Increase In Baseline Creatinine Research Articles

Outcomes of therapeutic plasma exchange for the treatment of patients with multiple myeloma cast nephropathy.

Current treatment guidelines of myeloma cast nephropathy (MCN) recommend the institution of plasma cell-directed therapy and consideration of therapeutic plasma exchange (TPE), with the goal of rapid reduction of the serum free light chain (sFLC). However, the role of TPE continues to remain a subject of debate. The goal of this retrospective bi-institutional study was to evaluate the clinical outcomes of TPE in combination with systemic therapy. Eighty patients were included in this analysis, of whom 72.5% had ≥50% drop in their initial involved sFLC. At 3months from TPE initiation, the overall hematologic response rate (ORR) was 67.5% with a very good partial response or better (≥VGPR) rate of 40%. At 6months, ORR was 57.5%, with ≥VGPR rate of 49%. The renal response rate at 3 and 6months was 47.5% and 43.75%, respectively; the overall renal response rate was 48.75%. On multivariable analysis, every one unit increase in baseline creatinine (odds ratio [OR] 0.76, p=0.006), and achievement of ≥VGPR (OR 21.7 p<0.0001) were significantly associated with renal response. Also, a ≥50% drop in sFLC was favorably associated with renal response (OR 3.39, p=0.09). With a median follow-up of 36.4months, the median overall survival (OS) was 11months. On multivariable analysis, achievement of renal response (hazard ratio [HR]0.3, p<0.0001) and newly diagnosed disease (NDMM; HR 0.43, p=0.0055) were associated with improved OS. Among NDMM patients, those treated with daratumumab-based regimens had a trend for better OS (p=0.15), compared to other regimens, but the difference was not significant. At the end of follow-up, an estimated 40.4% of patients who were on dialysis were able to become dialysis independent. In conclusion, our study highlights the poor survival of patients with MCN. Achievement of early renal response is crucial for prolonged OS, with daratumumab-based therapies showing promise.

#2692 Mayo Clinic Chronicity Score: a helpful tool to establish the prognosis of patients with chronic kidney disease

Abstract Background and Aims Kidney biopsy is a useful tool to establish the diagnosis and provide information about the activity and chronicity of kidney disease. Chronic changes are generally irreversible and act as a prognostic marker. The Mayo clinic chronicity score (MCCS) standardizes and semi-quantitatively classifies the degree of chronicity as minimal, mild, moderate, or severe, based on a score assigned according to the degree of glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriosclerosis. The objective of this study is to validate and assess whether the MCCS has prognostic value in predicting the initiation of kidney replacement therapy (KRT), death, or doubling of serum creatinine in a cohort of patients with various etiologies of chronic kidney disease (CKD). Method We conducted a single-center retrospective study including 101 patients with CKD who underwent native kidney biopsies. The degree of chronicity was classified according to MCCS into 4 categories: minimal (0–1), mild (2–4), moderate (5–7) and severe (8–10). The primary endpoint was defined as KRT, death, and/or a ≥50% increase in baseline creatinine. The kidney endpoint was defined as KRT or a ≥50% increase in baseline creatinine. Results The mean age of patients was 52.1 ± 16.8 years, 68.3% were male, with a median baseline creatinine of 1.4 mg/dL (IQR: 0.92-2.1), a median eGFR of 59.6 (33.7-96.8), and median proteinuria of 2.4 g/24 h (IQR: 0.98-3.9). The median follow-up time was 4 years (range: 1.9-6.4). Biopsies yielded a mean of 15.7 ± 8.6 glomeruli. The most frequent etiologies were IgA nephropathy (17.8%), Focal Segmental Glomerulosclerosis (13.9%), membranous nephropathy (11.9%), nephroangiosclerosis (10.9%) and diabetic kidney disease (9.9%). Median chronicity score was 3 (IQR: 1-5). 27 patients (26.7%) had a minimal chronicity score, 37 (36.6%) mild, 30 (29.7%) moderate, and 7 (6.9%) severe. Those patients with severe chronic damage had significantly higher baseline creatinine (p = 0.01), lower eGFR and were older (p = 0.01). During a median follow-up time of 4 years (IQR: 2-6.3), 10 patients died, 32 (61.9%) reached the primary endpoint, and 24 (28.6%) reached the kidney endpoint. According to the KM curves, patients in the severe chronicity group were at higher risk to meet the primary endpoint (Log-Rank: 21.03 p&amp;lt;0.001), and the kidney endpoint (Log-Rank: 24.9 p&amp;lt;0.001) compared to the other groups (Fig. 1). In the multivariable Cox regression analysis (adjusted for age, creatinine, sex, proteinuria), the chronicity index was significantly associated with the combined primary endpoint (HR: 6.5, 95% CI: 1.95-21.96, p: 0.002) and the kidney endpoint (HR: 8.6, 95% CI: 2.47-29.75, p: 0.001). The area under the ROC curve for the primary composite endpoint was 0.77 (95% CI: 0.68-0.87) and for the kidney endpoint was 0.79 (95% CI: 0.69-0.89). Conclusion The MCCS is a useful tool to predict the prognosis of patients undergoing kidney biopsy, regardless of the etiology of kidney disease. The MCCS could guide therapeutic management and help select patients who benefit from immunosuppressive treatment.

