Oliguria Research Articles

Il ritmo dialitico bisettimanale può essere utilizzato in pazienti selezionati all’avvio del trattamento emodialitico cronico

In recent years, several studies have evaluated the differences in survival and residual renal function between patients who underwent two times weekly haemodialysis (HDB) and three times weekly haemodialysis (HDT). In most cases, these studies have taken into account only the patient survival but not the time into treatment or “technique survival”. In our centre we have retrospectively evaluated the incident patients that were treated with HDB for at least three months between 01 January 2013 and 01 November 2015, focusing on the HDB technique survival. During the follow-up, 35 patients started treatment with HDB, while 13 with HDT. On average, patients treated with HDT were younger than HDB patients (60.9±15.9 years vs. 77.8±9.6 years, p=0.01), and body weight was higher in HDT patients (71±8 kg vs. 63±13 kg, p=0.01). HDT patients were more frequently affected by two or more comorbidities (diabetes, peripheral vasculopathy, cardiac disease, chronic obstructive lung disease) than patients treated by HDB. The creatinine clearance (CrCl) evaluated at the beginning of treatment was similar in the two groups (7.48±5 mL/min in HDB vs 5.4±5 mL/min in HDT, p=NS). Urine output at the beginning of the study was higher in the HDB than the HDT group (1,785±480 mL/24 h vs. 530±500 mL/24 h, p=0.001). Results. The mean survival of the HDB was 14.9±1.5 months (ranging from 12 to 17.9 months, median 14±2.4 months). During the follow-up period, 12 patients switched from HDB to HDT due to the presence of signs of fluid overload in ten of them. In these patients the CrCl and the urine output were significantly reduced by the end of the treatment (CrCl was 3.4±1.9 mL/min vs 6.8±2 mL/min, p=0.01; urine output was 995±567 mL/24h vs 1400±400 mL/24h, p = 0.02). No hospital admissions for uremic symptoms (pericarditis, pulmonary oedema, severe hyperkalaemia) were recorded throughout the follow-up period in HDB patients. Conclusions. Our study shows that HDB can be proposed in selected patients for a considerable period. Decrease of urine output and presence of symptoms related to fluid overload are the two main factors leading to the switch to HDT treatment.

Abstract PCCLB-69: TRANSFUSION RELATED ACUTE HEPATIC INJURY (TRAHI) IN PEDIATRIC PATIENTS UNDERGOING THE FONTAN PROCEDURE

Aims & Objectives: The final common pathway of single ventricle patients is the Fontan procedure. One of the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase (ALT) and aspartate transaminase (AST)). Aims: We aimed to determine the contribution of blood products transfusion to acute hepatic injury. Methods We retrospectively reviewed demographic, pre-, intra- and post-operative parameters including blood products transfusions and liver enzymes (Table 1). ALT and AST levels were transformed into log scale for the regression analysis. We used the Spearman correlation while adjusting for possible confounders. Propensity score was used in order to perform a stepwise weighted linear regression. Results 99 pediatric patients after the Fontan procedure were identified between 01/2009 and 12/2016. Out of the four types of blood products, transfusion of platelets was found to significantly impact post-operative levels of ALT and AST (Figure 1). Additional factors include post-operative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Cardiopulmonary bypass time, aortic cross-clamp time, amount of post-operative bleeding and vasoactive-inotropic score did not influence liver enzymes levels (Table 2). Conclusions In pediatric patients undergoing the Fontan procedure, platelets transfusions significantly contribute to acute hepatic injury. The relation between platelets and transfusion related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regards to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed.

Cytokine IL-12, Dengue in children: analysis of a unique relationship

Background: Dengue is a mosquito borne viral infection caused by one of the four serotypes of dengue viruses (DENV1-DENV4). The consequences of DENV infection range from asymptomatic condition, dengue fever (DF), or severe forms, such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). The host immune responses have been considered as the major factor responsible for dengue pathogenesis. In this study, the cytokine IL-12 is reviewed for its utility as potential biomarker of severe dengue disease.Methods: 120 children of paediatric age group with either dengue NS1 antigen or dengue IgM positive were included. Cases were classified as uncomplicated dengue (dengue without warning signs) and complicated dengue (dengue with warning signs and severe dengue). Clinical features and IL-12 (ELISA KIT) levels were analyzed in the study population.Results: Analysis of clinical features among the study groups revealed children with complicated dengue had persistent vomiting (95%), abdominal pain (80%), decreased urine output (50%), bleeding manifestations (83.3%), Hepatomegaly (70%) Haemoconcentration with concurrent thrombocytopenia (93.3%), altered coagulation profile (28.3%), ICU stay (54.7%), leukocytosis (15%), leucopoenia (66.6%) normal leucocytes, (18.4%). Analysis of IL-12 levels revealed children with complicated dengue showed significant elevation compared to controls and uncomplicated dengue.Conclusions: In our study IL-12 levels were significantly higher in complicated dengue patients in comparison with uncomplicated dengue patients as well as normal control population.

