Changes In Serum Creatinine Research Articles

#6321 ELECTRONIC CREATININE ALERT SYSTEM. A FIRST STEP TOWARDS PREVENTING HOSPITAL ACQUIRED ACUTE KIDNEY INJURY

Abstract Background and Aims Acute kidney injury (AKI) is a common complication in the critically ill and non-critically ill patient. There is currently no specific treatment for patients who develop AKI, so early recognition may help prevent progression to more advanced stages and the need for kidney replacement therapies (KRT). Electronic Alert Systems (EAS) emerge as a useful tool in different clinical scenarios to alert the clinician to potentially harmful situations. One of the utilities of the EAS is the AKI scenario, in which the clinician can be alerted early to serum creatinine (SCr) changes in real time and thus establish early intervention protocols to avoid the poor outcomes described above. The aim of the present study is to analyze the incidence of AKI in a tertiary hospital using an EAS based on SCr changes (Electronic Creatinine Alert System -ECAS-). Method Retrospective study conducted in a tertiary referral hospital. All discharges of patients over 18 years of age, which were issued from 1 January 2019 to 31 December 2021, were analyzed. Exclusion criteria were: discharges from critical care units, patients admitted to the emergency room, patients with AKI criteria on admission, patients admitted to the nephrology department and patients with CKD G5 or on KRT. The ECAS was developed with the aim of alerting patients with and increase of ≥ 0.3mg/dL of SCr or an elevation of ≥ 1.5 times the baseline creatinine value, based on AKI SCr from the KDIGO guidelines. The aims of the present study were: 1. Number of hospitals discharges that activated the ECAS, as well as the severity of AKI; 2. Categorize the departments in which ECAS was common; and 3. Assessing length of hospital stay, survival and kidney recovery during admission defined as SCr less than 1.5 times baseline. Results A total of 69,002 discharges were analyzed over 3 years. Finally, 46,149 discharges were included in the analysis, of which 5,593 (13.5%) discharges activated the ECAS. The distribution by year in which the ECAS was activated was 1,788 (11,8%) of all discharges in 2019, 1,860 (12,4%) in 2020 and 1,945 (12,1%) in 2021. The median age was 75 years (65 – 83), 62% were male. The 5 departments with the highest number of ECAS activations were: Geriatric (14.2%), Cardiology (11.9%), General Surgery (9.9%), Infectious Diseases (9.2%) and Cardiac Surgery (7.6%). Baseline SCr was 1.12mg/dL (0.80-1,79), maximum SCr was 1.99mg/dL(1.40 - 3.19) and SCr at discharge was 1.39 (0.96 - 2.23). 69,7% of patients had AKI stage 1, 21,3% had AKI stage 2 and finally 9% had AKI stage 3. Length of hospital stay was significantly elevated in patients who activated the ECAS [6 days (3 - 11) vs. 13 (8 - 22); p: <0.001], the survival distributions for the ECAS activation were statistically different, X2 (2) = 5.522, p: 0.019. Finally, kidney recovery at discharge was significantly lower in AKI 2 (18.5%) and AKI 3 (8.5%) patients compared to AKI 1 patients (73%) (p: <0.001 for all). Conclusion The ECAS is a suitable electronic alert system that allows rapid identification of patients with AKI. The activation of ECAS is associated with poor outcomes. This study led to the adoption of a nephrology rapid response team for early detection of AKI before creatinine elevation using among others Point-of-care ultrasonography and acute kidney stress biomarkers.

#4792 SECOND, THIRD, AND MORE HITS: IMPACT OF SUCCESSIVE AKI EPISODES ON CKD PROGRESSION AND AKI TO CKD TRANSITION

Abstract Background and Aims The second hit theory refers to the link between two or more deleterious events that cause AKI simultaneously (e.g., triple whammy) or successively (e.g., cardiac surgery after coronary angiography). We investigated the effect of 3 or more consecutive AKI episodes on baseline serum creatinine (SCr) and if these changes leaded to AKI to CKD transition (Transition), CKD progression (Progression) or stable SCr. Method Retrospective study of patients with AKI attended by nephrology during a 3-year period. AKI severity was categorized by KDIGO criteria. We searched for patient's successive admissions and if suffered a new AKI episode and included all patients with ≥3 AKI episodes during the study period. We analyzed the baseline SCr for every episode and investigated if serial AKI episodes leaded to incident CKD, Progression, or no changes in SCr. Results 144 individuals that suffered 525 AKI episodes were included. We observed 36 patients in the Transition, 70 in the Progression group, and 38 didn't vary their SCr. We found no statistically significant differences in hypertension, DM, Charlson's Index, admission to ICU, severity of AKI or length of stay between groups. See Table 1A. We found that progressors had shorter time to nephrology consultation, they were more prone to receive acute HD and to be dialysis dependent at discharge. With no difference in the mortality rate between groups. See Table 1B. Figure 1 plots baseline SCr of every episode that shows a trend to incremental cyphers. Conclusion In our study the clinical characteristics between Transition and Progression groups were similar. We observed more individuals in the Progression group and their time to nephrology consultation was significantly shorter, maybe because no nephrology specialists are afraid of managing CKD patients. Patients that progressed needed acute HD more frequently and were more dialysis dependent at discharge, this finding could be explained by their diminished renal reserve, with no differences in the rate of in-hospital mortality. Successive AKI episodes portend a higher risk of adverse clinical outcomes, with excessive burden for patients with previous CKD. New AKI therapies could change the course of these ominous outcomes? This issue is under intense investigation, but it is very difficult to translate bench to bedside. Therefore, now we can only count on prevention and timely nephrological attention.

