Common Cause Of Acute Kidney Injury Research Articles

#2581 Cryptococcosis in kidney transplant recipients: a nationwide multicenter retrospective cohort study—CRITERE study

Abstract Background and Aims Cryptococcosis stands as the third most common invasive fungal infection in solid organ transplant recipients. Clinical management and prognosis of the disease remains largely unexplored in the context of kidney transplant recipients. Our main objective was to describe the natural history of cryptococcosis after kidney transplantation from the graft patterns of kidney injury to the long term outcomes. Method We established a nationwide cohort of adult kidney transplant recipients diagnosed with cryptococcosis between 2002 and 2019 in France. All data were gathered starting from the transplantation date and encompassed up to the latest follow-up consultation. All putative causes of AKI as claimed by the attending clinicians were recorded. Cases were matched (ratio 1:6) with kidney transplant recipients from the French prospective multicenter cohort DIVAT with parameters at time of transplant including immunosuppression and known risk factors of cryptococcosis such as age, history of smoke, history of cancer and HIV status. Transplant outcomes (graft failure and patient death) were then compared between matched patients. Results 88 patients were included. Patients were predominantly male (n = 61, 69.3%), with a mean age of 57.0 years [SD ±13.3]. The majority of patients were primary kidney transplants (n = 71, 80.7%) with a median time from ESRD to transplantation of 2.8 years [IQ 1.25-5]. The majority of patients received ATG as induction therapy for their transplant (n = 50, 69.4%)Acute kidney injury (AKI) at diagnosis involved 37.3% of the patients with 13.3% requiring renal replacement therapy. AKI staging was distributed as follows, AKI grade 1 in 12.5% of patients, grade 2 in 13.3% of patients, and grade 3 in 11.5% of patients. During the induction stage, 39% of patients developed amphotericin B-related AKI. AKI resulting from tacrolimus overdose subsequent to tacrolimus/fluconazole interaction occurred in 25.7% of patients during the consolidation stage. Among the patients alive at 3 months following the diagnosis of cryptococcosis, 33.7% of patients exhibited graft dysfunction. Following cryptococcosis, 5 patients displayed T cell rejection and 4 patients developed antibody-mediated rejection. A total of 41 patients with cryptococcosis were matched to 246 controls (ratio 1:6), after a median follow-up of 52.3 [28.1-90.2] months, patients with cryptococcosis exhibited a higher risk of mortality with 35.9% compared with 9.8% (p < 0.001) and graft failure with 33.3% compared with 15.0% (p = 0.0005). Conclusion This study has shown that kidney injury manifests itself through a sequential, multi-step process that initially includes pre-renal impairment, ATN and iatrogenic mechanisms. Amphotericin B-related AKI, followed by tacrolimus overdose represent common causes of AKI.

Acute Kidney Injury in Chronic Liver Disease in Northwest India: Still a Battle to Conquer

Background: Patients with cirrhosis are susceptible to development of acute kidney injury (AKI), which leads to poor outcome. We conducted a study to evaluate the spectrum of AKI in patients with cirrhosis. Materials and Methods: This study was conducted in consecutive cirrhotic patients with AKI admitted in a tertiary care center of India from April 2020 to December 2022. Details including history, examination findings, and results of laboratory investigations were recorded. Results: A total of 243 patients were enrolled in this study. The majority (91.3%) of the patients were males. The most common etiology of cirrhosis was alcohol in 58.4% (n = 142) followed by hepatitis B in 10.3% (n = 25) of patients. Pre-renal form of AKI was present in 54.4% (n = 132) of patients and hepatorenal syndrome (HRS) in 21.8% (n = 53) of patients. IgA nephropathy was the commonest (n = 6) glomerular pathology in nonresponders with intrinsic renal disease. Majority of the patients belonged to stage II (46.9%) and stage I AKI (37%), while only 16.1% had stage III AKI. Various stages of AKI showed a significant correlation (P < 0.05) with Child–Turcotte–Pugh (CTP) score and Model for End-stage Liver Disease (MELD)-Na score. The overall in-hospital mortality rate was found to be 18.5% (n = 45). Conclusion: Renal dysfunction is a frequent complication among cirrhotic patients. Pre-renal factors were the most common cause of AKI in cirrhotics. Stages of AKI showed significant correlation with liver prognostic scores. Renal biopsy should be considered in patients not responding to treatment, to guide further management.