The Protective Role of TRPC6 Knockout in the Progression of Diabetic Nephropathy

Diabetic nephropathy (DN) is a chronic kidney pathology that leads to end stage renal disease (ESRD). It was previously found that a gain‐of‐function mutation in the Transient Receptor Potential Canonical 6 (TRPC6) channel, a non‐selective cation channel that is highly permeable for calcium ions, causes Focal Segmental Glomerulosclerosis (FSG) that is characterized with podocyte loss. Previous studies from our laboratory indicate that there is an association between the development of DN and over‐activation of the TRPC6 channel. We have demonstrated that there is an increase in TRPC6 expression and activity in the streptozotocin (STZ)‐induced diabetic Dahl Salt‐sensitive (SS) rat, an established model of type 1 DN. We have created the TRPC6 knock‐out on a SS rat background (SSTRPC6−/−), and test the hypothesis that the deletion of TRPC6 will protect podocytes and glomeruli during the development of DN. Four groups of animals – control SS, SSTRPC6−/−, and STZ‐treated SS and SSTRPC6−/− – were utilized in this study. Diabetes development was monitored for 11 weeks after STZ injection with periodic weight, glucose, and urinary output measurements. Glomerular filtration rate (GFR) was measured and tissue collections were made at the end of the protocol. Freshly isolated glomeruli of perfused kidneys were used from all four groups for either electron microscopy or confocal fluorescence microscopy to assess the foot process effacement and basal level of intracellular calcium ([Ca2+]i), respectively. Histochemical analysis of whole kidney slices was done to assess renal injury. There was a decrease in urinary output (49±29 vs 73±39 mL/day/100g BW) and a trend for blunted increase in albuminuria (97±34 vs 112±19 mg/day x 100g BW) in the STZ‐treated SSTRPC6−/− rats compared to the STZ‐SS animals. There was no significant difference in GFR between either of the 4 experimental groups; however there does appear to be a trend for hyperfiltration in the STZ‐treated animals. Importantly, pathological increases in basal [Ca2+]i levels and foot process damage of podocytes during the development of DN was attenuated in the STZ‐treated SSTRPC6−/− animals. Overall, our data indicates that inhibiting the TRPC6 channel may have renoprotective effects and the potential to lead to the development of new pharmacological tools to treat or prevent the progression of DN and kidney damage.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

PP-419 - A Great Mass in Thorax

80-years-old man with uncontrolled hypertension was admitted emergency service with the complaints of chest and back pain, dyspnea, weakness and decreased urine output, which were lasted for one week. On physical examination; he was hypotensive, tachycardic and tachypneic and no urine output since midnight. Chest X-ray was taken immediately which was standing out a great mass in left hemithorax just above heart (Figure 1). Because of deep hypotension, confusion and disorientation; transthoracic echocardiography was performed at bedside and the diameter of ascending aorta was measured as 74 mm with central moderate aortic regurgitation (Figure 3). Clinical findings of the patient were found as creatinin level: 2.5 mg/dl, blood urea nitrogen (BUN): 72 mg/dl, urea: 155 mg/dl and hemoglobin: 16.4 g/dl, consistent with prerenal acute renal failure. Computed thorax tomography without intravenous contrast revealed a giant ascending aorta aneurysm. The diameter of ascending aorta was measured as 80 mm, diameter of arcus aorta and proximal descending aorta as 90 mm and was visualized with a perivascular effusion compatible with Type-B aortic dissection (Figure 2). Intravenous fluid replacement and norepinephrine therapy started immediately before these imaging processes in order to restore blood pressure, but patient was lost within two hours before the planned high-risk surgery. Figure 2 View Large Image Figure Viewer Download Hi-res image Figure 3 View Large Image Figure Viewer Download Hi-res image

