Complete Recovery Of Kidney Function Research Articles

#4487 AN UNEXPECTED CASE OF 2,8-DIHYDROXYADENINE NEPHROPATHY AFTER KIDNEY TRANSPLANTATION RELATED TO NEW VARIANTS OF ADENINE PHOSPHORIBOSILTRANSFERASE GENE

Abstract Background and Aims Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder of the purine metabolism which results in the conversion of adenine into 2,8 dihydroxyadenine (DHA) due to the activity of the xanthine oxidoreductase (XOR). Patients affected by APRT deficiency if not treated with inhibitors of XOR may develop 2,8-DHA nephropathy that might progress to end-stage kidney disease (ESKD) with the need of kidney transplant. The high rate of misdiagnosis of 2,8-DHA nephropathy in native kidneys could lead to the failure of kidney graft in transplanted patients affected by APRT deficiency. Method Here, we report the case of a female, 63-years old patient with ESKD of unknown cause on regular hemodialysis treatment from 2018 after a period of three years on peritoneal dialysis, who underwent kidney transplantation in our Center in 2022. Her medical history showed a metabolic syndrome. She did not experience episodes of renal colic whereas family history reported a brother affected by frequent renal colic of unknown cause. In March 2022, she underwent kidney transplantation from a deceased death brain donor. Induction therapy includes basiliximab, tacrolimus, mycophenolic acid and steroids. Due to the persistence of delay graft function, ten days after kidney transplantation an allograft biopsy has been performed. The histological examination revealed tubular damage surrounded by inflammation cells and intratubular crystals in the renal cortex. The crystals were reddish brown tinged in hematoxylin and eosin stain and were birefringent under polarized light Fig. 1 A, B, so they were strongly related to the hypothesis of DHA crystals. Consistently, the urinalysis showed yellow-brown crystals of DHA. Thus, a genetic analysis of APRT gene has been performed showing two novel heterozygous variants c.388_397p.(Leu130ValfsTer4) and exon 3 deletion, expected pathogenic. The patient was treated with bolus of methylprednisolone (4mg/kg alternate to 50 mg) and a therapy with febuxostat 80 mg/die was started to reduce the amount of plasma DHA. In addition, based on our previous experience of recurrence DHA nephropathy after transplantation, we treated the patient with six consecutive hemodiafiltration (HDF) sessions without ultrafiltration, to promptly remove the serum DHA avoiding their precipitation in the graft while waiting for the lowering effect of febuxostat. At discharge the patient showed an increase of the urine output not associated with a complete recovery of kidney function (sCr 3.88 mg/dl, uric acid 1.6 mg/dl), so two other hemodialysis treatments were performed in the next two weeks. Results At present, almost one year after kidney transplant, the patient is doing well and the graft function is stable with a sCr of 1.6 mg/dl without significant presence of DHA crystals in the urine. Conclusion In conclusion, we find out an unexpected recurrence of 2,8-DHA nephropathy due to novel expected pathogenetic variants of APRT gene in patient without medical history of kidney stones successfully treated with steroid, febuxostat and hemodiafiltration.

Mortality and Recovery of Kidney Function in Kidney Replacement TherapyRequiring AKI: Data from All Affected In-Hospital Subjects

Acute kidney injury (AKI) affects increasing numbers of hospitalized patients in Central Europe and in the US. Kidney replacement therapy (KRT) becomes mandatory if other strategies fail to prevent patients from systemic intoxication, resistant hyperhydration, or refractory hyperkalemia. The majority of data related to survival rates of AKI subjects that require KRT have been acquired under intensive care conditions. In the current letter to the editor we provide outcome data of all patients with in-hospital diagnosed AKI that received KRT at least once. We retrospectively assessed subjects receiving one or more individual sessions of KRT due to AKI of various etiology. Subjects were partly treated in the ICU or under non-ICU conditions. The in-hospital mortality was 35.4% complete recovery of kidney function occurred in 48.8%. In summary, the mortality of all inhospital AKI subjects is comparable to the mortality of AKI patients in the ICU. In addition, more than 50% do not recovery completely. Therefore, subjects with hospital-acquired AKI and an incident or prolonged need for KRT require the highest attention of nephrologists in general, no matter whether they received intensive care treatment or not.

A patient with dialysis-dependent acute kidney injury due to hantavirus complicated with SARS-CoV-2 infection.

In this case, we report a 64-year-old man presenting with anorexia, nausea and vomiting, mild abdominal pain, and oligoanuria for a few hours. His previous medical history included diabetes, hypertension, and chronic kidney disease (CKD) stage 3. Upon arrival, laboratory results revealed stage III acute kidney injury (AKI) with hyperkalemia requiring dialysis treatment. During hospitalization, both pre-renal and post-renal causes of AKI were excluded, and a careful diagnostic evaluation, including kidney biopsy and serology testing, revealed acute interstitial nephritis and positive IgM for hantavirus. The patient was started on steroid treatment, which led to complete recovery of kidney function over 3 months. Moreover, during his hospitalization, the patient was also diagnosed with SARS-CoV-2 infection, possibly due to intra-hospital transmission and was hospitalized at the COVID-19 Department for 14 days, eventually with no further complications. Hantavirus nephropathy should be at the differential diagnosis of AKI, even in the absence of typical symptoms. Steroid treatment may be helpful in reversal of kidney injury.

