Diagnosis Of Acute Renal Failure Research Articles

Metabolomics profiling for diagnosis of acute renal failure after cardiopulmonary bypass.

Acute renal failure (ARF) is one of the most serious complications of cardiopulmonary bypass (CPB) surgery. Serum creatinine level is a key compound examined to understand whether renal function is normal. However, its level may vary based on age, gender, race, muscle mass, nutrition, and drugs taken by an individual. In addition, it may not be detected without a 50% reduction in renal function and may lead to delays in treatment. New markers are needed for early diagnosis of ARF. They were determined for early diagnosis of ARF after CPB. Metabolic differences in plasma samples of individuals who developed and did not develop ARF after cardiopulmonary bypass were determined. This study was the first to perform an untargeted metabolomics analysis for early diagnosis of ARF after CPB surgery. Plasma samples were taken from 105 patients (9 ARF patients) at five time points to identify the time at which a more accurate ARF diagnosis can be made. A total of 687 samples, including quality control samples, were analyzed. Two hundred twenty-six metabolites were identified using retention index libraries. Based on the statistical evaluations, tryptophan, threonine, and methionine were found in lower concentrations in patients with ARF compared to the control group at all time points. Whereas gluconic acid, hypoxanthine, and lactic acid showed a decreasing trend over time, longitudinal analysis showed that cysteine, hippuric acid, and uric acid levels increased over time in the ARF group. These metabolites are candidate biomarkers for early diagnosis of ARF as well as biomarkers for tracking the recovery of ARF patients.

Outcomes of Thoracic Aortic Interventions in Marfan Syndrome in the State of Texas Over Eleven Years.

Marfan Syndrome is a heritable connective tissue disorder with significant aortopathy and conveys substantial cardiovascular morbidity. This study characterizes the mortality and morbidities of thoracic aortic interventions in the Marfan Syndrome population in the state of Texas from 2009-2019. A retrospective review of the Texas Inpatient Discharge Dataset from 1/1/2009-31/12/2019. Discharges from acute care hospitals with a Marfan Syndrome diagnosis by International Classification of Diseases 9/10 codes and a procedure code for thoracic aortic intervention were analyzed utilizing descriptive, univariate, and multivariable regression statistics. There were 4,641 Marfan Syndrome discharges identified, of whom 644(13.9%) underwent thoracic aortic intervention. Thoracic or thoraco-abdominal aortic dissection or rupture was noted in 223(34.6%). Thirty-three(5.1%) had a concomitant coronary artery intervention. There were 30(4.7%) in-hospital mortalities, 126(19.6%) diagnoses of acute renal failure, 52(8.1%) had mechanical ventilation >96 hours, and the median length of stay was 10[IQR : 7-16] days. After adjustment, concomitant coronary artery intervention was associated with in-hospital mortality (OR : 3.69[IQR : 1.15-11.90], p = 0.029) and acute renal failure (OR : 2.66[IQR : 1.19-5.94], p = 0.017). Aortic dissections/ruptures were associated with acute renal failure (OR : 1.73[IQR : 1.14-2.63], p = 0.010), ventilation >96 hours (OR : 2.19[IQR : 1.21-3.97], p = 0.010), and 15% longer length of stay (95% CI : 2.4-29.1%, p = 0.038). Thoracic aortic interventions are frequent amongst the hospitalized Marfan Syndrome population. Concomitant coronary intervention is associated with increased risk of death and aortic dissections/ruptures are associated with increased morbidity. The high prevalence of aortic dissections/ruptures points to a potential target for improving imaging surveillance, adherence to treatment guidelines, and preventative management of Marfan Syndrome aortopathy.

Alectinib - induced acute renal failure.

