Oliguria Research Articles

443: Does acute kidney injury in pregnancy exacerbate maternal brain injury?

Women with severe preeclampsia and HELLP syndrome (sPE/HELLP) are more likely to develop acute kidney injury (AKI) compared to women without sPE/HELLP. AKI during pregnancy is associated with rates of maternal mortality and fetal loss that range from 30-60%. Women with a history of sPE/HELLP are more likely to develop hypertension, and have higher incidences of chronic kidney disease, end stage renal failure and cognitive failure compared to women with histories of normal pregnancies. We tested the hypothesis sPE/HELLP leads to brain damage during pregnancy which is exacerbated by AKI. On gestational day (GD) 12, mini-osmotic pumps infusing sFlt-1 and sEng were placed into rats to induce HELLP. A subset of HELLP and NP rats underwent bilateral renal ischemia-reperfusion surgery for 45 minutes on GD18 to create AKI. After rats had recovered, all rats were placed in metabolic cages for 24hrs. Mean arterial pressure was measured on GD19 followed by Evan’s blue infusion to assess blood brain barrier permeability, or tissue collection and euthanization. During pregnancy HELLP+AKI rats had a significant decrease in urine output compared to NP rats (1.4+0.28 vs. 0.48+ 0.12mL/hr; p=0.01). MAP was significantly increased in HELLP rats (p<0.0001) and HELLP+AKI rats (p=0.03) compared to NP rats. Kidney weight was also significantly increased in NP+AKI compared to NP rats (p=0.005) and in HELLP+AKI compared to HELLP rats (p=0.003). Urine creatinine levels were significantly lower in all groups of rats compared to NP rats (p=0.01). NP pups were significantly larger compared to HELLP (p=0.006), NP+AKI (p=0.0002) and HELLP+AKI (p=0.0005) pups. Rats with HELLP had increased blood brain barrier permeability in the brainstem/cerebellum compared to NP rats (p=0.04). Similar results were seen in NP+AKI (p=0.04) and HELLP+AKI (p=0.01) rats compared to NP rats. Whole brain water weight was significantly increased in HELLP+AKI rats compared to NP rats (p=0.03). The results from the current study suggest that AKI during pregnancy contributes to oliguria, hypertension, decreased urine creatinine, maternal brain injury and reduced pup size. In the setting of HELLP+AKI brain injury was worsened compared to rats with just AKI or HELLP syndrome. Studies are currently ongoing to examine the progression to chronic kidney disease and cognitive failure in rats with a history of sPE/HELLP with and without AKI during pregnancy.

Subclinical AKI: ready for primetime in clinical practice?

There has been considerable progress over the last decade in the standardization of the acute kidney injury (AKI) definition with the publication of the RIFLE, AKIN, KDIGO and ERBP classification criteria. However, these classification criteria still rely on imperfect parameters such as serum creatinine and urinary output. The use of timed urine collections, kinetic eGFR (estimated glomerular filtration rate), real time measurement of GFR and direct measures of tubular damage can theoretically aid in a more timely diagnosis of AKI and improve patients' outcome. There has been an extensive search for new biomarkers indicative of structural tubular damage but it remains controversial whether these new markers should be included in the current classification criteria. The use of these markers has also led to the creation of a new concept called subclinical AKI, a condition where there is an increase in biomarkers but without clinical AKI, defined as an increase in serum creatinine and/or a decrease in urinary output. In this review we provide a framework on how to critical appraise biomarker research and on how to position the concept of subclinical AKI. The evaluation of biomarker performance and the usefulness of the concept 'subclinical AKI' requires careful consideration of the context these biomarkers are used in (clinical versus research setting) and the goal we want to achieve (risk assessment versus prediction versus early diagnosis versus prognostication). It remains currently unknown whether an increase in biomarkers levels without functional repercussion is clinically relevant and whether including biomarkers in classification criteria will improve patients' outcome.

Rhabdomyolisys as a Cause of Acute Renal Injury

Abstract Rhabdomyolysis (RM) is defined as striate muscle-cell damage with disintegration of skeletal muscles and release of intracellular constituents to the circulation, with or without subsequent kidney injury. RM is one of the leading causes of acute kidney injury and is associated with substantial morbidity. The major signs of acute kidney injury in rhabdomyolysis are: pain, weakness and swelling of the injured muscle or muscle groups and myoglobinuria with reddish discoloration of the urine and decrease in urine output to anuria. The authors describe three cases of rhabdomyolysis with acute renal injury and discuss the current knowledge on the etiopathogenesis, clinical manifestations, diagnosis and treatment of this condition.

