Postoperative Bilateral Renal Cortical Necrosis Secondary to Antiphospholipid Syndrome: A Case Report and Literature Review

Quiz Page June 2014: A 45-Year-Old Woman With Acute Anuria

Is an aortic tissue valve the best choice for young adults?

The aim of this study was to identify anatomical variations in coronary artery orifices among high-risk patients with a small aortic root undergoing bioprosthetic aortic valve replacement (BAVR) and transcatheter aortic valve replacement (TAVR) in order to prevent coronary orifice obstruction perioperatively. Coronary orifice and root structure were identified in 400 patients using aortic multidetector-row computed tomography (MDCT). We measured the aortic root diameter; intercommissural distances; and distance from coronary orifice to valve annulus, commissure, and sinotubular junction. We examined positional relationships between the coronary orifice and stent post, or sewing cuff of the bioprosthetic valve and leaflet of the transcatheter aortic valve. Most left coronary artery orifices were distributed near the center of the non-left and left-right commissures; right ones were relatively distributed on the non-right commissural side. Thirty-four patients (8.5%) with BAVR (coronary orifice near the commissure: 31, 7.8%; low takeoff: 5, 1.3%; and both: 2) and 39 (9.8%) with TAVR were at risk for coronary orifice obstruction. During BAVR, one-stitch rotation of the stent and one-stitch rotation with intra-annular implantation were used in near-commissure and low takeoff cases, respectively. During TAVR, percutaneous coronary intervention may be required in the height of the coronary orifice was ≤10 mm from the base of the ventricle aortic junction. Potential coronary complications during BAVR and TAVR in high-risk patients for coronary obstruction were identified using preoperative aortic MDCT. Choice of appropriate surgical technique or valve is essential.

Reoperation in Bioprosthetic vs Mechanical Aortic Valve Replacement in The Society of Thoracic Surgeons Database.

Acute renal cortical necrosis is a rare cause of acute renal failure. It can occur following a variety of insults but has been most commonly reported following obstetric complications (Kleinknecht et al., 1973). The diagnosis is suspected when there is oliguria or anuria with little or no recovery within six weeks of onset in an appropriate clinical context. Confirmation of the diagnosis is usually made by renal biopsy but this may be unreliable if the necrosis is patchy (Wells et al., 1960; Kleinknecht et al., 1973). The radiographic demonstration of cortical “tramline” calcification has also been used to confirm a provisional diagnosis but only a minority of patients with cortical necrosis will develop this feature (Deutsch et al., 1971; Kleinknecht et al., 1973) and it is unusual to see such calcification until at least four weeks after the onset of necrosis. It has been shown that distinctive appearances may be seen during renal arteriography and that these appearances may be used to confirm a diagnosis of acute cortical necrosis at an early stage (Deutsch et al., 1971; Kleinknecht et al., 1973). It is usually thought that opacification of the renal substance during intravenous urography does not occur in patients with acute cortical necrosis. However, three cases showing such opacification have been reported in the French literature (Joffre et al., 1976) and the following case report is a further example. In all four cases the pattern of opacification was characteristic.

Vitamin deficiency and renal cortical necrosis

This study examines sex-based differences in baseline characteristics, practice patterns, and mid-term survival following aortic valve replacement (AVR). The study design included all consecutive patients from the AVR Registry with a three-year follow-up. Patients were initially categorized by sex and prosthesis type. The primary endpoint was 3-year all-cause mortality. Subgroup observations included the age-recommended threshold for mechanical prosthesis (<65 years) and the patient-prosthesis mismatch (PPM). The present study revealed that females (n = 517) compared to males (n = 732) were significantly older (67.2 ± 9.3 years vs 64.4 ± 12.2 years, p < 0.001), had higher body mass index (2.23 ± 7.2 cm2 vs 2.01 ± 0.2 cm2, p < 0.005) and lower left ventricular ejection fractions (51.8 ± 13.5% vs 57.7 ± 10.8%, p < 0.001) at the time of the index procedure. Additionally, females received significantly more bioprosthetic AVR than males (38.1% vs. 32.6%, p = 0.040). There were no significant differences in 3-year mortality risk between males and females (14.6% vs. 14.1%, p = 0.87). In subgroup analyses of patients with mechanical prostheses, females experienced a higher incidence of PPM than males (9.6% vs. 2.2%, p < 0.001), whereas no significant difference was observed among those who received bioprosthetic valves. The male cohort observed reduced mortality associated with mechanical versus bio-prostheses (HR 0.54, 95% CI 0.36-0.81, p = 0.003). This effect was particularly significant in males under 65 (HR 0.27, 95% CI 0.11-0.68, p = 0.005). However, there was no difference in mortality related to prosthesis type in females, regardless of age group. At the time of referral for AVR, female patients were significantly older and had worse clinical profiles than male patients. Despite the higher rates of bioprosthetic valve implantation and PPM in females, mid-term survival rates were not significantly different. In contrast, males, especially those under 65, showed higher mortality following bioprosthetic AVR. These findings underscore the need for further research focusing on the sex-based treatment determinates in AVR.

