Oliguria Research Articles

Outcomes of Children and Adolescents Admitted with Diabetic Ketoacidosis at Kenyatta National Hospital (KNH), Kenya.

Background Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication that mainly occurs in patients with type 1 diabetes mellitus and is the foremost cause of death in these children. Overall mortality in children with DKA varies from 3.4% to 13.4% in developing countries. There is a need to understand outcomes among children with DKA in sub-Saharan African countries. Objective To determine the death rate and clinical outcomes of children and adolescents aged 0-18 years managed for DKA at Kenyatta National Hospital (KNH). Study Methods. This was a retrospective study carried out among children aged 0–18 years admitted with DKA at KNH between February 2013 and February 2018. The study site was the central records department at KNH. The inclusion criteria were children aged 0-18 years admitted with a diagnosis of DKA based on the ISPAD guidelines biochemical criteria. Results Out of the 159 files reviewed, the median age of children was 13 years (IQR 10-15). 41.1% of patients had severe DKA while 35.7% had moderate DKA. We reported a mortality of 6.9% while 93.1% of children recovered and were discharged home. The median duration of hospital stay was 8 days. High risk of mortality was reported among children who had high serum creatinine (OR 5.8 (95% CI 1.6-21.2)), decreased urine output (OR 9.0 (95% CI 2.2-37.3)), and altered level of consciousness (OR 5.2 (95% CI 1.1-25.1)). Conclusion DKA-associated mortality in our study was low at 6.9%. High serum creatinine, decreased urine output, and altered level of consciousness were associated with a significantly higher risk of mortality.

Abdominal Compartment Syndrome after Cesarean Section: A Case Report

Background: Abdominal compartment syndrome (ACS) after cesarean section (CS) is a rare event which is associated with an increased risk of morbidity and mortality. This complication may arise as a result of musculoskeletal trauma and fluid accumulation. The present report aimed to introduce a case of ACS after the cesarean section. Case report: We present the case of a 32-year old woman who developed abdominal compartment syndrome 4 days after the cesarean section. The patient's symptoms included severe abdominal distension, fever, decreased haemoglobin level despite normal blood pressure, and decreased urine output. Nasogastric/colonic decompression was not effective. Computed tomography (CT) scan demonstrated partial bowel obstruction. After an emergency decompressive laparotomy due to increased intra-abdominal pressure, the patient was diagnosed with ACS and rescued by supportive conservative treatment. Conclusion: ACS is a rare complication of CS; nonetheless, delayed diagnosis and intervention can cause irreversible damages. The physicians and midwives should be cautious about post caesarean signs and symptoms, including massive abdominal distention, pain, fever, difficulty breathing, and decreased urine output. Conservative therapeutic strategy and decompressive laparotomy is the gold standard treatment for this disease.

Predictors of exploration in patients at high risk of abdominal compartment syndrome

Context Abdominal compartment syndrome (ACS) is caused when an acute increase in intra-abdominal pressure (IAP) occurs sufficient to impair vascular inflow and thereby compromising the viability of the tissues and organs within the abdomen. Familiarity with the presentation of ACS is mandatory for all clinicians who care for critically ill patients to avoid its high mortality if not recognized and treated. The measurement of IAP is a vital part of clinical management of ACS. Early recognition is important, and the need for surgical decompression may be urgent. Aim The aim was to evaluate the cases at high risk for development of ACS trying to prevent its fatal adverse effects by defining its predictors. Patients and methods This prospective, interventional, non-randomized clinical trial was conducted at Mansoura University and emergency hospitals over the period from February 2016 to February 2019. This study was conducted on patients at high risk of intra-abdominal hypertension. Two groups were included. The first group was managed conservatively, and the second one received decompressive laparotomy depending on clinical parameters, including IAP, and general status. Data were analyzed using SPSS v-24. Results A total of 40 patients who had an increased IAP greater than or equal to 20 cmH2O with several clinical presentations were included. These patients had respiratory distress (90%) and distended tense abdomen, whereas abdominal pain and oliguria were only present in ∼25% of cases. Overall, 20 (50%) patients underwent conservative management, and all these cases passed normally. Moreover, 20 (50%) patients underwent decompressive laparotomy. Univariate and multivariate analyses showed central venous pressure, BMI, urinary bladder pressure, and postoperative organ failure were found to be significant independent risk factors that increased the rate of mortality. The complications of the first group were owing to the primary operation and those of the second of group were owing to the primary operation as well as owing to operative decompression procedure. The mortality of the studied groups was 25% in the second one only, and there was a significant difference between both groups in the hospital stay. Conclusion These results had suggested that early detection of cases with ACS and proper management may be curative, and they could decrease multiorgan dysfunction and mortality in such cases. The avoidance of early abdominal closure, which may be distressing to the patients, could be mandatory in such conditions.