Complement-Mediated Thrombotic Microangiopathy: A Murky Presentation of a Rare Disease Entity

Complement-mediated thrombotic microangiopathy (TMA), also known as atypical hemolytic uremic syndrome (aHUS) is a rare, hereditary, progressive, life-threatening disorder caused by a disruption in regulation of the alternative pathway of the complement system. Eculizumab, a terminal complement inhibitor, has emerged as a first-line therapy, however data are limited to small case series (Brocklebank et al., 2017). Here, we present a diagnostically challenging case of complement-mediated TMA, who received eculizumab therapy with excellent hematologic response.A 68-year-old female with history of possible Sjogren's syndrome, migraine disorder, chronic fatigue syndrome, inflammatory colitis, hypertension, and poor medical follow up presented with 6-day history of severe fatigue, hematochezia, decreased urine output, dyspnea with exertion and anginal chest pain. 2 weeks prior, patient endorsed “flu-like” illness and had diffuse myalgias without fevers. Further history revealed ibuprofen usage of 800-1200 mg/day for several years. Shortly after admission, patient became severely agitated and confused with an attempt to elope from hospital.During diagnostic workup, labs were significant for hemoglobin 5.6 g/dL, platelets 57,000/uL, serum creatinine 6.6 mg/dL, BUN 101 mg/dL. Peripheral smear showed schistocytes and tear drop cells, low platelets without clumping, and hypochromic normocytic red cells. LDH of 2152 U/L, haptoglobin <34 mg/dL, and GI PCR was panel negative for E. coli O157 and Shiga-like toxin producing E. coli. She was presumed to have thrombotic thrombocytopenic purpura (TTP) as she presented with 4 of the 5 characteristic pentad, including microangiopathic hemolytic anemia, acute renal failure, thrombocytopenia, and severe neurologic findings. Patient received several PRBC transfusions, five plasma exchange treatments, hemodialysis and corticosteroids. She had initial improvement in platelet count and decrease in LDH with plasma exchange, however plateaued by day 5. Further testing revealed low complement C3 level of 51 mg/dL, low complement C4 level of 22.7 mg/dL, and pre-PLEX ADAMSTS13 level of 93%, suggesting complement-mediated TMA as the correct diagnosis.Patient was subsequently transferred to tertiary care center for initiation of eculizumab. Genetic testing was completed, notable for decreased Factor H and a heterozygous missense mutation in complement factor H of uncertain significance, only having been previously reported in a single patient with aHUS (Fremeaux-Bacci et al., 2013). She achieved excellent hematologic response with eculizumab evidenced by improved platelet count, haptoglobin, decreased LDH, however she unfortunately remained dialysis-dependent.Thrombotic microangiopathy (TMA) syndromes are overlapping entities which can be categorized by primary vs secondary etiology. Primary syndromes include TTP (hereditary or acquired), Shiga-toxin mediated HUS, drug-induced TMA and complement mediated TMA. Secondary causes include pregnancy-associated (pre-eclampsia/HEELP syndrome), malignancy, systemic infection, severe hypertension, autoimmune disorders like SLE, and complications from organ transplantation. When evaluating a patient with suspected TMA, it is important to correctly categorize their disease to guide appropriate treatment.Complement-mediated TMA results from a hereditary deficiency of regulatory proteins that restrict activation of alternative complement pathway. These proteins include complement factor H (CFG) and its related proteins (CFHRs), membrane cofactor protein (MCP), CFI. Instead, it may result from an autoantibody inhibiting CFH of CFI. The consequence of this up-regulation is uncontrolled damage to vascular endothelium and renal cells, which manifests as a characteristic pentad. In our case, a CFH gene mutation was identified and history revealed a flu-like illness preceding her hospitalization. It is plausible that this illness may have served as a “second-hit” via complement-amplification. (Asif et al., 2017). Alternatively, in this patient with history of inflammatory colitis and reported Sjogren's syndrome, subclinical autoimmune disorder may also have served as a trigger.This case presentation serves as a reminder to not overlook the “zebra” that is complement-mediated TMA, to allow for prompt initiation of eculizumab therapy. DisclosuresNo relevant conflicts of interest to declare.