The Quality of Discharge Summaries After Acute Kidney Injury.

Acute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care. The objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries. Retrospective chart review. Tertiary care academic center in Ontario, Canada. We examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017. We reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality. We used multivariable logistic regression to identify predictors of discharge summary quality. The median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29). The single-center study design limits generalizability. Most discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.

Prognostic Impact of Acute Kidney Injury on Decompensated Heart Failure

Decompensated heart failure (HF) is a complex and debilitating syndrome, which constitutes a severe emergency condition with high morbidity and mortality. Kidneys play fundamental roles in the pathophysiology of HF and, in the context of decompensations, acute kidney injury (AKI) has a bilateral cause-and-effect relationship, which can significantly worsen prognosis. However, the interaction between AKI and decompensated HF is poorly understood. This study aimed to assess the occurrence of AKI in patients hospitalized due to decompensated HF and to analyze its prognostic impact during hospitalization. This prospective single-center observational study included patients hospitalized due to decompensated HF in a tertiary-level teaching hospital, between July 2017 and January 2020. Patients who developed AKI during hospitalization were compared with those who did not develop it, until hospital discharge or death. AKI was defined as a serum creatinine increase greater than or equal to 0.3 mg/dl in 48 hours, a 1.5-fold increase in baseline creatinine in seven days or urinary volume &lt;0.5 ml/kg/h for six hours, according to the Acute Kidney Injury Network (AKIN) criteria. The endpoints analyzed were death, need for invasive mechanical ventilation (IMV), and length of hospital stay. The Wilcoxon, Mann-Whitney and unpaired student t tests were used. Ninety-nine patients were included, with a mean age of 65.4±14 years, of which 47 (47.5%) were male and 52 (52.5%) were female. Reduced ejection fraction (EF) was observed in 77.8% of patients, whilst 22.2% had a diagnosis of HF with preserved EF. Decompensation clinical classifications were dry and warm=7 (7.1%), wet and warm=72 (72.7%), wet and cold=15 (15.1%) and dry and cold=5 (5.1%). The average left ventricular ejection fraction was 38.3%±15. AKI occurred in 22 patients (22.2%). Comparison between patients who evolved with and without AKI showed higher mortality (36.4% vs 10.4%, p=0.004) and need for IMV (54.5% vs 13%, p=0.0001) in the first group. There was no significant difference regarding the length of hospitalization (22.9±19 vs 18.8±16 days, p=0.26). Our results pointed to the occurrence of AKI was frequent in patients with decompensated HF requiring hospitalization, affecting approximately one out of five patients. This complication was significantly associated with increased mortality and the need for IMV during hospitalization.