DIABETES INSIPIDUS AS A SYMPTOM OF COVID-19 INFECTION: CASE REPORT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: COVID-19 disease usually presents as a respiratory infection which can progress to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction. The more severe cases occur in older adults, with chronic conditions such as cardiovascular and cerebrovascular diseases and diabetes[1,2]. We present a case of COVID-19 infection complicated by central diabetes insipidus (DI). CASE PRESENTATION: A 68 y/o man with history of HTN, HLD, DM- 2, A flutter presented with fever, headache, diarrhea and productive cough for 10 days. In the ED he was hypoxemic with O2 sat of 70% on room air and had diffuse wheezing throughout the lung fields. Covid PCR was positive. He was started on Lopinavir/Ritonavir x 2 days, which was aborted due to transaminitis. He was then started on Hydroxychloroquine and steroids. His hypoxemia worsened and on hospital day #15 he was intubated. On day #23 his mentation changed, he became nonresponsive to noxious stimuli, gag reflex was absent and he was polyuric. Over 24 hours his urine output increased to 7 L, serum Na increased from 136 to 153 mEq/L, urine osm was 152, specific gravity 1.005, urine specific gravity Na 43, MRI of the head showed no acute infarction, intracranial hemorrhage or mass, no abnormal intracranial enhancement. He was diagnosed with Central Diabetes Insipidus (DI) He was given DDAVP which lead to decreased urine output, increased urine Na, increased urine osm and specific gravity. His mentation returned to baseline, with a good gag reflex. He subsequently required tracheotomy, had a prolonged ICU course, and died due to worsening hypoxic respiratory failure. DISCUSSION: Multiple electrolyte derangements were described in the COVID positive patients; hyponatremia was the most frequent sodium abnormality[2]. Our patient demonstrated rapid and adequate response to DDAVP administration. Central DI can be produced by many entities like idiopathic, autoimmune, trauma or malignancy. He did not have a history of head trauma, cancer or brain surgery. The patient was briefly placed on Ketamine for sedation which was described as a cause of the central DI in some cases[3]. However,Ketamine's half life is 160 min. Patient was placed on Ketamine during the subsequent hospital stay without repeated electrolyte derangements. Hypothalamus and hypophysis infarct was less likely given negative imaging results and continuous AC. No other infectious causes were identified at that time. CONCLUSIONS: Critically ill patients with COVID pneumonia may develop central DI. We assume possible mechanism of central DI can be hypoxic encephalopathy which can occur in the setting of severe ARDS, or some more specific mechanism like autoimmune dysregulation leading to autonomic and neuroendocrine derangements. It can also be a sign of poor prognosis. We believe further studies and data analysis regarding this novel and complex viral infection will give more answers. Reference #1: Harapan H, Itoh N, Yufika A, et al. Coronavirus disease 2019 (COVID-19): A literature review. J Infect Public Health. 2020;13(5):667-673. https://doi.org/10.1016/j.jiph.2020.03.019 Reference #2: Zhang X, Cai H, Hu J, et al. Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings. Int J Infect Dis. 2020;94:81-87. https://doi.org/10.1016/j.ijid.2020.03.040 Reference #3: Gaffar S, Eskander JP, Beakley BD, McClure BP, Amenta P, Pierre N. A case of central diabetes insipidus after ketamine infusion during an external to internal carotid artery bypass. J Clin Anesth. 2017;36:72-75. https://doi.org/10.1016/j.jclinane.2016.09.024 DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by Hana Rajevac, source=Web Response