Risk factors and outcome variables of cardiorenal syndrome type 1 from the nephrologist’s perspective

Background and aimIn cardiorenal syndrome (CRS) type 1, acute cardiac failure or acute decompensation of chronic heart failure causes acute kidney injury (AKI). Every individual AKI episode increases the risk for chronic kidney disease (CKD) in the long term. In this study, we aimed to evaluate epidemiological characteristics and outcome variables of CRS type 1 individuals from the nephrologist’s perspective.MethodsThe study was performed in a retrospective, observational manner. All AKI patients treated at the Brandenburg Hospital of the Medical School of Brandenburg between January and December 2019 were screened for diagnostic criteria of CRS type 1. Endpoints were in-hospital death, need for dialysis, and renal recovery.ResultsDuring the screening, 198 out of 1189 (16.6%) AKI subjects were assigned to the diagnosis CRS type 1. The overall in-hospital mortality was 19.2%; 9.6% of the patients required dialysis due to AKI. Complete recovery of kidney function was observed in 86 individuals (43.4%); incomplete recovery occurred in 55 patients (27.8%). Mortality-predictive variables were AKIN stage 2, longer ICU treatment, and insulin-dependent diabetes. Regarding dialysis, AKIN stage 3 and higher potassium at the time of diagnosis were predictive. Subjects with longer in-hospital stay recovered more often from CRS type 1.ConclusionsThe incidence of CRS type 1 is high (∼16% of all in-hospital AKI subjects) and the mortality is higher than the average mortality of AKI in general. At the same time, complete recovery of kidney function occurs less frequent. The kidney-related follow-up management of CRS type 1 needs to be significantly optimized to improve the long-term outcome of affected patients.

MO068RENAL HISTOPATHOLOGY IN CANCER PATIENTS: RESULTS OF A MULTICENTER STUDY

Abstract Background and Aims Some decades ago, patients with cancer were not submitted to invasive procedures because of their short life expectancy. This is one of the main reasons why data about kidney histology in oncological patients with kidney impairment is very scarce: kidney biopsies were not performed in this population. However, renal biopsy is an especially useful diagnostic and prognostic tool in these patients when they develop kidney injury. The aim of our study is to study clinical and histological characteristics of patients with active solid organ malignancy that underwent kidney biopsy in a multicenter cohort. Method We performed a multicenter collaborative retrospective study. Clinical, demographical, and histological data from patients with an active neoplasia or in active cancer treatment who underwent kidney biopsy were collected. Statistics: Quantitative variables are expressed as mean+/-SD (normal distribution) or median (IQ 25-75) (non-normal distribution).Qualitative variables are expressed as percentage. Actuarial survival curves were performed using Kaplan-Meier. Results 94 patients with cancer who underwent a kidney biopsy during the study period, from 9 hospitals were included.63.8% men, 36.2% woman and mean age 66 (SD +/- 10,95) years old. The indications for biopsy were acute renal failure (63.8%), proteinuria (17%), and exacerbation of chronic kidney disease (11.7%). At the time of the renal biopsy, 27.7% patients presented diabetes, 60.6% high blood pressure, 10.6% were on non-steroidal anti-inflammatory drugs treatment, and 74.5% were receiving renin angiotensin system blockers. Malignances were lung (31.9%), intestinal (13.8%) and prostate (8.5%), with 43.6% metastatic cancer. As oncospecific treatment, 33% received chemotherapy, 30.8% immunotherapy (of which 37.93% received more than 1 checkpoint inhibitor (CPI) and 24.13% had immune-related adverse events), 22.4 % specific therapies, 17 % surgery, and 3.2% conservative treatment. Previously to kidney injury, 51.06% presented Cr> 1 mg / dL. At the time of kidney biopsy, median creatinine was 2,63mg/dL [1,75-3,9 (IQ 25-75)], median urine protein/creatinine ratio 795 mg/g [221-3182(IQ 25-75)]; 51.1% presented haematuria and 22.3% nephrotic range proteinuria; 8.5% eosinophiluria and 7.44% hemolytic anemia and /or low platelet. At the time of renal biopsy, 8.5% presented ANCA and 5.31% decrease in C3 / C4 serum levels. The renal biopsy diagnosis was: 40.4% acute interstitial nephritis, followed by acute tubular necrosis (9.6%), thrombotic microangiopathy (6.4%), membranous nephropathy (5.3%) and IgA nephropathy (6.4%). 62.8% received corticosteroids (28.81% pulses) for an average of 5.8 months [3.7-9.1(IQ 25-75)]. 12.8% required kidney replacement therapy. 43.6% showed complete recovery of kidney function at the end of follow-up. Average follow-up 22.59 months. 40.2% of patients died at the end of follow-up and 72.34 % presented chronic kidney disease. As expected, and maybe related to the heterogeneous cancer disease studied, the only factor associated with mortality was the presence of the metastasis at the moment of kidney biopsy (p=0.028). Conclusion Histological kidney diagnosis in patients with active cancer involves various renal disorders, such as acute interstitial nephritis, thrombotic microangiopathy, membranous nephropathy and IgA nephropathy. Renal biopsy in this group of patients provides valuable diagnostic and prognostic information. More studies are needed to expand the consensus in the diagnosis and treatment of oncological patients with renal injury.