Introduction: Alectinib is a potent and selective orally active tyrosine kinase inhibitor used for anaplastic lymphoma kinase-positive non-small cell lung cancer, which has a better safety profile than other inhibitors of anaplastic lymphoma kinase. We report a case of a mixed pattern of acute interstitial nephritis and acute tubular necrosis proven by renal biopsy upon starting alectinib therapy. Case report: A 68-year-old man with diabetes, hypertension, and dyslipidaemia, diagnosed with anaplastic lymphoma kinase-positive non-small cell lung cancer stage IV, had 27 days previously started alectinib 600 mg twice daily. He presented at the emergency room due to vomiting, nausea, and more dyspnoea than usual. A high creatinine level and metabolic imbalances were detected in laboratory tests. Management and outcomes: After a diagnosis of acute renal failure, the patient was admitted to hospital. Nephrotoxic drugs were suspended, and haemodialysis was required. After dismissing other causes, a probable diagnosis of acute interstitial nephritis due to alectinib was established. Corticotherapy was initiated and renal function returned to baseline levels. Renal biopsy showed a mixed pattern of acute interstitial nephritis and acute tubular necrosis. The patient was discharged, and alectinib therapy was modified to lorlatinib. No polymorphisms were found in a pharmacogenetic test. After 10 months with lorlatinib, renal function remains stable. Discussion: The relationship between acute renal failure and alectinib initiation is considered probable in this patient. Although it is an adverse effect reported in less than 1% of cases, it would be advisable to monitor renal function in this kind of patient.

Electrochemically based targeted metabolomics for uric acid, xanthine, and hypoxanthine in plasma samples for early diagnosis of acute renal failure after cardiopulmonary bypass using rGO-GCE

Cardiopulmonary bypass (CPB) may cause a systemic inflammatory reaction in patients during cardiac surgery due to the interaction of blood with heart-lung machine circuits. This inflammation may lead to organ failure. One of the most severe complications of cardiac surgery is the development of acute renal failure (ARF). Early diagnosis of ARF using fast, accurate, and sensitive methods may prevent ARF development. Therefore, we developed and validated an electroanalytical method for simultaneous analysis of three biomarker candidates, uric acid (UA), hypoxanthine (HXA), and xanthine (XA), from plasma samples. Their quantification was performed using reduced graphene oxide modified glassy carbon electrode (rGO-GCE) synthesized through rapid one-step electropolymerization. The characterization studies of rGO-GCE with cyclic voltammetry (CV), electrochemical impedance spectroscopy (EIS), and scanning electron microscope (SEM) analyses showed a successful surface modification of GCE with rGO. The electrochemical oxidations of the biomarkers were examined using square wave voltammetry (SWV) with the rGO sensor in 0.1 M phosphate-borate (PB) buffer (pH 7). Various operational parameters, including pH and type of supporting electrolyte, instrumental parameters, electro polymerization cycles, and GO concentration, were optimized. Under optimum conditions, good linear responses were obtained for three metabolites (R2 > 0.99). The LOQ of the method was 0.12 μM for UA, 0.13 μM for XA, and 0.43 μM for HXA. The developed method was successfully applied to patient plasma samples of ARF (n = 9) and control (n = 17) collected at five-time points of CPB. The UA, HXA, and XA levels were significantly altered in ARF patients. The results showed the applicability of the developed method for early diagnosis of ARF developed after CPB.

Mcardle’s Disease Complicated by Acute Renal Failure

McArdle’s disease is a Glycogen storage disease (type V) which is caused due to the inherited deficiency of myophosphorylase enzyme required for the breakdown of muscle glycogen. It typically presents with complaints of exercise intolerance, early fatigability, and muscle aches. The disease can be complicated by rhabdomyolysis in severe cases. We present the case of a 27 years old male with McArdleʼs disease who presented with bilateral lower limbs weakness associated with muscle aches and dark colored urine which later turned into anuria. Diagnosis of acute renal failure complicating rhabdomyolysis in background of McArdle’s disease was made. Keywords: Glycogen storage disease, Glycogen phosphorylase, myopathy, rhabdomyolysis

FC023: Human Adult Renal Progenitor Cells Secrete in the Kidney Very High Levels of the Anti-Ageing Protein Klotho Sustained by the Long No-Coding RNA Hotair