Prognostic Impact of Acute Kidney Injury on Decompensated Heart Failure

Decompensated heart failure (HF) is a complex and debilitating syndrome, which constitutes a severe emergency condition with high morbidity and mortality. Kidneys play fundamental roles in the pathophysiology of HF and, in the context of decompensations, acute kidney injury (AKI) has a bilateral cause-and-effect relationship, which can significantly worsen prognosis. However, the interaction between AKI and decompensated HF is poorly understood. This study aimed to assess the occurrence of AKI in patients hospitalized due to decompensated HF and to analyze its prognostic impact during hospitalization. This prospective single-center observational study included patients hospitalized due to decompensated HF in a tertiary-level teaching hospital, between July 2017 and January 2020. Patients who developed AKI during hospitalization were compared with those who did not develop it, until hospital discharge or death. AKI was defined as a serum creatinine increase greater than or equal to 0.3 mg/dl in 48 hours, a 1.5-fold increase in baseline creatinine in seven days or urinary volume <0.5 ml/kg/h for six hours, according to the Acute Kidney Injury Network (AKIN) criteria. The endpoints analyzed were death, need for invasive mechanical ventilation (IMV), and length of hospital stay. The Wilcoxon, Mann-Whitney and unpaired student t tests were used. Ninety-nine patients were included, with a mean age of 65.4±14 years, of which 47 (47.5%) were male and 52 (52.5%) were female. Reduced ejection fraction (EF) was observed in 77.8% of patients, whilst 22.2% had a diagnosis of HF with preserved EF. Decompensation clinical classifications were dry and warm=7 (7.1%), wet and warm=72 (72.7%), wet and cold=15 (15.1%) and dry and cold=5 (5.1%). The average left ventricular ejection fraction was 38.3%±15. AKI occurred in 22 patients (22.2%). Comparison between patients who evolved with and without AKI showed higher mortality (36.4% vs 10.4%, p=0.004) and need for IMV (54.5% vs 13%, p=0.0001) in the first group. There was no significant difference regarding the length of hospitalization (22.9±19 vs 18.8±16 days, p=0.26). Our results pointed to the occurrence of AKI was frequent in patients with decompensated HF requiring hospitalization, affecting approximately one out of five patients. This complication was significantly associated with increased mortality and the need for IMV during hospitalization.

Evaluation of prediction score of contrast-induced nephropathy in inpatients undergone to digital or CT angiography

Objectives: To assess the incidence of contrast-induced nephropathy (CIN) and determine the Mehran Score's (MS) ability to predict CIN in patients undergoing digital angiography or computed tomography angiography. Methods: 252 medical records of inpatients who underwent DA or CTA over 28 months in a quaternary hospital were reviewed. CIN was defined as serum creatinine&gt; 0.5 mg / dL or &gt; 25% increase in baseline creatinine, 48 h after administration of iodinated contrast. The ROC curve and the area under the curve (AUC) were used as a score test. Results: The majority (159; 63.1%) were male, and the average age was 60.4 years. Anemia, diabetes mellitus, and age &gt; 75 years were the most prevalent factors. The incidence of CIN was 17.8% (n = 45). There was a decrease in the mean values ​​of creatinine pre and post among patients who did not suffer CIN (1.38 ± 1.22 vs 1.19 ± 0.89; t = 3.433; p = 0.0007), while among patients who suffering CIN, the mean increase was 1.03 mg / dL (1.43 ± 1.48 vs 2.46 ± 2.35 mg / dL; t = 5.44; p = 0.117). The ROC curve analysis identified a low correlation between MS and the occurrence of CIN (AUC = 0.506). Conclusion: The incidence of CIN in hospitalized patients undergoing angiography or computed tomography angiography was high. The EM did not allow the prediction of NIC.

A retrospective review of vancomycin dosing in paediatric patients

Background: Vancomycin has antimicrobial activity against most Gram-positive pathogens. Reduced susceptibility of vancomycin to many microbes has necessitated higher target vancomycin trough levels (VTL) of 10-20mg/L. Paediatric dosing algorithms have remained unchanged despite higher VTL targets; increased doses are required. The study outcomes were to assess the impact of new dosing guidelines on VTL, time to target VTL and vancomycin-associated acute kidney injury (vAKI). Methods: A single-centre review assessed 63 vancomycin treatment episodes between Apr-2016 and Feb-2019. Demographic data, treatment duration, daily vancomycin dosing and VTL were collected. Episodes were grouped as high-dose vancomycin (HDV) (≥60mg/kg/day) and low-dose vancomycin (LDV) (&lt;60mg/kg/day). Target VTL was 10-20mg/L. AKI was defined by modified pRIFLE criteria as ≥50% increase in baseline creatinine within 7 days of treatment commencement. The project was registered with the local audit team. Results: Initial VTL were significantly higher in the HDV group (mean 10.4, SD±4.7mg/L; n=20) than LDV (mean 7.9,SD±4.0mg/L;n=43), p=0.0397. Whilst time-taken to reach target VTL was improved in the HDV group (53.5±22.3 hours vs 66.1±37.1hours), this was statistically insignificant (p=0.2675). Paired t-tests revealed no significant changes to baseline creatinine in HDV (p=0.1267) and LDV (p=0.2006). No differences in vAKI incidence between the two groups were noted (p&gt;0.05). Conclusion: Increasing vancomycin dosages improved initial VTL but was insufficient to improve the length of time to reach target VTL. Reassuringly, there was no increase in vAKI incidence with HDV. The study suggests loading doses in paediatrics may be needed to improve time to target VTL.