Succinylation of Park7 activates a protective metabolic response to acute kidney injury.

Acute kidney injury (AKI) is extremely prevalent among hospitalizations and presents a significant risk for the development of chronic kidney disease and increased mortality. Ischemia caused by shock, trauma, and transplant are common causes of AKI. To attenuate ischemic AKI therapeutically, we need a better understanding of the physiological and cellular mechanisms underlying damage. Instances of ischemia are most damaging in proximal tubule epithelial cells (PTECs) where hypoxic signaling cascades, and perhaps more rapidly, posttranslational modifications (PTMs), act in concert to change cellular metabolism. Here, we focus on the effects of the understudied PTM, lysine succinylation. We have previously shown a protective effect of protein hypersuccinylation on PTECs after depletion of the desuccinylase sirtuin5. General trends in the results suggested that hypersuccinylation led to upregulation of peroxisomal activity and was protective against kidney injury. Included in the list of changes was the Parkinson's-related deglycase Park7. There is little known about any links between peroxisome activity and Park7. In this study, we show in vitro and in vivo that Park7 has a crucial role in protection from AKI and upregulated peroxisome activity. These data in combination with published results of Park7's protective role in cardiovascular damage and chronic kidney disease lead us to hypothesize that succinylation of Park7 may ameliorate oxidative damage resulting from AKI and prevent disease progression. This novel mechanism provides a potential therapeutic mechanism that can be targeted.NEW & NOTEWORTHY Succinylation is an understudied posttranslational modification that has been shown to increase peroxisomal activity. Furthermore, increased peroxisomal activity has been shown to reduce oxidative stress and protect proximal tubules after acute kidney injury. Analysis of mass spectrometry succinylomic and proteomic data reveals a novel role for Parkinson's related Park7 in mediating Nrf2 antioxidant response after kidney injury. This novel protection pathway provides new insights for kidney injury prevention and development of novel therapeutics.

Acute Kidney Injury in Pregnancy: A Prospective Study.

When acute kidney damage occurs during pregnancy, it poses a difficult clinical problem. One of the main causes of maternal and fetal morbidity and death is pregnancy-related acute kidney injury (AKI), a significant obstetric complication characterized by a fast deterioration in renal function and several subsequent clinical problems. The objective of the study is to analyze the etiological factors, clinical manifestations, and maternal and fetal outcomes of AKI during pregnancy. This prospective observational research involved patients hospitalized in the General Medicine and Obstetrics and Gynecology departments at Indira Gandhi Institute of Medical Sciences, Patna, for a year (October 2021 to September 2022) due to obstetric difficulties resulting in acute renal damage. The study included 62 patients with a mean age of 25.08±4.25 years. The majority of patients in our study were aged 18-25 years (38, 61.3%), followed by 26-30 years (19, 30.6%) and >30 years (5, 8.1%). The majority of patients in our study were non-booked (52, 83.9%) and presented as emergency cases, whereas 10 (16.1%) patients had booked. In addition, 34 (54.8%) patients were primigravida, while 28 (45.1%) were multigravida. There were 25 patients in their third trimester (40.3%), 19 who were postpartum (30.6%), 10 who were post-abortion (16.1%), and eight in their second trimester (12.9%). Upon admission, the majority of the patients showed signs of oliguria, accounting for 45 cases (72.6%). This was followed by nine cases of abnormal kidney function (14.5%) and eight cases of anuria (12.9%). Among the other symptoms, fever was observed in 25 cases (40.32%), whereas breathlessness increased to 15 cases (24.19%), edema was present in 14 cases (22.58%), vomiting and altered sensorium were observed in four cases (6.45%), abdominal pain was observed in three cases (4.83%), and burning micturition was observed in two cases (3.22%). The most common causes of AKI in pregnancy in the present study were puerperal sepsis (18 cases, 29.0%), followed by preeclampsia/eclampsia (14 cases, 22.6%), hemorrhagic shock (10 cases, 16.1%), septic abortion (six cases, 9.7%), hyperemesis gravidarum (four cases, 6.5%), acute fatty liver of pregnancy (three cases, 4.8%), disseminated intravascular coagulation (three cases, 4.8%), drug-induced sepsis (two cases, 3.2%), and urosepsis (two cases, 3.2%). Modes of delivery in this study were normal vaginal delivery (32 cases, 51.6%), lower segment cesarean section (21 cases, 33.9%), dilation and evacuation (seven cases, 11.3%), and total hysterectomy (two cases, 3.2%). Hemodialysis was performed in 39 patients (62.9%), and 51 (82.3%) received blood transfusions. The mean systolic and diastolic BP (mmHg) were 111.37±22.60 and 71.40±18.88, respectively. Maternal outcome data revealed that 48 (77.4%) women had fully recovered, eight (12.9%) had not recovered, 43 (69.4%) were lost to follow-up, and two (3.2%) had died. Neonatal outcomes in the present study were as follows: live birth, 43 (69.4%); abortion, eight (12.9%); intrauterine death of the fetus, five (8.1%); and neonatal mortality, six (9.7%). The diagnosis and treatment of AKI during pregnancy is a significant challenge for the treating physician because of the pathophysiological changes that occur during pregnancy, the variability of symptoms, and the fact that clinical and laboratory features may occasionally overlap.

