Oliguria Research Articles

#3311 INDEPENDENT PREDICTORS FOR COMMUNITY-ACQUIRED ACUTE KIDNEY INJURY: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Acute Kidney Injury (AKI) is a syndrome characterized by an abrupt drop in glomerular filtration and/or a decrease in urinary output. The awakening to a different kind of AKI that also occurs outside the hospital named community-acquired AKI (CA-AKI) occurred in 1991, however, few data have been published about its epidemiology, risk factors and outcome, especially in low-income countries. The recognition of risk factors for CA-AKI and development of symptom-based risk tool that aims to predict the risk of AKI might be able to avoid delays in its recognizing, improve the timely diagnosis and patient outcomes in this frequent syndrome. We aimed to assess CA-AKI incidence, characteristics and independent risk factors associated with CA-AKI; to evaluate the discriminatory capacity of a clinical score tool to AKI prediction to predict CA-AKI in our sample. Method We conducted a prospective observational study of general medical admissions to a tertiary hospital in Campinas (São Paulo) between 10th January 2019 and 16th September 2021; we included patients ≥ 14 years, medical suspicion of infection (or confirmed) and /or presence of at least one of the signs or symptoms on admission: fever, dyspnea, decrease in urine output, edema, hypotension, hemodynamic shock, jaundice, petechiae, ecchymosis or decreased level of consciousness. We excluded patients with stage 5 chronic kidney disease at baseline and pre-existing renal replacement therapy (undergoing dialysis and renal transplantation), and also patients with COVID diagnosis. All patients included were assessed utilizing a symptom-based risk score to predict the development of severe AKI, the need for dialysis and mortality. Patients were subjected to complete history taking, socioeconomic and education data were collected. Healthy literacy was assessed using the test of functional health literacy in adults – short version (S- TOFHLA). Predictors of CA-AKI risk were assessed using multivariate logistic regression analysis. Patients were followed up until discharged hospital. The study outcomes were development of CA-AKI, hospital mortality, dialytic need. Results We enrolled 261 patients. CA-AKI was diagnosed in 65 (25%) patients. The CA-AKI patients were older [59 (51-66) vs. 54 (38-65) years, p = 0,02], had higher basal serum creatinine [0,7 (0,5–0,9) vs. 0,6 (0,5-0,8) mg/dL; p = 0,01], lower baseline estimated glomerular filtration rate (eGFR) [103 (88–113) vs. 109 (97–121) mL/min/1,73 m2; p = 0,01] and lower eGFR on admission [64 (44 – 81) vs. 104 (82 – 116) mL/min/1,73 m2; p = 0,0001]. Liver and heart disease were most common comorbidities in the group CA-AKI [10 (16%) vs. 14 (7%) patients, p = 0.04 and 21 (33%) vs. 39 (20%), p = 0,03, respectively]. The risk score did not show significant accuracy to predicting CA-AKI, however, logistic regression showed that scores ≥7 points (OR 95% CI 1.282, 6.133 p = 0.010) followed by age (OR 95% CI 1.007, 1.044 p = 0.008] and liver disease (95% CI 1.063, 6.379 p = 0,036) were independent factors associated with increased risk for CA-AKI in our population. A higher percentage of patients in our sample declared household income < $ 719.73 (month) and the CA-AKI group maintained the same distribution. Only 41 (16%) patients were able to perform the S-TOFHLA and 18 (44%) were considered inadequate or insufficient health literacy. For hospitalized patients, the mean hospital stay in CA-AKI group was longer [8 (4-18) vs. 4 (2-11) days p = 0,001] than without CA-AKI. Overall mortality rate during the follow up was 5% (13 patients), need dialysis 1% (2 patients) and were not statistically significant between the groups. Conclusion Healthy literacy, education, and social class did not show association with CA-AKI; dialysis needed and mortality were not different between the groups CA-AKI or without CA-AKI. Covariates and factors associated with risk for CA-AKI were age, liver disease and scores ≥7 points. The main limitation of our study was not feasible to screen all the patients due to the high numbers seen daily.