Bilateral acute cortical necrosis is a rare form of acute renal failure characterized by necrosis of the renal cortex and sparing of the medulla. Little information on the imaging presentation of bilateral acute renal cortical necrosis is available. The enhanced CT appearance is pathognomonic and diagnostic. The unilateral presentation of acute cortical necrosis is extremely rare, and no imaging methods have been described. The authors chose to apply scintigraphic evaluation to this unique condition complementary to CT to confirm the diagnosis. Mercaptoacetylglycine (T3) was selected to assess tubular damage, in contrast to the pure glomerular agent DTPA. Evidence of some tubular function and clear delineation of the shrunken kidney was found. Conversely, in the DTPA study the kidney was not visualized. A DMSA scan was performed for assessment of viability of the renal cortex and showed a photopenic halo around the small area of the viable cortex of the upper pole. The halo sign represents a cortical loss. The visualization of the upper pole as evidence of cortical viability as a consequence of collateral blood flow from capsular vessels was seen on angiography. Radiographic and scintigraphic correlation of this rare condition may be an effective means to confirm the diagnosis and to establish the extent of involvement. However, contrast CT remains the preferred method in the diagnosis of acute cortical necrosis.

Acute bilateral renal cortical necrosis (RCN) is a rare but potentially lethal form of renal injury that poses a diagnostic and therapeutic challenge for clinicians. The causes of renal cortical necrosis are multi-factorial. Renal cortical necrosis shows a higher incidence in men than women in non-obstetric cases, and its clinical presentation is heterogeneous, ranging from asymptomatic to severe renal failure. In this case report, we describe the clinical course of a patient who presented with acute renal failure following a venomous snake bite and was subsequently diagnosed with renal cortical necrosis. Despite aggressive management, the patient ultimately succumbed to death on the 24th day of admission. The present case highlights the importance of early diagnosis, prompt initiation of appropriate management, and effective prevention of complications in patients with renal cortical necrosis to improve patient outcomes and reduce morbidity and mortality. A timely and accurate diagnosis of renal cortical necrosis is critical for initiating appropriate interventions, and management should aim to address the underlying cause and prevent potential complications.

Background: Postpartum acute kidney injury (AKI) is one of the serious complications of pregnancy and constitutes an important cause of obstetric AKI. Severe acute kidney injury in the postpartum period often necessitates initiation of short-term dialysis. It may be associated with varying degree of morbidity and mortality in young and often otherwise healthy women. Aims of the study: The aim of the study was to characterizing renal outcome in three months period following of postpartum acute kidney injury requiring hemodialysis. Methods: This prospective observational study was carried out in the Nephrology and Medicine department of Dhaka Medical College Hospital, Dhaka, from July 2019 to December 2020. A total of 64 postpartum AKI patients who required hemodialysis were enrolled in this study as study population. Demographic, clinical and laboratory data of the patients, outcome variables included survival at hospital, discharge and estimated glomerular filtration rate (eGFR) at three months of follow up were recorded. Results: In this study, 54(84.4%) patients survived and maternal mortality was 15.6%. The mean age was 26.13±4.59 in alive group and 24.3±4.95 years in death group. Majority of patients were multigravida and had LUCS delivery. Puerperal sepsis (70.4% in alive group and 100.0% in death group) was the most prevalent cause followed by obstetric hemorrhage (APH/PPH) and pre-eclampsia/eclampsia. The mean S. Creatinine was 6.66±1.42 (mg/dl) in alive group and 6.74±1.12 (mg/dl) in death group. Out of 48 patients who were followed up at three months, 47.92% had eGFR &lt;60ml/min/1.73m2. Duration of oligoanuria was the only predictor of eGFR&lt;60 mL/min/1.73m2 at three months of follow up. Renal biopsy was done in ten patients out of whom 40% had thrombotic microangiopathy with renal cortical necrosis and 30% patient had renal cortical necrosis. One patient with renal cortical necrosis remained dialysis dependent at three months of follow up. ...................

Quantitative Aspects of Blood Coagulation in the Generalized Shwartzman Reaction: 1. Effects of Variation of Preparative and Provocative Doses of E. Coli Endotoxin

Long-term Outcomes Following Mechanical or Bioprosthetic Aortic Valve Replacement in Young Women

Current evidence for prosthesis selection: What can we really say?

Bioprosthetic vs Mechanical AorticValve Replacement in Patients40to 75 Years of Age.

Catastrophic antiphospholipid syndrome (CAPS) leads to organ dysfunction due to thrombotic microangiopathy (TMA). Complement may play a role in CAPS, and its blockade could prevent antiphospholipid syndrome (APS) complications after kidney transplantation (KT). Here, we report a case of APS recurrence after KT in a 38-year-old woman with early acute cortical kidney allograft necrosis despite preventive eculizumab treatment, probably because of insufficient complement blockade. The patient had recurrent but controlled CAPS for years with renal dysfunction, leading to preemptive KT. Anticoagulation and eculizumab were administered to prevent thrombosis and TMA after KT. She developed acute kidney injury (AKI) with incomplete biological TMA. Imaging revealed cortical necrosis in the renal allograft. In the absence of donor-specific anti-HLA antibodies, we concluded a relapse. Additional doses of eculizumab and plasma exchange allowed the normalization of biological tests and improvement of kidney allograft function. A retrospective complement analysis showed an incomplete blockade at the time of AKI. One year after KT, the renal allograft function was impaired. This suggests that inadequate complement blockade leads to a relapse of APS in the renal allograft with cortical necrosis and dysfunction. Our case highlights the importance of monitoring complement activity and adjusting the dose of eculizumab or ravulizumab.