Galectin-3 and Autophagy in Renal Acute Tubular Necrosis.

Acute kidney injury (AKI) is a public health burden with increasing morbidity and mortality rates and health care costs. Acute tubular necrosis (ATN) is the most common cause of AKI. Cisplatin (CIS) is a platinum-based chemotherapeutic agent used in the treatment of a wide variety of malignancies such as lung, breast, ovary, testis, bladder, cervix, and head and neck cancers. Autophagy plays an important role in AKI. Galectin-3 (Gal-3) is significantly increased in renal tubules in AKI; however, its role in autophagy is not well understood. Male C57B6/J and B6.Cg-Lgals3 <tm 1 Poi>/J Gal-3 knockout (KO) mice were used to induce AKI using a CIS mouse model of ATN. Renal Gal-3 and autophagy proteins' expression were measured using standard histologic, immunofluorescent, and enzyme-linked immunosorbent assay techniques. The data were presented as the mean ± S.E. Statistically significant differences (p < 0.05) were calculated between experimental groups and corresponding control groups by one-way analysis of variance. There was a significant increase in renal concentrations of Gal-3 in the Gal-3 wild-type CIS-treated mice when compared with sham control mice. There were significantly higher concentrations of renal LC3B, ATG13, Ulk-1, Beclin, ATG5, ATG12, ATG9A, and p-AMPK in the CIS-treated Gal-3 KO mice than in the Gal-3 wild-type CIS-treated mice. Further, there were significantly higher concentrations of mTOR, p- NF-κB, beta-catenin, and p62 in the kidneys of the Gal-3 wild-type CIS-treated mice than in the Gal-3 KO CIS-treated mice. Our findings affirm the connection between Gal-3 and autophagy, revealing its central role as a connector with prosurvival signaling proteins. Gal-3 plays a pivotal role in orchestrating cellular responses by interacting with prosurvival signal pathways and engaging with autophagy proteins. Notably, our observations highlight that the absence of Gal-3 can enhance autophagy in CIS-induced ATN.

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI".

Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind. The ASPIRE study(part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice. From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%. Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

The role of peritoneal dialysis in the treatment of acute kidney injury in neurocritical patients: a retrospective Brazilian study.

Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome. Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer. A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, p = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, p = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, p = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, p = 0.009). Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI.

MicroRNA-192-5p downregulates Fat Mass and Obesity-associated Protein to aggravate renal ischemia/reperfusion injury