Abstract BACKGROUND AND AIMS The complex system of human adult renal stem/progenitor cells (ARPCs) and their crucial role in the renewal of epithelial renal cells and regenerative processes in the adult kidneys have been recently discovered. In the human kidney, CD133+/CD24+ ARPCs are present within different segments of the nephron as a population with epithelial expansion, self-renewal and differentiation capabilities. Understanding the factors that regulate the ARPCs behaviour is fundamental to completely take advantage of their potential and to develop treatments for renal injury. Recent studies showed that long no-coding RNA (lncRNAs) are essential to establish developmental patterning and maintain the stem cell pluripotency network, further underscoring their important role in stem cell biology/technology and cellular reprogramming. lncRNAs can be dysregulated in different types of diseases and can also modulate the cellular senescence processes. For the first time, we studied their function in ARPCs showing that they express high levels of a particular lncRNA, HOTAIR, influencing cell senescence. METHOD Whole-genome lncRNA expression was performed by Agilent microarray. lncRNA expression was validated by real-time PCR. CRISPR/Cas9 system has been used to knock-down HOTAIR lncRNA. SA-β-Gal experiments were used to evaluate cellular senescence in normal ARPCs and ARPCs knock-out for HOTAIR. By ELISA, it was evaluated the expression of secreted anti-ageing protein Klotho. Fluorescence-activated cell sorting (FACS) was applied to measure CD133 and protein p15 expression in normal and transfected cells. Chromatin immunoprecipitation assay (ChIP) was used to evaluate H3K27me3 in the promoter of p15. RESULTS We studied the lncRNA profile of renal proximal tubular cells (RPTEC) and tubular ARPCs. We found 611 lncRNAs specifically expressed in ARPCs compared with RPTECs (Fold Change > 2; FDR < 0.05). Among the most significantly modulated lncRNAs, we demonstrated that the lncRNA HOX Transcript Antisense RNA (HOTAIR) is highly expressed in ARPCs (Fold change = 15; P < 0.001). To study the functions related to the ARPCs properties, knock-out cell lines for HOTAIR were created by the CRISPR/Cas9 technique. The silenced lines for HOTAIR immediately assumed a senescent phenotype confirmed by the beta-galactosidase assay and decreased proliferation (proliferation rate of ˂60%, P < 0.001). Moreover, we found that the constitutional, functional and inverse-senescence marker CD133+ was downregulated in knock-out cells (Fold change = 15; P < 0.01). We then studied the secreted levels of the anti-ageing protein α-Klotho which is essential to the maintenance of normal renal function and has potential clinical applications in the diagnosis of acute renal failure (AKI) and chronic kidney disease (CKD). We discovered that ARPCs produce α-Klotho at much higher levels compared to RPTEC, at a mean concentration of 200 pg/mL versus 33 pg/mL (Fold increase = 6.6; P < 0.001). Interestingly, following the HOTAIR knock-out, the levels of α-Klotho secreted by the ARPCs dropped sharply, with a 4-fold decrease (P < .001). In addition, we found that HOTAIR was responsible for the ARPC self-renewal through the epigenetic induction of the cell cycle inhibitor p15 through the trimethylation of histone H3K27 associated with the promoter region of p15. In ARPCs knock-out for HOTAIR p15 increased significantly (Fold increase = 3; P < 0.005) and the H3K27me3 in the promoter of p15 was less enriched (Fold decrease = 1.5; P < 0.05), leading to the increase of the cell cycle inhibitor and cell senescence. CONCLUSION These data demonstrated that HOTAIR regulates the self-renewal capacity of ARPCs and prevents them from becoming senescent in the short term. Moreover, HOTAIR influences ARPC ability to secrete high levels of α-Klotho, and those renal progenitors, through α-Klotho secretion, are able to influence its levels in surrounding tissues and to modulate, therefore, kidney ageing.

Особливості ренального кровотоку при гострому пошкодженні нирок у недоношених новонароджених дітей з гемодинамічно значущою відкритою артеріальною протокою