Development of Gray Zone Lymphoma during Remission of Classical Hodgkin Lymphoma

Although Hodgkin lymphoma (HL) is largely curable with frontline treatment, many patients will not have a complete response or will later relapse. Recurrence of HL often occurs within the first five years in remission. However, recurrence rates vary widely and are largely dependent on lymphoma type, stage, patient age, and other variables [Devita, 2015]. In this case, we discuss an individual with HL in remission for over a decade, who was found to have Gray Zone Lymphoma (GZL). GZL is a rare lymphoma with intermediate features between classical Hodgkin lymphoma (cHL) and Diffuse Large B-cell Lymphoma (DLBCL), but cannot be classified as one or the other [Evans, 2015]. We report this case to discuss the recurrence of HL that progressed and transformed into GZL.A 75-year-old male with a significant history of HL in remission, presented with sudden onset of bilateral lower extremity weakness. The patient had associated back pain, 3 weeks of fatigue, decreased appetite, and decreased urine output for the last two days. He denied any nausea, vomiting, fever, chest pain, cough, and bowel or bladder incontinence.Vital signs were significant for blood pressure of 97/56 mmHg and fever of 102.5°F. Pertinent physical examination findings included diffuse cervical, axillary, and inguinal lymphadenopathies, and hepatomegaly. Pedal edema was also noted on both lower extremities, but more pronounced on the right lower extremity. Initial pertinent labs were a leukocytosis (37,600 u/L), lactic acid of 6.4 (0-1.99 mmol/L), hyponatremia (133 u/L), and bicarbonate of 18 (22-30 mEq/L) with a normal anion gap.The patient was admitted for sepsis of unknown origin and was started on vancomycin and meropenem. Ultra sound of the right leg, CT chest, and abdominal CT angiogram with and without contrast revealed right deep venous thrombosis, pulmonary embolism in the segmental branch of the left lung, and lymphadenopathy in the chest, abdomen and numerous retroperitoneal soft tissue masses that were suspicious for enlarged lymph nodes respectively. The patient was started on therapeutic enoxaparin.The bone marrow aspirate was found to be inconclusive. Cervical lymph node biopsy showed CD30+ large cell hematolymphoid neoplasm with features intermediate between DLBCL and HL - otherwise classified as GZL. There is no standard treatment for GZL, therefore the patient was given cHL chemotherapy regimen of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). The patient received 1 dose of ABVD in the hospital and was discharged to follow as outpatient. Although the patient was initially admitted for sepsis, pan cultures were unremarkable, suggesting that his symptoms were attributable to malignancy.We discuss this case to describe the recurrence and progression of Hodgkin lymphoma to Grey Zone lymphoma. Very few cases of GZL have been described in literature. To date, a treatment regimen for GZL remains to be elucidated due to the sparsity of this phenomenon. Because GZL shows intermediate characteristics between cHL and DLBCL, it is currently treated as either cHL and DLBCL [Pilichowska, 2017].[Pilichowska, 2017]. DisclosuresNo relevant conflicts of interest to declare.

Nephrotic syndrome associated with Kimura\u2019s disease: a case report and literature review

BackgroundKimura’s disease (KD) is a rare chronic inflammatory disorder with a high incidence of renal involvement. In this report, we present a case study of KD-associated nephrotic syndrome combined with minimal change disease (MCD) and acute renal tubular injury. Meanwhile, the clinical and histopathological characteristics of 26 patients with KD presenting with renal involvement were retrospectively evaluated.Case presentationHere, we report a case study of a 59-year-old male patient with KD confirmed by a lymph node biopsy. He developed widespread edema and decreased urine output. A palpable swollen mobile and non-tender lymph node behind the left ear was observed upon admission. A renal biopsy revealed minimal-change lesions and acute renal tubular injury. The patient received hemodialysis because of the oliguria and renal insufficiency, and an initial dose of 40 mg/d methylprednisolone and then continued treatment with 40 mg/d prednisolone. He exhibited a good clinical response to the steroid after 6 weeks of treatment. Of the other 26 patients included in the review, 13 patients presented with mesangial proliferative glomerulonephritis, 4 with membranous nephropathy, 3 with MCD, 3 with focal segmental glomerulosclerosis, 2 with IgA nephropathy and 1 with acute tubular injury. With the exception of 2 patients who progressed to end-stage renal disease and received hemodialysis, the majority of patients responded well to treatment with corticosteroids alone.ConclusionsMCD combined with acute renal tubular injury is rare in patients with KD presenting with renal involvement. Corticosteroids may be a beneficial treatment for renal injury in patients with KD.

Exacerbates kidney injury in mice subjected to sepsis: critical impact of used heparin

Sepsis is the leading cause of death in critically ill patients, and the incidence of sepsis is increasing causes multiorgan failure, including acute kidney injury (AKI) and patients with both sepsis and AKI have an especially high mortality rate. Several different pathophysiological mechanisms have been proposed for sepsis-induced AKI: vasodilation-induced glomerular hypoperfusion, dysregulated circulation within the peritubular capillary network, inflammatory reactions by systemic cytokine storm or local cytokine production, and tubular dysfunction induced by oxidative stress animal sepsis models have been developed using LPS infusion. Renal dysfunction evaluated by serum creatinine and BUN was found in acute non-survivors (&lt;24 hours) and decreased urine output in subacute non-survivors (24–96 hours). The study show that increased AKI in animal with blood collected heparin (P=0.002) compared to citrate, furthermore; sham mice that received heparin did not develop AKI.