Association between acute kidney injury and atrial fibrillation in patients undergoing cardiac surgery

Introduction Atrial fibrillation (AF) is the most common arrhythmia following cardiac surgery, affecting up to 50% of patients in the immediate postoperative period. Postoperative AF is associated with increased morbidity, mortality and prolonged ITU stay. Recent guidelines (1) have identified age >75, history of AF, renal failure, mitral valve surgery/pathology, heart failure and chronic obstructive pulmonary disease as preoperative risk factors for developing new postoperative AF, with the intention of providing these patients with pre-emptive treatment to reduce the risk of AF in the postoperative period. We hypothesised that acute kidney injury (AKI) in the postoperative period could be an additional risk factor for the development of AF. Methods We performed an analysis on routinely collected data from patients who underwent elective cardiac surgery at our institution between 1st July 2013 and 31st December 2018. Patients who had pre-existing cardiac arrhythmias and patients who had undergone previous cardiac surgery were excluded. Multivariable logistic regression was used to explore the associations that postoperative AKI (defined as an increase in baseline creatinine by a minimum of 26.4 µmol/L or by 50% of the baseline measurement, during the first 48 hours after surgery) and preoperative risk factors had with postoperative AF. Results A total of 5588 patients were included in the study. The incidence of postoperative AF was 1384 (24.8%), postoperative AKI occurred in 686 patients (12.3%). Postoperative AKI was significantly associated with postoperative AF after adjustment for preoperative variables (adjusted odds ratio = 1.572; confidence interval = 1.295 to 1.908; p = III, previous congestive heart failure, recent MI, routine use of hypertension medication, CABG + valve surgery and aortic surgery (see Table 1). Discussion This analysis of a large, contemporary cohort of patients identifies postoperative AKI as an associated risk factor for postoperative AF, along with other preoperative variables. Early identification of this patient cohort would allow targeted preventative treatment to reduce the incidence of postoperative AF. This analysis provides impetus for clinical trials that further explore the association between AF and AKI.

Abstract WP69: Computed Tomography Perfusion Imaging in Evaluation of Patients With Acute Stroke is Not Associated With Increased Risk of Acute Kidney Injury

Introduction: Mechanical thrombectomy has become standard of care in acute ischemic stroke with proximal arterial occlusion. For patients 6-24 hours from last known well, computed tomography perfusion (CTP) is now frequently used for assessment of endovascular therapy (EVT) eligibility. CTP requires an increased contrast load compared to computed tomographic angiography (CTA). Hypothesis: In patient assessment for EVT, CTA/CTP is not associated with higher incidence of acute kidney injury (AKI) compared to CTA alone. Methods: We reviewed data from consecutive acute stroke alerts at our institution from January-July 2018, and recorded baseline serum creatinine and creatinine at 24, 48, and 72 hours post-alert. AKI was defined by an increase in serum creatinine of 0.3, or more than a 1.5 fold increase in baseline creatinine, according to the Acute Kidney Injury Network definition. We compared patients receiving CTA/CTP versus CTA alone using independent samples t-test, including variables of age, NIHSS, baseline creatinine, and creatinine at 24, 48, and 72 hours. Chi-square testing was performed to compare incidence of AKI between groups. A binary logistic regression model was performed including covariates of age, sex, location of alert (emergency room or inpatient), NIHSS, baseline creatinine and imaging group. Significance was defined as p &lt; 0.05 for all tests. Results: Analysis included 285 patients: 210 receiving CTA alone, and 75 receiving CTA/CTP. Incidence of AKI was 4.7% in the CTA alone group versus 4% in the CTA/CTP group (χ2=0.74, p=0.786). The two groups did not differ with regard to age, NIHSS, or serum creatinine at any time point. In the binary logistic regression model, addition of CTP to CTA did not increase the odds ratio of developing AKI (OR 1.076 [95% CI 0.276-4.193]; p=0.916). Conclusions: In acute stroke assessment for EVT eligibility, the addition of CTP to CTA did not increase rates of AKI. While this retrospective analysis includes the possibility of selection bias, the two groups were similar in baseline characteristics including kidney function. These results provide Level II, Class B evidence supporting the safety of CTP in patient selection for EVT and may inform future AHA/ASA guidelines for management of acute ischemic stroke.