Association of Urine Galectin-3 With Cardiorenal Outcomes in Patients With Heart Failure

Approaches to distinguishing pathological cardiorenal dysfunction in heart failure (HF) from functional/hemodynamically mediated changes in serum creatinine are needed. We investigated urine galectin-3 as a candidate biomarker of renal fibrosis and a prognostic indicator of cardiorenal dysfunction phenotypes. We measured urine galectin-3 in 2 contemporary HF cohorts: the Yale Transitional Care Clinic (YTCC) cohort (n = 132) and the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial (n = 434). We assessed the association of urine galectin-3 with all-cause mortality in both cohorts and the association with an established marker of renal tissue fibrosis, urinary amino-terminal propeptide of type III procollagen (PIIINP) in TOPCAT. In the YTCC cohort, there was significant effect modification between higher urine galectin-3 and lower estimated glomerular filtration rates (eGFRs) (Pinteraction = 0.046), such that low eGFR levels had minimal prognostic importance if urine galectin-3 levels were low, but they were important and indicated high risk if urine galectin-3 levels were high. Similar observations were noted in the TOPCAT study (Pinteraction = 0.002). In TOPCAT, urine galectin-3 also positively correlated with urine PIIINP at both baseline (r = 0.43; P < 0.001) and at 12 months (r = 0.42; P < 0.001). Urine galectin-3 levels correlated with an established biomarker of renal fibrosis in 2 cohorts and was able to differentiate high- vs low-risk phenotypes of chronic kidney disease in HF. These proof-of-concept results indicate that additional biomarker research to differentiate cardiorenal phenotypes is warranted.

Effect of Exogenous Albumin Replacement on Plasma Colloid Osmotic Pressure in Severe Preeclampsia: A Case-control Study

Background: In preeclampsia, hypoalbuminemia reduces plasma colloid osmotic pressure (PCOP) and favors capillary leakage. Replacement with exogenous albumin is a therapeutic alternative.&#x0D; Objective: to determine the effect of exogenous albumin replacement on PCOP in patients with severe preeclampsia (SP).&#x0D; Methods: A case-control study was carried out in 76 pregnant patients with SP from the Intensive Care Unit (ICU). The case group (n=38) received 0.9% saline solution 1000 ml every 8 hours and 25% albumin 50 ml every 8 hours and the control group (n=38) only received 0.9% saline solution 1000 ml every 8 hours. Plasma albumin concentrations, PCOP, hemodynamic and laboratory data from admission (baseline measurement) vs discharge from the ICU (final measurement) of both groups were compared.&#x0D; Statistical Analysis: the data was analyzed with descriptive statistics, paired Student's t-test and Pearson's correlation coefficient with the statistical program SPSS® version 20. The p value &lt;0.05 was significant.&#x0D; Results: A significant decrease in plasma albumin was found (case group 2.72±0.44 vs 2.45±0.48 g/dL, p=0.0141; control group 3.06±0.33 vs 2.58±0.29 g/dL, p=0.0431). PCOP was also significantly reduced (case group 18.44±2.92 vs 16.82±2.70 mmHg, p=0.0210; control group 20.38±2.28 vs 17.46±1.96 mmHg, p=0.0763). The group of cases showed an increase in uresis (p=0.0326), but without changes in central venous pressure (p=0.3246) and serum creatinine (p=0.9515). With this evidence the recommendation is that its use in patients with preeclampsia should be reserved for the experience of the medical team.&#x0D; Conclusion: Exogenous albumin replacement therapy did not correct the PCOP values or the blood albumin concentration.

Geographic and Temporal Trends in COVID-Associated Acute Kidney Injury in the National COVID Cohort Collaborative.