Haemolytic uraemic syndrome associated with pancreatitis: report of four cases and review of the literature.

BackgroundThe incidence of acute kidney injury (AKI) in patients with acute pancreatitis ranges from 15% to 40% and is associated with poor prognosis. Haemolytic uraemic syndrome (HUS) in the setting of acute pancreatitis is an uncommon association with fewer than 30 cases reported in the literature.MethodsA retrospective review of the clinical records at our institution between January 1981 and December 2019 was carried out to identify patients with acute pancreatitis and HUS. Additionally, a literature review was conducted on this topic. The aims of the study were to describe the clinical course and outcomes of patients affected by this condition.ResultsFour cases of HUS following an acute pancreatitis were identified. The mean (±SD) age of the study group was 30 ± 6 years, all of which were males. Excessive alcohol consumption was the main cause of acute pancreatitis in all four patients. HUS with progressive AKI developed in a median interval of 2 days from the onset of pancreatitis (range 1–3 days). All patients required kidney replacement therapy during the course of follow-up. A kidney biopsy was performed in two patients, showing typical thrombotic microangiopathic features. One case was treated with eculizumab, whereas the rest were treated with supportive care and/or plasma exchange. A normalization of haematological parameters and complete recovery of kidney function were observed in all patients at last follow-up, although this improvement was significantly faster in the patient treated with eculizumab.ConclusionsHUS may infrequently develop in patients with acute pancreatitis. An early identification of this complication is mandatory, and complement blockade with eculizumab may be associated with a faster kidney function recovery.

Acute kidney injury in critically ill patients in the intensive care units

Introduction. Acute kidney injury is a serious complication in critically ill patients in the intensive care units. The incidence varies from 20% to as high as 80%. Acute kidney injury is associated with expensive supportive therapy, high morbidity and poor outcomes. The aim of this study was to determine the incidence, causes, risk factors, treatment options and treatment outcomes of acute kidney injury in critically ill patients. Material and Methods. The study included 44 patients, with an average age of 67 ? 13.20 years. The data were collected during a three-month prospective study at the Department of Emergency Internal Medicine of the Clinical Center of Vojvodina, Novi Sad. Demographic data were collected from the medical records, as well as data on blood tests, comorbidities, use of nephrotoxic agents, and treatment of these patients. Results. Of the 44 patients who were included in the study, 20% developed acute kidney injury. De novo acute kidney injury was diagnosed in 51.22% and 48.78% of patients had acute-onchronic renal failure. The most common type of acute kidney injury was pre-renal, 80.95%. Comorbidities were present in all patients, most often arterial hypertension, in 52.4% of patients. Complete recovery of kidney function was found in 42.86% of patients and the mortality was 28.57%. Conservative therapy was used in 90.48% of patients, while 9.52% of patients required renal replacement therapy. Conclusion. De novo acute kidney injury was found in approximately half of the critically ill patients in the intensive care unit, mainly older patients with comorbidities. The most common type of acute kidney injury was pre-renal. Older age and comorbidities were associated with poor outcomes and high mortality.

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

TO017CLINICAL CHARACTERISTICS AND INDEPENDENT PREDICTORS OF CHECK POINT INHIBITORS-ASSOCIATED AKI: WHAT DO WE KNOW?

