure during surgical correction of cardiovascular disease].

PubMed

Iarustovskiĭ, M B; Stupchenko, O S; Abramian, M V; Nazarova, E I; Popok, Z V

2010-01-01

End-stage of chronic renal failure (CRF) is frequently associated with cardiac and vascular comorbidities requiring cardiosurgical interventions. Over 9 years, from 2000 to 2009, the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, delivered cardiosurgical care to 16 patients aged 20 to 74 years with end-stage CRF. The duration of programmed hemodialysis was 1 to 102 months. The preoperative patient preparation protocol comprised correction of anemia, hypoproteinemia, hypertension, and water-electrolyte and acid-base balances. Five patients underwent endovascular myocardial revascularization; open heart surgery was performed in one patient. Interventions under extracorporeal circulation were made in 10 other patients. Ultrafiltration was intraoperatively carried out. On-line hemodiafiltration was performed following coronary artery stenting. After open operations, renal replacement therapy (first hemodiafiltration, then hemodialysis) as daily sessions was initiated on day 2 and, when the patients were transferred to intensive care units, it was performed by the programmed hemodialysis protocol. There were no fatal outcomes at the follow-up. The key aspects of treatment success achievement and improved quality of life in patients on programmed hemodialysis are the detection of cardiovascular diseases requiring surgery, the timely referral of the patients to a cardiosurgical hospital, the meticulous pre- and perioperative management (correction of anemia, hypoproteinemia, water-electrolyte balance, use of ultrafiltration and the adequate rate of perfusion at the stage of extracorporeal circulation, and daily renal replacement therapy in the postoperative period), and continuity in the work of all specialists.

[Cost-effectiveness analysis of renal replacement therapies: how should we design research on these interventions in Brazil?].

PubMed

Sancho, Leyla Gomes; Dain, Sulamis

2008-06-01

This study aims to contribute to the discussion on the possibility of applying health economics assessment, specifically the cost-effectiveness technique, to renal replacement therapies for end-stage renal failure. A review was conducted on the interventions and their alternative courses from the perspective of the various methodological proposals in the literature, considering the availability of data and information in Brazil to back this type of research.

Lithium overdose and delayed severe neurotoxicity: timing for renal replacement therapy and restarting of lithium.

PubMed

de Cates, Angharad N; Morlet, Julien; Antoun Reyad, Ayman; Tadros, George

2017-10-25

This is a case report of a man in his 60s who presented to an English hospital following a significant lithium overdose. He was monitored for 24 hours, and then renal replacement therapy was initiated after assessment by the renal team. As soon as the lithium level returned to normal therapeutic levels (from 4.7 mEq/L to 0.67 mEq/L), lithium was restarted by the medical team. At this point, the patient developed new slurred speech and later catatonia. In this case report, we discuss the factors that could determine which patients are at risk of neurotoxicity following lithium overdose and the appropriate decision regarding when and how to consider initiation of renal replacement therapy and restarting of lithium. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Enzyme replacement therapy of Fabry disease.

PubMed

Clarke, Joe T R; Iwanochko, R Mark

2005-08-01

Fabry disease is an X-linked lysosomal storage disease caused by deficiency of the enzyme alpha-galactosidase A and results in pain, progressive renal impairment, cardiomyopathy, and cerebrovascular disease. The results of two major randomized, double-blind, placebo-controlled clinical trials and open-label extensions have shown that replacement of the deficient enzyme with either of two preparations of recombinant human alpha-galactosidase A, agalsidase-alfa, and agalsidase-beta is safe. Biweekly i.v. infusions of 0.2 mg/kg of agalsidase-alfa were associated with a significant decrease in pain and stabilization of renal function. Biweekly infusions of 1 mg/kg of agalsidase-beta were associated with virtually complete clearing of accumulated glycolipid substrate from renal and cutaneous capillary endothelial cells. Several smaller, open-label studies, along with observations made in the course of monitoring large numbers of patients on enzyme replacement therapy, indicated that treatment stabilizes renal function and produces significant improvements in myocardial mass and function. Treatment of Fabry disease by enzyme replacement has a significant impact on at least some serious complications of the disease.

[Oral cavity pathology by renal failure].

PubMed

Maĭborodin, I V; Minikeev, I M; Kim, S A; Ragimova, T M

2014-01-01

The analysis of the scientific literature devoted to organ and tissue changes of oral cavity at the chronic renal insufficiency (CRI)is made. The number of patients in an end-stage of CRI constantly increases and patients receiving renal replacement therapy including hemodialysis, peritoneal dialysis or renal transplantation will comprise an enlarging segment of the dental patient population. Owing to CRI and its treatment there is a set of changes of teeth and oral cavity fabrics which remain even in a end-stage. Renal replacement therapy can affect periodontal tissues including gingival hyperplasia in immune suppressed renal transplantation patients and increased levels of bacterial contamination, gingival inflammation, formation of calculus, and possible increased prevalence and severity of destructive periodontal diseases. Besides, the presence of undiagnosed periodontitis may have significant effects on the medical management of the patients in end-stage of CRI.

[Hot rods in the ICU : What is the antibiotic mileage of your renal replacement therapy?

PubMed

Kielstein, J T; Kruse, A K; Anderson, N; Vaitiekunas, H; Scherneck, S

2017-05-08

We would neither be disappointed nor upset if the gas mileage on the sticker of a car didn't match our personal, real-life fuel consumption. Depending on our daily route to work, our style of accelerating and the number of passengers in our carpool, the gas mileage will vary. As soon as the falcon wing door of our car is closed and entrance to the ICU is granted, we tend to forget all of this, even though another hot rod is waiting there for us. Renal replacement therapy is like a car; it fulfills goals, such as the removal of uremic toxins and accumulated fluids, but it also "consumes" (removes) antibiotics. Unlike catecholamines, where we have the mean arterial pressure on our ICU dashboard, we do not have a gauge to measure antibiotic "consumption", i.e. elimination by renal replacement therapy. This manuscript describes the principles and basic knowledge to improve dosing of antibiotics in critically ill patients undergoing renal replacement therapy. As in modern cars, we briefly touch on hybrid therapies combining renal replacement therapy with extracorporeal lung support or adsorbent technologies that remove cytokines or bacteria. Further, the importance of considering body size and body composition is addressed, especially for choosing the right initial dose of antibiotics. Lastly we point out the dire need to increase the availability of timely and affordable therapeutic drug monitoring on the most commonly used antiinfectives, ideally using point-of-care devices at the bedside.

Successful 4th kidney transplantation: a case report from Iran.

PubMed

Nourbala, Mohammad Hossein; Ghadian, Alireza; Einollahi, Behzad; Azarabadi, Mehdi

2013-05-21

Kidney transplantation is generally considered the best option for most patients with end-stage renal disease requiring renal replacement therapy, even for patients with graft failure. Here, we describe a case of a 49-year-old man who received his 1st kidney transplant the United Kingdom from his brother when he was 18 years old in. Thirty-one year after the first transplant, he underwent successful 4th living-unrelated kidney transplantation with no serious complications at our transplant center. He continued to have excellent allograft function and his latest serum creatinine 33 months after his 4th transplant was 1.2 mg/dL. To our knowledge, this is the first case of 4th kidney transplantation from Iran.

Associations of race and ethnicity with anemia management among patients initiating renal replacement therapy.

PubMed Central

Weisbord, Steven D.; Fried, Linda F.; Mor, Maria K.; Resnick, Abby L.; Kimmel, Paul L.; Palevsky, Paul M.; Fine, Michael J.

2007-01-01

BACKGROUND: Many patients initiate renal replacement therapy with suboptimal anemia management. The factors contributing to this remain largely unknown. The aim of this study was to assess the associations of race and ethnicity with anemia care prior to the initiation of renal replacement therapy. METHODS: Using data from the medical evidence form filed for patients who initiated renal replacement therapy between 1995-2003, we assessed racial and ethnic differences in pre-end-stage renal disease hematocrit levels, the use of erythropoiesis stimulation agents (ESAs), the proportion of patients with hematocrit levels > or = 33% and the proportion of patients with hematocrit levels < 33% that did not receive ESA. We also examined secular trends in racial and ethnic differences in these parameters. RESULTS: In multivariable analyses, non-Hispanic blacks had lower hematocrit levels (delta hematocrit = -0.97%, 95% CI: -1.00-0.94%), and were less likely to receive ESA (OR = 0.82, 95% CI: 0.81-0.84), to initiate renal replacement therapy with hematocrit > or = 33% (OR = 0.78, 95% CI: 0.77-0.79) or to receive ESA if the hematocrit was < 33% (OR = 0.79, 95% CI: 0.77-0.80) than non-Hispanic whites. White Hispanics also had lower hematocrit levels (delta hematocrit = -0.42%, 95% CI:-0.47% to -0.37%), and were less likely to receive ESA (OR = 0.86, 95% CI: 0.85-0.88), to have hematocrit levels > or = 33% (OR = 0.91, 95% CI: 0.89-0.93) or to receive ESA if the hematocrit was < 33% (OR = 0.85, 95% CI: 0.83-0.87) than non-Hispanic whites. These disparities persisted over the eight-year study period. CONCLUSIONS: African-American race and Hispanic ethnicity are associated with suboptimal pre-end-stage renal disease anemia management. Efforts to improve anemia care should incorporate targeted interventions to decrease these disparities. PMID:18020096

The future of hemodialysis membranes.

PubMed

Humes, H D; Fissell, W H; Tiranathanagul, K

2006-04-01

Hemodialytic treatment of patients with either acute or chronic renal failure has had a dramatic impact on the mortality rates of these patients. Unfortunately, this membrane-based therapy is still incomplete renal replacement, as the mortality and morbidity of these patients remain unacceptably high. Much progress must be made to improve the biocompatibility of hemodialysis membranes as well as their hydraulic and permselective properties to remove small solutes and 'middle molecules' in compact cartridges. The next directions of development will leverage materials and mechanical engineering technology, including microfluidics and nanofabrication, to further improve the clearance functions of the kidney to replicate glomerular permselectivity while retaining high rates of hydraulic permeability. The extension of membrane technology to biohybrid devices utilizing progenitor/stem cells will be another substantive advance for renal replacement therapy. The ability to not only replace solute and water clearance but also active reabsorptive transport and metabolic activity will add additional benefit to the therapy of patients suffering from renal failure. This area of translational research is rich in creative opportunities to improve the unmet medical needs of patients with either chronic or acute renal failure.

Development and Validation of a Simplified Renal Replacement Therapy Suitable for Prolonged Field Care in a Porcine (Sus scrofa) Model of Acute Kidney Injury

DTIC Science & Technology

2018-03-01

of a Simplified Renal Replacement Therapy Suitable for Prolonged Field Care in a Porcine (Sus scrofa) Model of Acute Kidney Injury. PRINCIPAL...and methods, results - include tables/figures, and conclusions/applications.) Objectives/Background: Acute kidney injury (AKI) is a serious

Atypical haemolytic uraemic syndrome treated with the complement inhibitor eculizumab: the experience of the Australian compassionate access cohort.

PubMed

Mallett, A; Hughes, P; Szer, J; Tuckfield, A; Van Eps, C; Cambell, S B; Hawley, C; Burke, J; Kausman, J; Hewitt, I; Parnham, A; Ford, S; Isbel, N

2015-10-01

This study aimed to report the clinical characteristics and outcomes of Australian patients treated with eculizumab for atypical haemolytic uraemic syndrome (aHUS). A retrospective cohort study was undertaken of all patients in Australia treated with eculizumab provided in a compassionate access programme for a clinical diagnosis of aHUS using prospectively collected clinical data. A total of 10 patients with a median age of 23.5 years (interquartile range (IQR) 24.83 years) received compassionate access eculizumab for aHUS in Australia. Eight patients were female, and three had a family history of aHUS. Three received eculizumab for an initial acute aHUS presentation, three for relapsing and refractory acute aHUS, two for de novo aHUS post-renal transplantation, and one each for aHUS recurrence post-transplantation and facilitation of transplantation with a history of aHUS. The median duration of eculizumab therapy has been 911.5 days (IQR 569 days) with a cumulative exposure of 9184 days. At baseline all patients had renal and extra-renal aHUS involvement, with up to three non-renal organs affected. All but one patient, who died from uncontrollable gastrointestinal aHUS manifestations, have continued. The nine continuing patients achieved remission of aHUS. Two of the four patients requiring renal replacement therapy (RRT) at eculizumab commencement subsequently ceased RRT. Clinical events occurring in this cohort while on eculizumab treatment included neutropenia (two), posterior reversible encephalopathy syndrome (one), cardiomyopathy (one), pulmonary embolus (one), antibody-mediated rejection resulting in renal graft failure (one), iron deficiency (one), gastrointestinal haemorrhage (one) and death (one). Eculizumab has been an effective therapy for aHUS in this cohort, including when other therapies have failed. © 2015 Royal Australasian College of Physicians.

Update on dialysis economics in the UK.

PubMed

Sharif, Adnan; Baboolal, Keshwar

2011-03-01

The burgeoning population of patients requiring renal replacement therapy contributes a disproportionate strain on National Health Service resources. Although renal transplantation is the preferred treatment modality for patients with established renal failure, achieving both clinical and financial advantages, limitations to organ donation and clinical comorbidities will leave a significant proportion of patients with established renal failure requiring expensive dialysis therapy in the form of either hemodialysis or peritoneal dialysis. An understanding of dialysis economics is essential for both healthcare providers and clinical leaders to establish clinically efficient and cost-effective treatment modalities that maximize service provision. In light of changes to the provision of healthcare funds in the form of "Payment by Results," it is imperative for UK renal units to adopt clinically effective and financially accountable dialysis programs. This article explores the role of dialysis economics and implications for UK renal replacement therapy programs.

What is this chocolate milk in my circuit? A cause of acute clotting of a continuous renal replacement circuit: Questions.

PubMed

Kakajiwala, Aadil; Chiotos, Kathleen; Brothers, Julie; Lederman, April; Amaral, Sandra

2016-12-01

One of the greatest problems associated with continuous renal replacement therapy (CRRT) is the early clotting of filters. A literature search revealed three case reports of lipemic blood causing recurrent clotting and reduced CRRT circuit survival time in adult patients, but no reports of cases in children. A 23-month-old male infant with Martinez-Frias syndrome and multivisceral transplant was admitted to the hospital with severe sepsis and hemolytic anemia. He developed acute kidney injury, fluid overload and electrolyte imbalances requiring CRRT and was also administered total parenteral nutrition (TPN) and fat emulsion. The first circuit lasted 60 h before routine change was required. The second circuit showed acute clotting after only 18 h, and brownish-milky fluid was found in the circuit tubing layered between the clotted blood. The patient's serum triglyceride levels were elevated at 988 mg/dL. The lipid infusion was stopped and CRRT restarted. Serum triglyceride levels improved to 363 mg/dL. The new circuit lasted 63 h before routine change was required. Clotting of CRRT circuits due to elevated triglyceride levels is rare and has not been reported in the pediatric population. Physicians should be mindful of this risk in patients receiving TPN who have unexpected clotting of CRRT circuits.

High-volume forced diuresis with matched hydration using the RenalGuard System to prevent contrast-induced nephropathy: A meta-analysis of randomized trials.

PubMed

Shah, Rahman; Wood, Sarah J; Khan, Sajjad A; Chaudhry, Amina; Rehan Khan, M; Morsy, Mohamed S

2017-12-01

Contrast-induced nephropathy (CIN) is a well-recognized complication of coronary angiography that is associated with poor outcomes. Several small randomized controlled trials (RCTs) have recently shown that in patients with chronic kidney disease (CKD), furosemide-induced forced diuresis with matched hydration using the RenalGuard system can prevent its occurrence. However, individual studies have been underpowered and thus cannot show significant differences in major clinical endpoints. Forced diuresis with matched hydration using the RenalGuard system improves clinical outcomes in patients undergoing coronary angiography. Scientific databases and websites were searched for relevant RCTs. The pooled risk ratios were calculated using random-effects models. The primary endpoint was CIN, and the secondary endpoints were major adverse clinical events (MACEs) and the need for renal replacement therapy. Data from 3 trials including 586 patients were analyzed. High-volume forced diuresis with matched hydration using the RenalGuard system decreased risk of CIN by 60% (risk ratio: 0.40, 95% confidence interval: 0.25 to 0.65, P < 0.001), MACE rate by 59%, and the need for renal replacement therapy by 78%, compared with the standard of care. In patients with CKD undergoing coronary angiography, high-volume forced diuresis with matched hydration using the RenalGuard system significantly reduces the risk of CIN, MACE rate, and the need for renal replacement therapy. Larger RCTs with sufficient power are needed to confirm these findings. © 2017 Wiley Periodicals, Inc.

Continuous renal replacement therapy with a polymethyl methacrylate membrane hemofilter suppresses inflammation in patients after open-heart surgery with cardiopulmonary bypass.

PubMed

Mukaida, Hiroshi; Matsushita, Satoshi; Inotani, Takahiro; Nakamura, Atsushi; Amano, Atsushi

2018-06-01

Cardiopulmonary bypass (CPB) induces a complex inflammatory response involving an increase in inflammatory cytokines, called postperfusion syndrome. Previous studies demonstrated that adsorption of the serum cytokines can reduce acute inflammation and improve clinical outcomes. In this study, patients were placed on continuous renal replacement therapy (CRRT) with a polymethyl methacrylate (PMMA) membrane hemofilter immediately after the start of an open-heart surgery with CPB and throughout the postoperative course to prevent postperfusion syndrome. The aim of this study was to assess whether continuous CRRT using a PMMA filter (PMMA-CRRT) could affect cytokine expression and improve perioperative outcomes. We designed a randomized controlled trial, which included 19 consecutive adult patients on maintenance dialysis and 7 consecutive adult patients who were not on maintenance dialysis (NHD group). Patients on maintenance dialysis were randomly divided into two groups: Ten patients who received CRRT with a polysulfone membrane hemofilter (PS group) and nine patients who received CRRT with a PMMA membrane (PMMA group). Blood samples were collected from the radial or brachial artery at five different time points. Comparisons between the PS, PMMA, and NHD groups revealed a significant main effect of time on changes in serum IL-6 and IL-8 concentrations (p < 0.01) and an interaction (p < 0.05) between time and group. Plasma IL-6 and IL-8 levels after surgery were significantly lower in the PMMA group than in the PS group, while other cytokines measured in this study were not significantly different. In addition, clinical outcomes were not significantly different between the groups. The continuous use of PMMA-CRRT throughout the perioperative period suppressed serum IL-6 and IL-8 concentrations, although there were no differences in clinical outcomes.

Pharmacokinetics of Cefepime during Continuous Renal Replacement Therapy in Critically Ill Patients

PubMed Central

Malone, Rebecca S.; Fish, Douglas N.; Abraham, Edward; Teitelbaum, Isaac

2001-01-01

The pharmacokinetics of cefepime were studied in 12 adult patients in intensive care units during continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodiafiltration (CVVHDF) with a Multiflow60 AN69HF 0.60-m2 polyacrylonitrile hollow-fiber membrane (Hospal Industrie, Meyzieu, France). Patients (mean age, 52.0 ± 13.0 years [standard deviation]; mean weight, 96.7 ± 18.4 kg) received 1 or 2 g of cefepime every 12 or 24 h (total daily doses of 1 to 4 g/day) by intravenous infusion over 15 to 30 min. Pre- and postmembrane blood (serum) samples and corresponding ultrafiltrate or dialysate samples were collected 1, 2, 4, 8, and 12 or 24 h (depending on dosing interval) after completion of the drug infusion. Drug concentrations were measured using validated high-performance liquid chromatography methods. Mean systemic clearance (CLS) and elimination half-life (t1/2) of cefepime were 35.9 ± 6.0 ml/min and 12.9 ± 2.6 h during CVVH versus 46.8 ± 12.4 ml/min and 8.6 ± 1.4 h during CVVHDF, respectively. Cefepime clearance was substantially increased during both CVVH and CVVHDF, with membrane clearance representing 40 and 59% of CLS, respectively. The results of this study confirm that continuous renal replacement therapy contributes substantially to total CLS of cefepime and that CVVHDF appears to remove cefepime more efficiently than CVVH. Cefepime doses of 2 g/day (either 2 g once daily or 1 g twice daily) appear to achieve concentrations adequate to treat most common gram-negative pathogens (MIC ≤ 8 μg/ml) during CVVH or CVVHDF. PMID:11600370

Switch from agalsidase beta to agalsidase alfa in the enzyme replacement therapy of patients with Fabry disease in Latin America.

PubMed

Ripeau, Diego; Amartino, Hernán; Cedrolla, Martín; Urtiaga, Luis; Urdaneta, Bella; Cano, Marilis; Valdez, Rita; Antongiovanni, Norberto; Masllorens, Francisca

2017-01-01

There are currently two available enzyme replacement therapies for Fabry disease and little information regarding efficacy and safety of switching therapies. Between 2009 and 2012 there was a worldwide shortage of agalsidase beta and patients on that enzyme were switched to agalsidase alfa. This retrospective observational study assessed a 2-year period of efficacy and safety in a population of Fabry patients, in Argentina (30 patients) and Venezuela (3 patients), who switched therapies from algasidase beta to agalsidase alfa. Thirty-three patients completed 24-months follow-up after the switch (age 32.4 ± 2.0, range 10.0-55.9 years; male: female 23:10). Measures of renal function such as estimated glomerular filtration rate remained almost unchanged in 31 patients without end stage renal disease over the 2 years after switching and urine protein excretion continued stable. Cardiac functional parameters: left ventricular mass index, interventricular septum, left ventricular posterior wall showed no significant change from baseline in the 33 patients. Quality of life, pain and disease severity scores were mostly unchanged after 24-months and agalsidase alfa was generally well tolerated. Our findings showed there is no significant change in the efficacy measured through the renal or cardiac function, quality of life, pain, disease severity scoring and safety for at least 2 years after switching from agalsidase beta to agalsidase alfa.

Use of Erythropoietin-Stimulating Agents (ESA) in Patients With End-Stage Renal Failure Decided to Forego Dialysis: Palliative Perspective.

PubMed

Cheng, Hon Wai Benjamin; Chan, Kwok Ying; Lau, Hoi To; Man, Ching Wah; Cheng, Suk Ching; Lam, Carman

2017-05-01

Normochromic normocytic anemia is a common complication in chronic kidney disease (CKD) and is associated with many adverse clinical consequences. Erythropoiesis-stimulating agents (ESAs) act to replace endogenous erythropoietin for patients with end-stage renal disease having anemia. Today, ESAs remain the main tool for treating anemia associated with CKD. In current practice, the use of ESA is not limited to the patients on renal replacement therapy but has extended to nondialysis patients under palliative care (PC). Current evidence on ESA usage in patients with CKD decided to forego dialysis often have to take reference from studies conducted in other groups of patients with CKD, including pre-dialysis patients and those on renal replacement therapy. There is paucity of studies targeting use of ESAs in renal PC patients. Small-scale retrospective study in renal PC patients had suggested clinical advantage of ESAs in terms of hemoglobin improvement, reduction in fatigue, and hospitalization rate. With the expected growth in elderly patients with CKD decided to forego dialysis and manage conservatively, there remains an urgent need to call for large-scale prospective trial in exploring efficacy of ESAs in this population, targeting on quality of life and symptoms improvement outcome. This article also reviews the mechanism of action, pharmacology, adverse effects, and clinical trial evidence for ESA in patients with CKD under renal PC.

Quality indicators of continuous renal replacement therapy (CRRT) care in critically ill patients: a systematic review.

PubMed

Rewa, Oleksa G; Villeneuve, Pierre-Marc; Lachance, Philippe; Eurich, Dean T; Stelfox, Henry T; Gibney, R T Noel; Hartling, Lisa; Featherstone, Robin; Bagshaw, Sean M

2017-06-01

Renal replacement therapy is increasingly utilized in the intensive care unit (ICU), of which continuous renal replacement therapy (CRRT) is most common. Despite CRRT being a relatively invasive and resource intensive technology, there remains wide practice variation in its application. This systematic review appraised the evidence for quality indicators (QIs) of CRRT care in critically ill patients. A comprehensive search strategy was developed and performed in five citation databases (Medline, Embase, CINAHL, Cochrane Library, and PubMed) and select grey literature sources. Two reviewers independently screened, selected, and extracted data using standardized forms. Each retrieved citation was appraised for quality using the Newcastle-Ottawa Scale (NOS) and Cochrane risk of bias tool. Data were summarized narratively. Our search yielded 8374 citations, of which 133 fulfilled eligibility. This included 97 cohort studies, 24 randomized controlled trials, 10 case-control studies, and 2 retrospective medical audits. The quality of retrieved studies was generally good. In total, 18 QIs were identified that were mentioned in 238 instances. Identified QIs were classified as related to structure (n = 4, 22.2 %), care processes (n = 9, 50.0 %), and outcomes (n = 5, 27.8 %). The most commonly mentioned QIs focused on filter lifespan (n = 98), small solute clearance (n = 46), bleeding (n = 30), delivered dose (n = 19), and treatment interruption (n = 5). Across studies, the definitions used for QIs evaluating similar constructs varied considerably. When identified, QIs were most commonly described as important (n = 144, 48.3 %), scientifically acceptable (n = 32, 10.7 %), and useable and/or feasible (n = 17, 5.7 %) by their primary study authors. We identified numerous potential QIs of CRRT care, characterized by heterogeneous definitions, varying quality of derivation, and limited evaluation. Further study is needed to prioritize a concise inventory of QIs to measure, improve, and benchmark CRRT care for critically ill patients. PROSPERO CRD42015015530.

The association between renal recovery after acute kidney injury and long-term mortality after transcatheter aortic valve replacement.

PubMed

Thongprayoon, Charat; Cheungpasitporn, Wisit; Srivali, Narat; Kittanamongkolchai, Wonngarm; Sakhuja, Ankit; Greason, Kevin L; Kashani, Kianoush B

2017-01-01

This study aimed to examine the association between renal recovery status at hospital discharge after acute kidney injury (AKI) and long-term mortality following transcatheter aortic valve replacement (TAVR). We screened all adult patients who survived to hospital discharge after TAVR for aortic stenosis at a quaternary referral medical center from January 1, 2008, through June 30, 2014. An AKI was defined as an increase in serum creatinine level of 0.3 mg/dL or a relative increase of 50% from baseline. Renal outcome at the time of discharge was evaluated by comparing the discharge serum creatinine level to the baseline level. Complete renal recovery was defined as no AKI at discharge, whereas partial renal recovery was defined as AKI without a need for renal replacement therapy at discharge. No renal recovery was defined as a need for renal replacement therapy at discharge. The study included 374 patients. Ninty-eight (26%) patients developed AKI during hospitalization: 55 (56%) had complete recovery; 39 (40%), partial recovery; and 4 (4%), no recovery. AKI development was significantly associated with increased risk of 2-year mortality (hazard ratio [HR], 2.20 [95% CI, 1.37-3.49]). For patients with AKI, the 2-year mortality rate for complete recovery was 34%; for partial recovery, 43%; and for no recovery, 75%; compared with 20% for patients without AKI (P < .001). In adjusted analysis, complete recovery (HR, 1.87 [95% CI, 1.03-3.23]); partial recovery (HR, 2.65 [95% CI, 1.40-4.71]) and no recovery (HR, 10.95 [95% CI, 2.59-31.49]) after AKI vs no AKI were significantly associated with increased risk of 2-year mortality. The mortality rate increased for all patients with AKI undergoing TAVR. A reverse correlation existed for progressively higher risk of death and the extent of AKI recovery.

Renal Replacement Therapy in Austere Environments

PubMed Central

Yuan, Christina M.; Perkins, Robert M.

2011-01-01

Myoglobinuric renal failure is the classically described acute renal event occurring in disaster environments—commonly after an earthquake—which most tests the ingenuity and flexibility of local and regional nephrology resources. In recent decades, several nephrology organizations have developed response teams and planning protocols to address disaster events, largely focusing on patients at risk for, or with, acute kidney injury (AKI). In this paper we briefly review the epidemiology and outcomes of patients with dialysis-requiring AKI after such events, while providing greater focus on the management of the end-stage renal disease population after a disaster which incapacitates a pre-existing nephrologic infrastructure (if it existed at all). “Austere” dialysis, as such, is defined as the provision of renal replacement therapy in any setting in which traditional, first-world therapies and resources are limited, incapacitated, or nonexistent. PMID:21603109

[Frequency, etiology, and outcomes of acute renal failure (data of Kaunas University of Medicine Hospital in 1995-2006)].

PubMed

Skarupskiene, Inga; Kuzminskis, Vytautas; Ziginskiene, Edita

2007-01-01

The aim of this study was to determine the frequency, etiology, and outcomes of acute renal failure. We retrospectively collected data on all patients (n=1653) who received renal replacement therapy for acute renal failure at the Kaunas University of Medicine Hospital during 1995-2006. The number of patients with acute renal failure increased nine times during the 11-year period. The mean age of patients was 59.76+/-17.52 years and increased from 44.97+/-17.1 years in 1995 to 62.84+/-16.49 years in 2006. The most common causes of acute renal failure were renal (n=646, 39%), prerenal (n=380, 23%), and obstructive (n=145, 9%). The renal replacement therapy was discontinued because of recovery of renal function in 49.9% of cases. The overall hospital mortality rate was 45.1%. Renal function did not recover in 6.7% of patients. The mortality rate over the 11-year period varied from 37.8 to 57.5%. The highest mortality rate was in the neurosurgical (62.3%) and cardiac surgical (61.8%) intensive care units. High mortality rate (more than 50%) was in the groups of patients with acute renal failure that was caused by hepatorenal syndrome, shock, sepsis, and reduced cardiac output.

[A case of Legionella pneumonia with multiple organ failure].

PubMed

Li, Jiali; Wen, Rui; Deng, Hong; Li, Qian

2016-06-28

Legionella pneumonia (LP) is a rare systemic infectious disease, which is often misdiagnosed by clinicians due to the atypical symptoms. A middle-aged man who suffered from fever and dyspnea was diagnosed as community acquired pneumonia (CAP) in Changsha Central Hospital in March 2015. The treatment was unsatisfied firstly. The patients showed further symptoms of rhabdomyolysis, acute liver and renal failure, and impaired neural functions, who was diagnosed as LP with multiple organ failure based on a positive test for Legionella antibody. The patient was recovered after treated with moxifloxacin combined with azithromycin and continuous renal replacement therapy. LP should be paid attention when patient was diagnosed as CAP and failed to be treated. The satisfied outcome is achieved after application of macrolide, quinolones and comprehensive treatments.

[Colistin: a review].

PubMed

Antonucci, Elio; Taccone, Fabio Silvio; Regolisti, Giuseppe; Cabassi, Aderville; Morabito, Santo; Pistolesi, Valentina; Di Motta, Tommaso; Fiaccadori, Enrico

2014-01-01

Colistin (CS) is a polymyxin with bactericidal activity, which is increasingly used in nosocomial infections associated with multidrug-resistant Gram-negative bacteria (MDR-GNB). Intravenous CS is usually administered as a less toxic pro-drug, i.e. colistin sodium methanesulfonate (CMS). In water-containing solutions, CMS undergoes a spontaneous hydrolysis to form a complex mixture of partially sulfomethylated derivatives and CS. Pharmacokinetic of CS is dependent on the route of administration, i.e. parenteral, intramuscular, nebulized, intrathecal/intraventricular. Renal toxicity is the most common adverse effect of CS treatment, as the drug is excreted primarily by the kidney and elevated levels of CS may further impair renal function, with a dose-dependent effect. Clinical manifestations of CS associated nephrotoxicity include acute kidney injury, proteinuria and tubular damage. Only few data are currently available on the effects of different renal replacement therapy modalities on CS pharmacokinetics. In patients undergoing the most efficient forms of renal replacement therapies, the extracorporeal clearance of CMS may result in a substantial removal of the antibiotic. Thus, in this setting, the recommended daily doses should be increased. Future studies should better explore CS pharmacokinetics in patients undergoing different modalities of renal replacement therapy.

Advances in Machine Technology.

PubMed

Clark, William R; Villa, Gianluca; Neri, Mauro; Ronco, Claudio

2018-01-01

Continuous renal replacement therapy (CRRT) machines have evolved into devices specifically designed for critically ill over the past 40 years. In this chapter, a brief history of this evolution is first provided, with emphasis on the manner in which changes have been made to address the specific needs of the critically ill patient with acute kidney injury. Subsequently, specific examples of technology developments for CRRT machines are discussed, including the user interface, pumps, pressure monitoring, safety features, and anticoagulation capabilities. © 2018 S. Karger AG, Basel.

Continuous Renal Replacement Therapy Improves Survival in Severely Burned Military Casualties with Acute Kidney Injury

DTIC Science & Technology

2008-02-01

of burn casualties with greater than 40% to- tal body surface area (TBSA) burns, acute kidney injury, or nephrology consultation in the 2 years before...TBSA burns with kidney injury with or without nephrology consultation (control group); 18 were treated with CRRT since (CRRT group). Groups were...with nephrology con- sultation in eight patients. Both 28-day mor- tality (22% vs. 75%, p 0.002) and in-hospital mortality (56% vs. 88%, p 0.04

Continuous Renal Replacement Therapy Improves Survival in Severely Burned Military Casualties With Acute Kidney Injury

DTIC Science & Technology

2007-10-01

of burn casualties with greater than 40% to- tal body surface area (TBSA) burns, acute kidney injury, or nephrology consultation in the 2 years before...TBSA burns with kidney injury with or without nephrology consultation (control group); 18 were treated with CRRT since (CRRT group). Groups were...with nephrology con- sultation in eight patients. Both 28-day mor- tality (22% vs. 75%, p 0.002) and in-hospital mortality (56% vs. 88%, p 0.04

Etiopathology of chronic tubular, glomerular and renovascular nephropathies: Clinical implications

PubMed Central

2011-01-01

Chronic kidney disease (CKD) comprises a group of pathologies in which the renal excretory function is chronically compromised. Most, but not all, forms of CKD are progressive and irreversible, pathological syndromes that start silently (i.e. no functional alterations are evident), continue through renal dysfunction and ends up in renal failure. At this point, kidney transplant or dialysis (renal replacement therapy, RRT) becomes necessary to prevent death derived from the inability of the kidneys to cleanse the blood and achieve hydroelectrolytic balance. Worldwide, nearly 1.5 million people need RRT, and the incidence of CKD has increased significantly over the last decades. Diabetes and hypertension are among the leading causes of end stage renal disease, although autoimmunity, renal atherosclerosis, certain infections, drugs and toxins, obstruction of the urinary tract, genetic alterations, and other insults may initiate the disease by damaging the glomerular, tubular, vascular or interstitial compartments of the kidneys. In all cases, CKD eventually compromises all these structures and gives rise to a similar phenotype regardless of etiology. This review describes with an integrative approach the pathophysiological process of tubulointerstitial, glomerular and renovascular diseases, and makes emphasis on the key cellular and molecular events involved. It further analyses the key mechanisms leading to a merging phenotype and pathophysiological scenario as etiologically distinct diseases progress. Finally clinical implications and future experimental and therapeutic perspectives are discussed. PMID:21251296

Epidemiologic trends in chronic renal replacement therapy over forty years: a Swiss dialysis experience.

PubMed

Lehmann, Petra Rhyn; Ambühl, Manon; Corleto, Domenica; Klaghofer, Richard; Ambühl, Patrice M

2012-07-02

Long term longitudinal data are scarce on epidemiological characteristics and patient outcomes in patients on maintenance dialysis, especially in Switzerland. We examined changes in epidemiology of patients undergoing renal replacement therapy by either hemodialysis or peritoneal dialysis over four decades. Single center retrospective study including all patients which initiated dialysis treatment for ESRD between 1970 and 2008. Analyses were performed for subgroups according to dialysis vintage, based on stratification into quartiles of date of first treatment. A multivariate model predicting death and survival time, using time-dependent Cox regression, was developed. 964 patients were investigated. Incident mean age progressively increased from 48 ± 14 to 64 ± 15 years from 1st to 4th quartile (p < 0.001), with a concomitant decrease in 3- and 5-year survival from 72.2 to 67.7%, and 64.1 to 54.8%, respectively. Nevertheless, live span continuously increased from 57 ± 13 to 74 ± 11 years (p < 0.001). Patients transplanted at least once were significantly younger at dialysis initiation, with significantly better survival, however, shortened live span vs. individuals remaining on dialysis. Among age at time of initiating dialysis therapy, sex, dialysis modality and transplant status, only transplant status is a significant independent covariate predicting death (HR: 0.10 for transplanted vs. non-transplanted patients, p = 0.001). Dialysis vintage was associated with better survival during the second vs. the first quartile (p = 0.026). We document an increase of a predominantly elderly incident and prevalent dialysis population, with progressively shortened survival after initiation of renal replacement over four decades, and, nevertheless, a prolonged lifespan. Analysis of the data is limited by lack of information on comorbidity in the study population. Survival in patients on renal replacement therapy seems to be affected not only by medical and technical advances in dialysis therapy, but may mostly reflect progressively lower mortality of individuals with cardiovascular and metabolic complications, as well as a policy of accepting older and polymorbid patients for dialysis in more recent times. This is relevant to make demographic predictions in face of the ESRD epidemic nephrologists and policy makers are facing in industrialized countries.

Epidemiologic trends in chronic renal replacement therapy over forty years: A Swiss dialysis experience

PubMed Central

2012-01-01

Background Long term longitudinal data are scarce on epidemiological characteristics and patient outcomes in patients on maintenance dialysis, especially in Switzerland. We examined changes in epidemiology of patients undergoing renal replacement therapy by either hemodialysis or peritoneal dialysis over four decades. Methods Single center retrospective study including all patients which initiated dialysis treatment for ESRD between 1970 and 2008. Analyses were performed for subgroups according to dialysis vintage, based on stratification into quartiles of date of first treatment. A multivariate model predicting death and survival time, using time-dependent Cox regression, was developed. Results 964 patients were investigated. Incident mean age progressively increased from 48 ± 14 to 64 ± 15 years from 1st to 4th quartile (p < 0.001), with a concomitant decrease in 3- and 5-year survival from 72.2 to 67.7%, and 64.1 to 54.8%, respectively. Nevertheless, live span continuously increased from 57 ± 13 to 74 ± 11 years (p < 0.001). Patients transplanted at least once were significantly younger at dialysis initiation, with significantly better survival, however, shortened live span vs. individuals remaining on dialysis. Among age at time of initiating dialysis therapy, sex, dialysis modality and transplant status, only transplant status is a significant independent covariate predicting death (HR: 0.10 for transplanted vs. non-transplanted patients, p = 0.001). Dialysis vintage was associated with better survival during the second vs. the first quartile (p = 0.026). Discussion We document an increase of a predominantly elderly incident and prevalent dialysis population, with progressively shortened survival after initiation of renal replacement over four decades, and, nevertheless, a prolonged lifespan. Analysis of the data is limited by lack of information on comorbidity in the study population. Conclusions Survival in patients on renal replacement therapy seems to be affected not only by medical and technical advances in dialysis therapy, but may mostly reflect progressively lower mortality of individuals with cardiovascular and metabolic complications, as well as a policy of accepting older and polymorbid patients for dialysis in more recent times. This is relevant to make demographic predictions in face of the ESRD epidemic nephrologists and policy makers are facing in industrialized countries. PMID:22747751

Functional Renal Imaging with 2-Deoxy-2-18F-Fluorosorbitol PET in Rat Models of Renal Disorders.

PubMed

Werner, Rudolf A; Wakabayashi, Hiroshi; Chen, Xinyu; Hirano, Mitsuru; Shinaji, Tetsuya; Lapa, Constantin; Rowe, Steven P; Javadi, Mehrbod S; Higuchi, Takahiro

2018-05-01

Precise regional quantitative assessment of renal function is limited with conventional 99m Tc-labeled renal radiotracers. A recent study reported that the PET radiotracer 2-deoxy-2- 18 F-fluorosorbitol ( 18 F-FDS) has ideal pharmacokinetics for functional renal imaging. Furthermore, 18 F-FDS is available via simple reduction from routinely used 18 F-FDG. We aimed to further investigate the potential of 18 F-FDS PET as a functional renal imaging agent using rat models of kidney disease. Methods: Two different rat models of renal impairment were investigated: induction of acute renal failure by intramuscular administration of glycerol in the hind legs, and induction of unilateral ureteral obstruction by ligation of the left ureter. At 24 h after these procedures, dynamic 30-min 18 F-FDS PET data were acquired using a dedicated small-animal PET system. Urine 18 F-FDS radioactivity 30 min after radiotracer injection was measured together with coinjected 99m Tc-diethylenetriaminepentaacetic acid urine activity. Results: Dynamic PET imaging demonstrated rapid 18 F-FDS accumulation in the renal cortex and rapid radiotracer excretion via the kidneys in healthy control rats. On the other hand, significantly delayed renal radiotracer uptake (continuous slow uptake) was observed in acute renal failure rats and unilateral ureteral obstruction kidneys. Measured urine radiotracer concentrations of 18 F-FDS and 99m Tc-diethylenetriaminepentaacetic acid correlated well with each other ( R = 0.84, P < 0.05). Conclusion: 18 F-FDS PET demonstrated favorable kinetics for functional renal imaging in rat models of kidney diseases. 18 F-FDS PET imaging, with its advantages of high spatiotemporal resolution and simple tracer production, could potentially complement or replace conventional renal scintigraphy in select cases and significantly improve the diagnostic performance of renal functional imaging. © 2018 by the Society of Nuclear Medicine and Molecular Imaging.

Calorie intake and patient outcomes in severe acute kidney injury: findings from The Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study trial

PubMed Central

2014-01-01

Introduction Current practice in the delivery of caloric intake (DCI) in patients with severe acute kidney injury (AKI) receiving renal replacement therapy (RRT) is unknown. We aimed to describe calorie administration in patients enrolled in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study and to assess the association between DCI and clinical outcomes. Methods We performed a secondary analysis in 1456 patients from the RENAL trial. We measured the dose and evolution of DCI during treatment and analyzed its association with major clinical outcomes using multivariable logistic regression, Cox proportional hazards models, and time adjusted models. Results Overall, mean DCI during treatment in ICU was low at only 10.9 ± 9 Kcal/kg/day for non-survivors and 11 ± 9 Kcal/kg/day for survivors. Among patients with a lower DCI (below the median) 334 of 729 (45.8%) had died at 90-days after randomization compared with 316 of 727 (43.3%) patients with a higher DCI (above the median) (P = 0.34). On multivariable logistic regression analysis, mean DCI carried an odds ratio of 0.95 (95% confidence interval (CI): 0.91-1.00; P = 0.06) per 100 Kcal increase for 90-day mortality. DCI was not associated with significant differences in renal replacement (RRT) free days, mechanical ventilation free days, ICU free days and hospital free days. These findings remained essentially unaltered after time adjusted analysis and Cox proportional hazards modeling. Conclusions In the RENAL study, mean DCI was low. Within the limits of such low caloric intake, greater DCI was not associated with improved clinical outcomes. Trial registration ClinicalTrials.gov number, NCT00221013 PMID:24629036

Presence and Accuracy of Drug Dosage Recommendations for Continuous Renal Replacement Therapy in Tertiary Drug Information References

PubMed Central

Gorman, Sean K; Slavik, Richard S; Lam, Stefanie

2012-01-01

Background: Clinicians commonly rely on tertiary drug information references to guide drug dosages for patients who are receiving continuous renal replacement therapy (CRRT). It is unknown whether the dosage recommendations in these frequently used references reflect the most current evidence. Objective: To determine the presence and accuracy of drug dosage recommendations for patients undergoing CRRT in 4 drug information references. Methods: Medications commonly prescribed during CRRT were identified from an institutional medication inventory database, and evidence-based dosage recommendations for this setting were developed from the primary and secondary literature. The American Hospital Formulary System—Drug Information (AHFS–DI), Micromedex 2.0 (specifically the DRUGDEX and Martindale databases), and the 5th edition of Drug Prescribing in Renal Failure (DPRF5) were assessed for the presence of drug dosage recommendations in the CRRT setting. The dosage recommendations in these tertiary references were compared with the recommendations derived from the primary and secondary literature to determine concordance. Results: Evidence-based drug dosage recommendations were developed for 33 medications administered in patients undergoing CRRT. The AHFS–DI provided no dosage recommendations specific to CRRT, whereas the DPRF5 provided recommendations for 27 (82%) of the medications and the Micromedex 2.0 application for 20 (61%) (13 [39%] in the DRUGDEX database and 16 [48%] in the Martindale database, with 9 medications covered by both). The dosage recommendations were in concordance with evidence-based recommendations for 12 (92%) of the 13 medications in the DRUGDEX database, 26 (96%) of the 27 in the DPRF5, and all 16 (100%) of those in the Martindale database. Conclusions: One prominent tertiary drug information resource provided no drug dosage recommendations for patients undergoing CRRT. However, 2 of the databases in an Internet-based medical information application and the latest edition of a renal specialty drug information resource provided recommendations for a majority of the medications investigated. Most dosage recommendations were similar to those derived from the primary and secondary literature. The most recent edition of the DPRF is the preferred source of information when prescribing dosage regimens for patients receiving CRRT. PMID:22783029

THE PURVIEW OF PHYTOTHERAPY IN THE MANAGEMENT OF KIDNEY DISORDERS: A SYSTEMATIC REVIEW ON NIGERIA AND SOUTH AFRICA.

PubMed

Sabiu, Saheed; O'Neill, Frans Hendrik; Ashafa, Anofi Omotayo Tom

2016-01-01

The kidney is tasked with a number of metabolic functions in the body. In its role as a detoxifier and primary eliminator of xenobiotics, it becomes vulnerable to developing injuries. Currently, over 1 million people in the world are living on renal replacement therapies (RRTs). The case in sub-Sahara African countries like Nigeria and South Africa is not any better than the global trend. A systematic review of medicinal plants used in the treatment of kidney disorders was conducted. Information were gathered from published scientific journals, books, reports from national, regional and international institutions, conference proceedings and other high profile intellectual resources. MeSH words like 'prevalence of kidney disorders in Africa', 'renal replacement therapy', 'nephrotoxins or nephrotoxicants', 'nephroprotective plants', 'nephroprotective plants in Nigeria or South Africa' and 'nephroprotective phytocompounds' were used to retrieve information from online databases (Google, Pubmed, MEDLINE, Science Direct, Scopus and SID). Interestingly, our findings revealed that phytotherapy has emerged and is being employed to protect renal functions and delay progression of renal pathological conditions into end episodes where the last resort is RRT. In fact, in recent times, Phytotherapists are not only interested in developing relatively safe, more affordable, easily accessible and potent nephroprotective formulations but also increasing awareness on the prevalence of the disease and educating the populace on the probable preventive measures. More importantly, efforts at scientifically elucidating the pharmacological efficacy of the identified nephroprotective plants yet to be validated must be intensified through informed expert opinions. Till date, there is paucity of information on the concept of nephroprotection in most developing countries where kidney disorder is a major threat. Although, the concept is just emerging in South Africa, evidences have given credence to its application in complementary and alternative system of medicine in Nigeria. This review, therefore, reawaken researchers' consciousness in the continuous search for auspicious nephroprotective plants that could potentially be excellent candidates in developing new lead drugs to manage and treat renal disorders.

Effects of dialysate flow configurations in continuous renal replacement therapy on solute removal: computational modeling.

PubMed

Kim, Jeong Chul; Cruz, Dinna; Garzotto, Francesco; Kaushik, Manish; Teixeria, Catarina; Baldwin, Marie; Baldwin, Ian; Nalesso, Federico; Kim, Ji Hyun; Kang, Eungtaek; Kim, Hee Chan; Ronco, Claudio

2013-01-01

Continuous renal replacement therapy (CRRT) is commonly used for critically ill patients with acute kidney injury. During treatment, a slow dialysate flow rate can be applied to enhance diffusive solute removal. However, due to the lack of the rationale of the dialysate flow configuration (countercurrent or concurrent to blood flow), in clinical practice, the connection settings of a hemodiafilter are done depending on nurse preference or at random. In this study, we investigated the effects of flow configurations in a hemodiafilter during continuous venovenous hemodialysis on solute removal and fluid transport using computational fluid dynamic modeling. We solved the momentum equation coupling solute transport to predict quantitative diffusion and convection phenomena in a simplified hemodiafilter model. Computational modeling results showed superior solute removal (clearance of urea: 67.8 vs. 45.1 ml/min) and convection (filtration volume: 29.0 vs. 25.7 ml/min) performances for the countercurrent flow configuration. Countercurrent flow configuration enhances convection and diffusion compared to concurrent flow configuration by increasing filtration volume and equilibrium concentration in the proximal part of a hemodiafilter and backfiltration of pure dialysate in the distal part. In clinical practice, the countercurrent dialysate flow configuration of a hemodiafilter could increase solute removal in CRRT. Nevertheless, while this configuration may become mandatory for high-efficiency treatments, the impact of differences in solute removal observed in slow continuous therapies may be less important. Under these circumstances, if continuous therapies are prescribed, some of the advantages of the concurrent configuration in terms of simpler circuit layout and simpler machine design may overcome the advantages in terms of solute clearance. Different dialysate flow configurations influence solute clearance and change major solute removal mechanisms in the proximal and distal parts of a hemodiafilter. Advantages of each configuration should be balanced against the overall performance of the treatment and its simplicity in terms of treatment delivery and circuit handling procedures. Copyright © 2013 S. Karger AG, Basel.

CT imaging spectrum of infiltrative renal diseases.

PubMed

Ballard, David H; De Alba, Luis; Migliaro, Matias; Previgliano, Carlos H; Sangster, Guillermo P

2017-11-01

Most renal lesions replace the renal parenchyma as a focal space-occupying mass with borders distinguishing the mass from normal parenchyma. However, some renal lesions exhibit interstitial infiltration-a process that permeates the renal parenchyma by using the normal renal architecture for growth. These infiltrative lesions frequently show nonspecific patterns that lead to little or no contour deformity and have ill-defined borders on CT, making detection and diagnosis challenging. The purpose of this pictorial essay is to describe the CT imaging findings of various conditions that may manifest as infiltrative renal lesions.

A case of severe chlorite poisoning successfully treated with early administration of methylene blue, renal replacement therapy, and red blood cell transfusion: case report.

PubMed

Gebhardtova, Andrea; Vavrinec, Peter; Vavrincova-Yaghi, Diana; Seelen, Mark; Dobisova, Anna; Flassikova, Zora; Cikova, Andrea; Henning, Robert H; Yaghi, Aktham

2014-08-01

The case of a 55-year-old man who attempted suicide by ingesting <100 mL of 28% sodium chlorite solution is presented. On arrival in the intensive care unit, the patient appeared cyanotic with lowered consciousness and displayed anuria and chocolate brown serum.Initial laboratory tests revealed 40% of methemoglobin. The formation of methemoglobin was effectively treated with methylene blue (10% after 29 hours).To remove the toxin, and because of the anuric acute renal failure, the patient received renal replacement therapy. Despite these therapeutic measures, the patient developed hemolytic anemia and disseminated intravascular coagulation, which were treated with red blood cell transfusion and intermittent hemodialysis. These interventions led to the improvement of his condition and the patient eventually fully recovered. Patient gave written informed consent.This is the third known case of chlorite poisoning that has been reported. Based upon this case, we suggest the management of sodium chlorite poisoning to comprise the early administration of methylene blue, in addition to renal replacement therapy and transfusion of red blood cells.

A Case of Severe Chlorite Poisoning Successfully Treated With Early Administration of Methylene Blue, Renal Replacement Therapy, and Red Blood Cell Transfusion

PubMed Central

Gebhardtova, Andrea; Vavrinec, Peter; Vavrincova-Yaghi, Diana; Seelen, Mark; Dobisova, Anna; Flassikova, Zora; Cikova, Andrea; Henning, Robert H.; Yaghi, Aktham

2014-01-01

Abstract The case of a 55-year-old man who attempted suicide by ingesting <100 mL of 28% sodium chlorite solution is presented. On arrival in the intensive care unit, the patient appeared cyanotic with lowered consciousness and displayed anuria and chocolate brown serum. Initial laboratory tests revealed 40% of methemoglobin. The formation of methemoglobin was effectively treated with methylene blue (10% after 29 hours). To remove the toxin, and because of the anuric acute renal failure, the patient received renal replacement therapy. Despite these therapeutic measures, the patient developed hemolytic anemia and disseminated intravascular coagulation, which were treated with red blood cell transfusion and intermittent hemodialysis. These interventions led to the improvement of his condition and the patient eventually fully recovered. Patient gave written informed consent. This is the third known case of chlorite poisoning that has been reported. Based upon this case, we suggest the management of sodium chlorite poisoning to comprise the early administration of methylene blue, in addition to renal replacement therapy and transfusion of red blood cells. PMID:25144325

Trace elements in patients on continuous renal replacement therapy.

PubMed

Broman, M; Bryland, A; Carlsson, O

2017-07-01

Intensive care patients with acute kidney injury (AKI), treated with continuous renal replacement therapy (CRRT) are at great risk for disturbances in plasma levels of trace elements due to the underlying illness, AKI, and dialysis. This study was performed to increase our knowledge regarding eight different trace elements during CRRT. Thirty one stable patients with AKI, treated with CRRT, were included in the study. Blood, plasma and effluent samples were taken at the start of the study and 36 ± 12 h later. A group of 48 healthy volunteers were included as controls and exposed to one fasting blood sample. Samples were analysed for trace elements (Cr, Cu, Mn, Co, Zn, Rb, Mo, Se) and standard blood chemistry. Blood and plasma levels of selenium and rubidium were significantly reduced while the levels of chromium, cobalt, and molybdenum were significantly increased in the study group vs. healthy volunteers. There was an uptake of chromium, manganese, and zinc. Molybdenum mass balance was around zero. For selenium, copper, and rubidium there were a marked loss. The low levels of selenium and rubidium in blood and plasma from CRRT patients, together with the loss via CRRT effluent, raises the possibility of the need for selenium supplementation in this group of patients, despite the unchanged levels during the short study period. Further investigations on the effect of additional administration of trace elements to CRRT patients would be of interest. © 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

The influence of hypophosphatemia on outcomes of low- and high-intensity continuous renal replacement therapy in critically ill patients with acute kidney injury

PubMed Central

Kim, Soo Young; Kim, Ye Na; Shin, Ho Sik; Jung, Yeonsoon; Rim, Hark

2017-01-01

Background The purpose of this study was to assess the role of hypophosphatemia in major clinical outcomes of patients treated with low- or high-intensity continuous renal replacement therapy (CRRT). Methods We performed a retrospective analysis of data collected from 492 patients. We divided patients into two CRRT groups based on treatment intensity (greater than or equal to or less than 40 mL/kg/hour of effluent generation) and measured serum phosphate level daily during CRRT. Results We obtained a total of 1,440 phosphate measurements on days 0, 1, and 2 and identified 39 patients (7.9%), 74 patients (15.0%), and 114 patients (23.1%) with hypophosphatemia on each of these respective days. In patients treated with low-intensity CRRT, there were 23 episodes of hypophosphatemia/1,000 patient days, compared with 83 episodes/1,000 patient days in patients who received high-intensity CRRT (P < 0.01). Multiple Cox proportional hazards analysis showed that Acute Physiology and Chronic Health Evaluation (APACHE) III score, utilization of vasoactive drugs, and arterial pH on the second day of CRRT were significant predictors of mortality, while serum phosphate level was not a significant contributor to mortality. Conclusion APACHE score, use of vasoactive drugs, and arterial pH on the second CRRT day were identified as significant predictors of mortality. Hypophosphatemia might not be a major risk factor of increased mortality in patients treated with CRRT. PMID:28904875

The relationship between hypophosphataemia and outcomes during low-intensity and high-intensity continuous renal replacement therapy.

PubMed

Bellomo, Rinaldo; Cass, Alan; Cole, Louise; Finfer, Simon; Gallagher, Martin; Kim, Inbyung; Lee, Joanne; Lo, Serigne; McArthur, Colin; McGuinness, Shay; McGuiness, Shay; Norton, Robyn; Myburgh, John; Scheinkestel, Carlos

2014-03-01

To identify risk factors for development of hypophosphataemia in patients treated with two different intensities of continuous renal replacement therapy (CRRT) and to assess the independent association of hypophosphataemia with major clinical outcomes. We performed secondary analysis of data collected from 1441 patients during a large, multicentre randomised controlled trial of CRRT intensity. We allocated patients to two different intensities of CRRT (25mL/kg/hour vs 40 mL/kg/hour of effluent generation) and obtained daily measurement of serum phosphate levels. We obtained 14 115 phosphate measurements and identified 462 patients (32.1%) with hypophosphataemia, with peak incidence on Day 2 and Day 3. With lower intensity CRRT, there were 58 episodes of hypophosphataemia/1000 patient days, compared with 112 episodes/1000 patient days with higher intensity CRRT (P < 0.001). On multivariable logistic regression analysis, higher intensity CRRT, female sex, higher Acute Physiology and Chronic Health Evaluation score and hypokalaemia were independently associated with an increased odds ratio (OR) for hypophosphataemia. On multivariable models, hypophosphataemia was associated with better clinical outcomes, but when analysis was confined to patients alive at 96 hours, hypophosphataemia was not independently associated with clinical outcomes. Hypophosphataemia is common during CRRT and its incidence increases with greater CRRT intensity. Hypophosphataemia is not a robust independent predictor of mortality. Its greater incidence in the higher intensity CRRT arm of the Randomised Evaluation of Normal vs Augmented Level trial does not explain the lack of improved outcomes with such treatment.

Can renal and bladder ultrasound replace CT urogram in patients investigated for microscopic hematuria?

PubMed

Tan, Wei Shen; Sarpong, Rachael; Khetrapal, Pramit; Rodney, Simon; Mostafid, Hugh; Cresswell, Joanne; Hicks, James; Rane, Abhay; Henderson, Alastair; Watson, Dawn; Cherian, Jacob; Williams, Norman; Brew-Graves, Chris; Feber, Andrew; Kelly, John D

2018-04-24

Computed tomography urogram (CTU) is recommended when investigating patients with hematuria. We determine the incidence of urinary tract cancer and compare the diagnostic accuracy of CTU and renal and bladder ultrasound (RBUS) at identifying urinary tract cancer. The DETECT I study (clinicaltrials.gov NCT02676180) is a prospective observational study recruiting patients ≥18 years following a presentation of macroscopic or microscopic haematuria at 40 hospitals. All patients had cystoscopy and upper tract imaging (CTU, RBUS or both). 3,556 patients with a median age of 68 years were recruited, of which 2166 had RBUS and 1692 had CTU in addition to cystoscopy. The incidence of bladder, renal and upper tract urothelial cancer (UTUC) were 11.0%, 1.4% and 0.8% respectively in macroscopic hematuria patients. Patients with microscopic hematuria had a 2.7%, 0.4% and 0% incidence of bladder, renal and UTUC respectively. The sensitivity and negative predictive value (NPV) of RBUS for the detection of renal cancer was 85.7% and 99.9% respectively but 14.3% and 99.7% for the detection of UTUC. RBUS was poor at identifying renal calculi. Sensitivity of RBUS was lower than CTU for the detection of bladder cancer (both <85%). Cystoscopy has a specificity and PPV of 98.3% and 83.9% respectively. CTU can be safely replaced with RBUS in patients with microscopic hematuria. The incidence of UTUC is 0.8% in patients with macroscopic hematuria and CTU is recommended. Patients with suspected renal calculi will require non-contrast renal tract CT. Imaging cannot replace cystoscopy to diagnose bladder cancer. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Year in review 2005: Critical Care – nephrology

PubMed Central

Ricci, Zaccaria; Ronco, Claudio

2006-01-01

We summarize original research in the field of critical care nephrology accepted or published in 2005 in Critical Care and, when considered relevant or directly linked to this research, in other journals. The articles have been grouped into four categories to facilitate a rapid overview. First, physiopathology, epidemiology and prognosis of acute renal failure (ARF): an extensive review and some observational studies have been performed with the aim of describing aspects of ARF physiopathology, precise epidemiology and long-term outcomes. Second, several authors have performed clinical trials utilizing a potential nephro-protective drug, fenoldopam, with different results. Third, the issue of continuous renal replacement therapies dose has been addressed in a small prospective study and a large observational trial. And fourth, alternative indications to extracorporeal treatment of ARF and systemic inflammatory response syndrome have been explored by three original clinical studies. PMID:16919174

Bilateral blindness secondary to optic nerve ischemia from severe amlodipine overdose: a case report.

PubMed

Kao, Raymond; Landry, Yves; Chick, Genevieve; Leung, Andrew

2017-08-03

Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is becoming increasingly prevalent. The typical presentation of a calcium channel blocker overdose is hypotension and decreased level of consciousness. We describe a case of a calcium channel blocker overdose that led to bilateral cortical blindness, a presentation that has not previously been reported. A 49-year-old white woman with known bilateral early optic atrophy presented to our hospital with hypotension and obtundation following a known ingestion of 150 mg of amlodipine. She was transferred to our intensive care unit where she was intubated, mechanically ventilated, and required maximal vasopressor support (norepinephrine 40 mcg/minute, epinephrine 40 mcg/minute, and vasopressin 2.4 units/hour) along with intravenously administered crystalloid boluses. Despite these measures, she continued to deteriorate with persistent hypotension and tachycardia, as well as anuria. Intralipid emulsion therapy was subsequently administered to which no initial response was observed. A chest X-ray revealed diffuse pulmonary edema; intravenous diuresis as well as continuous renal replacement therapy was initiated. Following the initiation of continuous renal replacement therapy, her oxygen requirements as well as urine output began to improve, and 3 days later she was liberated from mechanical ventilation. Following extubation, she complained of new onset visual impairment, specifically seeing only red-green colors, but no objects. An ophthalmologic examination revealed that this was due to bilateral optic atrophy from prolonged hypotension during the first 24 hours after the overdose. Persistent hypotension in the setting of a calcium channel blocker overdose can lead to worsening optic atrophy resulting in bilateral cortical blindness.

Electrolyte and mineral disturbances in septic acute kidney injury patients undergoing continuous renal replacement therapy

PubMed Central

Jung, Su-Young; Kim, Hyunwook; Park, Seohyun; Jhee, Jong Hyun; Yun, Hae-Ryong; Kim, Hyoungnae; Kee, Youn Kyung; Yoon, Chang-Yun; Oh, Hyung Jung; Chang, Tae Ik; Park, Jung Tak; Yoo, Tae-Hyun; Kang, Shin-Wook; Lee, Hajeong; Kim, Dong Ki; Han, Seung Hyeok

2016-01-01

Abstract Electrolyte and mineral disturbances remain a major concern in patients undergoing continuous renal replacement therapy (CRRT); however, it is not clear whether those imbalances are associated with adverse outcomes in patients with septic acute kidney injury (AKI) undergoing CRRT. We conducted a post-hoc analysis of data from a prospective randomized controlled trial. A total of 210 patients with a mean age of 62.2 years (136 [64.8%] males) in 2 hospitals were enrolled. Levels of sodium, potassium, calcium, and phosphate measured before (0 hour) and 24 hours after CRRT initiation. Before starting CRRT, at least 1 deficiency and excess in electrolytes or minerals were observed in 126 (60.0%) and 188 (67.6%) patients, respectively. The excess in these parameters was greatly improved, whereas hypokalemia and hypophosphatemia became more prevalent at 24 hours after CRRT. However, 1 and 2 or more deficiencies in those parameters at the 2 time points were not associated with mortality. However, during 28 days, 89 (71.2%) deaths occurred in patients with phosphate levels at 0 hour of ≥4.5 mg/dL as compared with 49 (57.6%) in patients with phosphate levels <4.5 mg/dL. The 90-day mortality was also significantly higher in patients with hyperphosphatemia. Similarly, in 184 patients who survived at 24 hours after CRRT, hyperphosphatemia conferred a 2.2-fold and 2.6-fold increased risk of 28- and 90-day mortality, respectively. The results remained unaltered when the serum phosphate level was analyzed as a continuous variable. Electrolyte and mineral disturbances are common, and hyperphosphatemia may predict poor prognosis in septic AKI patients undergoing CRRT. PMID:27603344

76 FR 32085 - Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Rate...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-03

... description of comorbidity for chronic renal failure. In addition, we inadvertently omitted from Table 11 the comorbidity code ``V4511'' for chronic renal failure. These changes are not substantive changes to the... heading ``Diagnoses codes,'' for the renal failure, chronic diagnoses codes, replace code ``V451'' with...

Successful treatment of thyroid storm presenting as recurrent cardiac arrest and subsequent multiorgan failure by continuous renal replacement therapy.