Acute revascularization syndrome following successful treatment of chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a rare condition, usually caused by stenosis or occlusion of two visceral arteries. As its early symptoms are unspecific, this condition can be diagnosed late or misdiagnosed. Duplex ultrasound or CT angiography or MR angiography is available to reach the diagnosis. Open surgical or endovascular revascularization are two valid options in CMI, even if there is not an evidence-based technique recommended for its intervention. Morbidity and 30-day mortality differ based on the option chosen. We discuss a case of 59-year-old woman referred for chronic post prandial abdominal pain and weight loss. A computed tomography angiogram (CTA) of the chest, abdomen and pelvis with multiplanar and centerline reconstructions of the mesenteric vessels revealed a multivessel splanchnic mesenteric occlusive disease. We treated her with hybrid revascularization: a retrograde iliac-SMA bypass was performed using a 6-mm diameter PTFE graft end-to-side with SMA and a 5x12mm balloon-expandable stent was inserted into the main trunk of the IMA, via retrograde IMA access. After the second post-operative day, the patient developed several complications: chest pain associated with dyspnea, abdominal pain with diarrhea and melena, oliguria, sinus tachycardia and laboratory tests’s alterations (anemia, neutrophilic leucocytosis, thrombocytopenia, hyperbilirubinemia, increase in transaminases, troponin I and serum creatinine). A CT scan showed a normal perfusion of the aortic-SMA by-pass and a normal perfusion of the IMA stenting. Blood smear examination revealed presence of schistocytes. The etiopathogenesis was probably a thrombotic microangiopathy due to revascularization of both SMA and IMA. The patient was successfully treated with high volume fresh plasma infusion and red blood cells units. For those patients an early diagnosis should be considered, together with an aggressive treatment in the case of occurrence of a systemic inflammatory response syndrome. We therefore suggest to treat these patients only in centers which have the availability of multidisciplinary monitoring and adequate treatment options. No cases of revascularization syndrome after treatment for CMI are reported in literature.

Bile Acid G Protein-Coupled Membrane Receptor TGR5 Modulates Aquaporin 2-Mediated Water Homeostasis.

The bile acid-activated receptors, including the membrane G protein-coupled receptor TGR5 and nuclear farnesoid X receptor (FXR), have roles in kidney diseases. In this study, we investigated the role of TGR5 in renal water handling and the underlying molecular mechanisms. We used tubule suspensions of inner medullary collecting duct (IMCD) cells from rat kidneys to investigate the effect of TGR5 signaling on aquaporin-2 (AQP2) expression, and examined the in vivo effects of TGR5 in mice with lithium-induced nephrogenic diabetes insipidus (NDI) and Tgr5 knockout (Tgr5-/-) mice. Activation of TGR5 by lithocholic acid (LCA), an endogenous TGR5 ligand, or INT-777, a synthetic TGR5-specific agonist, induced AQP2 expression and intracellular trafficking in rat IMCD cells via a cAMP-protein kinase A signaling pathway. In mice with NDI, dietary supplementation with LCA markedly decreased urine output and increased urine osmolality, which was associated with significantly upregulated AQP2 expression in the kidney inner medulla. Supplementation with endogenous FXR agonist had no effect. In primary IMCD suspensions from lithium-treated rats, treatment with INT-767 (FXR and TGR5 dual agonist) or INT-777, but not INT-747 (FXR agonist), increased AQP2 expression. Tgr5-/- mice exhibited an attenuated ability to concentrate urine in response to dehydration, which was associated with decreased AQP2 expression in the kidney inner medulla. In lithium-treated Tgr5-/- mice, LCA treatment failed to prevent reduction of AQP2 expression. TGR5 stimulation increases renal AQP2 expression and improves impaired urinary concentration in lithium-induced NDI. TGR5 is thus involved in regulating water metabolism in the kidney.