Ureteral stent insertion failure in obstructive uropathy secondary to cervical cancer

Introduction: To identify preoperative features that predict ureteral stent placement failure in women with obstructive uropathy secondary to cervical cancer. Methods: Observational, descriptive, analytical study. Clinical registries of patients with diagnosis of obstructive uropathy secondary to cervical cancer were reviewed. Fifty-two patients attended between January 2017 to January 2021 were included. Diagnosis of obstructive uropathy consisted of hydronephrosis or hydroureter in imaging studies and elevation in baseline serum creatinine and blood urea nitrogen with uremic syndrome. An analysis of variables of interest was carried out to assess the association with ureteral stent placement failure. Results: We observed that the overall rate of failed ureteral stent placement was 55.8%. We did not find any differences in baseline characteristics between patients with successful or unsuccessful ureteral stent placement. A higher percentage of patients with failed urinary diversion on admission had a decrease in urinary output (58.6% vs. 30.4%, p=0.04), uremic syndrome (51.7% vs. 21.7%, p=0.02), as well as an increased median serum creatinine (6.6 vs. 2.6 mg/dL, p=0.03) compared to patients with successful ureteral stent placement. An admission serum creatinine cut-off value of 3.4 mg/dL yielded sensitivity of 69% and specificity of 65.2% for unsuccessful ureteral stent placement (AUC=0.674, 95% CI 0-52-0.82; p=0.03). Conclusion: Our data suggest that distal ureteral obstruction evidenced by imaging, regardless of the extent of invasion, is the most important factor related to unsuccessful ureteral stent placement.

Coexistence of acute pancreatitis and an obstructing upper ureteral calculus: does a calculus cause pancreatitis? a case report.

A 36-year-old male patient presented with epigastric, and right loin pain with decreased urine output for 3 days. On physical examination, he had central abdominal and right flank tenderness. An abdominal ultrasound showed mild to moderate ascites, a hyperechoic pancreas, a small (26×77mm) left kidney with increased echogenicity, right renal hypertrophy with moderate hydronephrosis, and a dilated upper ureter due to a 10mm obstructing stone with a perirenal fluid collection. The diagnosis of acute pancreatitis with an obstructing right upper ureteric stone was established. Under spinal anesthesia, an emergency ureteroscopy with laser fragmentation of the stone was performed, and a JJ stent was inserted. He developed postobstructive diuresis and his renal function was improved with a rapid decline of pancreatic enzymes as well. Two theories explain the presentation of acute pancreatitis by ureteral obstruction. First, the obstructed severe hydronephrotic kidney compresses the duodenum and head of the pancreas, obstructing the distal part of the common bile duct and triggering the elevation of pancreatic duct pressure, bile reflux, trypsin activation, and pancreatic autodigestion. The second theory states that acute pancreatitis develops when urine is extravasated from an obstructed kidney into the adjacent tissues, irritating the uncinate process of the pancreas. Although mentioning ureteral obstruction as a cause of pancreatitis is scarce, the clinician should be aware that in each case of ureteral obstruction, the emergence of acute pancreatitis is a possible complication.

CLINICOETIOLOGICAL PROFILE, MANAGEMENT AND OUTCOME OF NEONATAL SHOCK PRESENTING WITHIN FIRST 72 HOURS OF LIFE

Objective: To study the ethology, presentation, response to treatment and outcome of neonatal shock which is one of the most common causes of morbidity and mortality in neonates while at the same time being amongst the less studied topics in pediatrics, with data from children and adult being extrapolated to the neonates. Study Design: This was a cross sectional observational study done in a government hospital of north India from 1 January 2023 to 30 April 2023.All the neonates aged 0 – 72 hours who presented to the neonatal intensive care unit (NICU) of the pediatric department of the hospital as a case of shock were included in the study. Shock was defined as decreased perfusion, altered mental status, diminished or bounding pulses, cool extremities or decreased urine output. Results: Our study included 71 patients (54.9% males and 45.1% females) out of which 77.5 % participants presented within 24 hours of birth. 54.9% babies had normal weight and 47.9% were early term. Babies born via LSCS were more likely to develop and present earlier with shock. 43.7% cases were attributed to respiratory distress syndrome, 32.4% cases to perinatal asphyxia and 27.1% to sepsis. Sepsis and Meconium aspiration were more likely to present earlier. 25.4% required triple inotropic support and 7% had catecholamine refractory shock. Mortality was 18.3% with maximum mortality seen in patients on triple inotropic support, all of whom presented with shock at less than 24 hours of age.

Shortening of primary cilia length is associated with urine concentration in the kidneys.