Hemodynamically significant patent ductus arteriosus (HSPDA) in premature infants leads to renal hypoperfusion due to the phenomenon of «stealing» of the systemic circulation, which can contribute to the development of acute kidney injury (AKI). The use of ultrasound Doppler sonography of the renal vessels can be effective in assessing renal blood flow and in the early diagnosis of acute renal failure. Purpose — to assess the prognostic significance of the state of renal blood flow in the first day of life in premature infants with HSPDA in the early diagnosis of AKI. Materials and methods. We examined 40 preterm infants (gestational age 29–36 weeks) with HSPDA. Distribution of the examined patients: the group with AKI — 23 children, the group without AKI — 17 children. The observation period was 10 days. The patients underwent echocardiography with Doppler analysis using a broadband microconvex probe with a frequency of 5–8 MHz (TOSHIBA Nemso XG) at 5–11 hours of life. Color Doppler ultrasound scanning of renal vessels was performed on the first, third and tenth days of life. The parameters of blood flow in the main renal and interlobar renal arteries were studied: peak systolic velocity (PSV) and end diastolic velocity (EDV) of blood flow, resistance index (RI). Diagnosis and stratification of AKI severity met the KDIGO neonatal modification criteria. Results. On the third to fifth day of life, AKI was diagnosed in 23 (57.5%) children, but already in the first day of life, compared with patients without AKI, a significant decrease in PSV parameters of blood flow in the main renal artery was noted (20.6±5.87 cm/sec versus 25.4±6.17 cm/sec in children without AKI, p<0.02). In addition, the main changes in the first day of life in patients with AKI were revealed at the level of the interlobar renal artery, namely: a decrease in PSV blood flow (11.10±3.329 cm/sec versus 18.48±3.014 cm/sec in children without AKI, p<0.001) and EDV of blood flow (2.83±2.063 cm/sec versus 6.16±2.447 cm/sec in children without AKI, p<0.001), increased RI (0.758±0.137 versus 0.666±0.1216 in children without AKI, p<0.02). On the third day of life at AKI, there was a disorder in the parameters of blood flow in the interlobaric renal artery, the value of which on the tenth day of life did not differ from the parameters of children without AKI. Conclusions. In premature infants with HSPDA, who were diagnosed with AKI on the third to fifth day of life, in the first day of life, there is a decrease in PSV blood flow parameters in the main renal artery, changes in blood flow in the interlobar renal artery, namely: a decrease in PSV and EDV blood flow, an increase in RI. Thus, the assessment of the state of blood flow in the interlobar renal artery on the first day of life in premature infants with HSPDA is of diagnostic value for the timely determination of the risk group for AKI. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: premature infants, patent ductus arteriosus, renal blood flow, acute kidney injury.

PERSPECTIVE URINARY BIOMARKERS ACCORDING TO PATHOGENETIC MECHANISMS OF ACUTE KIDNEY INJURY IN PRETERM-BORN CHILDREN

Technologies for nursing preterm-born babies have evolved significantly in recent years. However, we still have several unresolved issues, among which acute kidney injury remains one of the most urgent. This pathological clinical syndrome is associated with high rates of morbidity and mortality, especially in premature infants with severe perinatal pathology. Arrester diagnosis is based on the classification proposed in 2012 by the International Expert Group - Kidney Disease: Improving Global Outcomes. The main criteria for verifying the diagnosis of acute renal injury are an increase in serum creatinine levels and a decrease in urine output. The problem of diagnosis and differential diagnosis of acute renal failure in prematurely born children occupies a leading place, because it is still no consensus on the possibilities of using specific biomarkers of kidney damage, and no nomograms are taking into account the gestational age at birth, body weight and the severity of perinatal pathology.Plasma creatinine is still the most commonly used marker of impaired filtration function, but in recent years there have been numerous scientific discussions and new, highly sensitive, and highly specific markers of renal injury. In particular, it was proposed to consider functional biomarkers and markers of tubular damage as separate categories, since impaired renal function and the injury itself can coexist independently, simultaneously, or a transition of categories is observed. Plasma cystatin C, urinary and serum fractions of alpha-1-microglobulin and beta-2-microglobulin, lipocalin associated with neutrophil gelatinase, and others are promising biomarkers. Attention is focused on the importance of the epigenetic concept in the formation of kidney damage, blocking of the renin- angiotensin-aldosterone-antidiuretic hormone system, and the role of transient receptor potential channels in the modulation of basic renal functions. Metabolic urine profiles are widely studied taking into account gestational age and body weight.