Acute Kidney Injury in Patients of Emergency and Surgical Intensive Care Units: Incidence and Risk Factors

Background: Acute kidney injury is an abrupt or rapid decline in renal filtration function. Objective: The study aimed to identify the incidence and analyze the risk factors (age and sex) for acute kidney injury development in patients of emergency and surgical intensive care units. Patients and Methods: This study was carried out at emergency and surgical intensive care units of Zagazig University Hospitals over a period of 6 months. Data collection were1: Peak of serum creatinine level. 2: Peak of decreased urine output. 3: At the peak of AKI: AKIN (Acute Kidney Injury Network) score. Results: Incidence of AKI in patients with normal kidney functions at admission and without history of any previous renal problems equal 7.015% according to AKIN score. Conclusion: our results reported that incidence rate of developing AKI in patients of emergency and postoperative critical care units along the period of 6 months according to the inclusion criteria and AKIN score is 7.015 %. Age and sex weren’t risk factors for AKI.

Acute kidney disease and long-term outcomes in critically ill acute kidney injury patients with sepsis: a cohort analysis.

BackgroundAcute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse short- and long-term consequences. Acute kidney disease (AKD) reflects the continuing pathological processes and adverse events developing after AKI. We aimed to evaluate the association of AKD, long-term adverse renal function and mortality in a cohort of patients with sepsis.MethodsWe performed a retrospective analysis of adult patients with septic AKI admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Patients were categorized according to the development of AKI using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. AKD was defined as presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated.ResultsFrom 256 selected patients with septic AKI, 53.9% developed AKD. The 30-day mortality rate was 24.5% (n = 55). The mean long-term follow-up was 45.9 ± 43.3 months. The majority of patients experience an adverse renal outcome [n = 158 (61.7%)] and 44.1% (n = 113) of patients died during follow-up. Adverse renal outcomes, 30-day mortality and long-term mortality after hospital discharge were more frequent among AKD patients [77.5 versus 43.2% (P < 0.001), 34.1 versus 6.8% (P < 0.001) and 64.8 versus 49.1% (P = 0.025), respectively]. The 5-year cumulative probability of survival was 23.2% for AKD patients, while it was 47.5% for patients with no AKD (log-rank test, P < 0.0001). In multivariate analysis, AKD was independently associated with adverse renal outcomes {adjusted hazard ratio [HR] 2.87 [95% confidence interval (CI) 2.0–4.1]; P < 0.001} and long-term mortality [adjusted HR 1.51 (95% CI 1.0–2.2); P = 0.040].ConclusionsAKD after septic AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.

Analgesic Nephropathy due to Diclofenac in a 24-year-old Indian Male Patient: A Case Report

Analgesics are commonly prescribed first line agent for the treatment of rheumatological disorders like rheumatoid arthritis and ankylosing spondylitis. Renal toxicities are known adverse reactions of analgesics, however, acute onset renal injury due to analgesics in rheumatological disorders is not currently known. Here we describe a case of a 24-yearold Indian male patient who was diagnosed with ankylosing spondylitis three years back and was prescribed tablet Diclofenac 150 mg in three divided doses per day. The patient presented with breathlessness, pedal edema and decreased urine output on 24th February 2019. The patient was diagnosed to have bilateral End Stage Renal Disease (ESRD) with small kidneys, pulmonary edema and left ventricular dysfunction using echocardiography. The patient was symptomatically treated and later transferred for renal transplant. Renal toxicity of analgesics is known but is usually reported after years of exposure. This case is first of the kind of occurrence of ESRD within three years of exposure. This case highlights the need for monitoring in patients who are prescribed analgesics for a long duration especially in patients of rheumatological disorders. Key words: Diclofenac, Nephropathy, Analgesic, Ankylosing spondylitis, Young.