Bile Acid Membrane Receptor TGR5 Regulates Renal AQP2 and Improves Lithiuminduced NDI

The bile acid‐activated receptors, which include the membrane G protein‐coupled receptor (TGR5) and nuclear farnesoid X receptor (FXR), are shown to play roles in kidney diseases. The purpose of current study was to investigate the role of TGR5 receptors in renal water handling and the underlying molecular mechanisms. The activation of TGR5 by lithocholic acid (LCA, a TGR5 endogenous ligand) induced aquaporin‐2 (AQP2) protein expression and intracellular trafficking in rat primary cultured inner medullary collecting duct (IMCD) cells via cAMP‐PKA signaling pathway. A synthetic specific TGR5 agonist INT‐777 has the same effects as LCA in IMCD cells. In mice with lithium‐induced nephrogenic diabetes insipidus (NDI), the activation of TGR5 by LCA markedly decreased urine output and increased urine osmolality, which was associated with significantly up‐regulated AQP2 expression in the inner medulla, whereas chenodeoxycholic acid (CDCA, a FXR endogenous ligand) had no effects. In primary cultured IMCD cells prepared from lithium‐treated rats, INT‐777 or INT‐767 (a FXR and TGR5 dual agonist), but not INT‐747 (a FXR agonist) increased AQP2 protein expression. Compared with wildtype mice, tgr5−/− mice exhibited a mild urine concentration defect after 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. In conclusion, TGR5 activation increases renal AQP2 expression via cAMP‐PKA signaling pathway and improves impaired urinary concentration in lithium‐induced NDI. TGR5 is thus involved in regulation of water metabolism in the kidney.Support or Funding InformationThis work was supported by the Natural Science Foundation of China (Grants 81370822, 81570635, and 81670646), by the 111 Project, China (No. B13037), and by the Natural Science Foundation of Guangdong Province, China (Grants 2014A020212623, 2014A030313168, and 2016A020215034).This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Purpura fulminans causing acute cortical necrosis in postpartum period

A 22-year-old woman underwent normal vaginal delivery; 3 days later, she developed fever and rashes over all four limbs followed by decreased urine output. Examination revealed pedal oedema, non-palpable purpuric...

Management of a patient with vesicocutaneous fistula presenting 13 years after radiotherapy performed for cervical cancer.

A vesicocutaneous fistula (VCF) is a tract that is formed abnormally between the bladder and the external surface of the body. VCF results in a great deal of inconvenience, discomfort, and physical disability for the affected patient. This condition can be caused by extensive trauma with pelvic bone fracture, radical pelvic surgery, irradiation of pelvic malignancies, hip arthroplasty, a large bladder calculus, and various other pathologies. The management of VCF should be approached on a case-by-case basis because of the complexity of the disease. In this report, we present a case of VCF that was managed by using vacuum-assisted closure therapy. A 72-year-old female was diagnosed with VCF as a late complication after radiotherapy for cervical cancer. After radiotherapy, she had lower urinary tract symptoms and was diagnosed as a neurogenic bladder. She started to perform clean intermittent catheterization (CIC). She was subsequently diagnosed as chronic kidney disease stage 5 due to hypertensive nephrosclerosis, and started to receive hemodialysis. Recently, she avoided CIC because of decreased urine output. Despite urinary diversion and surgical debridement, the surgical wound had not healed after several days. After vacuum assisted closure therapy, the surgical wound healed and filled with granulation tissue. This case shows that vacuum-assisted closure therapy is efficient for complicated wound healing of a VCF after radiotherapy.

Acute kidney Injury in Children: Impacts and its Management

The incidence of acute kidney injury (AKI) in children is increasing globally and is associated with increased mortality and long-term renal consequence.The definition of pediatric AKI was standardized for a more accurate assessment of the epidemiology of pediatric AKI. The definition of AKI is based on elevation in serum creatinine levels or decrease inurine output; accordingly, epidemiological studies have ensued. Recent advances in leveraging electronic medical health record systems and newbiomarkers appear to detect AKI earlier and predict prognosis more accurately than traditional markers have allowed for real-time risk stratification and prevention of pediatric AKI in the hospital setting. For high risk or early stage AKI patients, avoidance of nephrotoxins, optimization of blood pressure and volume status, sufficient nutritional support are necessary and have been demonstrated tobe effective in preventing the occurrence of AKI and improving prognosis. Lastly, renal replacement therapy is needed when conservative care fails. Further therapeutic innovation willdepend on improving the understanding of the basic mechanisms underlying AKI in children. CBMJ 2018 January: Vol. 07 No. 01 P: 48-53

