Low Urine Output Research Articles

Clinical Characteristics, Patient and Technique Survival in Elderly Patients on Peritoneal Dialysis.

The outcomes of the elderly population on peritoneal dialysis (PD) in developing countries are less known. In this study, we intended to study the clinical characteristics and patient and technique survival of elderly patients on PD. In this study, data of 148 elderly patients with end-stage renal disease who initiated PD between January 2001 and December 2015 were collected. Baseline clinical characteristics and events during the study period were recorded. Overall patient and technique survival rates of diabetic and non-diabetic elderly patients on PD were analyzed. Around 128 patients who were initiated PD during the study period were included for final analysis. The mean age of the study group was 70.3 ± 5.1 years, and 94 (80%) were males. Among these, 79 (65.8%) had diabetes. At the end of the study period, only 20 (16.6%) patients were remained on PD. Eighty-four (70%) patients died during PD and 15 (12.5%) patients were transferred to hemodialysis during the study period. The main reasons for death were cardiovascular (56.6%) and sepsis due to peritonitis (18.8%). The mean patient survival time was 38.2 ± 2.6 months. The patient survival rates were 91.2%, 45.3%, and 22.8% at 1, 3, and 5 years, respectively. Predictors of mortality were increased serum phosphorus, peritonitis episodes, urine output <400 mL, and ultrafiltration <1000 mL/day at beginning of PD. The mean technique survival time was 92.0 ± 5.1 months. Technique survival rates at 1, 3, and 5 years were 94.8%, 85.3%, and 71.7%, respectively. None of the factors was found to be predictive of technique survival. We found no significant difference between diabetic and non-diabetic patients in terms of technique and patient survival. Mortality was higher in elderly patients on PD. Factors affecting mortality in elderly patients on PD are low urine output, low ultrafiltration at beginning of PD, high serum phosphorus, and presence of peritonitis episodes. Patient and technique survival rates were comparable between diabetic and non-diabetic elderly patients on PD.

Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients.

ABSTRACTBackgroundWe determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients.Materials and MethodsThe hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups.ResultsSix hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003).ConclusionPD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival.How to cite this articleSahu MK, Bipin C, Arora Y, Singh SP, Devagouru V, Rajshekar P, et al. Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients. Indian J Crit Care Med 2019;23(8):371–375.

Losartan prevents the elevation of blood pressure in adipose-PRR deficient female mice while elevated circulating sPRR activates the renin-angiotensin system.

Deletion of the prorenin receptor (PRR) in adipose tissue elevates systolic blood pressure (SBP) and the circulating soluble form of PRR (sPRR) in male mice fed a high-fat (HF) diet. However, sex differences in the contribution of adipose-PRR and sPRR to the regulation of the renin-angiotensin system (RAS) in key organs for blood pressure control are undefined. Therefore, we assessed blood pressure and the systemic and intrarenal RAS status in adipose-PRR knockout (KO) female mice. Blockade of RAS with losartan blunted SBP elevation in HF diet-fed adipose-PRR KO mice. ANG II levels were significantly increased in the renal cortex of HF diet-fed adipose-PRR KO female mice, but not systemically. HF diet-fed adipose-PRR KO mice exhibited higher vasopressin levels, water retention, and lower urine output than wild-type (WT) mice. The results also showed that deletion of adipose-PRR increased circulating sPRR and total hepatic sPRR contents, suggesting the liver as a major source of elevated plasma sPRR in adipose-PRR KO mice. To mimic the elevation of circulating sPRR and define the direct contribution of systemic sPRR to the regulation of the RAS and vasopressin, C57BL/6 female mice fed a standard diet were infused with recombinant sPRR. sPRR infusion increased plasma renin levels, renal and hepatic angiotensinogen expression, and vasopressin. Together, these results demonstrate that the deletion of adipose-PRR induced an elevation of SBP likely mediated by an intrarenal ANG II-dependent mechanism and that sPRR participates in RAS regulation and body fluid homeostasis via its capacity to activate the RAS and increase vasopressin levels. NEW & NOTEWORTHY The elevation of systolic blood pressure appears to be primarily mediated by cortical ANG II in high-fat diet-fed adipose-prorenin receptor knockout female mice. In addition, our data support a role for soluble prorenin receptor in renin-angiotensin system activation and vasopressin regulation.