PubMed

Park, Han Soo; Kwon, Su Kyoung; Kim, Ye Na

2017-01-01

Thyroid storm is a rare and potentially life-threatening medical emergency. We experienced a case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course including recurrent cardiac arrest and subsequent multiple organ failure (MOF). A 22-year-old female patient with a 10-year history of Graves' disease was transferred to our emergency department (ED). She had a cardiac arrest at her home and a second cardiac arrest at the ED. Her heart recovered after 20 min of cardiac resuscitation. She was diagnosed with thyroid storm associated with hyperthyroidism complicated by pneumonia and sepsis. Although full conventional medical treatment was given, she had progressive MOF and hemodynamic instability consisting of hyperthermia, tachycardia and hypotension. Because of hepatic and renal failure with refractory hypotension, we reduced the patient's dose of beta-blocker and antithyroid drug, and she was started on continuous veno-venous renal replacement therapy (CRRT) with intravenous albumin and plasma supplementation. Subsequently, her body temperature and pulse rate began to stabilize within 1 h, and her blood pressure reached 120/60 mmHg after 6 h. We discontinued antithyroid drug 3 days after admission because of aggravated hyperbilirubinemia. The patient exhibited progressive improvement in thyroid function even after cessation of antithyroid drug, and she successfully recovered from thyroid storm and MOF. This is the first case of thyroid storm successfully treated by CRRT in a patient considered unfit for antithyroid drug treatment. The presenting manifestations of thyroid storm vary and can include cardiac arrest with multiorgan failure in rare cases.In some patients with thyroid storm, especially those with severe complications, conventional medical treatment may be ineffective or inappropriate.During thyroid storm, the initiation of CRRT can immediately lower body temperature and subsequently stabilize vital signs.Early initiation of CRRT can be life-saving in patients with thyroid storm complicated by MOF, even when used in combination with suboptimal medical treatment.

Effect of continuous renal replacement therapy on kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin in patients with septic acute kidney injury

PubMed Central

Shao, Yiming; Fan, Yinqiang; Xie, Yuliu; Yin, Lu; Zhang, Yuanli; Deng, Liehua; Sun, Xiaocong; Shao, Xin; Tan, Xinzhang; He, Junbing; Zhao, Shiman

2017-01-01

Kidney injury molecule-1 (Kim-1) and neutrophil gelatinase-associated lipocalin (NGAL) have been investigated as biomarkers for acute kidney injury (AKI). However, they are seldom investigated in patients with septic AKI treated with continuous renal replacement therapy (CRRT). The aim of the present study was to investigate the therapeutic effectiveness and possible mechanisms of CRRT in septic AKI by observing the changes in Kim-1 and NGAL levels. A group of 38 patients with septic AKI was randomly divided into the conventional drug treatment group (group A) and the CRRT group (group B). All patients were treated with standard antisepsis agents, and group B was additionally submitted to CRRT for 24 h. The levels of Kim-1 and NGAL in serum, urine and the ultrafiltrate of CRRT were measured prior to and at 12, 24, and 48 h after treatment. In group A, urinary Kim-1 (uKim-1) levels at 12, 24 and 48 h were lower than prior to treatment (P<0.05), whereas urinary NGAL (uNGAL) showed no difference among the various time points (P>0.05). In group B, uKim-1 was decreased at 24 and 48 h compared with before treatment (all P<0.05), whereas uNGAL was decreased at 48 h (P<0.05). Serum Kim-1 did not change with time in groups A and B (P>0.05), whereas serum NGAL was increased after treatment in group A (P<0.05) but did not change in group B (P>0.05). Kim-1 and NGAL were not detected in the ultrafiltrate of CRRT. uKim-1 and uNGAL decreased significantly after CRRT, and therefore may be used to reflect the change of renal function during CRRT and to evaluate the therapeutic effectiveness of the method. PMID:28588686

CT angiography of the renal arteries and veins: normal anatomy and variants.

PubMed

Hazırolan, Tuncay; Öz, Meryem; Türkbey, Barış; Karaosmanoğlu, Ali Devrim; Oğuz, Berna Sayan; Canyiğit, Murat

2011-03-01

Conventional angiography has long been regarded as gold standard imaging modality for evaluation of the renal vasculature. Introduction of multidetector computed tomography (MDCT) angiography had a groundbreaking impact on evaluation of the renal vessels and is gradually replacing conventional angiography as standard imaging. Herein, we review and illustrate the normal and variant anatomy of renal vessels with special emphasis on imaging protocols and reconstruction techniques in MDCT.

Strengthening Renal Registries and ESRD Research in Africa.

PubMed

Davids, M Razeen; Caskey, Fergus J; Young, Taryn; Balbir Singh, Gillian K

2017-05-01

In Africa, the combination of noncommunicable diseases, infectious diseases, exposure to environmental toxins, and acute kidney injury related to trauma and childbirth are driving an epidemic of chronic kidney disease and end-stage renal disease (ESRD). Good registry data can inform the planning of renal services and can be used to argue for better resource allocation, audit the delivery and quality of care, and monitor the impact of interventions. Few African countries have established renal registries and most have failed owing to resource constraints. In this article we briefly review the burden of chronic kidney disease and ESRD in Africa, and then consider the research questions that could be addressed by renal registries. We describe examples of the impact of registry data and summarize the sparse primary literature on country-wide renal replacement therapy in African countries over the past 20 years. Finally, we highlight some initiatives and opportunities for strengthening research on ESRD and renal replacement therapy in Africa. These include the establishment of the African Renal Registry and the availability of new areas for research. We also discuss capacity building, collaboration, open-access publication, and the strengthening of local journals, all measures that may improve the quantity, visibility, and impact of African research outputs. Copyright © 2017 Elsevier Inc. All rights reserved.

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela.

PubMed

Bellorin-Font, Ezequiel; Pernalete, Nidia; Meza, Josefina; Milanes, Carmen Luisa; Carlini, Raul G

2005-08-01

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela. Numerous studies have documented the presence of racial and minority disparities regarding the impact of renal disease and access to renal replacement therapy (RRT). This problem is less well documented in Latin America. Venezuela, like most countries in the region, is subject to severe constraints in the allocation of resources for high-cost chronic diseases, which limits the access of patients with chronic kidney disease to RRT. Although access to health care is universal, there is both a deficit in coverage and disparity in the access to RRT, largely as a result of socioeconomic limitations and budget constrains. With current rising trends of the incidence of end-stage renal disease (ESRD) and costs of medical technology, the long-term goal of complete RRT coverage will become increasingly out of reach. Current evidence suggests that prevention of progression of renal disease is possible at relatively low cost and broad coverage. Based on this evidence, the Ministry of Health has redesigned its policy with respect to renal disease based on 4 elements: 1. Prevention by means of early detection and referral to multidisciplinary health teams, as well as promotion of health habits in the community. 2. Prevention of progression of renal disease by pharmacologic and nonpharmacologic means. 3. An increase in the rate of coverage and reduction of disparities in the access to dialysis. 4. An increase in the rates of renal transplantation through better organ procurement programs and reinforcement of transplant centers. However, the projected increase in the number of patients with ESKD receiving RRT will represent a serious burden to the health care system. Therefore, implementation of these policies will require the involvement of international agencies as well as an adequate partnership between nephrologists and health care planners, so that meeting the increasing demands of ESKD programs may be balanced with other priorities of our national health system.

[Management of iodine-131 ablation therapy for thyroid carcinoma in a patient on chronic hemodialysis].

PubMed

Zenasni, Nadia; Elkhayat, Salma; Taleb, Sara; Zamd, Mohammed; Medkouri, Ghizlaine; Benghanem Gharbi, Mohammed; Ramdani, Benyounes; Aschawa, Hind; Guensi, Amal

2015-04-01

Iodine-131 ablation therapy for thyroid cancer in the patient on chronic hemodialysis represents a real problem since the main route of elimination of radioiodine is urinary. There is no recommendation on the management of this treatment in the patient on hemodialysis. We report our experience of management of this treatment in a patient aged 38 years, undergoing hemodialysis for chronic renal failure, and who have been indicated the treatment with iodine-131 for papillary thyroid carcinoma high risk. After multidisciplinary discussions (nephrologists and specialists in nuclear medicine and radiation safety), it has been decided to treat the patient with continuous ambulatory peritoneal dialysis therapy (CAPD). Because of the low but continuous elimination of iodine in the case of CAPD, the patient received a reduced ablative (131)I dose of 1850 MBq, which is 30% of the usual dose delivered in subjects with normal renal function. The patient was hospitalized for four days in nuclear medicine unit and the (131)I radioactivity emitted from him was 2.5 μSv/h at one meter at his hospital discharge. In conclusion, CAPD in relay of hemodialysis is a technique of renal replacement therapy that can be suggested to minimize exposure to radioactivity to the patient, his family and the medical staff. Copyright © 2015 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

Current Status of Nephron-Sparing Surgery (NSS) in the Management of Renal Tumours.

PubMed

Venkatramani, Vivek; Swain, Sanjaya; Satyanarayana, Ramgopal; Parekh, Dipen J

2017-06-01

Nephron-sparing surgery has emerged as the surgical treatment of choice for small renal masses over the past two decades, replacing the traditional teaching of radical nephrectomy for renal cell carcinoma. With time, there has been an evolution in the techniques and indications for partial nephrectomy. This review summarizes the current status of nephron-sparing surgery for renal carcinoma and also deals with the future of this procedure.

Prevention of Contrast-Induced Acute Kidney Injury by Furosemide With Matched Hydration in Patients Undergoing Interventional Procedures: A Systematic Review and Meta-Analysis of Randomized Trials.

PubMed

Putzu, Alessandro; Boscolo Berto, Martina; Belletti, Alessandro; Pasotti, Elena; Cassina, Tiziano; Moccetti, Tiziano; Pedrazzini, Giovanni

2017-02-27

The objective of this meta-analysis of randomized trials was to evaluate if the administration of furosemide with matched hydration using the RenalGuard System reduces contrast-induced acute kidney injury (CI-AKI) in patients undergoing interventional procedures. CI-AKI is a serious complication following angiographic procedures and a powerful predictor of unfavorable early and long-term outcomes. Online databases were searched up to October 1, 2016, for randomized controlled trials. The primary outcome was the incidence of CI-AKI, and the secondary outcomes were need for renal replacement therapy, mortality, stroke, and adverse events. A total of four trials (n = 698) published between 2011 and 2016 were included in the analysis and included patients undergoing percutaneous coronary procedures and transcatheter aortic valve replacement. RenalGuard therapy was associated with a lower incidence of CI-AKI compared with control treatment (27 of 348 [7.76%] patients vs. 75 of 350 [21.43%] patients; odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.19 to 0.50; I 2  = 4%; p < 0.00001) and with a lower need for renal replacement therapy (2 of 346 [0.58%] patients vs. 12 of 348 [3.45%] patients; OR: 0.19; 95% CI: 0.05 to 0.76; I 2  = 0%; p = 0.02). No major adverse events occurred in patients undergoing RenalGuard therapy. The main finding of this meta-analysis is that furosemide with matched hydration by the RenalGuard System may reduce the incidence of CI-AKI in high-risk patients undergoing percutaneous coronary intervention or transcatheter aortic valve replacement. However, further independent high-quality randomized trials should elucidate the effectiveness and safety of this prophylactic intervention in interventional cardiology. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Current status and standards for establishment of hemodialysis units in Korea

PubMed Central

Lee, Young-Ki; Kim, Kiwon

2013-01-01

The number of hemodialysis patients and dialysis facilities is increasing each year, but there are no surveillance programs validating that the services and equipment of each hemodialysis unit meet specified safety and quality standards. There is a concern that excessive competition and illegal activities committed by some dialysis facilities may violate patients' right to health. Contrastingly, developed countries often have their own survey program to provide initial certification and monitoring to ensure that these clinics continue to meet basic requirements. Because hemodialysis units provide renal replacement therapy to critical patients suffering from severe chronic renal failure, appropriate legal regulation is important for the provision of initial certification and maintenance of facility, equipment, and human resource quality. Therefore, several standards providing minimum requirements for the area of hemodialysis unit, equipment for emergency care, physician and nurse staffs, water purification and quality management are urgently needed. PMID:23682218

Wearable devices for blood purification: principles, miniaturization, and technical challenges.

PubMed

Armignacco, Paolo; Lorenzin, Anna; Neri, Mauro; Nalesso, Federico; Garzotto, Francesco; Ronco, Claudio

2015-01-01

The prevalences of end-stage renal disease (ESRD) and renal replacement therapy (RRT) continue to increase across the world imposing staggering costs on providers. Therefore, strategies to optimize the treatment and improve survival are of fundamental importance. Despite the benefits of daily dialysis, its implementation is difficult and wearable hemodialysis might represent an alternative by which frequent treatments can be delivered to ESRD patients with much less interference in their routines promoting better quality of life. The development of the wearable artificial kidney (WAK) requires incorporation of basic components of a dialysis system into a wearable device that allows mobility, miniaturization, and above all, patient-oriented management. The technical requirements necessary for WAK can be divided into the following broad categories: dialysis membranes, dialysis regeneration, vascular access, patient monitoring systems, and power sources. Pumping systems for blood and other fluids are the most critical components of the entire device. © 2015 Wiley Periodicals, Inc.

Kidney transplantation from donors with rhabdomyolysis and acute renal failure.

PubMed

Chen, Chuan-Bao; Zheng, Yi-Tao; Zhou, Jian; Han, Ming; Wang, Xiao-Ping; Yuan, Xiao-Peng; Wang, Chang-Xi; He, Xiao-Shun

2017-08-01

Rhabdomyolysis in deceased donors usually causes acute renal failure (ARF), which may be considered a contraindication for kidney transplantation. From January 2012 to December 2016, 30 kidneys from 15 deceased donors with severe rhabdomyolysis and ARF were accepted for transplantation at our center. The peak serum creatinine (SCr) kinase, myoglobin, and SCr of the these donors were 15 569±8597 U/L, 37 092±42 100 μg/L, and 422±167 μmol/L, respectively. Two donors received continuous renal replacement therapy due to anuria. Six kidneys exhibited a discolored appearance (from brown to glossy black) due to myoglobin casts. The kidney transplant results from the donors with rhabdomyolysis donors were compared with those of 90 renal grafts from standard criteria donors (SCD). The estimated glomerular filtration rate at 2 years was similar between kidney transplants from donors with rhabdomyolysis and SCD (70.3±14.6 mL/min/1.73 m 2 vs 72.3±15.1 mL/min/1.73 m 2 ). We conclude that excellent graft function can be achieved from kidneys donors with ARF caused by rhabdomyolysis. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Applying lean principles to continuous renal replacement therapy processes.

PubMed

Benfield, C Brett; Brummond, Philip; Lucarotti, Andrew; Villarreal, Maria; Goodwin, Adam; Wonnacott, Rob; Talley, Cheryl; Heung, Michael

2015-02-01

The application of lean principles to continuous renal replacement therapy (CRRT) processes in an academic medical center is described. A manual audit over six consecutive weeks revealed that 133 5-L bags of CRRT solution were discarded after being dispensed from pharmacy but before clinical use. Lean principles were used to examine the workflow for CRRT preparation and develop and implement an intervention. An educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient's condition or CRRT order. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. The primary outcome was the number of CRRT solution bags delivered in the preintervention and postintervention periods. Nurses and pharmacy technicians were surveyed to determine their satisfaction with the workflow change. After implementation of lean principles, the mean number of CRRT solution bags dispensed per day of CRRT decreased substantially. Respondents' overall satisfaction with the CRRT solution preparation process increased during the postintervention period, and the satisfaction scores for each individual component of the workflow after implementation of lean principles. The decreased solution waste resulted in projected annual cost savings exceeding $70,000 in product alone. The use of lean principles to identify medication waste in the CRRT workflow and implementation of an intervention to shift the workload from intensive care unit nurses to pharmacy technicians led to reduced CRRT solution waste, improved efficiency of CRRT workflow, and increased satisfaction among staff. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Insertion side, body position and circuit life during continuous renal replacement therapy with femoral vein access.

PubMed

Kim, In Byung; Fealy, Nigel; Baldwin, Ian; Bellomo, Rinaldo

2011-01-01

Choice of insertion side and patient position during continuous renal replacement therapy (CRRT) with femoral vein vascular access may affect circuit life. We investigated if there is an association between choice of insertion side and body position and its changes and circuit life during CRRT with femoral vein access. We studied 50 patients receiving CRRT via femoral vein access with a sequential retrospective study in a tertiary intensive care unit. We defined two groups: patients with right or left femoral vein access. We then obtained information on age, gender, circuit life, total heparin dose, hemoglobin concentration and coagulation variables (platelet count, international normalized ratio, and activated partial thromboplastin time) and percentage of time each patient spent in the supine, left lying, right lying, and sitting position during treatment. We studied 341 circuits in 50 patients. Mean circuit life was 13.9 h. Of these circuits, 251 (73.6%) were treated with right femoral vein access. Mean circuit life in this group was significantly longer compared with left femoral vein access (15.0 ± 14.3 vs. 10.6 ± 7.4; p = 0.019). Percentage spent in a particular position during CRRT was not significantly different between two groups. On multivariable linear regression analysis, mean circuit life was significantly and positively correlated with right vascular access site (p = 0.03) and lower platelet count (p = 0.03), but not with patient position. Right-sided insertion but not time spent in a particular position significantly affects circuit life during CRRT with femoral vein access. Copyright © 2010 S. Karger AG, Basel.

Fluid overload and survival in critically ill patients with acute kidney injury receiving continuous renal replacement therapy

PubMed Central

Kim, Il Young; Kim, Joo Hui; Lee, Dong Won; Lee, Soo Bong; Rhee, Harin; Seong, Eun Young; Kwak, Ihm Soo

2017-01-01

Background Fluid overload is known to be associated with increased mortality in patients with acute kidney injury (AKI) who are critically ill. In this study, we intended to uncover whether the adverse effect of fluid overload on survival could be applied to all of the patients with AKI who received continuous renal replacement therapy (CRRT). Methods We analyzed 341 patients with AKI who received CRRT in our intensive care units. The presence of fluid overload was defined as a minimum 10% increase in body weight from the baseline. Demographics, comorbid diseases, clinical data, severity of illness [the sequential organ failure assessment (SOFA) score, number of vasopressors, diagnosis of sepsis, use of ventilator] upon ICU admission, fluid overload status, and time elapsed from AKI diagnosis until CRRT initiation were reviewed from the medical charts. Results Patients with total fluid overload from 3 days before CRRT initiation to ICU discharge had a significantly lower survival rate after ICU admission, as compared to patients with no fluid overload (P < 0.001). Among patients with sepsis (P < 0.001) or with high SOFA scores (P < 0.001), there was a significant difference in survival of the patients with and without fluid overload. In patients without sepsis or with low SOFA score, there was no significant difference in survival of patients irrespective of fluid overload. Conclusion Our study demonstrates that the adverse effect of fluid overload on survival is more evident in patients with sepsis or with more severe illness, and that it might not apply to patients without sepsis or with less severe illness. PMID:28196107

Lacosamide Pharmacokinetics in a Critically Ill Patient Receiving Continuous Venovenous Hemofiltration.

PubMed

Franquiz, Miguel J; Kalaria, Shamir N; Armahizer, Michael J; Gopalakrishnan, Mathangi; McCarthy, Paul J; Badjatia, Neeraj

2018-02-01

Lacosamide is a new-generation antiepileptic drug (AED) that is eliminated by both hepatic and renal mechanisms. Lacosamide elimination by continuous renal replacement therapy (CRRT) has never been studied. The objective of this case report was to describe lacosamide pharmacokinetics in the setting of CRRT. We describe a single patient admitted to the study center with status epilepticus and multiorgan failure. The patient required both continuous venovenous hemofiltration (CVVH) and several AEDs. He was receiving intravenous lacosamide 200 mg twice/day at steady state prior to sampling. Plasma lacosamide concentrations were derived using a validated high-performance liquid chromatography method. Parameters were calculated using Phoenix WinNonlin 7.1 software. The peak concentration at steady state was 7.7 mg/L, the trough concentration was 5.9 mg/L (goal 5-12 mg/L). The volume of distribution was 0.7 L/kg, the elimination half-life was 21 hours, and the sieving coefficient was 0.8 (± 0.06). Lacosamide was cleared by CVVH as demonstrated by the sieving coefficient, but plasma concentrations remained within goal range throughout the dosing interval. These results may suggest that lacosamide 200 mg twice/day is a useful dosing strategy for critically ill patients who require CVVH. © 2017 Pharmacotherapy Publications, Inc.

Do the outcomes of living donor renal allograft recipients differ with peritoneal dialysis and hemodialysis as a bridge renal replacement therapy?

PubMed

Prasad, Narayan; Vardhan, Harsh; Baburaj, Vinod P; Bhadauria, Dharmendra; Gupta, Amit; Sharma, Raj K; Kaul, Anupama

2014-11-01

This study was undertaken to compare the outcomes of living donor renal transplant recipients using peritoneal dialysis (PD) and hemodialysis (HD) as a bridge modality for renal replacement therapy till renal transplantation. The demographic profiles of the recipients and donors, the patients' native kidney disease (diabetic versus non-diabetic), duration on dialysis, requirement of anti-hypertensive drugs, number of blood transfusions, human leukocyte antigen (HLA) mismatch status, pre- and post-transplant infectious complications, and post-transplant outcomes of patients were compared between the two groups. The demographic features of the study patients were similar in the two groups. The duration of dialysis prior to transplant was significantly longer in the PD group than in the HD group of patients. The anti-hypertensive drug requirement was lower and the hemoglobin level and residual urine volume at the time of transplant were relatively better in the PD patients compared to the HD patients. The number of acute rejection episodes, delayed graft function, surgical complications, glomerular filtration rate at one month and at the last follow-up, were also similar in both groups. The short-term and long-term graft survival was similar in both groups of patients. The one-, two-, five-, and eight-year death-censored graft survival rates of the PD patients were 98, 95, 85, and 73%, respectively, and in the HD group of patients, they were 100, 93, 84, and 79%, respectively. The one-, two-, five-, and eight-year patient survival rates in the PD group were 97, 92, 77, and 66%, respectively, and in the HD group, they were 97, 92, 79, and 69%, respectively. Our study suggests that the outcomes of the living donor renal allograft recipients did not differ between the groups of patients who used PD or HD as renal replacement therapy prior to renal transplantation.

Mechanical complications of continuous ambulatory peritoneal dialysis: Experience at the Ibn Sina University Hospital.

PubMed

Flayou, Kaoutar; Ouzeddoun, Naima; Bayahia, Rabia; Rhou, Hakima; Benamar, Loubna

2016-01-01

Peritoneal dialysis is a new renal replacement therapy recently introduced in Morocco since 2006. Continuous ambulatory peritoneal dialysis has proven to be as effective as hemodialysis. However, it is associated with several complications. The aim of this study was to evaluate the outcome of complications in patients treated with peritoneal dialysis at our center. The nature of non-infectious complications was noted during follow-up in these patients. Fiftyseven complications were noted among 34 patients between June 2006 and June 2014. Catheter migration was the most common complication (36.8%), followed by obstruction (14%), dialysate leaks (14%), hemorrhagic complications (10.5%) and, finally, hernia (12.2%), catheter perforation (5.2%) and externalization (3.5%).

Screening for Albuminuria Identifies Individuals at Increased Renal Risk

PubMed Central

van der Velde, Marije; Halbesma, Nynke; de Charro, Frank T.; Bakker, Stephan J.L.; de Zeeuw, Dick; de Jong, Paul E.; Gansevoort, Ronald T.

2009-01-01

It is unknown whether screening for albuminuria in the general population identifies individuals at increased risk for renal replacement therapy (RRT) or accelerated loss of renal function. Here, in a general population-based cohort of 40,854 individuals aged 28 to 75 yr, we collected a first morning void for measurement of urinary albumin. In a subset of 6879 individuals, we measured 24-h urinary albumin excretion and estimated GFR at baseline and during 6 yr of follow-up. Linkage with the national RRT registry identified 45 individuals who started RRT during 9 yr of follow-up. The quantity of albuminuria was associated with increased renal risk: the higher the level of albuminuria, the higher the risk of need for renal replacement therapy and the more rapid renal function decline. A urinary albumin concentration of ≥20 mg/L identified individuals who started RRT during follow-up with 58% sensitivity and 92% specificity. Of the identified individuals, 39% were previously unknown to have impaired renal function, and 50% were not being medically treated. Restricting screening to high-risk groups (e.g., known hypertension, diabetes, cardiovascular disease [CVD], older age) reduced the sensitivity of the test only marginally but failed to identify 45% of individuals with micro- and macroalbuminuria. In conclusion, individuals with elevated levels of urinary albumin are at increased risk for RRT and accelerated loss of renal function. Screening for albuminuria identifies patients at increased risk for progressive renal disease, 40 to 50% of whom were previously undiagnosed or untreated. PMID:19211710

A bio-artificial renal epithelial cell system conveys survival advantage in a porcine model of septic shock.

PubMed

Westover, Angela J; Buffington, Deborah A; Johnston, Kimberly A; Smith, Peter L; Pino, Christopher J; Humes, H David

2017-03-01

Renal cell therapy using the hollow fiber based renal assist device (RAD) improved survival time in an animal model of septic shock (SS) through the amelioration of cardiac and vascular dysfunction. Safety and ability of the RAD to improve clinical outcomes was demonstrated in a Phase II clinical trial, in which patients had high prevalence of sepsis. Even with these promising results, clinical delivery of cell therapy is hampered by manufacturing hurdles, including cell sourcing, large-scale device manufacture, storage and delivery. To address these limitations, the bioartificial renal epithelial cell system (BRECS) was developed. The BRECS contains human renal tubule epithelial cells derived from adult progenitor cells using enhanced propagation techniques. Cells were seeded onto trabeculated disks of niobium-coated carbon, held within cryopreservable, perfusable, injection-moulded polycarbonate housing. The study objective was to evaluate the BRECS in a porcine model of SS to establish conservation of efficacy after necessary cell sourcing and design modifications; a pre-clinical requirement to move back into clinical trials. SS was incited by peritoneal injection of E. coli simultaneous to insertion of BRECS (n=10) or control (n=15), into the ultrafiltrate biofeedback component of an extracorporeal circuit. Comparable to RAD, prolonged survival of the BRECS cohort was conveyed through stabilization of cardiac output and vascular leak. In conclusion, the demonstration of conserved efficacy with BRECS therapy in a porcine SS model represents a crucial step toward returning renal cell therapy to the clinical setting, initially targeting ICU patients with acute kidney injury requiring continuous renal replacement therapy. Copyright © 2014 John Wiley & Sons, Ltd. Copyright © 2014 John Wiley & Sons, Ltd.

THE PURVIEW OF PHYTOTHERAPY IN THE MANAGEMENT OF KIDNEY DISORDERS: A SYSTEMATIC REVIEW ON NIGERIA AND SOUTH AFRICA

PubMed Central

Sabiu, Saheed; O’Neill, Frans Hendrik; Ashafa, Anofi Omotayo Tom

2016-01-01

Background: The kidney is tasked with a number of metabolic functions in the body. In its role as a detoxifier and primary eliminator of xenobiotics, it becomes vulnerable to developing injuries. Currently, over 1 million people in the world are living on renal replacement therapies (RRTs). The case in sub-Sahara African countries like Nigeria and South Africa is not any better than the global trend. Materials and Methods: A systematic review of medicinal plants used in the treatment of kidney disorders was conducted. Information were gathered from published scientific journals, books, reports from national, regional and international institutions, conference proceedings and other high profile intellectual resources. MeSH words like ‘prevalence of kidney disorders in Africa’, ‘renal replacement therapy’, ‘nephrotoxins or nephrotoxicants’, ‘nephroprotective plants’, ‘nephroprotective plants in Nigeria or South Africa’ and ‘nephroprotective phytocompounds’ were used to retrieve information from online databases (Google, Pubmed, MEDLINE, Science Direct, Scopus and SID). Results: Interestingly, our findings revealed that phytotherapy has emerged and is being employed to protect renal functions and delay progression of renal pathological conditions into end episodes where the last resort is RRT. In fact, in recent times, Phytotherapists are not only interested in developing relatively safe, more affordable, easily accessible and potent nephroprotective formulations but also increasing awareness on the prevalence of the disease and educating the populace on the probable preventive measures. More importantly, efforts at scientifically elucidating the pharmacological efficacy of the identified nephroprotective plants yet to be validated must be intensified through informed expert opinions. Till date, there is paucity of information on the concept of nephroprotection in most developing countries where kidney disorder is a major threat. Although, the concept is just emerging in South Africa, evidences have given credence to its application in complementary and alternative system of medicine in Nigeria. Conclusion: This review, therefore, reawaken researchers’ consciousness in the continuous search for auspicious nephroprotective plants that could potentially be excellent candidates in developing new lead drugs to manage and treat renal disorders. PMID:28487892

The role of the renal specialist nurse in prevention of renal failure.

PubMed

Hurst, J

2002-01-01

This article will investigate the care required for those with reduced renal function before renal replacement therapy (RRT) commences. Renal nurses are often involved with the technical, monitoring and evaluative aspects of RRT for those with end stage renal failure. However, many patients may experience reduced renal function many years before reaching the stage of needing RRT. Renal nurses are already involved in the preparation of patients for RRT, but are not presently exercising their specialist skills in the period before this time by contributing to the prevention of end stage renal failure (ESRF). Screening programmes carried out in various parts of the world demonstrate that many members of the population have undetected renal insufficiency, and may benefit from intervention from the nephrology team to prevent further renal dysfunction. It is for this group of patients that this article will consider the potential for the renal nurse to expand their scope of practice.

End-stage renal disease treated in Provence-Alpes Côte d'Azur: 12-years follow-up and forecast to the year 2030.

PubMed

Durand, Anne-Claire; Jouve, Elisabeth; Delarozière, Jean-Christophe; Boucekine, Mohamed; Izaaryene, Ghizlane; Crémades, Adeline; Mazoué, Franck; Devictor, Bénédicte; Kakar, Asmatullah; Sambuc, Roland; Brunet, Philippe; Gentile, Stéphanie

2018-06-15

This study describes the time trend of renal replacement therapy for end-stage renal disease (ESRD) in the Provence-Alpes Côte d'Azur region (PACA) between 2004 and 2015, and forecasts up to 2030. A longitudinal study was conducted on all ESRD patients treated in PACA and recorded in the French Renal Epidemiology and Information Network (REIN) during this period. Time trends and forecasts to 2030 were analyzed using Poisson regression models. Since 2004, the number of new patients has steadily increased by 3.4% per year (95% CI, 2.8-3.9, p < 0.001) and the number of patients receiving RRT has increased by 3.7% per year (RR 1.037, 95% CI: 1.034-1.039, p < 0.001). If these trends continue, the PACA region will be face with 7371 patients on dialysis and 3891 with a functional renal transplant who will need to be managed in 2030. The two most significant growth rates were the percentage of obese people (RR 1.140, 95% CI: 1.131-1.149, p < 0.001) and those with diabetes (RR 1.070, 95% CI; 1.064-1.075, p < 0.001). This study highlights the increase in the number of ESRD patients over 12 years, with no prospect of stabilization. These findings allow us to anticipate the quality and quantity of care offered and to propose more preventive measures to combat obesity and diabetes.

A Rare Case of Renal Impairment Caused by Primary Hypothyroidism.

PubMed

Choy, Joleen; Yaxley, Julian; Yaxley, William

2018-05-01

An association between hypothyroidism and renal impairment has rarely been reported in the literature. We describe a case of hypothyroidism that was associated with otherwise unexplained acute kidney impairment, which was reversed with treatment. A 21-year-old female patient presented to her family physician with myalgia, and preliminary investigations revealed an elevated level of creatine kinase and poor renal function. Primary hypothyroidism was diagnosed and no other apparent etiology for renal failure could be identified despite extensive investigations by the Nephrology Department. Notably, the patient's renal impairment showed prompt resolution following thyroid hormone replacement.

A population approach to renal replacement therapy epidemiology: lessons from the EVEREST study.

PubMed

Caskey, Fergus J; Jager, Kitty J

2014-08-01

The marked variation that exists in renal replacement therapy (RRT) epidemiology between countries and within countries requires careful systematic examination if the root causes are to be understood. While individual patient-level studies are undoubtedly important, there is a complementary role for more population-level, area-based studies--an aetiological approach. The EVEREST Study adopted such an approach, bringing RRT incidence rates, survival and modality mix together with macroeconomic factors, general population factors and renal service organizational factors for up to 46 countries. This review considers the background to EVEREST, its key results and then the main methodological lessons and their potential application to ongoing work. © The Author 2013. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

External Validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy.

PubMed

Peeters, Patrick; Van Biesen, Wim; Veys, Nic; Lemahieu, Wim; De Moor, Bart; De Meester, Johan

2016-04-07

Shared decision making is nowadays acknowledged as an essential step when deciding on starting renal replacement therapy. Valid risk stratification of prognosis is, besides discussing quality of life, crucial in this regard. We intended to validate a recently published risk stratification model in a large cohort of incident patients starting renal replacement therapy in Flanders. During 3 years (2001-2003), the data set collected for the Nederlandstalige Belgische Vereniging voor Nefrologie (NBVN) registry was expanded with parameters of comorbidity. For all incident patients, the abbreviated REIN score(aREIN), being the REIN score without the parameter "mobility", was calculated, and prognostication of mortality at 3, 6 and 12 month after start of renal replacement therapy (RRT) was evaluated. Three thousand four hundred seventy-two patients started RRT in Flanders during the observation period (mean age 67.6 ± 14.3, 56.7 % men, 33.6 % diabetes). The mean aREIN score was 4.1 ± 2.8, and 56.8, 23.1, 12.6 and 7.4 % of patients had a score of ≤4, 5-6, 7-8 or ≥9 respectively. Mortality at 3, 6 and 12 months was 8.6, 14.1 and 19.6 % in the overall and 13.2, 21.5 and 31.9 % in the group with age >75 respectively. In RoC analysis, the aREIN score had an AUC of 0.74 for prediction of survival at 3, 6 and 12 months. There was an incremental increase in mortality with the aREIN score from 5.6 to 45.8 % mortality at 6 months for those with a score ≤4 or ≥9 respectively. The aREIN score is a useful tool to predict short term prognosis of patients starting renal replacement therapy as based on comorbidity and age, and delivers meaningful discrimination between low and high risk populations. As such, it can be a useful instrument to be incorporated in shared decision making on whether or not start of dialysis is worthwhile.

Australia and New Zealand Dialysis and Transplant Registry.

PubMed

McDonald, Stephen P

2015-06-01

The ANZDATA Registry includes all patients treated with renal replacement therapy (RRT) throughout Australia and New Zealand. Funding is predominantly from government sources, together with the non-government organization Kidney Health Australia. Registry operations are overseen by an Executive committee, and a Steering Committee with wide representation. Data is collected from renal units throughout Australia and New Zealand on a regular basis, and forwarded to the Registry. Areas covered include demographic details, primary renal disease, type of renal replacement therapy, process measures, and a variety of outcomes. From this data collection a number of themes of work are produced. These include production of Registry reports with an extensive range of national and regional data, a suite of quality assurance reports, key process indicator (KPI) reports, and data sets for a variety of audit and research purposes. The various types of information from the ANZDATA Registry are used in a wide variety of areas, including health services planning, safety and quality programs, and clinical research projects.

Optimization of SDS exposure on preservation of ECM characteristics in whole organ decellularization of rat kidneys.

PubMed

He, M; Callanan, A; Lagaras, K; Steele, J A M; Stevens, M M

2017-08-01

Renal transplantation is well established as the optimal form of renal replacement therapy but is restricted by the limited pool of organs available for transplantation. The whole organ decellularisation approach is leading the way for a regenerative medicine solution towards bioengineered organ replacements. However, systematic preoptimization of both decellularization and recellularization parameters is essential prior to any potential clinical application and should be the next stage in the evolution of whole organ decellularization as a potential strategy for bioengineered organ replacements. Here we have systematically assessed two fundamental parameters (concentration and duration of perfusion) with regards to the effects of differing exposure to the most commonly used single decellularizing agent (sodium dodecyl sulphate/SDS) in the perfusion decellularization process for whole rat kidney ECM bioscaffolds, with findings showing improved preservation of both structural and functional components of the whole kidney ECM bioscaffold. Whole kidney bioscaffolds based on our enhanced protocol were successfully recellularized with rat primary renal cells and mesenchymal stromal cells. These findings should be widely applicable to decellularized whole organ bioscaffolds and their optimization in the development of regenerated organ replacements for transplantation. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1352-1360, 2017. © 2016 Wiley Periodicals, Inc.

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock.

PubMed

Thiele, Holger; Akin, Ibrahim; Sandri, Marcus; Fuernau, Georg; de Waha, Suzanne; Meyer-Saraei, Roza; Nordbeck, Peter; Geisler, Tobias; Landmesser, Ulf; Skurk, Carsten; Fach, Andreas; Lapp, Harald; Piek, Jan J; Noc, Marko; Goslar, Tomaž; Felix, Stephan B; Maier, Lars S; Stepinska, Janina; Oldroyd, Keith; Serpytis, Pranas; Montalescot, Gilles; Barthelemy, Olivier; Huber, Kurt; Windecker, Stephan; Savonitto, Stefano; Torremante, Patrizia; Vrints, Christiaan; Schneider, Steffen; Desch, Steffen; Zeymer, Uwe

2017-12-21

In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial. In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke. At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups. Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

A bioartificial environment for kidney epithelial cells based on a supramolecular polymer basement membrane mimic and an organotypical culture system.

PubMed

Mollet, Björne B; Bogaerts, Iven L J; van Almen, Geert C; Dankers, Patricia Y W

2017-06-01

Renal applications in healthcare, such as renal replacement therapies and nephrotoxicity tests, could potentially benefit from bioartificial kidney membranes with fully differentiated and functional human tubular epithelial cells. A replacement of the natural environment of these cells is required to maintain and study cell functionality cell differentiation in vitro. Our approach was based on synthetic supramolecular biomaterials to mimic the natural basement membrane (BM) on which these cells grow and a bioreactor to provide the desired organotypical culture parameters. The BM mimics were constructed from ureidopyrimidinone (UPy)-functionalized polymer and bioactive peptides by electrospinning. The resultant membranes were shown to have a hierarchical fibrous BM-like structure consisting of self-assembled nanofibres within the electrospun microfibres. Human kidney-2 (HK-2) epithelial cells were cultured on the BM mimics under organotypical conditions in a custom-built bioreactor. The bioreactor facilitated in situ monitoring and functionality testing of the cultures. Cell viability and the integrity of the epithelial cell barrier were demonstrated inside the bioreactor by microscopy and transmembrane leakage of fluorescently labelled inulin, respectively. Furthermore, HK-2 cells maintained a polarized cell layer and showed modulation of both gene expression of membrane transporter proteins and metabolic activity of brush border enzymes when subjected to a continuous flow of culture medium inside the new bioreactor for 21 days. These results demonstrated that both the culture and study of renal epithelial cells was facilitated by the bioartificial in vitro environment that is formed by synthetic supramolecular BM mimics in our custom-built bioreactor. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Technical aspects of home hemodialysis.

PubMed

Alhomayeed, B; Lindsay, R M

2009-03-01

Home hemodialysis (HHD) has proved to be a useful form of renal replacement therapy. The economic advantage of HHD is well established and interest in it is renewed. Once it has been decided to establish a HHD program, a well developed strategic plan is required. This should address financial and logistical issues and establish policies that will address responsi-bilities of both patients and HD centers. The recruitment of patients is facilitated by ensuring that all incident patients have early access to an education program describing all forms of renal replacement therapy that the regional renal program provides. Patients and members of the pre-dialysis education program should understand the selection process criteria in advance. Once the assessment is completed and the patient agrees to the proceedings, a plan of action should be esta-blished for enrolling the patient into the program and initiating training. Patients' education pro-gram should take into consideration principles of adult learning. When choosing dialysis equip-ment for home use, the needs and preferences of the patients should be respected. As a rule of thumb, the equipment should be simple to use, yet still provide adequate and reliable therapy. De-ciding where to set up and position the HHD equipment is important. Installation of HHD ma-chine at home requires a continuous supply of accessories. Before establishing a HHD program, commitment of the dialysis center to provide and maintain the infrastructure of the program is mandatory. The estimated patients suitable for HHD are less than 15% of all prospective dialysis patients. Generally, those who are have greatly improved quality of life and by using modalities such as nocturnal and daily dialysis can have improved physical well-being with considerable potential cost savings.

UK Renal Registry 17th Annual Report: Chapter 9 Clinical, Haematological and Biochemical Parameters in Patients Receiving Renal Replacement Therapy in Paediatric Centres in the UK in 2013: National and Centre-specific Analyses.

PubMed

Hamilton, Alexander J; Pruthi, Rishi; Maxwell, Heather; Casula, Anna; Braddon, Fiona; Inward, Carol; Lewis, Malcolm; O'Brien, Catherine; Stojanovic, Jelena; Tse, Yincent; Sinha, Manish D

2015-01-01

The Paediatric Registry analyses renal replacement therapy (RRT) data in children. All 13 UK paediatric nephrology centres submit electronic data. To provide centre specific data and to determine adherence to relevant audit standards. Data analysis to calculate summary statistics and achievement of an audit standard. The median height z-score for children on dialysis was -2.0 and for children with a functioning transplant -1.3. Children transplanted before age 11 years improved their height z score subsequently, whereas those >11 maintained their height z-score, with all transplanted patients having a similar height z-score after 3 years of starting RRT.The median weight z-score for children on dialysis was -1.2, and for children with a functioning transplant -0.2.Of those with data, 75% of the prevalent paediatric RRT population had .1 risk factors for cardiovascular disease, with 1 in 10 having all three risk factors evaluated. For transplant patients, 76% achieved the systolic blood pressure (SBP)standard and 91% achieved the haemoglobin standard. For haemodialysis patients, 53% achieved the SBP standard,66% the haemoglobin standard, 84% the calcium standard,43% the phosphate standard and 43% achieved the parathyroid hormone (PTH) standard. For peritoneal dialysis patients, 61% achieved the SBP standard, 83% the haemoglobin standard, 71% the calcium standard, 56% the phosphate standard and 36% achieved the PTH standard. Quarterly data collection will improve quality and reporting. Continued focus on improving height and avoiding obesity is needed. Awareness and management of cardiovascular risk is an important long term strategy.

77 FR 34392 - Government-Owned Inventions; Availability for Licensing

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-11

... and efficacy against renal and prostate cancer cell lines in vivo. The compound can be efficiently... sperm binding persist after replacement of mouse sperm receptors with human homologs. Dev Cell. 2003 Jul....; 301-435- 4074; [email protected] . Englerin A: A Novel Renal Cancer Therapeutic Isolated...

Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy

PubMed Central

Selewski, David T.; Cornell, Timothy T.; Lombel, Rebecca M.; Blatt, Neal B.; Han, Yong Y.; Mottes, Theresa; Kommareddi, Mallika; Kershaw, David B.; Shanley, Thomas P.; Heung, Michael

2012-01-01

Purpose In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome. Methods This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n = 113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses. Results The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival. Conclusions Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside. PMID:21533569

Effects of hemoperfusion and continuous renal replacement therapy on patient survival following paraquat poisoning.

PubMed

Wang, Yadong; Chen, Yao; Mao, Lu; Zhao, Guangju; Hong, Guangliang; Li, Mengfang; Wu, Bin; Chen, Xiaorong; Tan, Meng; Wang, Na; Lu, Zhongqiu

2017-01-01

Mortality in patients with paraquat (PQ) poisoning is related to plasma PQ levels. Concentrations lower than 5,000 ng/mL are considered critical but curable. This study assessed the effects of hemoperfusion (HP) and continuous renal replacement therapy (CRRT) on the survival of PQ-poisoned patients with plasma PQ levels below 5,000ng/mL. We analyzed the records of 164 patients with PQ poisoning who were treated at the First Affiliated Hospital of Wenzhou Medical University in China between January 2011 and May 2015. We divided these patients into six sub-groups based on baseline plasma PQ levels and treatment, compared their clinical characteristics, and analyzed their survival rates. Patient sub-groups did not differ in terms of age, sex, time between poisoning and hospital admission, or time to first gavage. Biochemical indicators improved over time in all sub-groups following treatment, and the combined HP and CRRT treatment yielded better results than HP or CRRT alone. Fatality rates in the three treatment sub-groups did not differ among patients with baseline plasma PQ levels of 50-1,000 ng/mL, but in patients with 1,000-5,000 ng/mL levels, the mortality rate was 59.2% (HP treatment group), 48% (CRRT treatment group), and 37.9% (combined treatment group). Mortality rates were higher 10-30 days after hospitalization than in the first 10 days after admission. In the early stages of PQ poisoning, CRRT is effective in reducing patient fatality rates, particularly when combined with HP. Our data could be useful in increasing survival in acute PQ poisoning patients.

Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

PubMed Central

Maree, Jonathan David; Chirehwa, Maxwell T.; Benatar, Solomon R.

2016-01-01

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible. PMID:27701466

Role of estrogen and progesterone in the modulation of CNG-A1 and Na/K+-ATPase expression in the renal cortex.

PubMed

Gracelli, Jones B; Souza-Menezes, Jackson; Barbosa, Carolina M L; Ornellas, Felipe S; Takiya, Christina M; Alves, Leandro M; Wengert, Mira; Feltran, Georgia da Silva; Caruso-Neves, Celso; Moyses, Margareth R; Prota, Luiz F M; Morales, Marcelo M

2012-01-01

The steroid hormones, estrogen and progesterone, are involved mainly in the control of female reproductive functions. Among other effects, estrogen and progesterone can modulate Na(+) reabsorption along the nephron altering the body's hydroelectrolyte balance. In this work, we analyzed the expression of cyclic nucleotide-gated channel A1 (CNG-A1) and α1 Na(+)/K(+)-ATPase subunit in the renal cortex and medulla of female ovariectomized rats and female ovariectomized rats subjected to 10 days of 17β-estradiol benzoate (2.0 µg/kg body weight) and progesterone (1.7 mg/kg body weight) replacement. Na(+)/K(+) ATPase activity was also measured. Immunofluorescence localization of CNG-A1 in the cortex and medulla was performed in control animals. We observed that CNG-A1 is localized at the basolateral membrane of proximal and distal tubules. Female ovariectomized rats showed low expression of CNG-A1 and low expression and activity of Na(+)/K(+) ATPase in the renal cortex. When female ovariectomized rats were subjected to 17β-estradiol benzoate replacement, normalization of CNG-A1 expression and Na(+)/K(+) ATPase expression and activity was observed. The replacement of progesterone was not able to recover CNG-A1 expression and Na(+)/K(+) ATPase expression at the control level. Only the activity of Na(+)/K(+) ATPase was able to be recovered at control levels in animals subjected to progesterone replacement. No changes in expression and activity were observed in the renal medulla. The expression of CNG-A1 is higher in cortex compared to medulla. In this work, we observed that estrogen and progesterone act in renal tissues modulating CNG-A1 and Na(+)/K(+) ATPase and these effects could be important in Na(+) and water balance. Copyright © 2012 S. Karger AG, Basel.

Differences and inequalities in relation to access to renal replacement therapy in the BRICS countries.

PubMed

Ferraz, Fábio Humberto Ribeiro Paes; Rodrigues, Cibele Isaac Saad; Gatto, Giuseppe Cesare; Sá, Natan Monsores de

2017-07-01

End-stage renal disease (ESRD) is an important public health problem, especially in developing countries due to the high level of economic resources needed to maintain patients in the different programs that make up renal replacement therapy (RRT). To analyze the differences and inequalities involved in access to RRT in the BRICS countries (Brazil, Russian Federation, India, China and South Africa). This is an applied, descriptive, cross-sectional, quantitative and qualitative study, with documentary analysis and a literature review. The sources of data were from national censuses and scientific publications regarding access to RRT in the BRICS countries. There is unequal access to RRT in all the BRICS countries, as well as the absence of information regarding dialysis and transplants (India), the absence of effective legislation to inhibit the trafficking of organs (India and South Africa) and the use of deceased prisoners as donors for renal transplants (China). The construction of mechanisms to promote the sharing of benefits and solidarity in the field of international cooperation in the area of renal health involves the recognition of bioethical issues related to access to RRT in the BRICS countries.

In Search of Mechanisms Associated with Mesenchymal Stem Cell-Based Therapies for Acute Kidney Injury

PubMed Central

de Almeida, Danilo C; Donizetti-Oliveira, Cassiano; Barbosa-Costa, Priscilla; Origassa, Clarice ST; Câmara, Niels OS

2013-01-01

Acute kidney injury (AKI) is classically described as a rapid loss of kidney function. AKI affects more than 15% of all hospital admissions and is associated with elevated mortality rates. Although many advances have occurred, intermittent or continuous renal replacement therapies are still considered the best options for reversing mild and severe AKI syndrome. For this reason, it is essential that innovative and effective therapies, without side effects and complications, be developed to treat AKI and the end-stages of renal disease. Mesenchymal stem cell (MSC) based therapies have numerous advantages in helping to repair inflamed and damaged tissues and are being considered as a new alternative for treating kidney injuries. Numerous experimental models have shown that MSCs can act via differentiation-independent mechanisms to help renal recovery. Essentially, MSCs can secrete a pool of cytokines, growth factors and chemokines, express enzymes, interact via cell-to-cell contacts and release bioagents such as microvesicles to orchestrate renal protection. In this review, we propose seven distinct properties of MSCs which explain how renoprotection may be conferred: 1) anti-inflammatory; 2) pro-angiogenic; 3) stimulation of endogenous progenitor cells; 4) anti-apoptotic; 5) anti-fibrotic; 6) anti-oxidant; and 7) promotion of cellular reprogramming. In this context, these mechanisms, either individually or synergically, could induce renal protection and functional recovery. This review summarises the most important effects and benefits associated with MSC-based therapies in experimental renal disease models and attempts to clarify the mechanisms behind the MSC-related renoprotection. MSCs may prove to be an effective, innovative and affordable treatment for moderate and severe AKI. However, more studies need to be performed to provide a more comprehensive global understanding of MSC-related therapies and to ensure their safety for future clinical applications. PMID:24353358

Battle of oral anticoagulants in the field of atrial fibrillation scrutinized from a clinical practice (the real world) perspective

PubMed Central

2011-01-01

Warfarin has a long history of benefit and has become the gold standard medication for the prevention of ischemic stroke in patients with atrial fibrillation. Nevertheless, it is far from perfect and there is no doubt that new drugs must be found to replace warfarin. The new oral anticoagulants that are on the market or awaiting approval or under research offer some benefits but not enough to replace warfarin until results of additional studies can show an adequate balance between effectiveness/safety and cost/benefit. There are several issues concerning the new oral anticoagulants. It is essential that the effect of any anticoagulant can be measured in plasma. But to date, there is no test to assess the effect or therapeutic range for the new oral anticoagulants. There is no antidote to neutralize the action of the new drugs in cases of bleeding or when acute surgical intervention is necessary. Dabigatran requires dose adjustment in patients with moderate renal impairment and is contraindicated in patients with severe renal failure. Rivaroxaban should be used with caution in patients with severe renal impairment. Apixaban excretion is also partly dependent on renal function, although the impact of renal insufficiency has not yet been determined. How anticoagulant bridging can be done before surgery has not yet been established. In conclusion, although thousands of patients have been treated in phase III studies, additional data are necessary before conclusions can be drawn on the potential for these new anticoagulant drugs to replace warfarin in patients with atrial fibrillation. PMID:21794130

Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review

PubMed Central

2014-01-01

Rhabdomyolysis, a clinical syndrome caused by damage to skeletal muscle and release of its breakdown products into the circulation, can be followed by acute kidney injury (AKI) as a severe complication. The belief that the AKI is triggered by myoglobin as the toxin responsible appears to be oversimplified. Better knowledge of the pathophysiology of rhabdomyolysis and following AKI could widen treatment options, leading to preservation of the kidney: the decision to initiate renal replacement therapy in clinical practice should not be made on the basis of the myoglobin or creatine phosphokinase serum concentrations. PMID:25043142

Current state of continuous ambulatory peritoneal dialysis in Egypt.

PubMed

Elzorkany, Khaled Mohamed Amin

2017-01-01

Patients with end-stage renal disease (ESRD) continue to increase in number worldwide, especially in developing countries. Although continuous ambulatory peritoneal dialysis (CAPD) has comparable survival advantages as hemodialysis (HD), it is greatly underutilized in many regions worldwide. The prevalence of use of CAPD in Egypt is 0.29/million population in 2017. The aim of this study is to describe the current state and practice of CAPD in Egypt and included 22 adult patients who were treated by CAPD. All the study patients were switched to CAPD after treatment with HD failed due to vascular access problems. Patients were mainly female (68.2 %) with the mean age of 49.77 ± 11.41 years. The average duration on CAPD was 1.76 ± 1.30 years. Hypertension was the main cause of end-stage renal disease (ESRD) constituting 36.4%, followed by diabetes (27.3 %), and toxic nephropathy (4.5%). Of importance is that about 31.8% of patients had ESRD of unknown etiology. The mean weekly Kt/V urea of patients on PD was 1.92 ± 0.18. The mean hemoglobin, serum calcium, phosphorus, parathormone, and albumin levels were 10.27 ± 1.98 g/dL, 8.36 ± 1.19 mg/dL, 5.70 ± 1.35 mg/dL, 541.18 ± 230.12 pg/mL, and 2.98 ± 0.73 g/dL, respectively. There was no significant difference between diabetic and nondiabetic CAPD patients regarding demographic and laboratory data. Our data indicate that there is continuing underutilization of CAPD in Egypt which may be related to nonavailability of CAPD fluid, patient factors (education and motivation), gradual decline of the efficiency of health-care professionals, and lack of a national program to start PD as the first modality for renal replacement therapy. It is advised to start an organized program to make CAPD widespread and encourage local production of PD fluids to reduce the cost of CAPD.

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report

PubMed Central

Pippias, Maria; Stel, Vianda S.; Abad Diez, José Maria; Afentakis, Nikolaos; Herrero-Calvo, Jose Antonio; Arias, Manuel; Tomilina, Natalia; Bouzas Caamaño, Encarnación; Buturovic-Ponikvar, Jadranka; Čala, Svjetlana; Caskey, Fergus J.; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Alonso de la Torre, Ramón; García Bazaga, Maria de los Ángeles; De Meester, Johan; Díaz, Joan Manuel; Djukanovic, Ljubica; Ferrer Alamar, Manuel; Finne, Patrik; Garneata, Liliana; Golan, Eliezer; González Fernández, Raquel; Gutiérrez Avila, Gonzalo; Heaf, James; Hoitsma, Andries; Kantaria, Nino; Kolesnyk, Mykola; Kramar, Reinhard; Kramer, Anneke; Lassalle, Mathilde; Leivestad, Torbjørn; Lopot, Frantisek; Macário, Fernando; Magaz, Angela; Martín-Escobar, Eduardo; Metcalfe, Wendy; Noordzij, Marlies; Palsson, Runolfur; Pechter, Ülle; Prütz, Karl G.; Ratkovic, Marina; Resić, Halima; Rutkowski, Boleslaw; Santiuste de Pablos, Carmen; Spustová, Viera; Süleymanlar, Gültekin; Van Stralen, Karlijn; Thereska, Nestor; Wanner, Christoph; Jager, Kitty J.

2015-01-01

Background This article summarizes the 2012 European Renal Association—European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). Methods Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. Results In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3–60.0) which fell to 39.3% (95% CI: 38.7–39.9) in patients 65–74 years and 21.3% (95% CI: 20.8–21.9) in patients ≥75 years. PMID:26034584

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report.

PubMed

Pippias, Maria; Stel, Vianda S; Abad Diez, José Maria; Afentakis, Nikolaos; Herrero-Calvo, Jose Antonio; Arias, Manuel; Tomilina, Natalia; Bouzas Caamaño, Encarnación; Buturovic-Ponikvar, Jadranka; Čala, Svjetlana; Caskey, Fergus J; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Alonso de la Torre, Ramón; García Bazaga, Maria de Los Ángeles; De Meester, Johan; Díaz, Joan Manuel; Djukanovic, Ljubica; Ferrer Alamar, Manuel; Finne, Patrik; Garneata, Liliana; Golan, Eliezer; González Fernández, Raquel; Gutiérrez Avila, Gonzalo; Heaf, James; Hoitsma, Andries; Kantaria, Nino; Kolesnyk, Mykola; Kramar, Reinhard; Kramer, Anneke; Lassalle, Mathilde; Leivestad, Torbjørn; Lopot, Frantisek; Macário, Fernando; Magaz, Angela; Martín-Escobar, Eduardo; Metcalfe, Wendy; Noordzij, Marlies; Palsson, Runolfur; Pechter, Ülle; Prütz, Karl G; Ratkovic, Marina; Resić, Halima; Rutkowski, Boleslaw; Santiuste de Pablos, Carmen; Spustová, Viera; Süleymanlar, Gültekin; Van Stralen, Karlijn; Thereska, Nestor; Wanner, Christoph; Jager, Kitty J

2015-06-01

This article summarizes the 2012 European Renal Association-European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3-60.0) which fell to 39.3% (95% CI: 38.7-39.9) in patients 65-74 years and 21.3% (95% CI: 20.8-21.9) in patients ≥75 years.

Dialysis in the elderly. New possibilities, new problems.

PubMed

Cassidy, M J D; Sims, R J A

2004-09-01

In the last 2 decades, there has been a phenomenal increase in the number of incident and prevalent elderly patients receiving renal replacement therapy (RRT) and this trend is likely to continue. This article reviews the changing demographics of the renal patient population and discusses the possible reasons for this. The profile of the older adult patient group is discussed, and specific demands and requirements of this patient group are explained. In particular, the authors concentrate on dialysis mode and vascular access; malnutrition; falls and fractures; cognitive impairment and depression and drugs and pain. It is clear that the ''old old'' can benefit significantly from dialysis despite an increasing burden of comorbidity and prognosis on dialysis is discussed. In order to properly inform patients about treatment options it is essential to provide information about prognosis. For some patients dialysis may not be the preferred option and for others withdrawal from dialysis may be appropriate. Nephrologists therefore also need to be familiar with end of life issues and palliative symptom control.

Effect of renal replacement therapy on viscosity in end-stage renal disease patients.

PubMed

Feriani, M; Kimmel, P L; Kurantsin-Mills, J; Bosch, J P

1992-02-01

Viscosity, an important determinant of microcirculatory hemodynamics, is related to hematocrit (HCT), and may be altered by renal failure or its treatment. To assess these factors, we studied the effect of dialysis on the viscosity of whole blood, plasma, and reconstituted 70% HCT blood of eight continuous ambulatory peritoneal dialysis (CAPD) and nine hemodialysis (HD) patients under steady shear flow conditions at different shear rates, before and after dialysis, compared with nine normal subjects. The density of the red blood cells (RBCs), a marker of cell hydration, was measured in HD patients by a nonaqueous differential floatation technique. Whole blood viscosity was higher in controls than patients, and correlated with HCT before treatment (P less than 0.05) at shear rates of 11.5 to 230 s-1) in HD patients, and 23 to 230 s-1 in all end-stage renal disease (ESRD) patients. In contrast, whole blood viscosity correlated with HCT in CAPD patients only at the lowest shear rates (2.3 and 5.75 s-1, P less than 0.05). Plasma viscosity was higher in CAPD patients than both HD patients before treatment and controls (P less than 0.05, analysis of variance [ANOVA]), despite lower plasma total protein, albumin, and similar fibrinogen concentration compared with HD patients. When all samples were reconstituted to 70% HCT, CAPD patients had higher whole blood viscosity than control subjects'. The high HCT blood viscosity of the ESRD patients was higher than control subjects' at capillary shear rates, suggesting increased RBC aggregation and decreased RBC deformability in patients with renal disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex inequality in kidney transplantation rates.

PubMed

Schaubel, D E; Stewart, D E; Morrison, H I; Zimmerman, D L; Cameron, J I; Jeffery, J J; Fenton, S S

Men in the United States undergoing renal replacement therapy are more likely than women to receive a kidney transplant. However, the ability to pay may, in part, be responsible for this finding. To compare adult male and female transplantation rates in a setting in which equal access to medical treatment is assumed. Using data from the Canadian Organ Replacement Register, the rate of first transplantations was computed for the 20, 131 men and the 13,458 women aged 20 years or older who initiated renal replacement therapy between January 1, 1981, and December 31, 1996. Poisson regression analysis was used to estimate the male-female transplantation rate ratio, adjusting for age, race, province, calendar period, underlying disease leading to renal failure, and dialytic modality. Actuarial survival methods were used to compare transplantation probability for covariable-matched cohorts of men and women. Men experienced 20% greater covariable-adjusted kidney transplantation rates relative to women (rate ratio, 1.20; 95% confidence interval, 1.13-1.27). The sex disparity was stronger for cadaveric transplants (rate ratio, 1.23) compared with those from living donors (rate ratio, 1.10). The 5-year probability of receiving a transplant was 47% for men and 39% for women within covariable-matched cohorts (P<.001). The sex disparity in transplantation rates increased with increasing age. The sex effect was weaker among whites and Oriental persons (Chinese, Japanese, Vietnamese, Cambodian, Laotian, Filipino, Malaysian, Indonesian, and Korean) and stronger among blacks, Asian Indians (Indian, Pakistani, and Sri Lankan), and North American Indians (aboriginal). Since survival probability and quality of life are superior for patients who undergo transplantation relative to those who undergo dialysis, an increased effort should be made to distribute kidneys available for transplantation more equitably by sex among patients undergoing renal replacement therapy.

Human skeletal muscles replaced to a high degree by white adipose tissue.

PubMed

Ina, Keisuke; Kitamura, Hirokazu; Masaki, Takayuki; Tatsukawa, Shuji; Yoshimatsu, Hironobu; Fujikura, Yoshihisa

2011-02-01

Extreme replacement of skeletal muscles by adipose tissue was found in an 86-year old Japanese male cadaver during dissection practice for medical students at Oita University School of Medicine. Especially, the bilateral sartorius muscles looked overall like adipose tissue. The man had suffered from diabetes mellitus, renal failure, hypertension and hypothyroidism before his death. He was also an alcohol drinker. He had been bedridden late in life. The cause of death was renal failure. In microscopy, the adipose tissue-like sartorius muscle was shown to consist of leptin-positive adipocytes with a small number of degenerated muscle fibers. Fatty replacement, or fatty degeneration, appears to result from endocrine and metabolic disorders, and being bedridden leads to muscle atrophy and damage, although the origin of the adipocytes which emerged in the degenerated muscles is unknown.

[Renal Replacement Procedure: Information, Education, Documentation].

PubMed

Galle, Jan; Reitlinger, Jana

2018-06-01

In renal replacement therapy, different methods are available: hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KTx). In addition, variants can be used: HD as a home HD or center HD, PD as a conventional PD or automated (cycler) PD, KTx as a potentially short-term predictable living donation or conventional donor kidney donation. The patient and his familiar or caring environment must be informed accordingly. This means first of all: information about which procedures of kidney replacement therapy are possible and can be offered. Then the specific risks associated with each procedure should be elucidated (e. g. HD and shunt bleeding, PD and peritonitis, KTx and infections/neoplasias). This necessarily includes a structured documentation of the educating center/doctor about the communicated information and decisions taken. © Georg Thieme Verlag KG Stuttgart · New York.