The Incidence of Contrast-induced Nephropathy after Computed Tomography Angiography in Orthopedic Trauma Patients

Objectives: The aim of this study is to determine the incidence of contrast-induced nephropathy (CIN) after computed tomography angiography (CTA) in orthopedic trauma patients. Design: Retrospective chart review. Setting: Mount Sinai St. Luke's-Roosevelt patient data. Patients and Methods: Patients who presented to our Level I emergency department after a trauma who were diagnosed with a high energy or penetrating injury to an extremity or pelvis and who underwent CTA as a part of their initial work-up from July 2004 to June 2014. Intervention: The incidence of CIN was assessed. Main Outcome Measurements: The main outcome measure was the development of CIN after CTA. CIN was defined as an increase in baseline creatinine of 25% or greater or an increase in baseline creatinine of 0.5 mg/dL within 48–72 h of contrast exposure. Results: A total of 51 patients were included in this study. Of these patients, 27 had a repeat creatinine level available for review. The incidence of CIN was found to be 3.7% in this specific population of patients. The creatinine level of the 1 patient who developed CIN normalized by hospital day 2. None of the patients included in this study developed symptoms of or were readmitted for kidney injury. Conclusions: This review supports the use of CTA as a relatively safe diagnostic tool in orthopedic trauma patients.

Outcomes After Concomitant Procedures with Left Ventricular Assist Device Implantation: Implications by Device Type and Indication.

Guidelines for performing concomitant procedures (CPs) in patients undergoing continuous flow-left ventricular assist device (CF-LVAD) implantation are unclear. The impact of an increased surgical complexity outside the constraint of landmark clinical trials has not been reported. From May 2004 to December 2013, 614 patients (499 males, 81%) underwent CF-LVAD implant at our institutions. Median age was 57 ± 13 years and 364 (59%) were bridge to transplantation (BTT). Survival and device-related complications were analyzed and stratified based on the surgical intervention. A total of 398 patients (65%) underwent CF-LVAD implantation without CPs. The remaining patients (35%, n = 216) were grouped according to various CPs. Survival was comparable between groups and not influenced by the CP, device type, or indication for implant. Time-to-first device-related adverse event was shorter in patients with CPs. Regression analysis revealed only increased age (p = 0.03), increase in baseline creatinine (p = 0.002), cardiopulmonary bypass time (p = 0.03), and decreased body mass index (p = 0.03) were predictors of mortality, whereas only age (p = 0.006) and prior sternotomy (p = 0.02) were related to adverse device-related events. Performing CPs leads to comparable survival and device-related outcomes after implant. The decision to perform CPs should be balanced with age, preoperative renal dysfunction, and projected complexity of surgery.

Acute Kidney Injury and Long-term Risk of Cardiovascular Events After Cardiac Surgery: A Population-Based Cohort Study.

To examine the impact of postoperative acute kidney injury (AKI) on the long-term risk of myocardial infarction, heart failure, stroke, and all-cause mortality after elective cardiac surgery. The authors investigated whether time of onset of AKI altered the association between AKI and the adverse events. Population-based cohort study in 2006-2011. Two university hospitals. Adult elective cardiac surgical patients. None. AKI was defined as an increase in baseline creatinine according to the Kidney Disease Improving Global Outcomes criteria. AKI was defined within 30 days of surgery, and also analyzed as early- or late-onset AKI. The authors followed patients from postoperative day 30 until hospitalization with myocardial infarction, heart failure, stroke, or death. Adjustment for confounding factors was done using propensity scores and standardized-mortality-ratio weights. A total of 1,457 (30.7%) of 4,742 patients developed AKI within 30 days of surgery and 470 (9.9%) patients experienced a composite cardiovascular endpoint. Comparing patients with and without postoperative AKI, weighted hazard ratio (HR) and 95% confidence intervals (CI) of 5-year risk of the composite cardiovascular endpoint was 1.41 (95% CI: 1.11-1.80). For each endpoint separately the weighted HR was similarly increased. Ninety-one days to 5-year weighted HR of all-cause mortality was 1.37 (95% CI: 1.05-1.80). The effect of AKI was similar for early- and late-onset AKI. Early- and late-onset AKI within 30 days of elective cardiac surgery was associated with a similarly increased 5-year risk of myocardial infarction, heart failure, stroke, and increased all-cause mortality.