The primary cilium, a microtubule-based cellular organelle present in certain kidney cells, functions as a mechano-sensor to monitor fluid flow in addition to various other biological functions. In kidneys, the primary cilia protrude into the tubular lumen and are directly exposed to pro-urine flow and components. However, their effects on urine concentration remain to be defined. Here, we investigated the association between primary cilia and urine concentration. Mice either had free access to water (normal water intake, NWI) or were not allowed access to water (water deprivation, WD). Some mice received tubastatin, an inhibitor of histone deacetylase 6 (HDAC6), which regulates the acetylation of α-tubulin, a core protein of microtubules. WD decreased urine output and increased urine osmolality, concomitant with apical plasma membrane localization of aquaporin 2 (AQP2) in the kidney. After WD, compared with after NWI, the lengths of primary cilia in renal tubular epithelial cells were shortened and HDAC6 activity increased. WD induced deacetylation of α-tubulin without altering α-tubulin levels in the kidney. Tubastatin prevented the shortening of cilia through increasing HDAC6 activity and consequently increasing acetylated α-tubulin expression. Furthermore, tubastatin prevented the WD-induced reduction of urine output, urine osmolality increase, and apical plasma membrane localization of AQP2. WD shortens primary cilia length through HDAC6 activation and α-tubulin deacetylation, while HDAC6 inhibition blocks the WD-induced changes in cilia length and urine output. This suggests that cilia length alterations are involved, at least in part, in the regulation of body water balance and urine concentration.

An Atypical Case of Anti GBM Disease

Anti GBM disease is a very rare type of small vessel vasculitis. The incidence is around less than 1 per million per year .This disease is also known as “Good Pasteur Disease”. Usually it presents with rapidly progressive glomerulonephritis with or without lung haemorrhage. The pathognomonic hallmark of the disease is strong linear IgG deposition along the GBM along with positive anti GBM antibody. But when the circulating antibody is absent in the blood, with mild renal impairment it is termed as atypical anti GBM disease. Recently we have found a 26 years old gentleman who presented with leg swelling for 1.5 months along with decreased urine output. He was non diabetic, normotensive, there was no history of joint pain, rash, no offending medication intake, or coughing out of blood. His urine R/E report showed Alb+++, RBC-plenty. After admission his serum creatinine was increasing rapidly. We have done renal biopsy and started treatment with I/V methylprednisolone followed by oral steroid. He had nephrotic range proteinuria. His auto antibody profile and HBsAg, Anti HCV was negative. We have done renal biopsy and it showed crescentic GN with strong linear deposition of IgG. His anti GBM Ab was negative. Thus we labelled the case as atypical anti GBM disease. Now patient is on RRT and we started therapeutic plasma exchange. J Medicine 2023; Vol. 34, No. 2(1) Supplement: 220

SQUAMOUS CELL CARCINOMA OF RENAL PELVIS: A CASE REPORT

Primary squamous cell carcinoma of the renal parenchyma is a rare entity. The diagnosis of squamous cell carcinoma of the renal pelvis is usually unsuspected due to the rarity and inconclusive clinical and radiological features, hence patients present at advanced stages resulting in poor prognosis. It can be associated with long standing obstructive uropathy eg. renal calculi and chronic renal infection. Radical nephrectomy is the mainstay of the treatment. We presented a case of Squamous Cell Carcinoma of right kidney with Chronic Pyelonephritis in a patient of a 60 years old male who presented with complains of burning micturition and decreased urine output. The radiological examination showed gross hydronephrosis with staghorn calculi of right kidney. The patient was treated with radical nephrectomy. The significance of this case is highlighted by the unusual location of such a tumour, and while rare, it is an important consideration in the differential diagnosis of renal tumours

Secreted Cytokines within the Urine of AKI Patients Modulate TP53 and SIRT1 Levels in a Human Podocyte Cell Model

Acute kidney injury (AKI) is a major kidney disease with a poor clinical outcome. It is a common complication, with an incidence of 10-15% of patients admitted to hospital. This rate even increases for patients who are admitted to the intensive care unit, with an incidence of >50%. AKI is characterized by a rapid increase in serum creatinine, decrease in urine output, or both. The associated symptoms include feeling sick or being sick, diarrhoea, dehydration, decreased urine output (although occasionally the urine output remains normal), fluid retention causing swelling in the legs or ankles, shortness of breath, fatigue and nausea. However, sometimes acute kidney injury causes no signs or symptoms and is detected by lab tests. Therefore, the identification of cytokines for the early detection and diagnosis of AKI is highly desirable, as their application might enable the prevention of the progression from AKI to chronic kidney disease (CKD). In this study, we analysed the secretome of the urine of an AKI patient cohort by employing a kidney-biomarker cytokine assay. Based on these results, we suggest ADIPOQ, EGF and SERPIN3A as potential cytokines that might be able to detect AKI as early as 24 h post-surgery. For the later stages, as common cytokines for the detection of AKI in both male and female patients, we suggest VEGF, SERPIN3A, TNFSF12, ANPEP, CXCL1, REN, CLU and PLAU. These cytokines in combination might present a robust strategy for identifying the development of AKI as early as 24 h or 72 h post-surgery. Furthermore, we evaluated the effect of patient and healthy urine on human podocyte cells. We conclude that cytokines abundant in the urine of AKI patients trigger processes that are needed to repair the damaged nephron and activate TP53 and SIRT1 to maintain the balance between proliferation, angiogenesis, and cell cycle arrest.