Arterial Stiffness and Renal Replacement Therapy: A Controversial Topic

PubMed Central

Fischer, Edmundo Cabrera; Zócalo, Yanina; Galli, Cintia; Bia, Daniel

2015-01-01

The increase of arterial stiffness has been to have a significant impact on predicting mortality in end-stage renal disease patients. Pulse wave velocity (PWV) is a noninvasive, reliable parameter of regional arterial stiffness that integrates the vascular geometry and arterial wall intrinsic elasticity and is capable of predicting cardiovascular mortality in this patient population. Nevertheless, reports on PWV in dialyzed patients are contradictory and sometimes inconsistent: some reports claim the arterial wall stiffness increases (i.e., PWV increase), others claim that it is reduced, and some even state that it augments in the aorta while it simultaneously decreases in the brachial artery pathway. The purpose of this study was to analyze the literature in which longitudinal or transversal studies were performed in hemodialysis and/or peritoneal dialysis patients, in order to characterize arterial stiffness and the responsiveness to renal replacement therapy. PMID:26064684

Agalsidase Benefits Renal Histology in Young Patients with Fabry Disease

PubMed Central

Bostad, Leif; Larsen, Kristin Kampevold; Hirth, Asle; Vikse, Bjørn Egil; Houge, Gunnar; Svarstad, Einar

2012-01-01

The effect of early-onset enzyme replacement therapy on renal morphologic features in Fabry disease is largely unknown. Here, we evaluated the effect of 5 years of treatment with agalsidase alfa or agalsidase beta in 12 consecutive patients age 7–33 years (median age, 16.5 years). We performed renal biopsies at baseline and after 5 years of enzyme replacement therapy; 7 patients had additional biopsies after 1 and 3 years. After a median of 65 months, biopsy findings from all patients showed total clearance of glomerular endothelial and mesangial cell inclusions, and findings from 2 patients showed complete clearance of inclusions from epithelial cells of the distal tubule. The 4 patients who received the highest dose of agalsidase exhibited substantial clearance of podocyte inclusions, and the youngest patient had nearly complete clearance of these inclusions. Linear regression analysis showed a highly significant correlation between podocyte globotriaocylceramide clearance and cumulative agalsidase dose (r=0.804; P=0.002). Microalbuminuria normalized in five patients. In summary, long-term enzyme replacement therapy in young patients can result in complete globotriaocylceramide clearance of mesangial and glomerular endothelial cells across all dosage regimens, and clearance of podocyte inclusions is dose-dependent. PMID:23274955

The clinical epidemiology of young adults starting renal replacement therapy in the UK: presentation, management and survival using 15 years of UK Renal Registry data

PubMed Central

Hamilton, Alexander J; Casula, Anna; Ben-Shlomo, Yoav; Caskey, Fergus J; Inward, Carol D

2018-01-01

Abstract Background Clinical epidemiology data for young adults on renal replacement therapy (RRT) are lacking. While mostly transplanted, they have an increased risk of graft loss during young adulthood. Methods We combined the UK Renal Registry paediatric and adult databases to describe patient characteristics, transplantation and survival for young adults. We grouped patients 11–30 years of age starting RRT from 1999 to 2008 by age band and examined their course during 5 years of follow-up. Results The cohort (n = 3370) was 58% male, 79% white and 29% had glomerulonephritis. Half (52%) started RRT on haemodialysis (HD). Most (78%) were transplanted (18% pre-emptive, 61% as second modality); 11% were not listed for transplant. Transplant timing varied by age group. The deceased:living donor kidney transplant ratio was 2:1 for 11–<16 year olds and 1:1 otherwise. Median deceased donor transplant waiting times ranged from 6 months if <16 years of age to 17 months if ≥21 years. Overall 8% died, with being on dialysis and not transplant listed versus transplanted {hazard ratio [HR] 16.6 [95% confidence interval (CI) 10.8–25.4], P < 0.0001} and diabetes versus glomerulonephritis [HR 4.03 (95% CI 2.71–6.01), P < 0.0001] increasing mortality risk. Conclusions This study highlights the frequent use of HD and the importance of transplant listing and diabetes for young adults. More than half the young adults in our cohort started renal replacement therapy on HD. One in 10 young adults were not listed for transplant by 5 years and were ∼20 times more likely to die than those who were transplanted. Diabetes as a primary renal disease was common among young adults and associated with increased mortality. Overall, almost 1 in 10 young adults had died by 5 years from the start of RRT. PMID:28339838

Hydroxyethyl starch or saline for fluid resuscitation in intensive care.

PubMed

Myburgh, John A; Finfer, Simon; Bellomo, Rinaldo; Billot, Laurent; Cass, Alan; Gattas, David; Glass, Parisa; Lipman, Jeffrey; Liu, Bette; McArthur, Colin; McGuinness, Shay; Rajbhandari, Dorrilyn; Taylor, Colman B; Webb, Steven A R

2012-11-15

The safety and efficacy of hydroxyethyl starch (HES) for fluid resuscitation have not been fully evaluated, and adverse effects of HES on survival and renal function have been reported. We randomly assigned 7000 patients who had been admitted to an intensive care unit (ICU) in a 1:1 ratio to receive either 6% HES with a molecular weight of 130 kD and a molar substitution ratio of 0.4 (130/0.4, Voluven) in 0.9% sodium chloride or 0.9% sodium chloride (saline) for all fluid resuscitation until ICU discharge, death, or 90 days after randomization. The primary outcome was death within 90 days. Secondary outcomes included acute kidney injury and failure and treatment with renal-replacement therapy. A total of 597 of 3315 patients (18.0%) in the HES group and 566 of 3336 (17.0%) in the saline group died (relative risk in the HES group, 1.06; 95% confidence interval [CI], 0.96 to 1.18; P=0.26). There was no significant difference in mortality in six predefined subgroups. Renal-replacement therapy was used in 235 of 3352 patients (7.0%) in the HES group and 196 of 3375 (5.8%) in the saline group (relative risk, 1.21; 95% CI, 1.00 to 1.45; P=0.04). In the HES and saline groups, renal injury occurred in 34.6% and 38.0% of patients, respectively (P=0.005), and renal failure occurred in 10.4% and 9.2% of patients, respectively (P=0.12). HES was associated with significantly more adverse events (5.3% vs. 2.8%, P<0.001). In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who received resuscitation with HES were treated with renal-replacement therapy. (Funded by the National Health and Medical Research Council of Australia and others; CHEST ClinicalTrials.gov number, NCT00935168.).

Biology of sepsis: its relevance to pediatric nephrology.

PubMed

Blatt, Neal B; Srinivasan, Sushant; Mottes, Theresa; Shanley, Maureen M; Shanley, Thomas P

2014-12-01

Because of its multi-organ involvement, the syndrome of sepsis provides clinical challenges to a wide variety of health care providers. While multi-organ dysfunction triggered by sepsis requires general supportive critical care provided by intensivists, the impact of sepsis on renal function and the ability of renal replacement therapies to modulate its biologic consequences provide a significant opportunity for pediatric nephrologists and related care providers to impact outcomes. In this review, we aim to highlight newer areas of understanding of the pathobiology of sepsis with special emphasis on those aspects of particular interest to pediatric nephrology. As such, we aim to: (1) review the definition of sepsis and discuss advances in our mechanistic understanding of sepsis; (2) review current hypotheses regarding sepsis-induced acute kidney injury (AKI) and describe its epidemiology based on evolving definitions of AKI; (3) review the impact of renal failure on the immune system, highlighting the sepsis risk in this cohort and strategies that might minimize this risk; (4) review how renal replacement therapeutic strategies may impact sepsis-induced AKI outcomes. By focusing the review on these specific areas, we have omitted other important areas of the biology of sepsis and additional interactions with renal function from this discussion; however, we have aimed to provide a comprehensive list of references that provide contemporary reviews of these additional areas.

Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial.

PubMed

Semler, Matthew W; Self, Wesley H; Wang, Li; Byrne, Daniel W; Wanderer, Jonathan P; Ehrenfeld, Jesse M; Stollings, Joanna L; Kumar, Avinash B; Hernandez, Antonio; Guillamondegui, Oscar D; May, Addison K; Siew, Edward D; Shaw, Andrew D; Bernard, Gordon R; Rice, Todd W

2017-03-16

Saline, the intravenous fluid most commonly administered to critically ill adults, contains a high chloride content, which may be associated with acute kidney injury and death. Whether using balanced crystalloids rather than saline decreases the risk of acute kidney injury and death among critically ill adults remains unknown. The Isotonic Solutions and Major Adverse Renal Events Trial (SMART) is a pragmatic, cluster-level allocation, cluster-level crossover trial being conducted between 1 June 2015 and 30 April 2017 in five intensive care units at Vanderbilt University Medical Center in Nashville, TN, USA. SMART compares saline (0.9% sodium chloride) with balanced crystalloids (clinician's choice of lactated Ringer's solution or Plasma-Lyte A®). Each intensive care unit is assigned to provide either saline or balanced crystalloids each month, with the assigned crystalloid alternating monthly over the course of the trial. All adults admitted to participating intensive care units during the study period are enrolled and followed until hospital discharge or 30 days after enrollment. The anticipated enrollment is approximately 14,000 patients. The primary outcome is Major Adverse Kidney Events within 30 days-the composite of in-hospital death, receipt of new renal replacement therapy, or persistent renal dysfunction (discharge creatinine ≥200% of baseline creatinine). Secondary clinical outcomes include in-hospital mortality, intensive care unit-free days, ventilator-free days, vasopressor-free days, and renal replacement therapy-free days. Secondary renal outcomes include new renal replacement therapy receipt, persistent renal dysfunction, and incidence of stage 2 or higher acute kidney injury. This ongoing pragmatic trial will provide the largest and most comprehensive comparison to date of clinical outcomes with saline versus balanced crystalloids among critically ill adults. For logistical reasons, SMART was prospectively registered separately for the medical ICU (SMART-MED; ClinicalTrials.gov identifier: NCT02444988 ; registered on 11 May 2015; date of first patient enrollment: 1 June 2015) and the nonmedical ICUs (SMART-SURG; ClinicalTrials.gov identifier: NCT02547779 ; registered on 9 September 2015; date of first patient enrollment: 1 October 2015).

Clinical features, course and prognosis of idiopathic membranous nephropathy depending on the presence of antibodies against M-type phospholipase A2 receptor.

PubMed

Jatem Escalante, Elías; Segarra Medrano, Alfons; Carnicer Cáceres, Clara; Martín-Gómez, M Adoración; Salcedo Allende, María Teresa; Ostos Roldan, Helena; Agraz Pamplona, Irene

2015-01-01

In membranous nephropathy, the presence of antibodies against M-type phospholipase A2 receptor is considered highly specific for idiopathic forms. However, no specific association to a particular clinical profile has been found for such antibodies. To assess potential differences in initial clinical profile, course and prognosis of idiopathic membranous nephropathy depending on the presence of anti-PLA2R antibodies. Eighty-five patients with idiopathic membranous nephropathy were included (55 anti-PLA2R-positive and 30 anti-PLA2R-negative). Clinical, biochemical and pathological variables were recorded at the time of diagnosis. Frequency of spontaneous remission, incidence of response to first-line therapy, frequency and number of recurrences, survival of renal function free from renal replacement therapy, survival of renal function free from chronic renal insufficiency and frequency of occurrence of malignant, infectious or autoimmune diseases during follow-up were recorded. At the time of diagnosis, anti-PLA2R-negative patients were significantly older and had a higher frequency of spontaneous remission. No differences were noted in the response to first-line treatment, frequency and number of recurrences, survival of renal function free from renal replacement therapy, or survival of renal function free from chronic renal insufficiency. Anti-PLA2R-negative patients with idiopathic membranous nephropathy were older and experienced spontaneous remission more often than anti-PLA2R-positive patients. No differences in terms of treatment response, recurrences, and final prognosis were observed between both groups of patients. Copyright © 2015 The Authors. Published by Elsevier España, S.L.U. All rights reserved.

Gonadal dysfunction in men with chronic kidney disease: clinical features, prognostic implications and therapeutic options.

PubMed

Iglesias, Pedro; Carrero, Juan J; Díez, Juan J

2012-01-01

Gonadal dysfunction is a frequent finding in men with chronic kidney disease and with end-stage renal disease. Testosterone deficiency, usually accompanied by elevation of serum gonadotropin concentrations, is present in 26-66% of men with different degrees of renal failure. Uremia-associated hypogonadism is multifactorial in its origin, and rarely improves with initiation of dialysis, although it usually normalizes after renal transplantation. Experimental and clinical evidence suggests that testosterone may have important clinical implications with regards to kidney disease progression, derangements in sexual drive, libido and erectile dysfunction, development of anemia, impairment of muscle mass and strength, and also progression of atherosclerosis and cardiovascular disease. Additionally, low testosterone levels in hemodialysis patients have been associated with increased mortality risk in some studies. Currently, we count with available therapeutic options in the management of uremic hypogonadism, from optimal delivery of dialysis and adequate nutritional intake, to hormone replacement therapy with different testosterone preparations. Other potential options for treatment include the use of antiestrogens, dopamine agonists, erythropoiesis-stimulating factors, vitamins, essential trace elements, chorionic gonadotropin and renal transplantation. Potential adverse effects of androgen replacement therapy in patients with kidney disease comprise, however, erythrocytosis, prostate and breast cancer growth, reduced fertility, gynecomastia, obstructive sleep apnea and fluid retention. Androgen preparations should be used with caution with stringent monitoring in uremic men. Although there are encouraging data suggesting plausible benefits from testosterone replacement therapy, further studies are needed with regards to safety and effectiveness of this therapy.

Disruptive technological advances in vascular access for dialysis: an overview.

PubMed

Yeo, Wee-Song; Ng, Qin Xiang

2017-11-29

End-stage kidney disease (ESKD), one of the most prevalent diseases in the world and with increasing incidence, is associated with significant morbidity and mortality. Current available modes of renal replacement therapy (RRT) include dialysis and renal transplantation. Though renal transplantation is the preferred and ideal mode of RRT, this modality may not be available to all patients with ESKD. Moreover, renal transplant recipients are constantly at risk of complications associated with immunosuppression and immunosuppressant use, and posttransplant lymphoproliferative disorder. Dialysis may be the only available modality in certain patients. However, dialysis has its limitations, which include issues associated with lack of vascular access, risks of infections and vascular thrombosis, decreased quality of life, and absence of biosynthetic functions of the kidney. In particular, the creation and maintenance of hemodialysis vascular access in children poses a unique set of challenges to the pediatric nephrologist owing to the smaller vessel diameters and vascular hyperreactivity compared with adult patients. Vascular access issues continue to be one of the major limiting factors prohibiting the delivery of adequate dialysis in ESKD patients and is the Achilles' heel of hemodialysis. This review aims to provide a critical overview of disruptive technological advances and innovations for vascular access. Novel strategies in preventing neointimal hyperplasia, novel bioengineered products, grafts and devices for vascular access will be discussed. The potential impact of these solutions on improving the morbidity encountered by dialysis patients will also be examined.

Oral yeast colonization in peritoneal dialysis and hemodialysis patients and renal transplant recipients.

PubMed

Gulcan, Aynur; Gulcan, Erim; Keles, Mustafa; Aktas, Esin

2016-06-01

We aimed to investigate the frequency of oral yeast colonization (OYC) and the risk factors for patients who received continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis (HD) or were renal transplant recipients (RTRs). The patients admitted to the Nephrology Clinic at Ataturk University Medical School from January through April 2013 were included in the study. A questionnaire about risk factors was filled out, and swab cultures were taken from the tongue surface of each participant. OYC was detected in 32.1% of the RTRs, 40% of the HD patients, 20.9% of the CAPD patients, and 18% of the healthy control (HC) group. Of the 42 yeast strains isolated from the renal replacement therapy groups, 26 strains (61.9%) were Candida albicans, nine (21.4%) were Candida glabrata, two (4.7%) were Candida krusei, two (4.7%) were Candida kefyr, one (2.38%) was Candida parapsilosis, and two (4.7%) were Geotrichum candidum. Risk factors for OYC in the RTRs group included antibiotic use and the presence of dental prostheses; however, in patients with chronic renal failure undergoing CAPD, only the presence of dental prostheses was found to be a statistically significant risk factor. Although OYC was mostly detected in patients with chronic kidney disease (undergoing HD, a variety of isolated yeast strains in the RTRs was noted. The rates of OYC and isolated Candida species in CAPD were similar to those of the HC group. Copyright © 2016 Elsevier Ltd. All rights reserved.

[A mathematic analysis of different manners of replacement fluid infusion in continuous veno-venous hemofiltration].

PubMed

Wu, Yunzhen; Wang, Chunting

2015-05-01

To establish a mathematical formula for choosing the manner of replacement fluid infusion in continuous renal replacement therapy (CRRT), so as to provide the basis for improving the treatment effect. A mathematical formula for choosing the manner of replacement fluid infusion with continuous veno-venous hemofiltration (CVVH) was taken as an example, and it was compared with the result of standard replacement fluid in order to analyze the effect of different manners of infusion. (1) Comparison parameters: the plasma volume ("Vreturn") and some electrolyte concentration ("Creturn") in back way of CRRT ( if other thing was solute, filter coefficient should be 1.0). (2) Research objects: the actual replacement fluid (for example, the most complex should be sorted into A and B type) mode (pre or post) was compared with the standard replacement fluid (the A and B in one). (3) Based on the formula of standard replacement, four equations in different conditions were derived: pre-dilution and post-dilution mode; same direction and same ratio; same direction and different ratio; different direction and same ratio; different direction and different ratio. The calculated results of "Vreturn" (except hematocrit) and "Creturn" were same to the standard only following the rule of same direction and ratio for A and B no matter pre-dilution mode or post-dilution mode, and it was different from the standard in others. In pre-dilution mode and post-dilution mode, it showed: (1) A and B in same direction and different ratio: "Vreturn" and "Creturn" were different from the standard for the alterative ratio of B. (2) A and B in different direction and same ratio: "Vreturn" was same to the standard, but "Creturn" was different from the standard for the completely different and more complex computational formula. (3) A and B in different direction and different ratio: both "Vreturn" and "Creturn" were different from the standard. The different "Vreturn" was due to the different ratio of B. The different "Creturn" was caused by different ratio of B and the completely different computational formula. (1) For parts of replacement fluid which must be separated (for example, bicarbonate formula), the result is same to the standard, and is predicted and mastered only following the rule of same direction and ratio. Otherwise, we need to calculate the two parameters over and over again. The result will run out of our judgment. The wrongness of losing water and electrolyte disorders maybe come out. (2) Accordingly,the formula could be used to analyze the same case like the separated replacement infusion, for example, a large number of citrates as regional anticoagulation were infused only in the front of filter, while the replacement fluid can be done in varied forms.

Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making.

PubMed

Johnson, Robert F; Gustin, Jillian

2011-07-01

A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. Forty-one studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short-term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4%, respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.

Factors associated with postoperative requirement of renal replacement therapy following off-pump coronary bypass surgery.

PubMed

Kato, Tomoko S; Machida, Yoichiro; Kuwaki, Kenji; Yamamoto, Taira; Amano, Atsushi

2017-02-01

Cardiopulmonary bypass usage provokes a systemic inflammatory response resulting in deterioration of renal function. However, risk factors for requiring renal replacement therapy (RRT) following off-pump coronary artery bypass graft surgery (CABG) have not yet been fully elucidated. We reviewed 718 consecutive patients undergoing elective off-pump CABG at our institution, excluding patients on chronic hemodialysis preoperatively. Sub-analysis of patients with preserved renal function, defined as a creatinine level below a cut-off value of 1.12 mg/dL (obtained by receiver operating characteristic curve), was also performed. Of the 718 patients, 41 (5.7 %) required RRT. There were 556 patients (77.4 %) with preserved renal function preoperatively, and 13 (2.4 %) of these required postoperative RRT. Multivariate analysis revealed that age (years) and preoperative serum creatinine (mg/dL) and brain natriuretic peptide (BNP) levels (pg/dL) were associated with RRT [odds ratios (OR) 1.052, 95 % confidence interval (CI) 9.064 and 1.001, respectively, all p < 0.05] in the total population, whereas low albumin concentration was the only independent predictor for RRT in patients with preserved renal function (OR 0.062, p < 0.0001). When creatinine levels were below 1.5 mg/dL, the predictive power of hypoalbuminemia for RRT requirement overwhelmed that of creatinine or BNP levels. Older age, preoperative elevated creatinine and BNP levels were associated with a requirement for RRT following off-pump CABG. In patients with preserved renal function, hypoalbuminemia was most significantly related to the RRT requirement.

99mtechnetium-dimercapto-succinic acid renal scanning and excretory urography in diagnosis of renal scars in children

DOE Office of Scientific and Technical Information (OSTI.GOV)

McLorie, G.A.; Aliabadi, H.; Churchill, B.M.

1989-09-01

We compared the ability of excretory urography (without tomography) and 99mtechnetium-dimercapto-succinic acid renal scanning to detect renal scars in 32 children with primary vesicoureteral reflux. These children did not have hydronephrosis, renal failure or urinary tract obstruction. In all cases both studies were conducted within a 10-month period. The findings from both modalities were in agreement for 51 of the 64 renal units evaluated (80%). Evaluation of the excretory urogram indicated 6 cases of diffuse and 2 of focal scarring that were not detected by evaluation of the renal scan. The sensitivity of excretory urography to detect renal scars wasmore » 84% and the specificity was 83%. The 99mtechnetium-dimercapto-succinic acid renal scan showed 5 cases of focal renal scarring not detected by excretory urography. The sensitivity of the renal scan to detect renal scars was 77% and the specificity was 75%. We conclude that neither study alone could effectively replace the other for the detection of renal scars, and recommend that both be included in the initial evaluation and followup of patients with renal scars.« less

Desensitization protocol enabling pediatric crossmatch-positive renal transplantation: successful HLA-antibody-incompatible renal transplantation of two highly sensitized children.

PubMed

Adamusiak, Anna M; Stojanovic, Jelena; Shaw, Olivia; Vaughan, Robert; Sebire, Neil J; Drage, Martin; Kessaris, Nicos; Marks, Stephen D; Mamode, Nizam

2017-02-01

Renal transplantation improves quality of life (QoL) and survival in children requiring renal replacement therapy (RRT). Sensitization with development of a broad-spectrum of anti-HLA antibodies as a result of previous transplantation or after receiving blood products is an increasing problem. There are no published reports of desensitization protocols in children allowing renal transplantation from HLA-antibody-incompatible living donors. We adopted our well-established adult desensitization protocol for this purpose and undertook HLA antibody-incompatible living donor renal transplants in two children: a 14-year-old girl and a 13-year-old boy. After 2 and 1.5 years of follow-up, respectively, both patients have stable renal allograft function despite a rise in donor-specific antibodies in one case. HLA-incompatible transplantation should be considered in selected cases for sensitized children.

Baseline Predictors of Mortality among Predominantly Rural-Dwelling End-Stage Renal Disease Patients on Chronic Dialysis Therapies in Limpopo, South Africa

PubMed Central

Mapiye, Darlington; Swanepoel, Charles R.; Bello, Aminu K.; Ratsela, Andrew R.; Okpechi, Ikechi G.

2016-01-01

Background Dialysis therapy for end-stage renal disease (ESRD) continues to be the readily available renal replacement option in developing countries. While the impact of rural/remote dwelling on mortality among dialysis patients in developed countries is known, it remains to be defined in sub-Saharan Africa. Methods A single-center database of end-stage renal disease patients on chronic dialysis therapies treated between 2007 and 2014 at the Polokwane Kidney and Dialysis Centre (PKDC) of the Pietersburg Provincial Hospital, Limpopo South Africa, was retrospectively reviewed. All-cause, cardiovascular, and infection-related mortalities were assessed and associated baseline predictors determined. Results Of the 340 patients reviewed, 52.1% were male, 92.9% were black Africans, 1.8% were positive for the human immunodeficiency virus (HIV), and 87.5% were rural dwellers. The average distance travelled to the dialysis centre was 112.3 ± 73.4 Km while 67.6% of patients lived in formal housing. Estimated glomerular filtration rate (eGFR) at dialysis initiation was 7.1 ± 3.7 mls/min while hemodialysis (HD) was the predominant modality offered (57.1%). Ninety-two (92) deaths were recorded over the duration of follow-up with the majority (34.8%) of deaths arising from infection-related causes. Continuous ambulatory peritoneal dialysis (CAPD) was a significant predictor of all-cause mortality (HR: 1.62, CI: 1.07–2.46) and infection-related mortality (HR: 2.27, CI: 1.13–4.60). On multivariable cox regression, CAPD remained a significant predictor of all-cause mortality (HR: 2.00, CI: 1.29–3.10) while the risk of death among CAPD patients was also significantly modified by diabetes mellitus (DM) status (HR: 4.99, CI: 2.13–11.71). Conclusion CAPD among predominantly rural dwelling patients in the Limpopo province of South Africa is associated with an increased risk of death from all-causes and infection-related causes. PMID:27300372

[Denys-Drash syndrome: a case report].

PubMed

Puczko-Nogal, Barbara; Nogal, Paweł; Bilińska, Wiesława; Kulig, Andrzej; Nowicki, Michał

2003-04-01

Nephrotic syndrome (NS) rarely develops before the age of 1 year. The case is presented of nephrotic syndrome occurring in the form of Denys-Drash syndrome. In a newborn of female sex in birth certificate, dysmorphia was found of the external urogenital organs. The karyotype was 46XY. Massive proteinuria, low total serum protein level, dysproteinaemia, hypercholesterolaemia justified the diagnosis of NS. In renal biopsy performed diffuse mesangial fibrosis was found. The progression of renal insufficiency was very rapid and within few weeks terminal renal failure developed. The parents refused consent to renal replacement treatment. The baby died at the age of 102 days. The autopsy examination confirmed renal changes in the form of diffuse fibrosis; gonads of testicular structure were found in the abdominal cavity.

Outcomes of Male Patients with Alport Syndrome Undergoing Renal Replacement Therapy

PubMed Central

Temme, Johanna; Kramer, Anneke; Jager, Kitty J.; Lange, Katharina; Peters, Frederick; Müller, Gerhard-Anton; Kramar, Reinhard; Heaf, James G.; Finne, Patrik; Palsson, Runolfur; Reisæter, Anna V.; Hoitsma, Andries J.; Metcalfe, Wendy; Postorino, Maurizio; Zurriaga, Oscar; Santos, Julio P.; Ravani, Pietro; Jarraya, Faical; Verrina, Enrico; Dekker, Friedo W.

2012-01-01

Summary Background and objectives Patients with the hereditary disease Alport syndrome commonly require renal replacement therapy (RRT) in the second or third decade of life. This study compared age at onset of RRT, renal allograft, and patient survival in men with Alport syndrome receiving various forms of RRT (peritoneal dialysis, hemodialysis, or transplantation) with those of men with other renal diseases. Design, setting, participants, & measurements Patients with Alport syndrome receiving RRT identified from 14 registries in Europe were matched to patients with other renal diseases. A linear spline model was used to detect changes in the age at start of RRT over time. Kaplan-Meier method and Cox regression analysis were used to examine patient and graft survival. Results Age at start of RRT among patients with Alport syndrome remained stable during the 1990s but increased by 6 years between 2000–2004 and 2005–2009. Survival of patients with Alport syndrome requiring dialysis or transplantation did not change between 1990 and 2009. However, patients with Alport syndrome had better renal graft and patient survival than matched controls. Numbers of living-donor transplantations were lower in patients with Alport syndrome than in matched controls. Conclusions These data suggest that kidney failure in patients with Alport syndrome is now being delayed compared with previous decades. These patients appear to have superior patient survival while undergoing dialysis and superior patient and graft survival after deceased-donor kidney transplantation compared with patients receiving RRT because of other causes of kidney failure. PMID:22997344

Outcomes of male patients with Alport syndrome undergoing renal replacement therapy.

PubMed

Temme, Johanna; Kramer, Anneke; Jager, Kitty J; Lange, Katharina; Peters, Frederick; Müller, Gerhard-Anton; Kramar, Reinhard; Heaf, James G; Finne, Patrik; Palsson, Runolfur; Reisæter, Anna V; Hoitsma, Andries J; Metcalfe, Wendy; Postorino, Maurizio; Zurriaga, Oscar; Santos, Julio P; Ravani, Pietro; Jarraya, Faical; Verrina, Enrico; Dekker, Friedo W; Gross, Oliver

2012-12-01

Patients with the hereditary disease Alport syndrome commonly require renal replacement therapy (RRT) in the second or third decade of life. This study compared age at onset of RRT, renal allograft, and patient survival in men with Alport syndrome receiving various forms of RRT (peritoneal dialysis, hemodialysis, or transplantation) with those of men with other renal diseases. Patients with Alport syndrome receiving RRT identified from 14 registries in Europe were matched to patients with other renal diseases. A linear spline model was used to detect changes in the age at start of RRT over time. Kaplan-Meier method and Cox regression analysis were used to examine patient and graft survival. Age at start of RRT among patients with Alport syndrome remained stable during the 1990s but increased by 6 years between 2000-2004 and 2005-2009. Survival of patients with Alport syndrome requiring dialysis or transplantation did not change between 1990 and 2009. However, patients with Alport syndrome had better renal graft and patient survival than matched controls. Numbers of living-donor transplantations were lower in patients with Alport syndrome than in matched controls. These data suggest that kidney failure in patients with Alport syndrome is now being delayed compared with previous decades. These patients appear to have superior patient survival while undergoing dialysis and superior patient and graft survival after deceased-donor kidney transplantation compared with patients receiving RRT because of other causes of kidney failure.

TRENDS IN RENAL REPLACEMENT THERAPY IN BOSNIA AND HERZEGOVINA 2002-2008

PubMed Central

Resić, Halima; Mešić, Enisa

2010-01-01

Renal Registry (RR) of Bosnia and Herzegovina was established in 2002, with aim to follow up the trends of Renal Replacement Therapy in Bosnia and Herzegovina. The prevalence of Renal Replacement Therapy (RRT) in Bosnia and Herzegovina is rising steadily. One reason for this is an increasing number of patients starting RRT. The aim is to present the epidemiology and treatment of all aspects of RRT in Bosnia and Herzegovina in period 2002-2008. Centre-related and patient-related questionnaires were sent to all 25 dialysis centres in Bosnia and Herzegovina. The demographic data, prevalence and incidence, type of renal replacement therapy, cause of ESRD, erythropoietin administration, cause of death, and type of vascular access were obtained from the questionnaires. Collected data were analysed using SPSS statistics. The number of patients treated by Renal Replacement Therapy (RRT) increased steadily from 1,531 patients in 2002 to the 2,206 at the 2008 (43%). The prevalence has increased from 399 pmp in 2002 to 696 pmp. in 2008. Incidence (new patients) in 2002 was 110 pmp and incidence rate in 2008 was 163, and there were 249 new patients (day 1). The mean age for new patients increased from 60 years in 2002 to 63.5 years in 2008 and the population over 75 years rate from 8.79% to 11.3%. Most ESRD patients in Bosnia and Herzegovina are undergoing intermittent hemodialysis (92%), while some patients (8%) are treated by peritoneal dialysis and transplantation. The most significant cause of ESRD in 2008 was chronic glomerulonephritis (421 patients, 19.2%), followed by pyelonephritis (414 patients, 18.9%), BEN (14.7%) and Diabetes mellitus (12.2%). Hepatitis B and C virus infections had 397 (16.3%) patients, out of them 22 had both type of infections and 98 patients had B type infection. Only 10.5% of patients were tested on MRSA and 3 patients were positive on MRSA. There were no HIV-positive patients on RRT. The most common type of vascular access was AV fistula in 85% patients, AV graft 2% and catheters in 13%. Out of hemodialysis patients, 85.7% received ESA almost s.c. The median weekly dose was 4,000 UI. Cardiovascular diseases were the leading cause of death, gross mortality rate of dialysis patients being 13.01% in 2008. The need for RRT in Bosnia and Herzegovina is increasing and the number of patients increased by 43% since 2002. Hemodialysis is still the most common modality of treatment (92%), while proportion of PD and transplantation is slowly increasing. The preventive measures are necessary to prevent ESRD and also to decrease the number of patients on dialysis. PMID:20433425

Empirical relationships among oliguria, creatinine, mortality, and renal replacement therapy in the critically ill.

PubMed

Mandelbaum, Tal; Lee, Joon; Scott, Daniel J; Mark, Roger G; Malhotra, Atul; Howell, Michael D; Talmor, Daniel

2013-03-01

The observation periods and thresholds of serum creatinine and urine output defined in the Acute Kidney Injury Network (AKIN) criteria were not empirically derived. By continuously varying creatinine/urine output thresholds as well as the observation period, we sought to investigate the empirical relationships among creatinine, oliguria, in-hospital mortality, and receipt of renal replacement therapy (RRT). Using a high-resolution database (Multiparameter Intelligent Monitoring in Intensive Care II), we extracted data from 17,227 critically ill patients with an in-hospital mortality rate of 10.9 %. The 14,526 patients had urine output measurements. Various combinations of creatinine/urine output thresholds and observation periods were investigated by building multivariate logistic regression models for in-hospital mortality and RRT predictions. For creatinine, both absolute and percentage increases were analyzed. To visualize the dependence of adjusted mortality and RRT rate on creatinine, the urine output, and the observation period, we generated contour plots. Mortality risk was high when absolute creatinine increase was high regardless of the observation period, when percentage creatinine increase was high and the observation period was long, and when oliguria was sustained for a long period of time. Similar contour patterns emerged for RRT. The variability in predictive accuracy was small across different combinations of thresholds and observation periods. The contour plots presented in this article complement the AKIN definition. A multi-center study should confirm the universal validity of the results presented in this article.

Hypothyroidism presenting as reversible renal impairment: an interesting case report.

PubMed

Vikrant, Sanjay; Chander, Subhash; Kumar, Satish; Gupta, Dalip

2013-10-01

We describe an interesting case of reversible renal impairment secondary to hypothyroidism. A 57-years-old man was referred from peripheral institution for evaluation of elevated serum creatinine. He had vague complaints of weakness, lethargy and muscle ache but no urinary symptoms. He was found to have hypothyroidism, and thyroid hormone replacement therapy (THRT) was started which resulted in reversal of the renal dysfunction. There was marked improvement in estimated glomerular filtration rate. 99mTc DTPA renal scans done before and after THRT suggested hypothyroidism responsible for this reversible renal impairment. Several studies have described the pathophysiology of diminished renal function in hypothyroidism. Few studies or case reports have shown total amelioration of renal impairment as seen in our patient. The etiology is presumed to be multifactorial, in which hemodynamic effects and a direct effect of thyroid hormone on the kidney play an important role. We suggest that patients with renal impairment of unknown cause have thyroid function tests undertaken as part of routine investigation.

Quality standards for predialysis education: results from a consensus conference

PubMed Central

Isnard Bagnis, Corinne; Crepaldi, Carlo; Dean, Jessica; Goovaerts, Tony; Melander, Stefan; Nilsson, Eva-Lena; Prieto-Velasco, Mario; Trujillo, Carmen; Zambon, Roberto; Mooney, Andrew

2015-01-01

This position statement was compiled following an expert meeting in March 2013, Zurich, Switzerland. Attendees were invited from a spread of European renal units with established and respected renal replacement therapy option education programmes. Discussions centred around optimal ways of creating an education team, setting realistic and meaningful objectives for patient education, and assessing the quality of education delivered. PMID:24957808

Survival is not enough: reflections of a long-term renal patient.

PubMed

Eady, Robin A J

2008-01-01

A kidney patient recalls his experience of almost 45 years of renal replacement therapy covering nearly 25 years of dialysis and 20 years with a transplant. At the beginning, patient or graft survival was a major goal and symbol of successful treatment. But for the patient, what really matters is the quality of his life, assuming he can survive.

Active Learning in a Large Medical Classroom Setting for Teaching Renal Physiology

ERIC Educational Resources Information Center

Dietz, John R.; Stevenson, Frazier T.

2011-01-01

In this article, the authors describe an active learning exercise which has been used to replace some lecture hours in the renal portion of an integrated, organ system-based curriculum for first-year medical students. The exercise takes place in a large auditorium with ~150 students. The authors, who are faculty members, lead the discussions,…

A Simple and Computationally Efficient Approach to Multifactor Dimensionality Reduction Analysis of Gene-Gene Interactions for Quantitative Traits

PubMed Central

Gui, Jiang; Moore, Jason H.; Williams, Scott M.; Andrews, Peter; Hillege, Hans L.; van der Harst, Pim; Navis, Gerjan; Van Gilst, Wiek H.; Asselbergs, Folkert W.; Gilbert-Diamond, Diane

2013-01-01

We present an extension of the two-class multifactor dimensionality reduction (MDR) algorithm that enables detection and characterization of epistatic SNP-SNP interactions in the context of a quantitative trait. The proposed Quantitative MDR (QMDR) method handles continuous data by modifying MDR’s constructive induction algorithm to use a T-test. QMDR replaces the balanced accuracy metric with a T-test statistic as the score to determine the best interaction model. We used a simulation to identify the empirical distribution of QMDR’s testing score. We then applied QMDR to genetic data from the ongoing prospective Prevention of Renal and Vascular End-Stage Disease (PREVEND) study. PMID:23805232

History of technology in the intensive care unit.

PubMed

Puri, Nitin; Puri, Vinod; Dellinger, R P

2009-01-01

Critical care medicine is a young specialty and since its inception has been heavily reliant upon technology. Invasive monitoring has its humble beginnings in the continuous monitoring of heart rate and rhythm. From the development of right heart catheterization to the adaption of the echocardiogram for use in shock, intensivists have used technology to monitor hemodynamics. The care of the critically ill has been buoyed by investigators who sought to offer renal replacement therapy to unstable patients and worked to improve the monitoring of oxygen saturation. The evolution of mechanical ventilation for the critically ill embodies innumerable technological advances. More recently, critical care has insisted upon rigorous testing and cost-benefit analysis of technological advances.

Haemodialysing at home: the client experience of self-treatment.

PubMed

Polaschek, N

2005-01-01

This paper reports a study that sought to describe the experience of people using home haemodialysis as their modality of renal replacement therapy. The study employed a critical interpretive methodology. After developing a framework for the research, a small group of renal clients who haemodialyse themselves in their own homes were intensively interviewed. This study describing the renal client perspective indicates that, although more demanding for them than in-centre treatment, self-treatment at home can enable a superior quality of life for many people living on dialysis.

Chronic peritoneal dialysis in children

PubMed Central

Fraser, Nia; Hussain, Farida K; Connell, Roy; Shenoy, Manoj U

2015-01-01

The incidence of end-stage renal disease in children is increasing. Peritoneal dialysis (PD) is the modality of choice in many European countries and is increasingly applied worldwide. PD enables children of all ages to be successfully treated while awaiting the ultimate goal of renal transplantation. The advantages of PD over other forms of renal replacement therapy are numerous, in particular the potential for the child to lead a relatively normal life. Indications for commencing PD, the rationale, preparation of family, technical aspects, and management of complications are discussed. PMID:26504404

[Intensive hemoperfusion and long-term hemofiltration for treatment of paraquat poisoning: a case report].

PubMed

Peng, Zhi-Yun; Chang, Ping; Wang, Hua; Cen, Zhong-Ran; Zhou, Jian; Liu, Zhan-Guo

2015-10-01

A 20-year-old male patient was admitted in our department 14 h after paraquat poisoning at the dose of about 50 mL. The patient underwent intensive hemoperfusion for 2 h (3 times a day) for 9 consecutive days and received continuous renal replacement therapy (CRRT) in the mode of continuous veno-venous hemofiltration (CVVH) for 10 consecutive days in addition to routine medications. The biochemical indexes were monitored during the therapy. After the treatment, paraquat concentrations in the blood and urine were decreased, and the patient's urine volume (UV) increased, serum creatinine (Cr) level decreased, and the oxygenation index became normal. Dynamic CT scan showed no obvious pulmonary fibrosis. The patient was followed up for 6 months after discharge and no complaint of discomforts was reported. This case suggests that early intensive hemoperfusion and long-term CVVH may help improve the prognosis after paraquat poisoning.

Type of Renal Replacement Therapy (Hemodialysis versus Peritoneal Dialysis) Does Not Affect Cytokine Gene Expression or Clinical Parameters of Renal Transplant Candidates

PubMed Central

Kamińska, Dorota; Kościelska-Kasprzak, Katarzyna; Chudoba, Paweł; Mazanowska, Oktawia; Banasik, Mirosław; Żabinska, Marcelina; Boratyńska, Maria; Lepiesza, Agnieszka; Korta, Krzysztof; Gomółkiewicz, Agnieszka; Dzięgiel, Piotr; Klinger, Marian

2015-01-01

Patients with renal failure suffer from immune disturbances, caused by uremic toxins and influenced by dialysis treatment. The aim of the present study was to reveal whether type of dialysis modality (hemodialysis, HD, versus peritoneal dialysis, PD) differentially affects the immunocompetence, particularly the expression of genes involved in the immune response. Material. 87 renal transplant candidates (66 HD, 21 PD) were included in the study. Methods. The peripheral blood RNA samples were obtained with the PAXgene Blood system just before transplantation. The gene expression of CASP3, FAS, TP53, FOXP3, IFNG, IL2, IL6, IL8, IL10, IL17, IL18, LCN2, TGFB1, and TNF was assessed with real-time PCR on custom-designed low density arrays (TaqMan). Gene expression data were analyzed in relation to pretransplant clinical parameters. Results. The mean expression of examined genes showed no significant differences between PD and HD with the exception of FAS, expression of which was 30% higher in PD patients compared to the HD group. There was nonsignificantly higher expression of proinflammatory cytokines in the PD group. The clinical inflammatory parameters (CRP, albumin, cholesterol, and hemoglobin levels) did not differ between the groups. Conclusion. Type of renal replacement therapy exerts no differential effect on cytokine gene expression or inflammatory clinical parameters. PMID:26236736

Blood disorders typically associated with renal transplantation

PubMed Central

Yang, Yu; Yu, Bo; Chen, Yun

2015-01-01

Renal transplantation has become one of the most common surgical procedures performed to replace a diseased kidney with a healthy kidney from a donor. It can help patients with kidney failure live decades longer. However, renal transplantation also faces a risk of developing various blood disorders. The blood disorders typically associated with renal transplantation can be divided into two main categories: (1) Common disorders including post-transplant anemia (PTA), post-transplant lymphoproliferative disorder (PTLD), post-transplant erythrocytosis (PTE), and post-transplant cytopenias (PTC, leukopenia/neutropenia, thrombocytopenia, and pancytopenia); and (2) Uncommon but serious disorders including hemophagocytic syndrome (HPS), thrombotic microangiopathy (TMA), therapy-related myelodysplasia (t-MDS), and therapy-related acute myeloid leukemia (t-AML). Although many etiological factors involve the development of post-transplant blood disorders, immunosuppressive agents, and viral infections could be the two major contributors to most blood disorders and cause hematological abnormalities and immunodeficiency by suppressing hematopoietic function of bone marrow. Hematological abnormalities and immunodeficiency will result in severe clinical outcomes in renal transplant recipients. Understanding how blood disorders develop will help cure these life-threatening complications. A potential therapeutic strategy against post-transplant blood disorders should focus on tapering immunosuppression or replacing myelotoxic immunosuppressive drugs with lower toxic alternatives, recognizing and treating promptly the etiological virus, bacteria, or protozoan, restoring both hematopoietic function of bone marrow and normal blood counts, and improving kidney graft survival. PMID:25853131

Severe hyperkalaemia complicating parathyroidectomy in patients with end-stage renal disease.

PubMed

Pauling, M; Lee, J C; Serpell, J W; Wilson, S

2017-05-01

We evaluated the incidence of perioperative hyperkalaemia in end-stage renal disease (ESRD) patients undergoing parathyroidectomy and investigated possible contributors to this phenomenon. This was a retrospective cohort study looking at patients who had undergone parathyroidectomy for chronic kidney disease-associated mineral bone disease (CKD-MBD) at The Alfred Hospital, Melbourne, since 2001. Baseline demographics including age, gender, aetiology of renal failure and mode of renal replacement therapy as well as anaesthetic technique and duration of surgery were studied as possible contributors. Perioperative potassium values were compared to preoperative baseline. Following stratification into normokalaemic and hyperkalaemic groups, demographic and operative data were compared. Twenty-two patients met the inclusion criteria with a median (interquartile range, IQR) age of 48.5 (42-59) years. There was a male predominance of 68%. The median (IQR) surgical time was 131 (115-164) minutes. Potassium levels rose perioperatively, with a 27.3% incidence of perioperative hyperkalaemia. Median duration of surgery was longer in the hyperkalaemic patients (167 minutes versus 125 minutes). Following the withdrawal of cinacalcet, parathyroidectomy is increasingly required in ESRD patients with CKD-MBD. Potentially life-threatening hyperkalaemia poses a significant risk in the perioperative period. Serial electrolyte monitoring is crucial to safety in this patient group. A multidisciplinary approach to perioperative management is required to ensure optimal timing of renal replacement therapy and appropriate means of serial blood sampling.

Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched-cohort and population-based study in Taiwan.

PubMed

Chen, Shih-Feng; Wang, I-Jen; Lang, Hui-Chu

2016-01-01

The influence of different treatment modalities on the risk of developing major depression in patients with chronic renal failure (CRF) is not well understood. We aimed to explore the incidence of major depression among patients with CRF who were on different dialysis modalities, who had received renal transplantation (RT), and those who had not yet received any of the aforementioned renal replacement therapies. We conducted a population-based retrospective cohort study using a national health insurance research database. This study investigated 89,336 study controls, 17,889 patients with chronic kidney disease on conservative treatment, 3823 patients on hemodialysis (HD), 351 patients on peritoneal dialysis (PD), and 322 patients who had RT. We followed all individuals until the occurrence of major depression or the date of loss to follow-up. The PD group had the highest risk (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.26-4.69), whereas the RT group had the lowest risk (HR 0.18; 95% CI 0.03-1.29) of developing major depression compared with the control group. Patients initiated on PD had a higher risk of developing major depression than patients initiated on HD (pairwise comparison: HR 2.20; 95% CI 1.09-4.46). Different treatment modalities are associated with different risks of developing major depression in patients with CRF. Among renal replacement therapies, patients who have had RT have the lowest risk of developing major depression. Patients who initiate renal therapy on PD may have a higher risk of major depression compared with patients who initiate renal therapy on HD. © 2015 International Society for Hemodialysis.

Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual Report.

PubMed

Noordzij, Marlies; Kramer, Anneke; Abad Diez, José M; Alonso de la Torre, Ramón; Arcos Fuster, Emma; Bikbov, Boris T; Bonthuis, Marjolein; Bouzas Caamaño, Encarnación; Čala, Svetlana; Caskey, Fergus J; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Díaz Tejeiro, Rafael; Djukanovic, Ljubica; Ferrer-Alamar, Manuel; Finne, Patrik; García Bazaga, María de Los Angelos; Garneata, Liliana; Golan, Eliezer; Gonzalez Fernández, Raquel; Heaf, James G; Hoitsma, Andries; Ioannidis, George A; Kolesnyk, Mykola; Kramar, Reinhard; Lasalle, Mathilde; Leivestad, Torbjørn; Lopot, Frantisek; van de Luijtgaarden, Moniek W M; Macário, Fernando; Magaz, Ángela; Martín Escobar, Eduardo; de Meester, Johan; Metcalfe, Wendy; Ots-Rosenberg, Mai; Palsson, Runolfur; Piñera, Celestino; Pippias, Maria; Prütz, Karl G; Ratkovic, Marina; Resić, Halima; Rodríguez Hernández, Aurelio; Rutkowski, Boleslaw; Spustová, Viera; Stel, Vianda S; Stojceva-Taneva, Olivera; Süleymanlar, Gültekin; Wanner, Christoph; Jager, Kitty J

2014-04-01

This article provides a summary of the 2011 ERA-EDTA Registry Annual Report (available at www.era-edta-reg.org). Data on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data. The overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA-EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6-47.0], and on dialysis 39.3% (95% CI 39.2-39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2-87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6-95.0) for kidneys from living donors.

Influence of renal function on mortality and ventricular arrhythmias in patients undergoing first implantable cardioverter-defibrillator generator replacement.

PubMed

Waks, Jonathan W; Higgins, Angela Y; Mittleman, Murray A; Buxton, Alfred E

2015-03-01

Impaired renal function is associated with increased mortality among patients with implantable cardioverter-defibrillators (ICDs). The relationship between renal function at time of ICD generator replacement and subsequent appropriate ICD therapies is not known. We identified 441 patients who underwent first ICD generator replacement between 2000 and 2011 and had serum creatinine measured within 30 days of their procedure. Patients were divided into tertiles based on estimated glomerular filtration rate (eGFR). Adjusted Cox proportional hazard and competing risk models were used to assess relationships between eGFR and subsequent mortality and appropriate ICD therapy. Median eGFR was 37.6, 59.3, and 84.8 mL/min/1.73 m(2) for tertiles 1-3, respectively. Five-year Kaplan-Meier survival probability was 34.8%, 61.4%, and 84.5% for tertiles 1-3, respectively (P < 0.001). After multivariable adjustment, compared to tertile 3, worse eGFR tertile was associated with increased mortality (HR 2.84, 95% CI [1.36-5.94] for tertile 2; HR 3.84, 95% CI [1.81-8.12] for tertile 1). At 5 years, 57.0%, 58.1%, and 60.2% of patients remained free of appropriate ICD therapy in tertiles 1-3, respectively (P = 0.82). After adjustment, eGFR tertile was not associated with future appropriate ICD therapy. Results were unchanged in an adjusted competing risk model accounting for death. At time of first ICD generator replacement, lower eGFR is associated with higher mortality, but not with appropriate ICD therapies. The poorer survival of ICD patients with reduced eGFR does not appear to be influenced by arrhythmia status, and there is no clear proarrhythmic effect of renal dysfunction, even after accounting for the competing risk of death. © 2014 Wiley Periodicals, Inc.

Combined electrohydraulic and holmium: YAG laser ureteroscopic nephrolithotripsy of large (>2 cm) renal calculi

PubMed Central

Mariani, Albert J.

2008-01-01

Percutaneous nephrolithotripsy (PCL) is a standard treatment for renal calculi >2 cm. Modern flexible ureteroscopes and accessories employing the complementary effects of electrohydraulic lithotripsy (EHL) and Ho:YAG laser lithotrites can treat these renal calculi in a minimally invasive fashion with similar or superior results. Objective: To assess the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of >2 cm renal calculi in the community setting. Materials and Methods: Fifty nine patients with 63 renal calculi ranging from 20 to 97 mm (mean 44 mm) in length and 175 to 3300 mm2 (mean 728 mm2) area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (BMI > 30) was present in 54% and 19% were morbidly obese (BMI > 40). An infectious etiology was present in 49% and hard stone components in 89%. All patients presented with hematuria, pain, and/or recurrent urinary tract infection (UTI). Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly EHL. Laser drilling was employed (n = 6) to weaken very hard stones prior to EHL. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation. Results: All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 60/63 (95%) with a mean of 1.7 nephrolithotripsy stages and 0.38 secondary or ancillary procedures. Outpatient management was sufficient for 121/131 (92%) of the procedures. Operative time averaged 46 min/stage and 79 min/calculus. Complications included endotoxic shock (3), fever (5), ureteral fragments requiring treatment (11), delayed extubation (2), delayed pneumonia (1), and urinary retention (1). Conclusion: Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with PCL. It has largely replaced PCL at this institution. PMID:19468511

Unusual course of infective endocarditis: acute renal failure progressing to chronic renal failure.

PubMed

Sevinc, Alper; Davutoglu, Vedat; Barutcu, Irfan; Kocoglu, M Esra

2006-04-01

Infective endocarditis is an infection of the endocardium that usually involves the valves and adjacent structures. The classical fever of unknown origin presentation represents a minority of infective endocarditis. The presented case was a 21-yearold young lady presenting with acute renal failure and fever to the emergency room. Cardiac auscultation revealed a soft S1 and 4/6 apical holosystolic murmur extended to axilla. Echocardiography showed mobile fresh vegetation under the mitral posterior leaflet. She was diagnosed as having infective endocarditis. Hemodialysis was started with antimicrobial therapy. However, because of the presence of severe mitral regurgitation with left ventricle dilatation and large mobile vegetation, mitral prosthetic mechanical valve replacement was performed. Although treated with antibiotics combined with surgery, renal functions were deteriorated and progressed to chronic renal failure.

Severe lactic acidosis after an iatrogenic propylene glycol overdose.

PubMed

Zosel, Amy; Egelhoff, Elizabeth; Heard, Kennon

2010-02-01

Propylene glycol is a diluent found in many intravenous and oral drugs, including phenytoin, diazepam, and lorazepam. Propylene glycol is eliminated from the body by oxidation through alcohol dehydrogenase to form lactic acid. Under normal conditions, the body converts lactate to pyruvate and metabolizes pyruvate through the Krebs cycle. Lactic acidosis has occurred in patients, often those with renal dysfunction, who were receiving prolonged infusions of drugs that contain propylene glycol as a diluent. We describe a 50-year-old man who experienced severe lactic acidosis after receiving an accidental overdose of lorazepam, which contains propylene glycol. The patient was acutely intoxicated, with a serum ethanol concentration of 406 mg/dl. He had choked on a large piece of meat and subsequently experienced pulseless electrical activity with ventricular fibrillation cardiac arrest. He was brought to the emergency department; within 2 hours, he was admitted to the intensive care unit for initiation of the hypothermia protocol. The patient began to experience generalized tonic-clonic seizures 12 hours later, which resolved after several boluses of lorazepam. A lorazepam infusion was started; however, it was inadvertently administered at a rate of 2 mg/minute instead of the standard rate of 2 mg/hour. Ten hours later, the administration error was recognized and the infusion stopped. The patient's peak propylene glycol level was 659 mg/dl, pH 6.9, serum bicarbonate level 5 mEq/L, and lactate level 18.6 mmol/L. Fomepizole was started the next day and was continued until hospital day 3. Continuous renal replacement therapy was started and then replaced with continuous venovenous hemofiltration (CVVH) for the remainder of the hospital stay. The patient's acidosis resolved by day 3, when his propylene glycol level had decreased to 45 mg/dl. Fomepizole was discontinued, but the patient's prognosis was poor (anoxic brain injury); thus care was withdrawn and the patient died. Although the patient's outcome was death, his lactic acidosis was treated successfully with fomepizole and CVVH. Clinicians should be aware that an iatrogenic overdose of lorazepam may result in severe propylene glycol toxicity, which may be treated with fomepizole and CVVH.

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion

PubMed Central

Liu, Frank Xiaoqing; Gao, Xin; Inglese, Gary; Chuengsaman, Piyatida; Pecoits-Filho, Roberto; Yu, Alex

2015-01-01

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies. PMID:25082840

Association of Transcatheter Aortic Valve Replacement With 30-Day Renal Function and 1-Year Outcomes Among Patients Presenting With Compromised Baseline Renal Function: Experience From the PARTNER 1 Trial and Registry.

PubMed

Beohar, Nirat; Doshi, Darshan; Thourani, Vinod; Jensen, Hanna; Kodali, Susheel; Zhang, Feifan; Zhang, Yiran; Davidson, Charles; McCarthy, Patrick; Mack, Michael; Kapadia, Samir; Leon, Martin; Kirtane, Ajay

2017-07-01

The frequency of baseline renal impairment among high-risk and inoperable patients with severe aortic stenosis undergoing a transcatheter aortic valve replacement (TAVR) and the effect of TAVR on subsequent renal function are, to our knowledge, unknown. To determine the effect of TAVR among patients with baseline renal impairment. This substudy of patients with baseline renal impairment (estimated glomerular filtration rate [eGFR] ≤ 60 mL/min) and paired baseline and 30-day measures of renal function undergoing TAVR in the PARTNER 1 trial and continued access registries was conducted in 25 centers in the United States and Canada. Patients were categorized with improved eGFR (30-day follow-up eGFR≥10% higher than baseline pre-TAVR), worsened eGFR (≥10% lower), or no change in renal function (neither). Baseline characteristics, 30-day to 1-year all-cause mortality, and repeat hospitalization were compared. Multivariable models were constructed to identify predictors of 1-year mortality and of improvement/worsening in eGFR. Of the 821 participants, 401 (48.8%) were women and the mean (SD) age for participants with improved, unchanged, or worsening eGFR was 84.90 (6.91) years, 84.37 (7.13) years, and 85.39 (6.40) years, respectively. The eGFR was 60 mL/min or lower among 821 patients (72%), of whom 345 (42%) improved, 196 (24%) worsened, and 280 (34%) had no change at 30 days. There were no differences in baseline age, body mass index, diabetes, chronic obstructive pulmonary disease, coronary artery disease, peripheral arterial disease, hypertension, pulmonary hypertension, renal or liver disease, New York Heart Association III/IV symptoms, transaortic gradient, left ventricular ejection fraction, or procedural characteristics. The group with improved eGFR had more women, nonsmokers, and a lower cardiac index. Those with worsening eGFR had a higher median Society of Thoracic Surgeons score and left ventricle mass. From 30 days to 1 year, those with improved eGFR had no difference in mortality or repeat hospitalization. Those with worsening eGFR had increased mortality (25.5% vs 19.1%, P = .07) but no significant increases in repeat hospitalization or dialysis. Predictors of improved eGFR were being female (odds ratio [OR], 1.38; 95% CI, 1.03-1.85; P = .03) and nonsmoking status (OR, 1.49; 95% CI, 1.11-1.01; P = .01); predictors of worsening eGFR were baseline left ventricle mass (OR, 1.00; 95% CI, 1.00-1.01; P = .01), smoking (OR, 1.51; 95% CI, 1.06-2.14; P = .02), and age (OR, 1.03; 95% CI, 1.00-1.05; P = .05); and predictors of 1-year mortality were baseline left ventricular ejection fraction (OR, 0.98; 95% CI, 0.97-0.99; P = .003), baseline eGFR (OR, 0.98; 95% CI, 0.96-0.99; P < .001), and worsening eGFR vs no change in eGFR (OR, 1.51; 95% CI, 1.02-2.24; P = .04). Baseline renal impairment was frequent among patients who underwent TAVR. While improved eGFR did not improve 1-year outcomes, worsening eGFR was associated with increased mortality. clinicaltrials.gov Identifier: NCT00530894.

Levels of fatigue in people with ESRD living in far North Queensland.

PubMed

Bonner, Ann; Wellard, Sally; Caltabiano, Marie

2008-01-01

Levels of fatigue as experienced by people with end stage renal disease (ESRD), were assessed using the Fatigue Severity Scale (FSS). Fatigue, a common symptom reported by people with ESRD, is a multifaceted, subjective experience, which is readily understood by individuals but difficult to measure. There is limited understanding of the level of fatigue experienced by people with ESRD, with research currently limited to people treated with haemodialysis. The FSS was completed by 92 people with ESRD who were patients of a renal service in far North Queensland, Australia. Demographic and renal health history data were also collected with the self-report survey. Comparisons were preformed between overall fatigue levels and different renal disorders, genders, ethnicity and renal replacement therapy (RRT). Participants in this study were more fatigued than the general population; there was no difference in levels of fatigue between gender and ethnicity. Participants with diabetic nephropathy and those who were predialysis were the most fatigued. A significant difference between mean fatigue scores was found for type of RRT [F(3,88) = 2.4, p < 0.05], with participants using peritoneal dialysis reporting the most fatigue. Additionally, participants categorized according to type of RRT, erythropoietin replacement therapy and current haemoglobin levels revealed significant mean differences on fatigue levels [F(3,88) = 2.74, p < 0.05]. People with ESRD experience considerable fatigue; it is particularly important for nurses to understand this level of fatigue impacts on the daily life of patients. These findings provide the preliminary evidence to support the development of renal nursing practice guidelines related to symptom recognition and management of fatigue.

Fluid Overload and Fluid Removal in Pediatric Patients on Extracorporeal Membrane Oxygenation Requiring Continuous Renal Replacement Therapy

PubMed Central

Selewski, David T; Cornell, Timothy T; Blatt, Neal B; Han, Yong Y; Mottes, Theresa; Kommareddi, Mallika; Gaies, Michael G; Annich, Gail M; Kershaw, David B; Shanley, Thomas P; Heung, Michael

2012-01-01

Objective In pediatric patients fluid overload (FO) at continuous renal replacement (CRRT) initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at CRRT initiation, fluid removal during CRRT, the kinetics of fluid removal and mortality in a large pediatric population receiving CRRT while on extracorporeal membrane oxygenation (ECMO). Design Retrospective chart review. Setting Tertiary children’s hospital Patients ECMO patients requiring CRRT from July 2006 to September 2010 Interventions None Measurements and Main Results Overall ICU survival was 34% for 53 patients that were initiated on CRRT while on ECMO during the study period. Median FO at CRRT initiation was significantly lower in survivors compared to non-survivors (24.5 vs. 38%, p=0.006). Median FO at CRRT discontinuation was significantly lower in survivors compared to non-survivors (7.1 vs. 17.5%, p=0.035). After adjusting for percent FO at CRRT initiation, age and severity of illness, the change in FO at CRRT discontinuation was not significantly associated with mortality (p=0.212). Models investigating the rates of fluid removal in different periods, age, severity of illness and fluid overload at CRRT initiation found that fluid overload at CRRT initiation was the most consistent predictor of survival. Conclusions Our data demonstrates an association between FO at CRRT initiation and mortality in pediatric patients receiving ECMO. The degree of FO at CRRT discontinuation is also associated with mortality, but appears to reflect the effect of FO at initiation. Furthermore, correction of FO to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant FO may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of CRRT in this population, and warrant further clinical studies. PMID:22743776

Conformity Scores Differentiate Older Hemodialyzed Patients and Patients with Continuous Peritoneal Dialysis

PubMed Central

Nowak, Zbigniew; Laudanski, Krzysztof

2016-01-01

Background Conformity is a psychological variable related to the propensity of an individual to match his or her behavior and opinion to the perceived social and cultural norm, even if these do not represent the true beliefs of the person. The aim of the present study was to investigate whether the psychological variable of conformity is different in two distinct modes of renal replacement therapy (RRT) in end-stage renal disease (ESRD). Material/Methods A total of 56 hemodialyzed patients (HD group), 45 continuous ambulatory peritoneal dialysis patients (CAPD group) and 62 healthy volunteers (CONTR group) were enrolled in the study. The Social Appraisal Questionnaire (SAQ) was employed, and chart review was performed to collect clinical data. Results When age was not a factor, the conformity measure was significantly higher in the HD group compared with the CAPD and CONTR groups. The lowest conformity was found in healthy participants who were asked to imagine an acute medical problem. The highest conformity was found in older HD and CAPD patients. Conclusions Being chronically ill and having adaptable views may be more favorable traits for coping with ESRD in dialyzed patients, especially in elderly HD patients. On the other hand, conformity can be deleterious if CAPD patients decide to overlook certain facts or not confront the medical aspects of their condition. PMID:27886156

Cisplatin-Induced Renal Salt Wasting Requiring over 12 Liters of 3% Saline Replacement

PubMed Central

Reddy, Pavani; Qaqish, Shaker; Kamath, Ashvin; Rodriguez, Johana; Bolos, David; Zalom, Martina; Pham, Phuong-Thu

2017-01-01

Cisplatin is known to induce Fanconi syndrome and renal salt wasting (RSW). RSW typically only requires transient normal saline (NS) support. We report a severe RSW case that required 12 liters of 3% saline. A 57-year-old woman with limited stage small cell cancer was admitted for cisplatin (80 mg/m2) and etoposide (100 mg/m2) therapy. Patient's serum sodium (SNa) decreased from 138 to 133 and 125 mEq/L within 24 and 48 hours of cisplatin therapy, respectively. A diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) was initially made. Despite free water restriction, patient's SNa continued to decrease in association with acute onset of headaches, nausea, and dizziness. Three percent saline (3%S) infusion with rates up to 1400 mL/day was required to correct and maintain SNa at 135 mEq/L. Studies to evaluate Fanconi syndrome revealed hypophosphatemia and glucosuria in the absence of serum hyperglycemia. The natriuresis slowed down by 2.5 weeks, but 3%S support was continued for a total volume of 12 liters over 3.5 weeks. Attempts of questionable benefits to slow down glomerular filtration included the administration of ibuprofen and benazepril. To our knowledge, this is the most severe case of RSW ever reported with cisplatin. PMID:28573057

Continuous Venovenous Hemofiltration in Severely Burned Patients with Acute Kidney Injury: A Cohort Study

DTIC Science & Technology

2009-05-01

to result in any extra- renal effects. In the CVVH group the initial prescribed dose was variable based on hemo- dynamic compromise and perceived...associated with a decrease in 28-day and hospital mortality when compared with a historical control group, which largely did not receive any form of renal ...BUN: blood urea nitrogen; CVVH: continuous venovenous hemofiltration; CVVHDF: continuous venovenous hemodiafiltration; ESRD: end-stage renal disease

Paediatric dialysis and renal transplantation in the state of Rio Grande do Sul, Brazil.

PubMed

Garcia, C; Goldani, J; Garcia, V

1992-01-01

Renal replacement therapy (RRT) for Brazilian children with uraemia has been utilized since 1970 in the state of Rio Grande do Sul. One hundred and eighty patients receiving this therapy between 1970 and 1988 have been reviewed. The annual acceptance rate of new paediatric patients in this period increased from 0.6 to 6.5 patients per million child population. Glomerulonephritis (36.1%) and pyelonephritis including urological anomalies (31.7%) were the most frequent causes of end-stage renal disease. Outpatient hospital haemodialysis was the primary form of dialytic treatment in patients 5-15 years of age. Continuous ambulatory peritoneal dialysis was more often used in patients less than 5 years of age. The survival after 1 year on dialysis was 79.9% for children aged 5-15 years starting dialysis during the period 1985-1988. Fluid overload with congestive heart failure and infection were the main causes of death in children on dialysis. Eighty-four children received 93 grafts; only 14 (15%) were from cadaveric donors. One-year patient and graft survival of first living-related donor transplants were 92.2% and 78.5% respectively during the period 1985-1988. Infection accounted for 43.5% of deaths after transplantation. We conclude that RRT is becoming increasingly successful for children in our region but that greater emphasis upon patient compliance with all forms of RRT and upon cadaver kidney donation is needed.

A life-threatening case of TAFRO syndrome with dramatic response to tocilizumab, rituximab, and pulse steroids: The first case report in Latin America.