Prevalence and Prognosis of Percutaneous Coronary Intervention-associated Nephropathy in Patients With Acute Coronary Syndrome and Normal Kidney Function

Introduction and objectivesThe aim of this study was to analyze the prevalence, risk factors, and short- and long-term prognosis of patients with acute coronary syndrome and normal renal function who developed percutaneous coronary intervention-associated nephropathy. MethodsThis was an observational, retrospective, single-center study with a prospective follow-up of 470 consecutive patients hospitalized for acute coronary syndrome (not in cardiogenic shock) who underwent percutaneous coronary intervention, with no preexisting renal failure (admission creatinine ≤ 1.3mg/dL). Percutaneous coronary intervention-associated was defined as an increase in baseline creatinine ≥ 0.5 mg/dL or ≥ 25% baseline. The mean follow-up was 26.7 (14) months. ResultsOf the 470 patients, 30 (6.4%) developed percutaneous coronary intervention-associated nepfhropathy. The independent predictors for acute renal failure were admission hemoglobin level (odds ratio = 0.71) and maximum troponin I level prior to the procedure (odds ratio = 1.02). During the long-term follow-up, the patients whose renal function deteriorated had a higher incidence of total mortality (5 [16.7%] vs 27 [6.1%]; P = .027). In the Cox regression analysis, percutaneous coronary intervention-associated nepfhropathy was not an independent predictor for total mortality, but could be a predictor for cardiac mortality (hazard ratio=5.4; 95% confidence interval 1.35-21.3; P = .017). ConclusionsPercutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal preexisting renal function is not uncommon and influences long-term survival.

Prevalencia y pronóstico de la nefropatía tras intervencionismo coronario percutáneo de pacientes con síndrome coronario agudo y función renal normal

Introduction and objectivesThe aim of this study was to analyze the prevalence, risk factors, and short- and long-term prognosis of patients with acute coronary syndrome and normal renal function who developed percutaneous coronary intervention-associated nephropathy. MethodsThis was an observational, retrospective, single-center study with a prospective follow-up of 470 consecutive patients hospitalized for acute coronary syndrome (not in cardiogenic shock) who underwent percutaneous coronary intervention, with no preexisting renal failure (admission creatinine ≤ 1.3mg/dL). Percutaneous coronary intervention-associated nephropathy was defined as an increase in baseline creatinine ≥ 0.5mg/dL or ≥ 25% baseline. The mean follow-up was 26.7 (14) months. ResultsOf the 470 patients, 30 (6.4%) developed percutaneous coronary intervention-associated nepfhropathy. The independent predictors for acute renal failure were admission hemoglobin level (odds ratio=0.71) and maximum troponin I level prior to the procedure (odds ratio=1.02). During the long-term follow-up, the patients whose renal function deteriorated had a higher incidence of total mortality (5 [16.7%] vs 27 [6.1%]; P=.027). In the Cox regression analysis, percutaneous coronary intervention-associated nepfhropathy was not an independent predictor for total mortality, but could be a predictor for cardiac mortality (hazard ratio=5.4; 95% confidence interval 1.35-21.3; P=.017). ConclusionsPercutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal preexisting renal function is not uncommon and influences long-term survival.Full English text available from:www.revespcardiol.org/en

Coexisting intrarenal arteriovenous and caliceovenous fistulae after percutaneous nephrolithotomy: Case report and literature review

A 58-year-old man was re-admitted to the Urology service with delayed gross hematuria and unstable he-modynamics, following a percutaneous nephrolithotomy (PCNL) procedure performed for an obstructive solitary left lower calyceal stone. A selective left renal angiogram demonstrated an interpolar arteriovenous fistula (AVF), which was treated with successful coil embolization of a sub-segmental feeding branch. Sub-sequent nephrostogram confirmed a coexisting caliceovenous fistula, which was observed and healed spon-taneously. Iatrogenic coexisting intrarenal AVF and caliceovenous fistulae have never been reported and should be considered as a possible cause of delayed severe hematuria with unstable hemodynamics, and/or increase in baseline creatinine after PCNL.