Acute Kidney Injury Due to Obstetric Complications.

To evaluate the factors, causes, and outcomes of acute kidney injury (AKI) among pregnant females admitted to a tertiary care hospital. An observational study. Place and Duration of the Study: Department of Nephrology, Liaquat University Hospital, Hyderabad, from April to October 2022. Patients with AKI due to obstetric complications were enrolled and followed for three months. AKI was defined as a rise in serum creatinine of 0.3 mg/dl within 48 hours, an increase in serum creatinine of 1.5 times baseline value within the previous 7 days, or a decrease in urine output of 0.5 ml/kg/hr for 6 hours. Good antenatal care was defined as at least one visit to a healthcare provider during pregnancy. Patients with the history of diabetes or hypertension, chronic kidney disease or history of renal stones were excluded from the study. Favourable outcomes such as complete recovery were assessed at the time of discharge in terms of renal function testing. Patients who had normal renal function, adequate urine output, and became dialysis independent were labelled as completely recovered. Unfavourable outcomes were assessed in terms of progress towards either chronic kidney disease or death. Of the initially enrolled 66 patients, 6 were lost to follow-up and 60 patients were included in the final analysis. The mean age was 28.67±5.41 years. Only 2 patients had received good antenatal care (3.3%). Puerperal sepsis was the primary aaetiology of AKI in 20 patients (33.3%), antepartum haemorrhage in 14 patients (23.3%), and postpartum haemorrhage in 16 (26.7%) patients. In eight cases, there was combined haemorrhage and sepsis. Other causes of AKI were pre-eclampsia and placentae abruption. Nine of 60 patients were treated conservatively, while 51(85%) were treated with dialysis. Five patients died (8.3%), fifteen recovered (25%), and 40(66.7%) patients who needed dialysis at the time of discharge acquired chronic renal disease throughout the three-month follow-up period. An overwhelming majority of obstetric-related AKI patients had a suboptimal antenatal care history. The most frequent aetiology was puerperal sepsis, followed by haemorrhage. Majority of the patients with required hemodialysis and most of them did not recover in three months resulting in dialysis-dependent chronic kidney disease. Acute kidney injury, Obstetric acute kidney injury, Pregnancy, Obstetric complications, Antenatal care, Haemorrhage, Puerperal sepsis.

E027 An outlandish presentation of IgG4-related disease

Abstract Background/Aims IgG4-related sclerosing disease is a systemic disease characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs and tumour-like involvement of one or more exocrine glands or other extranodal sites. The major involved organs are the salivary glands, lacrimal glands, pancreas and retroperitoneal space. Cardiac masses in IgG4 disease include hematoma, tumours, vegetations, calcific lesions and other rare conditions. Cardiac tumours are rare and have a variety of benign and malignant entities. We herein report the case of a patient with antiphospholipid antibody syndrome with a mass lesion in the right atrium, histologically proven as IgG4-related disease. Methods A 52-year-old female, a known case of primary antiphospholipid antibody syndrome for 14 years, with five first trimester abortions and positive lupus anticoagulant, on anticoagulation with vitamin K antagonist, presented with: shortness of breath, bilateral lower limb swelling and exertional dyspnoea- grade 3, since one week before admission, associated with orthopnoea, without any h/o decreased urine output or facial puffiness. On examination, she had hypertension with raised JVP and loud P2 possibilities of myocarditis, hypertensive heart failure, and severe PAH with CCF were considered. Investigations showed iron deficiency anaemia, normal complements, and negative anti-dsDNA antibodies. she was treated with diuretics, PDE inhibitors and antihypertensives, 2D echo showed haziness in the right atrium, possible thrombus (1.5 × 2.3 cm), CTPA - showed enhancing mass lesion in right atrium wall, neoplastic origin was considered. Results To further evaluate the mass in the right atrium, a PET scan was performed, which showed a metabolically active isolated mass lesion in the right atrium, Cardiac MRI showed an ill-defined lobulated T1 hypointense, T2/STIR isointense lesion involving the right atrial wall, possible lymphoma/sarcoma. Planned for excision/debulking via sternotomy approach, intraoperative trans oesophageal echo showed right atrial mass of 25 cms possibility of lymphoma/sarcoma, during surgery mass could not be excised but a biopsy was taken and sent for histopathological analysis. The report was suggestive of IgG4 disease, plasma cells stain positive for IgG4 with ratio of IgG4 to IgG of 0.4. IHC results showed no evidence of malignancy. Serum IgG4 levels was 145mg/dl (<135mg/dl). Diagnosis of IgG4 disease was made and the patient was started on steroids, repeat 2D echo after 6 months showed that the mass in the right atrium had resolved and the patient was asymptomatic. Conclusion In conclusion, this was a rare case of primary antiphospholipid antibody syndrome, presenting as a cardiac mass which was difficult to distinguish from malignant lymphoma by a pathological examination alone, hence a biopsy was done to analyze the clonality of the cardiac tumour and accurate diagnosis of IgG4-RD was made. Disclosure K. Yerram: None. P. Devarasetti: None. L. Rajasekhar: None.