Acute kidney injury (AKI) is a common disorder without effective therapy yet. Renal ischemia/reperfusion (I/R) injury is a common cause of AKI. MicroRNA miR-192-5p has been previously reported to be upregulated in AKI models. However, its functional role in renal I/R injury is not fully understood. This study aimed to investigate the effects and the underlying mechanism of miR-192-5p in renal I/R progression. Hypoxia/reoxygenation (H/R)-induced cell injury model in HK-2 cells and I/R-induced renal injury model in mice were established in this study. Cell counting kit-8 assay was performed to determine cell viability. Quantitative real-time PCR and western blot analysis were performed to detect gene expressions. Hematoxylin-eosin and periodic acid-Schiff staining were performed to observe the histopathological changes. Enzyme-linked immunosorbent assay was performed to detect the kidney markers’ expression. In vivo and in vitro results showed that miR-192-5p was up-regulated in the I/R-induced mice model and H/R-induced cell model, and miR-192-5p overexpression exacerbated I/R-induced renal damage. Then, the downstream target of miR-192-5p was analyzed by combining the differentially expressed mRNAs and the predicted genes and confirmed using a dual-luciferase reporter assay. It was found that miR-192-5p was found to regulate fat mass and obesity-associated (FTO) protein expression by directly targeting the 3’ untranslated region of FTO mRNA. Moreover, in vivo and in vitro studies unveiled that FTO overexpression alleviated renal I/R injury and promoted HK-2 cell viability via stimulating autophagy flux. In conclusion, miR-192-5p aggravated I/R-induced renal injury by blocking autophagy flux via down-regulating FTO.

Factors of Development of Hepatorenal Syndrome in Patients with Liver Cirrhosis of Viral Etiology

Hepatorenal syndrome (HRS) is a type of acute kidney injury (AKI), occurring in patients with decompensated liver cirrhosis and is associated with high mortality. We aim to describe the predictors associated with the development of HRS in cirrhotic patients with AKI. We retrospectively analyzed 125 cirrhotic patient encounters with AKI across all Health institutions between 1 January 2019 and 31 December 2022. We performed multivariate analyses to determine independent predictors of development of HRS. Alcoholic cirrhosis was the most common identified etiology of cirrhosis. The mean Model for End-Stage Liver Disease Scorewas18 (±7). Ascites was the most commonly identified clinical feature of portal hypertension. Infection was identified in 38.4% of patients with urinary tract infection/pyelonephritis being the most common. Spontaneous bacterial peritonitis occurred in 5.9% of patients. The most common cause of AKI was pre-renal. Hepatorenal syndrome was identified in 9.8% of patient encounters. Predictors of HRS were history of ascites, serum creatinine &gt;2.5 mg/dL, albumin &lt;3 g/dL, bilirubin &gt;2 mg/dL and spontaneous bacterial peritonitis. We demonstrate strong predictors for the development of HRS which can aid clinicians to attain an early diagnosis of HRS, leading to prompt and targeted management and improving outcomes

Acute Kidney Injury in Liver Cirrhosis.

Acute kidney injury (AKI) is common in cirrhotic patients affecting almost 20% of these patients. While multiple etiologies can lead to AKI, pre-renal azotemia seems to be the most common cause of AKI. Irrespective of the cause, AKI is associated with worse survival with the poorest outcomes observed in those with hepatorenal syndrome (HRS) and acute tubular necrosis (ATN). In recent years, new definitions, and classifications of AKI in cirrhosis have emerged. More knowledge has also become available regarding the benefits and drawbacks of albumin and terlipressin use in these patients. Diagnostic tools such as urinary biomarkers and point-of-care ultrasound (POCUS) became available and they will be used in the near future to differentiate between different causes of AKI and direct management of AKI in these patients. In this update, we will review these new classifications, treatment recommendations, and diagnostic tools for AKI in cirrhotic patients.

Comparison of clinical characteristics and outcomes of acute kidney injury in the elderly and younger hospitalized patients