Renal Replacement Therapy in Acute Kidney Injury - Indication and Implementation

Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with a worse short- and long-term outcome. The KDIGO (Kidney Disease: Improving Global Outcomes) guidelines suggest to implement preventive strategies in high-risk patients. Definition and classification of acute kidney injury according to the KDIGO criteria are based on an increase in serum creatinine and/or a decrease in urinary output. Renal replacement therapy (RRT) is the only supportive measure in patients with severe AKI. The KDIGO guidelines recommend to initiate RRT immediately if an absolute indication exists. However, in the absence of absolute indication, there are no recommendations when to start RRT in AKI patients with a progressive decline of renal function. Continuous or intermittent techniques of renal replacement therapy may be used equally for treatment of acute kidney injury. In hemodynamically instable patients and patients with increased intracranial pressures continuous renal replacement therapy is recommended. Although weak evidence exists, regional citrate anticoagulation is suggested for patients receiving continuous renal replacement therapy and systemic heparin anticoagulation is suggested for patients receiving intermittent renal replacement therapy. The KDIGO guidelines recommend to deliver an effluent volume of 20 - 25 ml/kg/h for CRRT in AKI.

The effect of ultrafiltration on end-cardiopulmonary bypass hematocrit during cardiac surgery.

Ultrafiltration (UF) during cardiopulmonary bypass (CPB) is a well-accepted method for hemoconcentration to reduce excess fluid and increase hematocrit, platelet count and plasma constituents. The efficacy of this technique may confer specific benefit to certain patients presenting with acquired cardiac defects. The purpose of this study was to retrospectively evaluate the effect of UF on end-CPB hematocrit by cardiac surgical procedure type. A review of 73,506 cardiac procedures from a national registry (SCOPE) was conducted between April 2012 and October 2016 at 197 institutions. Cases included in this analysis were those completed without intraoperative red blood cell transfusion and where zero-balance UF was not used. The primary end point was the last hematocrit reading taken before the end of CPB, with a secondary end point of urine output during CPB. In order to isolate the effect of the UF volume removed, we controlled for a number of confounding factors, including: first hematocrit on CPB, total asanguineous volume, estimated circulating blood volume, CPB urine output, total volume of crystalloid cardioplegia, total volume of other asanguineous fluids administered by both perfusion and anesthesia, type of cardiac procedure, acuity, gender, age and total time on CPB. Descriptive statistics were calculated among five subgroups according to the UF volume removed: no volume removed and quartiles across the range of UF volume removed. The effect of UF volume on primary and secondary end points was modeled using ordinary least squares and restricted cubic splines in order to assess possible non-linearity in the effect of the UF volume while controlling for the above-named confounding factors. An interaction term was included in each model to account for possible differences by procedure type. The study found a statistically significant non-linear pattern in the relationship between the UF volume removed and the last hematocrit on bypass (X2 = 172.5, df=24, p<0.001). For most procedure types, UF was most effective at increasing the last hematocrit on CPB, from 1 mL to approximately 2.5 L, with continued improvements in hematocrit coming more slowly as the UF volume was increased above 2.5 L. There were statistically significant interactions between UF and procedure type (X2 = 78.5, df=24, p<0.0001) as well as UF and starting hematocrit on CPB (X2 = 234.0, df=4, p<0.0001). In a secondary end-point model, there was a statistically significant relationship between the ultrafiltration volume removed and urine output on bypass (X2 = 598.9, df=28, p<0.001). The use of UF during CPB resulted in significant increases in end-hematocrit, with the greatest benefit shown when volumes were under 2.5 L. We saw a positive linear benefit up to 2.5 L removed and, thereafter, in most procedures, the benefit leveled off. However, of note is markedly decreased urine output on bypass as the ultrafiltration volumes increase.