PubMed

José, Fabio Freire; Kerbauy, Lucila Nassif; Perini, Guilherme Fleury; Blumenschein, Danielle Isadora; Pasqualin, Denise da Cunha; Malheiros, Denise Maria Avancini Costa; Campos Neto, Guilherme de Carvalho; de Souza Santos, Fabio Pires; Piovesan, Ronaldo; Hamerschlak, Nelson

2017-03-01

This is the report of the first case of TAFRO syndrome (Thrombocytopenia, Anasarca, myelofibrosis, Renal dysfunction, Organomegaly) in Latin America. The patient was a 61-year-old white woman of Ashkenazi Jewish descent, who presented with a history of 8 days of nausea, vomiting, and fever; severe pitting edema in both legs, ascites, splenomegaly, and palpable axillary lymph nodes. Abdominal computed tomography (CT) showed bilateral pleural effusion and retroperitoneal lymph node enlargement. Anasarca and worsening of renal function led to admission to the intensive care unit (ICU) with multiple organ failure, requiring mechanical ventilation, vasopressor medications, and continuous renal replacement therapy (CRRT). Diagnosis of TAFRO syndrome was made on day 18 after admission, based on clinical findings and results of bone marrow and lymph node biopsies. She was treated with methylprednisolone, tocilizumab, and rituximab. One week after the first tocilizumab dose, she had dramatic improvements in respiratory and hemodynamic status, and was weaned from ventilator support and vasopressor medications. After 2 weeks of therapy, CRRT was switched to intermittent hemodialysis. On day 46, the patient was discharged from the ICU to the general ward, and 3 months after admission, she went home. Provided the interleukin-6 measurement is available, this approach is suggested in cases of TAFRO syndrome, in order to customize the treatment.

[Lung and kidney failure. Pathogenesis, interactions, and therapy].

PubMed

John, S; Willam, C

2015-09-01

The lungs and kidneys represent the most often affected organs (acute respiratory distress syndrome, ARDS or kidney failure) in multiple organ failure (MOF) due to shock, trauma, or sepsis with a still unacceptable high mortality for both organ failures. Although the exact pathophysiological mechanisms of MOF are not completely elucidated, it appears that the lungs and kidneys share several pathophysiologic pathways and have the potential to further harm each other (kidney-lung crosstalk). Inflammatory signals in both directions and volume overload with consecutive edema formation in both organs may play a key role in this crosstalk. The organ replacement therapies used in both organ failures have the potential to further injure the other organ (ventilator trauma, dialyte trauma). On the other hand, renal replacement therapy can have positive effects on lung injury by restoring volume and acid-base homeostasis. The new development of "low-flow" extracorporeal CO2 removal on renal replacement therapy platforms may further help to decrease ventilator trauma in the future.

Alkaline phosphatase for treatment of sepsis-induced acute kidney injury: a prospective randomized double-blind placebo-controlled trial

PubMed Central

2012-01-01

Introduction To evaluate whether alkaline phosphatase (AP) treatment improves renal function in sepsis-induced acute kidney injury (AKI), a prospective, double-blind, randomized, placebo-controlled study in critically ill patients with severe sepsis or septic shock with evidence of AKI was performed. Methods Thirty-six adult patients with severe sepsis or septic shock according to Systemic Inflammatory Response Syndrome criteria and renal injury defined according to the AKI Network criteria were included. Dialysis intervention was standardized according to Acute Dialysis Quality Initiative consensus. Intravenous infusion of alkaline phosphatase (bolus injection of 67.5 U/kg body weight followed by continuous infusion of 132.5 U/kg/24 h for 48 hours, or placebo) starting within 48 hours of AKI onset and followed up to 28 days post-treatment. The primary outcome variable was progress in renal function variables (endogenous creatinine clearance, requirement and duration of renal replacement therapy, RRT) after 28 days. The secondary outcome variables included changes in circulating inflammatory mediators, urinary excretion of biomarkers of tubular injury, and safety. Results There was a significant (P = 0.02) difference in favor of AP treatment relative to controls for the primary outcome variable. Individual renal parameters showed that endogenous creatinine clearance (baseline to Day 28) was significantly higher in the treated group relative to placebo (from 50 ± 27 to 108 ± 73 mL/minute (mean ± SEM) for the AP group; and from 40 ± 37 to 65 ± 30 mL/minute for placebo; P = 0.01). Reductions in RRT requirement and duration did not reach significance. The results in renal parameters were supported by significantly more pronounced reductions in the systemic markers C-reactive protein, Interleukin-6, LPS-binding protein and in the urinary excretion of Kidney Injury Molecule-1 and Interleukin-18 in AP-treated patients relative to placebo. The Drug Safety Monitoring Board did not raise any issues throughout the trial. Conclusions The improvements in renal function suggest alkaline phosphatase is a promising new treatment for patients with severe sepsis or septic shock with AKI. Trial Registration www.clinicaltrials.gov: NCTNCT00511186 PMID:22269279

Validity of /sup 99m/Tc dimercaptosuccinic acid renal uptake for an assessment for individual kidney function

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kawamura, J.; Hosakawa, S.; Yoshida, O.

/sup 99m/Tc dimercaptosuccinic acid is a new renal scanning agent that provides a good quality of renal image as a result of preferential cortical accumulation and also makes feasible a quantitative assessment of separate kidney function, correlating well with renal plasma flow obtained from a /sup 131/I hippuran renogram of each kidney. By measuring the dimercaptosuccinic acid uptake, the cortical functioning nephrons can be determined independent of the activity from the urinary outflow tract. Such evaluations may replace the conventional split renal function study in which traumatic procedures, such as cystoscopy and ureteral catheterizations, are required. /sup 99m/Tc dimercaptosuccinic acidmore » scintigraphy causes less discomfort to the patient and can be performed repeatedly and routinely even in children and debilitated geriatric patients.« less

Pregnancy in women with renal disease. Yes or no?

PubMed Central

Edipidis, K

2011-01-01

Women with renal disease who conceive and continue pregnancy, are at significant risk for adverse maternal and fetal outcomes. Although advances in antenatal and neonatal care continue to improve these outcomes, the risks remain proportionate to the degree of underlying renal dysfunction. The aim of this article, is to examine the impact of varying degrees of renal insufficiency on pregnancy outcome, in women with chronic renal disease and to provide if possible, useful conclusions whether and when, a woman with Chronic Kidney Disease (CKD), should decide to get pregnant. This article, reviews briefly the normal physiological changes of renal function during pregnancy, and make an attempt to clarify the nature and severity of the risks, in the settings of chronic renal insufficiency and end stage renal disease, including dialysis patients and transplant recipients. PMID:21897751

Does wealth make health? Cherchez la renal replacement therapy.

PubMed

Sanchez-Niño, Maria D; Ortiz, Alberto

2017-02-01

In this issue of CKJ , McQuarrie et al. have explored the relationship between socioeconomic status and outcomes among Scottish patients with a renal biopsy diagnosis of primary glomerulonephritis. Patients in the lower socioeconomic category had a twofold higher risk of death. No significant differences were observed on progression to end-stage renal disease (ESRD) requiring renal replacement therapy (RRT), suggesting that overall medical management was appropriate for all socioeconomic categories. The findings are significant since they come from an ethnically homogeneous population with free access to healthcare; they also relate to a specific aetiology of chronic kidney disease (CKD) expected to be less dependent on unhealthy lifestyles than other more frequent aetiologies that dominate studies of CKD in general, such as diabetic or hypertensive nephropathy. A closer look at the data suggests that living in a high socioeconomic area is associated with lower mortality, rather than the other way round. Furthermore, the differences in mortality were most pronounced during the RRT stage of CKD, providing clues for further research. In this regard, Wilmink et al. and Nee et al. point to access to pre-ESRD nephrology care and to the best kidney transplantation options as modifiable factors to be studied in the realm of T3 translational research to improve CKD patient outcomes.

Role of telehealth in renal replacement therapy education.

PubMed

Malkina, Anna; Tuot, Delphine S

2018-03-01

The prevalence of end-stage renal disease is rising in the United States, which bears high financial and public health burden. The most common modality of renal replacement therapy (RRT) in the United States is in-center hemodialysis. Many patients report lack of comprehensive and timely education about their treatment options, which may preclude them from participating in home-based dialysis therapies and kidney transplantation evaluation. While RRT education has traditionally been provided in-person, the rise of telehealth has afforded new opportunities to improve upon the status quo. For example, technology-augmented RRT education has recently been implemented into telehealth nephrology clinics, informational websites and mobile applications maintained by professional organizations, patient-driven forums on social media, and multimodality programs. The benefits of technology in RRT education are increased access for geographically isolated and/or medically frail patients, versatility of content delivery, information repetition to enhance knowledge retention, and interpersonal connection for educational content and emotional support. Challenges center around privacy and accuracy of information sharing, in addition to differential access to technology due to age and socioeconomic status. A review of available scholarly and social media resources suggests that technology-aided delivery of education about treatment options for end-stage renal disease provides an important alternative and/or supplemental resource for patients and families. © 2018 Wiley Periodicals, Inc.

Outcome and complications in peritoneal dialysis patients: a five-year single center experience.

PubMed

Alwakeel, Jamal S; Alsuwaida, Abdulkareem; Askar, Akram; Memon, Nawaz; Usama, Saira; Alghonaim, Mohammed; Feraz, Niaz A; Shah, Iqbal Hamid; Wilson, Hamsaveni

2011-03-01

Peritoneal dialysis (PD) is one of the modes of renal replacement therapy being utilized for the management of end-stage renal failure in King Khalid University Hospital, King Saud University, Riyadh, for more than two decades. The aim of this study was to evaluate the complications related to PD as well as its outcome in patients on this mode of therapy during the period between January 2004 and December 2008. There were 72 patients included in the study, of whom 43 were females. The average age was 50.7 ± 30.1 years (14-88 years). Diabetes was the leading cause of end-stage renal disease (ESRD) seen in 40.2% of the study patients. Twenty-eight patients (38.9%) were on continuous ambulatory peritoneal dialysis (CAPD) and 44 (61.1%) were on automated PD (nocturnal intermittent peritoneal dialysis, NIPD or continuous cycler peritoneal dialysis, CCPD). The mean duration on PD of the study patients was 25.5 ± 16.58 months (1-60 months). The peritonitis rate was one episode per 24.51 patient-months or one episode per 2.04 patient-years. The incidence of peritonitis per person-year was calculated as 0.42. The leading causative agent for peritonitis was Staphylococcus (32%). Exit-site infection (ESI) rate was one episode per 56.21 patient-months. The incidence of ESI was 0.214 per person-years. The most common infective organism for ESI was Pseudomonas aeru-ginosa (58.8%). At the end of 5 years, 35 patients were continuing on PD, 13 patients were shifted to hemodialysis (HD), nine patients underwent renal transplantation, and six patients were transferred to other centers. Among the 13 patients who were shifted to HD, four patients had refractory peritonitis, four others had catheter malfunction, three patients had inadequate clearance on PD and two patients had lack of compliance. A total of 11 patients died during the study period, giving an overall mortality rate of 15.27% for the five-year period. Our study suggests that there has been considerable improvement in overall outcome and mortality in patients on PD. Additionally, a marked reduction in the infectious and non-infectious complications was noted with the peritonitis and ESI rates in our center being comparable to other studies and international guidelines.

Current Status of Off-pump Coronary Artery Bypass Grafting in Patients with Multiple Coronary Artery Disease Compared with On-pump Coronary Artery Bypass Grafting: The Korean National Cohort Study.

PubMed

Kim, Hee Jung; Chung, Jae Eun; Jung, Jae Seung; Kim, In Seup; Son, Ho Sung

2018-05-31

 Despite advance in off-pump coronary artery bypass (OPCAB) grafting, there are large debating issues regarding survival benefit between OPCAB and on-pump coronary artery bypass grafting (CABG). The aim of this study is to address appropriateness of OPCAB approach in patients with ischemic heart disease having multiple vessels using South Korea national cohort data.  To evaluate the safety and efficacy of OPCAB, we accessed all causes of death, late repeat revascularization, hospitalization for cerebrovascular accident (CVA), and new renal replacement therapy in patients who underwent isolated CABG with multiple grafting (≥2 grafts) and who were registered in the Korean Health Insurance Review and Assessment Service Database between April 2011 and September 2014.  OPCAB was performed in 4,692 patients and on-pump CABG in 2,999 patients from 82 hospitals in South Korea. On multivariable analysis, on-pump CABG was associated with a significantly higher adjusted risk of overall all-cause death (hazard ratio [HR]: 1.876, 95% confidence interval [CI]: 1.587-2.216, p  < 0.001) and initiation of new renal replacement therapy (HR: 1.618, 95% CI: 1.124-2.331, p  = 0.009). However, we observed no significant difference in repeat revascularization and hospitalization for CVA between the two groups. In propensity score matching, matched patients (2,940 pairs) showed results similar to multivariable analysis that on-pump CABG was associated with a higher overall mortality and initiation of new renal replacement therapy ( p  < 0.001).  In this study, we found that OPCAB was associated with better survival rates and renal preservation compared with on-pump CABG. Georg Thieme Verlag KG Stuttgart · New York.

Dialysis patients refusing kidney transplantation: data from the Slovenian Renal Replacement Therapy Registry.

PubMed

Buturović-Ponikvar, Jadranka; Gubenšek, Jakob; Arnol, Miha; Bren, Andrej; Kandus, Aljoša; Ponikvar, Rafael

2011-06-01

Kidney transplantation is considered the best renal replacement therapy (RRT) for patients with end-stage renal disease; nevertheless, some dialysis patients refuse to be transplanted. The aim of our registry-based, cross-sectional study was to compare kidney transplant candidates to dialysis patients refusing transplantation. Data were collected from the Slovenian Renal Replacement Therapy Registry database, as of 31 December 2008. Demographic and some RRT data were compared between the groups. There were 1448 dialysis patients, of whom 1343 were treated by hemodialysis and 105 by peritoneal dialysis (PD); 132 (9%) were on the waiting list for transplantation, 208 (14%) were preparing for enrollment (altogether 340 [23%] dialysis patients were kidney transplant candidates); 200 (13.7%) patients were reported to refuse transplantation, all ≤ 65 years of age; 345 (24%) were not enrolled due to medical contraindications, 482 (33%) due to age, and 82 (6%) due to other or unknown reasons. No significant difference was found in age, gender, or presence of diabetes between kidney transplant candidates vs. patients refusing transplantation (mean age 50.5 ± 13.9 vs. 51.3 ± 9.6 years, males 61% vs. 63%, diabetics 18% vs. 17%). The proportion of patients ≤ 65 years old who were refusing transplantation was 28% (187/661) for hemodialysis and 17% (13/79) for PD patients (P = 0.03). There is a considerable group of dialysis patients in Slovenia refusing kidney transplantation. Compared to the kidney transplant candidates, they are similar in age, gender and prevalence of diabetes. Patients treated by peritoneal dialysis refuse kidney transplantation less often than hemodialysis patients. © 2011 The Authors. Therapeutic Apheresis and Dialysis © 2011 International Society for Apheresis.

Novel anatomic variation: heptafurcation of the celiac trunk.

PubMed

Rusu, M C; Manta, B A

2018-04-01

We report here anatomic variants which were found during a retrospective study of a male patient, 54 years old, evaluated in computed tomography: heptafurcation of the celiac trunk (CT) and bilateral double renal arteries. The seven branches of the heptafurcated CT were the (1) left and (2) right inferior phrenic arteries, the (3) splenic and (4) left gastric artery, the (5) common hepatic artery, further sending off the (a) proper, continued as left, hepatic artery and (b) the gastroduodenal artery, (6) a replaced right hepatic artery and (7) the dorsal pancreatic artery. To our knowledge, heptafurcation of the CT was not reported previously. The arterial variants have great importance during various surgical and interventional procedures and should be documented prior to respective procedures.

Rhabdomyolysis in a patient complicated with hypopituitarism and multiple organ dysfunction syndrome and the literature review.

PubMed

Zhou, Chuan; Lai, Shichao; Xie, Yong; Zhang, Shu; Lu, Yiping

2018-06-07

Muscular symptoms, including stiffness, myalgia, cramps, and fatigue, are present in the majority of the patients with hypopituitarism, adrenal insufficiency and hypothyroidism, but rhabdomyolysis, the rapid breakdown of skeletal muscle, is a rare manifestation. In most patients who develop rhabdomyolysis, precipitating factors, such as strenuous exercise or use of lipid-lowering drugs, can be identified. We report the case of a 23-year-old male with primary hypopituitarism who developed acute renal impairment (AKI) with rhabdomyolysis after strenuous physical activity (push-ups). His blood test confirmed marked hypopituitarism. Severe elevation of serum CK consistent with rhabdomyolysis was noted and an elevated creatinine indicated AKI and multiple organ dysfunction syndrome (MODS). Patient's condition improved significantly after continuous renal replacement therapy (CRRT), glucocorticoid hormone replacement therapy and aggressive hydration. MODS with rhabdomyolysis in patients with hypothyroidism is quite rare and we expect that this case report adds to the existing literature on this subject. We also emphasize that thyroid and adrenal gland status should be evaluated in patients with unexplained AKI, MODS and presenting with the symptoms of muscle involvement. We respectively reviewed 23 patients with hypopituitarism, adrenal Insufficiency and hypothyroidism induced rhabdomyolysis who were involved in the past 40 years relevant literatures. We report a successfully treated case of rhabdomyolysis, which is a rare but potentially serious complication of hypopituitarism. Screening for endocrine abnormality in patients with elevated muscle enzymes should be considered, since an early diagnosis and prompt treatment is essential to prevent rhabdomyolysis and its consequences. Copyright © 2018. Published by Elsevier Inc.

Ferumoxytol MRA for transcatheter aortic valve replacement planning with renal insufficiency.

PubMed

Kallianos, Kimberly; Henry, Travis S; Yeghiazarians, Yerem; Zimmet, Jeffrey; Shunk, Kendrick A; Tseng, Elaine E; Mahadevan, Vaikom; Hope, Michael D

2017-03-15

Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcatheter aortic valve replacement (TAVR) candidates. The iodinated contrast required, however, increases the risk of renal dysfunction in patients with pre-existing renal failure. Ferumoxytol is a magnetic resonance imaging (MRI) contrast agent that can be used with renal failure. Its long vascular resonance time allows gated MRA sequences that approach CTA in image quality. We present respiratory and cardiac gated MRA enabled by ferumoxytol that can be post-processed in an analogous fashion to CTA. Seven patients with renal failure presenting for TAVR were imaged with respiratory and cardiac gated MRA at 3T using ferumoxtyol for contrast. Aortic annulus, root and peripheral access dimensions were calculated in a fashion identical to that used for CTA. Of these, 6 patients underwent a TAVR procedure and 5 had intraoperative valve assessment with transesophageal echocardiograph (TEE) using standard clinical protocols that employed both two- and three-dimensional techniques. Good correlation between MRA aortic annulus measurements and those from TEE were shown in 5 patients with mean annulus area of 392.4mm 2 (290-470 range) versus 374.1mm 2 (285-440 range), with a pairwise correlation coefficient of 0.92, p=0.029. All patients received Sapien valve implants (one 20mm, three 23mm, and two 26mm valves). Access decisions were guided by MRA with no complications. Annulus sizing resulted in no greater than trace/mild aortic regurgitation in all patients. Ferumoxytol MRA is a safe alternative to CTA in patients with renal failure for pre-TAVR analysis of the aortic root and peripheral access. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Latin American special project: kidney health cooperation project between Uruguay and Bolivia.

PubMed

Sola, Laura; Plata-Cornejo, Raúl; Fernández-Cean, Juan

2015-01-01

Uruguay and Bolivia are two countries that show heterogenicity of the Latin American region, including the national income, the expenditure on health and the services for renal care. In Bolivia, there is manpower shortage for renal care with only 5 nephrologists per million people (pmp) and the prevalence of patients on dialysis is only 200 pmp. This is much lower than the mean prevalence rate of renal replacement therapy for Latin America as a whole. Uruguay on the other hand has more dedicated renal resources with 50 nephrologists pmp, and renal replacement therapy is provided to ~ 1,000 dialysis patients pmp. In November 2012, a collaborative project financed by the Uruguayan International Cooperation Agency was signed by both the Uruguay and Bolivia Ministries of Health, and the goal was to develop a comprehensive program for the prevention and management of all stages of chronic kidney disease (CKD) in Bolivia. The specific objectives were to: a) promote renal healthcare in the primary healthcare setting, b) identify kidney disease in populations at risk, and c) optimize patient care at all stages of CKD, including dialysis and transplantation supported with a national ESRD registry in Bolivia. As a first step, delegates from the Bolivian Health Ministry, visited Uruguay in April 2014, primarily to strengthen the development of tools required for developing and maintaining a national registry. In addition, during this visit, a meeting with the president of the Latin American Society of Nephrology and Hypertension (SLANH) culminated in designing a training program for peritoneal dialysis. This highly cooperative relationship is advancing the prevention and care of CKD in Bolivia and may serve as a model for international approaches to advance system level CKD care in countries with limited healthcare resources.

Severe acute hypophosphatemia during renal replacement therapy adversely affects outcome of critically ill patients with acute kidney injury.

PubMed

Schiffl, Helmut; Lang, Susanne M

2013-02-01

Hypophosphatemia during renal replacement therapy (RRT) is common in critically ill patients with acute kidney injury (AKI). The clinical consequences of RRT-induced phosphate depletion are not well defined in this patient population, and there is no evidence that intravenous sodium phosphate supplementation (PS) prevents the clinical sequelae of acute hypophosphatemia. The purpose of this retrospective analysis of the Acute Renal Support Registry of the University of Munich was to examine the association between severe hypophosphatemia and severity of and recovery from AKI. 289 ICU patients with AKI on intermittent hemodialysis (IHD) were included in the study. One hundred and forty-nine patients received PS during IHD. Outcomes were short-term (at discharge) and long-term (at 1 year) recovery of renal function and mortality. The two patient groups did not differ in demographics, clinical features, renal characteristics, and frequency of hypophosphatemia at initiation of IHD. Without PS, the frequency of hypophosphatemia increased from 20 to 35%. Severe hypophosphatemia was found in 50% of these patients. By comparison, PS was not associated with an increased frequency of hypophosphatemia. Compared with patients with acute phosphate depletion, patients receiving PS developed less oliguria during IHD, had shorter duration of AKI, higher incidence of complete renal recovery at discharge, and a lower risk of de novo chronic kidney disease. Hypophosphatemia was associated with higher all-cause in-hospital mortality and higher risk of long-term mortality. This multicenter study indicates for the first time that hypophosphatemia during IHD adversely affects short- and long-term outcome of critically-ill patients with AKI. The clinical consequences of the acute hypophosphatemic syndrome may be prevented by PS.

The Outcomes of Patients with ESRD and ANCA-Associated Vasculitis in Australia and New Zealand

PubMed Central

Tang, Wen; Bose, Bhadran; McDonald, Stephen P.; Hawley, Carmel M.; Badve, Sunil V.; Boudville, Neil; Brown, Fiona G.; Clayton, Philip A.; Campbell, Scott B.; Peh, Chen Au

2013-01-01

Summary Background and objectives This study aimed to evaluate dialysis and transplant outcomes of patients with ESRD secondary to ANCA-associated vasculitis (AAV). Design, setting, participants, & measurements All ESRD patients who commenced renal replacement therapy in Australia and New Zealand between 1996 and 2010 were included. Outcomes were assessed by Kaplan–Meier, multivariable Cox regression, and competing-risks regression survival analyses. Results Of 36,884 ESRD patients, 228 had microscopic polyangiitis (MPA) and 221 had granulomatosis with polyangiitis (GPA). Using competing-risks regression, compared with other causes of ESRD, MPA patients (hazard ratio [HR], 0.89; 95% confidence interval [95% CI], 0.73–1.08; P=0.24) and GPA patients (HR, 0.94; 95% CI, 0.74–1.19; P=0.62) experienced comparable survival on dialysis. Forty-six MPA patients (21%) and 47 GPA (20%) patients received 98 renal allografts. Respective 10-year first graft survival rates in MPA, GPA, and non-AAV patients were 50%, 62%, 70%, whereas patient survival rates were 68%, 85% and 83%, respectively. Compared with non-AAV patients, MPA transplant recipients had higher risks of graft failure (HR, 1.87; 95% CI, 1.07–3.25; P=0.03) and death (HR, 1.94; 95% CI, 1.02–3.69; P=0.04), whereas GPA transplant recipients experienced comparable renal allograft survival (HR, 0.91; 95% CI, 0.43–1.93; P=0.81) and patient survival (HR, 0.58; 95% CI, 0.23–2.27; P=0.58). AAV recurrence was observed in two renal allografts (2%). Conclusions Compared with ESRD patients without AAV, those with GPA have comparable renal replacement therapy outcomes, whereas MPA patients have comparable dialysis survival but poorer renal transplant allograft and patient survival rates. PMID:23349331

Glomerular Diseases

MedlinePlus

... dialysis or transplantation to replace renal function. Bacterial endocarditis, infection of the tissues inside the heart, is ... the most effective way of minimizing kidney damage. Endocarditis sometimes produces chronic kidney disease (CKD) . HIV, the ...

A case of staghorn stones in a kidney with an ileal ureter treated by percutaneous nephrolithotomy.

PubMed

Gao, Xiaofeng; Zhou, Tie; Li, Jinyi; Sun, Yinghao

2008-12-01

A 59-year-old man was admitted to hospital for investigation of a 1-year history of intermittent hematuria. He had undergone ileal ureteral replacement for left renal stones 36 years earlier. Renal ultrasonography, physical examination, abdominal plain radiography, intravenous urography, CT urography, measurement of serum levels of creatinine, urea and electrolytes, renal scintigraphy, urinalysis and urine culture. Staghorn calculi in the left kidney, with a high-lying anastomosis between the renal pelvis and the proximal ileal segment. The patient underwent percutaneous nephrolithotomy via a middle-calyx access for the large staghorn stones. After surgery, no residual calculi were found and the patient was discharged with an uneventful postoperative course. At 1 month, renal scintigraphy showed normal bilateral kidney function. The patient received potassium citrate supplementation and was followed up with 6-monthly imaging studies. At the last report, he had been stone-free for 7 months.

[Chronic renal disease--a global problem in the XXI century].

PubMed

Shutov, A M

2014-01-01

In 2002, it was proposed to consider functional renal disorders 3 and more months in duration under the general name chronic renal disease (CRD) bearing in mind the common mechanism behind progressive nephropathy and high cardiovascular mortality of such patients. The prevalence of CRD in Russia is unknown; it is supposed that every tenth adult in the world has CRD. Diagnostics of CRD requires at least measurement of serum creatinine, calculation of the glomerular filtration rate by CKD-EPI formula, and determination of albuminuria. A main cause of CRD is cardiovascular disorders. Complicated relationships between cardiac insufficiency and CRD account for 5 types of cardiorenal syndrome. CRD patients are at risk of terminal renal insufficiency requiring replacement therapy; moreover, CRD enhances cardiovascular morbidity and predisposes to acute renal lesion that in turn accelerates progress of CRD. Taken together these events account for the global character of the CRD problem.

Quality standards for predialysis education: results from a consensus conference.

PubMed

Isnard Bagnis, Corinne; Crepaldi, Carlo; Dean, Jessica; Goovaerts, Tony; Melander, Stefan; Nilsson, Eva-Lena; Prieto-Velasco, Mario; Trujillo, Carmen; Zambon, Roberto; Mooney, Andrew

2015-07-01

This position statement was compiled following an expert meeting in March 2013, Zurich, Switzerland. Attendees were invited from a spread of European renal units with established and respected renal replacement therapy option education programmes. Discussions centred around optimal ways of creating an education team, setting realistic and meaningful objectives for patient education, and assessing the quality of education delivered. © The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA.

Accelerated recovery from nephrotic syndrome with acute renal failure by double filtration plasmapheresis in a patient with lupus podocytopathy.

PubMed

Iwazu, Yoshitaka; Akimoto, Tetsu; Izawa, Sayoko; Inoue, Makoto; Muto, Shigeaki; Ando, Yasuhiro; Iwazu, Kana; Fukushima, Noriyoshi; Yumura, Wako; Kusano, Eiji

2012-06-01

We describe a case of an adult female who presented with nephrotic syndrome. She was diagnosed with systemic lupus erythematosus with serum antinuclear antibodies, leucopenia with lymphopenia, butterfly erythema, and nephrotic syndrome. Renal biopsy revealed normal glomeruli with diffuse effacement of the foot processes, consistent with lupus podocytopathy. Although human albumin replacement was performed initially, acute renal failure developed rapidly. Therefore, she was treated with double filtration plasmapheresis (DFPP) in addition to oral steroid. After steroid therapy combined with DFPP, the renal function and proteinuria improved rapidly. Although the impact of DFPP on the treatment of lupus nephritis remains to be delineated, our observations suggest that DFPP in lupus podocytopathy played a pivotal role in facilitating the early recovery from renal injuries. Because of the rapid improvement of renal function without any change in body weight by DFPP, acute renal failure in the setting of lupus podocytopathy might contribute to an alternative pathophysiological factor for the diminished glomerular filtration rate, similar to that observed in the setting of idiopathic minimal change glomerulopathy.

Comparative effectiveness of liver transplant strategies for end-stage liver disease patients on renal replacement therapy.

PubMed

Chang, Yaojen; Gallon, Lorenzo; Jay, Colleen; Shetty, Kirti; Ho, Bing; Levitsky, Josh; Baker, Talia; Ladner, Daniela; Friedewald, John; Abecassis, Michael; Hazen, Gordon; Skaro, Anton I

2014-09-01

There are complex risk-benefit tradeoffs with different transplantation strategies for end-stage liver disease patients on renal support. Using a Markov discrete-time state transition model, we compared survival for this group with 3 strategies: simultaneous liver-kidney (SLK) transplantation, liver transplantation alone (LTA) followed by immediate kidney transplantation if renal function did not recover, and LTA followed by placement on the kidney transplant wait list. Patients were followed for 30 years from the age of 50 years. The probabilities of events were synthesized from population data and clinical trials according to Model for End-Stage Liver Disease (MELD) scores (21-30 and >30) to estimate input parameters. Sensitivity analyses tested the impact of uncertainty on survival. Overall, the highest survival rates were seen with SLK transplantation for both MELD score groups (82.8% for MELD scores of 21-30 and 82.5% for MELD scores > 30 at 1 year), albeit at the cost of using kidneys that might not be needed. Liver transplantation followed by kidney transplantation led to higher survival rates (77.3% and 76.4%, respectively, at 1 year) than placement on the kidney transplant wait list (75.1% and 74.3%, respectively, at 1 year). When uncertainty was considered, the results indicated that the waiting time and renal recovery affected conclusions about survival after SLK transplantation and liver transplantation, respectively. The subgroups with the longest durations of pretransplant renal replacement therapy and highest MELD scores had the largest absolute increases in survival with SLK transplantation versus sequential transplantation. In conclusion, the findings demonstrate the inherent tension in choices about the use of available kidneys and suggest that performing liver transplantation and using renal transplantation only for those who fail to recover their native renal function could free up available donor kidneys. These results could inform discussions about transplantation policy. © 2014 American Association for the Study of Liver Diseases.

Ten-years trends in renal replacement therapy for end-stage renal disease in mainland France: Lessons from the French Renal Epidemiology and Information Network (REIN) registry.

PubMed

Vigneau, Cécile; Kolko, Anne; Stengel, Bénédicte; Jacquelinet, Christian; Landais, Paul; Rieu, Philippe; Bayat, Sahar; Couchoud, Cécile

2017-06-01

The incidence rate of renal replacement therapy (RRT) for end-stage renal disease (ESRD) is decreasing in several countries, but not in France. We studied the RRT trends in mainland France from 2005 to 2014 to understand the reasons for this discrepancy and determine the effects of ESRD management changes. Data were extracted from the French Renal Epidemiology and Information Network registry. Time trends of RRT incidence and prevalence rates, patients' clinical and treatment characteristics were analysed using the Joinpoint regression program and annual percentage changes. Survival within the first year of RRT was analysed using Kaplan-Meier estimates for 4 periods of time. The overall age- and gender-adjusted RRT incidence rate increased from 144 to 159 individuals per million inhabitants (pmi) (+0.8% per year; 95% CI: 0.5-1.2) and the prevalence from 903 to 1141 pmi (+2.4% per year; 95% CI: 2.2-2.7). This increase concerned exclusively ESRD associated with type 2 diabetes (+4.0%; 3.4-4.6) and mostly elderly men. Despite patient aging and increasing comorbidity burden and a persistent 30% rate of emergency dialysis start, the one-year survival rate slightly improved from 82.1% (81.4-82.8) to 83.8% (83.3-84.4). Pre-emptive wait listing for renal transplantation and the percentage of wait-listed patients within one year after dialysis start strongly increased (from 5.6% to 15.5% and from 29% to 39%, respectively). Kidney transplantation and survival significantly improved despite the heavier patient burden. However, the rise in type 2 diabetes-related ESRD and the stable high rate of emergency dialysis start remain major issues. Copyright © 2016 Association Société de néphrologie. Published by Elsevier Masson SAS. All rights reserved.

Perinatal Diagnosis, Management, and Follow-up of Cystic Renal Diseases: A Clinical Practice Recommendation With Systematic Literature Reviews.

PubMed

Gimpel, Charlotte; Avni, Fred E; Bergmann, Carsten; Cetiner, Metin; Habbig, Sandra; Haffner, Dieter; König, Jens; Konrad, Martin; Liebau, Max C; Pape, Lars; Rellensmann, Georg; Titieni, Andrea; von Kaisenberg, Constantin; Weber, Stefanie; Winyard, Paul J D; Schaefer, Franz

2018-01-01

Prenatal and neonatal cystic kidney diseases are a group of rare disorders manifesting as single, multiple unilateral, or bilateral cysts or with increased echogenicity of the renal cortex without macroscopic cysts. They may be accompanied by grossly enlarged kidneys, renal oligohydramnios, pulmonary hypoplasia, extrarenal abnormalities, and neonatal kidney failure. The prognosis is extremely variable from trivial to very severe or even uniformly fatal, which poses significant challenges to prenatal counseling and management. To provide a clinical practice recommendation for fetal medicine specialists, obstetricians, neonatologists, pediatric nephrologists, pediatricians, and human geneticists by aggregating current evidence and consensus expert opinion on current management of cystic nephropathies before and after birth. After 8 systematic literature reviews on clinically relevant questions were prepared (including 90 studies up to mid-2016), recommendations were formulated and formally graded at a consensus meeting that included experts from all relevant specialties. After further discussion, the final version was voted on by all members using the Delphi method. The recommendations were reviewed and endorsed by the working groups on inherited renal disorders of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and European Society for Paediatric Nephrology (ESPN); the German Society of Obstetrics and Gynecology (DGGG), German Society of Perinatal Medicine (DGPM), and German Society of Ultrasound in Medicine (DEGUM); and the alliance of patient organizations, PKD International. The group makes a number of recommendations on prenatal and postnatal imaging by ultrasound and magnetic resonance imaging, genetic testing, prenatal counseling, in utero therapeutic interventions, and postnatal management of prenatal and neonatal cystic kidney diseases, including provision of renal replacement therapy in neonates. In addition to detailed knowledge about possible etiologies and their prognosis, physicians need to be aware of recent improvements and remaining challenges of childhood chronic kidney disease, neonatal renal replacement therapy, and intensive pulmonary care to manage these cases and to empower parents for informed decision making.

Can computed tomography volumetry of the renal cortex replace MAG3-scintigraphy in all patients for determining split renal function?

PubMed

Houbois, Christian; Haneder, Stefan; Merkt, Martin; Morelli, John N; Schmidt, Matthias; Hellmich, Martin; Mueller, Roman-Ulrich; Wahba, Roger; Maintz, David; Puesken, Michael

2018-06-01

The current gold standard for determination of split renal function (SRF) is Tc-99m-mercapto-acetyltriglycin (MAG3) scintigraphy. Initial studies comparing MAG3-scintigraphy and CT-based renal cortex volumetry (RCV) for calculation of SRF have shown similar results in highly selected patient collectives with normal renal function (i.e. living kidney donors). This study aims to compare MAG3-scintigraphy and CT-RCV within a large unselected patient collective including patients with impaired renal function. For this assessment, 279 datasets (131 men, 148 women; mean age: 54.2 ± 12.9 years, range: 24-84 years) of patients who underwent MAG3-scintigraphy and contrast-enhanced abdominal CT within two weeks were retrospectively analyzed. Two independent readers assessed the CT-RCV in all CT datasets using a semi-automated volumetry tool. The MAG3-scintigraphy and CT-RCV methods were compared, stratified for the eGFR. Statistical analysis included descriptive statistics as well as inter- observer agreement. The absolute mean difference between the percentage contribution of the left and the right kidneys in total MAG3-clearance was 8.6%. Independent of eGFR, an overall sufficient agreement between both methods was established in all patients. A relatively small, tolerable systemic error resulted in an underestimation (max. 2%) of the left renal contribution to overall RCV. The results demonstrate that CT-RCV is a potential clinical replacement for MAG3-scintigraphy for calculation of SRF: CT-RCV demonstrates clinically tolerable differences with MAG3-scintigraphy, independent of patient eGFR. The relative complexity of the RCV method utilized is a potential limitation and may have contributed to the acceptable but only fair to moderate level of intra-reader reliability. Copyright © 2018 Elsevier B.V. All rights reserved.

Renal replacement therapy in Europe: a summary of the 2011 ERA–EDTA Registry Annual Report

PubMed Central

Noordzij, Marlies; Kramer, Anneke; Abad Diez, José M.; Alonso de la Torre, Ramón; Arcos Fuster, Emma; Bikbov, Boris T.; Bonthuis, Marjolein; Bouzas Caamaño, Encarnación; Čala, Svetlana; Caskey, Fergus J.; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Díaz Tejeiro, Rafael; Djukanovic, Ljubica; Ferrer-Alamar, Manuel; Finne, Patrik; García Bazaga, María de los Angelos; Garneata, Liliana; Golan, Eliezer; Gonzalez Fernández, Raquel; Heaf, James G.; Hoitsma, Andries; Ioannidis, George A.; Kolesnyk, Mykola; Kramar, Reinhard; Lasalle, Mathilde; Leivestad, Torbjørn; Lopot, Frantisek; van de Luijtgaarden, Moniek W.M.; Macário, Fernando; Magaz, Ángela; Martín Escobar, Eduardo; de Meester, Johan; Metcalfe, Wendy; Ots-Rosenberg, Mai; Palsson, Runolfur; Piñera, Celestino; Pippias, Maria; Prütz, Karl G.; Ratkovic, Marina; Resić, Halima; Rodríguez Hernández, Aurelio; Rutkowski, Boleslaw; Spustová, Viera; Stel, Vianda S.; Stojceva-Taneva, Olivera; Süleymanlar, Gültekin; Wanner, Christoph; Jager, Kitty J.

2014-01-01

Background This article provides a summary of the 2011 ERA–EDTA Registry Annual Report (available at www.era-edta-reg.org). Methods Data on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data. Results The overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA–EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6–47.0], and on dialysis 39.3% (95% CI 39.2–39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2–87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6–95.0) for kidneys from living donors. PMID:25852881

[Renal denervation in refractory hypertension: joint statement of the German hypertension league DHL eV and the German societies of cardiology, angiology, nephrology and radiology].

PubMed

Vonend, Oliver; Böhm, Michael; Eckert, Siegfried; Hausberg, Martin; Rittger, Harald; Rump, Lars-Christian; Schmieder, Roland; Schulte, Karl-Ludwig; Schunkert, Heribert; Uder, Michael; Veelken, Roland; Vorwerk, Dierk; Weil, Joachim; Wenzel, Ulrich; Mahfoud, Felix

2015-03-01

Arterial hypertension is a major risk factor for cardiovascular mortality and remains insufficiently controlled in Germany. The sham controlled Symplicity HTN-3 trial did meet its primary safety endpoint but failed to meet its primary efficacy endpoint. Renal denervation can not replace established, well-proven therapies. It can only be used in selected truly resistant hypertensive patients as an additive approach and should be performed by specialized centers only. Randomized controlled trials are needed to further evaluate renal denervation. © Georg Thieme Verlag KG Stuttgart · New York.

Patients with Fabry Disease after Enzyme Replacement Therapy Dose Reduction and Switch-2-Year Follow-Up.

PubMed

Lenders, Malte; Canaan-Kühl, Sima; Krämer, Johannes; Duning, Thomas; Reiermann, Stefanie; Sommer, Claudia; Stypmann, Jörg; Blaschke, Daniela; Üçeyler, Nurcan; Hense, Hans-Werner; Brand, Stefan-Martin; Wanner, Christoph; Weidemann, Frank; Brand, Eva

2016-03-01

Because of the shortage of agalsidase-β supply between 2009 and 2012, patients with Fabry disease either were treated with reduced doses or were switched to agalsidase-α. In this observational study, we assessed end organ damage and clinical symptoms with special focus on renal outcome after 2 years of dose-reduction and/or switch to agalsidase-α. A total of 89 adult patients with Fabry disease who had received agalsidase-β (1.0 mg/kg body wt) for >1 year were nonrandomly assigned to continue this treatment regimen (regular-dose group, n=24), to receive a reduced dose of 0.3-0.5 mg/kg and a subsequent switch to 0.2 mg/kg agalsidase-α (dose-reduction-switch group, n=28), or to directly switch to 0.2 mg/kg agalsidase-α (switch group, n=37) and were followed-up for 2 years. We assessed clinical events (death, myocardial infarction, severe arrhythmia, stroke, progression to ESRD), changes in cardiac and renal function, Fabry-related symptoms (pain, hypohidrosis, diarrhea), and disease severity scores. Determination of renal function by creatinine and cystatin C-based eGFR revealed decreasing eGFRs in the dose-reduction-switch group and the switch group. The Mainz Severity Score Index increased significantly in these two groups (P=0.02 and P<0.001, respectively), and higher frequencies of gastrointestinal pain occurred during follow-up. In conclusion, after 2 years of observation, all groups showed a stable clinical disease course with respect to serious clinical events. However, patients under agalsidase-β dose-reduction and switch or a direct switch to agalsidase-α showed a decline of renal function independent of the eGFR formula used. Copyright © 2016 by the American Society of Nephrology.

Patients with Fabry Disease after Enzyme Replacement Therapy Dose Reduction and Switch–2-Year Follow-Up

PubMed Central

Lenders, Malte; Canaan-Kühl, Sima; Krämer, Johannes; Duning, Thomas; Reiermann, Stefanie; Sommer, Claudia; Stypmann, Jörg; Blaschke, Daniela; Üçeyler, Nurcan; Hense, Hans-Werner; Brand, Stefan-Martin; Wanner, Christoph; Weidemann, Frank

2016-01-01

Because of the shortage of agalsidase-β supply between 2009 and 2012, patients with Fabry disease either were treated with reduced doses or were switched to agalsidase-α. In this observational study, we assessed end organ damage and clinical symptoms with special focus on renal outcome after 2 years of dose-reduction and/or switch to agalsidase-α. A total of 89 adult patients with Fabry disease who had received agalsidase-β (1.0 mg/kg body wt) for >1 year were nonrandomly assigned to continue this treatment regimen (regular-dose group, n=24), to receive a reduced dose of 0.3–0.5 mg/kg and a subsequent switch to 0.2 mg/kg agalsidase-α (dose-reduction-switch group, n=28), or to directly switch to 0.2 mg/kg agalsidase-α (switch group, n=37) and were followed-up for 2 years. We assessed clinical events (death, myocardial infarction, severe arrhythmia, stroke, progression to ESRD), changes in cardiac and renal function, Fabry-related symptoms (pain, hypohidrosis, diarrhea), and disease severity scores. Determination of renal function by creatinine and cystatin C–based eGFR revealed decreasing eGFRs in the dose-reduction-switch group and the switch group. The Mainz Severity Score Index increased significantly in these two groups (P=0.02 and P<0.001, respectively), and higher frequencies of gastrointestinal pain occurred during follow-up. In conclusion, after 2 years of observation, all groups showed a stable clinical disease course with respect to serious clinical events. However, patients under agalsidase-β dose-reduction and switch or a direct switch to agalsidase-α showed a decline of renal function independent of the eGFR formula used. PMID:26185201

[Renal colic in pregnancy].

PubMed

Negru, Irina; Pricop, C; Costăchescu, Gh

2010-01-01

Renal colic in pregnant women is a serious condition, mainly when is associated with fever. Our retro-prospective study analyzes 111 cases managed conservatively or with endourological procedures for renal colic--insertion of JJ stents and percutaneous nephrostomy. Clinical evolution determined the insertion of JJ stents in 60 cases and the failure of this procedure imposed percutaneous nephrostomy in 5 cases. In 56 cases urinary tract infection was associated and in 2 cases, despite all efforts, the patients deceased due to sever sepsis. The immediate drainage of the upper urinary tract for renal colic in pregnancy is the recommended treatment, especially when the pain is associated with fever. JJ stens were well tolerated, even when they were replaced after 3 months. Pregnant women with a history of UTI or stone disease should be carefully followed-up.

Massive postpartum right renal hemorrhage.

PubMed

Kiracofe, H L; Peterson, N

1975-06-01

All reported cases of massive postpartum right renal hemorrhage have involved healthy young primigravidas and blacks have predominated (4 of 7 women). Coagulopathies and underlying renal disease have been absent. Hematuria was painless in 5 of 8 cases. Hemorrhage began within 24 hours in 1 case, within 48 hours in 4 cases and 4 days post partum in 3 cases. Our first case is the only report in which hemorrhage has occurred in a primipara. Failure of closure or reopening of pyelovenous channels is suggested as the pathogenesis. The hemorrhage has been self-limiting, requiring no more than 1,500 cc whole blood replacement. Bleeding should stop spontaneously, and rapid renal pelvic clot lysis should follow with maintenance of adequate urine output and Foley catheter bladder decompression. To date surgical intervention has not been necessary.

End-stage renal disease and survival in people with diabetes: a national database linkage study

PubMed Central

Fletcher, E.H.; Brady, I.; Looker, H.C.; Levin, D.; Joss, N.; Traynor, J.P.; Metcalfe, W.; Conway, B.; Livingstone, S.; Leese, G.; Philip, S.; Wild, S.; Halbesma, N.; Sattar, N.; Lindsay, R.S.; McKnight, J.; Pearson, D.; Colhoun, H.M.

2015-01-01

Background: Increasing prevalence of diabetes worldwide is projected to lead to an increase in patients with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). Aim: To provide contemporary estimates of the prevalence of ESRD and requirement for RRT among people with diabetes in a nationwide study and to report associated survival. Methods: Data were extracted and linked from three national databases: Scottish Renal Registry, Scottish Care Initiative-Diabetes Collaboration and National Records of Scotland death data. Survival analyses were modelled with Cox regression. Results: Point prevalence of chronic kidney disease (CKD)5 in 2008 was 1.63% of 19 414 people with type 1 diabetes (T1DM) compared with 0.58% of 167 871 people with type 2 diabetes (T2DM) (odds ratio for DM type 0.97, P = 0.77, on adjustment for duration. Although 83% of those with T1DM and CKD5 and 61% of those with T2DM and CKD5 were receiving RRT, there was no difference when adjusted for age, sex and DM duration (odds ratio for DM type 0.83, P = 0.432). Diabetic nephropathy was the primary renal diagnosis in 91% of people with T1DM and 58% of people with T2DM on RRT. Median survival time from initiation of RRT was 3.84 years (95% CI 2.77, 4.62) in T1DM and 2.16 years (95% CI: 1.92, 2.38) in T2DM. Conclusion: Considerable numbers of patients with diabetes continue to progress to CKD5 and RRT. Almost half of all RRT cases in T2DM are considered to be due to conditions other than diabetic nephropathy. Median survival time for people with diabetes from initiation of RRT remains poor. These prevalence data are important for future resource planning. PMID:25140030

Effect of intraoperative transesophageal Doppler-guided fluid therapy versus central venous pressure-guided fluid therapy on renal allograft outcome in patients undergoing living donor renal transplant surgery: a comparative study.

PubMed

Srivastava, Divya; Sahu, Sandeep; Chandra, Abhilash; Tiwari, Tanmay; Kumar, Sanjay; Singh, P K

2015-12-01

Transesophageal Doppler (TED)-guided intraoperative fluid therapy has shown to noninvasively optimize intravascular volume and reduce postoperative morbidity. The aim of this study was to compare the effects of Doppler-guided intraoperative fluid administration and central venous pressure (CVP)-guided fluid therapy on renal allograft outcome and postoperative complications. A prospective nonrandomized active controlled study was conducted on end-stage renal disease patients scheduled for living donor renal transplant surgery. 110 patients received intraoperative fluid guided by corrected flow time (FTc) and variation in stroke volume values obtained by continuous TED monitoring. Data of 104 patients in whom intraoperative fluid administration was guided by CVP values were retrospectively obtained for a control. The amount of intraoperative fluid given in the study group (12.20 ± 4.24 ml/kg/h) was significantly lower than in the controls (22.21 ± 4.67 ml/kg/h). The amount of colloid used was also significantly less and fewer recipients were seen to require colloid (69 vs 85%). The mean arterial pressures were comparable throughout. CVP reached was 7.18 ± 3.17 mmHg in the study group. It was significantly higher in the controls (13.42 ± 3.12 mmHg). The postoperative graft function and rate of dysfunction were comparable. Side-effects like postoperative dyspnoea (4.8 vs 0%) and tissue edema (9.6 vs 2.7%) were higher in the controls. FTc-guided intraoperative fluid therapy achieved the same rate of immediate graft function as CVP-guided fluid therapy but used a significantly less amount of fluid. The incidence of postoperative complications related to fluid overload was also reduced. The use of TED may replace invasive central line insertions in the future.

Coordination of the cell cycle is an important determinant of the syndrome of acute renal failure.

PubMed

Megyesi, Judit; Andrade, Lucia; Vieira, Jose M; Safirstein, Robert L; Price, Peter M

2002-10-01

Recovery from injury is usually accompanied by cell replication, in which new cells replace those irreparably damaged. After acute renal failure, normally quiescent kidney cells enter the cell cycle, which in tubule segments is accompanied by the induction of cell cycle inhibitors. We found that after acute renal failure induced by either cisplatin injection or renal ischemia, induction of the p21 cyclin-dependent kinase (cdk) inhibitor is protective. Mice lacking this gene developed more widespread kidney cell death, more severe renal failure, and had reduced survival, compared with mice with a functional p21 gene. Here, we show induction of 14-3-3sigma, a regulator of G(2)-to-M transition, after acute renal failure. Our findings, using both in vivo and in vitro models of acute renal failure, show that this protein likely helps to coordinate cell cycle activity to maximize recovery of renal epithelial cells from injury and reduce the extent of the injury itself. Because in terminally differentiated cells, these proteins are highly expressed only after injury, we propose that cell cycle coordination by induction of these proteins could be a general model of tissue recovery from stress and injury.

Continuous Venovenous Hemodiafiltration in the Treatment of Maple Syrup Urine Disease.

PubMed

Demirkol, Demet; Şık, Güntülü; Topal, Nilüfer; Çıtak, Agop; Zeybek, Çigdem; Tüten, Abdülhamit; Bilge, Ilmay

2016-01-01

The study aims to define the efficacy of continuous renal replacement therapy in acute metabolic decompensation treatment of maple syrup urine disease (MSUD). All the neonates, infants and children who have had life threatening conditions due to MSUD and were treated with continuous venovenous hemodiafiltration (CVVHDF) were analyzed retrospectively. Fourteen patients underwent 15 sessions of CVVHDF (age range 15 days to 87 months, mean 40.8 ± 31.4 months). One patient required additional CVVHDF 1 week after cessation of CVVHDF. Twenty seven percent (n = 4) of the patients were intubated and mechanically ventilated. Twelve patients responded to treatment and dramatic neurological improvement was observed within 24 h. Two of the 14 patients required 36 h of CVVHDF for neurological improvement. The mean duration of CVVHDF was 20.2 ± 8.6 (9-36) h. The mean leucine level was 1,648 ± 623.8 (714-2,768) μmol/l before and was 256.5 ± 150.6 (117-646) μmol/l at the end of treatment. No mortality was observed. Continuous hemodiafiltration is an effective and safe method in correcting metabolic disturbances in MSUD. © 2016 S. Karger AG, Basel.

Functional significance of the pattern of renal sympathetic nerve activation.

PubMed

Dibona, G F; Sawin, L L

1999-08-01

To assess the renal functional significance of the pattern of renal sympathetic nerve activation, computer-generated stimulus patterns (delivered at constant integrated voltage) were applied to the decentralized renal sympathetic nerve bundle and renal hemodynamic and excretory responses determined in anesthetized rats. When delivered at the same integrated voltage, stimulus patterns resembling those observed in in vivo multifiber recordings of renal sympathetic nerve activity (diamond-wave patterns) produced greater renal vasoconstrictor responses than conventional square-wave patterns. Within diamond-wave patterns, increasing integrated voltage by increasing amplitude produced twofold greater renal vasoconstrictor responses than by increasing duration. With similar integrated voltages that were subthreshold for renal vasoconstriction, neither diamond- nor square-wave pattern altered glomerular filtration rate, whereas diamond- but not square-wave pattern reversibly decreased urinary sodium excretion by 25 +/- 3%. At the same number of pulses per second, intermittent stimulation produced faster and greater renal vasoconstriction than continuous stimulation. At the same number of pulses per second, increases in rest period during intermittent stimulation proportionally augmented the renal vasoconstrictor response compared with that observed with continuous stimulation; the maximum augmentation of 55% occurred at a rest period of 500 ms. These results indicate that the pattern of renal sympathetic nerve stimulation (activity) significantly influences the rapidity, magnitude, and selectivity of the renal vascular and tubular responses.

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus.

PubMed

Kramer, Anneke; Pippias, Maria; Stel, Vianda S; Bonthuis, Marjolein; Abad Diez, José Maria; Afentakis, Nikolaos; Alonso de la Torre, Ramón; Ambuhl, Patrice; Bikbov, Boris; Bouzas Caamaño, Encarnación; Bubic, Ivan; Buturovic-Ponikvar, Jadranka; Caskey, Fergus J; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Comas Farnés, Jordi; Garcia Bazaga, Maria de Los Ángeles; De Meester, Johan; Ferrer Alamar, Manuel; Finne, Patrik; Garneata, Liliana; Golan, Eliezer; G Heaf, James; Hemmelder, Marc; Ioannou, Kyriakos; Kantaria, Nino; Kolesnyk, Mykola; Kramar, Reinhard; Lassalle, Mathilde; Lezaic, Visnja; Lopot, Frantisek; Macário, Fernando; Magaz, Angela; Martín-Escobar, Eduardo; Metcalfe, Wendy; Ots-Rosenberg, Mai; Palsson, Runolfur; Piñera Celestino, Celestino; Resić, Halima; Rutkowski, Boleslaw; Santiuste de Pablos, Carmen; Spustová, Viera; Stendahl, Maria; Strakosha, Ariana; Süleymanlar, Gültekin; Torres Guinea, Marta; Varberg Reisæter, Anna; Vazelov, Evgueniy; Ziginskiene, Edita; Massy, Ziad A; Wanner, Christoph; Jager, Kitty J; Noordzij, Marlies

2016-06-01

This article provides a summary of the 2013 European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5-61.3] and 50.6% (95% CI 49.9-51.2) for patients with DM as the cause of ESRD.

[Survey on the management of acute renal failure and renal replacement techniques in Spanish intensive care units].

PubMed

Úbeda-Iglesias, A; Herrera-Rojas, D; Gómez-González, C

2015-03-01

To analyze knowledge and experience in the diagnosis and management of acute renal failure (ARF) and the use of renal replacement therapy (RRT) in different Spanish Intensive Care Units (ICUs). A case series with a survey conducted by the Nephro-Intensive Care Working Group of the SEMICYUC was compiled between January and November 2011. Spanish national ICUs. A survey of 28 questions with multiple and open responses. The survey was sent to 99 ICUs. Volunteers consisting of the medical staff belonging to the 51 ICUs that responded. Main variables of interest General characteristics of hospitals and ICUs, definitions of ARF and RRT (indications and management). RIFLE/AKIN scales to define ARF (47%). ARF diagnosis: plasma creatinine (80.4%), creatinine clearance (52.9%). Protocols for RRT: 72.5%. RRT in non-renal indications: 70.6%. Indications for initiation of RRT: oliguria, increased creatinine and urea. End of RRT: increased diuresis. RRT dose: 21-35 ml/kg/h (41.2%), 36-45ml/kg/h (33.3%). There is great variability in the ARF detection methods, and adequate incorporation of the RIFLE/AKIN systems to daily clinical practice in the ICU is still lacking. Written protocols aimed at establishing an early diagnosis of ARF are needed, based on these systems. On the other hand, there is growing interest in RRT, despite the fact that there are no definitive indications or guidelines on the use and handling of such techniques. Copyright © 2013 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Kidney transplantation from a mother with unrecognized Fabry disease to her son with low α-galactosidase A activity: A 14-year follow-up without enzyme replacement therapy.

PubMed

Odani, Keiko; Okumi, Masayoshi; Honda, Kazuho; Ishida, Hideki; Tanabe, Kazunari

2016-07-01

We report a case of kidney transplantation from mother to son, both of whom were likely to have had an unrecognized renal variant phenotype of Fabry disease. The patient was a 54-year-old man, with an unknown primary cause of end stage renal disease. He had no notable past medical history, other than end stage renal disease. He underwent living-related kidney transplantation from his mother at age 40 years. Foam cells in the glomeruli were identified on histology assessment of a 0-hour allograft biopsy, with zebra bodies identified in the glomerular visceral epithelial cells by electron microscopy. These findings were indicative of Fabry disease in the donated kidney. As a definitive diagnosis of Fabry's disease could not be confirmed, enzyme replacement therapy was not initiated. Thirteen years after kidney transplantation, the patient underwent left nephrectomy for a left renal tumour, with pathological findings of clear cell carcinoma, foam cells and zebra bodies in the native kidney. Detailed examinations identified low α-galactosidase A activity and mutation of the α-Gal A gene, confirming a diagnosis of a renal variant phenotype of Fabry disease. Histology of several allograft biopsies performed over the 14 years from the time of kidney transplantation revealed only moderate interstitial fibrosis and tubular atrophy, with no evidence of disease progression on electron microscopy, despite the presence of zebra bodies in the glomerular visceral epithelial cells. © 2016 Asian Pacific Society of Nephrology.

[Contraindications to succinylcholine in the intensive care unit. A prevalence study].

PubMed

Muñoz-Martínez, T; Garrido-Santos, I; Arévalo-Cerón, R; Rojas-Viguera, L; Cantera-Fernández, T; Pérez-González, R; Díaz-Garmendia, E

2015-03-01

To determine the prevalence of contraindications to succinylcholine in patients admitted to the ICU. An observational study was carried out, describing the frequency of succinylcholine contraindication by stays, and associating the contraindications to population variables. The adult general ICU of a reference hospital. Clinical-surgical critically ill patients. Thirty consecutive days were analyzed. None. Population variables: age, sex, APACHE II and SOFA scores, illness, days of hospitalization, mechanical ventilation and renal replacement therapy. hyperkalemia, bedridden patients, rhabdomyolysis, muscle trauma, burns, infusion of neuromuscular blocking agents, acute renal failure, chronic renal failure, intraocular hypertension, intracranial hypertension, statin use, malignant hyperthermia, neuromuscular disease, spinal cord sectioning, bradycardia < 50 bpm, succinylcholine allergy, and pseudo-cholinesterase deficiency. A total of 102 patients were admitted, aged 60 ± 16 years (56.9% males), with the generation of 657 stays. Main diseases: elective heart surgery (33%), respiratory failure (22%) and sepsis (14%). We documented 466 stays (70.9%) with contraindications, particularly bedridden patients (n=140), neuromuscular blocking agents (n=101), acute renal failure (n=126), statin use (n=167), neuromuscular disease (n=159) and bradycardia (n=76). We recorded 74 stays (11.3%) at high risk of complications, secondary to hyperkalemic risk associated to receptor dysregulation. A high risk of complications was associated to advanced age, prolonged hospitalization, prolonged length of stay in the ICU, higher APACHE II and SOFA scores, mechanical ventilation and renal replacement therapy. Given the high prevalence of contraindications to succinylcholine observed, we discourage its use in patients admitted to the ICU. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Acute diffuse alveolar haemorrhage accompanied by gastrointestinal bleeding in a patient with serious systemic lupus erythematosus: A case report.

PubMed

Du, Jing; Wang, Ying; Li, Yan-Chun; Wang, Tong-Tong; Zhou, Yong-Lie; Ying, Zhen-Hua

2018-05-01

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects many organs, but multisystem dysfunction is rare. Here, we report a case of a 29-year-old woman who was initially diagnosed with SLE complications including lupus nephritis, lupus encephalopathy, renal hypertension, thrombocytopenia, anaemia and hyperkalaemia. She recovered following treatment with high dose methylprednisolone, intravenous immunoglobulin (IVIG) and continuous renal replacement therapy (CRRT). However, a few days after hospital discharge, she developed gastrointestinal bleeding. Although intensive treatment was administered, the patient deteriorated rapidly and had a progressive decline in oxygen saturation followed by diffuse alveolar haemorrhage and acute left heart failure. Inotropic therapy, mechanical ventilation, blood transfusion, CRRT, antibiotics, intravenous glucocorticoids and other support therapies were initiated and gradually the patient's vital signs stabilized and haemoptysis subsided. This case report emphasises that complications of SLE can occur at any stage of the disease, especially in patients with active SLE. Therefore, it is important for clinicians to be aware of the rare presentations of SLE and its complex management. For multisystem dysfunction, early intensive treatment with high dose corticosteroids and cyclophosphamide is advocated.

[Severe caffeine poisoning with rhabdomyolysis].

PubMed

Wolter, J; Grün, D; Otto, S

2018-04-01

We report the case of a young man who took a large amount of caffeine powder dissolved in water in a suicide attempt. He was found comatose. The initial diagnosis was difficult. In hospital he suffered from rhabdomyolysis with renal failure and sepsis rapidly developed. After renal replacement treatment with hemodialysis, long-term artificial ventilation with tracheotomy and a 3‑week stay in the intensive care unit, the patient could be discharged to a rehabilitation center.

75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-12

...This final rule implements a case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1, 2011 (ESRD PPS), in compliance with the statutory requirement of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. This ESRD PPS also replaces the current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ESRD services.

Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics.

PubMed

Lim, Lee Moay; Tsai, Ni-Chin; Lin, Ming-Yen; Hwang, Daw-Yang; Lin, Hugo You-Hsien; Lee, Jia-Jung; Hwang, Shang-Jyh; Hung, Chi-Chih; Chen, Hung-Chun

2016-11-14

Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality, but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13-1.85, P < 0.05) in diuretic users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal replacement therapy in CKD patients treated with diuretics.

Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics

PubMed Central

Lim, Lee Moay; Tsai, Ni-Chin; Lin, Ming-Yen; Hwang, Daw-Yang; Lin, Hugo You-Hsien; Lee, Jia-Jung; Hwang, Shang-Jyh; Hung, Chi-Chih; Chen, Hung-Chun

2016-01-01

Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality, but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13–1.85, P < 0.05) in diuretic users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal replacement therapy in CKD patients treated with diuretics. PMID:27841359

Chronic Kidney Disease and Kidney Failure

MedlinePlus

... replacement therapies, dialysis and renal transplantation, developed through fundamental NIH research in the 1960s, were increasingly available; ... than 10 percent of diabetics develop kidney failure. Management of complications has markedly improved the quality of ...

Acute Kidney Injury With the RenalGuard System in Patients Undergoing Transcatheter Aortic Valve Replacement: The PROTECT-TAVI Trial (PROphylactic effecT of furosEmide-induCed diuresis with matched isotonic intravenous hydraTion in Transcatheter Aortic Valve Implantation).

PubMed

Barbanti, Marco; Gulino, Simona; Capranzano, Piera; Immè, Sebastiano; Sgroi, Carmelo; Tamburino, Claudia; Ohno, Yohei; Attizzani, Guilherme F; Patanè, Martina; Sicuso, Rita; Pilato, Gerlando; Di Landro, Alessio; Todaro, Denise; Di Simone, Emanuela; Picci, Andrea; Giannetto, Giuliana; Costa, Giuliano; Deste, Wanda; Giannazzo, Daniela; Grasso, Carmelo; Capodanno, Davide; Tamburino, Corrado

2015-10-01

The purpose of this study was to investigate the effect of the RenalGuard System (PLC Medical Systems, Milford, Massachusetts) on prevention of acute kidney injury (AKI) in patients undergoing transcatheter aortic valve replacement (TAVR). TAVR is associated with varying degrees of post-procedural AKI. The RenalGuard System is a dedicated device designed for contrast-induced AKI prevention. Whether this device is also effective in patients with severe aortic stenosis undergoing TAVR is unexplored. The present is an investigator-driven, single-center, prospective, open-label, registry-based randomized study that used the TAVR institutional registry of the Ferrarotto Hospital in Catania, Italy, as the platform for randomization, data collection, and follow-up assessment. A total of 112 consecutive patients undergoing TAVR were randomly assigned to hydration with normal saline solution controlled by the RenalGuard system and furosemide (RenalGuard group) or normal saline solution (control group). The primary endpoint was the incidence of Valve Academic Research Consortium-defined AKI in the first 72 h after the procedure. The AKI rate was lower in the RenalGuard group than in the control group (n = 3 [5.4%] vs. n =14 [25.0%], respectively, p = 0.014). The majority of patients (5.4% vs. 23.2%) developed a mild AKI (stage 1); severe damage (stage 3) occurred only in 1 patient in the control group (0.0% vs. 1.8%). No case of in-hospital renal failure requiring dialysis was reported. No significant differences in terms of mortality, cerebrovascular events, bleeding, and hospitalization for heart failure were noted in both groups at 30 days. Furosemide-induced diuresis with matched isotonic intravenous hydration using the RenalGuard system is an effective therapeutic tool to reduce the occurrence of AKI in patients undergoing TAVR. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Venovenous Bypass Is Associated With a Lower Incidence of Acute Kidney Injury After Liver Transplantation in Patients With Compromised Pretransplant Renal Function.