Data regarding the epidemiology, causes, and outcomes of acute kidney injury (AKI) are limited, especially in the elderly population. We aimed to investigate the clinical characteristics and early outcomes of AKI and to compare them between elderly and young patients hospitalized in an internal medicine clinic.&#x0D; Methods. This single-center retrospective study included patients with AKI who were hospitalized in a tertiary hospital. AKI was identified according to the Kidney Disease Improving Global Outcomes criteria. Sociodemographic, clinical, and laboratory data were recorded. Renal recovery, need for dialysis, and in-hospital mortality were compared between the elderly (&gt;60 years) and younger (≤60 years) patients.&#x0D; Results. A total of 454 patients (327 elderly and 127 younger) were included in the study. The frequency of AKI in hospitalized patients was 12%. The most common cause of AKI was prerenal (61%). Prerenal AKI due to absolute intravascular volume reduction was the most important cause in both groups. Compared with the elderly patients, younger patients exhibited an increased rate of renal AKI (23% vs. 39%, p=0.001) and an increased need for dialysis during hospitalization (21% vs. 31.5% p=0.027). The incidence of vasculitis and glomerulonephritis was higher in younger patients with renal AKI than in the elderly patients (12% vs. 1.3% for vasculitis and 24% vs. 4% for glomerulonephritis p=0.001). Twenty-four percent of patients required dialysis during hospital stay and 10% required dialysis at discharge. The overall in-hospital mortality was 6,4%. Considering the AKI pathophysiology, the highest mortality rate was observed in AKI patients with renal origin (3.5%). There were no significant differences between elderly and younger patients based on renal recovery (complete recovery, 41% vs. 50%; progression 59% vs. 50%, p=0,073), hospital mortality (5.5% vs. 6.7%, p=0.634), and the need for dialysis at discharge (14% vs. 8.8%, p=0.082).&#x0D; Conclusions. In our study, we concluded that there was no significant difference between elderly and younger hospitalized patients according to the early outcomes of AKI. However, the younger patients had a higher rate of renal AKI with a more severe course.

#3600 ACUTE KIDNEY INJURY IN THE ELDERLY: DIFFERENCES OVER TIME

Abstract Background and Aims The incidence of acute kidney injury (AKI) in people older than 60 years constantly increasing and it is higher than in the rest of the population. Increased risk of AKI in the elderly is due to decreased functional reserves of the kidneys, aggressive surgical and diagnostic interventions, and frequent use of nephrotoxic drugs. The aim of this study was to analyze the incidence and causes of AKI in a patient older than 60 years during three different periods: the first period between 1974-1994 year, the second between 1997-2001 year, and the third period between 2014-2018 year. At the same time, we examined the most common causes of AKI over time. Method The retrospective study included 927 patients with AKI treated in our clinic, 572 patients during the first period, 75 patients during the second period, and 280 patients in the third period. The diagnosis was made based on an absolute increase in serum creatinine by&amp;gt;26.5 umol/l, or an increase of 50% relative to basal values, or a decrease in urine output &amp;lt;0.5 ml/kg/h within 6 h. We analyzed causes and type of AKI, method of treatment, and mortality. Results Incidence of AKI in patients older than 60 years in the period 1974-1994 is 19%, only three years later this percentage has risen to 64%, while in the last period this percentage was 82%. Conservative method of treatment was more often used in the last examined period 83.6% compared to 33% and 56.2% in previous periods. In the last examined period, HD was used in 16.4% of patients (in two previous periods 4% and 8.3% respectively). While PD was used by 50.5% in the period 1997-2001 and 31.3% in the period 1974-1994, in the last period PD was not used. Mortality has declined slightly over time but remains high (27.1%, then 29.6%, and recently 22%). Regarding the type of AKI during all three examined periods, statistically the most common is the prerenal type over 50%, and the renal type during the last five-year period increased by 26.4% compared to the previous 17.5% and 20.8% respectively. Conclusion The incidence of AKI in people over the age of 60 is on the rise. Mortality, although still high, is noticeably declining compared to the previous periods, which may be a consequence of better treatment of both conservative and active dialysis treatment.

Management of acute renal failure in infants: a seven-year multicenter experience.

Background. An infant with acute kidney injury (AKI) represents a technical challenge with respect to vascular access. Acute peritoneal dialysis (PD) is often the only possible treatment modality. Patients and methods. Over a period of 7 years (2014 -2021), the outcome of acute PD was studied in 56 infants (38 boys) with AKI, aged 6 hours to 24 months, at 3 tertiary care centers of a teaching hospital in Algeria. Results. Acute tubular necrosis (58.9%) was the most common cause of AKI, followed by hemolytic uremic syndrome (23.2 %). Acute PD was highly effective in lowering retention markers (p &lt; 0.0001). The reduction of blood urea greater than 11% after 10 cycles of PD would be the first sign of good evolution followed by that of serum creatinine at 10% after 15 cycles (p &lt; 0.0001). Hypokaliemia was the most common complication (46.4%). Overall mortality was 23.2 %. The risk of mortality by multi-variate analysis was higher with the Severity of AKI and when patients were anuric (p &lt; 0.0001), septicemia (p &lt; 0.0001), or decompensated congenital heart disease (p &lt; 0.001) The survivors did not differ from those who died with respect to age, sex or weight when acute PD was initiated. The average time to renal function recovery was between 72 hours and 12 days. Conclusion. Acute PD is an appropriate treatment choice for infants with AKI. The reduction of blood urea after 10 cycles of PD is a good predictor of evolution.