Case 3: An Infant with Severe Dehydration, Weight Loss, and Abnormal Newborn Screening Test Results

A female infant is born at 37 weeks’ gestation via vaginal delivery to a gravida 4, para 3 woman. The woman’s pregnancy and delivery are uncomplicated. The infant’s birthweight is 2,680 g. She is discharged from the hospital in good condition; at home, she breastfeeds well and gains weight appropriately; on day 10, her weight is 2,778 g (4% above birthweight). On day 12, the mother notes that the infant has begun to breastfeed poorly. On day 14, formula feeding is attempted, but her intake remains poor, with an associated decrease in urine output. On day 16, she presents to an outpatient clinic, where she appears cachectic and severely dehydrated but responsive. Her weight is 1,760 g, a decrease of more than 1 kg (37%) from 6 days ago. She is transferred to the NICU for further evaluation and treatment. The infant’s newborn screening results from day 1 are normal; however, repeat newborn screening performed on day 10 shows an abnormality in the fatty acid oxidation profile, with malonyl carnitine levels of 0.68 μmol/L (normal ≤0.5 μmol/L). The patient’s initial laboratory tests were notable for the following results: sodium, 174 mEq/L (174 mmol/L); potassium, 7.2 mEq/L (7.2 mmol/L); chloride, 141 mEq/L (141 mmol/L); bicarbonate, 7 mEq/L (7 mmol/L); blood urea nitrogen, 273 mg/dL (97 mmol/L); creatinine, 5.61 mg/dL (428 μmol/L); glucose, 1,266 mg/dL (70.2 …

Usefulness of Urinary Neutrophil Gelatinase Associated Lipocalin (NGAL) as a predictor of Acute Kidney Injury (AKI) in critically ill children

Background : Rise in serum creatinine and decrease in urine output are late markers of Acute Kidney Injury (AKI) in children. Markers which can predict kidney damage early can help to intervene quickly and optimize treatment. Urinary NGAL is one of the early markers of AKI being studied widely. Methods : Children in the age group of 1 month to 18 years admitted to the PICU of our hospital from September 2016 to April 2017 were included in the study. Children with preexisting renal disease, UTI, post surgical patients and children with expected duration of stay Results : Ninety-six children were enrolled during the study period. Of these, 39 (40.6%) developed AKI. Among patients with shock, 42.8% of children developed AKI. Urine NGAL value at admission greater than 88 ng/ml had a sensitivity of 84.6% and specificity of 80.7 % in predicting AKI, with AUC of 0.86 whereas admission creatinine had an AUC of 0.66 in predicting AKI. PRISM III scores for predicting AKI had AUC of 0.752. Among children who developed AKI, 43.7% had normal creatinine at admission but had urine NGAL value > 88 ng/ml. Only 25.5% of children with AKI required Renal replacement therapy (RRT). Urine NGAL value was >500 ng/mL in 80% of children requiring RRT. Children with AKI had a mortality rate of 20.5%, compared with 4.2% in children without AKI. Conclusion : Urinary NGAL is a better and more sensitive marker for predicting the development of AKI in critically ill children compared with serum creatinine. Urine NGAL value greater than 500 ng/ml could be used to predict the requirement of RRT in critically ill children with AKI.

Early diagnosis and treatment of anastomotic leak after rectal cancer surgery

Anastomotic leakage is the most common major complication after mid-low rectal cancer surgery. Due to lack of knowledge regarding the virtual mechanisms of anastomotic leakage, not much can be done to prevent its development. The aim of the present review was to discuss the prevention, early diagnosis, and treatment of anastomotic leakage after rectal cancer surgery. For patients with risk factors, such as anastomotic site within 4 cm from anus, obese men, lack of blood supply of the anastomotic site, neoadjuvant chemo radiotherapy, or patients with severe co-morbidity, aggressive preventive strategy should be adopted. The effectiveness of diverting stoma, preoperative bowel preparation, and transanal decompression are still in debate. The combination of fluorescence imaging to assess anastomotic perfusion and selective preservation of the left colic artery can be used in the future to prevent anastomotic leakage intraoperatively. With increasing use of neoadjuvant chemo radiotherapy and diverting stoma, more than half of the leaks present in a more subtle and insidious manner, including ileus, diarrhea, anal discharge of pus, mild fever, accelerated heart rate, tachypnea, and oliguria. Surgeons should be more cautious regarding these insidious clinical presentations. Computed tomography scan and endoscopy are among the most important diagnostic workups that can early diagnose leakage and indicate the size of the defect and extent of infection. For patients presenting with diffuse peritonitis, emergency surgical exploration is mandatory along with fluid resuscitation. For those with limited infection, appropriate treatment plan should be made after consideration of the extent of infection, methods to eradicate the infectious source, strategies following adjuvant therapy, and the possibility and necessity of re-establishing bowel continuity.