PubMed

Sun, Kai; Hong, Fu; Wang, Yun; Agopian, Vatche G; Yan, Min; Busuttil, Ronald W; Steadman, Randolph H; Xia, Victor W

2017-11-01

Although the hemodynamic benefits of venovenous bypass (VVB) during liver transplantation (LT) are well appreciated, the impact of VVB on posttransplant renal function is uncertain. The aim of this study was to determine if VVB was associated with a lower incidence of posttransplant acute kidney injury (AKI). Medical records of adult (≥18 years) patients who underwent primary LT between 2004 and 2014 at a tertiary hospital were reviewed. Patients who required pretransplant renal replacement therapy and intraoperative piggyback technique were excluded. Patients were divided into 2 groups, VVB and non-VVB. AKI, determined by the Acute Kidney Injury Network criteria, was compared between the 2 groups. Propensity match was used to control selection bias that occurred before VVB and multivariable logistic regression was used to control confounding factors during and after VVB. Of 1037 adult patients who met the study inclusion criteria, 247 (23.8%) received VVB. A total of 442 patients (221 patients in each group) were matched. Aftermatch patients were further divided according to a predicted probability AKI model using preoperative creatinine (Cr), VVB, and intraoperative variables into 2 subgroups: normal and compromised pretransplant renal functions. In patients with compromised pretransplant renal function (Cr ≥1.2 mg/dL), the incidence of AKI was significantly lower in the VVB group compared with the non-VVB group (37.2% vs 50.8%; P = .033). VVB was an independent risk factor negatively associated with AKI (odds ratio, 0.1; 95% confidence interval, 0.1-0.4; P = .001). Renal replacement in 30 days and 1-year recipient mortality were not significantly different between the 2 groups. The incidence of posttransplant AKI was not significantly different between the 2 groups in patients with normal pretransplant renal function (Cr <1.2 mg/dL). In this large retrospective study, we demonstrated that utilization of intraoperative VVB was associated with a significantly lower incidence of posttransplant AKI in patients with compromised pretransplant renal function. Further studies to assess the role of intraoperative VVB in posttransplant AKI are warranted.

The essential of 2012 results from the French Renal Epidemiology and Information Network (REIN) ESRD registry.

PubMed

Lassalle, Mathilde; Ayav, Carole; Frimat, Luc; Jacquelinet, Christian; Couchoud, Cécile

2015-04-01

The French Renal Epidemiology and Information Network (REIN) registry began in 2002 to provide a tool for public health decision support, evaluation and research related to renal replacement therapies (RRT) for end-stage renal disease (ESRD). It is relying on a network of nephrologists, epidemiologists, patients and public health representatives. Continuous registration covers all dialysis and transplanted patients. In 2012, in France, 10,048 patients started a RRT (154 per million inhabitants). Elders provided majority of new patients (median age at RRT start: 70 years old). New patients had a high and age increasing rate of comorbidities, especially diabetes (42% of the new patients) and cardiovascular comorbidities (>50% of the new patients). Like previous years, incidence is stabilized. On December 31, 2012, 73,491 patients were receiving a RRT in France (1127 per million inhabitants, 56% on dialysis and 44% living with a functional renal transplant). More than 50% of patients were undergoing in-center hemodialysis with significant variations among regions. An increase in medical satellite unit hemodialysis but a decrease in self-care unit hemodialysis rates were noticed across the time, whereas peritoneal dialysis remained stable at 7%. Five years after starting RRT, the overall survival rate was 51% but only 16% among patients over 85 years. Mortality rate was highly dependent on treatment and age; transplanted patients aged 60-69 had a 27/1000 patients-year mortality rate versus 133 for a dialysis patient. Patients who started dialysis had a probability of first wait-listing of 4.8% at the start of dialysis (pre-emptive registrations) and 27% at 72 months. Whatever their diabetes status was, patients older than 60 had poor access to the waiting list. Seventeen percent of the patients received a first renal transplant within 15.4 month median time; 3% had received a pre-emptive graft. Ten years after the start of the French ESRD registry, this report provides a comprehensive and nation-wide overview of dialysis and transplantation cares in France, including overseas. Copyright © 2014 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Aburano, T.; Takayama, T.; Nakajima, K.

The three different methods to evaluate the alterations of split renal function following continued captopril treatment were studied in patients with hypertension. Five patients had unilateral and 2 had bilateral renal artery stenosis, and 13 had normal renal arteries. The studies were performed the day prior to receiving captopril (baseline), and 6th or 7th day following continued captorpril treatment (37.5mg or 75mg/day): Split effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) after injections of I-131 iodohippuran and Tc-99m DTPA were measured respectively by the methods using kidney counting corrected for depth and dose, described by Schlegel and Gates.more » And Tc-99m DMSA uptake was also evaluated qualitatively. In most of patients with renal artery stenosis, split GFR and Tc-99m DMSA uptake in the affected kidney were markedly decreased 6th or 7th day following continued captorpril treatment. These findings suggest that the captopril induced alterations of split renal function may be of importance for the diagnosis of renovascular hypertension. For this purpose, split GFR determination and Tc-99m DMSA study are more useful than split ERPF determination.« less

New Developments in Hepatorenal Syndrome.

PubMed

Mindikoglu, Ayse L; Pappas, Stephen C

2018-02-01

Hepatorenal syndrome (HRS) continues to be one of the major complications of decompensated cirrhosis, leading to death in the absence of liver transplantation. Challenges in precisely evaluating renal function in the patient with cirrhosis remain because of the limitations of serum creatinine (Cr) alone in estimating glomerular filtration rate (GFR); current GFR estimating models appear to underestimate renal dysfunction. Newer models incorporating renal biomarkers, such as the Cr-Cystatin C GFR Equation for Cirrhosis appear to estimate measured GFR more accurately. A major change in the diagnostic criteria for HRS based on dynamic serial changes in serum Cr that regard HRS type 1 as a special form of acute kidney injury promises the possibility of earlier identification of renal dysfunction in patients with cirrhosis. The diagnostic criteria of HRS still include the exclusion of other causes of kidney injury. Renal biomarkers have been disappointing in assisting with the differentiation of HRS from prerenal azotemia and other kidney disorders. Serum metabolomic profiling may be a more powerful tool to assess renal dysfunction, although the practical clinical significance of this remains unclear. As a result of the difficulties of assessing renal function in cirrhosis and the varying HRS diagnostic criteria and the rigor with which they are applied, the precise incidence and prevalence of HRS is unknown, but it is likely that HRS occurs more commonly than expected. The pathophysiology of HRS is rooted firmly in the setting of progressive reduction in renal blood flow as a result of portal hypertension and splanchnic vasodilation. Progressive marked renal cortical ischemia in patients with cirrhosis parallels the evolution of diuretic-sensitive ascites to diuretic-refractory ascites and HRS, a recognized continuum of renal dysfunction in cirrhosis. Alterations in nitrous oxide production, both increased and decreased, may play a major role in the pathophysiology of this evolution. The inflammatory cascade, triggered by bacterial translocation and endotoxemia, increasingly recognized as important in the manifestation of acute-on-chronic liver failure, also may play a significant role in the pathophysiology of HRS. The mainstay of treatment remains vasopressor therapy with albumin in an attempt to reverse splanchnic vasodilation and improve renal blood flow. Several meta-analyses have confirmed the value of vasopressors, chiefly terlipressin and noradrenaline, in improving renal function and reversing HRS type 1. Other interventions such as renal replacement therapy, transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Liver transplantation remains the definitive treatment for HRS. The frequency of simultaneous liver-kidney transplantation has increased dramatically in the Model for End-stage Liver Disease era, with changes in organ allocation policies. This has resulted in a more urgent need to predict native kidney recovery from HRS after liver transplantation alone, to avoid unnecessary simultaneous liver-kidney transplantation. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.

Predictors of renal recovery in patients with pre-orthotopic liver transplant (OLT) renal dysfunction.

PubMed

Iglesias, Jose; Frank, Elliot; Mehandru, Sushil; Davis, John M; Levine, Jerrold S

2013-07-13

Renal dysfunction occurs commonly in patients awaiting orthotopic liver transplantation (OLT) for end-stage liver disease. The use of simultaneous liver-kidney transplantation has increased in the MELD scoring era. As patients may recover renal function after OLT, identifying factors predictive of renal recovery is a critical issue, especially given the scarcity of available organs. Employing the UNOS database, we sought to identify donor- and patient-related predictors of renal recovery among 1720 patients with pre-OLT renal dysfunction and transplanted from 1989 to 2005. Recovery of renal function post-OLT was defined as a composite endpoint of serum creatinine (SCr) ≤1.5 mg/dL at discharge and survival ≥29 days. Pre-OLT renal dysfunction was defined as any of the following: SCr ≥2 mg/dL at any time while awaiting OLT or need for renal replacement therapy (RRT) at the time of registration and/or OLT. Independent predictors of recovery of renal function post-OLT were absence of hepatic allograft dysfunction, transplantation during MELD era, recipient female sex, decreased donor age, decreased recipient ALT at time of OLT, decreased recipient body mass index at registration, use of anti-thymocyte globulin as induction therapy, and longer wait time from registration. Contrary to popular belief, a requirement for RRT, even for prolonged periods in excess of 8 weeks, was not an independent predictor of failure to recover renal function post-OLT. These data indicate that the duration of renal dysfunction, even among those requiring RRT, is a poor way to discriminate reversible from irreversible renal dysfunction.

Can we use an ex vivo continuous hemofiltration model to describe the adsorption and elimination of meropenem and piperacillin?

PubMed

Jamal, Janattul-Ain; Udy, Andrew A; Wallis, Steven C; Ranganathan, Dwarakanathan; McWhinney, Brett C; Ungerer, Jacobus P J; Lipman, Jeffrey; Roberts, Jason A

2015-08-01

To determine the adsorption and elimination characteristics of meropenem and piperacillin during simulated continuous renal replacement therapy (CRRT), and to compare the observed data from this ex vivo study with previous data from clinical studies. This was an experimental study utilizing a modified CRRT circuit and polysulfone membrane (1.2 m2), circulated with a blood-crystalloid mixture. Adsorption onto the CRRT circuit was tested over a 4-h period, and clearance was assessed separately using variable continuous hemofiltration settings. A rapid 9% reduction in circulating meropenem and piperacillin concentrations was observed at approximately 0.5 and 1.0 h for each antibiotic, respectively. The post-dilution setting was associated with a significantly higher sieving coefficient (Sc) and filter clearance (CLfilter) (mean ± SD) (Sc 1.14 ± 0.10 versus 1.06 ± 0.04; CLfilter 19.05 ± 1.63 versus 17.59 ± 0.62 ml/min, P values < 0.05) for meropenem. No significant differences were observed for piperacillin pharmacokinetics. Clinically comparable Sc data were observed between data obtained from the ex vivo study and data from previous clinical studies, for both antibiotics. Meropenem and piperacillin appear to be rapidly adsorbed into the CRRT circuit, and the delivery site of fluid replacement significantly influences meropenem pharmacokinetics. However, these findings are likely to be clinically insignificant and not affect dosing requirements. This ex vivo method could be a surrogate for future clinical pharmacokinetic studies of CRRT. Further research is required to explore the applicability of the ex vivo method to further characterize antibiotic pharmacokinetics during CRRT.

Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy.

PubMed

Zhang, Zhongheng; Hongying, Ni

2012-01-01

Regional citrate anticoagulation (RCA) is an attractive anticoagulation mode in continuous renal replacement therapy (CRRT) because it restricts the anticoagulatory effect to the extracorporeal circuit. In recent years, several randomized controlled trials have been conducted to investigate its superiority over other anticoagulation modes. Thus, we performed a systematic review of available evidence on the efficacy and safety of RCA. A systematic review of randomized controlled trials investigating the efficacy and safety of RCA was performed. PubMed, Current Contents, CINAHL, and EMBASE databases were searched to identify relevance articles. Data on circuit life span, bleeding events, metabolic derangement, and mortality were abstracted. Mean difference was used for continuous variables, and risk ratio was used for binomial variables. The random effects or fixed effect model was used to combine these data according to heterogeneity. The software Review Manager 5.1 was used for the meta-analysis. Six studies met our inclusion criteria, which involved a total of 658 circuits. In these six studies patients with liver failure or a high risk of bleeding were excluded. The circuit life span in the RCA group was significantly longer than that in the control group, with a mean difference of 23.03 h (95% CI 0.45-45.61 h). RCA was able to reduce the risk of bleeding, with a risk ratio of 0.28 (95% CI 0.15-0.50). Metabolic stability (electrolyte and acid-base stabilities) in performing RCA was comparable to that in other anticoagulation modes, and metabolic derangements (hypernatremia, metabolic alkalosis, and hypocalcemia) could be easily controlled without significant clinical consequences. Two studies compared mortality rate between RCA and control groups, with one reported similar mortality rate and the other reported superiority of RCA over the control group (hazards ratio 0.7). RCA is effective in maintaining circuit patency and reducing the risk of bleeding, and thus can be recommended for CRRT if and when metabolic monitoring is adequate and the protocol is followed. However, the safety of citrate in patients with liver failure cannot be concluded from current analysis. The metabolic stability can be easily controlled during RCA. Survival benefit from RCA is still controversial due to limited evidence.

Urine output on an intensive care unit: case-control study.

PubMed

Solomon, Anthony W; Kirwan, Christopher J; Alexander, Neal D E; Nimako, Kofi; Jurukov, Angela; Forth, Rebecca J; Rahman, Tony M

2010-12-14

To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. Case-control study. General intensive care unit in a tertiary referral hospital. 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as "cases." Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m(2), and renal replacement therapy. Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. Doctors were classed as oliguric and "at risk" of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being "in injury" on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit.

Risk Predictors and Causes of Technique Failure Within the First Year of Peritoneal Dialysis: An Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) Study.

PubMed

See, Emily J; Johnson, David W; Hawley, Carmel M; Pascoe, Elaine M; Badve, Sunil V; Boudville, Neil; Clayton, Philip A; Sud, Kamal; Polkinghorne, Kevan R; Borlace, Monique; Cho, Yeoungjee

2017-12-22

Concern regarding technique failure is a major barrier to increased uptake of peritoneal dialysis (PD), and the first year of therapy is a particularly vulnerable time. A cohort study using competing-risk regression analyses to identify the key risk factors and risk periods for early transfer to hemodialysis therapy or death in incident PD patients. All adult patients who initiated PD therapy in Australia and New Zealand in 2000 through 2014. Patient demographics and comorbid conditions, duration of prior renal replacement therapy, timing of referral, PD modality, dialysis era, and center size. Technique failure within the first year, defined as transfer to hemodialysis therapy for more than 30 days or death. Of 16,748 patients included in the study, 4,389 developed early technique failure. Factors associated with increased risk included age older than 70 years, diabetes or vascular disease, prior renal replacement therapy, late referral to a nephrology service, or management in a smaller center. Asian or other race and use of continuous ambulatory PD were associated with reduced risk, as was initiation of PD therapy in 2010 through 2014. Although the risk for technique failure due to death or infection was constant during the first year, mechanical and other causes accounted for a greater number of cases within the initial 9 months of treatment. Potential for residual confounding due to limited data for residual kidney function, dialysis prescription, and socioeconomic factors. Several modifiable and nonmodifiable factors are associated with early technique failure in PD. Targeted interventions should be considered in high-risk patients to avoid the consequences of an unplanned transfer to hemodialysis therapy or death. Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

Clinical preparedness for severe pneumonia with highly pathogenic avian influenza A (H5N1): experiences with cases in Vietnam.

PubMed

Kudo, Koichiro; Binh, Nguyen Gia; Manabe, Toshie; Co, Dao Xuan; Tuan, Nguyen Dang; Izumi, Shinyu; Takasaki, Jin; Minh, Dang Hung; Thuy, Pham Thi Phuong; Van, Vu Thi Tuong; Hanh, Tran Thuy; Chau, Ngo Quy

2012-12-01

Avian influenza A (H5N1) in human presents a global pandemic threat, and preparedness is urgently required in high-risk countries. A retrospective chart review was conducted on 8 patients with H5N1 infection (aged 2-30 years; 3 fatal) who were hospitalized in Bach Mai Hospital (BMH), Vietnam, or in affiliated hospitals with consultation by physicians in BMH between 2007 and 2010. Demographic background, chest radiographs, and clinical and laboratory data were evaluated to determine the critical issues in relation to clinical outcomes. Treatment of 4 patients with acute respiratory distress syndrome (ARDS) (2 fatal) was assessed for renal replacement therapy using continuous hemodiafiltration (CHDF), polymyxin B-immobilized (PMX) hemoperfusion, or their combination. Patients had direct contact with dead/sick poultry infected with H5N1 virus or lived in areas where H5N1 poultry outbreaks had been reported at the same time as their illness. Time to initiation of oseltamivir from symptom onset was 2-6 days for survivors and 7-9 days for non-survivors. All patients except one had infiltrative shadows on chest radiographs on admission. Patients with delayed treatment developed ARDS. Renal replacement therapy contributed to patient survival, with improvement of oxygenation and a dramatic decrease in serum cytokine levels if initiated earlier. Understanding local H5N1 poultry outbreaks and chest radiography assist early diagnosis and initiation of antiviral treatment. Developing a network among local and tertiary care hospitals can reduce the time to initiation of treatment. CHDF and PMX hemoperfusion are possible candidates for effective treatment of ARDS with H5N1 if applied earlier. Copyright © 2012 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

Enzyme replacement therapy for Fabry disease: some answers but more questions.

PubMed

Alfadhel, Majid; Sirrs, Sandra

2011-01-01

Fabry disease (FD) is a multisystem, X-linked disorder of glycosphingolipid metabolism caused by enzyme deficiency of α-galactosidase A. Affected patients have symptoms including acroparesthesias, angiokeratomas, and hypohidrosis. More serious manifestations include debilitating pain and gastrointestinal symptoms, proteinuria and gradual deterioration of renal function leading to end-stage renal disease, hypertrophic cardiomyopathy, and stroke. Heterozygous females may have symptoms as severe as males with the classic phenotype. Before 2001, treatment of patients with FD was supportive. The successful development of enzyme replacement therapy (ERT) has been a great advancement in the treatment of patients with FD and can stabilize renal function and cardiac size, as well as improve pain and quality of life of patients with FD. In this review, we have provided a critical appraisal of the literature on the effects of ERT for FD. This analysis shows that data available on the treatment of FD are often derived from studies which are not controlled, rely on surrogate markers, and are of insufficient power to detect differences on hard clinical endpoints. Further studies of higher quality are needed to answer the questions that remain concerning the efficacy of ERT for FD.

End-of-life matters in chronic renal failure.

PubMed

Berman, Nathaniel

2014-12-01

The population considered eligible for dialysis has expanded dramatically over the past 4 decades, so that a significant proportion of patients receiving renal replacement therapy are elderly, frail and infirm. These patients have an extremely limited life expectancy and suffer from significant symptom burden, similar to patients with other end-stage organ failure or cancer. As dialysis has been offered more broadly, it is now initiated earlier than in decades past, further adding to cost and patient burden. The trend toward more expansive and intensive care has not been corroborated by robust data. In response, an increasing number of studies has focused on establishing reasonable limits to renal replacement therapy. Multiple authors have explored the role of conservative kidney management for high-risk dialysis patients as an alternative to dialysis, which may offer similar survival and improved quality of life in certain populations. For those who chose dialysis, deferring initiation until the patient becomes symptomatic may be a reasonable. Evidence-based symptom management guidelines for dialysis patients remain largely absent, with few proven approaches. Hospice and palliative care resources remain underutilized. For a subset of dialysis patients, palliative care and conservative kidney management are appropriate and underutilized. http://links.lww.com/COSPC/A8

Rhabdomyolysis-Associated Acute Kidney Injury With Normal Creatine Phosphokinase.

PubMed

Kamal, Faisal; Snook, Lindsay; Saikumar, Jagannath H

2018-01-01

Rhabdomyolysis is a syndrome characterized by the breakdown of skeletal muscle and leakage of intracellular myocyte contents, such as creatine phosphokinase (CPK) and myoglobin, into the interstitial space and plasma resulting in acute kidney injury (AKI). Elevated CPK of at least 5 times the upper limit of normal is an important diagnostic marker of Rhabdomyolysis. We present a case of rhabdomyolysis with severe AKI with a normal CPK at presentation. A 32-year-old man presented with acute respiratory failure and AKI after an overdose of recreational drugs. Urinalysis at presentation showed trace amounts of blood, identified as rare red blood cells under microscopy. CPK was 156 U/L at presentation. Workup for glomerulonephritis and vasculitis was negative. He was initiated on renal replacement therapy, and a kidney biopsy showed severe acute tubular injury with positive myoglobin casts. Supportive management and renal replacement therapy was provided, and renal function spontaneously improved after a few weeks. This is an uncommon clinical presentation of severe rhabdomyolysis complicated by AKI. This suggests that CPK alone may not be a sensitive marker for rhabdomyolysis-induced AKI in some cases. Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

[Pulmonary-renal crosstalk in the critically ill patient].

PubMed

Donoso F, Alejandro; Arriagada S, Daniela; Cruces R, Pablo

2015-01-01

Despite advances in the development of renal replacement therapy, mortality of acute renal failure remains high, especially when occurring simultaneously with distant organic failure as it is in the case of the acute respiratory distress syndrome. In this update, birideccional deleterious relationship between lung and kidney on the setting of organ dysfunction is reviewed, which presents important clinical aspects of knowing. Specifically, the renal effects of acute respiratory distress syndrome and the use of positive-pressure mechanical ventilation are discussed, being ventilator induced lung injury one of the most common models for studying the lung-kidney crosstalk. The role of renal failure induced by mechanical ventilation (ventilator-induced kidney injury) in the pathogenesis of acute renal failure is emphasized. We also analyze the impact of the acute renal failure in the lung, recognizing an increase in pulmonary vascular permeability, inflammation, and alteration of sodium and water channels in the alveolar epithelial. This conceptual model can be the basis for the development of new therapeutic strategies to use in patients with multiple organ dysfunction syndrome. Copyright © 2015 Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

[Perioperative acute kidney injury and failure].

PubMed

Chhor, Vibol; Journois, Didier

2014-04-01

Perioperative period is very likely to lead to acute renal failure because of anesthesia (general or perimedullary) and/or surgery which can cause acute kidney injury. Characterization of acute renal failure is based on serum creatinine level which is imprecise during and following surgery. Studies are based on various definitions of acute renal failure with different thresholds which skewed their comparisons. The RIFLE classification (risk, injury, failure, loss, end stage kidney disease) allows clinicians to distinguish in a similar manner between different stages of acute kidney injury rather than using a unique definition of acute renal failure. Acute renal failure during the perioperative period can mainly be explained by iatrogenic, hemodynamic or surgical causes and can result in an increased morbi-mortality. Prevention of this complication requires hemodynamic optimization (venous return, cardiac output, vascular resistance), discontinuation of nephrotoxic drugs but also knowledge of the different steps of the surgery to avoid further degradation of renal perfusion. Diuretics do not prevent acute renal failure and may even push it forward especially during the perioperative period when venous retourn is already reduced. Edema or weight gain following surgery are not correlated with the vascular compartment volume, much less with renal perfusion. Treatment of perioperative acute renal failure is similar to other acute renal failure. Renal replacement therapy must be mastered to prevent any additional risk of hemodynamic instability or hydro-electrolytic imbalance. Copyright © 2014 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

Impact of age at onset for children with renal failure on education and employment transitions.

PubMed

Lewis, Helen; Arber, Sara

2015-01-01

Previous medical research has shown that children with end-stage renal failure experience delay or underachievement of key markers of transition to adulthood. This article analyses 35 qualitative interviews with end-stage renal failure patients, aged 20-30 years, first diagnosed at 0-19 years of age, to explore how far delayed or underachievement in education and employment is related to their age at onset of end-stage renal failure. This study shows how unpredictable failures of renal replacement therapies, comorbidities and/or side effects of treatment in the early life course often coincided with critical moments for education and employment. Entering school, college, work-related training or employment, and disclosing health status or educational underachievement to an employer, were particularly critical, and those who were ill before puberty became progressively more disadvantaged in terms of successful transition into full-time employment, compared with those first diagnosed after puberty. © The Author(s) 2014.

Permissive hypofiltration

PubMed Central

2012-01-01

Acute kidney injury (AKI) is a syndrome with a multitude of causes and is associated with high mortality and a permanent loss of renal function. Our current understanding of the most common causes of AKI is limited, and thus a silver bullet therapy remains elusive. A change in the approach to AKI that shifts away from the primary composite endpoint of death/dialysis, and instead focuses on improving survival and mitigating permanent renal damage, is likely to be more fruitful. We suggest that the current approach of augmenting renal function by increasing the renal blood flow or glomerular filtration rate during AKI may actually worsen outcomes. Analogous to the approach towards adult respiratory distress syndrome that limits ventilator-induced lung injury, we propose the concept of permissive hypofiltration. The primary goals of this approach are: resting the kidney by providing early renal replacement therapy, avoiding the potentially injurious adverse events that occur during AKI (for example, fluid overload, hypophosphatemia, hypothermia, and so forth), and initiating therapies focused on improving survival and mitigating permanent loss of kidney function. PMID:22839207

Patients' perceptions of information and education for renal replacement therapy: an independent survey by the European Kidney Patients' Federation on information and support on renal replacement therapy.

PubMed

Van Biesen, Wim; van der Veer, Sabine N; Murphey, Mark; Loblova, Olga; Davies, Simon

2014-01-01

Selection of an appropriate renal replacement modality is of utmost importance for patients with end stage renal disease. Previous studies showed provision of information to and free modality choice by patients to be suboptimal. Therefore, the European Kidney Patients' Federation (CEAPIR) explored European patients' perceptions regarding information, education and involvement on the modality selection process. CEAPIR developed a survey, which was disseminated by the national kidney patient organisations in Europe. In total, 3867 patients from 36 countries completed the survey. Respondents were either on in-centre haemodialysis (53%) or had a functioning graft (38%) at the time of survey. The majority (78%) evaluated the general information about kidney disease and treatment as helpful, but 39% did not recall being told about alternative treatment options than their current one. Respondents were more often satisfied with information provided on in-centre haemodialysis (90%) and transplantation (87%) than with information provided on peritoneal dialysis (79%) or home haemodialysis (61%), and were more satisfied with information from health care professionals vs other sources such as social media. Most (75%) felt they had been involved in treatment selection, 29% perceived they had no free choice. Involvement in modality selection was associated with enhanced satisfaction with treatment (OR 3.13; 95% CI 2.72-3.60). Many respondents (64%) could not remember receiving education on how to manage their kidney disease in daily life. Perceptions on information seem to differ between countries. Kidney patients reported to be overall satisfied with the information they received on their disease and treatment, although information seemed mostly to have been focused on one modality. Patients involved in modality selection were more satisfied with their treatment. However, in the perception of the patients, the freedom to choose an alternative modality showed room for improvement.

21 CFR 876.4650 - Water jet renal stone dislodger system.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Water jet renal stone dislodger system. 876.4650... (CONTINUED) MEDICAL DEVICES GASTROENTEROLOGY-UROLOGY DEVICES Surgical Devices § 876.4650 Water jet renal stone dislodger system. (a) Identification. A water jet renal stone dislodger system is a device used to...

21 CFR 876.4650 - Water jet renal stone dislodger system.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Water jet renal stone dislodger system. 876.4650... (CONTINUED) MEDICAL DEVICES GASTROENTEROLOGY-UROLOGY DEVICES Surgical Devices § 876.4650 Water jet renal stone dislodger system. (a) Identification. A water jet renal stone dislodger system is a device used to...

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus

PubMed Central

Kramer, Anneke; Pippias, Maria; Stel, Vianda S.; Bonthuis, Marjolein; Abad Diez, José Maria; Afentakis, Nikolaos; Alonso de la Torre, Ramón; Ambuhl, Patrice; Bikbov, Boris; Bouzas Caamaño, Encarnación; Bubic, Ivan; Buturovic-Ponikvar, Jadranka; Caskey, Fergus J.; Castro de la Nuez, Pablo; Cernevskis, Harijs; Collart, Frederic; Comas Farnés, Jordi; Garcia Bazaga, Maria de los Ángeles; De Meester, Johan; Ferrer Alamar, Manuel; Finne, Patrik; Garneata, Liliana; Golan, Eliezer; G. Heaf, James; Hemmelder, Marc; Ioannou, Kyriakos; Kantaria, Nino; Kolesnyk, Mykola; Kramar, Reinhard; Lassalle, Mathilde; Lezaic, Visnja; Lopot, Frantisek; Macário, Fernando; Magaz, Angela; Martín-Escobar, Eduardo; Metcalfe, Wendy; Ots-Rosenberg, Mai; Palsson, Runolfur; Piñera Celestino, Celestino; Resić, Halima; Rutkowski, Boleslaw; Santiuste de Pablos, Carmen; Spustová, Viera; Stendahl, Maria; Strakosha, Ariana; Süleymanlar, Gültekin; Torres Guinea, Marta; Varberg Reisæter, Anna; Vazelov, Evgueniy; Ziginskiene, Edita; Massy, Ziad A.; Wanner, Christoph; Jager, Kitty J.; Noordzij, Marlies

2016-01-01

Background This article provides a summary of the 2013 European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). Methods In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. Results In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5–61.3] and 50.6% (95% CI 49.9–51.2) for patients with DM as the cause of ESRD. PMID:27274834

Changes in co-morbidity pattern in patients starting renal replacement therapy in Europe-data from the ERA-EDTA Registry.

PubMed

Ceretta, Maria L; Noordzij, Marlies; Luxardo, Rosario; De Meester, Johan; Abad Diez, Jose M; Finne, Patrik; Heaf, James G; Couchoud, Cécile; Kramar, Reinhard; Collart, Frederic; Cases, Aleix; Palsson, Runolfur; Reisæter, Anna V; Rydell, Helena; Massy, Ziad A; Jager, Kitty J; Kramer, Anneke

2018-01-18

Patients starting renal replacement therapy (RRT) for end-stage renal disease often present with one or more co-morbidities. This study explored the prevalence of co-morbidities in patients who started RRT in Europe during the period from 2005 to 2014. Using data from patients aged 20 years or older from all 11 national or regional registries providing co-morbidity data to the European Renal Association - European Dialysis and Transplant Association Registry, we examined the prevalence of the following co-morbidities: diabetes mellitus (DM) (primary renal disease and/or co-morbidity), ischaemic heart disease (IHD), congestive heart failure (CHF), peripheral vascular disease (PVD), cerebrovascular disease (CVD) and malignancy. Overall, 70% of 7578 patients who initiated RRT in 2014 presented with at least one co-morbidity: 39.0% presented with DM, 25.0% with IHD, 22.3% with CHF, 17.7% with PVD, 16.4% with malignancy and 15.5% with CVD. These percentages differed substantially between countries. Co-morbidities were more common in men than in women, in older patients than in younger patients, and in patients on haemodialysis at Day 91 when compared with patients on peritoneal dialysis. Between 2005 and 2014 the prevalence of DM and malignancy increased over time, whereas the prevalence of IHD and PVD declined. More than two-thirds of patients initiating RRT in Europe have at least one co-morbidity. With the rising age at the start of RRT over the last decade, there have been changes in the co-morbidity pattern: the prevalence of cardiovascular co-morbidities decreased, while the prevalence of DM and malignancy increased. © The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effect of ionized serum calcium on outcomes in acute kidney injury needing renal replacement therapy: Secondary analysis of the Acute Renal Failure Trial Network Study

PubMed Central

Afshinnia, Farsad; Belanger, Karen; Palevsky, Paul M.; Young, Eric W.

2014-01-01

Background Hypocalcemia is very common in critically ill patients. While the effect of ionized calcium (iCa) on outcome is not well understood, manipulation of iCa in critically ill patients is a common practice. We analyzed all-cause mortality and several secondary outcomes in patients with acute kidney injury (AKI) by categories of serum iCa among participants in the Acute Renal Failure Trial Network (ATN) Study. Methods This is a post hoc secondary analysis of the ATN Study which was not preplanned in the original trial. Risk of mortality and renal recovery by categories of iCa were compared using multiple fixed and adjusted time-varying Cox regression models. Multiple linear regression models were used to explore the impact of baseline iCa on days free from ICU and hospital. Results A total of 685 patients were included in the analysis. Mean age was 60 (SD=15) years. There were 502 male patients (73.3%). Sixty-day all-cause mortality was 57.0%, 54.8%, and 54.4%, in patients with an iCa <1, 1–1.14, and ≥1.15 mmol/L, respectively (P=0.87). Mean of days free from ICU or hospital in all patients and the 28-day renal recovery in survivors to day 28 were not significantly different by categories of iCa. The hazard for death in a fully adjusted time-varying Cox regression survival model was 1.7 (95% CI: 1.3–2.4) comparing iCa <1 to iCa ≥1.15 mmol/L. No outcome was different for levels of iCa >1 mmol/L. Conclusion Severe hypocalcemia with iCa <1 mmol/L independently predicted mortality in patients with AKI needing renal replacement therapy. PMID:23992422

End-stage renal disease and its treatment in Latin America in the twenty-first century.

PubMed

Cusumano, Ana; Garcia-Garcia, Guillermo; Di Gioia, Cristina; Hermida, Osvaldo; Lavorato, Carlos; Carreño, Cesar Agost; Torrico, Maria Placida Garron; Batista, Paulo Benigno Pena; Romão, João Egídio; Badal, Hugo Poblete; Miranda, Susana Elgueta; Gomez, Rafael; Calderon, Manuel Cerdas; Sanchez, Sergio Herra; Lopez, Miguel Almaguer; Moscoso, Julio; Merino, Ricardo Leiva; Polo, Jose Vicente Sánchez; Lopez, Alirio; Romero, Norman Jiron; Garcia, Ramiro; Acosta, Blanca V Franco; Lopez, Augusto Saavedra; Delpin, Eduardo Santiago; Mena, Emilio; González, Carlota; Milanés, Carmen Luisa; Acchiardo, Sergio

2006-01-01

The Latin American Society of Nephrology and Arterial Hypertension's Dialysis and Transplant Registry was chartered in 1991. It collects information on ESRD and its treatment in 20 countries of the region. The prevalence of patients on renal replacement therapy (RRT) increased from 129 pmp in 1992 to 447 pmp in 2004; in 2004, 56% of the patients were on hemodialysis, 23% on peritoneal dialysis, and 21% had a functioning kidney graft. The highest rates of prevalence were reported in Puerto Rico (1027 pmp), Chile (686 pmp), and Uruguay (683 pmp). Hemodialysis was widely used, except in El Salvador, Mexico, Guatemala, Nicaragua, and the Dominican Republic, where peritoneal dialysis predominated. Incidence rate increased from 27.8 pmp to 147 pmp in the same period of observation; the lowest rate was reported in Guatemala (11.4 pmp) and the highest in Puerto Rico (337.4 pmp). Diabetes mellitus was the leading cause of renal failure in incident patients; the highest rates were reported in Puerto Rico (62.2%) and Mexico (60%). Forty-four percent of the incident population were older than 65 years. Access to renal replacement therapy was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Uruguay, and Venezuela, while was restricted in other countries. Main causes of death in dialysis were cardiovascular (44%) and infectious disease (26%). The rate of renal transplantation increased from 3.7 pmp in 1987 to 14.5 in 2004; fifty-three percent of the organs came from cadavers. Overall, donation rate was 5.9 pmp. In conclusion, the prevalence and incidence rates have increased over the years, and diabetes mellitus has emerged as the leading cause of kidney disease in the region. Although the rate of kidney transplantation has increased, the number remains insufficient to match the growing demand. The implementation of renal health programs in the region is urgently needed.

Predictors of renal recovery in patients with pre-orthotopic liver transplant (OLT) renal dysfunction

PubMed Central

2013-01-01

Background Renal dysfunction occurs commonly in patients awaiting orthotopic liver transplantation (OLT) for end-stage liver disease. The use of simultaneous liver-kidney transplantation has increased in the MELD scoring era. As patients may recover renal function after OLT, identifying factors predictive of renal recovery is a critical issue, especially given the scarcity of available organs. Methods Employing the UNOS database, we sought to identify donor- and patient-related predictors of renal recovery among 1720 patients with pre-OLT renal dysfunction and transplanted from 1989 to 2005. Recovery of renal function post-OLT was defined as a composite endpoint of serum creatinine (SCr) ≤1.5 mg/dL at discharge and survival ≥29 days. Pre-OLT renal dysfunction was defined as any of the following: SCr ≥2 mg/dL at any time while awaiting OLT or need for renal replacement therapy (RRT) at the time of registration and/or OLT. Results Independent predictors of recovery of renal function post-OLT were absence of hepatic allograft dysfunction, transplantation during MELD era, recipient female sex, decreased donor age, decreased recipient ALT at time of OLT, decreased recipient body mass index at registration, use of anti-thymocyte globulin as induction therapy, and longer wait time from registration. Contrary to popular belief, a requirement for RRT, even for prolonged periods in excess of 8 weeks, was not an independent predictor of failure to recover renal function post-OLT. Conclusion These data indicate that the duration of renal dysfunction, even among those requiring RRT, is a poor way to discriminate reversible from irreversible renal dysfunction. PMID:23849513

Evaluating staff and student experiences of multidisciplinary continuous professional development via distance-learning.

PubMed

Hurst, J

2005-01-01

Continuous professional development (CPD) in caring for people with kidney disease is limited in some regions of the UK and within Europe generally. This is compounded for all by limited resources for course fees and the lack of study leave granted away from the clinical area for full-time courses. This is set against recommendations from National and European governments, and renal clinical guidelines concerning expectations of CPD and clinical competency levels of renal nurses (1-4). In the past renal practitioners have been trained in all areas of the renal speciality by Schools of Nursing linked to renal units based in large teaching hospitals. However, more recent changes in the structure of Health Care provision have led in some instances to a rationalising of post registration education delivery.

Atrial natriuretic peptide for management of acute kidney injury: a systematic review and meta-analysis.

PubMed

Nigwekar, Sagar U; Navaneethan, Sankar D; Parikh, Chirag R; Hix, John K

2009-02-01

Randomized controlled trials (RCTs) with atrial natriuretic peptide (ANP) have shown inconsistent effects for renal end-points. The authors aimed to systematically review these trials to ascertain the benefit of ANP in prevention and treatment of acute kidney injury (AKI). The authors searched MEDLINE, EMBASE, and Cochrane Renal Health Library that investigated ANP in adult patients considered with or at risk for AKI. Outcomes were analyzed separately for prevention and treatment of AKI. Nineteen RCTs (11 prevention, 8 treatment) involving 1861 participants were included. Pooled analysis of prevention trials showed a trend toward reduction in renal replacement therapy in the ANP group (OR = 0.45, 95% CI, 0.21 to 0.99) and good safety profile, but no improvement in mortality. For the treatment of established AKI, ANP, particularly in high doses, was associated with a trend toward increased mortality and more adverse events. Subgroup analysis of AKI after a major surgery (14 RCTs, 817 participants) showed a significant reduction in renal replacement therapy requirement in the ANP group (OR = 0.49, 95% CI, 0.27 to 0.88). Included RCTs were mostly low- or moderate-quality, underpowered studies. There are an insufficient number of high-quality studies to make any definite statement about the role of ANP in AKI. Analysis of the existing literature suggests ANP might be associated with beneficial clinical effects when administered in patients undergoing major surgery such as cardiovascular surgery. Its use, in low doses, should be explored further in this setting.

Hypervitaminosis a in pediatric hematopoietic stem cell patients requiring renal replacement therapy.

PubMed

Lipkin, Ann Connell; Lenssen, Polly

Chronic renal failure patients have been known to develop vitamin A toxicity, but a descriptive study of hypervitaminosis A in patients with acute renal failure (ARF) has not yet been published. The authors observed hypervitaminosis A in pediatric hematopoietic stem cell transplant (HSCT) patients. All HSCT patients admitted between January 2001 and May 2006 who experienced ARF, received renal replacement therapy (RRT), and had a vitamin A level drawn were included in this retrospective, descriptive study. Molar ratios of vitamin A and retinol-binding protein (RBP) were calculated to more accurately assess vitamin A status. Nineteen patients met the criteria for this study. At initial testing (generally between days 6 and 10 after initiation of RRT), 17 of the 19 patients had abnormally elevated vitamin A levels for their age. Molar ratios of vitamin A to RBP were elevated in 6 patients at initial testing. Prescribed vitamin A intake information (parenteral and enteral) was available for most patients; all but 3 had an average daily intake greater than 2000 IU/kg over the 30 days prior to RRT initiation. Many patients had symptoms possibly related to vitamin A toxicity, although interpretation of hair, skin, and liver abnormalities are difficult to ascertain in HSCT patients. Seven patients had other findings that may have been associated with vitamin A toxicity. Children undergoing HSCT who receive nutrition support (predominantly parenteral nutrition), experience ARF, and require RRT are at risk for hypervitaminosis A and toxicity.

Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology.

PubMed

Miyamoto, Takuma; Karimov, Jamshid H; Fukamachi, Kiyotaka

2018-03-01

Continuous-flow (CF) left ventricular assist devices (LVADs) are widely used to treat end-stage heart failure. Despite substantial improvement in clinical results, numerous complications remain associated with this technology. Worsening renal function is one, associated with morbidity and mortality in patients supported by CF LVADs. The effects of CF LVAD support on renal function have been investigated since the mid-1990s by many research groups. Area covered: We review the current status of LVAD therapy, experimental results regarding the effects of types of flow generated by LVADs on renal function and pathology, changes in renal function after LVAD implant, the influence of renal function on outcomes, and risk factors for renal dysfunction post implant. This information was obtained through online databases and direct extraction of single studies. Expert commentary: Immediately after CF LVAD implantation, renal function improves temporarily as patients recover from the kidneys' previously low perfusion and congestive state. However, many studies have shown that this initially recovered renal function gradually declines during long-term CF LVAD support. Although it is known that CF LVAD support adversely affects renal function over the long term, just how it does has not yet been clearly defined in terms of clinical symptoms or signs.

Impact of intravenous magnesium infusion rate during ambulatory replacements on serum magnesium concentrations after allogeneic stem cell transplant.

PubMed

Snyder, Matthew; Shillingburg, Alexandra; Newton, Michael; Hamadani, Mehdi; Kanate, Abraham S; Craig, Michael; Cumpston, Aaron

2016-10-01

For an outpatient cancer center to operate efficiently, optimizing the use of chair time is essential. Allogeneic hematopoietic cell transplant (allo-HCT) recipients are seen frequently in this setting after hospital discharge and regularly for several months thereafter. Aggressive electrolyte replacement is commonly required in these patients, primarily due to renal wasting with calcineurin inhibitor use. Frequent intravenous (IV) magnesium repletion, requiring several hours of infusion time, is often needed in these patients to adequately manage their magnesium deficiencies. The purpose of this study is to explore the impact of extending the infusion rate of intravenous magnesium sulfate on the frequency and degree of IV magnesium replacements required in allo-HCT recipients. We conducted a retrospective study to compare two cohorts of patients administered IV magnesium sulfate at a rate of 4 g/1 h versus 4 g/2 h. A total of 103 continuous patients were assessed in two groups as cohort 1 at the 4 g/1 h rate and cohort 2 at the 4 g/2 h rate. Cohort 1 required less IV magnesium per outpatient visit (median 2.2 vs. 2.9 g/visit, P = 0.0211) and less total IV magnesium replacement through day +100 (median 68 vs. 85 g, P = 0.0479) than cohort 2. These data suggest that there is no apparent benefit of prolonging magnesium infusion from 1 to 2 h in our outpatient allo-HCT population.

[Long-term outcome with end-stage renal disease - survival is not enough: does dialysis or kidney transplantation matter?].

PubMed

Schulz, K-H; Thaiss, F

2012-04-01

Patients with end-stage renal disease require renal replacement therapy with either dialysis or kidney transplantation. Survival and quality of life (QoL) after transplantation are superior to chronic dialysis. Early living donor kidney transplantation is best for patient and graft survival. Preemptive living-related kidney transplantation therefore is the best medical treatment option for these patients. Patients with end-stage renal disease suffer from multiple physical and psychological complaints. The prevalence of depressive disorders is 20-25% in this population. Studies on QoL in children after kidney transplantation show a reduced physical QoL, but an overall good psychological QoL. Alarming results of numerous studies are the high non-adherence rates in adolescents. Especially exercise interventions during dialysis and after kidney transplantation show promising results. Whether QoL of patients will improve with new approaches to immunosuppressive therapy remains to be evaluated in future studies.

Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes.

PubMed

Wanner, Christoph; Inzucchi, Silvio E; Lachin, John M; Fitchett, David; von Eynatten, Maximilian; Mattheus, Michaela; Johansen, Odd Erik; Woerle, Hans J; Broedl, Uli C; Zinman, Bernard

2016-07-28

Diabetes confers an increased risk of adverse cardiovascular and renal events. In the EMPA-REG OUTCOME trial, empagliflozin, a sodium-glucose cotransporter 2 inhibitor, reduced the risk of major adverse cardiovascular events in patients with type 2 diabetes at high risk for cardiovascular events. We wanted to determine the long-term renal effects of empagliflozin, an analysis that was a prespecified component of the secondary microvascular outcome of that trial. We randomly assigned patients with type 2 diabetes and an estimated glomerular filtration rate of at least 30 ml per minute per 1.73 m(2) of body-surface area to receive either empagliflozin (at a dose of 10 mg or 25 mg) or placebo once daily. Prespecified renal outcomes included incident or worsening nephropathy (progression to macroalbuminuria, doubling of the serum creatinine level, initiation of renal-replacement therapy, or death from renal disease) and incident albuminuria. Incident or worsening nephropathy occurred in 525 of 4124 patients (12.7%) in the empagliflozin group and in 388 of 2061 (18.8%) in the placebo group (hazard ratio in the empagliflozin group, 0.61; 95% confidence interval, 0.53 to 0.70; P<0.001). Doubling of the serum creatinine level occurred in 70 of 4645 patients (1.5%) in the empagliflozin group and in 60 of 2323 (2.6%) in the placebo group, a significant relative risk reduction of 44%. Renal-replacement therapy was initiated in 13 of 4687 patients (0.3%) in the empagliflozin group and in 14 of 2333 patients (0.6%) in the placebo group, representing a 55% lower relative risk in the empagliflozin group. There was no significant between-group difference in the rate of incident albuminuria. The adverse-event profile of empagliflozin in patients with impaired kidney function at baseline was similar to that reported in the overall trial population. In patients with type 2 diabetes at high cardiovascular risk, empagliflozin was associated with slower progression of kidney disease and lower rates of clinically relevant renal events than was placebo when added to standard care. (Funded by the Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance; EMPA-REG OUTCOME ClinicalTrials.gov number, NCT01131676.).

Current structure and organization for renal patient assistance in Italy.

PubMed

Alloatti, Sandro; Strippoli, Giovanni Fm; Buccianti, Gherardo; Daidone, Giuseppe; Schena, Francesco P

2008-04-01

Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) has compiled a national census of Renal Units (RU) existing in the twenty Italian regions related to the year 2004. An on-line questionnaire including 158 items explored structural and human resources, organization aspects, activities and epidemiological data in SIN, 2004. The census identified 363 public RU, 303 satellite Dialysis Centres (DC) and 295 private DC totalling 961 DC [16.4 per million population (pmp)]. The inpatient renal beds were 2742 (47 pmp). Renal and dialysis activity was performed by 3728 physicians (64 pmp), of whom 2964 (80%) were nephrologists. There was no permanent medical assistance in 41% of satellite DC. There were 1802 renal admissions pmp and 99 renal biopsies pmp. The management of acute renal failure (13 456 cases; 230 pmp) represented a relevant proportion of the activities conducted in public RU. In 2004 there were 9858 new cases of end-stage kidney disease requiring renal replacement therapy (RRT) (169 pmp). On 31 December 2004, 60 058 patients were on RRT (1027 pmp), 43 293 of which (740 pmp) were on dialysis and 16 765 (287 pmp) with renal graft. This census of the Italian RU and DC in 2004 provides decision makers and healthcare stakeholders with detailed data for benchmarking and has financial implications for the public health system. Similar analyses may be conducted in other countries permitting standardization of medical and cost-related aspects of renal care.

Renal Replacement Therapy in Support of Combat Operations

DTIC Science & Technology

2008-07-01

potentially cardiotoxic electro- lyte abnormalities ( hyperkalemia , hyper- phosphatemia, hypocalcemia). AKI is ex- acerbated further by hypovolemia...and is inefficient at providing metabolic control for highly catabolic or hyperkalemia pa- tients. Conventional single-pass dialysis sys- tems are the

Association Between the Use of Proton Pump Inhibitors and the Risk of ESRD in Renal Diseases: A Population-Based, Case-Control Study

PubMed Central

Peng, Yen-Chun; Lin, Cheng-Li; Yeh, Hong-Zen; Chang, Chi-Sen; Wu, Yu-Lin; Kao, Chia-Hung

2016-01-01

Abstract Proton pump inhibitors (PPIs) use may be associated with nephritis and acute renal injury. The risk of PPIs and deterioration of renal function, in patients with renal diseases, needs to be investigated. A case-control study was conducted in a nation-wide data setting from the Taiwan National Health Insurance Research Database (NHIRD). This case-control study used data extracted from NHIRD between the years 2006 and 2011. We used propensity scores to match 3808 patients suffering from renal diseases (ICD-9-CM codes 580–589), with patients (aged ≥20 years) who had had a recent diagnosis of end-stage renal diseases (ESRDs) and had undertaken renal replacement therapy during the period of 2006 to 2011. The 3808 control subjects were selected from people who had a history of renal diseases, but no ESRD. The risk of ESRD in patients with renal diseases and PPIs use was estimated by using odds ratios (ORs) and 95% confidence intervals (CI). The use of a PPIs was associated with a significantly higher risk of ESRD (adjusted OR = 1.88, 95% CI = 1.71–2.06) in renal disease patients. Of all the types of PPI combined, the adjusted OR was 1.92 (95% CI = 1.74–2.13) for those on <100 cumulative DDD and was 1.74-fold (95% CI = 1.52–2.00) for those on ≥100 cumulative DDD. PPIs use is associated with the risk of ESRD in patients with renal diseases. It is necessary that appropriate prescription of PPIs coordinated with the close monitoring renal function of patients diagnosed with renal disease. PMID:27082596

Red Kidney: Kidney Transplant From a Deceased Donor Who Received Massive Blood Transfusion During Cardiopulmonary Bypass.

PubMed

Bell, Richard; Hanif, Faisal; Prasad, Padmini; Ahmad, Niaz

2016-06-01

Here, we present a case of a deceased-donor kidney transplant. The brain-dead donor had received a massive blood transfusion during cardiopulmonary bypass, which lead to hemolysis, hemoglobinuria, acute kidney injury, and renal replacement therapy. The kidney appeared red after in situ flush. Postoperatively, the recipient developed delayed graft function. Protocol biopsy during the postoperative period revealed the widespread deposition of heme pigment in the renal tubules. Massive blood transfusion and cardiopulmonary bypass surgery are associated with hemolysis and heme pigment deposition in the renal tubules, which subsequently lead to acute kidney injury. Kidneys from such donors appear red and, while this does not preclude transplant, are likely to develop delayed graft function.

Rhabdomyolysis and acute myoglobinuric renal failure in a patient with bilateral pheochromocytoma following open pyelolithotomy.

PubMed

Anaforoglu, Inan; Ertorer, M Eda; Haydardedeoglu, Filiz E; Colakoglu, Tamer; Tokmak, Naime; Demirag, Nilgun G

2008-04-01

Rhabdomyolysis is an unusual manifestation of pheochromocytoma. Early diagnosis and prompt management are crucial, as it may have life-threatening consequences. This is the case of a 19-year-old man with bilateral pheochromocytoma complicated with rhabdomyolysis and acute myoglobinuric renal failure after surgery for nephrolithiasis. A massive catecholamine release during the procedure manifested itself as a hypertensive crisis, producing severe vasoconstriction and thereby provoking ischemia of the patient's muscle tissue. This insult resulted in rhabdomyolysis and acute myoglobinuric renal failure. After making sure that all necessary medical precautions were performed, including blood pressure stabilization with alpha receptor blockade and adequate fluid replacement, the patient successfully underwent a bilateral cortex-sparing medullar adrenalectomy. The operation specimen was reported as pheochromocytoma.

Kidney transplantation in the context of renal replacement therapy.

PubMed

Pesavento, Todd E

2009-12-01

Kidney transplantation has dramatically evolved from a life-saving yet unproven therapy for patients with renal failure to a mature field that is the preferred treatment for those suffering from ESRD. Patients who receive a transplant experience a 68% lower risk of death compared with those waiting on dialysis for a transplant. This benefit is afforded to all patient subgroups including the elderly (> or =70 yr), and diabetics, who can gain 11 yr of extra life with transplantation. Prolonged transplant wait times result in a higher risk of death but this can be ameliorated with preemptive transplantation. Future challenges will focus on appropriate organ allocation and addressing long-term renal function and comorbid conditions so patients can enjoy the full benefits of transplantation.

Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock - a case report.

PubMed

Nemeth, Endre; Szigeti, Szabolcs; Varga, Tamas; Daroczi, Laszlo; Barati, Zoltan; Merkely, Bela; Gal, Janos

2018-05-01

The acute surgical treatment of infective endocarditis (IE) carries a high risk of postoperative mortality. Most complications are linked to uncontrolled sepsis and inflammatory processes. Cytokine haemoadsorption is an extracorporeal technique which has benefits reported in haemodynamic stability and inflammatory response. A 46-year-old male patient underwent emergency cardiac surgery due to progressive IE. Postcardiotomy cardiogenic shock associated with cardiac surgery required the implantation of venoarterial (VA)-ECMO. Three days later, the patient developed secondary septic shock. The novel application of continuous CytoSorb TM treatment installed in the VA-ECMO circuit is demonstrated in this case during the management of simultaneous shocks. Advanced intensive care led to an improvement in the patient's condition, which facilitated successful weaning from mechanical ventilation. However, the patient died from a new onset fulminant septic shock two months after his initial cardiac surgery. VA-ECMO is suitable for installation of the CytoSorb TM cartridge. This modality could be an option for high-volume, continuous cytokine haemoadsorption when VA-ECMO is employed without renal replacement therapy. This specific application of CytoSorb TM was safe, feasible and contributed to the optimal management of simultaneous shocks.

[Utility of atazanavir in special populations].

PubMed

Antela López, Antonio

2008-12-01

ART (antiretroviral therapy) currently continues to indefinitely prolong the survival of patients who live with HIV. Due to this, we are increasingly faced with specific problems that previously did not have time to develop or did not have the importance that they have now, and which are related to the existence of special patient populations. Examples of situations that characterise these special populations are: co-infection with hepatitis virus B and/or C, pregnancy, lipodystrophy, cardiovascular risk, renal failure, treatment of children and adolescents, immigrant health care, and the management of patients receiving methadone replacement therapy, among others. In this article we review the role that Atazanavir (ATV) can play in the ART of patients in the situations mentioned, except those that are already dealt with specifically in other articles, such as co-infection by hepatitis virus B and/or C.

Bridge to transplantation with a left ventricular assist device.

PubMed

Jung, Jae Jun; Sung, Kiick; Jeong, Dong Seop; Kim, Wook Sung; Lee, Young Tak; Park, Pyo Won

2012-04-01

A 61-year-old female patient was diagnosed with dilated cardiomyopathy with severe left ventricle dysfunction. Two days after admission, continuous renal replacement therapy was performed due to oliguria and lactic acidosis. On the fifth day, an intra-aortic balloon pump was inserted due to low cardiac output syndrome. Beginning 4 days after admission, she was supported for 15 days thereafter with an extracorporeal left ventricular assist device (LVAD) because of heart failure with multi-organ failure. A heart transplant was performed while the patient was stabilized with the LVAD. She developed several complications after the surgery, such as cytomegalovirus pneumonia, pulmonary tuberculosis, wound dehiscence, and H1N1 infection. On postoperative day 19, she was discharged from the hospital with close follow-up and treatment for infection. She received follow-up care for 10 months without any immune rejection reaction.

Prognostic Factors for Hospital Mortality and ICU Admission in Patients With ANCA-Related Pulmonary Vasculitis

PubMed Central

Holguin, Fernando; Ramadan, Bassel; Gal, Anthony A.; Roman, Jesse

2015-01-01

Background The objective of this study was to evaluate the factors predictive of 28-day mortality and admission to Intensive Care Unit (ICU) in patients with ANCA-related pulmonary vasculitis. Methods We reviewed the medical records and imaging studies of 65 patients diagnosed with ANCA-related vasculitis hospitalized with pulmonary complications between February 1985 and November 2002. All patients underwent open or video-assisted thoracoscopic lung biopsy, had a positive ANCA serology, and were negative for glomerular basement membrane antibodies. Results At presentation, 72% had dyspnea, 68% fever, 47% cough, 45% elevated blood pressure, 32.3% hemoptysis, 26.1% sinus involvement, 15% renal failure, and 4.6% scleritis. Pathological findings included alveolar hemorrhage (60%), granulomatous inflammation (46%), and capillaritis (38%). A significant number required mechanical ventilation (27.7%), hemodialysis (24.6%), continuous renal replacement therapy (3.1%), and plasmapheresis (3.1%). The 28-day mortality was 16.9% (11/65). Mechanical ventilation (OR 68, P < 0.005), admission to ICU (OR 18.5, P < 0.01), and blood transfusion (OR 22.4, P < 0.004) were strong predictors of increased mortality within 28 days after admission. Respiratory failure (OR 31, P < 0.0007), hemoptysis (OR 2.9, P < 0.06), smoking (OR 5.9, P < 0.02), and acute renal failure (OR 7.8, P < 0.01) were also predictors for admission to the ICU. Conclusion In patients with ANCA-related pulmonary vasculitis several clinical factors, but not pathologic findings or ANCA titers, are associated with ICU admission and/or 28-day mortality. PMID:18854674

Application of instant messaging software in the follow-up of patients using peritoneal dialysis, a randomised controlled trial.

PubMed

Cao, Fang; Li, Lanfei; Lin, Miao; Lin, Qinyu; Ruan, Yiping; Hong, Fuyuan

2018-04-20

This study aims to investigate the application value of Internet-based instant messaging software in the follow-up of patients using peritoneal dialysis. Peritoneal dialysis is an effective renal replacement treatment for end-stage renal disease. The clinical usefulness of Internet-based instant messaging software in the follow-up of peritoneal dialysis patients, including the incidence of peritonitis and exit-site infection, the levels of albumin and electrolytes and the degree of patients' satisfaction, remains unknown. Between January 2009-April 2016, a total of 160 patients underwent continuous peritoneal dialysis in the Department of Nephrology, Fujian Provincial Hospital were invited to participate voluntarily in this study. The patients were randomly assigned to the instant messenger (QQ) follow-up group (n = 80) and the traditional follow-up group (n = 80). The differences in death, hospitalisation, peritonitis, exit-site infection, and patients' satisfaction were investigated during 1 year of follow-up. The mean follow-up duration is 11.4 ± 1.5 months. Compared with the patients in the traditional follow-up group, patients in the QQ follow-up group showed higher levels of serum albumin (p = .009) and haemoglobin (p = .009), lower levels of phosphorus (p < .001) and calcium-phosphorus product (p = .001), and better degree of satisfaction (p < .001). Internet-based follow-up by instant messaging software appears to be a feasible and acceptable method of delivering peritoneal dialysis treatment for patients with end-stage renal disease. © 2018 John Wiley & Sons Ltd.

Uremic pericarditis in patients with End Stage Renal Disease: Prevalence, symptoms and outcome in 2017.

PubMed

Bentata, Yassamine; Hamdi, F; Chemlal, A; Haddiya, I; Ismaili, N; El Ouafi, N

2018-03-01

The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%-20% and to <5% in the last decades, as hemodialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Disease (ESRD) with UP. This is a retrospective study (May 2015-September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation. 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Pericardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericardial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11±3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis. UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD. Copyright © 2017 Elsevier Inc. All rights reserved.

The Effects of Preoperative Volume Replacement in Diabetic Patients Undergoing Coronary Artery Bypass Grafting Surgery: Protocol for a Randomized Controlled Trial (VeRDiCT Trial)

PubMed Central

Clout, Madeleine; Harris, Tracy; Rogers, Chris; Culliford, Lucy; Taylor, Jodi; Angelini, Gianni; Narayan, Pradeep; Reeves, Barnaby; Hillier, James; Ashton, Kate; Sarkar, Kunal

2017-01-01

Background Diabetes mellitus is a major risk factor for prolonged hospital stays, renal failure, and mortality in patients having coronary artery bypass grafting (CABG). Complications pose a serious threat to patients and prolong intensive care and hospital stays. Low glomerular filtration rate (GFR) due to existing renal impairment or volume depletion may exacerbate acute renal impairment/failure in these patients. Preoperative volume replacement therapy (VRT) is reported to increase the GFR and we hypothesize that VRT will reduce renal impairment and related complications in diabetic patients. Objective The objective of this study is to establish the efficacy of preoperative VRT in reducing postoperative complications in diabetic patients undergoing CABG surgery. Time to “fit for discharge”, incidence of postoperative renal failure, cardiac injury, inflammation, and other health outcomes will be investigated. Methods In this open parallel group randomized controlled trial, 170 diabetic patients undergoing elective or urgent CABG surgery received 1 mL/kg/hour of Hartmann’s solution for 12 consecutive hours prior to surgery, versus routine care. The primary outcome was time until participants were “fit for discharge”, which is defined as presence of: normal temperature, pulse, and respiration; normal oxygen saturation on air; normal bowel function; and physical mobility. Secondary outcomes included: incidence of renal failure; markers of renal function, inflammation, and cardiac damage; operative morbidity; intensive care stay; patient-assessed outcome, including the Coronary Revascularization Outcome Questionnaire; and use of hospital resources. Results Recruitment started in July 2010. Enrolment for the study was completed in July 2014. Data analysis commenced in December 2016. Study results will be submitted for publication in the summer of 2017. Conclusions VRT is a relatively easy treatment to administer in patients undergoing surgical procedures who are at risk of renal failure. This experimental protocol will increase scientific and clinical knowledge of VRT in diabetic patients undergoing elective or urgent CABG surgery. Findings supporting the efficacy of this intervention could easily be implemented in the health care system. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 02159606; http://www.controlled-trials.com/ISRCTN02159606 (Archived by WebCite at http://www.webcitation.org/6rDkSSkkK) PMID:28630035

Bilateral simultaneous robot-assisted pyelolithotomy for large (>6 cm) kidney stones: technique and review of literature.

PubMed

Rajiv, Yadav; Kumar, Abhay; Poonam, Yadav

2015-09-01

With wide availability and demonstrable efficacy of endourological techniques, open surgery for renal stone disease has largely been replaced in contemporary urological practice. However, with increasing experience of laparoscopy and robotic surgery in urology, the principle of open renal surgery is being revisited. In certain situations, laparoscopic or robotic pyelolithomy may be an excellent minimally invasive alternative to percutaneous nephrolithomy with its unique advantages. We present a case of bilateral large kidney stones managed with bilateral simultaneous robot-assisted laparoscopic pyelolithotomy with excellent results.

Hyperkalemia by Euro-Collins solution in anesthesia for renal transplantation: a case report.

PubMed

Hirata, Eunice Sizue; Pereira, Rosa Inês Costa; Filho, Gentil Alves; Braga, Angélica de Fátima Assunção

2013-01-01

To describe anesthesia for renal transplantation that progressed to a sharp potassium increase after kidney reperfusion with Euro-Collins' solution in the operative field. We will also report on diagnosis and treatment used. The use of infusion solutions in the surgical field requires careful monitoring, such as electrocardiography, measurement of serum potassium, and availability of calcium gluconate, insulin, and albuterol for immediate use. The replacement of Euro-Collins' solution for saline solution immediately before the implant may be a useful option in patients with high levels of potassium.