Cell-Free DNA Sequencing, Pathogen Detection, and the Journey to Value.

A previously healthy 9-month-old girl presented to the emergency department for fever, rash, and decreased urine output for 3 days. She was in compensated shock: temperature of 39.6°C, heart rate of 168 beats per minute, and blood pressure of 130/63. Her examination was notable for a diffuse blanching rash. Laboratory studies showed an elevated procalcitonin of 21.74 ng/mL, normal white blood cell count of 7.90 K/µL, and elevated creatinine of 0.36 mg/dL. Urinalysis demonstrated large blood, negative nitrites, trace leukocyte esterase, and 30 to 49 white blood cells per high-power field. Renal ultrasound was consistent with pyelonephritis. Because of concern for septic shock, she was given 60 mL/kg of normal saline and ceftriaxone and transferred to the PICU. In the PICU, vancomycin was added on the first day of admission because of worsening clinical status. She required vasopressor support with epinephrine for 2 days. Her initial microbiologic evaluation was unrevealing: urine culture grew 1000 to 9000 colony-forming units of normal flora, blood culture was negative, and respiratory pathogen panel result was positive for rhinovirus. Abdominal ultrasound on hospital day 1 showed developing left perinephric abscesses. Her rash worsened, and she developed lip peeling and conjunctivitis on day 2, concerning for Kawasaki disease or a toxin-mediated process, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Because it is unusual for either pathogen to cause pyelonephritis in infants, and because the patient had persistent fevers, a blood sample was sent for sequencing of microbial cell-free DNA (cfDNA) on day 3. On day 7, testing resulted with evidence of S aureus in the blood. She was switched from vancomycin and ceftriaxone to ceftaroline for methicillin-sensitive …

Acute kidney failure after total knee arthroplasty revision with antibiotic-impregnated cement spacer.

Gentamicin-impregnated cement beads and spacers are frequently used in case of infective complications after Total Knee Arthroplasty (TKA). A great number of studies in the literature demonstrated that the local administration of gentamicin produces high local antibiotic levels but low serum and urine gentamicin concentrations. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility. We report a case of acute renal failure using a gentamicin-impregnated block spacer. An 83-year-old woman underwent a gentamicinimpregnated bone–cement spacer implant because of an infected TKA removal. Three days later patient clinical status got worse reporting a decreased urine output and increasing C-reactive protein (CRP), Serum Creatinine (SCr) and Blood Urea Nitrogen (BUN). Because the symptoms could be related to the knee spacer lead us to the decision of gentamicin-impregnated cement spacer removal. The day following the removal procedure showed progressive improvement of general condition with evidence of SCr and BUN normalization. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility.

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

Septic shock after liver transplantation successfully treated with endotoxin and cytokine adsorption continuous renal replacement therapy: a case report and literature review

Endotoxins and cytokines play an important role in multiple organ failure pathogenesis in patients with severe Gram-negative bacterial infection. We present a clinical case where an oXiris hemofilter was used for continuous renal replacement therapy (CRRT) treatment in a patient with septic shock after liver transplantation. A 35-year-old man with a 20-year history of hepatitis B presented with jaundice, loss of appetite, and decreased urine output. He was diagnosed with decompensated cirrhosis with acute-on-chronic liver failure, and liver transplantation was indicated. The day after surgery, he developed hyperthermia, hypotension, anuria, and a progressive increase in blood inflammatory markers and creatinine. Combined with the donor source and blood culture results, septic shock after transplantation was considered. The patient was immediately treated with endotoxin and cytokine adsorption CRRT (oXiris hemofilter) with tigecycline, caspofungin, and ganciclovir as anti-infectives. After 48 hours on CRRT, his blood pressure gradually stabilized, the CLIF Consortium Acute-on-Chronic Liver Failure score decreased from 63 to 43. Procalcitonin, endotoxin, and the inflammatory factors interleukin (IL)-6 and IL-10 also decreased gradually. The patient’s liver and kidney functions were completely restored. Our experience suggests that oXiris CRRT combined with antibacterial therapy is an effective treatment for septic shock after liver transplantation.