Decreased Urine Output and Vomiting in a 4 Year Old Boy

Globally, post infectious glomerulonephritis is a common cause of acute glomerular disease. Persistent hypocomplementemia is known to be associated with dysregulation of the complement alternative pathway. Experimental evidence regarding the effect of viral illness in case of acute glomerular disease are very limited. The following report illustrates a unique presentation of post infectious glomerulonephritis associated with viral infection and discussion of C3 glomerulonephritis.

Heat-Related Training and Educational Material Needs among Oil Spill Cleanup Responders.

Heat-related illness (HRI), injury, and death among oil spill cleanup responders can be prevented through training and educational materials. This study assessed heat-related training and educational materials currently used and desired by oil spill cleanup responders. A needs assessment was completed by 65 oil spill cleanup responders regarding their occupational heat-related experiences and training needs. Oil spill cleanup responders reported participating on average in 37 oil spill cleanup activities per year. Most reported experiencing additional HRI risk factors, such as high temperatures and humidity and wearing personal protective equipment and clothing ensembles, respirators, and personal flotation devices. Many reported experiencing symptoms of HRI (profuse sweating, headache, weakness, decreased urine output, high body temperatures) and experiencing heat exhaustion. Although multiple prevention controls were reported, only 1 in 4 reported using an acclimatization plan. The most common training delivery method and education received included just-in-time training and printed materials. The most desirable future training delivery methods and education products were smartphone or tablet applications, printed materials, and online training. Findings from this study may be beneficial to safety and health professionals and health educators, particularly those interested in developing heat stress training and educational materials for oil spill cleanup responders.

Effect of Frequent Dialysis on Renal Recovery: Results From the Acute Renal Failure Trial Network Study

IntroductionThe optimal frequency of intermittent hemodialysis (IHD) in the treatment of acute kidney injury (AKI) remains unclear. Increasing the frequency of IHD, while offering the possible advantage of reduced ultrafiltration requirement and less hemodynamic instability per session, amplifies patient contact with an extracorporeal circuit with possible deleterious cardiovascular and immunological consequences. A recent study suggested that intensive renal replacement therapy (RRT) is associated with a decrease in urine output during AKI. We hypothesized that increased frequency of IHD may be associated with delayed renal recovery.MethodsThis is a post hoc analysis of the Acute Renal Failure Trial Network (ATN) study. The ATN study was a large randomized multicenter trial of intensive versus less-intensive RRT in critically ill patients with AKI. This study used either continuous RRT or IHD, depending on the hemodynamic status of the patient. Of 1124 patients, 246 were treated solely with IHD during the study period and were included in this analysis. The participants were randomized to receive IHD 3 days per week (L-IntRRT) or 6 days per week (IntRRT). The primary outcome of interest was renal recovery at day 28.ResultsL-IntRRT was associated with higher number of RRT-free days through day 28 than IntRRT (mean difference 2.5 days; 95% confidence interval [CI]: −4.79 to −0.27 days; P = 0.028). The likelihood for renal recovery at day 28 was lower in the IntRRT group (OR: 0.49; 95% CI: 0.28–0.87; P = 0.016).ConclusionIn hemodynamically stable patients with AKI, intensifying the frequency of IHD from 3 to 6 days per week may be associated with impaired renal recovery.

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A Case of Tenofovir Causing Fanconi Syndrome and Pancreatitis