Abstract Background and Aims Checkpoint inhibitors (CPI) are used to treat solid organ malignancies. CPI–associated acute renal injury (AKI) is an adverse effect of these therapies and its incidence is 13-29%. Clinical data on this complication is scarce. The aim of our study is to define clinical characteristics and risk factors of CPI-associated AKI. Method Clinical and demographic data of all patients receiving immunotherapy between March 2018 and May 2019 at our center were evaluated. Patients were divided into two groups depending on the development of AKI during the study period. AKI was defined according to AKIN classification. We compared clinical and demographic characteristics between these two groups and patients who developed mild AKI and severe AKI. Results During the study period, 821 patients received CPIs. Mean age 62.03±12.06 years and 486(59.2%) men. Malignancies were lung in 249 (30.3%), urogenital tract in 168 (20.5%), melanoma in 89 (10.8%) and others in 315 patients (38.4%). 446(54.3%) patients received anti-PD1, 230(28%) anti-PDL1, 13 (1.6%) anti-CTLA4, 36 (4.4%) received other drug and 96(11.7%) were treated with both anti-CTLA4 and anti-PD1 or anti.PDL1. Baseline creatinine was 0.85±0.30 mg/dL and 188 (22.9%) patients presented creatinine>1 mg/dL before starting CPI. 125 patients (15.2%) developed AKI during the study period, 85(68%) men and mean age 65.1±10.7 years. Baseline creatinine of these patients 0.97±0.45 mg/dL and 44 (35.2%) presented basal creatinine>1mg/dL. Mean creatinine at the diagnosis of AKI 2.27±1.34 mg/dL and two patients required haemodialysis. Leukocyturia was present in 21 patients(16.8%) and haematuria in 12 (9.6%). 5 patients presented AKI secondary to obstructive uropathy. Mean time from CPI initiation to AKI was 5.6±5.8 months. Of those 125 patients, 23 (18.4%) were referred to Nephrology and 9 (7.2%) underwent kidney biopsy. 1 patient presented endocapillar proliferative non-CPI related glomerulonephritis and 8 (6.4%) acute tubule-interstitial nephritis (ATIN). 23 (18.4%) patients were treated with corticosteroids. Mean creatinine at 6 months after AKI was 1.04±0.34 mg/dL (data from 45 patients) and 40 patients (data from 45 patients) showed complete recovery of kidney function at 6 months. Patients who developed a severe AKI stage 2 or 3 were more frequently women (41.8% vs 24.3%, p=0.03), had lower basal creatinine (0.86±0.25 vs 1.06±0.54 mg/dL, p=0.0130), showed and increased latency from CPI initiation to AKI (6.9±6 vs 4.5±5.5 months, p=0.0267) and presented worse recovery of kidney function at 6 months than patients with AKI stage 1(creatinine 6 months 1.18±0.40 mg/dL, p=0.0398 and complete recovery of kidney function at 6 months 70.5% vs 93.3%, p=0.0353). There was no association between the severity of AKI and type of CPI and type of malignance. When comparing patients who developed AKI with patients whit patient who did not, patients with AKI were older (65.1±10.7 vs 62.03±12.06 years old, p=0.0017), more frequently men (68% vs 57.9%), p=0.0296) and presented higher baseline creatinine (0.97±0.45 vs 0.85±0.30 mg/dL, p<0.0001), as well as more frequently a baseline creatinine > 1 mg/dL (35.2% vs 20.7%, p=0.0004). Type of CPI and type of malignance were not associated with the presence of AKI. Older age (OR 1.020, CI 95% 1.002-1.038) and baseline creatinine (OR 3.293, CI 95% 1.678-6.461) were identified as independent predictors of AKI development in our CPI treated patients Conclusion CPI-associated AKI incidence in our centre is 15.2%. Of them, 44% developed severe AKI. Only 18.4% were referred to a nephrologist and kidney biopsy performed in 7.2%. ATIN was the most common diagnosis. 18.4% received corticosteroids. Older age and higher baseline creatinine were identified as independent predictors for AKI development in patients with cancer CPI-treated. Patients developing a severe AKI showed worse kidney function at 6 months.

P0610ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS IN THE ICU

Abstract Background and Aims Acute kidney injury (AKI) is common and serious complication in critically ill patients in intensive care unit (ICU). The rapid increase in aging populations with more comorbidities contribute to high incidence AKI in ICU. Incidence varies from 20% to as high as 70%. AKI in the ICU frequently requires costly supportive therapies, has high morbidity and it’s associated with poor outcomes. We aimed to determine incidence of AKI, causes, risk factors, treatment and outcomes of AKI in critically ill patients in ICU. Method We collected data prospectively from case records of adult patients (older than 18 years of age) admitted to the ICU at the Department of Internal medicine, Emergency Center, Clinical center of Vojvodina in Novi Sad, Serbia, during 3 months. We included patients who had at least two measurements of serum creatinine. Data on patient demographics, diagnosis at the time of ICU admission, complete blood count, biochemistry, comorbidities (diabetes mellitus, arterial hypertension, other cardiovascular diseases, renal disease, prostate diseases, dehydration, burns, gastrointestinal bleeding, pancreatitis, peritonitis, sepsis), use of nephrotoxic agents, radiological procedures and treatment of AKI were recorded. We excluded patients with chronic renal disease who were on hemodialysis. There were no interventions. Results Of the 44 patients included in the study, median age was 67+/-13,20 years (range: 21 to 88). Of those 44 patients 20% developed AKI. De novo AKI was diagnosed in 51,22% of those patients and 48,78% had chronic renal failure in acutisation. The most frequent etiology was pre-renal, in 80,95% of patients. Renal origin and obstructive (post-renal) causes were detected in the same number of patients, 9,52%. Comorbidities were present present in all patients. Most common comorbidity was arterial hypertension, in 52,4% of patients, other cardiovascular diseases in 47,6 % of patients, sepsis also in 47,6% of patients and gastrointestinal bleeding in 33,3% of patients. Complete recovery of kidney function was detected in 42,86% of patients. Mortality was 28,57%. During the hospitalisation 90,48% of patients were treated conservative and 9,52% of patients required renal replacement therapy. Conclusion De novo AKI occurred in approximately half of the critically ill patients in ICU. The most frequent etiology was pre-renal. AKI was mainly detected in older patients with comorbidities. Age and comorbidities were also associated with the poor outcome. Mortality was high.