Reflex anuria causing acute kidney injury following myomectomy: A case report

Reflex anuria is a rare cause of acute renal failure, which may occur following ureteric manipulation or painful stimuli to adjacent organs during pelvic surgery. This condition, relatively unfamiliar to the general gynecologist, should be considered even when no obvious cause of anatomical obstruction is found. We present a case of reflex anuria in a 28-year-old woman for two large intramural fibroids. Evaluation did not reveal any organic obstruction of the urinary tract. Bilateral ureteric stenting and other supportive measures resulted in diuresis and improvement of renal function. Stents were removed after 10 days and patient was discharged on the 15th postoperative day with normal renal parameters. Intrarenal arteriolar spasm or ureteric spasm following pelvic manipulation can cause reflex anuria and should be considered in the differential diagnosis of acute renal failure in cases following pelvic surgery.

Early renal biopsy in acute renal failure - Expect the unexpected

Present study was carried out to determine the contribution of early renal biopsy in diagnosis and management of acute renal failure (ARF) cases suspected on clinical grounds to be other than acute tubular necrosis (non ATN-ARF). Total 37 cases fulfilled the inclusion criteria. In 20 out of 37 (54.05%) cases the clinical diagnosis was in concordance with biopsy diagnosis. In 13 out of 37 (35.13%) cases the clinical diagnosis was in discordance with biopsy diagnosis which altered the management of the patient. Remaining 4 out of 37 (10.81%) cases were not diagnosed clinically and diagnosis of ARF was totally based on renal biopsy. So overall management alteration in non ATN - ARF patients was 45.94% (17 out of 37 cases). Thus, early renal biopsy contributes to specific treatment and therefore the outcome of patients with non ATN–ARF. Keywords: Acute Renal failure, Acute tubular necrosis, Amyloidosis, glomerulonephritis, Multiple myeloma, Vasculitis.

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.

Protocolo diagnóstico de la insuficiencia renal aguda en el paciente hospitalizado. Factores predisponentes y precipitantes

Diagnosis of acute renal failure (ARF) in inpatient requires fulfill clinical history, precise physical examination and correct complementary tests data interpretation. Accurate initial syndromic diagnostic approach is required, determining functional impairment, and identifying pathological mechanisms involved, and the etiology. Treatment varies according with the origin of ARF (prerenal, postrenal or parenchymatous). Prognosis depends on proper initial diagnosis and treatment.

253: Quality of administrative data in measuring hemorrhage-related morbidity

Postpartum hemorrhage (PPH) is a leading cause of severe maternal morbidity (SMM). SMM related to PPH such as disseminated intravascular coagulation (DIC), transfusion, and acute renal failure (ARF) can be readily measured with billing diagnosis and procedure codes. Given that the validity of these codes relative to chart data is unknown, the purpose of this study was to assess hemorrhage-related morbidity codes in an obstetric population. Delivery hospitalizations between 7/2014 and 7/2017 in three hospitals were analyzed. Data was obtained by querying the electronic medical record (EMR) including laboratory values and blood bank documentation. We evaluated whether billing codes (ICD-9 and ICD-10) used by the CDC to measure SMM aligned with EMR documentation for (i) blood transfusion, (ii) ARF, and (iii) DIC. The accuracy of blood transfusion diagnosis codes was assessed based on whether blood bank documentation demonstrated transfusion. The accuracy of ARF diagnosis codes was assessed based on whether laboratory values demonstrated serum creatinine ≥1.2mg/dL. The accuracy of DIC diagnosis codes was assessed based on whether laboratory values demonstrated serum fibrinogen at the following cutoffs: ≤200, ≤150, and ≤100 mg/dL. Test characteristics were calculated including sensitivity, specificity, positive predictive value (PPV), and negative predictive values with corresponding 95% confidence intervals. 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65.4% sensitive and 99.9% specific with a 91.3% PPV (Table). DIC codes were 56.3% sensitive, 99.6% specific with a PPV of 6.3% for fibrinogen ≤100mg/dL, 35.0% sensitive 99.6% specific with a PPV of 9.8% for a fibrinogen ≤150mg/dL, and 22.2% sensitive, 99.7% specific with a PPV of 15.4% for fibrinogen ≤200mg/dL. ARF codes were 33.3% sensitive with a PPV of 62.9% and specificity of 99.7%. ICD 9 and 10 codes were of poor to moderate quality in measuring diagnoses commonly used to assess PPH-related morbidity. Many PPH-related outcomes can be readily queried from the EMR. For hospitals analyzing quality and safety outcomes related to PPH, data directly ascertained from the clinical record is more valid than administrative codes.