AKI is associated with mortality in patients hospitalized with coronavirus disease 2019 (COVID-19); however, its incidence, geographic distribution, and temporal trends since the start of the pandemic are understudied. Electronic health record data were obtained from 53 health systems in the United States in the National COVID Cohort Collaborative. We selected hospitalized adults diagnosed with COVID-19 between March 6, 2020, and January 6, 2022. AKI was determined with serum creatinine and diagnosis codes. Time was divided into 16-week periods (P1-6) and geographical regions into Northeast, Midwest, South, and West. Multivariable models were used to analyze the risk factors for AKI or mortality. Of a total cohort of 336,473, 129,176 (38%) patients had AKI. Fifty-six thousand three hundred and twenty-two (17%) lacked a diagnosis code but had AKI based on the change in serum creatinine. Similar to patients coded for AKI, these patients had higher mortality compared with those without AKI. The incidence of AKI was highest in P1 (47%; 23,097/48,947), lower in P2 (37%; 12,102/32,513), and relatively stable thereafter. Compared with the Midwest, the Northeast, South, and West had higher adjusted odds of AKI in P1. Subsequently, the South and West regions continued to have the highest relative AKI odds. In multivariable models, AKI defined by either serum creatinine or diagnostic code and the severity of AKI was associated with mortality. The incidence and distribution of COVID-19-associated AKI changed since the first wave of the pandemic in the United States. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_08_08_CJN0000000000000192.mp3.

Factors associated with a higher need for antihypertensive medications at 12-months in postkidney transplant recipients: a retrospective cohort study.

The authors reviewed the pre-KTx cardiovascular (CV) imaging, and the changes of CV risk factors during the first-year post-KTx. The authors divided patients according to the number of their blood pressure medications at one year into two groups: requiring less than or equal to 1 and requiring greater than or equal to 2 medications (DTC hypertension). The target blood pressure during the time of this study was less than 140/90mmHg. Two hundred forty-five KTRs were included with an average age of 43.2. 56.3% were male and 79.2% were living donor KTRs. Pre-emptive KTx was 6.5%, previous coronary artery disease was 12.7%, diabetes and smoking 40.8 and 9%, respectively. 38% of the patients had DTC HTN. Risk factors were age (P<0.01), pre-KTx hypertension (P<0.01), and diabetes mellitus (P<0.01). Dialysis vintage, type of dialysis, type of KTx, and smoking were not different between the groups.Patients with abnormal pre-KTx CV imaging, including abnormal ejection fraction less than 55% (P=0.03), abnormal wall motion on echocardiography (P<0.01), abnormal perfusion stress test (P<0.01), higher calcium scoring (P<0.01), abnormal cardiac catheterization (P<0.01), or higher degree of calcifications on CT of pelvic arteries (P<0.01) were at higher risk of DTC hypertension. Post-KTx factors including rejection, change in serum creatinine and weight, A1c, new-onset diabetes post-KTx, and persistent hyperparathyroidism were not different between the groups.Multivariate analysis revealed associations with age (aOR=1.027), male sex (aOR=2.057), baseline diabetes mellitus (aOR=2.065), baseline HTN (aOR=2.82), and use of greater than or equal to 2 antihypertensive medications at 1-month post-KTx (aOR=6.146). At one year post transplantation, about a third of the KTRs required had DTC HTN. These patients were more likely to be older, males, diabetics, previously hypertensive, on greater than or equal to 2 HTN medications at 1-month post-KTx, and to have abnormal baseline pretransplant CV imaging.

A single administration of FGF2 after renal ischemia-reperfusion injury alleviates post-injury interstitial fibrosis.

Despite lack of clinical therapy in acute kidney injury (AKI) or its progression to chronic kidney disease (CKD), administration of growth factors shows great potential in the treatment of renal repair and further fibrosis. At an early phase of AKI, administration of exogenous fibroblast growth factor 2 (FGF2) protects against renal injury by inhibition of mitochondrial damage and inflammatory response. Here, we investigated whether this treatment attenuates the long-term renal interstitial fibrosis induced by ischemia-reperfusion (I/R) injury. Unilateral renal I/R with contralateral nephrectomy was utilized as an in vivo model for AKI and subsequent CKD. Rats were randomly divided into four groups: Sham-operation group, I/R group, I/R-FGF2 group and FGF2-3D group. These groups were monitored for up to 2 months. Serum creatinine, inflammatory response and renal histopathology changes were detected to evaluate the role of FGF2 in AKI and followed renal interstitial fibrosis. Moreover, the expression of vimentin, α-SMA, CD31 and CD34 were examined. Two months after I/R injury, the severity of renal interstitial fibrosis was significantly attenuated in both of I/R-FGF2 group and FGF2-3D group, compared with the I/R group. The protective effects of FGF2 administration were associated with the reduction of high-mobility group box 1 (HMGB1)-mediated inflammatory response, the inhibition of transforming growth factor beta (TGF-β1)/Smads signaling-induced epithelial-mesenchymal transition and the maintenance of peritubular capillary structure. A single dose of exogenous FGF2 administration 1 h or 3 days after reperfusion inhibited renal fibrogenesis and thus blocked the transition of AKI to CKD. Our findings provided novel insight into the role of FGF signaling in AKI-to-CKD progression and underscored the potential of FGF-based therapy for this devastating disease.