Impact of Continuous Renal Replacement Therapy Initiation on Urine Output and Fluid Balance: A Multicenter Study

Introduction: The effect of continuous renal replacement therapy (CRRT) on renal function is poorly understood. However, the initiation of CRRT may induce oliguria. We aimed to investigate the impact of CRRT commencement on urine output (UO). Methods: This was a retrospective cohort study in two intensive care units. We included all patients who underwent CRRT and collected data on hourly UO and fluid balance before and after CRRT commencement. We performed an interrupted time series analysis using segmented regression to assess the relationship between CRRT commencement and UO. Results: We studied 1,057 patients. Median age was 60.7 years (interquartile range [IQR], 48.3–70.6), and the median APACHE III was 95 (IQR, 76–115). Median time to CRRT was 17 h (IQR, 5–49). With start of CRRT, the absolute difference in mean hourly UO and mean hourly fluid balance was −27.0 mL/h (95% CI: −32.1 to −21.8; p value < 0.01) and – 129.3 mL/h (95% CI: −169.2 to −133.3), respectively. When controlling for pre-CRRT temporal trends and patient characteristics, there was a rapid post-initiation decrease in UO (−0.12 mL/kg/h; 95% CI: −0.17 to −0.08; p value < 0.01) and fluid balance (−78.1 mL/h; 95% CI: −87.9 to −68.3; p value < 0.01), which was sustained over the first 24 h of CRRT. Change in UO and fluid balance were only weakly correlated (r −0.29; 95% CI: −0.35 to −0.23; p value < 0.01). Conclusion: Commencement of CRRT was associated with a significant decrease in UO that could not be explained by extracorporeal fluid removal.

West Syndrome – Infantile Spasms: A Rare Paediatric Case Report

West syndrome (WS) is a rare, severe form of epilepsy with onset in infancy and early childhood. It involves clustered epileptic spasm episodes, the aberrant interictal electroencephalogram pattern known as hypsarrhythmia, and neuropsychomotor delay. In this view, we present a case of a 6-year-old female child a known case of west syndrome, global developmental delay, hypothyroidism, and post-operative laparoscopic gastrotomy performed under general anaesthesia on March 31/2022, in view of recurrent aspiration and came with the chief complaints of seizure 6-7 episodes per day, decreased urine output, constipation for two days, straining to pass urine, and three episodes of vomiting. The history included that the baby cried immediately after birth, seizure on day 5 of life, and was shifted to the Neonatal intensive care unit (NICU), admitted there for 5 days because of respiratory distress syndrome and hyperalbuminemia. During their stay in the hospital, the child has been prescribed Lamotrigine 50mg, Levocarnitine 500mg, Levetiracetam 250mg, Clobazam 5mg, Phenobarbital 60mg, Sodium Valproate 100mg, Thyronorm 50mcg. Now the patient is symptomatically better. This case report intends to sensitize physicians in this region toward this rare neurological syndrome.&#x0D; Keywords: Hypsarrhythmia, Infantile, Seizure, West syndrome.

CLINICAL PROFILE AND OUTCOME OF NEONATES WITH HYPERNATREMIC DEHYDRATION - A TERTIARY CARE HOSPITAL BASED STUDY

Objectives: Materials And Methods: Clinical prole and outcome of neonates with hypernatremic dehydration. Cross sectional study conducted in a tertiary care centre in central India, includes sick neonates aged less than 28 days admitted in hospital for a period from April 2022 to March 2023, who found to have hypernatremic dehydration on admission with serum soidum &gt;150 mEq/L. Clinical and demographic information in relation to mother and baby were recorded. Out of total 2076 neonates admitted during t Results: he study period, 25 babies were diagnosed as a hypernatremic dehydration, showing an institute prevalence of 1.2%. Median age of presentation was 9 days, with female to male ratio 1.03. 92% of the babies were exclusively breast fed.76 % were born via normal delivery. Maximum presented with not accepting feed (96%), along with fever (64%), decreased urine output (52%), convulsions (28%). Admitted babies had a mean serum sodium level of 173.9 mEq/L, with as high as 200 mEq/L. 9 babies (36%) presented with shock,19 (76%) presented with evidence of kidney injury. Statistically signicant correlation was found between percentage of weight loss to mortality and serum sodium levels to mortality. Hypernatremic dehydration is a common Conclusion: medical emergency encountered in neonatal ICU and can be caused by poor feeding. Early diagnosis and appropriate treatment are crucial for survival and better prognosis.