P0306ACUTE KIDNEY INJURY AFTER CHECKPOINT INHIBITOR TREATMENT: FACING THE FUTURE

Abstract Background and Aims Checkpoint inhibitors (CPI) are used to treat solid organ metastatic malignancies. They act on by triggering a vigorous immune response against tumoral cells, preventing their proliferation. CPIs reinvigorate antitumor immune responses by interrupting co-inhibitory signaling pathways and promote immune-mediated elimination of tumor cells.This is not a selective response, deriving in immune related adverse events (irAEs). The kidney can potentially be damaged with an incidence of 13-29%. The most frequent type of toxicity is acute interstitial nephritis (AIN). Method We evaluated all the patients with solid organ metastatic malignancies treated with immunotherapy that developed acute renal injury (AKI) and underwent to kidney biopsy from March 2018 to November 2019 at Vall d’Hebron University Hospital. Results 11 patients with solid organ metastatic malignancies treated with immunotherapy developed AKI and underwent to kidney biopsy during the study period. The most frequent malignancy was lung cancer - in 6 patients-, followed by 3 patients with melanoma. 8 patients (72%) had already received previous oncological therapy, and for the remaining 3 patients (27%), CPI was the first line therapy. 8 patients (72%) were treated with anti-PD1 (programmed cell death protein 1), 4 patients (36 %) received anti PDL-1 (programmed death-ligand 1) 1 of these patients in combination with an anti CTLA-4 (cytotoxic T-lymphocyte antigen 4) and another patient received both anti PD1 and anti PDL-1. The time between the start of CPI and the onset of the AKI ranged between 2-11 months. The most frequent urine findings were subnephrotic range proteinuria with a mean protein/creatinine (mg/g creatinine) 503.6 ± 190.5 and leukocyturia in 9 of 11 patients. Mean creatinine (mg/dl) at diagnosis was 3.4 ± 1.3. 10 out of the 11 patients were diagnosed of AIN after performing a kidney biopsy. The remaining patient presented chronic changes (IFTA and glomerulosclerosis) in the biopsy, performed after receiving steroids for a month. 3 patients who presented AIN received pulses of methylprednisolone 250-500mg as induction treatment and 7 patients received prednisone 1mg/kg/day. Mean prednisone accumulated dose (mg) during the first month of treatment was 1387.5 ± 540. 9 patients experienced complete recovery of kidney function and two patients progressed to CKD. Conclusion We reported 11 patients who presented AKI associated to CPI treatment and underwent to kidney biopsy in the last 20 months at our center. 10 out of 11 presented biopsy confirmed CPI related AIN. In our experience, CPI related AIN is the most frequent renal lesion associated to the novel immunotherapy treatments. This entity seems to have good renal prognosis as long as steroid treatment is early started.

TO013ADSORPTION THERAPY AND SEPTIC SHOCK: A RETROSPECTIVE STUDY COMPARING COUPLED PLASMA FILTRATION-ADSORPTION AND CYTOSORB

Abstract Background and Aims Septic shock is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Excessive release of cytokines and other inflammatory mediators is a key mechanism and cytokines adsorption therapies are applied in this context to restore a balanced immune homeostasis. Different adsorption techniques are available but there are no studies comparing these different adsorption approaches. The aim of this retrospective observational study was to compare Coupled Plasma Filtration Adsorption (CPFA) and CytoSorbTM in terms of hemodynamic and clinical response, mortality and renal function recovery. Method A retrospective observational study was designed enrolling all patients admitted to ICU with a diagnosis of septic shock treated with blood adsorption, either CPFA or CytoSorbTM, from January 2015 to December 2017. Primary endpoints of the study were the assessment of changes in NE dosage, MAP values, SOFA score and PCT levels before and after blood adsorption. Secondary endpoints ICU length of stay (LOS), mortality at 30, 60 and 90 days from adsorption initiation; renal outcome at 30 and 90 days from adsorption initiation. Results The study included 28 patients (14 CPFA, 14 CytosorbTM). Adsorption treatment was associated with a significant (p=0.03) improvement in hemodynamics with a Norepinephrine/Mean Arterial Pressure ratio (NE/MAP) of 0.64 (0.14-2.6) pre-treatment vs 0.11 (0.0-0.32) post-treatment regardless of the applied technique. Furthermore, a significant (p<0.001) procalcitonin (PCT) post treatment reduction was demonstrated with a comparable effect in the two groups (p=0.32) (Fig.1). No difference has been found in SOFA score changes (p=0.06) and again without any difference between groups (p=0.17). Overall Survival (OS) rate at 30 days was comparable between groups being 64.3% in CPFA and 78.6% in CytoSorbTM group (p=0.34). Finally, a complete recovery of kidney function at 30 and 90 days has been obtained in respectively 90% and 100% of survived patients without any difference between groups (p=1.00) (Fig.2). Conclusion These data confirmed the effectiveness of adsorption in terms of short-term clinical improvement independently from the applied technique, supporting the role of both these adjunctive therapies in septic shock treatment. CPFA and CytosorbTM have comparable effects in terms of hemodynamic improvement, clinical outcome, mortality and recovery of kidney function from septic shock AKI.