Haemolytic Uraemic Syndrome Associated with Docetaxel: A Case Report

Haemolytic uraemic syndrome (HUS) has no recognised association with single-agent docetaxel. We present the first documented case of HUS associated with docetaxel in a patient receiving adjuvant chemotherapy for early breast cancer. A previously fit 49-year-old presented nineteen days post final cycle of docetaxel (100 mg/m2 ) with general malaise, epistaxis and decreased urine output. Baseline bloods revealed haemoglobin (53 g/L), urea (45.2 mmol/L), creatinine (1706 µmol/L) and LDH (2140 IU/L). Tumor lysis syndrome was excluded on further biochemical analysis. Blood film analysis demonstrated evidence of acanthocytes, anisocytosis and red cell fragments. Septic, viral and autoimmune screens were negative. There was clear evidence of microangiopathic haemolysis alongside renal dysfunction. She required dialysis, plasma exchanges and blood transfusions. Renal function and blood counts normalised within two months post-admission due to prompt and aggressive management. HUS should be considered in any patient receiving docetaxel who develops simultaneous acute kidney injury and severe anemia.

Ethanolic stem bark extract of Terminalia ivorensis A. Chev. protects against potassium dichromate–induced nephrotoxicity in rats

ObjectiveThe plant Terminalia ivorensis is used in traditional medicine as a diuretic and in the management of renal failure. We reported previously that the ethanol stem bark extract of the plant protects against gentamicin-induced renal and hepatic damage in rats. To further elucidate the mechanism of its renoprotective activity, we studied the effects of the extract on Potassium dichromate–induced nephrotoxicity in rats. The present study assessed the effectiveness of the ethanol stem bark extract of Terminalia ivorensis - against renal oxidative injury evoked by potassium dichromate. MethodsAdult Sprague Dawley rats pre-treated with (100–1000 mg/kg p.o. bwt) of Terminalia ivorensis extract for 5 days were challenged with a single dose of Potassium dichromate (20 mg/kg Sc) in the neck region on the 4th day. On the sixth day, renal function and markers of oxidative injury were assessed. ResultsTerminalia ivorensis (300–1000 mg/kg p.o) pre-treatment dose dependently prevented decreases in urine output in rats challenged with a nephrotoxic dose of Potassium Dichromate. The extract also protected the rats against Potassium dichromate-induced rise in serum electrolytes, urea and creatinine. Furthermore, it dose dependently prevented Potassium dichromate-induced decrease in renal glutathione (GSH) levels whereas tissue oxidative enzymes Superoxide dismutase (SOD) and catalase were protected from damage. Markers of lipid peroxidation such as level of renal Malondialdehyde (MDA) and myeloperoxidase (MPO) also decreased dose dependently when compare with Potassium dichromate treated groups. The extract also protected the histomorphology of the kidney against Potassium dichromate induced damage. ConclusionThe ethanol stem bark extract of Terminalia ivorensis protects kidney against Potassium dichromate-induced renal damage.