Factors Associated with Mortality and Long-Term Outcomes of Pediatric Acute Kidney Injury in a Resource Limited Setting

Introduction: Despite being a leading cause of morbidity and mortality globally, acute kidney injury (AKI) is worse in resource-limited areas. This study explores AKI incidence, inhospital mortality, and long-term outcomes in resource-limited settings. Methods: This was a prospective study of children with AKI from 2014 to 2019. KDIGO 2012 defined AKI. We assessed the etiology, inhospital mortality, and long-term outcome of AKI in a mission hospital. Results: Only 169 of 201 AKI patients had complete data. The ages ranged from 1.08 months to 17.5 years; 65.7% were male and 65.1% were from lower socioeconomic class. The incidence of AKI was 59.6 cases per 1,000 persons (95% CI: 5.42, 47.1). Most patients had stage 1 KDIGO AKI (91; 53.8%). 1–5 years old had the highest incidence of AKI (65; 38.5%); sepsis (26.6%), severe malaria (15.4%), and nephrotic syndrome (14.8%) were common AKI causes. Fever (72.8%), pallor (52.1%), and vomiting (45.6%) were the most common symptoms. Thirty-two (27.8%) patients had high blood pressure. Inhospital mortality was 14.8% (95% CI: 9.8, 21.1). The cumulative incidence of AKI-related mortality was 93.2 per 1,000 person-years. Poor outcome was associated with breathlessness, hyponatremia, and leukocytosis. Kaplan-Meier survival curve showed 81% (CI: 74–87%) survival after 5 years of AKI. On Cox proportional-hazards analysis, the absence of breathlessness (HR: 2.537, 95%: CI 1.210–5.317) and hyponatremia (HR: 2.914, 95% CI: 1.343–6.324) were associated with increased survival. Conclusion: In resource-limited settings, infectious diseases and nephrotic syndrome are common causes of AKI. Factors associated with mortality include breathlessness and hyponatremia.

Onconephrology: acute kidney disease after preventive ileostomy in a patient with colorectal cancer

The risk of acute kidney injury (AKI) in cancer patients is much higher than in the general population. Common causes of AKI in this group of patients are toxicity of chemotherapy com ponents and water-electrolyte imbalances. The risks of AKI increase significantly if the patient has a history of chronic kidney disease of any etiology. Risk assessment and correction, prevention and treatment of acute and chronic renal dysfunction are the standard tasks of onconephrology The clinical case of acute kidney disease described here illustrates the main mechanisms and factors of organ dysfunction and its outcomes as a con­ sequence of colorectal cancer treatment. The necessity of multidisciplinary cooperation in determining the management and treatm ent tactics of such patients is shown, that is essential for the long-term prognosis.

Spectrum, Outcomes, and Mortality Predictors of Acute Kidney Injury among Non-COVID-19 Patients during COVID-19 Pandemic: Data from Four Intensive Care Units.