Large Desmoid Tumor Presenting With Abdominal Pain

Desmoid tumors are firm, infiltrative and locally aggressive fibrous neoplasms that have no known potential for metastasis but can cause local recurrence. They are rare, accounting for 0.03% of all neoplasms. However the risk is increased with familial adenomatous polyposis(FAP). A 31 year-old male with no significant past medical history presented with a three to four month history of progressive weight loss and abdominal distention. He deniednausea, diarrhea, decreased oral intake, constipation, melena, hematochezia, hematuria, decreased urine output, fever, chills or night sweats. Physical exam revealed a smooth, firm, non-pulsatile, periumbilical mass that was 20 cm in diameter and not freely moveable. Laboratory studies were normal. Computed tomography showed a large, bulky anterior abdominal mass extending from the sella gastric region into the pelvis. It extended over a craniocaudal length of about 29 cm and measured approximately 22.4 by 11.7 cm in diameter. The lesion compressed the right and left colon posteriorly into the paracolic gutters and the inferior vena cava was markedly compressed. He subsequently underwent exploratory laparotomy to resect the mass. A 30 cm by 20 cm by 15 cm mass was found attached to body of the pancreas, transverse colon, and greater curvature of the stomach. Since the mass was locally infiltrative, he required a partial colectomy, subtotal pancreatectomy, partial gastrectomy, cholecystectomy and splenectomy. Pathology showed desmoid fibromatosis with adhesion to the stomach and infiltration into the pancreas as well as the outer colonic wall. Surgical margins were negative for tumor. There were no polyps involving the resected colon. Immunohistochemistry showed nuclear positivity for beta-catenin and patchy positivity for desmin with focal positivity for smooth muscle actin also seen. The patient recovered from his surgery and was subsequently discharged from the hospital with oncology follow up. The risk of desmoid tum or is increased in patients with FAP, with a prevalence as high as 13%. Patients typically present with slow growing masses in the anterior abdominal wall and shoulder girdle. A history of trauma at the site of the tumor, including previous surgery, has been associated with desmoid tumors. Surgical resection with negative margins is the most successful approach in treatment, including patients with FAP. Radiation therapy can be considered for patients that are not surgical candidates.1505_A Figure 1. The abdominal mass has an overall measurement of 35.0 x 31.0 x 11.5 cm. The mass showed desmoid fibromatosis with adhesion to the stomach and infiltration into the pancreas as well as the outer colonic wall. The spleen is also seen attached. Surgical margins were negative for tumor.1505_B Figure 2. Tumor shows nuclear positivity for Beta-catenin and patchy positivity for desmin with focal positivity for smooth muscle actin also seen.

International Survey on the Management of Acute Kidney Injury and Continuous Renal Replacement Therapies: Year 2018

Introduction: Definition, prevention, and management of acute kidney injury (AKI) and the optimal prescription and delivery of renal replacement therapy (RRT) are currently matters of ongoing discussion. Due to the lack of definitive published literature, a wide gap might exist between routine clinical practice and available recommendations. The aim of this survey was to explore the clinical approach to AKI and RRT in a broad population of nephrologists and intensivists participating in the 36th International course on AKI and Continuous RRT (CRRT), held in Vicenza in June 2018. The responses of the 369 participants to a questionnaire on several aspects of critical care nephrology were analyzed and detailed. Results: Approximately 450 participants attended the course; of these, 369 (82%) correctly filled the survey forms. According to the reported answers, the average incidence of AKI in respondents’ intensive care units (ICU) was 26.8% (SD ±15.99) and AKI requiring dialysis was 13% (SD ±29.7). Sixty-four percent of participants defined AKI as an increase in serum creatinine (SCr) up to 0.99 mg/dL (SD ±0.88 mg/dL); 2.4% defined AKI as an increase in urea nitrogen up to 83.6 mg/dL (SD ±36.6 mg/dL); 33.6% defined AKI as decreased urine output to less than 1 mL/kg/h (SD ±0.6 mL/kg/h). The most common answer to classify AKI was Kidney Disease: Improving Global Outcomes (KDIGO; 41%) criteria. Most of the participants (25%) think novel biomarkers should replace SCr on daily routine laboratory screening, and Cystatin C was the most commonly used biomarker (19%). The use of diuretics in AKI patients was high (62%). Continuous RRT (59%) and heparin anticoagulation (42%) appeared to be the most common approaches in ICU. Conclusions: KDIGO appeared to be widely applied. The use of novel biomarkers has also emerged in recent years even if some consistent cost-benefit evidence is still lacking. There is a trend of increased awareness about AKI and extracorporeal treatments seem to be increasingly applied, when compared to previous surveys. Educational efforts and AKI management standardization still appear to be a fundamental aspect to harmonize therapeutic approaches and improve patients’ outcomes.

Abdominal Pain Presenting as a Tight Squeeze on a Tchaikovsky Score

Question: A 23-year-old woman presented to the gastroenterology outpatient clinic with severe and progressively worsening abdominal pain. Her pain was exacerbated by only a few mouthfuls of food, and even drinking water could instigate pain that would last for several hours. Her inability to eat eventually required parenteral nutrition. She additionally experienced nausea, and described postprandial diarrhea approximately 2-4 times a day, which sometimes alternated with constipation. She reported a decreased urine output and difficulty voiding her bladder.