Dengue Shock Syndrome Unusual Appearance With Multisystem Inflammatory Syndrome in Children: A Case Report

Background: Dengue and coronavirus disease 2019 (COVID-19) have recently become endemic in various tropical countries. Multisystem inflammatory syndrome in children (MIS-C) is a clinical manifestation of COVID-19 with a life-threatening syndrome of hyperinflammation, multiorgan failure, and shock, and it closely resembles the manifestations of severe dengue. Many attempts have been made in research to differentiate the two. Here we aims to describe a case of a patient with dengue coinfection with MIS-C. Case Presentation: A 17-year-old woman came in a state of shock, with cold extremities, fever, jaundice, shortness of breath, acute abdominal pain, and hematuria, decreased urine output. Further investigations reveal increased parameters of hepato-renal organ damage, c-reactive protein, and anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG). Patient was positive for anti-dengue IgM and IgG, but negative for COVID-19 based on SARS-CoV-2 antigen and polymerase chain reaction. Conclusion: This case demonstrates the possibility of dengue coinfection and MIS-C co-occurring, causing the patient to develop a hyperinflammatory syndrome and clinical deterioration.

A CROSS SECTIONAL STUDY TO ASSESS THE CLINICAL PROFILE OF ACUTE KIDNEY INJURY DURING PREGNANCY AND PUERPERIUM IN A TERTIARY CARE HOSPITAL OF CENTRAL INDIA

Background:Acutekidneyinjury(AKI)is rare in women during pregnancy andpuerperiumhowever, it is related to increased morbidity and mortality rates. The present study was undertaken to assess the clinical profile and outcome of AKI during pregnancy and puerperium. Methods: This cross-sectional study was conducted on the total 94 pregnant and postnatal patients diagnosed with AKI during a period from July 2020 to October 2022. Results: Maximum patients (89.36%) were visiting the hospital at postnatal period of pregnancy, in the age group of 21-25 years (48.94%) and primipara (58.51%). Decreased urine output was the commonest clinical presentation (74.46%)and puerperal sepsis was the most common etiology for AKI (48.94%). Most common laboratory findings were anemia (75.53%). At presentation and on day 3 of admission, maximum cases had serumcreatinine level between 2-5 mg/dl, also, among death cases, 50% had serum creatinine levelbetween 2-5 mg/dl (50%).74.47% of patients required dialysis. Mean hospital stays were 10.23 days, mean blood transfused was 5.83 units, mean ICU stay was 4.11 days. Out of 94 patients, 81(86.17%) patients were recovered, 3(3.19%) patientshad CKD and 10(10.64%) patients were died. Most common cause of death was sepsis (40%).There was statistically significant association between dialysis required and outcome, (p&lt;0.01). Conclusion: The maternal outcome after therapy is good as most of the patients were recovered. Improvement of pregnancy care, greater access to emergency obstetrics services, and an early diagnosis and referral could decrease the pregnancy related AKI and its consequences as well as reduce the burden of morbidity and mortality related to AKI.

An Evaluation of Complications of Ultrasound Guided Percutaneous Nephrostomy in Cases of Obstructive Uropathy

Objective: To evaluate the complications of ultrasound guided percutaneous nephrostomy in cases of obstructive uropathy at tertiary care hospital. Study design: Case series Duration of study: From February 2022 to August 2022. Setting: Department of Urology, Sheikh Zaid Hospital, Rahim Yar Khan. Material and methods: Total 133 patients having age between 20-40 years either gender with obstructive uropathy due to ureteric obstruction caused by (impacted ureteric stones, PUJ obstruction, carcinoma prostate involving ureters, iatrogenic ureteric injury and bladder tumors) were included in the study and post procedure complications were evaluated. Results: Mean age was 44.83 ± 13.05 years. Regarding presenting symptoms, total 94 (71%) patients had decreased urine amount, 29 (22%) patients had flank pain while 10 (7%) patients had fever. Septicemia was found in 11 (8.33%) patients, bleeding in 4 (3%) patients followed by PCN dislodgement in 8 (6%) patients. Conclusion: Results of this study revealed that septicemia was the most common complication in cases of obstructive uropathy after PCN. More than 50% patients were between 41-60 years. Male population was commonly suffered from obstructive uropathy. Most of the patients had bilateral obstructive uropathy and decreased urine output was common presenting symptom. Keywords: PCN, obstructive uropathy, nephrostomy, bleeding, blockage