Attempting to define a role for renal artery stenting: Another analysis of the CORAL trial

Modrall et al 1 Modrall G.J. Zhu H. Prasad T. Moe O. Dworkin L.D. Cutlip D.E. et al. Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the cardiovascular outcomes in renal atherosclerotic lesions trial.. J Vasc Surg. 2023; 77: 1685-1692 Abstract Full Text Full Text PDF Scopus (1) Google Scholar have reanalyzed data from the CORAL trial 2 Cooper C.J. Murphy T.P. Cutlip D.E. Jamerson K. Henrich W. Reid D.M. et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014; 370: 13-22 Crossref PubMed Scopus (666) Google Scholar to identify a role for renal artery stenting (RAS) in the subset of patients with chronic kidney disease (CKD). They demonstrated, again, that stenting does not provide a benefit compared with optimal medical therapy in terms of event-free survival, the primary end point of their analysis and the parent trial. The blood pressure response was similar between their groups, although the change in serum creatinine and the percentage of change in the estimated glomerular filtration rate (eGFR) were better in the stented group, albeit modest. A larger percentage of the stented patients had had a ≥20% increase in their eGFR (responders) vs the medical group (25.6% vs 17.1%), although the percentage of those with a ≥20% decrease in the eGFR was similar. These responders had had improved event-free, non–renal event-free, and overall survival compared with the nonresponders. However, the presence of diabetes (negative) was the only predictor of a good response. Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions trialJournal of Vascular SurgeryVol. 77Issue 6PreviewThe Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial with 947 patients, concluded that there was no benefit of renal artery stenting (RAS) over medical therapy. However, patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL trial. CKD is a risk factor for cardiovascular and renal morbidity. We hypothesized that improved renal function after RAS would be associated with increased long-term survival and a lower risk of cardiovascular and renal events in patients with CKD. Full-Text PDF

Using urine output tending to manage fluid balance among patients with acute decompensated heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Positive fluid balance has been associated with adverse outcomes in patients admitted to intensive care units (ICU). Urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance in patients admitted to the general ICU. In the cardiac ICU, patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome and increased morbidity and mortality. Studies have shown that poor fluid management in these patients contributes to worse outcomes in this patient population (1). Aim To investigate the possible effect of real-time monitoring of UO trends on the individualized pharmacologic management, fluid balance, and clinical outcomes of patients admitted to the cardiac ICU with ADHF. Methods We performed a case series of 35 patients admitted to the cardiac ICU from July 2021 and January 2022 with ADHF. Their standard Foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (2). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to detect dynamic changes in urine output and guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included incidence of acute kidney injury (AKI), as defined by the KDIGO criteria for changes in serum creatinine (SCr), and 30-day mortality. The case series group was than compared to a historical group of 35 matched controlled patients admitted between 2018-2019. Patients were matched according to cause of admission, age and glomerular filtration rate. Results Mean age was 71 ± 11 years and 49 (70%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P&amp;lt;0.001 for all, Figure 1). Incidence of AKI and AKI combined with 30-day mortality was significantly lower in the electronic UO monitoring cohort (23% vs. 57%, p&amp;lt;0.001, and 34% vs. 63%, p&amp;lt;0.001, respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (CKD) (Figure 2). Conclusion We demonstrated that real time monitoring of UO trends may be used for goal-directed care for the prevention of fluid overload and adverse outcomes in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.

Abstract #1406144: Safety and Efficacy of SGLT2 Inhibitors Use in Patient with Diabetes After Renal Transplant

The sodium glucose cotransporter2 inhibitors (SGLT2i) are preferred anti-glycemic agents for patients with diabetes mellitus (DM) and chronic kidney disease (CKD). These agents have been shown to slow the progression of kidney disease. There is limited experience of SGLT2i in renal transplantation (RT). Concerns have been that the glycosuria induced osmotic diuresis might cause a decrease in renal perfusion and there might be a possible increased risk of urinary tract infections (UTI). We therefore performed a retrospective review of data of patients with DM and RT treated with SGLT2i compared to those without SGLT2i. The primary outcome was the change in eGFR or serum creatinine at 1-year. Secondary outcomes were documentations of serious adverse events (SAE). Data were retrieved from the electronic medical record of a Midwestern academic medical center using the program Epic and the sub-program Slicer/ Dicer. The search algorithm inclusion criteria were: “Diabetes Mellitus” “kidney transplant”, and “medicine: sodium glucose transport inhibitor”, which resulted in an inclusion of 44 patients in the “SGLT2i group”. A comparator group of patients with DM and RT who matched the above screening criteria (except for SGLT2i use), was then retrieved. We then devised a propensity score by performing a multivariate regression analysis with the covariates of age, type of transplant, duration of transplantation, and baseline eGFR. Data from 44 patients on SGLT2i were closely matched (by standardized effects size) for age, estimated GFR, duration and source of transplant with 70 control patients with DM and RT who were not on SGLT2i. Weight changed in SGLT2i group from baseline at 3, 6 and 12months (by -4.1 ± 3.3 kg, -5.1 ± 5.0 kg and -5.2 ± 6.5 kg) and did not change in controls (p [ANOVA, drug] = 0.009). There was no significant difference at 3, 6 or 12 months in changes in: A1c, systolic or diastolic blood pressure, hematocrit, hemoglobin, total cholesterol, LDL cholesterol, HDL cholesterol, or serum triglycerides. There were no documented significant increases in SAE in those on SGLT2i compared with controls in hospitalizations for acute kidney injury, episodes of acute transplant rejections, amputations, cellulitis, diabetic ketoacidosis, or outpatient treatment for urinary tract infections, or genital mycotic infections. Use of SGLT2i in patients with diabetes and renal transplant showed beneficial effect in reducing weight without a higher risk of SAE. Longer follow up may be necessary to define the impact on eGFR.