Simulation + student response systems = success

Simulation + student response systems = success

P0640DIAGNOSTIC AND TREATMENT OF THE SEVERE FORMS OF ACUTE RENAL FAILURE DURING MALARIA UNDER LIMITED CONDITIONS

Abstract Background and Aims To explore clinical features and outcome of the most severe forms of acute renal failure (ARF) during Plasmodium falciparum malaria in United Nations personnel stationed in Central African Republic, during “MINUSCA ” mission. ARF is one of the most important negative predictive criteria for outcome of malaria.Etiology is multifactorial, but most often is consequence of prerenal dehydration and tubular damages with hemoglobinuria during severe hemolysis Method We analyzed records of 54 inpatients with complicated forms of Plasmodium falciparum malaria who were treated in the Serbian level 2 hospital during 2017. Diagnosis of ARF was estimated based on RIFLE criteria. Having in mind the occasional lack of diagnostic kits for creatinine, at the almost one third of patients we used daily diuresis monitoring (with follow up of volume status) to diagnose this complication (according with RIFLE criteria). Results Total of 19 patients (35,19%) have developed ARF. Beside parenteral treatment with Artemisin, they were treated with parenteral solutions and diuretics. Despite therapy, 8 patients (14,81%) developed progressive and dialysis depended form of ARF (one had hemolytic-uremic syndrome) and they have been urgently evacuated accompanied by AMET into a senior medical institution. Based on provided back information, average creatinine on admission was 1242+/-342 µmol/l, Hb level 10,6 g/dl, potassium 6,8mmol/l. Six out of 8 patients completely recovered renal function (they needed average 7+/- 2 HD procedures; patient with HUS performed 5 plasma exchange sessions), one developed CRF grade 3 and one developed ESRD with necessity for chronic HD treatment. There were not lethal outcomes. Conclusion Early recognition of systemic complications including parameters of acute renal failure (decreasing urine output or changing of urine color could be useful markers under limited medical conditions)is necessaryin the purpose of timely recognition and promptly evacuation into higher medical facilities for further treatment.

SUN-283 Lithium Induced Partial Nephrogenic Insipidus: An Unusual Presentation

Background: Diabetes insipidus (DI) is characterized by hypotonic polyuria and polydipsia. Nephrogenic DI is the result of an inadequate response of the kidneys to arginine vasopressin (AVP), either due to hereditary causes or acquired from various drugs, most commonly lithium. Clinical case: A 30 year old male with past medical history of Hashimoto’s thyroiditis, severe mental impairment was admitted to the hospital for abdominal pain. Medical history was difficult to obtain since the patient was nonverbal. His thyroid function tests, electrolytes including sodium, potassium were all normal on admission. During the hospital course, he was made NPO for both an upper and lower GI endoscopy. He notably had a mild increase in sodium level with subsequent improvement after restitution of diet. Two days after the procedure, he was found to be drinking out of the toilet and also attempting to drink from the urine jug. Due to this odd behavior, he had to be put on physical restraints. The day after, he was found to have a serum sodium of 158 mEq/L. Hypotonic saline was started and urine output was notably ranging from 6-10 L/day with a negative balance. Desmopressin (DDAVP) test was done with a resultant urine osmolality of 170, 237, 257 and 264 mOsm/kg after 30, 60, 90 and 180 mins. Subcutaneous DDAVP was started with some improvement of serum sodium and decrease in urine output. Endocrinology service was consulted for the evaluation of hypernatremia and polyuria. Initial review of his medications did not show any potential cause of DI. Further inquiry of his prior medication history revealed that he had taken Lithium for over 10 years and stopped 4 months prior to the admission due to polyuria. After excluding other causes of polyuria, with partial improvement of urine osmolality to a level <300 mOsm/kg and a clinical history of prior Lithium therapy, a diagnosis of partial nephrogenic DI was made. Patient was started on HCTZ and given adequate water intake with subsequent improvement of his serum sodium back to normal. Conclusion: Nephrogenic DI due to Lithium use usually recovers after treatment is stopped but could be persistent for several years after. In our case, the patient compensated for his polyuria with increased water intake. When his water intake was restricted due to physical restraints, polyuria and subsequently hypernatremia became evident. A thorough medication history including past drug use is essential as it can help unravel the offending agent which was Lithium in our case. There needs to be an increased awareness that the effect of Lithium in the kidneys could be persistent even after stopping the drug for up to many years.