Plasma exchange and hemodialysis for severe manifestations of multiple wasp stings in a child

Wasp stings occur frequently in developing countries and often lead to fatal outcomes due to the effects of wasp venom. Hemolysis and rhabdomyolysis often complicate wasp stings and result in acute kidney injury (AKI). We report a case of multiple wasp stings leading to AKI and multiple organ dysfunction syndrome (MODS) in a 9-year-old Indonesian girl. Kidney biopsy revealed acute tubular necrosis and acute interstitial nephritis. Despite delayed admission, she recovered in 33 days after 3 days of intravenous steroid administration, eight sessions of intermittent hemodialysis, and two sessions of plasma exchange (PE). Complete recovery of kidney function, indicated by normal diuresis, normal estimated glomerular filtration rate, and negative albuminuria, was reached within 12 weeks. This case showed that immediate admission following multiple wasp stings (particularly >10 stings) to initiate early dialysis is important to promptly remove toxins and preserve kidney function. The case also showed that PE can be beneficial in cases of hemolysis and rhabdomyolysis complicated by MODS.

Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia.

Some patients with COVID-19 pneumonia also present with kidney injury, and autopsy findings of patients who died from the illness sometimes show renal damage. However, little is known about the clinical characteristics of kidney-related complications, including hematuria, proteinuria, and AKI. In this retrospective, single-center study in China, we analyzed data from electronic medical records of 333 hospitalized patients with COVID-19 pneumonia, including information about clinical, laboratory, radiologic, and other characteristics, as well as information about renal outcomes. We found that 251 of the 333 patients (75.4%) had abnormal urine dipstick tests or AKI. Of 198 patients with renal involvement for the median duration of 12 days, 118 (59.6%) experienced remission of pneumonia during this period, and 111 of 162 (68.5%) patients experienced remission of proteinuria. Among 35 patients who developed AKI (with AKI identified by criteria expanded somewhat beyond the 2012 Kidney Disease: Improving Global Outcomes definition), 16 (45.7%) experienced complete recovery of kidney function. We suspect that most AKI cases were intrinsic AKI. Patients with renal involvement had higher overall mortality compared with those without renal involvement (28 of 251 [11.2%] versus one of 82 [1.2%], respectively). Stepwise multivariate binary logistic regression analyses showed that severity of pneumonia was the risk factor most commonly associated with lower odds of proteinuric or hematuric remission and recovery from AKI. Renal abnormalities occurred in the majority of patients with COVID-19 pneumonia. Although proteinuria, hematuria, and AKI often resolved in such patients within 3 weeks after the onset of symptoms, renal complications in COVID-19 were associated with higher mortality.