Development of liposomal contrast agent with high iodine concentration and minimal effect on renal function

PurposeThe use of contrast media is essential to achieve high accuracy in diagnostic imaging. Iodine contrast media, one of these contrast media, has nephrotoxicity as a side effect. Therefore, the development of iodine contrast media that can reduce nephrotoxicity is expected. Since liposomes are generally adjustable in size (100–300 nm) and are not filtered by the renal glomerulus, we hypothesized that iodine contrast media could be encapsulated in liposomes and administered to avoid the nephrotoxicity of iodine contrast media. The aim of this study is to develop an iomeprol-containing liposome (IPL) agent with high iodine concentration and to investigate the effect of intravenous administration of IPL on renal function in a rat model with chronic kidney injury. Materials and methodsIPLs were prepared by encapsulating an iomeprol (400mgI/mL) solution in liposomes by a kneading method using a rotation–revolution mixer. Radiodensities of iomeprol and IPL were measured. IPL or iopamidol at normal dose (0.74 g I/kg) or high dose (3.7 g I/kg) was administered to healthy and 5/6-nephrectomized rats (n = 3–6). Serum creatinine (sCr) and histopathological change of tubular epithelial cells were evaluated after injection. ResultsThe iodine concentration of IPL was 220.7 mgI/mL, equivalent to 55.2% of the iodine concentration of iomeprol. The CT values of IPL was 4731.6 ± 53.2 HU, 59.04% that of iomeprol. The ratios of change in sCr in 5/6-nephrectomized rats that received high-dose iopamidol were 0.73, which were significantly higher than that in 5/6-nephrectomized rats that received high-dose IPL (−0.03) (p = 0.006). Change in foamy degeneration of tubular epithelial cells was confirmed in 5/6-nephrectomized rats that received high-dose iopamidol than that in the sham control group and healthy rats that received normal dose iopamiron (p = 0.016, p = 0.032, respectively). Foamy degeneration of tubular epitherial cells was rarely observed in the IPL injection group. ConclusionsWe developed new liposomal contrast agents that have high iodine concentration and minimal effect on renal function.

Factors Affecting Kidney Functions in One-Year Follow-up After COVID-19 in Kidney Transplant Patients

Background Coronavirus disease (COVID-19) is more severe, and mortality is higher in kidney transplantation (KTx) patients; it is still unclear how renal functions progress and the conditions affecting renal functions in the post-COVID-19 period. We aimed to investigate the changes in kidney functions and the factors affecting this change after COVID-19.&#x0D; Material and Methods Forty-one kidney transplantation patients who were hospitalised for COVID-19 were included in this retrospective study. The patient's personal information, examination, and treatment information regarding their hospitalisation and follow-ups were obtained from the hospital system.&#x0D; Results Patients with elevated serum creatinine in the first year post-COVID had higher baseline proteinuria and systemic immune inflammation index (SII). Proteinuria increased more in patients with a long transplantation period, hypertension, high basal creatinine, and SII. Also, proteinuria was higher in patients who developed AKI during the COVID period. In addition, baseline SII was an independent predictor of the change in serum creatinine and proteinuria.&#x0D; Conclusions We found that patients with signs of increased inflammation, such as high SII were more fragile regarding renal functions. Therefore, the post-COVID-19 follow-up process of KTx patients with COVID-19 should be individualised.