A rare reason for hospital admission with muscle weakness in the Covid-19 rra: CPT-2 deficiency

Abstract Introduction Carnitine Palmitoyl Transferase-2 (CPT-2) is a mitochondrial enzyme involved in the pathway of long chain fatty acids. CPT-2 deficiency is a rare autosomal recessive disease. Except for neonatal and severe infantile hepatocardiomuscular forms, the myopathic form diagnosed at later ages often presents with attacks of muscle weakness and recurrent rhabdomyolysis attacks. Clinical Case A 27-year-old male patient who applied to the emergency department with complaints of pain all over the body, muscle weakness, nausea, vomiting, headache and decreased urine output in the last 2 days. He was consulted because of LDH: 456 U/L (0–248 U/L), CK: 5567 U/L (0–190 U/L), AST: 382 U/L (10–37), ALT: 89.8 U/L (10–40 U/L), creatinine: 1.23 mg/dL (0–1,2 mg/dL). He was interned with the prediagnosis of acute kidney injury secondary to rhabdomyolysis. It was learned that he had been fasting for 2 days and working at an intense physical pace. There were intensive care hospitalizations due to rhabdomyolysis at the age of 16 and 24 years and Reye's syndrome at the age of 15. It was not diagnosed at that time. His mother's cousin when he was 15 had sudden cardiac death. On physical examination, he was conscious and his general condition was poor. Blood pressure: 141/100mmHg, pulse: 76/min, and fever: 37.4. There were 4/5 muscle weakness in bilateral lower extremity proximal muscles 3/5, distal muscles 4/5, upper extremity proximal and distal muscles 4/5. Pre-diagnoses of very long chain fatty acid dehydration deficiency, CPT-2 deficiency, glutaric acidemia type-2 were considered, IV hydration and riboflavin 3×100mg, coenzyme-Q 2×100mg, carnitine 2×1gr mitochondrial cocktail were started. Tandem Mass and urine amino acid levels were requested from the patient who was in the attack period. During his hospitalization, he had increases of acute phase reactants and respiratory symptoms, Covid PCR+ was detected. Liver function tests increased under favipravir treatment. In the follow-up, the values of CK, creatinine and liver function tests ​​decreased with hydration. Homozygous c.338C&amp;gt;T(p.Ser113Leu) mutation was detected in the CPT-2 gene. Conclusion CPT-2 deficiency should be kept in mind as a rare cause of increased muscle weakness after fasting, intense exercise, and all infections, especially Covid and other upper respiratory tract infections. Intense hydration and mitochondrial cocktail therapy should be added to the patient until the diagnosis is clarified.