SUN-168 OUTCOMES OF ACUTE KIDNEY INJURY FOLLOWING HEMOTOXIC SNAKE ENVENOMATION

Snake envenomation is a common cause of acute kidney injury in the tropics. There is only limited data on predictors of mortality and long-term outcomes of snake bite related AKI. The current study aims to identify the predictors of mortality in patients with snake bite AKI. The study also aims to assess the long-term outcomes (GFR <60 ml, urine albumin excretion > 30, presence of hypertension/prehypertension) in patients who recover from snake bite AKI. All adult patients admitted with features of systemic haem toxicity and AKI from January 2016 to June 2017, were recruited for the study . AKI was defined according to KDIGO criteria . Patients with history history of CKD were excluded . Demographic, clinical and laboratory details were collected during hospital admission. A first follow up visit was scheduled 2 weeks after discharge from the hospital. All patients were called for the final follow up visit in June 2018. Among a total number of 420 patients with hemotoxic snake bites , 214 (50.9 %) had features of systemic hemotoxicity . 184 patients (43.8 %) satisfied the KDIGO criteria for AKI( stage 1= 14 (07.6 %),stage 2- 35(19%),stage 3- 115(62.5%). KDIGO urine output as well as creatinine criteria was met in 106 (57.6%) patients . 45(24.5%) patients met only the creatinine criteria and 33 (17.9%) met only urine output criteria. The comorbidities present in the population were systemic hypertension (n=7) and diabetes mellitus (n=2). The mortality rate for patients with hemotoxic envenomation was 21.1% (n = 46 /214). The mortality was considerably higher in patients with stage 3 AKI ( RR- 5.05 ; 95% CI 1.28 -19.85) as well as those who met both urine output and creatinine criteria (RR- 3 .02; 95% CI 2.01-4.53). On cox regression analysis, the independent predictors of mortality were presence of capillary leak syndrome (RR- 2.02; 95% CI 1.05-3.88), mechanical ventilation (RR- 5.59; 95% CI 2.90 -10.81) and hypotension (RR- 2.48; 95% CI h1.31-4.72). Among the survivors (n=140), at the time of discharge, 44 patients (31.4%) had a complete recovery of kidney function . At 2 weeks post discharge, 23 patients had e GFR values < 60 ml/1.73 m 2 (32.3%). Long term follows up data was available for 53 patients. The median follows up duration was 20 months (IQR 6-24.5). The mean eGFR at the end of follow up was 85.62 ml /1.73 m2 (95% CI 79.1,92.2). A total of 12/53(22.6%) patients developed adverse renal outcomes at the end of follow up . Among these . 08 patients (15%) patients developed CKD, 3 patients developed prehypertension and one patient had new onset hypertension. Kidney biopsy was done in three patients, chronic thrombotic microangiopathy was documented in 2 patients and one patient showed persistent acute tubular necrosis Higher stages of AKI,mechanical ventilation,hypotension and capillary leak were associated with a higher risk of mortality in snake bite related AKI. One fifth of patients who sustain AKI following snake envenomation develop adverse renal outcomes on follow up.

Acute Kidney Injury in Subjects With Chronic Kidney Disease Undergoing Total Joint Arthroplasty

BackgroundChronic kidney disease (CKD) has been associated with higher incidence of complications after total joint arthroplasty (TJA) but the incidence, risk factors and outcomes of acute kidney injury (AKI) in this setting remains insufficiently understood. MethodsWe assessed the impact of baseline CKD on the risk of developing AKI after TJA performed between 1/2012 and 12/2016 in a single-center, retrospective cohort study. CKD was defined by estimated glomerular filtration rate <60 mL/min/1.73 m2 on 2 separate occasions within 3 months prior TJA. AKI was defined using a modified Kidney Disease: Improving Global Outcomes criteria based on serum creatinine (sCr) only to assess the severity of AKI. Complete AKI recovery was defined as the lowest post-AKI sCr within 20% of pre-AKI sCr values and partial recovery if within 30%, all within 90 days after TJA. ResultsTwenty-four percent of the 1,212 subjects undergoing TJA had pre-existing CKD. The overall incidence of AKI in the CKD subjects was 30%; of these, 55% had stage-1 AKI, 1% had stage-2 AKI and 44% had stage-3 AKI. AKI was more common in African Americans, those with diabetes or heart failure, requiring perioperative transfusions or receiving diuretics before surgery. While 82% of the AKI subjects achieved complete recovery of kidney function, 4% had only partial recovery and 14% did not reach a post-AKI sCr level within 30% of pre-AKI values. The incidence (P < 0.001) but not the severity (P = 0.202) of AKI correlated with stages of baseline CKD. ConclusionsThe presence of CKD was associated with a high incidence of AKI after TJA. In these subjects, more than half the cases of AKI were of mild degree and had a favorable outcome. However, 18% of them did not have complete recovery of kidney function. Stages of baseline CKD were associated with increased incidence but not severity of AKI after TJA.

Eculizumab Modifies Outcomes in Adults with Atypical Hemolytic Uremic Syndrome with Acute Kidney Injury

Background: Atypical hemolytic uremic syndrome (aHUS) is a rare disease associated with congenital or acquired genetic abnormalities that result in uncontrolled complement activation, leading to thrombotic microangiopathy and kidney failure. Until recently, the only treatment was plasma exchange or plasma infusion (PE/PI), but 60% of patients died or had permanent kidney damage despite treatment. Eculizumab, a complement inhibitor, has shown promising results in aHUS. However, data are mainly extracted from case reports or studies of heterogeneous cohorts, and no direct comparison with PE/PI is available. Methods: An observational retrospective study of adult, dialysis-dependent aHUS patients with acute kidney injury (AKI) who were treated with either PE/PI alone or with second-line eculizumab in our center. We compared the effect of PE/PI and eculizumab on kidney function, hypertension, proteinuria, hematologic values, relapse, and death. Results: Thirty-one patients were included (females, 18; sporadic aHUS, 29; mean age, 46 ± 20 years). Twenty-six patients were treated with PE/PI alone, and 5 were deemed to be plasma-resistant and received eculizumab after stopping PE/PI. Among patients receiving eculizumab, 80% attained complete recovery of kidney function, 100% stopped dialysis, 20% had decreased proteinuria, and no patient relapsed (vs. 38.5, 50, 15.4, and 11.5%, respectively, of patients receiving only PE/PI). At 1-year of follow-up, no deaths had occurred in either group. Conclusion: Eculizumab shows greater efficacy than PE/PI alone for the treatment of adult aHUS patients with AKI. Prospective studies and meta-analyses are warranted to confirm our findings and set guidelines for treatment, monitoring, and maintenance.