Epidemiological, Clinical and Therapeutic Profile of Obstructive Renal Failure

Aim: To describe the epidemiological, clinical, etiologic and therapeutic aspects of patients with acute obstructive renal failure at the Medical Surgical Center of Urology (MSCU). Materials and methods: this was a descriptive retrospective study of 106 patient records treated for acute renal failure from January 2012 to December 2016. Patients came for spontaneous consultation or were referred. They had benefited from a clinical and paraclinical assessment at the end of which the diagnosis of acute renal failure was retained and then an effective management at the MSCU. The variables studies were clinical, paraclinical, therapeutic and progressive. The treatment included: hemodialysis, urinary diversion (suprapubic, urethrovesical and ureteral), trans-urethral resection of the prostate, trans-urethral resection of the bladder, nephrostomy, endoscopic incision of catheter valves, posterior urethra or laparoscopic nephroureterectomy as indicated. The emergency treatments consisted of removing the obstacle and the etiological treatment was done later. External follow-up consultation varied by etiology. Results: In 4 years we had treated 106 patients, a frequency of 26.5%. The average age was 47.83 years with extreme of 2 and 80 years old. The sex ratio was 68 men for 38 women. The mean serum creatinine level was 37.8 mg/l (335 μmol/l). The etiologies were: prostatic pathologies (n = 38), lithiasic pathologies (n = 20) and gynecological pathologies (n = 18). The treatments were: endoscopic resection of prostate (n = 24), bladder (n = 6), posterior urethral valves (n = 4), JJ probe (n = 27) and nephrostomy (n = 23). The result was good (normalization of creatinine serum) in 79 patients, the persistence of elevated serum creatinine was observed in 4 patients and 18 patients died. Conclusion: Acute obstructive renal failure is a common diagnosis in our exercise setting at MSCU where it can be managed with respect to our technical platform.

Severe Hydroureteronephrosis From a Fecal Impaction

Fecal impaction frequently occurs in elderly, demented patients, particularly those who are institutionalized. Though very rare, fecal impaction can be severe enough to cause hydroureternephrosis and should be considered in the differential diagnosis of hydronephrosis with worsening renal function. This is a case of an 83 year old woman with a history of dementia and PEG tube secondary to failure-to-thrive who presented to the hospital from an assisted living facility with altered mental status. She was found to have a urinary tract infection and acute renal failure (creatinine 1.3mg/dL, baseline 0.6mg/dL). Despite aggressive IV fluid hydration, adequate urinary output and completion of IV antibiotics, renal function did not improve and peaked with a creatinine of 1.5mg/dL. This prompted obtaining a renal ultrasound which revealed moderate to severe right hydroureteronephrosis and mild left hydronephrosis with increased echogenicity of the kidneys bilaterally. Further evaluation with CT abdomen/pelvis revealed significant impacted stool in the rectum with proximal colonic dilation with large quantity of stool in the colon (14cm) compressing the left and right ureters causing severe right and moderate left hydroureteronephrosis. The patient was manually disimpacted and received 2L Golytely via PEG tube with ample relief of stool burden. Home bowel regimen, which the patient had been on consistently, was continued. Serial abdominal xrays were obtained over the following days which showed decreased stool in the rectum with non-obstructive bowel gas pattern. Creatinine improved to her baseline 0.6mg/dL and repeat renal ultrasound demonstrated resolution of the previously identified bilateral hydronephrosis. Mental status improved to her baseline and she was safely discharged back to her assisted living facility. During hospitalization, neither constipation nor fecal impaction was considered given this patient's denial of abdominal pain and daily soft but occasionally liquid bowel movements. It was not until further investigation with imaging that an impressive stool burden was revealed as the cause of her acute renal failure. Particularly in elderly, demented and institutionalized individuals, fecal impaction should be considered in the differential diagnosis of acute renal failure and hydronephrosis.Figure: Significant impacted stool in the rectum with proximal colonic dilation with large quantity of stool in the colon.Figure: Severe right hydroureteronephrosis and moderate left hydronephrosis with a transition point in the distal course of the ureter as it is being externally compressed by a distended sigmoid colon anterior to the external iliac artery.