Angiotensin converting enzyme inhibitor use soon after renal transplantation: a randomized, double-blinded placebo-controlled safety study

Activation of the renin-angiotensin system (RAS) followed by increased inflammatory cytokines may be important in the pathogenesis of chronic allograft dysfunction. As many renal transplant recipients show chronic changes on biopsy within the first year, early RAS blockade with angiotensin converting enzyme inhibitor (ACEI) could be beneficial. However, it remains unclear that early ACEI use is safe. We conducted a prospective, randomized, placebo-controlled trial to assess the safety of enalapril 5 mg during the early post-transplant period. Subjects took the study medication for six months. Primary endpoints were serum potassium (K) >5.9 mEq/L and 30% increase in baseline creatinine. A total of 53 subjects were randomized, and of them, 27 received the study drug. Twenty-nine subjects, 14 ACEI and 15 controls, completed the six-month protocol without reaching an endpoint. Patients on ACEI had higher K and higher BUN at six months. Serum creatinine, hematocrit, and urinary protein were not different. There was no difference in urinary TGF-β1. Twenty-four subjects reached study endpoints. When the common clinical endpoints of elevated creatinine and hyperkalemia were combined, ACEI group had significantly increased endpoints vs. control (10/13, 77% vs. 5/11, 45%, p < 0.05). We conclude that ACEI use in the early post-transplant period can be safe but patients must be carefully selected and monitored for elevations in serum creatinine and potassium. Whether early ACEI is beneficial in preserving allograft function requires further study.

Effects of a predominantly hydroxyethyl starch (HES)-based and a predominantly non HES-based fluid therapy on renal function in surgical ICU patients

To compare the effects of predominantly hydroxyethyl starch (HES 6% 130/0.4)-based with predominantly gelatin 4%-based fluid therapy on renal function in surgical intensive care unit (ICU) patients. Before-after, retrospective, study of surgical ICU patients. All patients admitted from January to June 2005 formed the HES group, with HES 130/0.4 as the standard colloid of choice. All patients admitted from January to June 2006 formed the GEL group, with gelatin 4% as the primary colloid. Acute renal failure (ARF) was defined as new need for renal replacement therapy (RRT) or at least a two-fold increase in baseline creatinine. There were 1383 patients in the HES group and 1528 in the GEL group; 118 and 87, in each group respectively, had severe sepsis. The incidence of ARF and ICU and hospital mortality rates were similar in the two groups. In a post-hoc multivariable analysis, cumulative doses >33 ml/kg of either HES (OR = 1.85, 95% CI: 1.01-3.41, p < 0.001) or gelatin (OR = 1.99, 95% CI: 1.05-3.79, p = 0.035) were associated with a higher risk of ARF. The incidence of ARF was similar in patients who received predominantly HES (6% 130/.04) fluid therapy and in those who received predominantly gelatin 4%. Moderate cumulative doses of modern HES or gelatin solutions may be associated with a higher risk of ARF.

Renal dysfunction during and after high-dose methotrexate

To evaluate renal dysfunction in adult patients encountered during and immediately after repeated administrations of high-dose methotrexate (HDMTX) for treatment of primary central nervous system lymphoma (PCNSL). In this single-center, retrospective, open label trial, 23 consecutive adult patients aged between 19 and 94 years diagnosed with PCNSL were given >or=4 consecutive cycles of HDMTX (8 gm/m(2)/dose) every 14 days as per institution protocol. Serum creatinine and serum methotrexate levels were measured at 24, 48 and 72 h after beginning of HDMTX infusion. Forty-eight percent of all patients (30% of all HDMTX cycles) experienced a >or=200% increase in baseline creatinine during treatment. Nine percent of patients met requirements for administration of carboxypeptidase-G(2) (glucarpidase) under compassionate use from National Cancer Institute. Thirty percent of patients at the conclusion of HDMTX therapy demonstrated a NCI Common Toxicity Criteria (CTC) grade 2 or higher increase in post-treatment serum creatinine compared to pre-treatment serum creatinine amongst whom ten patients (43%) had levels outside of the normal range. Renal dysfunction of CTC grade 2, 3 or 4 is common during treatment with HDMTX in the treatment of PCNSL, occurring in 40% of all cycles. Renal dysfunction persists at least 4 months following the conclusion of therapy in nearly 30% of patients. Male patients age greater than 50 years are at greatest risk of renal dysfunction.