Repetitive administration of rituximab can achieve and maintain clinical remission in patients with MCD or FSGS

Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are glomerulopathies associated with nephrotic syndrome. Primary forms of these diseases are treated with various regimes of immunosuppression. Frequently relapsing or glucocorticoid-dependent courses remain challenging. Here, a B-cell-depleting strategy with rituximab represents a salvage option although data are sparse in the adult population. In particular, there is limited evidence on the efficacy of restoring remission after initial successful treatment with rituximab and whether patients benefit from an individualized, relapse-based approach. We identified 13 patients who received multiple therapies with rituximab from the FOrMe-registry (NCT03949972), a nationwide registry for MCD and FSGS in Germany, or from the University Hospital of Cologne. Disease status, changes in serum creatinine, proteinuria, and time to relapse were evaluated. Relapse-free survival was compared to the patients’ previous therapy regimens. Through all treatment cycles, an improvement of disease activity was shown leading to a complete remission in 72% and partial remission in 26% after 3 (p<0.001) and 6 months (p<0.001). Relapse-free survival increased from 4.5 months (95%-CI 3–10 months) to 21 months (95%-CI 16–32 months) (p<0.001) compared to previous immunosuppression regimens with no loss in estimated glomerular filtration over time (p = 0.53). Compared to continuous B-cell depletion, an individualized relapse-based approach led to a reduced rituximab exposure and significant cost savings. Relapse-based administration of rituximab in patients with MCD/FSGS with an initial good clinical response did not result in a decreased efficacy at a median follow-up duration of 110 months. Thus, reinduction therapies may provide an alternative to continuous B-cell-depletion and reduce the long-term side effects of continuous immunosuppression.

Incidences of and risk factors for clinical and subclinical contrast-associated acute kidney injury in patients who underwent neuroendovascular surgery.

Contrast-associated acute kidney injury (CA-AKI) can develop after intravascular administration of iodinated contrast media. Neutrophil gelatinase-associated lipocalin (NGAL) is an early marker for AKI that helps to detect subclinical CA-AKI. We investigated the incidence of and risk factors for clinical and subclinical CA-AKI in patients who underwent neuroendovascular surgery. We retrospectively investigated 228 patients who underwent neuroendovascular surgery in 2020. Changes in serum creatinine and urine output were used to detect clinical CA-AKI. Urine NGAL concentration was used to detect subclinical CA-AKI in 67 out of 228 patients. In 228 patients, serum creatinine, hemoglobin, hematocrit, total protein, and blood urea nitrogen (BUN) decreased significantly (p < 0.001) after surgery. However, serum creatinine decreased less significantly (p < 0.05) than hemoglobin, hematocrit, total protein, and BUN on postoperative Day 3. Two patients out of 228 developed clinical CA-AKI, and seven patients out of 67 with urine NGAL measurements developed subclinical CA-AKI. Multivariate regression analysis revealed that diabetes mellitus and carotid artery stenosis were significantly (p < 0.05) associated with the development of clinical and/or subclinical CA-AKI. There was a large difference between the incidences of clinical CA-AKI (0.88%) and subclinical CA-AKI (10.4%). The difference might have primarily resulted from the different sensitivities between serum creatinine and urine NGAL and possibly from underestimation of the incidence of clinical AKI due to a postoperative decrease in serum creatinine caused by hemodilution. In addition to diabetes mellitus, carotid artery stenosis could also be a risk factor for CA-AKI.

Epidemiology of childhood acute kidney injury in England using e-alerts.

Few studies describe the epidemiology of childhood acute kidney injury (AKI) nationally. Laboratories in England are required to issue electronic (e-)alerts for AKI based on serum creatinine changes. This study describes a national cohort of children who received an AKI alert and their clinical course. A cross-section of AKI episodes from 2017 are described. Hospital record linkage enabled description of AKI-associated hospitalizations including length of stay (LOS) and critical care requirement. Risk associations with critical care (hospitalized cohort) and 30-day mortality (total cohort) were examined using multivariable logistic regression. In 2017, 7788 children (52% male, median age 4.4 years, interquartile range 0.9-11.5 years) experienced 8927 AKI episodes; 8% occurred during birth admissions. Of 5582 children with hospitalized AKI, 25% required critical care. In children experiencing an AKI episode unrelated to their birth admission, Asian ethnicity, young (<1 year) or old (16-<18years) age (reference 1-<5 years), and high peak AKI stage had higher odds of critical care. LOS was higher with peak AKI stage, irrespective of critical care admission. Overall, 30-day mortality rate was 3% (n=251); youngest and oldest age groups, hospital-acquired AKI, higher peak stage and critical care requirement had higher odds of death. For children experiencing AKI alerts during their birth admission, no association was seen between higher peak AKI stage and critical care admission. Risk associations for adverse AKI outcomes differed among children according to AKI type and whether hospitalization was related to birth. Understanding the factors driving AKI development and progression may help inform interventions to minimize morbidity.