Rhabdomyolysis caused by intractable postpartum hemorrhage: a case report

We reported a case of rhabdomyolysis following hemorrhagic shock caused by intractable postpartum hemorrhage. During the resuscitation, the patient was clearly diagnosed with the following manifestations, including dark urine, oliguria, significantly increased creatine kinase and positive myoglobin in both serum and urine. Acute kidney injury occurred after emergent abdominal hysterectomy. The patient was fully recovered after active anti-shock management, including a successful resuscitation, aggressive hydration, urine alkalinization, diuresis, treatment on acidosis, hyperpotassemia and hypocalcemia. Key words: Postpartum hemorrhage; Rhabdomyolysis; Shock, hemorrhagic; Acute kidney injury

Timing and effectiveness of continuous renal replacement therapy for neonatal acute kidney injury

Objective To investigate the timing and efficacy of continuous renal replacement therapy (CRRT) in neonatal acute kidney injury (AKI). Methods Nineteen AKI neonates treated with CRRT were enrolled during hospitalization in the Department of Neonatology of the Children's Hospital of Shanghai from June 2011 to June 2018. Their clinical data were retrospectively analyzed. According to their baseline renal function, these neonates were divided into two groups using an improved RIFLE (Risk, Injury, Failure, Loss and End-stage renal disease) standard: AKI stage 1-2 group and AKI stage 3 group. CRRT included continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PE). Several parameters included blood pressure (BP), renal function, electrolyte, blood gas and hemodynamic indicators were analyzed before, 12 h, 24 h, and 48 h after the initiation of CRRT and at the end of CRRT. Changes in neonatal renal function before, 24 h after the initiation of CRRT and at the end of CRRT were compared between the two groups. Efficacy of CRRT was evaluated, and clinical outcomes were analyzed. Kruskal-Wallis H-test or t-test was applied for statistic analysis. Results (1) Among the 19 neonates with AKI, there were 12 in stage 1-2 and seven in stage 3. Seventeen cases were treated with CVVHDF, and the other two underwent plasma exchange. The duration of CRRT was 49-190 h with an average of (89.2±33.9) h. (2) After 12 h of CRRT, the blood pressure of all 19 AKI neonates returned to normal (40-60 mmHg, 1 mmHg=0.133 kPa) and was maintained at that level during the treatment. The blood pH value also increased to a normal range (7.35-7.45) at the same time. The oxygenation index reached 200 mmHg after 12 h of CRRT and rose to over 300 mmHg after 24 h. The levels of serum potassium, urea nitrogen, and creatinine decreased significantly after 12 h of CRRT and reached the normal range after 24 h of CRRT. After 24 h of CRRT, the urine volume significantly increased. (3) Serum levels of urea nitrogen and creatinine in neonates with AKI stage 1-2 decreased significantly after 24 h of CRRT. At any time points before and after CRRT (24 h before, 24 h after and at the end of CRRT), serum levels of urea nitrogen and creatinine in AKI stage 3 neonates were higher than those in AKI stage 1-2 neonates [urea nitrogen: (15.8±4.1) mmol/L vs (10.2±5.1) mmol/L, (11.5±2.4) mmol/L vs (6.3±2.3) mmol/L, (9.8±2.1) mmol/L vs (5.1±2.2) mmol/L, t=2.468, 2.226 and 2.171, respectively; creatinine: (184±32) μmol/L vs (152±26) μmol/L, (110±35) μmol/L vs (87±25) μmol/L, (63±12) μmol/L vs (44±9) μmol/L, t= 2.404, 2.423 and 3.972, respectively; all P<0.05]. (4) Venous catheterization was successful in the 19 AKI neonates. Three cases were complicated with thrombocytopenia, two with obstruction and two with hypotension during CRRT. Complications such as hypothermia, hemorrhage, thrombosis, and infection were not reported. (5) Among the 19 AKI neonates, 12 (including five of severe asphyxia, five of septic sepsis and two of inherited metabolic disorders and in metabolic crisis) were cured and discharged. The other seven cases (two in stage 1-2 and five in stage 3) lived through the oliguria stage but died after their family members gave up the treatment. Conclusions CRRT is a safe and effective management for neonatal AKI. The optimal opportunity for CRRT treatment in AKI neonates should be at stage 1-2. Key words: Acute kidney injury; Renal replacement therapy; Infant, newborn; Treatment outcome

Protocol for a pilot randomized controlled trial comparing plasma with balanced crystalloid resuscitation in surgical and trauma patients with septic shock

BackgroundSeptic shock is a public health problem with high mortality. There remains a knowledge gap regarding the optimal resuscitation fluid to improve clinical outcomes, and the underlying mechanism by which...

Post-hospital mortality in children aged 2-12 years in Tanzania: A prospective cohort study.