The data of acute kidney injury (AKI), that is, community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI) among non-COVID patients from intensive care units (ICU) during the coronavirus disease-2019 (COVID-19) pandemic are scarce. We planned to study the change in the profile of such patients compared to the pre-pandemic era. This prospective observational study was conducted at four ICUs dealing with non-COVID patients at a government hospital in North India, and was aimed at assessing outcomes, and mortality predictors of AKI among non-COVID patients during the COVID-19 pandemic. Renal and patient survival at ICU transfer-out and hospital discharge, ICU and hospital stay duration, mortality predictors, and dialysis requirement at discharge were evaluated. The current or previous COVID-19 infection, previous AKI or chronic kidney disease (CKD), organ donors, and organ transplant patients were excluded. Among the 200 non-COVID-19 AKI patients, diabetes mellitus (DM), primary hypertension, and cardiovascular diseases were the predominant comorbidities in descending order. The commonest cause of AKI was severe sepsis, followed by systemic infections and post-surgery patients. Dialysis requirements at ICU admission during ICU stay and above 30 days were seen in 20.5, 47.5, and 6.5% of patients, respectively. Incidence of CA-AKI and HA-AKI was 1.24:1, whereas dialysis requirement above 30 days was 0.85:1, respectively. The 30-day mortality was 42%. Hepatic dysfunction [hazard ratio (HR): 3.471], septicemia (HR: 3.342), age above 60 years (HR: 4.000), higher sequential organ failure assessment (SOFA) score (HR: 1.107; p = 0.001), anemia (p = 0.003), and low serum iron (p = 0.001) were important mortality predictors in AKI. Compared to the pre-COVID era, CA-AKI was more common than HA-AKI due to restricted elective surgeries during the COVID-19 pandemic. Acute kidney injury with multiorgan involvement and hepatic dysfunction, elderly age with higher SOFA score and sepsis were predictors of adverse renal and patient outcomes. Singh B, Dogra PM, Sood V, Singh V, Katyal A, Dhawan M, et al. Spectrum, Outcomes, and Mortality Predictors of Acute Kidney Injury among Non-COVID-19 Patients during COVID-19 Pandemic: Data from Four Intensive Care Units. Indian J Crit Care Med 2023;27(2):119-126.

CLINICAL PROFILE OF ACUTE KIDNEY INJURY IN ICU PATIENT IN TERTIARY CARE HOSPITAL AND MEDICAL COLLEGE DAHOD, A TRIBAL AREA OF GUJARAT

Acute kidney injury (AKI) is an outcome of multiple etiologies and is mostly reversible. Data on its incidence and outcome,particularly from India,are limited.Our aim was to study the etiology,clinical profile,and short-term prognosis in AKI.It was a hospital-based prospective observational study on AKI. Seventy-five AKI patients diagnosed by Acute Kidney Injury network criteria were selected. Patients with preexisting chronic kidney disease were excluded.Data were compiled using the Statistical Package for the Social Sciences version 17. Regression analysis was done for determining the association of various variables for mortality.P &lt; 0.05 was considered statistically significant.The mean age of patients was 41.09 ± 16.17 years with a male:female ratio of 1.42:1. Comorbidities were present in 37.3%, with diabete smellitus (10.6%) and chronic liver disease (10.6%) being the most common.Fever was the most common (40%) presenting symptom, followed by oliguria (25.8%). Infection was the most common cause of AKI (56%), with sepsis in 26.7% followed by acute gastroenteritis in 17.3%. Pneumonia was the primary focus in 50% of cases with sepsis. Mean serum creatinine and urea at admission were 2.37 ± 0.90 and 92.44 ± 39.67 mg/dl, respectively. Serum creatinine rose progressively to 2.96 ± 1.18 and 3.26 ± 1.56 mg/dl at 24 and 48 h,respectively,since hospitalization.Majority of the cases (73.3%) were nonoliguric. Hemodialysis was necessary in 24% of cases. Mean hospital stay was 8.16 days. In-hospital mortality was 24%.Among survivors, 92.9% had complete renal recovery on discharge. Sepsis,need for hemodialysis, urea &gt;100 mg/dl,and peak serum creatinine &gt;3 mg/dl were contributors to mortality (P &lt; 0.01).

Spectrum of Renal Involvement in Cancer Patients: A Cross-sectional Descriptive Study