Impact of feline AIM on the susceptibility of cats to renal disease

PubMed Central

Sugisawa, Ryoichi; Hiramoto, Emiri; Matsuoka, Shigeru; Iwai, Satomi; Takai, Ryosuke; Yamazaki, Tomoko; Mori, Nobuko; Okada, Yuki; Takeda, Naoki; Yamamura, Ken-ichi; Arai, Toshiro; Arai, Satoko; Miyazaki, Toru

2016-01-01

Renal failure is one of the most important social problems for its incurability and high costs for patients’ health care. Through clarification of the underlying mechanism for the high susceptibility of cats to renal disease, we here demonstrates that the effective dissociation of serum AIM protein from IgM is necessary for the recovery from acute kidney injury (AKI). In cats, the AIM-IgM binding affinity is 1000-fold higher than that in mice, which is caused by the unique positively-charged amino-acid cluster present in feline AIM. Hence, feline AIM does not dissociate from IgM during AKI, abolishing its translocation into urine. This results in inefficient clearance of lumen-obstructing necrotic cell debris at proximal tubules, thereby impairing AKI recovery. Accordingly, mice whose AIM is replaced by feline AIM exhibit higher mortality by AKI than in wild-type mice. Recombinant AIM administration into the mice improves their renal function and survival. As insufficient recovery from AKI predisposes patients to chronic, end-stage renal disease, feline AIM may be involved crucially in the high mortality of cats due to renal disease. Our findings could be the basis of the development of novel AKI therapies targeting AIM-IgM dissociation, and may support renal function in cats and prolong their lives. PMID:27731392

Preemptive Renal Transplantation-The Best Treatment Option for Terminal Chronic Renal Failure.

PubMed

Arze Aimaretti, L; Arze, S

2016-03-01

Renal transplantation is the best therapeutic option for end-stage chronic renal disease. Assuming that it is more advisable if performed early, we aimed to show the clinical, social, and economic advantages in 70% of our patients who were dialyzed only for a short period. For this purpose, we retrospectively collected data over 28 years in 142 kidney transplants performed in patients with <6 weeks on dialysis. 66% of our patients were 30-60 years old; 98% of the patients had living donors. At transplantation, 64% of our patients had no public support; however, 64% of them returned to work and got health insurance 2 months later. Full rehabilitation was achieved in all cases, including integration to the family, return to full-time work, school and university, sports, and reproduction. Immunosuppression consisted of 3 drugs, including steroids, cyclosporine, and azathioprine or mycophenolate. The cost in the 1st year, including patient and donor evaluation, surgery, immunosuppression, and follow-up, was $13,300 USD versus $22,320 for hemodialysis. We conclude that preemptive renal transplantation with <6 weeks on dialysis is the best therapeutic option for end-stage renal failure, especially in developing countries such as Bolivia, where until last year, full public support for renal replacement therapy was unavailable. Copyright © 2016 Elsevier Inc. All rights reserved.

Impact of feline AIM on the susceptibility of cats to renal disease.

PubMed

Sugisawa, Ryoichi; Hiramoto, Emiri; Matsuoka, Shigeru; Iwai, Satomi; Takai, Ryosuke; Yamazaki, Tomoko; Mori, Nobuko; Okada, Yuki; Takeda, Naoki; Yamamura, Ken-Ichi; Arai, Toshiro; Arai, Satoko; Miyazaki, Toru

2016-10-12

Renal failure is one of the most important social problems for its incurability and high costs for patients' health care. Through clarification of the underlying mechanism for the high susceptibility of cats to renal disease, we here demonstrates that the effective dissociation of serum AIM protein from IgM is necessary for the recovery from acute kidney injury (AKI). In cats, the AIM-IgM binding affinity is 1000-fold higher than that in mice, which is caused by the unique positively-charged amino-acid cluster present in feline AIM. Hence, feline AIM does not dissociate from IgM during AKI, abolishing its translocation into urine. This results in inefficient clearance of lumen-obstructing necrotic cell debris at proximal tubules, thereby impairing AKI recovery. Accordingly, mice whose AIM is replaced by feline AIM exhibit higher mortality by AKI than in wild-type mice. Recombinant AIM administration into the mice improves their renal function and survival. As insufficient recovery from AKI predisposes patients to chronic, end-stage renal disease, feline AIM may be involved crucially in the high mortality of cats due to renal disease. Our findings could be the basis of the development of novel AKI therapies targeting AIM-IgM dissociation, and may support renal function in cats and prolong their lives.

Xuezhikang ameliorates contrast media-induced nephropathy in rats via suppression of oxidative stress, inflammatory responses and apoptosis.

PubMed

Chu, Shichun; Hu, Liuhua; Wang, Xiaolei; Sun, Shiqun; Zhang, Tuo; Sun, Zhe; Shen, Linghong; Jin, Shuxuan; He, Ben

2016-11-01

The aim of this study was to assess the preventive effect of xuezhikang (XZK) to replace atorvastatin on the contrast media-induced acute kidney injury (CI-AKI). The male Sprague-Dawley rats were divided into five groups: group 1 (sham), injected with normal saline; group 2 (XZK), treated with XZK; group 3 contrast media (CM), injected with CM; group 4 (CM + ATO), injected with CM + pretreatment with atorvastatin; group 5 (CM + XZK), injected with CM + pretreatment with XZK. Twenty-four hours after injection with normal saline or CM, the blood sample and the kidneys were collected for the measurement of biochemical parameters, oxidative stress markers, nitric oxide production, inflammatory parameters, as well as renal histopathology and apoptosis detection. Our results indicated that XZK restored the renal function by reducing serum blood urea nitrogen (BUN) and serum creatinine (Scr), depressing renal malondialdehyde (MDA), increasing renal NO production, decreasing TNF-ɑ and IL-6 expression, attenuating renal pathological changes and inhibiting the apoptosis of renal tubular cells. XZK's therapeutic effect is similar, or even better than atorvastatin at the same effectual dose in some parts.

Prevention of renal failure: the Malaysian experience.

PubMed

Hooi, Lai Seong; Wong, Hin Seng; Morad, Zaki

2005-04-01

Renal replacement therapy in Malaysia has shown exponential growth since 1990. The dialysis acceptance rate for 2003 was 80 per million population, prevalence 391 per million population. There are now more than 10,000 patients on dialysis. This growth is proportional to the growth in gross domestic product (GDP). Improvement in nephrology and urology services with widespread availability of ultrasonography and renal pathology has improved care of renal patients. Proper management of renal stone disease, lupus nephritis, and acute renal failure has decreased these as causes of end-stage renal disease (ESRD) in younger age groups. Older patients are being accepted for dialysis, and 51% of new patients on dialysis were diabetic in 2003. The prevalence of diabetes is rising in the country (presently 7%); glycemic control of such patients is suboptimal. Thirty-three percent of adult Malaysians are hypertensive and blood pressure control is poor (6%). There is a national coordinating committee to oversee the control of diabetes and hypertension in the country. Primary care clinics have been provided with kits to detect microalbuminuria, and ACE inhibitors for the treatment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors have been launched, opportunistic screening at health clinics is being carried out, and public education targeting high-risk groups is ongoing. The challenge in Malaysia is to stem the rising tide of diabetic ESRD.

Renal transplantation in systemic lupus erythematosus: outcome and prognostic factors in 50 cases from a single centre.

PubMed

Cairoli, Ernesto; Sanchez-Marcos, Carolina; Espinosa, Gerard; Glucksmann, Constanza; Ercilla, Guadalupe; Oppenheimer, Federico; Cervera, Ricard

2014-01-01

End-stage renal disease (ESRD) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). To analyze the outcome and prognostic factors of renal transplantation in patients with ESRD due to SLE from January 1986 to December 2013 in a single center. Fifty renal transplantations were performed in 40 SLE patients (32 female (80%), mean age at transplantation 36±10.4 years). The most frequent lupus nephropathy was type IV (72.2%). Graft failure occurred in a total of 15 (30%) transplantations and the causes of graft failure were chronic allograft nephropathy (n=12), acute rejection (n=2), and chronic humoral rejection (1). The death-censored graft survival rates were 93.9% at 1 year, 81.5% at 5 years, and 67.6% at the end of study. The presence of deceased donor allograft (P=0.007) and positive anti-HCV antibodies (P=0.001) negatively influence the survival of the renal transplant. The patient survival rate was 91.4% at the end of the study. Recurrence of lupus nephritis in renal allograft was observed in one patient. Renal transplantation is a good alternative for renal replacement therapy in patients with SLE. In our cohort, the presence of anti-HCV antibodies and the type of donor source were related to the development of graft failure.

Renal Transplantation in Systemic Lupus Erythematosus: Outcome and Prognostic Factors in 50 Cases from a Single Centre

PubMed Central

Cairoli, Ernesto; Sanchez-Marcos, Carolina; Espinosa, Gerard; Glucksmann, Constanza; Ercilla, Guadalupe; Oppenheimer, Federico; Cervera, Ricard

2014-01-01

Background. End-stage renal disease (ESRD) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Objectives. To analyze the outcome and prognostic factors of renal transplantation in patients with ESRD due to SLE from January 1986 to December 2013 in a single center. Results. Fifty renal transplantations were performed in 40 SLE patients (32 female (80%), mean age at transplantation 36 ± 10.4 years). The most frequent lupus nephropathy was type IV (72.2%). Graft failure occurred in a total of 15 (30%) transplantations and the causes of graft failure were chronic allograft nephropathy (n = 12), acute rejection (n = 2), and chronic humoral rejection (1). The death-censored graft survival rates were 93.9% at 1 year, 81.5% at 5 years, and 67.6% at the end of study. The presence of deceased donor allograft (P = 0.007) and positive anti-HCV antibodies (P = 0.001) negatively influence the survival of the renal transplant. The patient survival rate was 91.4% at the end of the study. Recurrence of lupus nephritis in renal allograft was observed in one patient. Conclusion. Renal transplantation is a good alternative for renal replacement therapy in patients with SLE. In our cohort, the presence of anti-HCV antibodies and the type of donor source were related to the development of graft failure. PMID:25013800

Renal aspects of the term and preterm infant: a selective update.

PubMed

Drukker, Alfred; Guignard, Jean-Pierre

2002-04-01

This review discusses new aspects of normal and abnormal renal development that expand insight into the adaptation of the neonatal kidneys to the stress of extrauterine life. Highlighted are some pitfalls in measuring glomerular filtration rate in the neonate mainly caused by postnatal fluctuations in serum creatinine levels. Serum creatinine levels are correlated with the authors' recent finding of tubular reabsorption of creatinine in the immature neonatal kidney. Renal maldevelopment in premature and small-for-date babies has been shown related to serious medical problems in adult life, including hypertension. This finding presents the pediatrician with a new role in the time-honored vocation of preventing disease. Mutations in several genes may be responsible for most cases of congenital or hereditary renal aberrations. Two renal disorders, congenital nephrotic syndrome and neonatal acute renal failure, and one form of treatment modality of newborn infants, renal replacement therapy, are discussed in detail. These conditions are rare in general pediatric practice, but they illustrate some of the new developments in the renal care of the newborn. A word of caution is offered about the use of nonsteroidal anti-inflammatory drugs during pregnancy and the newborn period. All nonsteroidal anti-inflammatory drugs administered indirectly to the unborn fetus and directly to the young newborn impair renal structure (fetus) and function (both fetus and newborn). The new data have been obtained with genetic and molecular biology techniques and with established methods of developmental renal physiology. A better understanding of the pathogenesis of neonatal renal disorders will result in new diagnostic procedures and improved preventive and therapeutic possibilities relevant to the neonate with a renal disorder.

Fabry disease and enzyme replacement therapy in classic patients with same mutation: different formulations--different outcome?

PubMed

Politei, J; Schenone, A B; Cabrera, G; Heguilen, R; Szlago, M

2016-01-01

We describe the results of the multidisciplinary evaluation in patients with Fabry disease and the same genetic mutation and their outcomes using different approved enzyme replacement therapy (ERT). We measured baseline data and serial results of neuropathic pain assessment and renal, cardiac and cerebrovascular functioning. Pain scale showed improvement in all male cases treated with agalsidasa beta. A mild improvement was detected in agalsidasa alfa-treated patients after 1 year with posterior increase. During the agalsidase beta shortage, two male patients were switched to agalsidasa alfa, after 1 year both cases presented an increase in scale values. Renal evolution showed a tendency toward a decrease in proteinuria in patients using agalsidase beta and worsening with agalsidase alfa. We found improvement in two females using agalsidase beta and no changes in the other cases regarding cardiac functioning. Brain magnetic resonance imaging (MRI) showed increase of white matter lesions in four patients. Improvement and stabilization in neuropathic pain, renal and cardiac functioning and brain MRI were found mainly in patients treated with agalsidase beta. Following the reported recommendations on reintroduction of agalsidase beta after the enzyme shortage, we decided to switch all patients to agalsidase beta. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Renal ammonia metabolism and transport.

PubMed

Weiner, I David; Verlander, Jill W

2013-01-01

Renal ammonia metabolism and transport mediates a central role in acid-base homeostasis. In contrast to most renal solutes, the majority of renal ammonia excretion derives from intrarenal production, not from glomerular filtration. Renal ammoniagenesis predominantly results from glutamine metabolism, which produces 2 NH4(+) and 2 HCO3(-) for each glutamine metabolized. The proximal tubule is the primary site for ammoniagenesis, but there is evidence for ammoniagenesis by most renal epithelial cells. Ammonia produced in the kidney is either excreted into the urine or returned to the systemic circulation through the renal veins. Ammonia excreted in the urine promotes acid excretion; ammonia returned to the systemic circulation is metabolized in the liver in a HCO3(-)-consuming process, resulting in no net benefit to acid-base homeostasis. Highly regulated ammonia transport by renal epithelial cells determines the proportion of ammonia excreted in the urine versus returned to the systemic circulation. The traditional paradigm of ammonia transport involving passive NH3 diffusion, protonation in the lumen and NH4(+) trapping due to an inability to cross plasma membranes is being replaced by the recognition of limited plasma membrane NH3 permeability in combination with the presence of specific NH3-transporting and NH4(+)-transporting proteins in specific renal epithelial cells. Ammonia production and transport are regulated by a variety of factors, including extracellular pH and K(+), and by several hormones, such as mineralocorticoids, glucocorticoids and angiotensin II. This coordinated process of regulated ammonia production and transport is critical for the effective maintenance of acid-base homeostasis.

Engineering kidney cells: reprogramming and directed differentiation to renal tissues.

PubMed

Kaminski, Michael M; Tosic, Jelena; Pichler, Roman; Arnold, Sebastian J; Lienkamp, Soeren S

2017-07-01

Growing knowledge of how cell identity is determined at the molecular level has enabled the generation of diverse tissue types, including renal cells from pluripotent or somatic cells. Recently, several in vitro protocols involving either directed differentiation or transcription-factor-based reprogramming to kidney cells have been established. Embryonic stem cells or induced pluripotent stem cells can be guided towards a kidney fate by exposing them to combinations of growth factors or small molecules. Here, renal development is recapitulated in vitro resulting in kidney cells or organoids that show striking similarities to mammalian embryonic nephrons. In addition, culture conditions are also defined that allow the expansion of renal progenitor cells in vitro. Another route towards the generation of kidney cells is direct reprogramming. Key transcription factors are used to directly impose renal cell identity on somatic cells, thus circumventing the pluripotent stage. This complementary approach to stem-cell-based differentiation has been demonstrated to generate renal tubule cells and nephron progenitors. In-vitro-generated renal cells offer new opportunities for modelling inherited and acquired renal diseases on a patient-specific genetic background. These cells represent a potential source for developing novel models for kidney diseases, drug screening and nephrotoxicity testing and might represent the first steps towards kidney cell replacement therapies. In this review, we summarize current approaches for the generation of renal cells in vitro and discuss the advantages of each approach and their potential applications.

The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study.

PubMed

Stengel, Bénédicte; Combe, Christian; Jacquelinet, Christian; Briançon, Serge; Fouque, Denis; Laville, Maurice; Frimat, Luc; Pascal, Christophe; Herpe, Yves-Edouard; Deleuze, Jean-François; Schanstra, Joost; Pisoni, Ron L; Robinson, Bruce M; Massy, Ziad A

2014-08-01

While much has been learned about the epidemiology and treatment of end-stage renal disease (ESRD) in the last 30 years, chronic kidney disease (CKD) before the end-stage has been less investigated. Not enough is known about factors associated with CKD progression and complications, as well as its transition to ESRD. We designed the CKD-renal epidemiology and information network (REIN) cohort to provide a research platform to address these key questions and to assess clinical practices and costs in patients with moderate or advanced CKD. A total of 46 clinic sites and 4 renal care networks participate in the cohort. A stratified selection of clinic sites yields a sample that represents a diversity of settings, e.g. geographic region, and public versus for-profit and non-for-profit private clinics. In each site, 60-90 patients with CKD are enrolled at a routine clinic visit during a 12-month enrolment phase: 3600 total, including 1800 with Stage 3 and 1800 with Stage 4 CKD. Follow-up will continue for 5 years, including after initiation of renal replacement therapy. Data will be collected from medical records at inclusion and at yearly intervals, as well as from self-administered patient questionnaires and provider-level questionnaires. Patients will also be interviewed at baseline, and at 1, 3 and 5 years. Healthcare costs will also be determined. Blood and urine samples will be collected and stored for future studies on all patients at enrolment and at study end, and at 1 and 3 years in a subsample of 1200. The CKD-REIN cohort will serve to improve our understanding of the biological, clinical and healthcare system determinants associated with CKD progression and adverse outcomes as well as of international variations in collaboration with the CKD Outcome and Practice Pattern Study (CKDopps). It will foster CKD epidemiology and outcomes research and provide evidence to improve the health and quality of life of patients with CKD and the performances of the healthcare system in this field. © The Author 2013. Published by Oxford University Press on behalf of ERA-EDTA.

Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference.

PubMed

Bellomo, Rinaldo; Ronco, Claudio; Mehta, Ravindra L; Asfar, Pierre; Boisramé-Helms, Julie; Darmon, Michael; Diehl, Jean-Luc; Duranteau, Jacques; Hoste, Eric A J; Olivier, Joannes-Boyau; Legrand, Matthieu; Lerolle, Nicolas; Malbrain, Manu L N G; Mårtensson, Johan; Oudemans-van Straaten, Heleen M; Parienti, Jean-Jacques; Payen, Didier; Perinel, Sophie; Peters, Esther; Pickkers, Peter; Rondeau, Eric; Schetz, Miet; Vinsonneau, Christophe; Wendon, Julia; Zhang, Ling; Laterre, Pierre-François

2017-12-01

The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools, (c) old and new treatments, (d) renal replacement therapy and management, (e) acute renal failure witness of other conditions, (f) prognosis and recovery, (g) extracorporeal epuration beyond the kidney, (h) the use of biomarkers in clinical practice http://www.srlf.org/5th-paris-international-conference-jeudi-18-et-vendredi-19-juin-2015/ .

Letter: The clinical course of patients with analgesic nephropathy.

PubMed Central

Gault, M. H.

1975-01-01

Thirty-four patients with analgesic nephropathy were followed at intervals of 1 to 3 months with measurements of creatinine clearance and serum concentration of acetylsalicylic acid (ASA) for a total of 105 patient-years. Diagnostic criteria included total consumption of at least 2 kg of phenacetin and 3 kg of ASA, compatible tissue abnormality on biopsy and evidence of papillary necrosis on an intravenous pyelogram. Nephropathy was induced by the same compound analgesic containing ASA, pehnacetin, caffeine and codeine (APC&C) in 30. Phenacetin was removed from this preparation in 1970 and replaced by an approximately equal amount of ASA (ACC). Creatinine clearance remained unchanged or improved in 11 of 15 patients who stopped taking analgesics containing phenacetin or ASA and in 10 of 11 of those who continued to take the ACC preparation. In contrast, renal function deteriorated in seven of eight patients who continued to abuse APC&C analgesics. The results suggest that phenacetin is necessary for the major nephrotoxic effect of this APC&C combination, but that ASA is not absolved of some nephrotoxicity. PMID:1139519

Myths in peritoneal dialysis.

PubMed

Lee, Martin B; Bargman, Joanne M

2016-11-01

To clarify misconceptions about the feasibility and risks of peritoneal dialysis that unnecessarily limit peritoneal dialysis uptake or continuation in patients for whom peritoneal dialysis is the preferred dialysis modality. The inappropriate choice of haemodialysis as a result of these misconceptions contributes to low peritoneal dialysis penetrance, increases transfer from peritoneal dialysis to haemodialysis, increases expenditure on haemodialysis and compromises quality of life for these patients. Peritoneal dialysis is an excellent renal replacement modality that is simple, cost-effective and provides comparable clinical outcomes to conventional in-centre haemodialysis. Unfortunately, many patients are deemed unsuitable to start or continue peritoneal dialysis because of false or inaccurate beliefs about peritoneal dialysis. Here, we examine some of these 'myths' and critically review the evidence for and against each of them. We review the feasibility and risk of peritoneal dialysis in patients with prior surgery, ostomies, obesity and mesh hernia repairs. We examine the fear of mediastinitis with peritoneal dialysis after coronary artery bypass graft surgery and the belief that the use of hypertonic glucose dialysate causes peritoneal membrane failure. By clarifying common myths about peritoneal dialysis, we hope to reduce overly cautious practices surrounding this therapy.

Intra-dialytic exercise training: a pragmatic approach.

PubMed

Greenwood, Sharlene A; Naish, Patrick; Clark, Rachel; O'Connor, Ellen; Pursey, Victoria A; Macdougall, Iain C; Mercer, Thomas H; Koufaki, Pelagia

2014-09-01

This continuing education paper outlines the skills and knowledge required to plan, implement and evaluate a pragmatic approach to intra-dialytic exercise training. The aim of this continuing education article is to enable the nephrology multi-disciplinary team (MDT) to plan, implement and evaluate the provision of intra-dialytic exercise training for patients receiving haemodialysis therapy. After reading this article the reader should be able to: Appreciate the level of evidence base for the clinical effectiveness of renal exercise rehabilitation and locate credible sources of research and educational information Understand and consider the need for appropriate evaluation and assessment outcomes as part of a renal rehabilitation plan Understand the components of exercise programming and prescription as part of an integrated renal rehabilitation plan Develop a sustainable longer term exercise and physical activity plan. © 2014 The Authors Journal of Renal Care published by John Wiley & Sons Ltd on behalf of European Dialysis & Transplant Nurses Association/European Renal Care Association.

Is renal replacement therapy for all possible in developing countries?

PubMed

Aviles-Gomez, Raymundo; Luquin-Arellano, Victor Hugo; Garcia-Garcia, Guillermo; Ibarra-Hernandez, Margarita; Briseño-Renteria, Gregorio

2006-01-01

Chronic kidney disease is a worldwide public health problem. More than one million individuals in the world are on maintenance dialysis, a number that is estimated to double in the next decade. Access to dialysis is significantly different between developed and developing nations. Close to 80% of the world dialysis population is treated in Europe, North America, and Japan, representing 12% of the world's population. The remaining dialysis patients are treated in the developing world. This disparity is likely due to the high cost and complexity of renal replacement therapy (RRT). Dialysis is so costly that is out of reach for low-income countries, which are struggling to provide preventive and therapeutic measures for communicable diseases and other basic needs. Providing renal care to all developing nations, although a difficult task, is not impossible. A number of strategies are proposed. These include the prevention of kidney disease, as well as dialysis and transplantation. Dialysis programs should be decentralized, and kidney transplantation should be promoted as the treatment of choice. The use of generic immunosuppressive drugs can make this therapy more affordable. Peritoneal dialysis seems a good, affordable, therapy for patients living in areas where hemodialysis is not available. Governments should provide funds not only for RRT but also for the prevention of kidney failure. The provision of tax incentives and reaching a critical number of patients on RRT could be incentives for industry to lower the cost of dialysis. The challenges are enormous, but renal care for all could be achieved through a concerted effort between nephrologists, governments, patients, charitable organizations, and industry.

Continuous arteriovenous haemofiltration to regulate hyperkalaemia during renal transplantation: a case report.

PubMed

Tripathi, Mukesh; Kaushik, Soma; Pandey, Rajesh

2006-11-01

Progressive hyperkalaemia is common in end stage renal disease patients waiting for renal transplantation. Ventricular tachycardia and ventricular fibrillation due to hyperkalaemia are life-threatening complications in these patients. In live and related renal transplant, after induction and anaesthesia, ventricular fibrillation and pulmonary oedema occurred. After immediate resuscitation by defibrillation and intravenous injection of adrenaline, the patient was put on continuous femoral arteriovenous haemofiltration (CAVH). This improved his pulmonary oedema, controlled hyperkalaemia and surgery could be completed uninterruptedly. After anaesthetising live and related kidney donor for nephrectomy, since it is not prudent to stop recipient surgery because of unforeseen complication, the authors wish to recommend CAVH as an alternative method to prevent life threatening cardiac complication of hyperkalaemia.

Technological advances in renal replacement therapy: five years and beyond.

PubMed

Rastogi, Anjay; Nissenson, Allen R

2009-12-01

The worldwide epidemic of chronic kidney disease shows no signs of abating in the near future. Current dialysis forms of renal replacement therapy (RRT), even though successful in sustaining life and improving quality of life somewhat for patients with ESRD, have many limitations that result in still unacceptably high morbidity and mortality. Transplantation is an excellent option but is limited by the scarcity of organs. An ideal form of RRT would mimic the functions of natural kidneys and be transparent to the patient, as well as affordable to society. Recent advances in technology, although generally in early stages of development, might achieve these goals. The application of nanotechnology, microfluidics, bioreactors with kidney cells, and miniaturized sorbent systems to regenerate dialysate makes clinical reality seem closer than ever before. Finally, stem cells hold much promise, both for kidney disease and as a source of tissues and organs. In summary, nephrology is at an exciting crossroad with the application of innovative and novel technologies to RRT that hold considerable promise for the near future.

[Fundamental aspects in the choice of renal replacement therapy].

PubMed

González Calvo, Carlos; Alvarez Rodríguez, Lucía

2016-01-01

Chronic kidney disease (CKD) is a disease with a high prevalence in our environment, and those suffering the disease should be as clear as possible that renal replacement therapy (RRT) may better suit your lifestyle. It is important that the patient has enough information about the techniques that can be accessed in a clear manner, so as to evaluate the different possibilities, advantages and disadvantages. The timing on this election is crucial and stressful for the patient's life, not only by the effects of the disease itself, but also by the assimilation of a new lifestyle that should keep the rest of it. This work was done thinking about the need for patients and health professionals in acquiring a holistic and comprehensive understanding of all the features that can have both peritoneal dialysis (PD) and hemodialysis (HD); form own patient factors (diet, family environment, etc.) related to nurses (care, information provided, etc.) without forgetting the conditions outside the patient and the nurse as they can be structural and economic aspects.

Death and Dialysis After Transcatheter Aortic Valve Replacement: An Analysis of the STS/ACC TVT Registry.

PubMed

Hansen, James W; Foy, Andrew; Yadav, Pradeep; Gilchrist, Ian C; Kozak, Mark; Stebbins, Amanda; Matsouaka, Roland; Vemulapalli, Sreekanth; Wang, Alice; Wang, Dee Dee; Eng, Marvin H; Greenbaum, Adam B; O'Neill, William O

2017-10-23

The authors sought to elucidate the true incidence of renal replacement therapy (RRT) after transcatheter aortic valve replacement (TAVR). There is a wide discrepancy in the reported rate of RRT after TAVR (1.4% to 40%). The true incidence of RRT after TAVR is unknown. The STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) registry was linked to the Centers for Medicare & Medicaid database to identify all patients that underwent TAVR from November 2011 through September 2015 and their outcomes. The authors compared rates of death, new RRT, and a composite of both as a function of pre-procedure glomerular filtration rate (GFR), both in stages of chronic kidney disease (CKD), as well as on a continuous scale. Pre-procedure GFR is associated with the risk of death and new RRT after TAVR when GFR is <60 ml/min/m 2 , and increases significantly when GFR falls below 30 ml/min/m 2 . Incremental increases in GFR of 5 ml/min/m 2 were statistically significant (unadjusted hazard ratio: 0.71; p < 0.001) at 30 days, and continued to be significant at 1 year when pre-procedure GFR was <60 ml/min/m 2 . One in 3 CKD stage 4 patients will be dead within 1 year, with 14.6% (roughly 1 in 6) requiring dialysis. In CKD stage 5, more than one-third of patients will require RRT within 30 days; nearly two-thirds will require RRT at 1 year. In both unadjusted and adjusted analysis, pre-procedural GFR was associated with the outcomes of death and new RRT. Increasing CKD stage leads to an increased risk of death and/or RRT. Continuous analysis showed significant differences in outcomes in all levels of CKD when GFR was <60 ml/min/m 2 . Pre-procedure GFR should be considered when selecting CKD patients for TAVR. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Prevalence trend of renal replacement therapy in Thailand: impact of health economics policy.

PubMed

Praditpornsilpa, Kearkiat; Lekhyananda, Sookruetai; Premasathian, Nalinee; Kingwatanakul, Pornchai; Lumpaopong, Adisorn; Gojaseni, Pongsathorn; Sakulsaengprapha, Amporn; Prasithsirikul, Wisit; Phakdeekitcharoen, Bunyong; Lelamali, Kumthorn; Teepprasan, Tavichai; Aumanaphong, Chatsuda; Leerawat, Benjaporn; Pongpiyadej, Jintana; Srangsomvong, Soysaang; Kanjanabuch, Talerngsak; Eiam-Ong, Somchai; Vareesaengthip, Kriengsak; Lumlertkul, Dusit

2011-09-01

The national health insurance fund in Thailand initiated by the national health security act in November, 2002. In October 2007, the national health insurance fund launched the first renal replacement therapy (RRT) reimbursement plan by the "Peritoneal Dialysis-First" (PD First) policy. The rationale of the PD First Policy resulted from the perspective that PD for end stage renal disease (ESRD) treatment offers the most economic and efficient outcome. The present study was conducted to determine whether the increase of RRT penetration by national health policy could impact the national RRT prevalence. The Thailand Renal Replacement Therapy (TRT) database in 2007, 2008, and 2009 were retrieved and analyzed. By TRT registry data, the total yearly prevalence of RRT increased by an average of 14.8% after the implementation of national health insurance and the "PD First" policy from 2007 to 2009. The total yearly prevalence of hemodialaysis (HD) modestly increased (14.7%) while the total yearly prevalence of PD remarkably expanded by 107.3%. The yearly incidence of all RRT modalities increased by an average of 34.8% in 2007 to 2009. The yearly incidence of HD modestly increased (8.1%) while the total yearly incidence of PD remarkably elevated by 157.8%. Civil Servants Medical Benefit Compensation (CSMBS) was the major funding source of RRT cases (34.5%) while national health insurance funding was the second major funding source (26.0%). From 2007-2009, the CSMBS funding was the majority of HD while national health insurance funding was the majority of PD. The sharing of PD by national health insurance increased from 33.9% in 2007, 58.6% in 2208, and 77.2% in 2009. The coverage ofESRD patients by national health insurance fund by the "PD First" policy impacted the RRT prevalence and incidence both the total prevalence and total incidence due to the universal penetration to RRT treatment of Thai population. Also, the policy altered the RRT modality predisposition. PD modality willfinally be the majority ofThaiRRT modalities if the policy can be managed successfully.

[Hyperhydration and dialysis in acute kidney failure].

PubMed

Saner, Fuat H; Bienholz, Anja; Tyczynski, Bartosz; Kribben, Andreas; Feldkamp, Thorsten

2015-05-01

Despite the advances in critical care medicine, the hospital mortality in patients with acute kidney injury (AKI) requiring dialysis remains high. Depending on the underlying disease the in-house mortality is reported to be up to 80%. Several observational studies demonstrated an association between mortality and fluid overload. A primary mechanism of interest is that fluid overload causes tissue edema and subsequent reduction of perfusion, oxygenation and nutrient delivery. This results in further renal damage. In addition, fluid overload-related dilution within the extracellular space causes artificially low serum creatinine, which masks AKI diagnosis. As a consequence, renal protective management strategies are deferred, which further aggravates kidney injury. This aggravation of renal damage subsequently increases the mortality. This review discusses the role of fluid overload for outcomes in critically ill patients as described in the current literature and assesses criteria for the initiation of renal replacement therapy in this critically ill population. © Georg Thieme Verlag KG Stuttgart · New York.

Retrospective study of long-term outcomes of enzyme replacement therapy in Fabry disease: Analysis of prognostic factors

PubMed Central

Biegstraaten, Marieke; Hughes, Derralynn A.; Mehta, Atul; Elliott, Perry M.; Oder, Daniel; Watkinson, Oliver T.; Vaz, Frédéric M.; van Kuilenburg, André B. P.; Wanner, Christoph; Hollak, Carla E. M.

2017-01-01

Despite enzyme replacement therapy, disease progression is observed in patients with Fabry disease. Identification of factors that predict disease progression is needed to refine guidelines on initiation and cessation of enzyme replacement therapy. To study the association of potential biochemical and clinical prognostic factors with the disease course (clinical events, progression of cardiac and renal disease) we retrospectively evaluated 293 treated patients from three international centers of excellence. As expected, age, sex and phenotype were important predictors of event rate. Clinical events before enzyme replacement therapy, cardiac mass and eGFR at baseline predicted an increased event rate. eGFR was the most important predictor: hazard ratios increased from 2 at eGFR <90 ml/min/1.73m2 to 4 at eGFR <30, compared to patients with an eGFR >90. In addition, men with classical disease and a baseline eGFR <60 ml/min/1.73m2 had a faster yearly decline (-2.0 ml/min/1.73m2) than those with a baseline eGFR of >60. Proteinuria was a further independent risk factor for decline in eGFR. Increased cardiac mass at baseline was associated with the most robust decrease in cardiac mass during treatment, while presence of cardiac fibrosis predicted a stronger increase in cardiac mass (3.36 gram/m2/year). Of other cardiovascular risk factors, hypertension significantly predicted the risk for clinical events. In conclusion, besides increasing age, male sex and classical phenotype, faster disease progression while on enzyme replacement therapy is predicted by renal function, proteinuria and to a lesser extent cardiac fibrosis and hypertension. PMID:28763515

UK Renal Registry 16th annual report: chapter 13 clinical, haematological and biochemical parameters in patients receiving renal replacement therapy in paediatric centres in the uk in 2012: national and centre-specific analyses.

PubMed

Pruthi, Rishi; Maxwell, Heather; Casula, Anna; Braddon, Fiona; Lewis, Malcolm; O'Brien, Catherine; Stojanovic, Jelena; Tse, Yincent; Inward, Carol; Sinha, Manish D

2013-01-01

The British Association for Paediatric Nephrology Registry (BAPN) was established to analyse data related to renal replacement therapy (RRT) in children. The registry receives data from the 13 paediatric nephrology centres in the UK. This chapter aims to provide centre specific data so that individual centres can reflect on the contribution that their data makes to the national picture and to determine the extent to which their patient parameters meet nationally agreed audit standards for the management of children with established renal failure (ERF). Data returns included a mixture of electronic (92%) and paper (8%) returns. Data were analysed to calculate summary statistics and where applicable the percentage achieving an audit standard. The standards used were those set out by the Renal Association and the National Institute for Health and Clinical Excellence. Anthropometric data confirmed that children receiving RRT were short compared to healthy peers. Amongst patients with a height of <2SD between 2001 and 2012, 29.2%were receiving growth hormone if they were on dialysis compared to 11.9% if they had a functioning transplant. Prevalence rates of overweight and obese status in children with ERF remain concerningly high. Blood pressure control remained challenging with wide inter-centre variation although this was significantly better in children with a functioning transplant. Over a quarter of haemodialysis patients and 17.3% of peritoneal dialysis patients were anaemic, compared to only 8.3% of transplanted patients. ESA use in the dialysis population exceeded 90% amongst anaemic patients. The control of renal bone disease remained challenging. Optimising growth and reducing prevalent excess weight in children on RRT remains challenging. The likelihood of complete electronic reporting in the near future with plans for quarterly reporting in the format of the recently finalised NEW paediatric dataset will hopefully improve quality of data and their reporting, allowing improvements in patient care. © 2014 S. Karger AG, Basel.

Oxalate nephropathy associated with chronic pancreatitis.

PubMed

Cartery, Claire; Faguer, Stanislas; Karras, Alexandre; Cointault, Olivier; Buscail, Louis; Modesto, Anne; Ribes, David; Rostaing, Lionel; Chauveau, Dominique; Giraud, Patrick

2011-08-01

Enteric overabsorption of oxalate may lead to hyperoxaluria and subsequent acute oxalate nephritis (AON). AON related to chronic pancreatitis is a rare and poorly described condition precluding early recognition and treatment. We collected the clinical characteristics, treatment, and renal outcome of 12 patients with chronic pancreatitis-associated AON followed in four French renal units. Before AON, mild to moderate chronic kidney disease was present in all patients, diabetes mellitus in eight (insulin [n = 6]; oral antidiabetic drugs [n = 2]), and known chronic pancreatitis in only eight. At presentation, pancreas imaging showed gland atrophy/heterogeneity, Wirsung duct dilation, calcification, or pseudocyst. Renal findings consisted of rapidly progressive renal failure with tubulointerstitial profile. Acute modification of glomerular filtration preceded the AON (i.e., diarrhea and diuretics). Increase in urinary oxalate excretion was found in all tested patients and hypocalcemia in nine (<1.5 mmol/L in four patients). Renal biopsy showed diffuse crystal deposits, highly suggestive of oxalate crystals, with tubular necrosis and interstitial inflammatory cell infiltrates. Treatment consisted of pancreatic enzyme supplementation, oral calcium intake, and an oxalate-free diet in all patients and renal replacement therapy in five patients. After a median follow-up of 7 months, three of 12 patients reached end-stage renal disease. AON is an under-recognized severe crystal-induced renal disease with features of tubulointerstitial nephritis that may occur in patients with a long history of chronic pancreatitis or reveal the pancreatic disease. Extrinsic triggering factors should be prevented.

Ammonia transport in the kidney by Rhesus glycoproteins

PubMed Central

Verlander, Jill W.

2014-01-01

Renal ammonia metabolism is a fundamental element of acid-base homeostasis, comprising a major component of both basal and physiologically altered renal net acid excretion. Over the past several years, a fundamental change in our understanding of the mechanisms of renal epithelial cell ammonia transport has occurred, replacing the previous model which was based upon diffusion equilibrium for NH3 and trapping of NH4+ with a new model in which specific and regulated transport of both NH3 and NH4+ across renal epithelial cell membranes via specific membrane proteins is required for normal ammonia metabolism. A major advance has been the recognition that members of a recently recognized transporter family, the Rhesus glycoprotein family, mediate critical roles in renal and extrarenal ammonia transport. The erythroid-specific Rhesus glycoprotein, Rh A Glycoprotein (Rhag), was the first Rhesus glycoprotein recognized as an ammonia-specific transporter. Subsequently, the nonerythroid Rh glycoproteins, Rh B Glycoprotein (Rhbg) and Rh C Glycoprotein (Rhcg), were cloned and identified as ammonia transporters. They are expressed in specific cell populations and membrane domains in distal renal epithelial cells, where they facilitate ammonia secretion. In this review, we discuss the distribution of Rhbg and Rhcg in the kidney, the regulation of their expression and activity in physiological disturbances, the effects of genetic deletion on renal ammonia metabolism, and the molecular mechanisms of Rh glycoprotein-mediated ammonia transport. PMID:24647713

Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy.

PubMed

Wadei, H M; Geiger, X J; Cortese, C; Mai, M L; Kramer, D J; Rosser, B G; Keaveny, A P; Willingham, D L; Ahsan, N; Gonwa, T A

2008-12-01

The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m(2) (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with >or=30% interstitial fibrosis (IF), >or=40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 liver-transplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderate-to-excellent. After a mean of 78 +/- 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last follow-up. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.

Care of the Patient with Renal Disease: Peritoneal Dialysis and Transplants, Nursing 321A.

ERIC Educational Resources Information Center

Hulburd, Kimberly

A description is provided of a course, "Care of the Patient with Renal Disease," offered at the community college level to prepare licensed registered nurses to care for patients with renal disease, including instruction in performing the treatments of peritoneal dialysis and continuous ambulatory peritoneal dialysis (CAPD). The first…

Risk factors for severe clinical events in male and female patients with Fabry disease treated with agalsidase beta enzyme replacement therapy: Data from the Fabry Registry.

PubMed

Hopkin, Robert J; Cabrera, Gustavo; Charrow, Joel; Lemay, Roberta; Martins, Ana Maria; Mauer, Michael; Ortiz, Alberto; Patel, Manesh R; Sims, Katherine; Waldek, Stephen; Warnock, David G; Wilcox, William R

2016-09-01

Fabry disease, an X-linked lysosomal storage disorder, causes intracellular accumulation of glycosphingolipids leading to progressive renal, cardiovascular, and cerebrovascular disease, and premature death. This longitudinal Fabry Registry study analyzed data from patients with Fabry disease to determine the incidence and type of severe clinical events following initiation of enzyme replacement therapy (ERT) with agalsidase beta, as well as risk factors associated with occurrence of these events. Severe events assessed included chronic dialysis, renal transplantation, cardiac events, stroke, and death. The analyses included 969 male and 442 female Fabry patients. The mean age at first agalsidase beta infusion was 35 and 44, and median treatment follow-up 4.3years and 3.2years, respectively. Among males, cardiac events were the most common on-ERT events, followed by renal, stroke, and non-cardiac death. Among females, cardiac events were also most common followed by stroke and renal events. Patients with on-ERT events had significantly more advanced cardiac and renal disease at baseline as compared with patients without on-ERT events. Severe events were also associated with older age at ERT initiation (males and females), a history of pre-ERT events (females; approaching statistical significance in males), and a higher urinary protein/creatinine ratio (females). Approximately 65% of patients with pre-ERT events did not experience subsequent on-ERT events. Of patients without pre-ERT events, most (84% of males, 92% of females) remained event-free. Patients with on-ERT severe events had more advanced Fabry organ involvement at baseline than those without such events and patients who initiated ERT at a younger age had less residual risk of on-ERT events. The observed patterns of residual risk may aid clinicians in multidisciplinary monitoring of male and female patients with Fabry disease receiving ERT, and in determining the need for administration of adjunctive therapies. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Stage progression and need for renal replacement therapy in a renal protection programme in Colombia. A cohort study.

PubMed

Yepes Delgado, Carlos Enrique; Pérez Dávila, Sara; Montoya Jaramillo, Marcela; Orrego Orozco, Beatriz Elena

Due to the global burden represented by chronic kidney disease (CKD), the World Health Organization encouraged the implementation of renal protection programmes (RPP) to affect its incidence through prevention and control measures. To assess the effectiveness of a Colombian RPP in terms of its effect on the stage progression of CKD and the need for renal replacement therapy (RRT). An analytical study that monitored 2cohorts of patients diagnosed with CKD. The study compares the behaviour of clinical and renal impairment indicators from patients exposed to a RPP with that of patients following conventional treatment (CT). The population of both intervention groups was considered when determining the sample size. The incidence rate was calculated as well as patient survival (Kaplan Meier). In addition, a multivariate analysis (Cox) was used to calculate the influence that exposure to the RPP had on the outcomes of the patients following the RPP and those following CT. The patients exposed to the RPP took longer to advance to the next CKD stage and require RRT. The incidence rate for progression is higher for the patients following CT (0.050, IC 95%: 0.040-0.064) compared to those in the RPP (0.034, IC 95%: 0.030-0.039). The ratio of incidence rates was 1.480 (IC 95% 1.21-1.90). The hazard of progression was lower for the RPP (HR: 0.855, IC 95%: 0.74- 0.98), as was the hazard of requiring RRT (HR: 0.797, IC 95%: 0.606-1.049). The RPP is a secondary prevention strategy against CKD which has an effect on the stage progression of CKD and the need for RRT. Early patient detection has a positive effect on the outcomes studied. Copyright © 2017 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

The impact of renal artery stenosis on outcomes after open-heart surgery.

PubMed

Philip, Femi; Gornik, Heather L; Rajeswaran, Jeevanantham; Blackstone, Eugene H; Shishehbor, Mehdi H

2014-02-04

The aim of this study was to assess the impact of atherosclerotic renal artery stenosis (ARAS) on outcomes after open-heart surgery (OHS). Acute kidney injury after OHS portends significant morbidity and mortality. Data from all adult patients undergoing OHS from January 2000 to April 2010 who underwent renal duplex ultrasound were prospectively collected. ARAS was severe (60% to 99% stenosis) if peak systolic velocity was >200 cm/s. The associations between ARAS and post-operative reduction in glomerular filtration rate (GFR), need for renal replacement therapy, length of stay, and overall short-term and long-term mortality (up to 8 years) were tested using multivariate time-to-event adjusted analysis. A total of 714 patients were evaluated, with a mean age of 67 ± 12 years (63% men) and a mean GFR of 52 ± 25.9 ml/min/1.73 m(2). A total of 206 (29%) had ARAS; of these, 79% (n = 163) had unilateral and 21% (n = 43) had bilateral ARAS. ARAS was associated with peripheral artery disease (p = 0.004) and lower high-density lipoprotein levels (p = 0.04). Patients with advanced age (p = 0.01) and descending aorta grafting (p = 0.004) had significant post-operative reductions in GFR. Adjusted models showed a nonsignificant trend between ARAS and reduction in GFR (p = 0.09). ARAS was not associated with need for renal replacement therapy (p = 0.4), longer length of stay (p = 0.7), or mortality (p = 0.7), but low pre-operative GFR was a strong predictor of long-term mortality. ARAS does not appear to be associated with post-operative change in GFR, need for hemodialysis, longer length of stay, or mortality in patients undergoing OHS. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Renal Ammonia Metabolism and Transport

PubMed Central

Weiner, I. David; Verlander, Jill W.

2015-01-01

Renal ammonia metabolism and transport mediates a central role in acid-base homeostasis. In contrast to most renal solutes, the majority of renal ammonia excretion derives from intrarenal production, not from glomerular filtration. Renal ammoniagenesis predominantly results from glutamine metabolism, which produces 2 NH4+ and 2 HCO3− for each glutamine metabolized. The proximal tubule is the primary site for ammoniagenesis, but there is evidence for ammoniagenesis by most renal epithelial cells. Ammonia produced in the kidney is either excreted into the urine or returned to the systemic circulation through the renal veins. Ammonia excreted in the urine promotes acid excretion; ammonia returned to the systemic circulation is metabolized in the liver in a HCO3−-consuming process, resulting in no net benefit to acid-base homeostasis. Highly regulated ammonia transport by renal epithelial cells determines the proportion of ammonia excreted in the urine versus returned to the systemic circulation. The traditional paradigm of ammonia transport involving passive NH3 diffusion, protonation in the lumen and NH4+ trapping due to an inability to cross plasma membranes is being replaced by the recognition of limited plasma membrane NH3 permeability in combination with the presence of specific NH3-transporting and NH4+-transporting proteins in specific renal epithelial cells. Ammonia production and transport are regulated by a variety of factors, including extracellular pH and K+, and by several hormones, such as mineralocorticoids, glucocorticoids and angiotensin II. This coordinated process of regulated ammonia production and transport is critical for the effective maintenance of acid-base homeostasis. PMID:23720285

De novo Uroplakin IIIa heterozygous mutations cause human renal adysplasia leading to severe kidney failure.

PubMed

Jenkins, Dagan; Bitner-Glindzicz, Maria; Malcolm, Sue; Hu, Chih-Chi A; Allison, Jennifer; Winyard, Paul J D; Gullett, Ambrose M; Thomas, David F M; Belk, Rachel A; Feather, Sally A; Sun, Tung-Tien; Woolf, Adrian S

2005-07-01

Human renal adysplasia usually occurs sporadically, and bilateral disease is the most common cause of childhood end-stage renal failure, a condition that is lethal without intervention using dialysis or transplantation. De novo heterozygous mutations in Uroplakin IIIa (UPIIIa) are reported in four of 17 children with kidney failure caused by renal adysplasia in the absence of an overt urinary tract obstruction. One girl and one boy in unrelated kindreds had a missense mutation at a CpG dinucleotide in the cytoplasmic domain of UPIIIa (Pro273Leu), both of whom had severe vesicoureteric reflux, and the girl had persistent cloaca; two other patients had de novo mutations in the 3' UTR (963 T-->G; 1003 T-->C), and they had renal adysplasia in the absence of any other anomaly. The mutations were absent in all sets of parents and in siblings, none of whom had radiologic evidence of renal adysplasia, and mutations were absent in two panels of 192 ethnically matched control chromosomes. UPIIIa was expressed in nascent urothelia in ureter and renal pelvis of human embryos, and it is suggested that perturbed urothelial differentiation may generate human kidney malformations, perhaps by altering differentiation of adjacent smooth muscle cells such that the metanephros is exposed to a functional obstruction of urine flow. With advances in renal replacement therapy, children with renal failure, who would otherwise have died, are surviving to adulthood. Therefore, although the mechanisms of action of the UPIIIa mutations have yet to be determined, these findings have important implications regarding genetic counseling of affected individuals who reach reproductive age.

Clinical presentation and outcome prediction of clinical, serological, and histopathological classification schemes in ANCA-associated vasculitis with renal involvement.

PubMed

Córdova-Sánchez, Bertha M; Mejía-Vilet, Juan M; Morales-Buenrostro, Luis E; Loyola-Rodríguez, Georgina; Uribe-Uribe, Norma O; Correa-Rotter, Ricardo

2016-07-01

Several classification schemes have been developed for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), with actual debate focusing on their clinical and prognostic performance. Sixty-two patients with renal biopsy-proven AAV from a single center in Mexico City diagnosed between 2004 and 2013 were analyzed and classified under clinical (granulomatosis with polyangiitis [GPA], microscopic polyangiitis [MPA], renal limited vasculitis [RLV]), serological (proteinase 3 anti-neutrophil cytoplasmic antibodies [PR3-ANCA], myeloperoxidase anti-neutrophil cytoplasmic antibodies [MPO-ANCA], ANCA negative), and histopathological (focal, crescenteric, mixed-type, sclerosing) categories. Clinical presentation parameters were compared at baseline between classification groups, and the predictive value of different classification categories for disease and renal remission, relapse, renal, and patient survival was analyzed. Serological classification predicted relapse rate (PR3-ANCA hazard ratio for relapse 2.93, 1.20-7.17, p = 0.019). There were no differences in disease or renal remission, renal, or patient survival between clinical and serological categories. Histopathological classification predicted response to therapy, with a poorer renal remission rate for sclerosing group and those with less than 25 % normal glomeruli; in addition, it adequately delimited 24-month glomerular filtration rate (eGFR) evolution, but it did not predict renal nor patient survival. On multivariate models, renal replacement therapy (RRT) requirement (HR 8.07, CI 1.75-37.4, p = 0.008) and proteinuria (HR 1.49, CI 1.03-2.14, p = 0.034) at presentation predicted renal survival, while age (HR 1.10, CI 1.01-1.21, p = 0.041) and infective events during the induction phase (HR 4.72, 1.01-22.1, p = 0.049) negatively influenced patient survival. At present, ANCA-based serological classification may predict AAV relapses, but neither clinical nor serological categories predict renal or patient survival. Age, renal function and proteinuria at presentation, histopathology, and infectious complications constitute the main outcome predictors and should be considered for individualized management.

Renal outcomes of agalsidase beta treatment for Fabry disease: role of proteinuria and timing of treatment initiation.

PubMed

Warnock, David G; Ortiz, Alberto; Mauer, Michael; Linthorst, Gabor E; Oliveira, João P; Serra, Andreas L; Maródi, László; Mignani, Renzo; Vujkovac, Bojan; Beitner-Johnson, Dana; Lemay, Roberta; Cole, J Alexander; Svarstad, Einar; Waldek, Stephen; Germain, Dominique P; Wanner, Christoph

2012-03-01

The purpose of this study was to identify determinants of renal disease progression in adults with Fabry disease during treatment with agalsidase beta. Renal function was evaluated in 151 men and 62 women from the Fabry Registry who received agalsidase beta at an average dose of 1 mg/kg/2 weeks for at least 2 years. Patients were categorized into quartiles based on slopes of estimated glomerular filtration rate (eGFR) during treatment. Multivariate logistic regression analyses were used to identify factors associated with renal disease progression. Men within the first quartile had a mean eGFR slope of -0.1 mL/min/1.73m(2)/year, whereas men with the most rapid renal disease progression (Quartile 4) had a mean eGFR slope of -6.7 mL/min/1.73m(2)/year. The risk factor most strongly associated with renal disease progression was averaged urinary protein:creatinine ratio (UP/Cr) ≥1 g/g (odds ratio 112, 95% confidence interval (95% CI) 4-3109, P = 0.0054). Longer time from symptom onset to treatment was also associated with renal disease progression (odds ratio 19, 95% CI 2-184, P = 0.0098). Women in Quartile 4 had the highest averaged UP/Cr (mean 1.8 g/g) and the most rapid renal disease progression: (mean slope -4.4 mL/min/1.73m(2)/year). Adults with Fabry disease are at risk for progressive loss of eGFR despite enzyme replacement therapy, particularly if proteinuria is ≥1 g/g. Men with little urinary protein excretion and those who began receiving agalsidase beta sooner after the onset of symptoms had stable renal function. These findings suggest that early intervention may lead to optimal renal outcomes.

Role of NH3 and NH4+ transporters in renal acid-base transport.

PubMed

Weiner, I David; Verlander, Jill W

2011-01-01

Renal ammonia excretion is the predominant component of renal net acid excretion. The majority of ammonia excretion is produced in the kidney and then undergoes regulated transport in a number of renal epithelial segments. Recent findings have substantially altered our understanding of renal ammonia transport. In particular, the classic model of passive, diffusive NH3 movement coupled with NH4+ "trapping" is being replaced by a model in which specific proteins mediate regulated transport of NH3 and NH4+ across plasma membranes. In the proximal tubule, the apical Na+/H+ exchanger, NHE-3, is a major mechanism of preferential NH4+ secretion. In the thick ascending limb of Henle's loop, the apical Na+-K+-2Cl- cotransporter, NKCC2, is a major contributor to ammonia reabsorption and the basolateral Na+/H+ exchanger, NHE-4, appears to be important for basolateral NH4+ exit. The collecting duct is a major site for renal ammonia secretion, involving parallel H+ secretion and NH3 secretion. The Rhesus glycoproteins, Rh B Glycoprotein (Rhbg) and Rh C Glycoprotein (Rhcg), are recently recognized ammonia transporters in the distal tubule and collecting duct. Rhcg is present in both the apical and basolateral plasma membrane, is expressed in parallel with renal ammonia excretion, and mediates a critical role in renal ammonia excretion and collecting duct ammonia transport. Rhbg is expressed specifically in the basolateral plasma membrane, and its role in renal acid-base homeostasis is controversial. In the inner medullary collecting duct (IMCD), basolateral Na+-K+-ATPase enables active basolateral NH4+ uptake. In addition to these proteins, several other proteins also contribute to renal NH3/NH4+ transport. The role and mechanisms of these proteins are discussed in depth in this review.

[Nephrology in Tunisia: From yesterday to now].

PubMed

Ben Maïz, Hédi

2010-06-01

Professor Hassouna Ben Ayed is the founder of Tunisian nephrology. He introduced in 1962 the first artificial kidney for the treatment of acute renal failure. In 1963, the first acute peritoneal dialysis was done. Renal biopsy started in 1967 with general pathologists. A special laboratory of renal pathology was set up in 1975 with Pr H. Ben Maïz. Epidemiology of glomerular diseases, when histologically proven, was published [8]. A comprehensive program of chronic hemodialysis was started in 1968 and was developed markedly since 1975 with Pr A. El Matri. An intermittent peritoneal dialysis programme was started in 1982 and CAPD in 1983 by Pr T. Ben Abdallah. The Tunisian renal failure patient association was created in 1982 and the Tunisian society of nephrology in November 1983. A national registry for ESRD treatment is available since 1986. Since this time, the number of patients initiating renal replacement therapy (RRT) for ESRD has increased dramatically due to the extension of acceptance criteria for RRT and the increase of the elderly population. The incidence was 13 pmp in 1986 and 133 pmp in 2008. The prevalence was 48.5 pmp in 1986 and 734 pmp in 2008. From 1971 up to 1986, locally dialysed patients have been transplanted abroad, especially in France. On 4 June 1986, the local transplantation program was started at Charles Nicolle Hospital in Tunis. A national center of organ transplantation was created on 12 June 1995. At the end of 2008, there were 106 nephrologists, 26 residents in nephrology and 253 doctors with a training in hemodialysis during 1 year. In university hospitals, the number of nephrology departments is five, with one unit in an army hospital and two units for pediatric nephrology. Five hospitals perform renal transplantation (Tunis: 2 - Sfax: 1 - Sousse: 1 - Monastir: 1). There are 138 centers of hemodialysis: 39 public, 99 private. Seven thousand and eighty patients were treated by HD, 127 patients underwent renal transplantation. The vast majority of these transplants have been performed using living related donors (103/127). The cost of renal replacement therapy (RRT) is taken in charge by the Ministry of Health and the national security boards. Legislation on HD was promulgated by the Tunisian government, setting rigorous and detailed rules for the implementation of new dialysis centers, as well as for the functioning of already active units (4 August 1986 - 4 April 1998). For transplantation, legislation was promulgated on 25 March 1991. Copyright 2010 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

The Effects of Preoperative Volume Replacement in Diabetic Patients Undergoing Coronary Artery Bypass Grafting Surgery: Protocol for a Randomized Controlled Trial (VeRDiCT Trial).

PubMed

Clout, Madeleine; Harris, Tracy; Rogers, Chris; Culliford, Lucy; Taylor, Jodi; Angelini, Gianni; Narayan, Pradeep; Reeves, Barnaby; Hillier, James; Ashton, Kate; Sarkar, Kunal; Ascione, Raimondo

2017-06-19

Diabetes mellitus is a major risk factor for prolonged hospital stays, renal failure, and mortality in patients having coronary artery bypass grafting (CABG). Complications pose a serious threat to patients and prolong intensive care and hospital stays. Low glomerular filtration rate (GFR) due to existing renal impairment or volume depletion may exacerbate acute renal impairment/failure in these patients. Preoperative volume replacement therapy (VRT) is reported to increase the GFR and we hypothesize that VRT will reduce renal impairment and related complications in diabetic patients. The objective of this study is to establish the efficacy of preoperative VRT in reducing postoperative complications in diabetic patients undergoing CABG surgery. Time to "fit for discharge", incidence of postoperative renal failure, cardiac injury, inflammation, and other health outcomes will be investigated. In this open parallel group randomized controlled trial, 170 diabetic patients undergoing elective or urgent CABG surgery received 1 mL/kg/hour of Hartmann's solution for 12 consecutive hours prior to surgery, versus routine care. The primary outcome was time until participants were "fit for discharge", which is defined as presence of: normal temperature, pulse, and respiration; normal oxygen saturation on air; normal bowel function; and physical mobility. Secondary outcomes included: incidence of renal failure; markers of renal function, inflammation, and cardiac damage; operative morbidity; intensive care stay; patient-assessed outcome, including the Coronary Revascularization Outcome Questionnaire; and use of hospital resources. Recruitment started in July 2010. Enrolment for the study was completed in July 2014. Data analysis commenced in December 2016. Study results will be submitted for publication in the summer of 2017. VRT is a relatively easy treatment to administer in patients undergoing surgical procedures who are at risk of renal failure. This experimental protocol will increase scientific and clinical knowledge of VRT in diabetic patients undergoing elective or urgent CABG surgery. Findings supporting the efficacy of this intervention could easily be implemented in the health care system. International Standard Randomized Controlled Trial Number (ISRCTN): 02159606; http://www.controlled-trials.com/ISRCTN02159606 (Archived by WebCite at http://www.webcitation.org/6rDkSSkkK). ©Madeleine Clout, Tracy Harris, Chris Rogers, Lucy Culliford, Jodi Taylor, Gianni Angelini, Pradeep Narayan, Barnaby Reeves, James Hillier, Kate Ashton, Kunal Sarkar, Raimondo Ascione. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 19.06.2017.

The repair of a type Ia endoleak following thoracic endovascular aortic repair using a stented elephant trunk procedure.

PubMed

Qi, Rui-Dong; Zhu, Jun-Ming; Liu, Yong-Min; Chen, Lei; Li, Cheng-Nan; Xing, Xiao-Yan; Sun, Li-Zhong

2018-04-01

Type Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent-graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. From July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. All cases of type Ia endoleak (100%) were repaired successfully. There were no in-hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow-up. During follow-up, there were 3 deaths. Acceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Incorporating Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio in Place of Neutrophil Count and Platelet Count Improves Prognostic Accuracy of the International Metastatic Renal Cell Carcinoma Database Consortium Model

PubMed Central

Chrom, Pawel; Stec, Rafal; Bodnar, Lubomir; Szczylik, Cezary

2018-01-01

Purpose The study investigated whether a replacement of neutrophil count and platelet count by neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) within the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model would improve its prognostic accuracy. Materials and Methods This retrospective analysis included consecutive patients with metastatic renal cell carcinoma treated with first-line tyrosine kinase inhibitors. The IMDC and modified-IMDC models were compared using: concordance index (CI), bias-corrected concordance index (BCCI), calibration plots, the Grønnesby and Borgan test, Bayesian Information Criterion (BIC), generalized R2, Integrated Discrimination Improvement (IDI), and continuous Net Reclassification Index (cNRI) for individual risk factors and the three risk groups. Results Three hundred and twenty-one patients were eligible for analyses. The modified-IMDC model with NLR value of 3.6 and PLR value of 157 was selected for comparison with the IMDC model. Both models were well calibrated. All other measures favoured the modified-IMDC model over the IMDC model (CI, 0.706 vs. 0.677; BCCI, 0.699 vs. 0.671; BIC, 2,176.2 vs. 2,190.7; generalized R2, 0.238 vs. 0.202; IDI, 0.044; cNRI, 0.279 for individual risk factors; and CI, 0.669 vs. 0.641; BCCI, 0.669 vs. 0.641; BIC, 2,183.2 vs. 2,198.1; generalized R2, 0.163 vs. 0.123; IDI, 0.045; cNRI, 0.165 for the three risk groups). Conclusion Incorporation of NLR and PLR in place of neutrophil count and platelet count improved prognostic accuracy of the IMDC model. These findings require external validation before introducing into clinical practice. PMID:28253564

Incorporating Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio in Place of Neutrophil Count and Platelet Count Improves Prognostic Accuracy of the International Metastatic Renal Cell Carcinoma Database Consortium Model.

PubMed

Chrom, Pawel; Stec, Rafal; Bodnar, Lubomir; Szczylik, Cezary

2018-01-01

The study investigated whether a replacement of neutrophil count and platelet count by neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) within the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model would improve its prognostic accuracy. This retrospective analysis included consecutive patients with metastatic renal cell carcinoma treated with first-line tyrosine kinase inhibitors. The IMDC and modified-IMDC models were compared using: concordance index (CI), bias-corrected concordance index (BCCI), calibration plots, the Grønnesby and Borgan test, Bayesian Information Criterion (BIC), generalized R 2 , Integrated Discrimination Improvement (IDI), and continuous Net Reclassification Index (cNRI) for individual risk factors and the three risk groups. Three hundred and twenty-one patients were eligible for analyses. The modified-IMDC model with NLR value of 3.6 and PLR value of 157 was selected for comparison with the IMDC model. Both models were well calibrated. All other measures favoured the modified-IMDC model over the IMDC model (CI, 0.706 vs. 0.677; BCCI, 0.699 vs. 0.671; BIC, 2,176.2 vs. 2,190.7; generalized R 2 , 0.238 vs. 0.202; IDI, 0.044; cNRI, 0.279 for individual risk factors; and CI, 0.669 vs. 0.641; BCCI, 0.669 vs. 0.641; BIC, 2,183.2 vs. 2,198.1; generalized R 2 , 0.163 vs. 0.123; IDI, 0.045; cNRI, 0.165 for the three risk groups). Incorporation of NLR and PLR in place of neutrophil count and platelet count improved prognostic accuracy of the IMDC model. These findings require external validation before introducing into clinical practice.

[Continuous Veno-venous Hemofiltration in Goat Model with Crush Syndrome].