Oral Sodium to Preserve Renal Efficiency in Acute Heart Failure: A Randomized, Placebo-Controlled, Double-Blind Study

Evidence for modulating the sodium chloride (NaCl) intake of patients hospitalized with acute heart failure (AHF) is inconclusive. Salt restriction may not benefit; hypertonic saline may aid diuresis. To compare the safety and efficacy of oral NaCl during intravenous (IV) diuretic therapy in renal function and weight. Seventy hospitalized patients with AHF who were being treated with IV furosemide infusion consented to receive, randomly, 2 grams of oral NaCl or placebo 3 times a day in a double-blind manner during diuresis. Treatment efficacy (bivariate primary endpoints of change in serum creatinine levels and change in weight) was measured at 96 hours, and adverse safety events were tracked for 90 days. Sixty-five patients (34 NaCl, 31 placebo) were included for analysis after 5 withdrew. A median of 13 grams of NaCl was given compared to placebo. At 96 hours, there was no significant difference between treatment groups with respect to the primary endpoint (P = 0.33); however, the trial was underpowered, and there was greater than expected standard deviation in weight change. The mean change in creatinine levels and weight was 0.15 ± 0.44 mg/dL and 4.6 ± 4.2 kg in the placebo group compared with 0.04 ± 0.40 mg/dL and 4.0 ± 4.3 kg in the NaCl group (P = 0.30 and 0.57, respectively). Across efficacy and safety endpoints, we observed no significant difference between the 2 groups other than changes in serum sodium levels (-2.6 ± 2.7 in the placebo group and -0.3 ± 3.3 mEq/L in the NaCl group; P < 0.001) and in serum blood urea nitrogen levels (11 ± 15 in the placebo group; 3.1 ± 13 mEq/L in the NaCl group; P = 0.025). In this single-center study, liberal vs restrictive oral sodium chloride intake strategies did not impact the safety and efficacy of intravenous diuretic therapy in patients with AHF. (ClinicalTrials.gov registration NCT04334668.).

Impact of Inpatient Initiation of SGLT2 Inhibitors on Diuretic Requirements in Patients With Heart Failure.

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve outcomes in patients with heart failure (HF) and are now included in guideline-directed medical therapy. Trials reporting the change in loop diuretic dose following SGLT2i initiation have indicated conflicting results. There is no clear guidance on whether reducing loop diuretic doses following SGLT2i initiation is appropriate. Objective: The purpose of this study is to assess the impact of SGLT2i initiation on diuretic adjustment in hospitalized patients with known or new HF. Methods: This was a retrospective, single health-system study assessing the change in loop diuretic dose in the 60days following discharge for patients with HF initiated on SGLT2i therapy during a hospital admission or upon discharge. Secondary outcomes assessed effect on renal function and discontinuation of SGLT2i within the 60day follow up period. Results: Forty percent of patients required loop diuretic dose adjustment, with 29% requiring a dose reduction within the 60days following discharge. There was minimal change in serum creatinine or blood urea nitrogen. The SGLT2i was discontinued in 6 patients. Conclusions: After inpatient initiation of SGLT2is, approximately one-third of patients required a reduction in loop diuretic dose within 60days following hospital discharge. Further study is recommended to confirm if empiric diuretic dose adjustments are appropriate in this HF population.

Effects of the Modified Antitubercular Treatment Regimen on Renal Function in Patients With Chronic Kidney Disease and Pulmonary Tuberculosis: An Observational Study.

Chronic kidney disease (CKD) increases an individual's vulnerability to infections like tuberculosis. Doses of pyrazinamide and ethambutol are modified to treat such individuals. Additionally, the renal function tends to decline with advancing age. Therefore, it is crucial to study the effect of antitubercular drugs on renal function in youngand elderly patients. The primary objective of this study was to determine the change in serum creatinine levels at six months from baseline in two study groups that included patients aged ≤50 and >50 years. The secondary objectivewas to determine changes in estimated glomerular filtration rate (eGFR) and BMI six months from baseline. We recruited 40 patients with CKD and pulmonary tuberculosis from Srirama Chandra Bhanja (SCB) Medical College and Hospital, India. Each participant received the modified doses of antitubercular drugs. Their serum creatinine, eGFR, and BMI were assessed at baseline, two and six months.Participants had a mean age of 50.93±9.83 years. The median changes in serum creatinine and eGFR values from baseline were -0.19 and -0.23 mg/dl and 4.16 and 3.93 ml/min/m2 for the two study groups, respectively. Furthermore, the differences in BMI from baseline were 1.91 and 2.14 kg/m2, respectively, for the two groups. The renal function was found to be improved after six months of treatment with modified antitubercular drugs. The intergroup comparisons were not statistically significant. We conclude that the modifiedregimen helps effectively cure pulmonary tuberculosis and significantly improves renal function in CKD patients. Further studies are required togeneralize these findings.