Impact of LUTS on urine volume in stone formers The impact of lower urinary tract symptomatology on urine volumes in stone formers.

We aimed to determine if there is a correlation between International Prostate Symptom scores (IPSS) and 24-hour urine collection volumes, as patients experiencing lower urinary tract symptoms (LUTS) may have impaired ability to increase fluid intake for stone prevention. We conducted a single-centre, retrospective review was performed of stone-formers presenting from 2014-2016. Inclusion criteria were completion of an IPSS questionnaire and a 24-hour urine collection. Exclusion criteria included symptomatic stone or urinary tract infection at time of IPSS completion, inadequate 24-hour collection, or incomplete IPSS questionnaire. A total of 131 patients met inclusion criteria. Stratification by IPSS severity into mild (0-7), moderate (8-19), and severe (20-35) yielded groups of n=96, 28, and 7, respectively. Linear regression modelling did not reveal a correlation between IPSS score and volume (p=0.10). When compared to those with adequate urine volumes (&gt;2 L/day, n=65), low-volume patients (&lt;1 L/day, n=10) had a significantly higher total IPSS (11.7 vs. 6.1; p=0.036). These groups showed significant differences in their responses to questions about incomplete emptying (p=0.031), intermittency (p=0.011), and stranguria (p=0.0020), with higher scores noted in the low urine output group. This study is the first to examine the correlation between IPSS and 24-hour urine volume. Though our data does not show a linear relationship between urine output and IPSS, those with lower urine volumes appear to have worse self-reported voiding symptoms when compared to those with adequate volumes (&gt;2 L/day) for stone prevention. The overall number of patients in our study is relatively small, which may account for the lack of a relationship between IPSS and 24-hour urine volumes.

Abstract 341: Urine Output and Blood Urea Nitrogen Predict Mortality After Out-of-Hospital Cardiac Arrest

Introduction: Renal dysfunction, as defined by elevated serum creatinine, is associated with decreased survival among patients resuscitated after out-of-hospital cardiac arrest (OHCA). Less is known about other measures of renal function and outcomes after OHCA. Hypothesis: BUN and urine output will predict mortality after OHCA. Methods: Retrospective single-center cohort study of 276 adult OHCA patients treated with targeted temperature management after OHCA between December 2005 and September 2016. Fluid balance and urine output were recorded for the first 6, 12 and 24 hours. Initial laboratory values were determined from electronic records. Hospital survivors and non-survivors were compared using the Wilcoxon test, and multivariate analysis was performed to determine predictors of hospital death. Results: Mean age was 63±12 years, and 204 (73%) were male; shockable rhythm occurred in 241 (87%). Inpatient death occurred in 111 (40%). Hospital survivors had lower initial BUN (13 vs. 20 mg/dL) and creatinine (1.1 vs. 1.5 mg/dL); all p &lt;.001. Hospital survivors had higher (p &lt;.001) urine output during the first 6 hours (1,091 vs. 559 ml), 12 hours (1,583 vs. 843 ml), and 24 hours (2,215 vs. 1,294 ml). Higher initial BUN (OR 1.12, 95% CI 1.07-1.18) and creatinine (OR 3.036, 95% CI 1.65-5.59) predicted hospital mortality; all p &lt;.001. Urine output during the first 24 hours was associated with hospital mortality (OR 0.57 per each 1 L, 95% CI 0.45-0.72, p &lt;.001; AUROC 0.73, optimal cut-off 1 L). Patients with 24-hour urine output &lt;1 L were at increased risk of hospital death (66.3% vs. 26.0%, unadjusted OR 5.61, 95% CI 3.27-9.63, p &lt;.001). Initial BUN (adjusted OR 1.09, 95% CI 1.01-1.16, p=.02) and urine output during the first 24 hours (adjusted OR 0.71 per each 1 L; 95% CI 0.52-0.97, p=.03) remained predictive of hospital mortality after adjustment for patient characteristics and illness severity. Conclusions: Lower 24-hour urine output and higher initial BUN were associated with higher hospital mortality among patients resuscitated from OHCA, even after adjustment for illness severity. Serum creatinine was not a significant predictor of mortality. This emphasizes the importance of low urine output as a prognostic marker and therapeutic target after OHCA.