Incidence, Predictors, and Outcomes of Post-Percutaneous Coronary Intervention Nephropathy in Patients With Diabetes Mellitus and Normal Baseline Serum Creatinine Levels

Diabetes mellitus is an independent predictor of nephropathy after percutaneous coronary intervention (PCI). The outcomes of patients with diabetes with normal baseline serum creatinine who undergo PCI remain underevaluated. The aim of the present study was to assess the incidence, outcomes, and correlates of post-PCI nephropathy in this subset. The study cohort consisted of 570 patients with diabetes with normal serum creatinine (< or =1.3 mg/dl) who underwent PCI from August 2004 to December 2006. Patients aged >75 years and those presenting with either acute myocardial infarctions or cardiogenic shock were excluded. Post-PCI nephropathy was defined as a > or =25% increase in baseline creatinine. The study end points were post-PCI nephropathy and major adverse cardiac events at 6 months. Logistic regression was performed to identify independent predictors. Post-PCI nephropathy occurred in 70 patients (incidence 12.3%). These patients were more likely to be women (55.7% vs 35.5%, p = 0.001) and to have histories of congestive heart failure (24.2% vs 14.7%, p = 0.048). Entry-site complications (hematoma, pseudoaneurysm) and the need for blood transfusion (16.7% vs 1.7%, p <0.001) were more common in this group. In-hospital mortality (8.6% vs 0.2%, p <0.001) and length of stay (4.51 +/- 5.2 vs 2.23 +/- 2.9 days, p <0.001) were significantly higher in the group with post-PCI nephropathy. No study patient required dialysis. At 6 months, major adverse cardiac events were markedly higher in patients with post-PCI nephropathy (21.4% vs 6.0%, p <0.001), driven by death and revascularization. Independent predictors of post-PCI nephropathy were lower body mass index and blood transfusion. Post-PCI nephropathy independently predicted major adverse cardiac events (hazard ratio 4.3, 95% confidence interval 2.1 to 8.6, p <0.001). In conclusion, post-PCI nephropathy occurred in 12.3% of patients with diabetes with normal baseline serum creatinine and carried a significant detrimental impact on prognosis. The requirement for blood transfusions was the strongest correlate identified.

Value of a Complete or Partial Remission in Severe Lupus Nephritis

The value of a complete remission in severe lupus nephritis is well known but little is known about the impact of a partial remission in this patient population. The purpose of this study was to evaluate the long-term prognosis of achieving a complete or partial remission in a well-defined group of patients with severe lupus nephritis. In this study, 86 patients with diffuse lupus glomerulonephritis were reviewed for assessment of the value of a partial remission (50% reduction in baseline proteinuria to < or =1.5 g/d and < or =25% increase in baseline creatinine) and complete remission (proteinuria < or =0.33 g/d and serum creatinine < or =1.4 mg/dl) on outcomes compared with patients who did not attain a remission. These well-characterized patients were entered into a prospective therapeutic trial conducted by the Collaborative Study Group and were followed for more than 10 yr. All biopsies showed diffuse lupus nephritis. A complete remission was attained in 37 (43%) patients, a partial remission in 21 (24%) patients, and no remission in 28 (32%) patients. Baseline clinical and serologic features were similar among the groups, but patients with a complete remission had a lower serum creatinine and chronicity index compared with patients with partial or no remission. The patient survival at 10 yr was 95% for complete remission, 76% for partial remission, and 46% for no remission. The renal survival at 10 yr was 94% for complete remission, 45% for partial remission, and 19% for no remission, and the patient survival without end-stage renal disease at 10 yr was 92% for complete remission, 43% for partial remission, and 13% for no remission. Even a partial remission in lupus nephritis is associated with a significantly better patient and renal survival compared with no remission.