MP41-19 BILATERAL MULTIFOCAL RENAL ONCOCYTOMA: CLINICAL CHARACTERISTICS AND OUTCOMES OF MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP41-19 BILATERAL MULTIFOCAL RENAL ONCOCYTOMA: CLINICAL CHARACTERISTICS AND OUTCOMES OF MANAGEMENT Shiva Singh, Aditi Chaurasia, Nikhil Gopal, Noah Pinson, W. Marston Linehan, Ashkan Malayeri, and Mark Ball Shiva SinghShiva Singh More articles by this author , Aditi ChaurasiaAditi Chaurasia More articles by this author , Nikhil GopalNikhil Gopal More articles by this author , Noah PinsonNoah Pinson More articles by this author , W. Marston LinehanW. Marston Linehan More articles by this author , Ashkan MalayeriAshkan Malayeri More articles by this author , and Mark BallMark Ball More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003279.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal oncocytomas are benign neoplasms, accounting for 3-7% of renal tumors. A select number of patients can present with bilateral and/or multifocal oncocytomas and negative germline testing. There is limited data on the clinical course of this subset of patients and optimum treatment strategy remains unclear. This study seeks to evaluate the renal functional and oncological outcomes in patients with bilateral multifocal renal oncocytomas. METHODS: We retrospectively reviewed a cohort of 64 patients with histopathologically confirmed bilateral multifocal renal oncocytomas with negative genetic testing who underwent active surveillance, partial or radical nephrectomy at our institution. Demographics, oncologic outcomes, renal function change and tumor growth rate using 2-dimensional measurements on cross-sectional imaging were assessed. Renal function outcomes were assessed using serum creatinine levels within and between two groups (based on management strategy) with Wilcoxon signed ranked test and Mann-Whitney test respectively. RESULTS: A total of 64 patients (51 males, 13 females) with a median age of diagnosis of 64 years and mean follow-up of 5.7 years were studied. 19 patients underwent only active surveillance, and 45 patients underwent at least one surgical intervention during the study period. Median age of first procedure was 61.5 years. Interventions included 2 renal ablation, 52 partial, and 13 radical nephrectomies. The median growth rate was 0.21 cm/year (0.16-0.27 cm/year), with a new tumor diagnosed on imaging every five years. The median change in serum creatinine was 0.13 mg/dL on active surveillance and 0.12 mg/dL after surgery (p=0.6). No metastases were noted in this cohort throughout the study period. The median age of death was 82.4 years. CONCLUSIONS: Bilateral multifocal renal oncocytomas with negative genetic workup are benign tumors with an indolent course and are seen primarily in 6th decade of life. Considering a minimal difference in functional outcomes between active surveillance and surgical management, surgeons may consider the additional clinical characteristics of patients to design the individual management plan. Source of Funding: This research was supported, in part, by the Intramural Research Program of the National Institutes of Health Clinical Center. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e564 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shiva Singh More articles by this author Aditi Chaurasia More articles by this author Nikhil Gopal More articles by this author Noah Pinson More articles by this author W. Marston Linehan More articles by this author Ashkan Malayeri More articles by this author Mark Ball More articles by this author Expand All Advertisement PDF downloadLoading ...

Mean perfusion pressure in cardiopulmonary bypass as a factor of intraoperative acute kidney injury

The OBJECTIVE was to evaluate the role of mean perfusion pressure in the development of acute kidney injury (AKI) in patients operated with CPB.METHODS AND MATERIALS. A retrospective monocenter observational study was conducted among patients CPB (n=97) who underwent planned heart surgery using CPB. Inclusion criteria: age over 18 years, duration of surgery from 90 to 180 minutes, no signs of end-stage renal disease. The group was divided into subgroups according to the level of mean perfusion pressure (MPP): 1st – MPP&lt;60 mmHg, 2nd – MPP equal to and &gt;60 mmHg. Diagnosis of AKI was carried out on the basis of changes in serum creatinine and biomarkers (NGAL, IgG, albumin in urine). The studied parameters were recorded 15 minutes after the start and end of general anesthesia as well as 24 and 48 hours after surgery.RESULTS. In the 1st subgroup, the frequency of AKI was higher: after 24 hours – 48 (78.7 %), in the 2nd subgroup – 10 (27.8 %), and after 48 hours – 21 (34.4 %) and 5 (13.9 %), respectively. In the 1st subgroup, the need for renal replacement therapy was 5 (8.2 %), while in the 2nd subgroup only 1 patient needed renal replacement therapy (2.8 %). Also, in the 1st subgroup, a higher level of lactate was detected at the end of general anesthesia – the median in the 1st subgroup was 4.6 mmol/l (2.5–11.6), in the 2nd – 2.5 mmol/l (1.4–7.2) (p= 0.022). The levels of AKI biomarkers in urine after 24 hours also differed: NGAL in the 1st – 473.1 ng/ml (235.7–749.5) and in the 2nd –111.3 ng/ ml (53.4–152.9) (p=0.003), albumin 174.6 mg/l (151.2–236.9) and 35.8 mg/l (21.3–52.5) respectively (p=0.006), IgG – 61.7 mg/l (24.9–88.5) and 9.7 mg/l (7.1–14.4) (p=0.002).CONCLUSION. Mean perfusion pressure is an important indicator of the adequacy of cardiopulmonary bypass. Lowering it below 60 mmHg leads to hypoperfusion of the kidneys with the risk of acute kidney injury.