BackgroundSub-Saharan Africa has the highest rates of child mortality worldwide. Little is known about post-hospital outcomes after an index hospitalization for older children. We determined 12-month post-hospital mortality rate and identified factors associated with higher mortality.MethodsIn this prospective cohort study, we enrolled children 2–12 years of age admitted to the pediatric wards of two public hospitals in northwestern Tanzania. Participants or proxies were contacted at 3, 6 and 12 months post-hospitalization. The primary outcome measured was mortality. Factors associated with mortality were determined using Cox regression analysis.ResultsA total of 506 participants were enrolled. In-hospital mortality rate was 7.7% (39/506). Of the 467 participants discharged, the post-hospital mortality rate was 10.1% (47/467). Sickle cell disease (Hazard Ratio (HR) 3.32, 95% CI 1.44–7.68), severe malnutrition (HR 3.19, 95% CI 1.18–8.57), neurologic diseases (HR 3.51, 95% CI 1.35–9.11), heart disease (HR 7.11, 95% CI, 2.89–17.51), cancer (HR 11.79, 95% CI 4.95–28.03), and septic shock (HR 4.64, 95% CI 1.42–15.08) had higher association with mortality compared to other diagnoses. The risk factors significantly associated with mortality included older age (HR 1.01, 95% CI 1.00–1.08), lower hemoglobin level (HR 0.83, 95% CI 0.76–0.90), lower Glasgow Coma Scale (HR 0.66, 95% CI 0.59–0.74), history of decreased urine output (HR 2.87, 95% CI 1.49–5.53), higher respiratory rate (HR 1.02, 95% CI 1.00–1.03), estimated glomerular filtration rate less than 60 ml/min/1.73m2 (binary) (HR 1.84, 95% CI 1.10–3.10), and lower oxygen saturation (HR 0.96, 95% CI 0.92–0.99).ConclusionsPost-hospital mortality is disturbingly high among children 2–12 years of age in Tanzania. Post-hospital interventions are urgently needed especially for older children with chronic illnesses.

Long-term Outcomes after Transplant Renal Artery Stenosis Surgery

The occurrence of transplant renal artery stenosis (TRAS) ranges from 1 to 23% and is associated with resistant hypertension, volume overload, graft dysfunction, and poor long-term graft and patient survival. Enhancing graft availability with expanded criteria donors results in the transplantation of kidneys with atherosclerotic arteries, increasing the risk of vascular complications. Although endovascular management is the first-line strategy in this context, in some patients, surgery has to be considered. We report the experience and long-term follow-up of TRAS surgery in a French kidney transplantation center. Between 2004 and 2009, 10 patients with postoperative TRAS, considered unfit for an endovascular procedure by a multidisciplinary team, were addressed for surgery. Mean time from transplantation to surgery was 139.8±136.4days. Clinical indications were oliguria, anuria, or acute decrease in urine output (n=5), resistant hypertension (n=4), and persistence of a decreased allograft function (n=1). Imaging-revealed ostial stenosis is associated with external iliac artery stenosis (n=3) or early bifurcation (n=2), and kinking (n=5). Revascularization techniques consisted in a great saphenous vein bypass (n=5) and internal iliac artery anastomosis (n=5). In the postoperative period, there was no graft loss, but 2 patients required hemodialysis during the first week. Mean follow-up was 9.8±2.1years. One patient lost his graft 10.3years after transplantation due to chronic rejection, and 1 patient needed endovascular dilation. There was no graft loss at 5years. Blood pressure was controlled in all patients. Surgical intervention for TRAS is safe and effective on graft survival and graft function and has to be considered for patients unsuitable for endovascular repair.

A multi-center epidemiological investigation on therapeutic plasma exchange for the children with hemolytic uremic syndrome

Objective To study the current status of therapeutic plasma exchange(TPE) for the children with hemolytic uremic syndrome(HUS) in China, and to provide evidence for further standardizing the consensus of diagnosis and treatment. Methods The questionaires were designed after discussion by Pediatric Blood Purification Specialist Committee to investigate the data of 146 hospitalized HUS children with TPE, which were collected and analyzed from January 2012 to December 2017 in 22 units. Results (1)Among the 146 cases, there were 91 males and 55 females, with an average age of 5.68 years old (2 months to 18 years old). The causes included infection(41.1%, 60 cases), complement defects(12.3%, 18 cases), drugs(10.3%, 15 cases), rheumatic diseases(6.2%, 9 cases)and hereditary metabolic diseases(4.1%, 6 cases). (2)Before TPE, the main manifestations of the sick children were oliguria or anuria(101 cases), and disturbance of consciousness(45 cases), hypertension(52 cases), and gastrointestinal bleeding(42 cases), which were significantly relieved after TPE.(3)Before TPE, hemoglobin[(68.26±18.17) g/L], red blood cell count[(2.43±0.70) ×109/L], platelet count[(77.49±72.93) ×109/L], C3[(0.70±0.26) g/L], glomerular filtration rate(GFR)[(26.98±17.16) mL/1.73 m2]were all decreased, and total bilirubin[(44.33±42.07) μmol/L], unconjugated bilirubin [(30.78±26.68) μmol/L], fibrin breakdown products(FDP)[(12.52±14.97) mg/L], D-dimer[(2 306.20±2 354.97) μg/L], creatinine[(305.45±290.19) μmol/L], 24-hour urinary protein [(2.17±2.55) g/d] all increased, the above indicators were significantly improved after the TPE[ (85.08±18.98) g/L, (2.80±0.98) ×109/L, (183.80±131.95) ×109/L, (0.85±0.25) g/L, (98.58±66.02) mL/1.73 m2, (19.71±33.24) μmol/L, (9.60±10.00) μmol/L, (7.33±9.81) mg/L, (1 322.05±1 595.23) μg/L, (139.28±163.75) μmol/L, (1.46±2.03) g/d, respectively], and the differences were all statistically significant (all P<0.05). (4)Complications occurred in 5 cases, including hypotension shock (2 cases), blockage of pipe (1 case), thrombocytopenia (1 case), anemia (1 case). (5)After TPE, 130 cases (89%) were significantly effective, but 16 cases (11%) died. Conclusions TPE for children with HUS has been widely carried out in China, and its effectiveness and safety had been confirmed.The timing of treatment is further confirmed by evidence-based medicine. Key words: Hemolytic uremic syndrome; Therapeutic plasma exchange; Child; Epidemiology