PubMed

Tang, Yi; Zhang, Ling; Yang, Ying-ying; Zhao, Yu-liang; Fu, Ping

2016-01-01

Crush syndrome (CS) is a common critical condition. This study aimed to establish crush syndrome goat model through muscle injection of glycerol and test the effect of continuous veno-venous hemofiltraion (CVVH). 12 male goats at 12-15 months age were randomly assigned into control, model, and CVVH groups. After 2 weeks of normal feeding, the goats were weighed and stripped off foods for 24 h. Goats in the model and CVVH groups were then injected with 50% glycerol athind legs. Diagnosis of CS was established based on serum creatine kinase (CK) > 1 000 U/L and serum creatinine (sCr) > 2 times of standard. No intervention was given to goats in the control group. A catheter was planted to get blood access. CVVH was administered using a Prisma-flex machine, with blood flow being set at 100 mL/min and replacement fluid with predilution at 35 mL/(kg x h). After 23 h of treatment, the goats were sacrificed. Plasma and kidney samples were taken. Bloody urine hyperkalemia and decrease of urine volume were found in all of the goats injected with glycerol. Serum CK and sCr increased 1 h after the injection compared with the controls. After 23 h of CVVH treatment, serum CK and sCr decreased compared with goats in the model group. The light microscope revealed manifestation of tubular necrosis and interstitial edema, but the glomeruli were almost normal. The electronic microscope found prominent signs of cell apoptosis, such as chromatin aggregation, mitochondrial swelling, and endoplasmic reticulum expansion. Caspase12 expression in the goats with CS was significantly higher than that in the controls. The CVVH treated goats had lower level of expression than those in the model group (P < 0.05). TUNEL staining identified a higher proportion of renal cell apoptosis in the goats in the model group compared with those in the CVVH group. Muscle injection with glycerol can induce CS in goats. Early CVVH intervention improves renal function and alleviates renal tubular cell apoptosis.

Regional differences in renal replacement therapy in northern Norway 2000–2012

PubMed Central

Norum, Jan; Leivestad, Torbjørn; Eriksen, Bjørn Odvar; Skår, Siw; Fagerheim, Anne; Reisæter, Anna Varberg

2015-01-01

Objective Distance from residence location to a centre for renal replacement therapy (RRT) may influence patients’ quality of life and prognosis. Northern Norway constitutes 45% of Norway's landmass, but has less than 10% of the population. Methods In this study, we analysed all patients in northern Norway consecutively registered in the Norwegian Renal Registry during 2000–2012. A total of 634 patients (Nordland County 321 patients, Troms County 215 patients and Finnmark County 98 patients) were investigated. Results There were more smokers (31% vs. 22%) and patients with diabetes (32% vs. 22%) in Finnmark, but the difference did not reach statistical significance. Patients undergoing RRT and living in Finnmark County had a significantly worse outcome (P=0.03). The median survivals after initiation of RRT were 3.8 years (Finnmark), 6.4 years (Troms) and 5.4 years (Nordland), respectively. The most common causes of death were cardiovascular disease (53%), infections (16%), withdrawal from therapy (15%) and malignancy (13%). In a Cox analysis, age (P<0.0001), diabetes (P=0.008) and smoking at any time (P<0.004) were individual factors correlated with inferior prognosis. Conclusion Age, smoking and diabetes were prognostic factors. Residents of the northernmost county (Finnmark) experienced an inferior prognosis. Long distance from residence location to hospital may be another factor, but this could not be documented. Preventive strategies should be improved. PMID:25672881

Regional differences in renal replacement therapy in northern Norway 2000-2012.

PubMed

Norum, Jan; Leivestad, Torbjørn; Eriksen, Bjørn Odvar; Skår, Siw; Fagerheim, Anne; Reisæter, Anna Varberg

2015-01-01

Distance from residence location to a centre for renal replacement therapy (RRT) may influence patients' quality of life and prognosis. Northern Norway constitutes 45% of Norway's landmass, but has less than 10% of the population. In this study, we analysed all patients in northern Norway consecutively registered in the Norwegian Renal Registry during 2000-2012. A total of 634 patients (Nordland County 321 patients, Troms County 215 patients and Finnmark County 98 patients) were investigated. There were more smokers (31% vs. 22%) and patients with diabetes (32% vs. 22%) in Finnmark, but the difference did not reach statistical significance. Patients undergoing RRT and living in Finnmark County had a significantly worse outcome (P=0.03). The median survivals after initiation of RRT were 3.8 years (Finnmark), 6.4 years (Troms) and 5.4 years (Nordland), respectively. The most common causes of death were cardiovascular disease (53%), infections (16%), withdrawal from therapy (15%) and malignancy (13%). In a Cox analysis, age (P<0.0001), diabetes (P=0.008) and smoking at any time (P<0.004) were individual factors correlated with inferior prognosis. Age, smoking and diabetes were prognostic factors. Residents of the northernmost county (Finnmark) experienced an inferior prognosis. Long distance from residence location to hospital may be another factor, but this could not be documented. Preventive strategies should be improved.

A numerical study of the effect of catheter angle on the blood flow characteristics in a graft during hemodialysis

NASA Astrophysics Data System (ADS)

Ryou, Hong Sun; Kim, Soyoon; Ro, Kyoungchul

2013-02-01

For patients with renal failure, renal replacement therapies are needed. Hemodialysis is a widely used renal replacement method to remove waste products. It is important to improve the patency rate of the vascular access for efficient dialysis. Since some complications such as an intimal hyperplasia are associated with the flow pattern, the hemodynamics in the vascular access must be considered to achieve a high patency rate. In addition, the blood flow from an artificial kidney affects the flow in the vascular access. Generally, the clinical techniques of hemodialysis such as the catheter angle or dialysis dose have been set up empirically. In this study, a numerical analysis is performed on the effect of the catheter angle on the flow in the graft. Blood is assumed to be a non-Newtonian fluid. According to the high average wall shear stress value, the leucocytes and platelets can be activated not only at the arterial anastomosis, but also at the bottom of the venous graft, when the catheter angle is not zero. For a catheter angle less than five degrees, there is a low shear and high oscillatory shear index region that appears at the venous graft and the venous anastomosis. Thus, a catheter angle less than five degrees should be avoided to prevent graft failure.

Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD).

PubMed

Vinsonneau, Christophe; Allain-Launay, Emma; Blayau, Clarisse; Darmon, Michael; Ducheyron, Damien; Gaillot, Theophile; Honore, Patrick M; Javouhey, Etienne; Krummel, Thierry; Lahoche, Annie; Letacon, Serge; Legrand, Matthieu; Monchi, Mehran; Ridel, Christophe; Robert, René; Schortgen, Frederique; Souweine, Bertrand; Vaillant, Patrick; Velly, Lionel; Osman, David; Van Vong, Ly

2015-12-01

Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

Epidemiological Transition of End-Stage Kidney Disease in Oman.

PubMed

Al Ismaili, Faisal; Al Salmi, Issa; Al Maimani, Yaqoub; Metry, Abdul Massiah; Al Marhoobi, Humood; Hola, Alan; Pisoni, Ronald L

2017-01-01

The number of persons receiving renal replacement therapy (RRT) is estimated at more than 2.5 million worldwide, and is growing by 8% annually. Registries in the developing world are not up to standards compared to the United States Renal Data System (USRDS). Herein we examine the causes, progression, and magnitude of end-stage kidney disease (ESKD) over 3 decades in Oman. We examined ESKD data from 1983 to 2013. Data from 1998 to 2013 were obtained through an Information Management System. Data before 2008 were collected from patients' files. A questionnaire based on USRDS form 2728 was completed by nephrologists once a citizen reached ESKD. A total of 4066 forms were completed, with a response rate of 90% (52% male). The mean (SD) age was 50.1 (14.0) years. By 31 December 2013, there were 2386 patients alive on RRT, of whom 1206 were on hemodialysis (50.5%), 1080 were living with a functioning kidney transplant (45.3%), and 100 were receiving peritoneal dialysis (4.2%). The incidence of ESKD on RRT was 21, 75, and 120 per million population in 1983, 2001, and 2013, respectively. Similarly, the prevalence of ESKD was 49, 916, and 2386 in 1983, 2001, and 2013 respectively. Among patients with ESKD on RRT, a progressive rise was seen in diabetic nephropathy, with 5.8%, 32.1%, and 46% in 1983, 2001, and 2013 respectively. The incidence and prevalence of ESKD has increased progressively over last 30 years. This is anticipated to continue at an even higher rate in view of the progressive rise in noncommunicable diseases. Continuous improvement in registries is required to improve capturing of ESKD patients for providing accurate data to health authorities, and enhancing public awareness of the magnitude, future trends, treatments, and outcomes regarding ESKD.

Renal effects of continuous negative pressure breathing

NASA Technical Reports Server (NTRS)

Kinney, M. J.

1975-01-01

Continuous negative pressure breathing (CNPB) was utilized to simulate the thoracic vascular distension of zero G in 11 anesthetized rats. The animals underwent renal clearance and micropuncture renal nephron studies before, during, and after CNPB. Four rats were pretreated with a high salt diet and I-M desoxycorticosterone (DOCA) in excess. None of these rats diuresed with CNPB. In contrast, five of the seven remaining rats increased the fraction of the filtered sodium excreted and their urinary flow rate. Potassium excretion increased. End proximal tubular fluid specimen's TF/P inulin ratios were unchanged. Whole kidney and single nephron glomerular filtration rates fell 10%. CNPB, a mechanism for atrial distension, appears to cause in the rat a decrease in distal tubular sodium and water reabsorption. Exogenous mineral-corticoid prevents the diuresis, saluresis, and kaluresis. The adequacy of other nonatrial volume control mechanisms in regulating renal salt and water conservation in opposition to the studied atrial-renal (Henry-Gauer) reflex of thoracic vascular distension is confirmed.

21 CFR 876.4650 - Water jet renal stone dislodger system.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Water jet renal stone dislodger system. 876.4650 Section 876.4650 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GASTROENTEROLOGY-UROLOGY DEVICES Surgical Devices § 876.4650 Water jet renal stone dislodger system. (a) Identification....

Lifetime risk of renal replacement therapy in Europe: a population-based study using data from the ERA-EDTA Registry.

PubMed

van den Brand, Jan A J G; Pippias, Maria; Stel, Vianda S; Caskey, Fergus J; Collart, Frederic; Finne, Partik; Heaf, James; Jais, Jean-Philippe; Kramar, Reinhard; Massy, Ziad A; De Meester, Johan; Traynor, Jamie P; Reisæter, Anna Varberg; Wetzels, Jack F M; Jager, Kitty J

2017-02-01

Upcoming KDIGO guidelines for the evaluation of living kidney donors are expected to move towards a personal risk-based evaluation of potential donors. We present the age and sex-specific lifetime risk of renal replacement therapy (RRT) for end-stage renal disease in 10 European countries. We defined lifetime risk of RRT as the cumulative incidence of RRT up to age 90 years. We obtained RRT incidence rates per million population by 5-year age groups and sex using data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, and used these to estimate the cumulative incidence of RRT, adjusting for competing mortality risk. Lifetime risk of RRT varied from 0.44% to 2.05% at age 20 years and from 0.17% to 1.59% at age 70 years across countries, and was twice as high in men as in women. Lifetime RRT risk decreased with age, ranging from an average of 0.77% to 0.44% in 20- to- 70-year-old women, and from 1.45% to 0.96% in 20- to- 70-year-old men. The lifetime risk of RRT increased slightly over the past decade, more so in men than in women. However, it appears to have stabilized or even decreased slightly in more recent years. The lifetime risk of RRT decreased with age, was lower in women as compared with men of equal age and varied considerably throughout Europe. Given the substantial differences in lifetime risk of RRT between the USA and Europe, country-specific estimates should be used in the evaluation and communication of the risk of RRT for potential living kidney donors. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

A prospective 10-year study of individualized, intensified enzyme replacement therapy in advanced Fabry disease.

PubMed

Schiffmann, Raphael; Swift, Caren; Wang, Xuan; Blankenship, Derek; Ries, Markus

2015-11-01

To test the hypothesis that more frequent enzyme replacement therapy (ERT) slows the decline in kidney function in adult patients with Fabry disease. A single center open label 10-year prospective clinical trial of 12 patients with advanced Fabry disease who, after having experienced an ongoing decline in renal function after 2-4 years of receiving ERT at the approved dose of 0.2 mg/kg agalsidase alfa every other week (EOW), were switched to weekly (EW) ERT at the same dose. We used linear regression to fit each individual patient's longitudinal estimated glomerular filtration rate (eGFR) record in order to compare the deterioration rates between EOW and EW ERT. For the entire group, mean slope on agalsidase alfa every 2 weeks was -7.92 ± 2.88 ml/min/1.73 m(2)/year and 3.84 ± 4.08 ml/min/1.73 m(2)/year on weekly enzyme infusions (p = 0.01, two-tailed paired t test). Three patients (25 %) completed the entire study with relatively preserved renal function while 50 % of patients reached end-stage renal disease (ESRD) during the 10 years of this study. The estimated average delay to ESRD was 13.8 years [n = 11; 95 % CI 0.66, 27]. One patient had a positive eGFR slope on weekly infusions while the patient with the highest antibody titer had a steeper slope after switching. Mean globotriaosylceramide concentrations in urine and plasma as well as urine protein excretion remained unchanged. Weekly enzyme infusions slow the decline of renal function in a subgroup of more severe patients thus showing that existing ERT can be further optimized.

Determinants of anxiety in patients with advanced somatic disease: differences and similarities between patients undergoing renal replacement therapies and patients suffering from cancer.

PubMed

Janiszewska, Justyna; Lichodziejewska-Niemierko, Monika; Gołębiewska, Justyna; Majkowicz, Mikołaj; Rutkowski, Bolesław

2013-10-01

Anxiety is the most frequent emotional reaction to the chronic somatic disease. However, little is known about anxiety and coping strategies in patients with end-stage renal disease (ESRD) undergoing renal replacement therapies (RRTs). The purpose of the study was to assess the intensity and determinants of anxiety in patients treated with different RRTs in comparison with end-stage breast cancer patients and healthy controls. The study involved (1) ESRD patients undergoing different RRTs: 32 renal transplant recipients, 31 maintenance haemodialysis and 21 chronic peritoneal dialysis patients, (2) women with end-stage breast cancer (n = 25) and (3) healthy persons (n = 55). We used State-Trait Anxiety Inventory, Scale of Personal Religiousness, Mental Adjustment to Cancer Scale, Rotterdam Symptom Checklist with reference to medical history. The data thus obtained were analysed using the analysis of variance, the Tukey's HSD post hoc test and Spearman's rank correlation coefficient. Both ESRD and breast cancer patients revealed higher level of anxiety state and trait than healthy controls; however, there was no statistically significant difference found between both findings. There was a tendency towards higher levels of anxiety state in breast cancer patients when compared to ESRD patients undergoing the RRT treatment and for both groups non-constructive coping strategies correlated with the levels of anxiety state. With ESRD patients undergoing RRTs, the intensity of anxiety state did not depend on the mode of treatment but on the correlation between the levels of anxiety and the general quality of their life, psychological condition and social activity. In patients with advanced somatic disease (ESRD and end-stage breast cancer), non-constructive strategies of coping with the disease require further evaluation and possibly psychological support.

Economic impact of a modification of the treatment trajectories of patients with end-stage renal disease

PubMed Central

Couchoud, Cécile; Couillerot, Anne-Line; Dantony, Emmanuelle; Elsensohn, Mad-Hélénie; Labeeuw, Michel; Villar, Emmanuel; Ecochard, René; Bongiovanni, Isabelle

2015-01-01

Background This study assumed that some patients currently treated at hospital-based haemodialysis centres can be treated with another renal replacement therapy (RRT) modality without any increase in mortality risk and sought to evaluate the monthly cost impact of replacing hospital-based haemodialysis, for which fees are highest, by different proportions of other modalities. Methods We used a deterministic model tool to predict the outcomes and trajectories of hypothetical cohorts of incident adult end-stage renal disease (ESRD) patients for 15 years of RRT (10 different modalities). Our estimates were based on data from 67 258 patients in the REIN registry and 65 662 patients in the French national health insurance information system. Patients were categorized into six subcohorts, stratified for age and diabetes at ESRD onset, and analyses run for each subcohort. We simulated new strategies of care by changing any or all of the following: initial distributions in treatment modalities, transition rates and some costs. Strategies were classified according to their monthly per-patient cost compared to current practices (cost-minimization analysis). Results Simulations of the status quo for the next 15 years predicted a per-patient monthly cost of €2684 for a patient aged 18–45 years without diabetes and €7361 for one older than 70 years with diabetes. All of the strategies we analysed had monthly per-patient costs lower than the status quo, except for daily home HD. None impaired expected survival. Savings varied by strategy. Conclusions Alternative strategies may well be less expensive than current practices. The decision to implement new strategies must nonetheless consider the number of patients concerned, feasibility of renal care reorganization, and investment costs. It must also take into account the role of patients' choice and the availability of professionals. PMID:26268714

Tourniquet-induced rhabdomyolysis after total knee replacement.

PubMed Central

Palmer, S. H.; Graham, G.

1994-01-01

A case is described of a patient who developed rhabdomyolysis and acute renal failure after the use of an intraoperative tourniquet for elective orthopaedic surgery. A review of the literature revealed four similar cases in the last 20 years. The clinical features and management of such patients are discussed. PMID:7702328

Treatment of Renal Calculi with Extracorporeal Shock Wave Lithotripsy

PubMed Central

Eberwein, P. M.; Denstedt, J. D.

1992-01-01

In 12 years, extracorporeal shock wave lithotripsy has replaced other treatment techniques for most surgical calculi in the upper urinary tract. Worldwide clinical series have documented its efficacy. Technological advances and modifications have significantly expanded the clinical applications of this technique. Imagesp1673-aFigure 3 PMID:21221368

Renal amyloidosis: current views on pathogenesis and impact on diagnosis.

PubMed

Herrera, Guillermo A; Teng, Jiamin; Turbat-Herrera, Elba A

2011-01-01

The amyloidoses constitute a group of diseases in which misfolding of extracellular proteins plays a fundamental role. The aggregation of normally soluble proteins into insoluble unbranching fibrils is the basic underlying pathology in amyloidosis. The process of amyloid formation generates toxic insoluble (in saline) protein aggregates that are deposited in tissues in the form of β- pleated sheets of fibrillary material. The amyloidoses are considered to be part of the so-called protein storage diseases (protein thesauroses). In addition, due to the unusual protein folding associated with amyloid, this group of diseases has been referred to as conformational and protein folding disorders. For many years amyloidosis was considered an extremely rare, somewhat mysterious disease. However, in recent years its pathogenesis, particularly that of renal amyloidosis, has been carefully dissected in the research laboratory using in vitro and, to a lesser extent, in vivo models. These have provided a molecular understanding of sequential events that take place in the renal mesangium leading to the formation of amyloid fibrils and eventual extrusion into the mesangial matrix, which itself becomes seriously damaged and, in due time, replaced by the fibrillary material. Amyloid, once considered to be an 'inert' substance, has been proven to be involved in crucial biological processes that result in the destruction and eventual replacement of normal renal constituents. Although there are more than two dozen recognized amyloid precursor proteins (and new ones being added to the list) that can be involved in the genesis of amyloid fibrils, the pathophysiologic mechanisms that occur in the renal mesangium are likely to be very similar, if not the same, regardless of the type of amyloidosis. Likewise, the same is true of amyloid formation in the renal vasculature. Mesangial cells are essentially smooth muscle cells and the events that take place in the mesangium and vasculature (where smooth muscle cells and/or pericytes are present) in the entire body responsible for the formation of amyloid are the same. In the renal interstitium, fibroblasts likely participate in the formation of amyloid, following a similar sequence of events as smooth muscle cells. Although much of the information gathered has been from in vitro systems, an in vivo model of renal amyloidosis has recently been designed to study renal amyloidogenesis. Crucial steps in the cascade of events that result in the formation of amyloid fibrils have been elucidated in the laboratory. The information that has been gathered regarding the pathogenesis of amyloidosis has been translated to the clinical arena where implementation of new therapeutic approaches is beginning to occur. Additional molecular-based therapies will be implemented in the near future. Copyright © 2011 S. Karger AG, Basel.

Regenerating the kidney using human pluripotent stem cells and renal progenitors.

PubMed

Becherucci, Francesca; Mazzinghi, Benedetta; Allinovi, Marco; Angelotti, Maria Lucia; Romagnani, Paola

2018-06-25

Introduction Chronic kidney disease is a major healthcare problem worldwide and its cost is becoming no longer affordable. Indeed, restoring damaged renal structures or building a new kidney represent an ambitious and ideal alternative to renal replacement therapy. Streams of research have explored the possible application of pluripotent SCs (embryonic SCs and induced pluripotent SCs) in different strategies aimed at regenerate functioning nephrons and at understanding the mechanisms of kidney regeneration. Areas covered In this review, we will focus on the main potential applications of human pluripotent SCs to kidney regeneration, including those leading to rebuilding new kidneys or part of them (organoids, scaffolds, biological microdevices) as well as those aimed at understanding the pathophysiological mechanisms of renal disease and regenerative processes (modeling of kidney disease, genome editing). Moreover, we will discuss the role of endogenous renal progenitors cells in order to understand and promote kidney regeneration, as an attractive alternative to pluripotent SCs. Expert opinion Opportunities and pitfalls of all these strategies will be underlined, finally leading to the conclusion that a deeper knowledge of the biology of pluripotent SCs is mandatory, in order to allow us to hypothesize their clinical application.

The cytoskeleton as a novel target for treatment of renal fibrosis.

PubMed

Parrish, Alan R

2016-10-01

The incidence of chronic kidney disease (CKD) is increasing, with an estimated prevalence of 12% in the United States (Synder et al., 2009). While CKD may progress to end-stage renal disease (ESRD), which necessitates renal replacement therapy, i.e. dialysis or transplantation, most CKD patients never reach ESRD due to the increased risk of death from cardiovascular disease. It is well-established that regardless of the initiating insult - most often diabetes or hypertension - fibrosis is the common pathogenic pathway that leads to progressive injury and organ dysfunction (Eddy, 2014; Duffield, 2014). As such, there has been extensive research into the molecular and cellular mechanisms of renal fibrosis; however, translation to effective therapeutic strategies has been limited. While a role for the disruption of the cytoskeleton, most notably the actin network, has been established in acute kidney injury over the past two decades, a role in regulating renal fibrosis and CKD is only recently emerging. This review will focus on the role of the cytoskeleton in regulating pro-fibrotic pathways in the kidney, as well as data suggesting that these pathways represent novel therapeutic targets to manage fibrosis and ultimately CKD. Copyright © 2016. Published by Elsevier Inc.

Renal function improves with the treatment of hypothyroidism.

PubMed

Bulur, Oktay; Dal, Kursat; Ertugrul, Derun Taner; Eser, Murat; Kaplan Efe, Fatma; Karakaya, Serdar; Şahin, Kubilay; Baser, Salih; Ata, Naim; Aybal Kutlugun, Aysun; Beyan, Esin

2017-08-01

It has been known that thyroid hormones may affect renal function. In this study, we aimed to investigate the effect of levothyroxine replacement on renal function in hypothyroid patients before and after treatment. We retrospectively investigated free T3 (fT3), free T4 (fT4), TSH, creatinine, and eGFR measurements during both hypothyroid and euthyroid states of hypothyroid patients. The eGFR was calculated using the simplified Modification of Diet in Renal Disease formula. fT3, fT4, and eGFR measurements increased, meanwhile creatinine and TSH levels decreased significantly after euthyroidism was achieved with levothyroxine treatment (p < 0.0001 for all). The correlation analyses revealed that ∆creatinine and ∆TSH levels were significantly correlated before and after levothyroxine treatment (r: 0.288, p < 0.0001). ∆eGFR and ∆TSH levels were significantly correlated before and after LT4 treatment (r: -0.272, p < 0.0001). In this study, we evaluated creatinine and eGFR levels in patients with hypothyroidism and found out that renal function improved in most patients after euthyroidism was achieved. In some patients, above-normal creatinine levels completely returned to normal once the patients became euthyroid.

[Review of the knowledge on acute kidney failure in the critical patient].

PubMed

Romero García, M; Delgado Hito, P; de la Cueva Ariza, L

2013-01-01

Acute renal failure affects from 1% to 25% of patients admitted to intensive care units. These figures vary depending on the population studied and criteria. The complications of acute renal failure (fluid overload, metabolic acidosis, hyperkalemia, bleeding) are treated. However, mortality remains high despite the technological advances of recent years because acute renal failure is usually associated with sepsis, respiratory failure, serious injury, surgical complications or consumption coagulopathy. Mortality ranges from 30% to 90%. Although there is no universally accepted definition, the RIFLE classification gives us an operational tool to define the degree of acute renal failure and to standardize the initiation of renal replacement techniques as well as to evaluate the results. Therefore, nurses working within the intensive care unit must be familiar with this disease, with its treatment (drug or alternative) and with the prevention of possible complications. Equally, they must be capable of detecting the manifestations of dependency each one of the basic needs and to be able to identify the collaboration problems in order to achieve an individualized care plan. Copyright © 2012 Elsevier España, S.L. y SEEIUC. All rights reserved.

Stenting and medical therapy for atherosclerotic renal-artery stenosis.

PubMed

Cooper, Christopher J; Murphy, Timothy P; Cutlip, Donald E; Jamerson, Kenneth; Henrich, William; Reid, Diane M; Cohen, David J; Matsumoto, Alan H; Steffes, Michael; Jaff, Michael R; Prince, Martin R; Lewis, Eldrin F; Tuttle, Katherine R; Shapiro, Joseph I; Rundback, John H; Massaro, Joseph M; D'Agostino, Ralph B; Dworkin, Lance D

2014-01-02

Atherosclerotic renal-artery stenosis is a common problem in the elderly. Despite two randomized trials that did not show a benefit of renal-artery stenting with respect to kidney function, the usefulness of stenting for the prevention of major adverse renal and cardiovascular events is uncertain. We randomly assigned 947 participants who had atherosclerotic renal-artery stenosis and either systolic hypertension while taking two or more antihypertensive drugs or chronic kidney disease to medical therapy plus renal-artery stenting or medical therapy alone. Participants were followed for the occurrence of adverse cardiovascular and renal events (a composite end point of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal-replacement therapy). Over a median follow-up period of 43 months (interquartile range, 31 to 55), the rate of the primary composite end point did not differ significantly between participants who underwent stenting in addition to receiving medical therapy and those who received medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94; 95% confidence interval [CI], 0.76 to 1.17; P=0.58). There were also no significant differences between the treatment groups in the rates of the individual components of the primary end point or in all-cause mortality. During follow-up, there was a consistent modest difference in systolic blood pressure favoring the stent group (-2.3 mm Hg; 95% CI, -4.4 to -0.2; P=0.03). Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease. (Funded by the National Heart, Lung and Blood Institute and others; ClinicalTrials.gov number, NCT00081731.).

Urine output on an intensive care unit: case-control study

PubMed Central

Kirwan, Christopher J; Alexander, Neal D E; Nimako, Kofi; Jurukov, Angela; Forth, Rebecca J; Rahman, Tony M

2010-01-01

Objective To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. Design Case-control study. Setting General intensive care unit in a tertiary referral hospital. Participants 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as “cases.” Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m2, and renal replacement therapy. Main outcome measures Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. Results Doctors were classed as oliguric and “at risk” of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being “in injury” on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). Conclusions Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit. PMID:21156738

Deciding in the dark: advance directives and continuation of treatment in chronic critical illness.

PubMed

Camhi, Sharon L; Mercado, Alice F; Morrison, R Sean; Du, Qingling; Platt, David M; August, Gary I; Nelson, Judith E

2009-03-01

Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation. Prospective cohort study. Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital. Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit. None. We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3-20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1-127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0-45.0) days after hospital admission and 13 (8.0-29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement. Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.

Increased ICU resource needs for an academic emergency general surgery service*.

PubMed

Lissauer, Matthew E; Galvagno, Samuel M; Rock, Peter; Narayan, Mayur; Shah, Paulesh; Spencer, Heather; Hong, Caron; Diaz, Jose J

2014-04-01

ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Retrospective database review. Academic, tertiary care, nontrauma surgical ICU. All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. None. Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

Reductions in Red Blood Cell 2,3-Diphosphoglycerate Concentration during Continuous Renal Replacment Therapy

PubMed Central

Brugnara, Carlo; Betensky, Rebecca A.; Waikar, Sushrut S.

2015-01-01

Background and objectives Hypophosphatemia is a frequent complication during continuous renal replacement therapy (CRRT), a dialytic technique used to treat AKI in critically ill patients. This study sought to confirm that phosphate depletion during CRRT may decrease red blood cell (RBC) concentration of 2,3-diphosphoglycerate (2,3-DPG), a crucial allosteric effector of hemoglobin’s (Hgb’s) affinity for oxygen, thereby leading to impaired oxygen delivery to peripheral tissues. Design, setting, participants, & measurements Phosphate mass balance studies were performed in 20 patients with severe AKI through collection of CRRT effluent. RBC concentrations of 2,3-DPG, venous blood gas pH, and oxygen partial pressure required for 50% hemoglobin saturation (P50) were measured at CRRT initiation and days 2, 4, and 7. Similar measurements were obtained on days 0 and 2 in a reference group of 10 postsurgical patients, most of whom did not have AKI. Associations of 2,3-DPG with laboratory parameters and clinical outcomes were examined using mixed-effects and Cox regression models. Results Mean 2,3-DPG levels decreased from a mean (±SD) of 13.4±3.4 µmol/g Hgb to 11.0±3.1 µmol/g Hgb after 2 days of CRRT (P<0.001). Mean hemoglobin saturation P50 levels decreased from 29.7±4.4 mmHg to 26.7±4.0 mmHg (P<0.001). No significant change was seen in the reference group. 2,3-DPG levels after 2 days of CRRT were not significantly lower than those in the reference group on day 2. Among patients receiving CRRT, 2,3-DPG decreased by 0.53 µmol/g Hgb per 1 g phosphate removed (95% confidence interval 0.38 to 0.68 µmol/g Hgb; P<0.001). Greater reductions in 2,3-DPG were associated with higher risk for death (hazard ratio, 1.43; 95% confidence interval, 1.09 to 1.88; P=0.01). Conclusions CRRT-induced phosphate depletion is associated with measurable reductions in RBC 2,3-DPG concentration and a shift in the O2:Hgb affinity curve even in the absence of overt hypophosphatemia. 2,3-DPG reductions may be associated with higher risk for in-hospital death and represent a potentially avoidable complication of CRRT. PMID:25538269

Reductions in red blood cell 2,3-diphosphoglycerate concentration during continuous renal replacment therapy.

PubMed

Sharma, Shilpa; Brugnara, Carlo; Betensky, Rebecca A; Waikar, Sushrut S

2015-01-07

Hypophosphatemia is a frequent complication during continuous renal replacement therapy (CRRT), a dialytic technique used to treat AKI in critically ill patients. This study sought to confirm that phosphate depletion during CRRT may decrease red blood cell (RBC) concentration of 2,3-diphosphoglycerate (2,3-DPG), a crucial allosteric effector of hemoglobin's (Hgb's) affinity for oxygen, thereby leading to impaired oxygen delivery to peripheral tissues. Phosphate mass balance studies were performed in 20 patients with severe AKI through collection of CRRT effluent. RBC concentrations of 2,3-DPG, venous blood gas pH, and oxygen partial pressure required for 50% hemoglobin saturation (P50) were measured at CRRT initiation and days 2, 4, and 7. Similar measurements were obtained on days 0 and 2 in a reference group of 10 postsurgical patients, most of whom did not have AKI. Associations of 2,3-DPG with laboratory parameters and clinical outcomes were examined using mixed-effects and Cox regression models. Mean 2,3-DPG levels decreased from a mean (±SD) of 13.4±3.4 µmol/g Hgb to 11.0±3.1 µmol/g Hgb after 2 days of CRRT (P<0.001). Mean hemoglobin saturation P50 levels decreased from 29.7±4.4 mmHg to 26.7±4.0 mmHg (P<0.001). No significant change was seen in the reference group. 2,3-DPG levels after 2 days of CRRT were not significantly lower than those in the reference group on day 2. Among patients receiving CRRT, 2,3-DPG decreased by 0.53 µmol/g Hgb per 1 g phosphate removed (95% confidence interval 0.38 to 0.68 µmol/g Hgb; P<0.001). Greater reductions in 2,3-DPG were associated with higher risk for death (hazard ratio, 1.43; 95% confidence interval, 1.09 to 1.88; P=0.01). CRRT-induced phosphate depletion is associated with measurable reductions in RBC 2,3-DPG concentration and a shift in the O2:Hgb affinity curve even in the absence of overt hypophosphatemia. 2,3-DPG reductions may be associated with higher risk for in-hospital death and represent a potentially avoidable complication of CRRT. Copyright © 2015 by the American Society of Nephrology.

Total Laparoscopic Hysterectomy in the Setting of Prior Bilateral Renal Transplant, a Case Report and Review of the Literature.

PubMed

Tamhane, Nupur; Al Sawah, Entidhar; Mikhail, Emad

2018-06-01

In recent years, more women are undergoing renal transplantation as a treatment for end-stage renal disease. Women with kidney transplants are prone to certain gynecologic issues which might necessitate hysterectomy. Laparoscopic hysterectomy can safely be performed in patients with prior unilateral or bilateral renal transplantation. Laparoscopy offers magnification of anatomy, decreased wound-related problems, and continuation of immunosuppression therapy. We present a case report and review of the literature for total laparoscopic hysterectomy and bilateral salpingectomy for a patient with prior bilateral renal transplant.

[Chronic kidney disease and dyslipidaemia].

PubMed

Pascual, Vicente; Serrano, Adalberto; Pedro-Botet, Juan; Ascaso, Juan; Barrios, Vivencio; Millán, Jesús; Pintó, Xavier; Cases, Aleix

Chronic kidney disease (CKD) has to be considered as a high, or even very high risk cardiovascular risk condition, since it leads to an increase in cardiovascular mortality that continues to increase as the disease progresses. An early diagnosis of CKD is required, together with an adequate identification of the risk factors, in order to slow down its progression to more severe states, prevent complications, and to delay, whenever possible, the need for renal replacement therapy. Dyslipidaemia is a factor of the progression of CKD that increases the risk in developing atherosclerosis and its complications. Its proper control contributes to reducing the elevated cardiovascular morbidity and mortality presented by these patients. In this review, an assessment is made of the lipid-lowering therapeutic measures required to achieve to recommended objectives, by adjusting the treatment to the progression of the disease and to the characteristics of the patient. In CKD, it seems that an early and intensive intervention of the dyslipidaemia is a priority before there is a significant decrease in kidney function. Treatment with statins has been shown to be safe and effective in decreasing LDL-Cholesterol, and in the reduction of cardiovascular events in individuals with CKD, or after renal transplant, although there is less evidence in the case of dialysed patients. Copyright © 2016 Sociedad Española de Arteriosclerosis. Publicado por Elsevier España, S.L.U. All rights reserved.

Bioartificial organ support for hepatic, renal, and hematologic failure.

PubMed

Maguire, P J; Stevens, C; Humes, H D; Shander, A; Halpern, N A; Pastores, S M

2000-10-01

The current strategy to the treatment of SIRS and MODS uses a multidisciplinary approach that emphasizes supportive therapy. Herein, we have presented a futuristic approach that focuses on replacing the function of failed organs using bioartificial technology (Table 1). Bioartificial organ technology may allow the intensivist to provide physiologic organ replacement either as a bridge to transplantation or as a "time-buying" element until native organs that have become acutely dysfunctional or nonfunctional in a variety of clinical settings, can recover their function or regenerate their mass. As bioartificial organ technology matures, it is conceivable as an ultimate goal that non-immunogenic bioartificial organs would be miniaturized or redesigned and acutely placed within the intracorporeal space as replacement organs.

Arteriovenous fistula and prolonged hematuria after renal biopsy: treatment with epsilon aminocaproic acid

PubMed Central

Silverberg, D. S.; Dossetor, J. B.; Eid, T. C.; Mant, M. J.; Miller, J. D. R.

1974-01-01

A patient with membranoproliferative glomerulonephritis and mild hypertension is described who, after a renal biopsy, developed an arteriovenous fistula and then severe continuous hematuria from the seventh to the 38th postbiopsy day. Treatment with epsilon aminocaproic acid was associated with rapid and permanent cessation of bleeding, gradual improvement in renal function, and disappearance of the renal artery bruit. No complications were encountered. ImagesFIG. 2FIG. 3FIG. 4FIG. 5FIG. 6 PMID:4817213

Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction.

PubMed

Ruano, Rodrigo; Safdar, Adnan; Au, Jason; Koh, Chester J; Gargollo, Patricio; Shamshirsaz, Alireza A; Espinoza, Jimmy; Cass, Darrell L; Olutoye, Oluyinka O; Olutoye, Olutoyin A; Welty, Stephen; Roth, David R; Belfort, Michael A; Braun, Michael C

2016-04-01

The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.

The lectin pathway in renal disease: old concept and new insights.

PubMed

Gaya da Costa, Mariana; Poppelaars, Felix; Berger, Stefan P; Daha, Mohamed R; Seelen, Marc A

2018-04-26

The complement system is composed of a network of at least 40 proteins, which significantly contributes to health and disease. The lectin pathway (LP) is one of three pathways that can activate the complement system. Next to protection of the host against pathogens, the LP has been shown to play a crucial role in multiple renal diseases as well as during renal replacement therapy. Therefore, several complement-targeted drugs are currently being explored in clinical trials. Among these complement inhibitors, specific LP inhibitors are also being tested in renal abnormalities such as in immunoglobulin A nephropathy and lupus nephritis. Using various in vitro models, Yaseen et al. (Lectin pathway effector enzyme mannan-binding lectin-associated serine protease-2 can activate native complement component 3 (C3) in absence of C4 and/or C2. FASEB J 2017; 31: 2210-2219) showed that Mannan-associated serine protease2 can directly activate C3 thereby bypassing C2 and C4 in the activation of the LP. These new findings broaden our understanding of the mechanisms of complement activation and could potentially impact our strategies to inhibit the LP in renal diseases. In support of these findings, we present data of human renal biopsies, demonstrating the occurrence of the LP bypass mechanism in vivo. In conclusion, this review provides a detailed overview of the LP and clarifies the recently described bypass mechanism and its relevance. Finally, we speculate on the role of the C4 bypass mechanism in other renal diseases.

Evaluating the benefits of home-based peritoneal dialysis

PubMed Central

François, Karlien; Bargman, Joanne M

2014-01-01

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy. PMID:25506238

From the Cover: Cell-replacement therapy for diabetes: Generating functional insulin-producing tissue from adult human liver cells

NASA Astrophysics Data System (ADS)

Sapir, Tamar; Shternhall, Keren; Meivar-Levy, Irit; Blumenfeld, Tamar; Cohen, Hamutal; Skutelsky, Ehud; Eventov-Friedman, Smadar; Barshack, Iris; Goldberg, Iris; Pri-Chen, Sarah; Ben-Dor, Lya; Polak-Charcon, Sylvie; Karasik, Avraham; Shimon, Ilan; Mor, Eytan; Ferber, Sarah

2005-05-01

Shortage in tissue availability from cadaver donors and the need for life-long immunosuppression severely restrict the large-scale application of cell-replacement therapy for diabetic patients. This study suggests the potential use of adult human liver as alternate tissue for autologous beta-cell-replacement therapy. By using pancreatic and duodenal homeobox gene 1 (PDX-1) and soluble factors, we induced a comprehensive developmental shift of adult human liver cells into functional insulin-producing cells. PDX-1-treated human liver cells express insulin, store it in defined granules, and secrete the hormone in a glucose-regulated manner. When transplanted under the renal capsule of diabetic, immunodeficient mice, the cells ameliorated hyperglycemia for prolonged periods of time. Inducing developmental redirection of adult liver offers the potential of a cell-replacement therapy for diabetics by allowing the patient to be the donor of his own insulin-producing tissue. pancreas | transdifferentiation

Inclusion and definition of acute renal dysfunction in critically ill patients in randomized controlled trials: a systematic review.

PubMed

da Hora Passos, Rogerio; Ramos, Joao Gabriel Rosa; Gobatto, André; Caldas, Juliana; Macedo, Etienne; Batista, Paulo Benigno

2018-04-24

In evidence-based medicine, multicenter, prospective, randomized controlled trials (RCTs) are the gold standard for evaluating treatment benefits and ensuring the effectiveness of interventions. Patient-centered outcomes, such as mortality, are most often the preferred evaluated outcomes. While there is currently agreement on how to classify renal dysfunction in critically ill patients , the application frequency of this new classification system in RCTs has not previously been evaluated. In this study, we aim to assess the definition of renal dysfunction in multicenter RCTs involving critically ill patients that included mortality as a primary endpoint. A comprehensive search was conducted for publications reporting multicenter randomized controlled trials (RCTs) involving adult patients in intensive care units (ICUs) that included mortality as a primary outcome. MEDLINE and PUBMED were queried for relevant articles in core clinical journals published between May 2004 and December 2017. Of 418 articles reviewed, 46 multicenter RCTs with a primary endpoint related to mortality were included. Thirty-six (78.3%) of the trial reports provided information on renal function in the participants. Only seven articles (15.2%) included mean or median serum creatinine levels, mean creatinine clearance or estimated glomerular filtration rates. Sequential organ failure assessment (SOFA) score was the most commonly used definition of renal dysfunction (20 studies; 43.5%). Risk, Injury, Failure, Loss, End-stage renal disease (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria were used in five (10.9%) trials. In thirteen trials (28.3%), no renal dysfunction criteria were reported. Only one trial excluded patients with renal dysfunction, and it used urinary output or need for renal replacement therapy (RRT) as criteria for this diagnosis. The presence of renal dysfunction was included as a baseline patient characteristic in most RCTs. The RIFLE, AKIN and KDIGO classification systems were infrequently used; renal dysfunction was generally defined using the SOFA score.

Total Artificial Heart and Chronic Haemodialysis: A Possible Bridge to Transplantation?

PubMed

Demiselle, Julien; Besson, Virginie; Sayegh, Johnny; Subra, Jean-François; Augusto, Jean-François

2016-01-01

Total artificial heart (TAH) device is sometimes necessary to treat end stage heart failure (HF). After surgery, renal impairment can occur with the need of renal replacement therapy. We report the case of a 51-year-old man who was treated with conventional hemodialysis (HD) while on support with TAH. The patient underwent HD while on TAH support during 14 months. He benefited from conventional HD, 6 sessions per week. HD sessions were well tolerated, and patient's condition and quality of life improved significantly. The main difficulty was to maintain red blood cell level because of chronic hemolysis due to TAH, which required repetitive blood transfusions, resulting in a high rate of human leukocyte antigen sensitization. Unfortunately, the patient died of mesenteric ischemia due to anticoagulation under dosing. We conclude that HD treatment is possible despite TAH and should be considered in patients with both end stage renal and HF. © 2016 S. Karger AG, Basel.

Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management

PubMed Central

Gorbatkin, Chad; Finkelstein, Fredric O.; Gorbatkin, Steven M.

2018-01-01

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities. PMID:29760854

Pharmacokinetics and hemostasis following administration of a new, injectable oxacephem (6315-S, flomoxef) in volunteers and in patients with renal insufficiency.

PubMed

Andrassy, K; Koderisch, J; Gorges, K; Sonntag, H; Hirauchi, K

1991-01-01

Flomoxef is a new oxacephem of broad antibacterial activity. The compound is mainly excreted through the kidneys. Two dose finding studies in patients with various degrees of renal insufficiency revealed that the dosage of flomoxef has to be reduced exactly according to the renal function. Although the N-methylthiotetrazole group has been replaced by a hydroxyethyl group, an inhibitory effect of flomoxef on vitamin K metabolism persisted. This effect was, however, less pronounced than with latamoxef. Only patients with low vitamin K stores are endangered. For those in whom low vitamin K stores are suspected repeated controls of prothrombin time are advised during the treatment. In contrast to latamoxef the platelet system was not affected by flomoxef. With the exception of loose stools in some patients no other clinical side effects during treatment were observed.

Aortoiliac aneurysm with congenital right pelvic kidney.

PubMed

Date, Kazuma; Okada, Shuuichi; Ezure, Masahiko; Takihara, Hitomi; Okonogi, Shuuichi; Hasegawa, Yutaka; Sato, Yasushi; Kaneko, Tatsuo

2015-05-01

The association of congenital pelvic kidney with abdominal aortoiliac aneurysm is an extremely rare clinical finding. Previous reports have described various methods of aneurysm repair with successful preservation of the function of pelvic kidney. However, to our knowledge, reconstruction of more than two renal arteries has not been established. We report a case of abdominal aortic aneurysm complicated by congenital right pelvic kidney in a 72-year-old man. Computed tomography (CT) revealed an abdominal aortic aneurysm with a maximum diameter of 54 mm and a right common iliac aneurysm of 45 mm. In addition, he had a congenital right pelvic kidney and CT angiography identified three right pelvic renal arteries. The upper artery originated from the bifurcation of the terminal aorta and the lower two originated from the right common iliac artery. Three-dimensional CT was helpful for the accurate planning of the operation. Open surgical repair of the aortoiliac aneurysm with a Dacron bifurcated graft replacement was decided and reimplantation of all three right pelvic kidney arteries to the right limb of the graft was also performed. For renal preservation, the right pelvic kidney arteries were perfused with cold Ringer's lactate using a rapid infusion pump and coronary perfusion cannula. The patient's postoperative course was uneventful, and worsening of renal function was not observed. The perfusion of renal arteries with cold Ringer's solution was thought to be a simple and appropriate procedure for renal protection.

[State of the art in fluid and volume therapy : A user-friendly staged concept].

PubMed

Rehm, M; Hulde, N; Kammerer, T; Meidert, A S; Hofmann-Kiefer, K

2017-03-01

Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient's preoperative normovolemia by using a sophisticated, rational infusion strategy.Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5-1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient's blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.

Use, misuse and abuse of diuretics.

PubMed

Bartoli, Ettore; Rossi, Luca; Sola, Daniele; Castello, Luigi; Sainaghi, Pier Paolo; Smirne, Carlo

2017-04-01

Resolution of edema requires a correct interpretation of body fluids-related renal function, to excrete the excess volume while restoring systemic hemodynamics and avoiding renal failure. In heart failure, the intensive diuresis should be matched by continuous fluids refeeding from interstitium to plasma, avoiding central volume depletion. The slowly reabsorbed ascites cannot refeed this contracted volume in cirrhosis: the ensuing activation of intrathoracic receptors, attended by increased adrenergic and Renin release, causes more avid sodium retention, producing a positive fluid and Na balance in the face of continuous treatment. High-dose-furosemide creates a defect in tubular Na causing diuresis adequate to excrete the daily water and electrolyte load in Chronic Renal Failure. Diuretic treatment requires care, caution and bedside "tricks" aimed at minimizing volume contraction by correctly assessing the homeostatic system of body fluids and related renal hemodynamics. Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

The possibility of renal function recovery in chronic hemodialysis patients should not be overlooked: Single center experience.

PubMed

Letachowicz, Krzysztof; Madziarska, Katarzyna; Letachowicz, Waldemar; Krajewska, Magdalena; Penar, Józef; Kusztal, Mariusz; Gołębiowski, Tomasz; Weyde, Wacław; Klinger, Marian

2016-04-01

Chronic hemodialysis is implemented when irreversible loss of kidney function occurs. Sometimes renal recovery is overlooked. From January 2005 to December 2014, we identified 28 patients hemodialyzed for more than 3 months who had renal replacement therapy discontinued. The group consisted of 17 (57.7%) males and 11 (42.3%) females. Patients were 18-87 years old. Time of hemodialysis ranged from 3 to 97 months. Of note, 14 (50%) patients were referred from local dialysis units for solution of vascular access problems. In 13 (46.2%) patients dialysis was abandoned within the first 6 months, in 5 (17.8%) patients between 6 and 12 months, and in 10 (35.7%) patients beyond 12 months. Estimated dialysis-free survival was 94.4% (SE 0.054) and 82% (SE 0.095) at 12 and 24 months, respectively. All physicians must be aware of possible kidney function improvement. In patients with preserved diuresis fall in periodical urea or creatinine measurements might be a sign of renal recovery. © 2015 International Society for Hemodialysis.

Protective effect of C-peptide on experimentally induced diabetic nephropathy and the possible link between C-peptide and nitric oxide.

PubMed

Elbassuoni, Eman A; Aziz, Neven M; El-Tahawy, Nashwa F

2018-06-01

Diabetic nephropathy one of the major microvascular diabetic complications. Besides hyperglycemia, other factors contribute to the development of diabetic complications as the proinsulin connecting peptide, C-peptide. We described the role of C-peptide replacement therapy on experimentally induced diabetic nephropathy, and its potential mechanisms of action by studying the role of nitric oxide (NO) as a mediator of C-peptide effects by in vivo modulating its production by N G -nitro-l-arginine methyl ester (L-NAME). Renal injury markers measured were serum urea, creatinine, tumor necrosis factor alpha, and angiotensin II, and malondialdehyde, total antioxidant, Bcl-2, and NO in renal tissue. In conclusion, diabetic induction resulted in islet degenerations and decreased insulin secretion with its metabolic consequences and subsequent renal complications. C-Peptide deficiencies in diabetes might have contributed to the metabolic and renal error, since C-peptide treatment to the diabetic rats completely corrected these errors. The beneficial effects of C-peptide are partially antagonized by L-NAME coadministration, indicating that NO partially mediates C-peptide effects.

Multiple variations of the coeliac axis, hepatic and renal vasculature as incidental findings illustrated by MDCTA.

PubMed

Rafailidis, Vasileios; Papadopoulos, Georgios; Kouskouras, Konstantinos; Chryssogonidis, Ioannis; Velnidou, Anastasia; Kalogera-Fountzila, Anna

2016-08-01

Vascular anatomical variations are not uncommon and may affect any organ's arterial or venous vasculature. The coexistence of variations in different organic systems is less commonly found, but of great clinical significance in a series of clinical conditions like organ transplantation and surgical preoperative planning. Multidetector computed tomography angiography (MDCTA) has emerged as a valuable alternative to the conventional angiography for accurate evaluation of vascular anatomy and pathology. Radiologists should be familiar with each organ's vascular variations and always report them to the clinician, even if they represent an incidental finding. This case report presents a 52-year-old female patient undergoing abdominal MDCTA for characterization of a renal lesion. This examination revealed the presence of three hilar arteries on the left kidney, a main renal vein in combination with an additional renal vein in both sides along with a replaced right hepatic artery originating from the superior mesenteric artery. Moreover, both inferior phrenic arteries were found originating from the coeliac axis. 3D volume rendering technique images were used in the evaluation of vascular anatomy as illustrated in this case report.

Increased Intracranial Pressure during Hemodialysis in a Patient with Anoxic Brain Injury.

PubMed

Lund, Anton; Damholt, Mette B; Strange, Ditte G; Kelsen, Jesper; Møller-Sørensen, Hasse; Møller, Kirsten

2017-01-01

Dialysis disequilibrium syndrome (DDS) is a serious neurological complication of hemodialysis, and patients with acute brain injury are at increased risk. We report a case of DDS leading to intracranial hypertension in a patient with anoxic brain injury and discuss the subsequent dialysis strategy. A 13-year-old girl was admitted after prolonged resuscitation from cardiac arrest. Computed tomography (CT) revealed an inferior vena cava aneurysm and multiple pulmonary emboli as the likely cause. An intracranial pressure (ICP) monitor was inserted, and, on day 3, continuous renal replacement therapy (CRRT) was initiated due to acute kidney injury, during which the patient developed severe intracranial hypertension. CT of the brain showed diffuse cerebral edema. CRRT was discontinued, sedation was increased, and hypertonic saline was administered, upon which ICP normalized. Due to persistent hyperkalemia and overhydration, ultrafiltration and intermittent hemodialysis were performed separately on day 4 with a small dialyzer, low blood and dialysate flow, and high dialysate sodium content. During subsequent treatments, isolated ultrafiltration was well tolerated, whereas hemodialysis was associated with increased ICP necessitating frequent pauses or early cessation of dialysis. In patients at risk of DDS, hemodialysis should be performed with utmost care and continuous monitoring of ICP should be considered.

[Successful continuous renal replacement therapy in a neonate with early-onset group B streptococcal sepsis and multi-organ dysfunction syndrome].

PubMed

von Schnakenburg, C; Hufnagel, M; Superti-Furga, A; Rieger-Fackeldey, E; Berner, R

2009-01-01

Group B streptococcal early-onset sepsis (GBS EOS) in neonates has a mortality rate of approximately 5%, particularly in the presence of multi-organ dysfunction. Fluid management is crucial in these patients, and continuous venovenous haemofiltration (CVVH) should be considered a therapeutic option even in newborn babies. After an uneventful pregnancy within hours after birth, a female term infant presented with dyspnoea, irritability and cyanosis. The systemic inflammatory response syndrome (SIRS) progressed to multi-organ dysfunction with acute respiratory distress syndrome (ARDS), impaired myocardial contractility, pulmonary hypertension and fluid overload. The maximum PRISM score was 51. The child required maximal respiratory and inotropic support with high volume intravenous fluid administration. However, only by using of CVVH from day 5 to 14, we successfully resolved progressive pulmonary and cardiovascular dysfunction. The child improved directly after initiation of fluid removal, was extubated on day 17 and discharged without obvious sequelae on day 57. All microbiology studies revealed GBS. Perinatal GBS-infections remain a major life-threatening event for newborn babies. CVVH should be considered an option for reversing fluid overload even in neonates with overwhelming SIRS. Alternatively, extracorporeal membrane oxygenation (ECMO) is discussed.

Renal calculi in primary hyperaldosteronism.

PubMed Central

Kabadi, U. M.

1995-01-01

Increased urinary calcium (Ca++) excretion and the presence of negative Ca++ balance is well documented in primary hyperaldosteronism. However, renal calculi as a major manifestation of this disorder has not previously been described. This report describes a patient who presented with renal calculi in association with primary hyperaldosteronism. We believe that primary hyperaldosteronism was a major pathogenetic factor in the formation of renal calculi since the increased urinary excretion of Ca++ and uric acid noted at onset declined following a short-term spironolactone administration and remission from renal calculi has persisted following initial nephrolithotomy and continued spironolactone therapy, which also corrected hypertension and hypokalemia, a hallmark of this disorder. Images Figure PMID:7479473

Endovascular repair of abdominal aortic aneurysms in patients with congenital renal vascular anomalies.

PubMed

Kaplan, D B; Kwon, C C; Marin, M L; Hollier, L H

1999-09-01

The endovascular repair of abdominal aortic aneurysms (AAAs) has been suggested as an alternative to conventional aortic reconstruction. The presence of anomalous renal vascular anatomy frequently necessitates special planning during conventional aortic replacement and may also create unique challenges for endovascular repair. We analyzed our experience with 24 patients with variant renal vascular anatomies who underwent treatment with aortic endografts to determine the safety and efficacy of this technique in this population. During a 6-year period, 204 patients underwent aortic endograft procedures, 24 (11.8%) of whom had variations in renal vascular anatomy. There were 19 men and five women. Each of the 24 patients had variant renal vascular anatomy, which was defined by the presence of multiple renal arteries (n = 32), with or without a renal parenchymal anomaly (horseshoe or solitary pelvic kidney). Twenty patients underwent aneurysm repair with balloon expandable polytetrafluoroethylene grafts, and the remaining patients underwent endograft placement with self-expanding attachment systems. Eighteen patients underwent exclusion and presumed thrombosis of anomalous renal branches to effectively attach the aortic endograft. The decision to sacrifice a supernumerary artery was made on the basis of the vessel size (<3 mm), the absence of coexisting renal insufficiency, and the expectation for successful aneurysm exclusion. The successful exclusion of the AAAs was achieved in all the patients, with the loss of a total of 17 renal artery branches in 12 patients. Small segmental renal infarcts (<20%) were detected in only six of the 12 patients with follow-up computed tomographic scan results, despite angiographic evidence of vessel occlusion at the time of endografting. No evidence of new onset hypertension or changes in antihypertensive medication was seen in this group. No retrograde endoleaks were detected through the excluded renal branches on late follow-up computed tomographic scans. Serum creatinine levels before and after endografting were unchanged after the exclusion of the AAA in all but one patient with multiple renal branches. One patient had a transient rise in serum creatinine level presumed to be caused by contrast nephropathy. On the basis of this experience, we recommend the consideration of endovascular grafting for patients with AAAs and anomalous renal vessels when the main renal vascular anatomy can be preserved and when the loss of only small branches (<3 mm) is necessitated in patients with otherwise normal renal functions.

Morphological and clinical aspects of the occurrence of accessory (multiple) renal arteries

PubMed Central

Gulas, Ewelina; Wysiadecki, Grzegorz; Szymański, Jacek; Majos, Agata; Stefańczyk, Ludomir; Topol, Mirosław

2016-01-01

Renal vascularization variants vastly differ between individuals due to the very complex embryogenesis of the kidneys. Moreover, each variant may have implications for clinical and surgical interventions. The number of operating procedures continues to grow, and includes renal transplants, aneurysmorrhaphy and other vascular reconstructions. In any surgical technique, unawareness of the presence of multiple renal arteries may result in a fatal outcome, especially if laparoscopic methods are used. The aim of this review is to comprehensively identify the variation within multiple renal arteries and to highlight the connections between the presence of accessory renal arteries and the coexistence of other variants of vascularization. Another aim is to determine the potential clinical implications of the presence of accessory renal arteries. This study is of particular importance for surgeons, intervention radiologists, nephrologists and vascular surgeons. PMID:29593819

A kidney transplantation model in a low-resource country: an experience from Pakistan.

PubMed

Rizvi, Syed Adibul Hasan; Naqvi, Syed Ali Anwar; Zafar, Mirza Naqi; Akhtar, Syed Fazal

2013-05-01

Pakistan is a low-resource country with a population of 185 million where expenditure on health is 1.3% of the gross national product. The estimated incidence of end-stage renal disease (ESRD) is 100 per million of the population. The paucity and high costs of renal replacement therapy render more than 90% of the ESRD population disenfranchised from replacement therapy. Our center, which is a government sector organization, established as an integrated dialysis and living related renal transplant program in the 1980s, where all services were provided free of cost to all patients with life-long follow-up care including medications. The model was based on a concept of community/government partnership where the contributions to funds vary between 40% and 60% for each partner. The model has been self sustaining for 25 years, with an annual budget of $28 million in 2010. Presently, over 600 patients are dialyzed each day and each week, 7-10 patients have received live related transplants. The overall 1- and 5-year graft survival rate of 3150 transplants is 92% and 85%, respectively. Free dialysis and transplantation established our institute as a focus of transplantation in the country. This model therefore allowed the institute to have a vital role in the campaign against transplant tourism and in the promulgation of the transplant law. It shows that in low-resource countries, specialized centers in the government sector can, with community support, provide high-quality ESRD care to the disenfranchised population.

The need for dialysis in Haiti: dream or reality?

PubMed

Exantus, Judith; Desrosiers, Florence; Ternier, Alexandra; Métayer, Audie; Abel, Gérard; Buteau, Jean-Hénold

2015-01-01

According to the World Health Organization reports, nowadays burden of chronic kidney diseases (CKD) is well documented. The high prevalence of noncommunicable diseases (NCD) such as hypertension, diabetes, and obesity, which are the main causes of CKD, is a big concern in the world health scenario. These NCD can progress slowly to end-stage renal disease (ESRD) and the low-middle income countries (LMIC) like Haiti are not left unscathed by this worldwide scourge. Several well-known public health issues prevalent in Haiti such as acute diarrheal infections, malaria, tuberculosis, cholera, and acquired immunodeficiency syndrome (AIDS), can also impair the function of the kidney. Dialysis, a form of renal replacement therapy (RRT), represents a life-saving therapy for all patients affected with impaired kidney. In Haiti, few patients have access to health insurance or disability financial support. Considering that seventy-two percent (72%) of Haitians live with less than USD 2 per day, survival with CKD can be quite stressful for them. Data on the weight of the dialysis and its management are scarce. Addressing the need for dialysis in Haiti is an important component in decision-making and planning processes in the health sector. This paper is intended to bring forth discussion on the use of this type of renal replacement therapy in Haiti: the past, the present, and the challenges it presents. We will also make some recommendations in order to manage this serious problem. © 2015 S. Karger AG, Basel.

Hemodialysis and peritoneal dialysis are associated with similar outcomes for end-stage renal disease treatment in Canada.

PubMed

Yeates, Karen; Zhu, Naisu; Vonesh, Edward; Trpeski, Lilyanna; Blake, Peter; Fenton, Stanley

2012-09-01

There were 35 265 patients receiving renal replacement therapy in Canada at the end of 2007 with 11.0% of patients on peritoneal dialysis (PD) and 48.9% on hemodialysis (HD) and a remaining 40.1% living with a functioning kidney transplant. There are no contemporary studies examining PD survival relative to HD in Canada. The objective was to compare survival outcomes for incident patients starting on PD as compared to HD in Canada. Using data from the Canadian Organ Replacement Register, the Cox proportional hazards (PH) model was employed to study survival outcomes for patients initiating PD as compared to HD in Canada from 1991 to 2004 with follow-up to 31 December 2007. Comparisons of outcomes were made between three successive calendar periods: 1991-95, 1996-2000 and 2001-04 with the relative risk of death of incident patients calculated using an intent-to-treat (ITT) analysis with proportional and non-PH models using a piecewise exponential survival model to compare adjusted mortality rates. In the ITT analysis, overall survival for the entire study period favored PD in the first 18 months and HD after 36 months. However, for the 2001-04 cohort, survival favored PD for the first 2 years and thereafter PD and HD were similar. Among female patients > 65 years with diabetes, PD had a 27% higher mortality rate. Overall, HD and PD are associated with similar outcomes for end-stage renal disease treatment in Canada.

Renal angiomyolipoma bleeding in a patient with TSC2/PKD1 contiguous gene syndrome after 17 years of renal replacement therapy.

PubMed

Furlano, Mónica; Barreiro, Yaima; Martí, Teresa; Facundo, Carme; Ruiz-García, César; DaSilva, Iara; Ayasreh, Nadia; Cabrera-López, Cristina; Ballarín, José; Ars, Elisabet; Torra, Roser

We report the case of a 32-year-old male diagnosed with TSC2/PKD1 contiguous gene syndrome, presenting with tuberous sclerosis (TS) and autosomal dominant polycystic kidney disease simultaneously. He progressed to end-stage renal disease and received a kidney transplant at the age of 12. The native kidneys presented angiomyolipomas (AML), which are common benign tumours in patients with TS. Seventeen years after transplantation, he presented with abdominal pain, anaemia and a retroperitoneal haematoma, the latter caused by renal AML bleeding. Selective embolisation was performed. Our patient could have benefited from the administration of mTOR inhibitors at transplant. This therapy is immunosuppressive and reduces the size of benign tumours in TS as well as the risk of rupture and bleeding. This patient did not receive mTOR inhibitors at the time of the transplant because the relationship between mTOR inhibitors and TS was unknown at that time. This case confirms the persistent risk of renal AML bleeding for both transplanted patients and patients on dialysis. As a result, we would recommend routine check-ups of native kidneys and nephrectomy assessment. Copyright © 2017 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

A comparative study of renal care in Brazil and Mexico: hemodialysis treatment from the perspective of ESRD sufferers.

PubMed

Mercado-Martinez, Francisco J; da Silva, Denise Guerreiro V; Correa-Mauricio, Mauricio E

2017-04-01

Renal replacement therapy is the indicated treatment for individuals with chronic kidney disease (CKD) to survive. However, not all sick people have access to the same treatment. This study compares renal care in two developing countries with different health systems. Specifically, it explores hemodialysis treatment from the perspective of low-income individuals. A qualitative, comparative study was performed in Brazil and Mexico. Using purposive sampling, the research was based on open-ended interviews with nineteen participants with kidney failure undergoing hemodialysis treatment in public hospitals and ten relatives. According to our results, Brazilian participants perceived hemodialysis care as satisfactory because of health personnel courtesy as well as free access to dialysis treatment, prescription drugs, hospitalization and transportation. However, they reported deficiencies in the care they were receiving due to shortages of specialists, prescription drugs, laboratory tests and transportation. Mexican participants, in contrast, highlighted the catastrophic costs of medical care because they had no free access to renal therapy, nor adequate financial resources. Our findings suggest that low-income Brazilian CKD sufferers experience renal care differently, as they are more satisfied and face less obstacles with hemodialysis compared with those of Mexico. More studies on the topic are needed. © 2016 John Wiley & Sons Ltd.

Renal redox stress and remodeling in metabolic syndrome, type 2 diabetes mellitus, and diabetic nephropathy: paying homage to the podocyte.

PubMed

Hayden, Melvin R; Whaley-Connell, Adam; Sowers, James R

2005-01-01

Type 2 diabetes mellitus has reached epidemic proportions and diabetic nephropathy is the leading cause of end-stage renal disease. The metabolic syndrome constitutes a milieu conducive to tissue redox stress. This loss of redox homeostasis contributes to renal remodeling and parallels the concurrent increased vascular redox stress associated with the cardiometabolic syndrome. The multiple metabolic toxicities, redox stress and endothelial dysfunction combine to weave the complicated mosaic fabric of diabetic glomerulosclerosis and diabetic nephropathy. A better understanding may provide both the clinician and researcher tools to unravel this complicated disease process. Cellular remodeling of podocyte foot processes in the Ren-2 transgenic rat model of tissue angiotensin II overexpression (TG(mREN-2)27) and the Zucker diabetic fatty model of type 2 diabetes mellitus have been observed in preliminary studies. Importantly, angiotensin II receptor blockers have been shown to abrogate these ultrastructural changes in the foot processes of the podocyte in preliminary studies. An integrated, global risk reduction, approach in therapy addressing the multiple metabolic abnormalities combined with attempts to reach therapeutic goals at an earlier stage could have a profound effect on the development and progressive nature to end-stage renal disease and ultimately renal replacement therapy.