Effects of Intensive Blood Pressure Treatment on Acute Kidney Injury Events in the Systolic Blood Pressure Intervention Trial (SPRINT)

Treating to a lower blood pressure (BP) may increase acute kidney injury (AKI) events. Data for AKI resulting in or during hospitalization or emergency department visits were collected as part of the serious adverse events reporting process of the Systolic Blood Pressure Intervention Trial (SPRINT). 9,361 participants 50 years or older with 1 or more risk factors for cardiovascular disease. Participants were randomly assigned to a systolic BP target of<120 (intensive arm) or<140mmHg (standard arm). Primary outcome was the number of adjudicated AKI events. Secondary outcomes included severity of AKI and degree of recovery of kidney function after an AKI event. Baseline creatinine concentration was defined as the most recent SPRINT outpatient creatinine value before the date of the AKI event. There were 179 participants with AKI events in the intensive arm and 109 in the standard arm (3.8% vs 2.3%; HR, 1.64; 95% CI, 1.30-2.10; P<0.001). Of 288 participants with an AKI event, 248 (86.1%) had a single AKI event during the trial. Based on modified KDIGO (Kidney Disease: Improving Global Outcomes) criteria for severity of AKI, the number of AKI events in the intensive versus standard arm by KDIGO stage was 128 (58.5%) versus 81 (62.8%) for AKI stage 1, 42 (19.2%) versus 18 (14.0%) for AKI stage 2, and 42 (19.2%) versus 25 (19.4%) for AKI stage 3 (P=0.5). For participants with sufficient data, complete or partial resolution of AKI was seen for 169 (90.4%) and 9 (4.8%) of 187 AKI events in the intensive arm and 86 (86.9%) and 4 (4.0%) of 99 AKI events in the standard arm, respectively. Trial results are not generalizable to patients with diabetes mellitus or without risk factors for cardiovascular disease. More intensive BP lowering resulted in more frequent episodes of AKI. Most cases were mild and most participants had complete recovery of kidney function. Registered at ClinicalTrials.gov with study number NCT01206062.

The Friday evening case of acute kidney injury: a crystal dilemma.

We report a case of acute kidney injury (AKI) induced by amoxycillin crystalluria suggested by massive amounts of urinary crystals of unusual morphology. This hypothesis was further reinforced by a particular solubility pattern when the urine sample was exposed to various temperatures, alkali, acids and alcohol. We therefore suspended amoxycillin, which produced a rapid and complete recovery of kidney function. Infrared spectroscopy later confirmed the amoxycillin composition of the crystals. Since infrared spectroscopy is not easily available, we propose that these solubility tests of urinary crystals be used as a first-step investigation when amoxycillin crystalluria is suspected.

Disparity between Nephrologists' Opinions and Contemporary Practices for Community Follow-Up after AKI Hospitalization.

Recent guidelines suggest that patients should be evaluated after AKI for resolution versus progression of CKD. There is uncertainty as to the role of nephrologists in this process. The objective of this study was to compare the follow-up recommendations from nephrologists with contemporary processes of care for varying scenarios of patients hospitalized with AKI. We surveyed Canadian nephrologists using a series of clinical vignettes of patients hospitalized with severe AKI and asked them to rank their likelihood of recommending follow-up for each patient after hospital discharge. We compared these responses with administrative health data on rates of community follow-up with nephrologists for patients hospitalized with AKI in Alberta, Canada between 2005 and 2014. One hundred forty-five nephrologists participated in the survey (46% of the physician membership of the Canadian Society of Nephrology). Nephrologists surveyed indicated that they would definitely or probably re-evaluate patients in 87% of the scenarios provided, with a higher likelihood of follow-up for patients with a history of preexisting CKD (89%), heart failure (92%), receipt of acute dialysis (91%), and less complete recovery of kidney function (98%). In contrast, only 24% of patients with similar characteristics were seen by a nephrologist in Alberta within 1 year after a hospitalization with AKI, with a trend toward lower rates of follow-up over more recent years of the study. Follow-up with a nephrologist was significantly less common among patients over the age of 80 years old (20%) and more common among patients with preexisting CKD (43%) or a nephrology consultation before or during AKI hospitalization (78% and 41%, respectively). There is a substantial disparity between the opinions of nephrologists and actual processes of care for nephrology evaluation of patients after hospitalization with severe AKI.