Spontaneous remission of adult-onset minimal change nephrotic syndrome associated with influenza B infection: a case report

BackgroundWhile the majority of adult-onset minimal change nephrotic syndrome (MCNS) is a primary or an idiopathic form of disease, it can also occur as a secondary form. Reports on the spontaneous remission of MCNS are rare since the condition is typically treated with corticosteroids. We herein describe the spontaneous remission of adult-onset MCNS in a patient who developed nephrotic syndrome after type B influenza infection.Case presentationA 50-year-old woman experienced fever, cough, malaise, and low back pain, which had persisted for 6 days before she presented to our hospital, and edema of the face and limbs, which had persisted for 5 days before her presentation. She was diagnosed with type B influenza infection and later exhibited an exacerbation of facial edema, decreased urine output, and a high level of proteinuria. She was referred to our department after the diagnosis of nephrotic syndrome. On admission, her proteinuria level was 20.88 g/gCr and her selectivity index value was 0.13. The examination of a kidney biopsy specimen obtained on the fourth day of hospitalization under a light microscope revealed minor abnormalities. An immunofluorescence showed only nonspecific granular IgM deposits in the mesangium. Electron microscopy showed extensive foot process effacement without any immune complex deposits. Based on these findings, the patient was diagnosed with MCNS. After admission, the proteinuria decreased to 0.06 g/gCr with rest and sodium restriction (6 g/day) alone; a complete remission from nephrotic syndrome was observed at approximately 2 weeks after the onset of symptoms. There have been no signs of recurrence of nephrotic syndrome in the one years since.ConclusionWe experienced a rare case in which spontaneous remission of MCNS occurred within a short period of 2 weeks after influenza B infection. When patients present with nephrotic syndrome after an infection, it is necessary to consider MCNS in the differential diagnosis, which also includes post-infectious glomerulonephritis and the acute exacerbation of IgA nephropathy.

Seroprevalence and clinical manifestations of scrub typhus infection in Chennai city: A cross-sectional study

BACKGROUND: Scrub typhus is a zoonotic rickettsial illness caused by Orientia tsutsugamushi and has been reported from Southeast Asia, the Asian Pacific Rim, and Australia. It is an emerging pathogen in Southern India, especially in the urban setting. The objective of this study was to identify scrub typhus infection among febrile patients and to identify clinical manifestations related to the disease. METHODS: In this prospective cross-sectional study, febrile patients who presented to the Department of Experimental Medicine at the Tamil Nadu Dr. M.G.R. Medical University between November 2015 and February 2016 were enrolled. Demographics and clinical manifestations were recorded using a semi-structured questionnaire. Serum was separated from 2 ml of blood sample for testing. The Scrub Typhus Detect ELISA test was performed as per manufacturer's instructions. Statistical data analysis was done. RESULTS: A total of 100 patients were enrolled and their age ranged from 4 to 80 years with a mean of 30 years. Nearly 56% were males. Ig M antibodies for O. tsutsugamushi were present in 23% of cases. Most (65%) of the positive patients were females. About 48% positives for scrub typhus were 4–20 years old. Clinical presentations in these patients were fever (100%), myalgia (73.9%), headache (65.2%), nausea (60.9%), cough (60.9%), abdominal pain (52.2%), vomiting (47.8%), breathlessness (39.1%), diarrhea (34.8%), and decreased urine output (26.1%). Eschar was seen in 7 patients of whom 2 were positive for scrub typhus. CONCLUSIONS: In this study, 23% of febrile patients were positive for scrub typhus infection. Therefore, it needs to be included in the differential diagnosis of febrile illnesses in Chennai city.