Comparison of the Efficacy of Serum Creatinine and Microalbuminuria in Early Diagnosis of Renal Injury in Asphyxiated Infants in Calabar, Southern Nigeria

Background: Microalbuminuria and serum creatinine are the specific markers of acute renal injury. Perinatal asphyxia is responsible for 50% of all neonatal deaths and nonoliguric acute renal injuryis one of its complications. This study was undertaken to determine the efficacy of serum creatinine and microalbuminuria for early diagnosis of renal injury in severely asphyxiated neonates in Calabar, Nigeria.Methods: This prospective cross-sectional study was performed among severely asphyxiated newborns admitted into the neonatal wards of the University of Calabar Teaching Hospital (UCTH). Standard methods for the determination of blood urea and electrolyte were executed. Micral-test strips have been applied using urine dipstick and the result of the test was negative only for albumin. The developed colors have been compared five minutes after the first test.Results: Fifty full-term newborns were enrolled and their serum electrolytes, creatinine and the creatinine clearance were essentially normal. Six neonates demonstrated positive results in the microalbominuria assessment, while the rest were negative in this regard. The test has 0% sensitivity and 100% specificity, while the positive and negative predictive values were 0% and 88%, respectively.Conclusion: Microalbuminuria is not a useful marker for early diagnosis of acute renal failure in the newborns with severe prenatal asphyxia, but further studies are recommended.

Investigation of a Rise in Obstetric Acute Renal Failure in the United States, 1999-2011.

To estimate whether the reported increase in obstetric acute renal failure in the United States was attributable to a concurrent rise in postpartum hemorrhage, a change in other risk factors, or changes in the diagnosis of acute renal failure. We conducted a retrospective cohort study to quantify temporal trends in acute renal failure among 10,969,263 hospital deliveries in the United States from 1999 to 2011 using data from the Nationwide Inpatient Sample. Dialysis and maternal death were used as markers of severe acute renal failure. Logistic regression was used to determine whether changes in risk factors explained the temporal rise in acute renal failure. Obstetric acute renal failure rose from 2.4 to 6.3 per 10,000 deliveries between 1999-2001 and 2010-2011, a 10% yearly increase (95% confidence interval [CI] 8-11%) and adjustment for risk factors only partially explained the rise (adjusted yearly increase 6%, 95% CI 5-8%). The overall severity of acute renal failure decreased, although acute renal failure with dialysis rose from 0.27 to 0.36 per 10,000 deliveries (P for trend=.01), and acute renal failure associated with maternal death increased from 0.13 to 0.23 per 10,000 deliveries (P for trend=.01). The temporal increase in acute renal failure with dialysis was abolished by adjustment for chronic kidney disease and chronic hypertension. Changes in diagnosis or ascertainment have led to substantial increases in obstetric acute renal failure, whereas increases in chronic kidney disease and chronic hypertension among pregnant women have resulted in modest but significant increases in acute renal failure with dialysis.

Acute Renal Failure in Aneurysmal Subarachnoid Hemorrhage: Nationwide Analysis of Hospitalizations in the United States

Medical complications in the setting of aneurysmal subarachnoid hemorrhage (aSAH) are common and associated with poor prognosis. We analyzed the incidence, risk factors, and short-term outcomes associated with acute renal failure (ARF) in aSAH. We queried discharge records from all patients admitted to U.S. hospitals between 2002 and 2011 toidentify primary diagnoses of aSAH and secondary diagnoses of ARF. The effect of demographics, hospital characteristics, and pre-existing comorbidity on ARF occurrence and the impact of ARF occurrence on length of stay (LOS), in-hospital costs, moderate to severe disability, and in-hospital mortality were explored in both bivariate and multivariable analyses. The incidence of ARF in patients hospitalized for aSAH (N= 260,885) was 4.0% and increased from 2.1% in 2002 to 5.7% in 2011 (P < 0.0001). The strongest predictors of ARF in multivariable analysis were fluid and electrolyte disorder (odds ratio [OR], 3.24; 95% confidence interval [CI], 3.07-3.42), coagulopathy (OR, 2.43; 95% CI, 2.25-2.63), HIV (OR, 2.42; 95% CI, 1.79-3.27), and diabetes (OR, 2.37; 95% CI, 2.08-2.69). ARF onset in aSAH increased the mean length of stay by 7.2 days and mean total costs by $28,813 (all P < 0.0001). After adjusting for confounding factors, patients with ARF had increased likelihood of moderate to severe disability (OR, 2.03; 95% CI, 1.89-2.19) and in-hospital death (OR, 2.14; 95% CI, 2.03-2.26). The burden of ARF in hospitalized patients with aSAH has increased in the past decade and is detrimental to patient outcomes and healthcare costs. The identification of patient-centered risk factors may allow for close surveillance of high-risk patients.