Update on role of agalsidase alfa in management of Fabry disease

PubMed Central

Ramaswami, Uma

2011-01-01

Fabry disease (FD) is an X-linked lysosomal storage disorder that affects both men and women. The manifestations of this heterogeneous disease are multisystemic and progressive. Prior to the development of enzyme replacement therapy, the management and treatment for Fabry disease was largely nonspecific and supportive. Because enzyme replacement therapy became commercially available in 2001, a variety of clinical benefits in Fabry patients have been consistently reported, including improved renal pathology and cardiac function, and reduced severity of neuropathic pain and improved pain-related quality of life. This update focuses on published data on the efficacy and tolerability of enzyme replacement therapy with agalsidase alfa, and gives a brief overview on some of the outstanding management issues in the treatment of this complex disease. PMID:21552486

Aortic valve replacement in a dialysis-dependent Jehovah's Witness: successful use of a minicircuit, microplegia, and multimodality blood conservation technique

PubMed Central

Sutton, Steve W.; Marcel, Randy

2007-01-01

We present the first reported case of an aortic valve replacement operation without blood transfusion in a 62-year-old Jehovah's Witness with dialysis-dependent chronic renal failure, severe anemia, severe aortic stenosis, and symptomatic angina with minimal exertion after an accident in which she suffered fractures of both her right arm and leg. She underwent successful valve replacement surgery after preoperative stabilization of her fractures and high-dose erythropoietin and iron supplement therapy preoperatively and postoperatively. The intraoperative blood conservation technique included a novel approach with a miniature cardiopulmonary bypass circuit and microplegia with limited hemodilution. High-risk valve surgery in patients who are Jehovah's Witnesses can be successful with a carefully planned multimodality blood conservation strategy. PMID:17256040

Renal outcomes of agalsidase beta treatment for Fabry disease: role of proteinuria and timing of treatment initiation

PubMed Central

Ortiz, Alberto; Mauer, Michael; Linthorst, Gabor E.; Oliveira, João P.; Serra, Andreas L.; Maródi, László; Mignani, Renzo; Vujkovac, Bojan; Beitner-Johnson, Dana; Lemay, Roberta; Cole, J.Alexander; Svarstad, Einar; Waldek, Stephen; Germain, Dominique P.; Wanner, Christoph

2012-01-01

Background. The purpose of this study was to identify determinants of renal disease progression in adults with Fabry disease during treatment with agalsidase beta. Methods. Renal function was evaluated in 151 men and 62 women from the Fabry Registry who received agalsidase beta at an average dose of 1 mg/kg/2 weeks for at least 2 years. Patients were categorized into quartiles based on slopes of estimated glomerular filtration rate (eGFR) during treatment. Multivariate logistic regression analyses were used to identify factors associated with renal disease progression. Results. Men within the first quartile had a mean eGFR slope of –0.1 mL/min/1.73m2/year, whereas men with the most rapid renal disease progression (Quartile 4) had a mean eGFR slope of –6.7 mL/min/1.73m2/year. The risk factor most strongly associated with renal disease progression was averaged urinary protein:creatinine ratio (UP/Cr) ≥1 g/g (odds ratio 112, 95% confidence interval (95% CI) 4–3109, P = 0.0054). Longer time from symptom onset to treatment was also associated with renal disease progression (odds ratio 19, 95% CI 2–184, P = 0.0098). Women in Quartile 4 had the highest averaged UP/Cr (mean 1.8 g/g) and the most rapid renal disease progression: (mean slope –4.4 mL/min/1.73m2/year). Conclusions. Adults with Fabry disease are at risk for progressive loss of eGFR despite enzyme replacement therapy, particularly if proteinuria is ≥1 g/g. Men with little urinary protein excretion and those who began receiving agalsidase beta sooner after the onset of symptoms had stable renal function. These findings suggest that early intervention may lead to optimal renal outcomes. PMID:21804088

Long-term renal outcome in patients with malignant hypertension: a retrospective cohort study

PubMed Central

2012-01-01

Background Malignant hypertension is frequently complicated by renal insufficiency. Although the survival of this hypertensive emergency has improved, recent data on renal outcome and its predictors are lacking. We assessed renal outcome and its predictors in patients with malignant hypertension. Methods Retrospective analysis of patients admitted with malignant hypertension in Amsterdam, the Netherlands between August 1992–January 2010. Follow-up data on vital status, renal function and blood pressure (BP) were obtained from the outpatient department and from general practitioners. The primary composite endpoint was end-stage renal disease (ESRD) defined as the start of kidney replacement therapy (KRT) or ≥ 50% decline of estimated glomerular filtration rate (eGFR). The secondary endpoint was all cause mortality. Results A total of 120 patients admitted with malignant hypertension were included. After a median follow-up period of 67 months (IQR 28 to 108 months) the primary endpoint was reached by 37 (31%) patients, whereas 18 patients (15%) reached the secondary endpoint. Twenty-nine (24%) patients started KRT and 8 patients (7%) had an eGFR decline ≥ 50%. After the acute phase (> 3 months after admission), initial serum creatinine and follow-up BP were the main predictors of future ESRD with hazard ratios of 6.1 (95% CI, 2.2–17) for patients with initial serum creatinine ≥ 175 μmol /L and 4.3 (95% CI, 1.4–14) for patients with uncontrolled hypertension. Conclusions Progressive renal function decline leading to ESRD remains a major threat to patients with malignant hypertension. BP control during follow-up was an important modifiable predictor of renal outcome. PMID:22846257

[Fabry nephropathy in a female with superposed IgA glomerulonephritis].

PubMed

Pisani, A; Sessa, A; Sabbatini, M; Andreucci, M V; Fusco, C; Balletta, M; Cianciaruso, B

2005-01-01

In Anderson-Fabry disease (AFd), the kidney is affected in all hemizygous males and in some heterozygous females. Female carriers can present subtle renal abnormalities due to glycosphingolipid (GSL) accumulation within renal cells. Renal biopsy is rarely performed in female Fabry patients because clinical renal manifestations are usually lacking. However, female carriers can accumulate GSL in their renal cells despite the absence of clinically evident kidney disease. We performed a kidney biopsy in a 52-year-old female patient, a Fabry disease carrier. The patient showed normal glomerular filtration rate, persistent microhematuria and proteinuria (about 1.7 g/24 hr), cornea "verticillata", and evident left ventricular hypertrophy. The molecular study documented a missense mutation R227Q in exon 5 of the alpha-galactosidase A gene. Optical microscopy showed electron-dense mesangial deposits due IgA glomerulonephritis, as confirmed by immunofluorescence. We decided to start therapy with angiotensin-converting enzyme inhibitors (ACE-I). After 8 months of treatment, the patient demonstrated proteinuria of 0.9 g/24 hr. To decide when to start treatment using enzyme replacement therapy (ERT) with human recombinant GAL A (Fabrazyme), we decided to perform an electron microscopy study of the renal biopsy. The renal ultrastructural findings were typical GSL inclusions in all kinds of glomerular cells, in tubular epithelial cells and in endothelial cells of interstitial capillaries, confirming the hypothesis of Fabry nephropathy. Consequently, Fabrazyme was given at a standard dose of 1 mg/kg every 2 weeks. After 24 months of combined treatment (ACE-I-Fabrazyme), proteinuria decreased to 0.2 g/24 hr. The importance of performing the ultrastructural examination of the kidney biopsy is stressed, especially in heterozygous Fabry patients to evaluate the need to treat them with ERT and to evaluate the degree of renal involvement.

The influence of renal manifestations to the progression of autosomal dominant polycystic kidney disease

PubMed Central

Idrizi, A; Barbullushi, M; Petrela, E; Kodra, S; Koroshi, A; Thereska, N

2009-01-01

Background: Renal stones, urinary tract infections (UTI) and gross hematuria (GH) are the most important renal manifestations of autosomal dominant polycystic kidney disease (ADPKD). They are not only common, but are also frequent cause of morbidity, influencing renal dysfunction. The aim of this study was to evaluate the frequency of these manifestations in our patients with ADPKD and their impact on renal function. Methods: One hundred eighty ADPKD patients were included in the study. Subjects were studied for the presence of UTI, gross hematuria frequency and responsible factors of nephrolithiasis. Survival times were calculated as the time to renal replacement therapy or time of serum creatinine value up to 10 mg/dl. Kaplan-Meier product-limit survival curves were constructed, and log rank test was used to compare the survival curves. Results: Kidney stones were present in 76/180 (42% of pts). The stones were composed of urate (47%) calcium oxalate (39%), and other compounds 14%. UTI was observed in 60% (108 patients). Patients treated with urinary disinfectants had a significant lower frequency of urinary infection (p<0.001) and hematuria (p<0.001) after one year than untreated patients. Gross hematuria was present in 113 patients (63%). In 43 patients hematuria was diagnosed before age 30 (38%), while in 70 patients it was diagnosed after age 30 (62%). Conclusions: UTI is frequent in our ADPKD patients. The correct treatment of UTI decreases its frequency and has beneficial role in the rate of progression to renal failure in ADPKD patients. Patients with recurrent episodes of gross hematuria may be at risk for more severe renal disease. PMID:19918304

Plasma inflammatory and apoptosis markers are associated with dialysis dependence and death among critically ill patients receiving renal replacement therapy

PubMed Central

Murugan, Raghavan; Wen, Xiaoyan; Shah, Nilesh; Lee, Minjae; Kong, Lan; Pike, Francis; Keener, Christopher; Unruh, Mark; Finkel, Kevin; Vijayan, Anitha; Palevsky, Paul M.; Paganini, Emil; Carter, Melinda; Elder, Michele; Kellum, John A.

2014-01-01

Background Survivors of critical illness complicated by acute kidney injury requiring renal replacement therapy (RRT) are at an increased risk of dialysis dependence and death but the mechanisms are unknown. Methods In a multicenter, prospective, cohort study of 817 critically ill patients receiving RRT, we examined association between Day 1 plasma inflammatory [interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-18; macrophage migration inhibitory factor (MIF) and tumor necrosis factor]; apoptosis [tumor necrosis factor receptor (TNFR)-I and TNFR-II and death receptor (DR)-5]; and growth factor (granulocyte macrophage colony stimulating factor) biomarkers and renal recovery and mortality at Day 60. Renal recovery was defined as alive and RRT independent. Results Of 817 participants, 36.5% were RRT independent and 50.8% died. After adjusting for differences in demographics, comorbid conditions; premorbid creatinine; nephrotoxins; sepsis; oliguria; mechanical ventilation; RRT dosing; and severity of illness, increased concentrations of plasma IL-8 and IL-18 and TNFR-I were independently associated with slower renal recovery [adjusted hazard ratio (AHR) range for all markers, 0.70–0.87]. Higher concentrations of IL-6, IL-8, IL-10 and IL-18; MIF; TNFR-I and DR-5 were associated with mortality (AHR range, 1.16–1.47). In an analysis of multiple markers simultaneously, increased IL-8 [AHR, 0.80, 95% confidence interval (95% CI) 0.70–0.91, P < 0.001] and TNFR-I (AHR, 0.63, 95% CI 0.50–0.79, P < 0.001) were associated with slower recovery, and increased IL-8 (AHR, 1.26, 95% CI 1.14–1.39, P < 0.001); MIF (AHR, 1.18, 95% CI 1.08–1.28, P < 0.001) and TNFR-I (AHR, 1.26, 95% CI 1.02–1.56, P < 0.03) were associated with mortality. Conclusions Elevated plasma concentrations of inflammatory and apoptosis biomarkers are associated with RRT dependence and death. Our data suggest that future interventions should investigate broad-spectrum immune-modulation to improve outcomes. PMID:24619058

The comparison of the diuretic and natriuretic efficacy of continuous and bolus intravenous furosemide in patients with chronic kidney disease.

PubMed

Sanjay, Srinivas; Annigeri, Rajeev A; Seshadri, Rajagopalan; Rao, Budithi Subba; Prakash, Kowdle C; Mani, Muthu Krishna

2008-06-01

To compare natriuretic, kaliuretic, diuretic and free water clearance efficacy of continuous versus bolus intravenous furosemide administration in patients with chronic renal insufficiency. In a prospective randomized cross-over trial, 42 patients of chronic renal insufficiency were randomized to receive the same dose of intravenous furosemide as bolus and continuous infusion. The effects of bolus and intravenous administration of furosemide on the volume of urine, sodium and potassium excretion were assessed. Mean age was 53.6 +/- 14 years and 23 (55%) were male. The mean modification of diet in renal disease glomerular filtration rate was 20.5 +/- 17 mL/min per 1.73 m(2). The urinary excretion of sodium in intravenous bolus and infusion was 98.1 +/- 78 and 114.4 +/- 100 mmol, respectively (P = 0.001). Total urinary volume following bolus and infusion of furosemide was 1064 +/- 627 and 1170 +/- 764 mL, respectively (0.001). The excretion of potassium was similar in bolus (15.8 +/- 16.6) and infusion (14.3 +/- 9) administration (P = 0.11). The fractional excretion of sodium was higher following infusion (16.63 +/- 16.1) than bolus administration (12.87 +/- 9) of furosemide (P = 0.016). Continuous intravenous infusion of furosemide has significantly better natriuretic and diuretic effect than bolus administration of the same dose of the drug in patients with advanced chronic renal insufficiency.

Augmented renal clearance in the ICU: results of a multicenter observational study of renal function in critically ill patients with normal plasma creatinine concentrations*.

PubMed

Udy, Andrew A; Baptista, João P; Lim, Noelle L; Joynt, Gavin M; Jarrett, Paul; Wockner, Leesa; Boots, Robert J; Lipman, Jeffrey

2014-03-01

To describe the prevalence and natural history of augmented renal clearance in a cohort of recently admitted critically ill patients with normal plasma creatinine concentrations. Multicenter, prospective, observational study. Four, tertiary-level, university-affiliated, ICUs in Australia, Singapore, Hong Kong, and Portugal. Study participants had to have an expected ICU length of stay more than 24 hours, no evidence of absolute renal impairment (admission plasma creatinine < 120 µmol/L), and no history of prior renal replacement therapy or chronic kidney disease. Convenience sampling was used at each participating site. Eight-hour urinary creatinine clearances were collected daily, as the primary method of measuring renal function. Augmented renal clearance was defined by a creatinine clearance more than or equal to 130 mL/min/1.73 m. Additional demographic, physiological, therapeutic, and outcome data were recorded prospectively. Nine hundred thirty-two patients were admitted to the participating ICUs over the study period, and 281 of which were recruited into the study, contributing 1,660 individual creatinine clearance measures. The mean age (95% CI) was 54.4 years (52.5-56.4 yr), Acute Physiology and Chronic Health Evaluation II score was 16 (15.2-16.7), and ICU mortality was 8.5%. Overall, 65.1% manifested augmented renal clearance on at least one occasion during the first seven study days; the majority (74%) of whom did so on more than or equal to 50% of their creatinine clearance measures. Using a mixed-effects model, the presence of augmented renal clearance on study day 1 strongly predicted (p = 0.019) sustained elevation of creatinine clearance in these patients over the first week in ICU. Augmented renal clearance appears to be a common finding in this patient group, with sustained elevation of creatinine clearance throughout the first week in ICU. Future studies should focus on the implications for accurate dosing of renally eliminated pharmaceuticals in patients with augmented renal clearance, in addition to the potential impact on individual clinical outcomes.

Hypertension and Hyperglycemia Synergize to Cause Incipient Renal Tubular Alterations Resulting in Increased NGAL Urinary Excretion in Rats

PubMed Central

Blázquez-Medela, Ana M.; García-Sánchez, Omar; Blanco-Gozalo, Víctor; Quiros, Yaremi; Montero, María J.; Martínez-Salgado, Carlos; López-Novoa, José M.; López-Hernández, Francisco J.

2014-01-01

Background Hypertension and diabetes are the two leading causes of chronic kidney disease (CKD) eventually leading to end stage renal disease (ESRD) and the need of renal replacement therapy. Mortality among CKD and ESRD patients is high, mostly due to cardiovascular events. New early markers of risk are necessary to better anticipate the course of the disease, to detect the renal affection of additive risk factors, and to appropriately handle patients in a pre-emptive and personalized manner. Methods Renal function and NGAL urinary excretion was monitored in rats with spontaneous (SHR) or L-NAME induced hypertension rendered hyperglycemic (or not as controls). Results Combination of hypertension and hyperglycemia (but not each of these factors independently) causes an increased urinary excretion of neutrophil gelatinase-associated lipocalin (NGAL) in the rat, in the absence of signs of renal damage. Increased NGAL excretion is observed in diabetic animals with two independent models of hypertension. Elevated urinary NGAL results from a specific alteration in its tubular handling, rather than from an increase in its renal expression. In fact, when kidneys of hyperglycaemic-hypertensive rats are perfused in situ with Krebs-dextran solution containing exogenous NGAL, they excrete more NGAL in the urine than hypertensive rats. We also show that albuminuria is not capable of detecting the additive effect posed by the coexistence of these two risk factors. Conclusions Our results suggest that accumulation of hypertension and hyperglycemia induces an incipient and quite specific alteration in the tubular handling of NGAL resulting in its increased urinary excretion. PMID:25148248

Hypertension and hyperglycemia synergize to cause incipient renal tubular alterations resulting in increased NGAL urinary excretion in rats.

PubMed

Blázquez-Medela, Ana M; García-Sánchez, Omar; Blanco-Gozalo, Víctor; Quiros, Yaremi; Montero, María J; Martínez-Salgado, Carlos; López-Novoa, José M; López-Hernández, Francisco J

2014-01-01

Hypertension and diabetes are the two leading causes of chronic kidney disease (CKD) eventually leading to end stage renal disease (ESRD) and the need of renal replacement therapy. Mortality among CKD and ESRD patients is high, mostly due to cardiovascular events. New early markers of risk are necessary to better anticipate the course of the disease, to detect the renal affection of additive risk factors, and to appropriately handle patients in a pre-emptive and personalized manner. Renal function and NGAL urinary excretion was monitored in rats with spontaneous (SHR) or L-NAME induced hypertension rendered hyperglycemic (or not as controls). Combination of hypertension and hyperglycemia (but not each of these factors independently) causes an increased urinary excretion of neutrophil gelatinase-associated lipocalin (NGAL) in the rat, in the absence of signs of renal damage. Increased NGAL excretion is observed in diabetic animals with two independent models of hypertension. Elevated urinary NGAL results from a specific alteration in its tubular handling, rather than from an increase in its renal expression. In fact, when kidneys of hyperglycaemic-hypertensive rats are perfused in situ with Krebs-dextran solution containing exogenous NGAL, they excrete more NGAL in the urine than hypertensive rats. We also show that albuminuria is not capable of detecting the additive effect posed by the coexistence of these two risk factors. Our results suggest that accumulation of hypertension and hyperglycemia induces an incipient and quite specific alteration in the tubular handling of NGAL resulting in its increased urinary excretion.

Early detection and prevention of diabetic nephropathy: a challenge calling for mandatory action for Mexico and the developing world.

PubMed

Correa-Rotter, Ricardo; González-Michaca, Luis

2005-09-01

During the last decades, developing countries have experienced an epidemiologic transition characterized by a reduction of infectious diseases and an increase of chronic degenerative diseases. This situation is generating tormenting public health, financial, and social consequences. Of particular relevance is type 2 diabetes mellitus and its chronic complications, particularly cardiovascular disease and diabetic nephropathy, because mortality of the patient with diabetes is, in most instances, related to these complications. There is a clear need to implement diagnostic and treatment strategies to reduce risk factors for development of diabetes (primary prevention), to detect risk factors of chronic complications in early stages of diabetes (secondary prevention), and to prevent further progression of those that already have renal injury (tertiary prevention). Microalbuminuria is an early marker of renal injury in diabetes, and its early detection can help the timely use of renal preventive measures, which would avoid the extremely high costs of renal replacement treatment for end-stage renal disease as well as that of other cardiovascular complications. Preventive strategies are of very little or no impact, if the primary physician has limited knowledge about the natural history of diabetic nephropathy, the beneficial effect of early preventive maneuvers for delaying its progression, and the social and economic impact of end-stage renal disease. It is therefore imperative to assure in our health systems that general practitioners have the ability and commitment to detect early diabetes complications, in order to promote actions that support regression or retard highly morbid cardiovascular and renal conditions.

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis.

PubMed

Brain, Matthew; Winson, Elizabeth; Roodenburg, Owen; McNeil, John

2017-02-20

Optimising filter life and performance efficiency in continuous renal replacement therapy has been a focus of considerable recent research. Larger high quality studies have predominantly focussed on optimal anticoagulation however CRRT is complex and filter life is also affected by vascular access, circuit and management factors. We performed a systematic search of the literature to identify and quantify the effect of vascular access, circuit and patient factors that affect filter life and presented the results as a meta-analysis. A systematic review and meta-analysis was performed by searching Pubmed (MEDLINE) and Ovid EMBASE libraries from inception to 29 th February 2016 for all studies with a comparator or independent variable relating to CRRT circuits and reporting filter life. Included studies documented filter life in hours with a comparator other than anti-coagulation intervention. All studies comparing anticoagulation interventions were searched for regression or hazard models pertaining to other sources of variation in filter life. Eight hundred nineteen abstracts were identified of which 364 were selected for full text analysis. 24 presented data on patient modifiers of circuit life, 14 on vascular access modifiers and 34 on circuit related factors. Risk of bias was high and findings are hypothesis generating. Ranking of vascular access site by filter longevity favours: tunnelled semi-permanent catheters, femoral, internal jugular and subclavian last. There is inconsistency in the difference reported between femoral and jugular catheters. Amongst published literature, modality of CRRT consistently favoured continuous veno-venous haemodiafiltration (CVVHD-F) with an associated 44% lower failure rate compared to CVVH. There was a trend favouring higher blood flow rates. There is insufficient data to determine advantages of haemofilter membranes. Patient factors associated with a statistically significant worsening of filter life included mechanical ventilation, elevated SOFA or LOD score, elevations in ionized calcium, elevated platelet count, red cell transfusion, platelet factor 4 (PF-4) antibodies, and elevated fibrinogen. Majority of studies are observational or report circuit factors in sub-analysis. Risk of bias is high and findings require targeted investigations to confirm. The interaction of patient, pathology, anticoagulation, vascular access, circuit and staff factors contribute to CRRT filter life. There remains an ambiguity from published data as to which site and side should be the first choice for vascular access placement and what interaction this has with patient factors and timing. Early consideration of tunnelled semi-permanent access may provide optimal filter life if longer periods of CRRT are anticipated. There remains an absence of robust evidence outside of anti-coagulation strategies despite over 20 years of therapy delivery however trends favour CVVHD-F over CVVH.

[Relationship between continuous renal replacement therapy and hypophosphatemia in critically ill children].

PubMed

Sun, T; Ren, Y Q; Wang, F; Miao, H J; Shan, Y J; Wang, C X; Zhang, Y C

2018-04-02

Objective: To investigate the incidence and prognosis of hypophosphatemia in critically ill children treated with continuous blood purification (CBP). Methods: The medical records of the critically ill patients, who were treated with CBP, admitted to pediatric intensive care unit (PICU) of Shanghai Children's Hospital from May 2014 to April 2017 were retrospectively analyzed. The serum phosphorus levels were tested before CBP, at 48-72 h during CBP, at the end of CBP and on the next day after CBP finished. Phosphorus supplement was given to the children with severe hypophosphatemia. Results: A total of 85 patients met the inclusion criteria. The serum phosphorus levels at the 4 indicated time points were (1.4±0.5), (0.7±0.3), (0.8±0.3), (0.9±0.4) mmol/L, respectively ( F =45.21, P< 0.05). Among the children, 66 cases (78%) had hypophosphatemia during CBP. The incidences of moderate and severe hypophosphatemia were 32 (48%) and 9 (14%), respectively. There were 41 patients with CBP replacement rates of (35-49) ml/(kg·h), while 44 patients with CBP replacement rates of 50-70 ml/(kg·h). There were significant differences at 48-72 h during CBP, the end of CBP and on the next day after CBP ((0.8±0.4) vs. (0.5±0.2), (1.0±0.3) vs. (0.6±0.2), and (1.1±0.4) vs. (0.8±0.2) mmol/L; t= 7.672, 4.060, 14.440, P< 0.05). Atotal of 9 cases were treated with sodium glycerophosphate. Among the 85 children, 24 (28%) patients died while 61 (72%) survived. There were no significant differences between the two groups in serum phosphorus levels at the indicated time points ((1.4±0.5) vs . (1.4±0.5), (0.7±0.3) vs. (0.7±0.3), (0.7±0.3) vs. (0.8±0.3), and (1.0±0.3) vs. (0.9±0.3) mmol/L, respectively, P> 0.05). Conclusions: Hypophosphatemia is prone to occur during CBP, which probably related to the replacement rate. There was no significant relationship between hypophosphatemia and mortality in critically ill children after giving phosphorus supplementation.

Diagnostic Importance of Hyphae on Heart Valve Tissue in Histoplasma Endocarditis and Treatment With Isavuconazole.

PubMed

Wiley, Zanthia; Woodworth, Michael H; Jacob, Jesse T; Lockhart, Shawn R; Rouphael, Nadine G; Gullett, Jonathan C; Guarner, Jeannette; Workowski, Kimberly

2017-01-01

A patient who never resided in an endemic area for dimorphic fungi was diagnosed with Histoplasma capsulatum endocarditis. His diagnosis was suggested by yeast and hyphae on cardiac valve tissue pathology. Isavuconazole was an optimal therapeutic option due to renal dysfunction and anticoagulation with warfarin for mechanical valve replacement.

Diagnostic Importance of Hyphae on Heart Valve Tissue in Histoplasma Endocarditis and Treatment With Isavuconazole

PubMed Central

Wiley, Zanthia; Woodworth, Michael H; Jacob, Jesse T; Lockhart, Shawn R; Rouphael, Nadine G; Gullett, Jonathan C; Guarner, Jeannette

2017-01-01

Abstract A patient who never resided in an endemic area for dimorphic fungi was diagnosed with Histoplasma capsulatum endocarditis. His diagnosis was suggested by yeast and hyphae on cardiac valve tissue pathology. Isavuconazole was an optimal therapeutic option due to renal dysfunction and anticoagulation with warfarin for mechanical valve replacement. PMID:29255737

International study of health care organization and financing: development of renal replacement therapy in Germany.

PubMed

Kleophas, Werner; Reichel, Helmut

2007-09-01

The German health system represents the case of a global budget with negotiated fees and competing medical insurance companies. Physicians in private practice and non-profit dialysis provider associations provide most dialysis therapy. End-stage renal disease (ESRD) modalities are well integrated into the overall health care system. Dialysis therapy, independent of the mode of treatment, is reimbursed at a weekly flat rate. Mandatory health insurance covers health expenses, including those related to ESRD, for more than 90% of the population. Both employees and employers contribute to the premium for this insurance. Private medical insurance covers the remainder of the population. Access to treatment, including dialysis therapy, is uniformly available.

Extraskeletal Ewing's sarcoma.

PubMed

El-Essawy, Manar T

2009-06-01

We report 2 rare cases of extraskeletal Ewing's sarcoma, one is arising primarily from the posterior mediastinum in a middle-aged man (patient 1), and the other one is arising from the left kidney in a young male patient (patient 2). The CT in the first case showed a large mass of heterogeneous texture, with areas of cystic changes in the right side of the posterior mediastinum, no underlying bony changes or intra-spinal extension, and this mass was diagnosed as lymphoma. The second case showed almost complete replacement of the left kidney by a mass with extension through the renal vein and inferior vena cava, and it was diagnosed as renal cell carcinoma. The histological analysis of these lesions revealed extraskeletal Ewing's sarcoma.

Hypokalemic muscular paralysis causing acute respiratory failure due to rhabdomyolysis with renal tubular acidosis in a chronic glue sniffer.

PubMed

Kao, K C; Tsai, Y H; Lin, M C; Huang, C C; Tsao, C Y; Chen, Y C

2000-01-01

A 34-year-old male was admitted to the emergency department with the development of quadriparesis and respiratory failure due to hypokalemia after prolonged glue sniffing. The patient was subsequently given mechanical ventilatory support for respiratory failure. He was weaned from the ventilator 4 days later after potassium replacement. Toluene is an aromatic hydrocarbon found in glues, cements, and solvents. It is known to be toxic to the nervous system, hematopoietic system, and causes acid-base and electrolyte disorders. Acute respiratory failure with hypokalemia and rhabdomyolysis with acute renal failure should be considered as potential events in a protracted glue sniffing.

Continuous infusion of antibiotics in critically ill patients.

PubMed

Smuszkiewicz, Piotr; Szałek, Edyta; Tomczak, Hanna; Grześkowiak, Edmund

2013-02-01

Antibiotics are the most commonly used drugs in intensive care unit patients and their supply should be based on pharmacokinetic/pharmacodynamic rules. The changes that occur in septic patients who are critically ill may be responsible for subtherapeutic antibiotic concentrations leading to poorer clinical outcomes. Evolving in time the disturbed pathophysiology in severe sepsis (high cardiac output, glomerular hyperfiltration) and therapeutic interventions (e.g. haemodynamically active drugs, mechanical ventilation, renal replacement therapy) alters antibiotic pharmacokinetics mainly through an increase in the volume of distribution and altered drug clearance. The lack of new and efficacious drugs and increased bacterial resistance are current problems of contemporary antibiotic therapy. Although intermittent administration is a standard clinical practice, alternative methods of antibiotic administration are sought, which may potentialise effects and reduce toxicity as well as contribute to inhibition of bacterial resistance. A wide range of studies prove that the application of continuous infusion of time-dependent antibiotics (beta-lactams, glycopeptides) is more rational than standard intermittent administration. However, there are also studies which do not confirm the advantage of one method over the other. In spite of controversy the continuous administration of this group of antibiotics is common practice, because the results of both studies point to the higher efficacy of this method in critically ill patients. Authors reviewed the literature to determine whether any clinical benefits exist for administration of time-dependent antibiotics by continuous infusion. Definite specification of the clinical advantage of administration this way over standard dosage requires a large-scale multi-centre randomised controlled trial.

Reassessing marketing of kidneys from the 2008 perspective.

PubMed

Friedman, Eli A; Friedman, Amy L

2009-01-01

Progressive improvements in all aspects of the kidney transplant regimen establish this form of renal replacement therapy as superior to peritoneal or hemodialysis in terms of extent of rehabilitation and long-term recipient survival. Continuous growth in the number of patients with kidney failure sustained by dialytic therapy has not been associated with substantially increased deceased donor kidney contributions, causing intensified stressful waiting periods for potential recipients lacking a live kidney donor. Neither public relation campaigns nor local government efforts have substantially increased kidney donation. Buying a donor kidney is illegal and condemned as fostering exploitation of poor people by the wealthy. Widely publicized examples of coercion of unwilling donors create a negative image of harmful, inhumane conduct deployed to obtain kidneys sold and transplanted under unsavory circumstances. Yet efforts to establish and test governmental programs to supervise and sustain acceptable standards for the sale and implantation of kidneys from fully informed, medically evaluated and protected, fairly compensated donors have been resisted and frustrated by those who consider such compensation loathsome. Accordingly, while selling kidneys is prohibited by law, pressure from those wanting to quench the number of deaths of wait-listed dialysis patients continues forcing reexamination of an issue that, like prohibition of the possession and sale of alcohol in the United States in 1920, places the will of a people in opposition to unreasonably restrictive laws. The debate continues.

Effect of conservative treatment on the renal outcome of children with primary hyperoxaluria type 1.

PubMed

Fargue, Sonia; Harambat, Jérôme; Gagnadoux, Marie-France; Tsimaratos, Michel; Janssen, Françoise; Llanas, Brigitte; Berthélémé, Jean-Pierre; Boudailliez, Bernard; Champion, Gérard; Guyot, Claude; Macher, Marie-Alice; Nivet, Hubert; Ranchin, Bruno; Salomon, Rémi; Taque, Sophie; Rolland, Marie-Odile; Cochat, Pierre

2009-10-01

Primary hyperoxaluria type 1 results from alanine:glyoxylate aminotransferase deficiency. Due to genotype/phenotype heterogeneity in this autosomal recessive disorder, the renal outcome is difficult to predict in these patients and the long-term impact of conservative management in children is unknown. We report here a multicenter retrospective study on the renal outcome in 27 affected children whose biological diagnosis was based on either decreased enzyme activity or identification of mutations in the patient or his siblings. The median age at first symptoms was 2.4 years while that at initiation of conservative treatment was 4.1 years; 6 children were diagnosed upon family screening. The median follow-up was 8.7 years. At diagnosis, 15 patients had an estimated glomerular filtration rate (eGFR) below 90, and 7 children already had stage 2-3 chronic kidney disease. The median baseline eGFR was 74, which rose to 114 with management in the 22 patients who did not require renal replacement therapy. Overall, 20 patients had a stable eGFR, however, 7 exhibited a decline in eGFR of over 20 during the study period. In a Cox regression model, the only variable significantly associated with deterioration of renal function was therapeutic delay with a relative risk of 1.7 per year. Our study strongly suggests that early and aggressive conservative management may preserve renal function of compliant children with this disorder, thereby avoiding dialysis and postponing transplantation.

The epidemiology of end-stage renal disease in Nigeria: the way forward.

PubMed

Odubanjo, M O; Oluwasola, A O; Kadiri, S

2011-09-01

The incidence of CKD (Chronic kidney disease) in Nigeria has been shown by various studies to range between 1.6 and 12.4%. We have shown that the burden of renal disease in Nigeria is probably significantly higher than any previous study on end-stage renal disease (ESRD) has documented, as most studies are hospital-based and fail to include the many patients who do not have access to hospital care. The increased prevalence of ESRD among blacks in the United States and South Africa compared with other races also suggests that ESRD may be more prevalent in Africa than in the United States and other developed nations. Common causes of CKD in Nigerian adults are glomerulonephritis and hypertension, while common causes in children are glomerulonephritis and posterior urethral valves. In the United States, diabetes and hypertension are the commonest causes of CKD and glomerulonephritis plays a less important role. Access to renal replacement therapy (RRT) in Nigeria is limited, and mortality rates are very high, ranging between 40 and 50%. Important steps towards improving the situation are the development of prevention programmes and increased funding to ensure increased availability of RRT. To achieve this, health policies concerning CKD must be formulated, and the lack of a renal registry makes it difficult for this to be done. There is need for the development of a functional organizational structure for the reporting of CKD in Nigeria, the Nigerian Renal Registry.

Management of renal artery stenosis - an update.

PubMed

Alhadad, A

2008-06-01

The role of the renal vasculature in eliciting renovascular hypertension (RVH) was established in 1934, when Goldblatt et al. [1] in a classical experimental study demonstrated that partial obstruction of the renal artery increased mean arterial blood pressure (BP). The pathophysiology of renal artery stenosis (RAS) is incompletely understood but has been postulated to be related to increased afterload from neurohormonal activation and cytokine release [2]. Atherosclerotic RAS (ARAS) is increasingly diagnosed in the expanding elderly population, which also has a high prevalence of arterial hypertension. There is still considerable uncertainty concerning the optimal management of patients with RAS. Many hypertensive patients with RAS have co-existing essential hypertension and furthermore, it is often difficult to determine to what degree the RAS is responsible for the impairment of renal function. There are three possible treatment strategies: medical management, surgery, or percutaneous transluminal renal angioplasty (PTRA) with or without stent implantation. The use of stents has improved the technical success rate of PTRA and also led to lower risk of restenosis, in particular for ostial RAS. PTRA with stenting has therefore replaced surgical revascularisation for most patients with RAS and has led to a lower threshold for intervention. The treatment of choice to control hypertension in fibromuscular dysplasia (FMD) is generally accepted to be PTRA [3]. In ARAS, on the other hand, the benefits with PTRA are less clear [4] and the challenge to identify which patients are likely to benefit from revascularisation remains unknown.

Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury

PubMed Central

Vesconi, Sergio; Cruz, Dinna N; Fumagalli, Roberto; Kindgen-Milles, Detlef; Monti, Gianpaola; Marinho, Anibal; Mariano, Filippo; Formica, Marco; Marchesi, Mariano; René, Robert; Livigni, Sergio; Ronco, Claudio

2009-01-01

Introduction The optimal dialysis dose for the treatment of acute kidney injury (AKI) is controversial. We sought to evaluate the relationship between renal replacement therapy (RRT) dose and outcome. Methods We performed a prospective multicentre observational study in 30 intensive care units (ICUs) in eight countries from June 2005 to December 2007. Delivered RRT dose was calculated in patients treated exclusively with either continuous RRT (CRRT) or intermittent RRT (IRRT) during their ICU stay. Dose was categorised into more-intensive (CRRT ≥ 35 ml/kg/hour, IRRT ≥ 6 sessions/week) or less-intensive (CRRT < 35 ml/kg/hour, IRRT < 6 sessions/week). The main outcome measures were ICU mortality, ICU length of stay and duration of mechanical ventilation. Results Of 15,200 critically ill patients admitted during the study period, 553 AKI patients were treated with RRT, including 338 who received CRRT only and 87 who received IRRT only. For CRRT, the median delivered dose was 27.1 ml/kg/hour (interquartile range (IQR) = 22.1 to 33.9). For IRRT, the median dose was 7 sessions/week (IQR = 5 to 7). Only 22% of CRRT patients and 64% of IRRT patients received a more-intensive dose. Crude ICU mortality among CRRT patients were 60.8% vs. 52.5% (more-intensive vs. less-intensive groups, respectively). In IRRT, this was 23.6 vs. 19.4%, respectively. On multivariable analysis, there was no significant association between RRT dose and ICU mortality (Odds ratio (OR) more-intensive vs. less-intensive: CRRT OR = 1.21, 95% confidence interval (CI) = 0.66 to 2.21; IRRT OR = 1.50, 95% CI = 0.48 to 4.67). Among survivors, shorter ICU stay and duration of mechanical ventilation were observed in the more-intensive RRT groups (more-intensive vs. less-intensive for all: CRRT (median): 15 (IQR = 8 to 26) vs. 19.5 (IQR = 12 to 33.5) ICU days, P = 0.063; 7 (IQR = 4 to 17) vs. 14 (IQR = 5 to 24) ventilation days, P = 0.031; IRRT: 8 (IQR = 5.5 to 14) vs. 18 (IQR = 13 to 35) ICU days, P = 0.008; 2.5 (IQR = 0 to 10) vs. 12 (IQR = 3 to 24) ventilation days, P = 0.026). Conclusions After adjustment for multiple variables, these data provide no evidence for a survival benefit afforded by higher dose RRT. However, more-intensive RRT was associated with a favourable effect on ICU stay and duration of mechanical ventilation among survivors. This result warrants further exploration. Trial Registration Cochrane Renal Group (CRG110600093). PMID:19368724

[Adequate anti-infective treatment : Importance of individual dosing and application].

PubMed

Brinkmann, A; Röhr, A C; Köberer, A; Fuchs, T; Krüger, W A; König, C; Richter, D; Weigand, M A; Frey, O R

2018-05-15

Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (V d ) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beat-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.

The first imported case of Rift Valley fever in China reveals a genetic reassortment of different viral lineages.

PubMed

Liu, Jingyuan; Sun, Yulan; Shi, Weifeng; Tan, Shuguang; Pan, Yang; Cui, Shujuan; Zhang, Qingchao; Dou, Xiangfeng; Lv, Yanning; Li, Xinyu; Li, Xitai; Chen, Lijuan; Quan, Chuansong; Wang, Qianli; Zhao, Yingze; Lv, Qiang; Hua, Wenhao; Zeng, Hui; Chen, Zhihai; Xiong, Haofeng; Jiang, Chengyu; Pang, Xinghuo; Zhang, Fujie; Liang, Mifang; Wu, Guizhen; Gao, George F; Liu, William J; Li, Ang; Wang, Quanyi

2017-01-18

We report the first imported case of Rift Valley fever (RVF) in China. The patient returned from Angola, a non-epidemic country, with an infection of a new reassortant from different lineages of Rift Valley fever viruses (RVFVs). The patient developed multiorgan dysfunction and gradually recovered with continuous renal replacement therapy and a short regimen of methylprednisolone treatment. The disordered cytokines and chemokines in the plasma of the patient revealed hypercytokinemia, but the levels of protective cytokines were low upon admission and fluctuated as the disease improved. Whole-genome sequencing and phylogenetic analysis revealed that the imported strain was a reassortant comprising the L and M genes from lineage E and the S gene from lineage A. This case highlights that RVFV had undergone genetic reassortment, which could potentially alter its biological properties, cause large outbreaks and pose a serious threat to global public health as well as the livestock breeding industry.

Pathogenesis and Prevention of Acute Renal Failure

DTIC Science & Technology

1987-12-01

nifedipine, renal tubules, anoxia , hypoxia, isolated GO -U4 perfused kidney, nuclear magnetic resonance 19. ABSTRACT (Continue on reverse if...5. Effect of anoxia on cultured CCr ceb. Conditions and drugs are the samne as in figure 4. U.1 F a Arox~a control 0 1 2 3 4 5 6 24 HOURS In summary...100 lM PBPB reduced LDH release from over 70 to 60% after anoxia . We are continuing these studies and will compare the results to those achieved with

Minimally invasive aortic valve replacement in high risk patient groups

PubMed Central

Lewis, Harriet; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni; Vohra, Hunaid A.

2017-01-01

Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts. PMID:28740685

State of the art in fluid and volume therapy : A user-friendly staged concept. English version.

PubMed

Rehm, M; Hulde, N; Kammerer, T; Meidert, A S; Hofmann-Kiefer, K

2017-04-10

Adequate intraoperative infusion therapy is essential for the perioperative outcome of a patient. Both hypo- and hypervolemia can lead to an increased rate of perioperative complications and to a worse outcome. Perioperative infusion therapy should therefore be needs-based. The primary objective is the maintenance of preoperative normovolemia using a rational infusion strategy. Perioperative fluid losses should be differentiated from volume losses due to surgical bleeding or protein losses into the interstitial space. Fluid loss via urine excretion or insensible perspiration (0.5-1.0 ml/kg/h) should be replaced with balanced, isooncotic, crystalloid infusion solutions in a ratio of 1:1. Volume therapy stage 1: intraoperative volume losses up to a blood loss corresponding to 20% of the patient's total blood volume are compensated for by balanced crystalloids in a ratio of 4-5:1. Stage 2: blood losses exceeding this level are to be treated with isooncotic colloids (preferably balanced) in a 1:1 ratio. In this regard taking into consideration the contraindications, e. g., sepsis, burns, critical illness (usually patients in the intensive care unit), impaired renal function or renal replacement therapy, intracranial hemorrhage, or severe coagulopathy, artificial colloids such as hydroxyethyl starch (HES) can be used perioperatively for volume replacement. Stage 3: if an allogeneic blood transfusion is indicated, blood and blood products are applied in a differentiated manner.

Diabetes Mellitus After Pediatric Kidney Transplant.

PubMed

Almardini, Reham; Salaita, Ghazi; Albderat, Jawaher; Alrabadi, Katiba; Alhadidi, Aghadir; Alfarah, Mahdi; Abu Ruqa'a, Ala'; Dahabreh, Dina

2018-06-01

Kidney transplant is the best renal replacement therapy for pediatric patients with end-stage renal disease; however, this procedure is not without complications. A major complication is the development of new-onset diabetes mellitus, which affects the outcomes of transplant in terms of kidney and patient survival. In this study, our objective was to calculate the percentage of pediatric patients who developed new-onset diabetes mellitus or transient hyperglycemia after kidney transplant, compare our data with international data, and discuss the related factors that predispose to diabetes. A retrospective study was conducted by reviewing the medical records of pediatric patients who had transplant procedures or were followed at the Royal Medical Services (Amman, Jordan) from 2007 to 2017. Our study cohort included 104 patients. The average follow-up time was 4 years and 7 months, with a maximum follow-up of 9 years. Ten patients developed posttransplant hyperglycemia, with 8 developing early hyperglycemia (during the first 3 months posttransplant). In 40% of patients, this complication was transient, and patients stopped insulin after immunosuppressant medications were decreased. However, 60% of patients continued to have diabetes, with 20% having late-onset diabetes and treatment with oral hypoglycemic agent. Pretransplant awareness of risk factors of new-onset diabetes mellitus after transplant and close monitoring of hyperglycemia during the posttransplant period are mandatory. Transient hyperglycemia after kidney transplant is common, and kidney transplant does not alleviate the high risk of diabetes in patients with chronic kidney disease.

The impact on quality of life of dialysis patients with renal insufficiency.

PubMed

Dąbrowska-Bender, Marta; Dykowska, Grażyna; Żuk, Wioletta; Milewska, Magdalena; Staniszewska, Anna

2018-01-01

The aim of the study was the subjective assessment of the quality of life (QoL) of 140 patients treated with dialysis (peritoneal dialysis and hemodialysis). Chronic kidney disease and the methods of its treatment play an important part in shaping the QoL of patients receiving dialysis. As a result, kidney failure causes many limitations in patients' physical, mental, and social activities. The instrument to measure the QoL was the authors' own questionnaire made on the basis of Kidney Disease and Quality of Life Short Form version 1.2 (KDQOL - SF 1.2) and their selection of areas influencing the perceived QoL of chronically ill patients. The research showed that patients receiving peritoneal dialysis assessed their QoL in its different dimensions as much higher than patients receiving hemodialysis. The parameter having the biggest negative impact on the QoL of patients receiving hemodialysis was an impeded possibility to continue work or studies and a change of life plans. The will to live was more highly assessed by patients receiving peritoneal dialysis as compared to patients receiving hemodialysis. In order to improve the functioning of hemodialysis patients in a manner most similar to healthy persons, the renal replacement therapy should consider patients' individual needs and expectations, ie, guarantee flexible hours of work or study and of receiving dialysis. In addition, patients treated with hemodialysis should receive psychological care, in particular those demonstrating emotional problems, in order to achieve better results in therapy and improve their QoL.

CKD.QLD: establishment of a chronic kidney disease [CKD] registry in Queensland, Australia.

PubMed

Venuthurupalli, Sree K; Hoy, Wendy E; Healy, Helen G; Cameron, Anne; Fassett, Robert G

2017-06-07

Chronic kidney disease [CKD] is recognised as a global public health problem. Until recently, the majority of information informing on CKD has been generated from renal registries reporting on patients with end-stage kidney disease [ESKD] and on renal replacement therapy [RRT]. There has been a paucity of information on pre-dialysis CKD cohorts, and many issues related to these poorly described populations are unresolved. To this end, international organizations have called for CKD surveillance systems across all countries. In Australia, we have responded by developing the Chronic Kidney Disease in Queensland [CKD.QLD] with three main platforms consisting of CKD Registry, clinical trials and development of biobank. This registry which is the core component of CKD surveillance was conceptualized specifically for the pre-dialysis population in the public health system in Queensland, Australia. Recruitment started in May 2011, and to date the Registry has evolved as one of the largest CKD cohorts in the world with recruitment close to 7000 patients. The Registry has had many outcomes, including being the nidus for Australia's first National Health and Medical Research Council [NHMRC] CKD Centre of Research Excellence [CKD.CRE]. The Registry, with its linkage to Queensland Health datasets, is reporting, and is expected to continue generating, significant information on multiple aspects of CKD, its trajectory, management and patient outcomes. Intent of the CKD.CRE is to facilitate an expanded Registry network that has representation from health services, both public and private, across Australia.

Inappropriate Prescription and Renal Function Among Older Patients with Cognitive Impairment.

PubMed

Sönnerstam, Eva; Sjölander, Maria; Gustafsson, Maria

2016-12-01

Older people are more sensitive to drugs and adverse drug reactions than younger people because of age-related physiological changes such as impaired renal function. As people with dementia are particularly vulnerable to the effects of drugs, it is especially important to evaluate the dosages of renally cleared medications in this group. The aim of this study was to estimate the prevalence of impaired renal function and inappropriate prescriptions on the basis of renal function among older patients with dementia or cognitive impairment. The medical records of 428 patients aged ≥65 years who were admitted to two hospitals in northern Sweden were reviewed and renally cleared medications were identified. The Cockcroft-Gault equation was used to evaluate renal function. Doses were evaluated according to the Geriatric Dosage Handbook. Renal function was impaired (estimated glomerular filtration rate <60 ml/min) in 65.4 % of the study population. Impaired renal function was associated with increasing age. Among 547 prescriptions identified as renally cleared medications, 9.1 % were inappropriate based on the patient's renal function; 13.5 % of the 326 patients prescribed renally cleared medications had inappropriate prescriptions. Inappropriate prescriptions were more common among patients living in nursing homes. Impaired renal function is common and inappropriate prescription is prevalent among old people with cognitive impairment in northern Sweden. Continuous consideration of renal function is important when prescribing medications to this group.

Long-Term Outcomes of Renal Transplant in Recipients With Lower Urinary Tract Dysfunction.

PubMed

Wilson, Rebekah S; Courtney, Aisling E; Ko, Dicken S C; Maxwell, Alexander P; McDaid, James

2018-01-02

Lower urinary tract dysfunction can lead to chronic kidney disease, which, despite surgical intervention, will progress to end-stage renal disease, requiring dialysis. Urologic pathology may damage a transplanted kidney, limiting patient and graft survival. Although smaller studies have suggested that urinary tract dysfunction does not affect graft or patient survival, this is not universally accepted. Northern Ireland has historically had the highest incidence of neural tube defects in Europe, giving rich local experience in caring for patients with lower urinary tract dysfunction. Here, we analyzed outcomes of renal transplant recipients with lower urinary tract dysfunction versus control recipients. We identified 3 groups of kidney transplant recipients treated between 2001 and 2010; those in group 1 had end-stage renal disease due to lower urinary tract dysfunction with prior intervention (urologic surgery, long-term catheter, or intermittent self-catheterization), group 2 had end-stage renal disease secondary to lower urinary tract dysfunction without intervention, and group 3 had end-stage renal disease due to polycystic kidney disease (chosen as a relatively healthy control cohort without comorbid burden of other causes of end-stage renal disease such as diabetes). The primary outcome measured, graft survival, was death censored, with graft loss defined as requirement for renal replacement therapy or retransplant. Secondary outcomes included patient survival and graft function. In 150 study patients (16 patients in group 1, 64 in group 2, and 70 in group 3), 5-year death-censored graft survival was 93.75%, 90.6%, and 92.9%, respectively, with no significant differences in graft failure among groups (Cox proportional hazards model). Five-year patient survival was 100%, 100%, and 94.3%, respectively. Individuals with a history of lower urinary tract dysfunction had graft and patient survival rates similar to the control group. When appropriately treated, lower urinary tract dysfunction is not a barrier to successful renal transplant.

Comparison of computer tomographic volumetry versus nuclear split renal function to determine residual renal function after living kidney donation.

PubMed

Patankar, Khalil; Low, Ronny Su-Tong; Blakeway, Darryn; Ferrari, Paolo

2014-07-01

Living-donor kidney transplantation is an established practice. Traditionally a combination of renal scintigram and computed tomography (CT) is used to select the kidney that is to be harvested in each donor. To evaluate the ability of split renal volume (SRV) calculated from volumetric examination of CT images compared to nuclear split renal function (nSRF) derived from gamma camera scintigram to predict donor residual single kidney function after donor nephrectomy. This pilot study comprised a retrospective analysis of CT images and renal scintigrams from 12 subsequent live kidney donors who had at least 12 months post-donation renal function follow-up. nSRF derived from the renal scintigram, expressed as the right kidney's function in percent of the total, was 50.2 ± 3.3 (range, 44.1-54.0%) and SRV estimated following analysis of CT imaging was 49.0 ± 2.9 (range, 46.4-52.3%). Although the correlation between nSRF and SRV was moderate (R = 0.46), there was 92% agreement on the dominant kidney if a difference of <2% in nSRF versus SRV was considered. Post-donation glomerular filtration rate (GFR) by CKD-EPI formula was 92 ± 10 mL/min/1.73m2 at 1 year and the correlation between estimated GFR (eGFR) at 1 year and extrapolated single kidney eGFR adjusted by nSRF (R(2 )= 0.69, P = 0.0007) or SRV (R(2 )= 0.74, P = 0.0003) was similar. Calculation of SRV from pre-donation CT examination is a valid method to estimate nSRF with good concordance with nSRF determined by renal scintigram and could replace the latter in the assessment of potential kidney donors. © The Foundation Acta Radiologica 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

End-stage renal disease, dialysis, kidney transplantation and their impact on CD4+ -T-cell differentiation.

PubMed

Schaier, Matthias; Leick, Angele; Uhlmann, Lorenz; Kälble, Florian; Morath, Christian; Eckstein, Volker; Ho, Anthony; Mueller-Tidow, Carsten; Meuer, Stefan; Mahnke, Karsten; Sommerer, Claudia; Zeier, Martin; Steinborn, Andrea

2018-05-02

Premature aging of both CD4 + -regulatory- (Tregs) and CD4 + -responder-T-cells (Tresps) in end-stage renal disease (ESRD) patients is expected to affect the success of later kidney transplantation. Both T-cell populations are released from the thymus as inducible co-stimulatory (ICOS + -) and ICOS - -recent thymic emigrant (RTE)-Tregs/Tresps, which differ primarily in their proliferative capacities. In this study, we analysed the effect of ESRD and subsequent renal replacement therapies on the differentiation of ICOS + - and ICOS - -RTE-Tregs/Tresps into ICOS + - or ICOS - -CD31 - -Memory-Tregs/Tresps and examined whether diverging pathways affected the suppressive activity of ICOS + - and ICOS - -Tregs in co-culture with autologous Tresps. Compared to healthy controls, we found an increased differentiation of ICOS + -RTE-Tregs/Tresps and ICOS - -RTE-Tregs via CD31 + -memory-Tregs/Tresps into CD31 - -memory-Tregs/Tresps in ESRD and dialysis patients. In contrast, ICOS - -RTE-Tresps showed an increased differentiation via ICOS - -mature naïve (MN)-Tresps into CD31 - -memory-Tresps. Thereby, the ratio of ICOS + -Tregs/ICOS + -Tresps was not changed, while that of ICOS - -Tregs/ICOS - -Tresps was significantly increased. This differentiation preserved the suppressive activity of both Treg populations in ESRD and partly in dialysis patients. After transplantation, the increased differentiation of ICOS + - and ICOS - -RTE-Tresps proceeded, while that of ICOS + -RTE-Tregs ceased and that of ICOS - -RTE-Tregs switched to an increased differentiation via ICOS - -MN-Tregs. Consequently, the ratios of ICOS + -Tregs/ICOS + -Tresps and of ICOS - -Tregs/ICOS - -Tresps decreased significantly, reducing the suppressive activity of Tregs markedly. Our data reveal that an increased tolerance-inducing differentiation of ICOS + - and ICOS - -Tregs preserves the functional activity of Tregs in ESRD patients, but this cannot be maintained during long-term renal replacement therapy. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Estimation of Daily Proteinuria in Patients with Amyloidosis by Using the Protein-To-Creatinine ratio in Random Urine Samples.

PubMed

Talamo, Giampaolo; Mir Muhammad, A; Pandey, Manoj K; Zhu, Junjia; Creer, Michael H; Malysz, Jozef

2015-02-11

Measurement of daily proteinuria in patients with amyloidosis is recommended at the time of diagnosis for assessing renal involvement, and for monitoring disease activity. Renal involvement is usually defined by proteinuria >500 mg/day. We evaluated the accuracy of the random urine protein-to-creatinine ratio (Pr/Cr) in predicting 24 hour proteinuria in patient with amyloidosis. We compared results of random urine Pr/Cr ratio and concomitant 24-hour urine collections in 44 patients with amyloidosis. We found a strong correlation (Spearman's ρ=0.874) between the Pr/Cr ratio and the 24 hour urine protein excretion. For predicting renal involvement, the optimal cut-off point of the Pr/Cr ratio was 715 mg/g. The sensitivity and specificity for this point were 91.8% and 95.5%, respectively, and the area under the curve value was 97.4%. We conclude that the random urine Pr/Cr ratio could be useful in the screening of renal involvement in patients with amyloidosis. If validated in a prospective study, the random urine Pr/Cr ratio could replace the 24 hour urine collection for the assessment of daily proteinuria and presence of nephrotic syndrome in patients with amyloidosis.

Delayed presentation of severe rhabdomyolysis leading to acute kidney injury following atorvastatin-gemfibrozil combination therapy: a case report.

PubMed

Dalugama, Chamara; Pathirage, Manoji; Kularatne, S A M

2018-05-22

Rhabdomyolysis is a rare but serious complication of lipid-lowering therapy. Statin and fibrate combination increases the risk of rhabdomyolysis possibly by pharmacodynamic interactions. Advanced age, diabetes, hypothyroidism, polypharmacy, and renal impairment are known to increase the risk of rhabdomyolysis. Management strategies include fluid resuscitation and urine alkalinization. Renal indications such as refractory hyperkalemia, acidosis, fluid overload, or uremic complications mandate renal replacement therapy in rhabdomyolysis. We report the case of a 62-year-old Sri Lankan Sinhalese man with dyslipidemia, type 2 diabetes mellitus with renal impairment, and hypothyroidism who was on atorvastatin; he was started on gemfibrozil and developed muscle symptoms. Although gemfibrozil was discontinued soon after, he presented with rhabdomyolysis with acute kidney injury 1 month later. He needed hemodialysis due to refractory hyperkalemia, metabolic acidosis, and fluid overload. Rhabdomyolysis is a rare but serious complication due to lipid-lowering therapy with statins and fibrates. Treating physicians should be aware and patients should be warned to report about muscle symptoms after starting statins or fibrates. Rhabdomyolysis may occur with mild symptoms and signs and may occur later, even after discontinuation of the drug.

Exercise Induced Rhabdomyolysis with Compartment Syndrome and Renal Failure

PubMed Central

Bhalla, Mary Colleen; Dick-Perez, Ryan

2014-01-01

Exertional rhabdomyolysis is sequela that is occasionally seen after strenuous exercise. The progression to compartment syndrome or renal failure is a rare complication that requires prompt recognition and treatment to prevent morbidity (Giannoglou et al. 2007). We present a case of a 22-year-old college football player who presented to the emergency department (ED) after a typical leg workout as part of his weight conditioning. He was found to have rhabdomyolysis with evidence of renal insufficiency. His condition progressed to bilateral compartment syndrome and renal failure requiring dialysis. After bilateral fasciotomies were performed he had resolution of his compartment syndrome. He continued to be dialysis dependent and had no return of his renal function at discharge 12 days after admission. PMID:25105034

Exercise induced rhabdomyolysis with compartment syndrome and renal failure.

PubMed

Bhalla, Mary Colleen; Dick-Perez, Ryan

2014-01-01

Exertional rhabdomyolysis is sequela that is occasionally seen after strenuous exercise. The progression to compartment syndrome or renal failure is a rare complication that requires prompt recognition and treatment to prevent morbidity (Giannoglou et al. 2007). We present a case of a 22-year-old college football player who presented to the emergency department (ED) after a typical leg workout as part of his weight conditioning. He was found to have rhabdomyolysis with evidence of renal insufficiency. His condition progressed to bilateral compartment syndrome and renal failure requiring dialysis. After bilateral fasciotomies were performed he had resolution of his compartment syndrome. He continued to be dialysis dependent and had no return of his renal function at discharge 12 days after admission.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chaudhuri, T.K.; Fink, S.

The records of 18 consecutive patients referred to a Veterans Administration Hospital nuclear medicine service for renal scintigraphic tests to rule out renovascular hypertension were reviewed. The men were elderly (mean age, 62 years), and risk factors for untoward reactions, including long-standing hypertension, severe peripheral vascular disease, diabetes, chronic renal failure, and recent diuretic use were present. Despite these risks, there was no test morbidity, and the authors conclude that the renal scintigraphic test with captopril enhancement is well tolerated and deserves continued application and evaluation.

Role of pressure in angiotensin II-induced renal injury: chronic servo-control of renal perfusion pressure in rats.

PubMed

Mori, Takefumi; Cowley, Allen W

2004-04-01

Renal perfusion pressure was servo-controlled chronically in rats to quantify the relative contribution of elevated arterial pressure versus angiotensin II (Ang II) on the induction of renal injury in Ang II-induced hypertension. Sprague-Dawley rats fed a 4% salt diet were administered Ang II for 14 days (25 ng/kg per minute IV; saline only for sham rats), and the renal perfusion pressure to the left kidney was continuously servo-controlled to maintain a normal pressure in that kidney throughout the period of hypertension. An aortic occluder was implanted around the aorta between the two renal arteries and carotid and femoral arterial pressure were measured continuously throughout the experiment to determine uncontrolled and controlled renal perfusion pressure, respectively. Renal perfusion pressure of uncontrolled, controlled, and sham kidneys over the period of Ang II or saline infusion averaged 152.6+/-7.0, 117.4+/-3.5, and 110.7+/-2.2 mm Hg, respectively. The high-pressure uncontrolled kidneys exhibited tubular necrosis and interstitial fibrosis, especially prominent in the outer medullary region. Regional glomerular sclerosis and interlobular artery injury were also pronounced. Controlled kidneys were significantly protected from interlobular artery injury, juxtamedullary glomeruli injury, tubular necrosis, and interstitial fibrosis as determined by comparing the level of injury. Glomerular injury was not prevented in the outer cortex. Transforming growth factor (TGF)-beta and active NF-kappaB proteins determined by immunohistochemistry were colocalized in the uncontrolled kidney in regions of interstitial fibrosis. We conclude that the preferential juxtamedullary injury found in Ang II hypertension is largely induced by pressure and is probably mediated through the TGF-beta and NF-kappaB pathway.

Serum uric acid levels contribute to new renal damage in systemic lupus erythematosus patients.

PubMed

Reátegui-Sokolova, C; Ugarte-Gil, Manuel F; Gamboa-Cárdenas, Rocío V; Zevallos, Francisco; Cucho-Venegas, Jorge M; Alfaro-Lozano, José L; Medina, Mariela; Rodriguez-Bellido, Zoila; Pastor-Asurza, Cesar A; Alarcón, Graciela S; Perich-Campos, Risto A

2017-04-01

This study aims to determine whether uric acid levels contribute to new renal damage in systemic lupus erythematosus (SLE) patients. This prospective study was conducted in consecutive patients seen since 2012. Patients had a baseline visit and follow-up visits every 6 months. Patients with ≥2 visits were included; those with end-stage renal disease (regardless of dialysis or transplantation) were excluded. Renal damage was ascertained using the SLICC/ACR damage index (SDI). Univariable and multivariable Cox-regression models were performed to determine the risk of new renal damage. Uric acid was included as a continuous and dichotomous (per receiving operating characteristic curve) variable. Multivariable models were adjusted for age at diagnosis, disease duration, socioeconomic status, SLEDAI, SDI, serum creatinine, baseline use of prednisone, antimalarials, and immunosuppressive drugs. One hundred and eighty-six patients were evaluated; their mean (SD) age at diagnosis was 36.8 (13.7) years; nearly all patients were mestizo. Disease duration was 7.7 (6.8) years. Follow-up time was 2.3 (1.1) years. The SLEDAI was 5.2 (4.3) and the SDI 0.8 (1.1). Uric acid levels were 4.5 (1.3) mg/dl. During follow-up, 16 (8.6%) patients developed at least one new point in the renal domain of the SDI. In multivariable analyses, uric acid levels (continuous and dichotomous) at baseline predicted the development of new renal damage (HR 3.21 (1.39-7.42), p 0.006; HR 18.28 (2.80-119.48), p 0.002; respectively). Higher uric acid levels contribute to the development of new renal damage in SLE patients independent of other well-known risk factors for such occurrence.

Dialysis treatment in patients with rheumatoid arthritis.

PubMed

Hezemans, R L; Krediet, R T; Arisz, L

1995-07-01

The results of dialysis treatment in 24 rheumatoid arthritis patients, 20 chronic rheumatoid arthritis (RA) and 4 juvenile rheumatoid arthritis (JRA), were analysed. Presence of secondary amyloidosis, renal function, morbidity and survival were examined. Amyloidosis was present in 13 patients. Especially among amyloidosis patients, renal function declined rapidly in the last year before dialysis started. On average, 63 days per patient-year were spent in the hospital, 58% was dialysis-related, mainly due to vascular access problems. Hospitalization was even more widespread in amyloidosis patients (79 days, 72% dialysis-related). Median survival in RA patients with amyloidosis was 11 months; in RA patients without amyloidosis this was 29 months. Two-year survival was only 1 out of 10 for the RA amyloidosis patients; for the RA non-amyloidosis patients this was 5 out of 6 (p < 0.01). Cardiovascular causes of death were most frequent. In conclusion, high morbidity and low survival make RA patients with amyloidosis a high-risk group on renal replacement therapy.