SAT-372 A Case of Hypercalcemia Secondary to Rhabdomyolysis Induced by Heroin Use

Background: Rhabdomyolysis is a potential life threatening condition defined as injury of the skeletal muscle, which results in the release of intracellular contents into the circulation. This muscle injury is often associated with the development of myoglobinuria, electrolyte abnormalities, and often ARF; it can be caused by diverse mechanisms including drugs and toxins. We present a case of rhabdomyolysis complicated by hypercalcemia and ARF in a patient with a history of polysubstance abuse after using intravenous heroin. Case: A 28 y/o male with h/o polysubstance comes to the ED with c/o fatigue, nausea, vomiting and decreased urine output for about 5 days; patient acknowledged using heroin and afterwards he developed weakness and tenderness in upper and lower extremities. Additionally he admitted cocaine and marijuana abuse. On physical exam vital signs were unremarkable and he had some mild tenderness to palpation mostly of the quadriceps bilaterally. Laboratory data was significant for acute kidney injury (cr 11.33 mg/dl, n: 0.7–1.5 mg/dl) and CPK 171920 u/l (n: 22–269 u/l). He received 2 L of NS in the ED and was started on NS at 100cc/hour.He underwent hemodialysis on day 2; initially he was treated for hypocalcemia with calcium and vitamin D supplementation until day 11 were hypercalcemia (calcium 12.7 mg/dl, n: 8.7–10.3 mg/dl; ionized calcium 1.7 mmol/l, n: 1.12–1.32) was noted; this was associated with concomitant suppression of PTH (5 pg/ml, n: 10–65 pg/ml). He remained asymptomatic from calcium abnormalities during his hospitalization, his urine output recovered progressively, hemodialysis was discontinued on day 13. Upon discharge was recommended to f/u with nephrology. Discussion: Various neurological and neuromuscular complications of heroin abuse have been described; one of these is rhabdomyolysis; its pathophysiology in heroin abuse is thought to be multifactorial; including acidosis, hypoxia, muscle compression and adulterants found in heroin. Narcotics may also have direct cell toxicity and alter membrane transport. Usually upon initial presentation hypocalcemia is one of the most common electrolyte imbalances seen with rhabdomyolysis. The proposed mechanism is precipitation of serum calcium salts in necrotic muscle. This may be followed by hypercalcemia during the diuretic phase of ARF which appears to be a relatively unusual complication associated with the presence of severe muscle damage due to metastatic calcium salts that are liberated from the necrotic muscle and the return to the serum. Conclusion: This case report highlights the importance of recognizing potential electrolyte imbalances in patients with rhabdomyolysis; it appears, that concomitant rhabdomyolysis and ARF are needed for a patient to develop hypercalcemia.Serum calcium should always be routinely measured and the appropriate treatment should be implemented to improve outcomes.

Contraindications to Magnesium Sulfate and Alternative Seizure Prophylaxis for Severe Preeclampsia [09L

INTRODUCTION: Intravenous magnesium sulfate is considered first-line seizure prophylaxis for preeclampsia, reducing the risk of eclampsia by half. Absolute or relative contraindications to this medication include myasthenia gravis, severe renal failure, cardiac ischemia, heart block and pulmonary edema. Levetiracetam, an alternative antiepileptic drug considered safe in pregnancy, has been suggested in such cases though its efficacy remains uncertain. Our objective was to determine how frequently alternative anticonvulsant medications are administered for seizure prophylaxis in severe preeclampsia and to identify the documented indications in such cases. METHODS: IRB approved, retrospective cohort study of women with a diagnosis of preeclampsia at 34 weeks of gestation or greater who received seizure prophylaxis at a tertiary university hospital from 2014-2017. Demographics, clinical characteristics and contraindications to magnesium sulfate, if present, were evaluated. Patients were excluded if they had a pre-existing seizure disorders or incomplete medical records. RESULTS: A total of 1,370 patients were included; 3.2% (n=44) received levetiracetam for seizure prophylaxis. Most of the levetiracetam group (79.5%) initially received magnesium. The most commonly documented contraindication was pulmonary edema (n=14) which was confirmed by imaging (either ultrasound or chest x-ray) in less than half of cases; other reasons included changes in laboratory data (n=11; increasing serum creatinine, serum magnesium &gt;7 mg/dL), development of additional signs/symptoms (n=11; hypotension, headache, vision changes, decreased urine output) and patient refusal (n=3). Five cases did not document any contraindication. CONCLUSION: The use of alternative anticonvulsant medications in preeclampsia, which may be less efficacious, must be reserved for true contraindications to magnesium sulfate.