SESSION TITLE: Critical Care 5 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Fanconi syndrome is known to cause type 2 proximal renal tubular acidosis characterized by inadequate reabsorption in the proximal tubule. As a result there is excessive loss of substances in the urine including amino acids, glucose, phosphate and bicarbonate in the absence of high serum levels. CASE PRESENTATION: A 62-year-old female on Stribid therapy for aquired immunodeficiency syndrome presented to the emergency department with diarrhea, nausea, vomiting and decreased urine output. She was hypotensive and laboratory testing revealed acute renal failure. She also had significant electrolyte and metabolic derangements including hyponatremia, hypokalemia, hyperchloremic non-anion gap metabolic acidosis, low serum uric acid. Urine studies showed high urine protein and glucose levels. The patient was subsequently diagnosed with Fanconi syndrome. Furthermore lipase was also elevated supported by radiologic evidence of acute pancreatitis. DISCUSSION: Acquired causes of Fanconi syndrome include multiple myeloma, renal transplantation, and medications. Tenofovir has been documented as a causative agent in inducing Fanconi syndrome worldwide. In all of these cases the patients had been boosted by lopinavir-ritonavir, a component that is absent from this presentation. Tenofovir is primarily excreted from the renal tubules via MDR-2 (multi drug resistance) protein. Ritonavir inhibits MDR-2, which is what leads to the accumulation of tenofovir in the tubules allowing the drug to damage the tubular cells. Our patient was being treated with elvitegravir (as opposed to ritonavir), which is also a documented, strong MDR reversing agent. It is likely the elvitegravir acted in a similar method to the ritonavir documented in other cases. Unfortunately, in our case, the patient had pancreatitis as well. Although not listed as a side effect, there are multiple reports of pancreatitis with concomitant use of tenofovir and didanosine. It is unclear whether our patient presented with an idiopathic pancreatitis or if there is actually a link between tenofovir treatment alone and pancreatitis. This is the first documented case to our knowledge of tenofovir, without didanosine, causing pancreatitis. CONCLUSIONS: Fanconi syndrome continues to be a rare cause of renal failure and tenofovir has been implicated as a cause when combined with a MDR inhibitor such as ritonavir, and now possibly elvitegravir. This case of pancreatitis and Fanconi syndrome caused by tenofovir may be the first documented, but not the first existant case. More cases must be documented to be sure of this relationship. The risks and benefits must always be weighed when initiating therapies, which have the potential to cause significant harm. Reference #1: Mathew, G., & Knaus, S. J. (2006). Acquired Fanconi’s syndrome associated with tenofovir therapy. Journal of General Internal Medicine, 21(11), 1206-1206. doi:10.1111/j.1525-1497.2006.00518_1.x DISCLOSURE: The following authors have nothing to disclose: Brittany Duchene, Bibi Aneesah Jaumally, Francois Gregoire No Product/Research Disclosure Information

Partial Priapisim: A rare presentation of sickle cell anemia

Introduction Partial segmental thrombosis of the corpus cavernosum (PSTCC); known as partial priapism; is an uncommon urological condition which predominantly affects young men in which the proximal part of one corpus cavernosum is thrombosed. Many risk factors are described in the literature, the exact etiology of penile thrombosis and its pathogenesis remains unclear. Several treatment options are available ranging from conservative medical treatment with NSAIDs, antibiotics, analgesics, low molecular weight heparin, acetylsalicylic acid and antibiotics, surgical or to a follow-up observation without treatment. In this study we presented a sickle cell patient who presented with pain and perineal swelling and diagnosed with PSTCC using MRI and was treated conservatively. Case description A 23-year-old male, known case of sickle cell anemia, presented to casualty with a 1-day history of perineal pain of a sudden onset, increasing in severity, no aggravating or relieving factors. It was associated with perineal swelling, decrease in urine output and vomiting, not associated with urethral discharge, erectile dysfunction, trauma, sexual contact, fever, abdominal pain, lower urinary tract symptoms, change in bowel habits, or bleeding per rectum. He had a past history of left pyeloplasty in childhood. He was a smoker, non-alcohol consumer with a family history of liver malignancy. Examination revealed a stable vitals, abdomen was soft and non-tender, genitourinary exam findings confirmed the absence of priapism. There was a normal circumcised penis, normal bilateral testis and epididymis, separated perineal mass slightly hard in consistency, fixed and tender at the proximal part of the penis. Digital rectal examination was unremarkable. The complete blood count showed mild leukocytosis, electrolytes, coagulation profile, urine analysis and urine culture were unremarkable. MRI perineal and penis showed the right intratunical corpus cavernosum with altered signal intensity involving the root, proximal and mid third sparing the distal third of corpus cavernosum, maximum width of 26mm (predominantly hyposignal intensity with few areas of hypersignal intensity). Visualized Buck’s fascia and tunica albuginea were intact. Features mostly suggestive of right corpus cavernosum hematoma. Conservative treatment was initiated with 6 hourly IV paracetamol and the response was observed with gradually disappearing pain, reduction in swelling size and leukocytic count. On follow up patient was pain free, reduction in swelling size with a recovery of painless erection. A follow up ultrasound of the scrotum and a hematologist referral were arranged. Results and conclusions PSTCC is not an urological crisis and has an excellent prognosis. Conservative treatment appears to be a reliable therapeutic option. Surgery is reserved for patients in whom conservative management fails.