Acute renal failure in critically ill newborns increases the risk of death: a prospective observational study from India

Objective: To determine the incidence and risk factors of acute renal failure (ARF) in hospitalized critically ill neonates and analyze outcome of all neonates with renal failure in relation to risk factors. Material & methods: In this prospective observational study 815 infants were enrolled. Renal profile (blood urea and serum creatinine) was done after 12 h of life (or at the time of admission for outborn babies) and then every 12 hourly. Daily 24 h urine output was evaluated. Results: Incidence of renal failure in critically ill neonates was 10.67%. Out of 87 ARF neonates 52 (60%) expired. Mortality in the renal failure group was significantly higher in comparison to control group (p < 0.01). Non-oliguric renal failure was more common than oliguric renal failure, but mortality in the oliguric renal failure group was more. Neonatal sepsis was the most common cause of ARF. Eight neonates underwent peritoneal dialysis (PD) out of which there were seven neonatal deaths. Conclusion: Prognosis of neonates with ARF requiring PD was very poor. It can thus be concluded that the health care personal should do rapid diagnosis of ARF in neonates with potential risk factors and also goal at an early and effective treatment of these risk factors in neonates with ARF.

Abstract 272: Association of Renal Insufficiency With Outcomes of Percutaneous Coronary Intervention

Background: Limited data are available on the impact of chronic kidney disease (CKD) and end stage renal disease (ESRD) on outcomes after percutaneous coronary intervention (PCI). Objectives: To determine the association between baseline renal insufficiency with in-hospital outcomes after PCI. Methods: We queried the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥ 18 years undergoing PCI. Patients who underwent coronary artery bypass grafting during the same admission were excluded. Patients with concomitant diagnosis of CKD (ICD-9 codes 585.1-585.5 and 585.9) and ESRD (ICD-9 diagnosis code 585.6 or procedure code for hemodialysis [39.95, excluding patients with concurrent diagnosis of acute renal failure] or peritoneal dialysis [54.98]) were then identified. Multivariable logistic regression was used to compare outcomes between patients with CKD and patients with ESRD to those without CKD or ESRD. Results: Of 6,417,970 patients who underwent PCI, 93.3% (mean age 64.2±12.3 years, 33.7% females) had no CKD/ESRD; 4.9% (mean age 71.5±11.3 years, 35% females) had CKD; and 1.8% (mean age 64.2±11.8 years, 42.2% females) had ESRD. The prevalence of smoking was highest in patients with no CKD/ESRD; that of dyslipidemia, coronary artery disease, prior myocardial infarction, atrial fibrillation, and obesity was highest in CKD patients; diabetes mellitus, hypertension, and congestive heart failure were most prevalent in ESRD patients (p&lt;0.001 for all). Of patients undergoing PCI, 61.2% patients in no CKD/ESRD group had an acute coronary syndrome, as compared to 65.4% in CKD group, and 58.2% in ESRD group (p&lt;0.001). Compared to patients with no CKD/ESRD, those with CKD and those with ESRD had higher in-hospital mortality and higher incidence of post-procedure hemorrhage. Baseline renal insufficiency was also associated with longer average length of stay and higher average total hospital charges (Table). Conclusions: In patients undergoing PCI, baseline renal insufficiency is associated with worse outcomes. Patients with CKD and patients with ESRD had increased in-hospital mortality, higher hemorrhagic complications, longer average length of hospital stay, and higher average hospital charges than those without CKD or ESRD.