Serum levels of neutrophil Gelatinase associated Lipocalin (NGAL) predicts hemodialysis after coronary angiography in high risk patients with acute coronary syndrome

BackgroundContrast-induced nephropathy (CIN) following a percutaneous coronary intervention (PCI) is the third most common cause of acute kidney injury (AKI) worldwide. Patients who require hemodialysis secondary to CIN have an elevated mortality rate as high as 55%. The current definition of CIN is based on an elevation of creatinine and decrease in urinary output. Creatinine typically increases 48 h after the contrast exposure, which delays the diagnosis and treatment of CIN. The neutrophil gelatinase associated lipocalin (NGAL) has emerged as a sensitive and specific biomarker of renal injury. Limited data exists about the effectiveness of NGAL to predict CIN in high-risk patients with acute coronary syndrome (ACS) that underwent PCI. The primary aim of this study was to determine the association of serum NGAL levels and the need for hemodialysis after PCI.MethodsThis is a prospective, observational study. NGAL levels were measured using ELISA. Blood samples were obtained within the first 6 h of hospital admission, and 12 and 24 h after contrast exposure from angiography. The primary outcome was the requirement of hemodialysis. The non-parametric Mann-Whitney U test was used to test for differences in median serum levels of NGAL. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL to predict the need for hemodialysis after PCI.ResultsA total of 2875 were screened; however, 45 patients with ACS that underwent PCI were included. All patients were at high risk of developing CIN defined by Mehran score > 11 points. The median (IQR) serum concentration of NGAL was significantly higher in patients that required versus did not require hemodialysis (340 [83–384] vs. 169 [100–210], p = 0.01). Elevated serum levels of NGAL with a cut-off at 6 h post PCI of 281 mg/dL predicted the need for hemodialysis with an area under the curve of 0.86 (95% CI, 0.66–1.00).ConclusionsIn patients with ACS undergoing PCI; and high risk of developing CIN, an elevated serum level of NGAL 6 h after contrast exposure predicts the development of acute kidney injury requiring hemodialysis.

Сравнительная клинико-эпидемиологическая характеристика ротавирусной инфекции у детей раннего возраста

This article gives a comparative description of the clinical and epidemiological characteristics of rotavirus infection in children under 1 year and 1–3 years old. An analysis of 83 case histories of the examined children for rotavirus infection under the age of 3 years was carried out. Patients were divided into 2 groups: group 1 — children under 1-year-old (48 patients), group 2 — children from 1 to 3 years old (35 patients). As a result of the study, it was found that in children of the 1st group, rotavirus infection proceeded predominantly (Р˂0.01) in the form of severe enteritis (71.0%), in combination with bacterial intestinal infection (75.0%), with significant (P ˂0.05) frequent (31.3%) bloating due to profuse watery diarrhea. In children of this group in 4.0% of cases, the disease was fatal. In the vast majority (96.7%) of children of the 2nd group, rotavirus infection proceeded in the form of gastroenteritis, with almost the same ratio of moderate to severe forms (47.0, 50.0%). Due to large losses with repeated vomiting and loose stools, significantly (Р˂0.01) more often (53.3%) there was a decrease in urine output and an increase in creatinine level (40.0%).