Cerebral venous thrombosis and B12 deficiency

Infants with prematurity and necrotizing enterocolitis (NEC) are at increased risk for short bowel syndrome and subsequent nutritional deficiencies. In particular, ileal resection is associated with vitamin B12 malabsorption, which interferes with normal myelination and homocysteine metabolism.1, 2 Vitamin B12 deficiency is associated with neurodevelopmental delay as well as hyperhomocysteinemia, which increases the risk for venous thrombosis.2, 3 This eight-year-old boy presented with severe headache, dehydration, and lethargy. He developed acute onset severe frontal headache followed by decreased oral intake, decreased urine output, and recurrent vomiting. The headache was dull and radiating to the back of his head. At the same time, he appeared to be sleepy and less active. These symptoms lasted for two to three days before he was brought to the primary doctor's office and then referred to the emergency department. On assessment, he was tired-looking and exhibited mild microcephaly, but his neurological examination was normal, as was an examination by an ophthalmologist. He experienced mild global developmental delay. He was born at 25 weeks gestational age and had a prolonged stay in the neonatal intensive care unit, complicated by NEC and a hemicolectomy with ileostomy and removal of ileocecal valve. He had low normal levels of B12 for several years prior to presentation and was not treated (151 pg/ml after surgery [normal 160-950]). Brain magnetic resonance imaging and magnetic resonance venography (MRV) showed filling defects in the inferior sagittal, straight, torcula, and proximal transverse sinuses consistent with cerebral venous sinus thrombosis (CVST) with no evidence of acute infarction (Figure 1). Dehydration was initially considered to be the cause. Enoxaparin sodium was started at 1 mg/kg every 12 h with the goal of anti-Xa level between 0.5 and 1.0 U/ml. The hypercoagulation evaluation was normal. The B12 level was 86 pg/ml. His hematocrit was 33.3, and his mean corpuscular volume (MCV) was 87.4. He was not treated at that time. He was discharged within a week after the repeat imaging remained stable with the goal to continue enoxaparin sodium for three months. After three months, he again developed headache and lethargy, and MRV showed a new thrombus. Enoxaparin was switched to warfarin. After a year of warfarin, the clot resolved but he still had headaches. Two B12 levels were obtained, both below 200. His anemia worsened (hematocrit 24.7) and his MCV increased to 96.9. The homocysteine level was 184 μmol/L (normal <11.4). At this point, he began B12 injections (1000 mcg daily for one week followed by monthly and then quarterly injections thereafter). His B12 levels normalized and remained normal throughout his course. The warfarin was discontinued and thrombus has not recurred. Our patient had a difficult-to-treat CVST secondary to a condition predisposing to nutritional deficiency. His chronic B12 deficiency was overlooked by his treating physicians until he presented with a profound deficiency with megaloblastic anemia. The association between B12 deficiency and CVST has been described in children with nutritional deficiency and megaloblastic anemia.4 Previous authors suggested that testing for hyperhomocysteinemia and with B12 supplementation should be considered in pediatric patients with CVST.5 The diagnosis becomes even more crucial in patients with conditions known that promote nutritional deficiencies, such as a history of NEC and ileal surgery. In such children, early recognition of vitamin B12 deficiency and timely vitamin supplementation may prevent the occurrence of CVST as well as other manifestations of B12 deficiency, such as developmental delay.6, 7 In this patient, the B12 deficiency was chronic. While it is difficult to prove that the deficiency caused the CVST, it likley played a substantial role. Hyperhomocysteinemia can damage the vascular endothelium, predisposing to thrombus formation.8, 9 Consequently, vitamin B12 deficiency is a potential risk factor in children with CVST. Fatemeh Mohammadpour Touserkani: Conceptualization; supervision; writing – original draft; writing – review and editing. Theodora Andriotis: Conceptualization; investigation; writing – original draft; writing – review and editing. Yaoping Zhang: Conceptualization; supervision; writing – original draft; writing – review and editing. Steven Pavlakis: Conceptualization; supervision; writing – original draft; writing – review and editing. We would like to thank the patient's parents for their consent for this publication. The authors declare no conflict of interest.

Subcapsular hematoma in postrenal transplant patients: A report of three cases

Subcapsular hematomas are not uncommon after renal transplantation but they rarely cause parenchymal compression or graft dysfunction. They occur following trauma during kidney retrieval or benching, and appear soon after reperfusing the graft kidney. Significant subcapsular hematoma may present with flank pain and tenderness, hypertension, increased drain output and decreased urine output. Duplex ultrasonography and computed tomography help in diagnosis. Early recognition and surgical intervention are important to restore graft function. We report successful outcome after hematoma evacuation in three patients with post-transplant subcapsular hematomas that caused renal allograft dysfunction.

Decreased urine output is associated with increased in-hospital mortality from sepsis-associated acute respiratory distress syndrome

The relationship between urine output (UO) and in-hospital mortality in patients with sepsis-associated acute respiratory distress syndrome (ARDS) has not been elucidated. The demographic and clinical characteristics of patients from the intensive care unit with sepsis-associated ARDS in the Medical Information Mart for Intensive Care-IV database were collected, and binomial logistic regression was performed to determine whether UO was an independent risk factor for in-hospital death. Using the Logistic Organ Dysfunction System (LODS) and Sequential Organ Failure Assessment (SOFA) as a reference, receiver operating characteristic (ROC) curves were drawn to analyze the efficacy of UO in predicting in-hospital mortality, and the Kaplan-Meier curve was drawn with the optimal cut-off value of the ROC curve. Decision curve analysis (DCA) was performed to assess the clinical net benefit of UO in predicting in-hospital mortality. UO was an independent risk factor for in-hospital mortality in patients with sepsis-associated ARDS. The area under the ROC (AUC) for UO in predicting in-hospital mortality was 0.712, which was comparable to LODS and SOFA. The patients were grouped by the optimal UO cut-off value (1515 mL/day) identified by the ROC curve. The results showed that the median in-hospital survival time for the low-UO group was 20.565 days, and that of the high-UO group was 84.670 days. The risk of in-hospital death of the low-UO group was 3.0792 times that of the high-UO group. DCA showed that when using UO to predict in-hospital mortality, the clinical net benefit was higher than LODS or SOFA at almost all available threshold probabilities, particularly when the threshold probability was between 0.2 and 0.4. As a result, UO showed moderate efficacy in predicting in-hospital mortality, and when used to predict the in-hospital mortality of patients with sepsis-related ARDS, its clinical net benefit was higher than that of LODS or SOFA.