Introduction: Cancer is associated with multiple renal manifestations like Acute Kidney Injury (AKI), Chronic Kidney Disease (CKD), proteinuria, and electrolyte imbalance. The reason behind renal dysfunction in cancer patients is multifactorial and can be attributed to underlying cancer and treatment modalities, in addition to co-morbidities surgical procedures and infections. Aim: To assess the spectrum of renal involvement in cancer patients presenting at a tertiary care hospital. Materials and Methods: The cross-sectional descriptive study, was conducted in the Department of Medicine of University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India. One hundred consecutive patients referred for nephrology consultation with diagnosed cancer, irrespective of cancer aetiology between the age group of 15-70 years with deranged kidney function test were recruited. Detailed medical and treatment history, including the type of cancer-solid or haematological, cancer status-cured or continuing, treatment given-chemotherapy, radiotherapy or surgery or a combination and associated co-morbidities like diabetes mellitus and hypertension were recorded. Routine investigations and special investigations, including assessment of estimated Glomerular Filtration Rate (eGFR) and estimation of Albumin-Creatinine Ration (ACR) was done. Patients were then segregated, based on their kidney function test into groups with AKI or CKD and underlying cause was valuated. Summary statistics was presented as mean, median or frequency and data analysed using Statistical Package of Social Sciences (SPSS) version 24.0. Results: The mean age of the study population was 53.73±12.20 years with 63% male and 37% female participants; 87% patients had solid cancers, while 13% had haematological cancers. The median duration, since the diagnosis was seven months and the patients were undergoing chemotherapy, radiotherapy or a combination of both; seven patients had surgery for underlying malignancy and an additional six had received chemotherapy or radiation therapy along with surgery. At the time of recruitment, 78% patients had AKI and 22% patients were diagnosed with CKD. Chemotherapy-induced nephropathy was the most common cause of AKI (n=46). In the CKD group diabetes (n=7) was the most common aetiology. Conclusion: The kidneys in cancer patients can be involved in a number of ways, as a consequence of the cancer itself, its treatment, superimposed infections or associated comorbidities. Chemotherapy-induced nephropathy is the most common cause of AKI, whereas, diabetes is the most common cause of CKD in cancer patients.

ACUTE KIDNEY INJURY AS A PREDICTOR OF MORTALITY IN PATIENTS WITH COVID-19

ACUTE KIDNEY INJURY AS A PREDICTOR OF MORTALITY IN PATIENTS WITH COVID-19

Outcomes of CD19-Targeted Chimeric Antigen Receptor T Cell Therapy for Patients with Reduced Renal Function Including Dialysis

Patients with renal impairment (RI) are typically excluded from trials evaluating chimeric antigen receptor (CAR) T cell therapies. We evaluated the outcomes of patients with RI receiving standard of care (SOC) CAR T cell therapy for relapsed/refractory (R/R) diffuse large B cell lymphoma (DLBCL). In this retrospective, single-center cohort study of patients with R/R DLBCL treated with SOC axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) after 2 or more prior lines of therapy, renal and survival outcomes were compared based on RI and fludarabine dose reduction (DR) status. RI was defined by an estimated glomerular filtration rate <60 mL/min/1.73 m2 as determined by the Modification of Diet in Renal Disease equation using day -5 creatinine (Cr) values. Acute kidney injury (AKI) was identified and graded using standard Kidney Disease: Improving Global Outcomes criteria. Renal recovery was considered to occur if Cr was within .2 mg/mL of baseline by day +30. Fludarabine was considered DR if given at <90% of the recommended Food and Drug Administration label dose. Among 166 patients treated with CAR T cell therapy were 17 patients (10.2%) with baseline RI and 149 (89.8%) without RI. After CAR T cell infusion, the incidence of any grade AKI was not significantly different between patients with baseline RI and those without RI (42% versus 21%; P=.08). Similarly, severe grade 2/3 AKI was seen in 1 of 17 patients (5.8%) with baseline RI and in 11 of 149 patients (7.3%) without RI (P=1). Decreased renal perfusion (28 of 39; 72%) was the most common cause of AKI, with cytokine release syndrome (CRS) contributing to 17 of 39 AKIs (44%). Progression-free survival (PFS) and overall survival (OS) did not differ between patients with RI and those without RI or between those who received standard-dose fludarabine and those who received reduced-dose fludarabine. In contrast, patients with AKI had worse clinical outcomes than those without AKI (multivariable PFS: hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2 to 3.7; OS: HR, 3.9; 95% CI, 2.1 to 7.4). Notably, peak inflammatory cytokine levels were higher in patients who experienced AKI. Finally, we describe 2 patients with end-stage renal disease (ESRD) on dialysis who received lymphodepletion and CAR T cell therapy. Baseline renal function did not affect renal or efficacy outcomes after CAR T cell therapy in DLBCL. On the other hand, patients with AKI went on to experience worse clinical outcomes. AKI was commonly related to CRS and high peak inflammatory cytokine levels. CAR T cell therapy is feasible in patients with ESRD and requires careful planning of lymphodepletion.