Indications for fluid resuscitation in patients with septic shock: Post-hoc analyses of the CLASSIC trial.

Fluid resuscitation is recommended in septic shock, but the specific indications for fluids have not been established. Our aim was to investigate the indications currently used for fluid resuscitation and the effect of fluid on these indications in patients with septic shock admitted to the intensive care unit (ICU). This was a post-hoc analysis of the CLASSIC trial, where patients with septic shock were randomized to fluid restriction or standard care. We recorded indications for and effect of each fluid bolus during the first 24hours. In total, 256 fluid boluses were administered on 515 indications to the 76 patients in the standard care group. The most frequent indications were low blood pressure/increase in noradrenalin dose (199 boluses, 78%), high lactate (94, 37%), and low urinary output (68, 27%). While the analyses of all 418 fluid boluses given in all 151 patients failed to show any effect of fluid on these variables, the data did suggest that time from randomization altered the effect; fluid may have increased urinary output when given early and increased noradrenalin dose when given later. For 56% of the fluid boluses given on the most frequent indications, a second fluid bolus was given on the same indication. In ICU patients with septic shock, low blood pressure, high lactate, and low urinary output were the most frequent indications for fluid. The effects of fluids when given on these indications were less clear, but may dependent on the time course of sepsis resuscitation.

Effect of fluid bolus triggers and their combination on fluid responsiveness in optimization phase of severe sepsis and septic shock resuscitation

to evaluate the fluid responsiveness according to fluid bolus triggers and their combination in severe sepsis and septic shock. observational study. patients with severe sepsis and septic shock who already received fluid after rescue phase of resuscitation. Fluid bolus (FB) was prescribed upon perceived hypovolemic manifestations: low central venous pressure (CVP), low blood pressure, tachycardia, low urine output (UOP), hyperlactatemia. FB was performed by Ringer lactate 500 ml/30 min and responsiveness was defined by increasing in stroke volume (SV) ≥15%. 84 patients were enrolled, among them 30 responded to FB (35.7%). Demographic and hemodynamic profi before fluid bolus were similar between responders and non-responders, except CVP was lower in responders (7.3 ± 3.4 mmHg vs 9.2 ± 3.6 mmHg) (p 0.018). Fluid response in low CVP, low blood pressure, tachycardia, low UOP, hyperlactatemia were 48.6%, 47.4%, 38.5%, 37.0%, 36.8% making the odd ratio (OR) of these triggers were 2.81 (1.09-7.27), 1.60 (0.54-4.78), 1.89 (0.58-6.18), 1.15 (0.41-3.27) and 1.27 (0.46-3.53) respectively. Although CVP &lt; 8 mmHg had a higher response rate, the association was not consistent at lower cut-offs. The combination of these triggers appeared to raise fluid response but did not reach statistical signifi 26.7% (1 trigger), 31.0% (2 triggers), 35.7% (3 triggers), 55.6% (4 triggers), 100% (5 triggers). fluid responsiveness was low in optimization phase of resuscitation. No fluid bolus trigger was superior to the others in term of providing a higher responsiveness, their combination did not improve fluid responsiveness as well.

Novel renal markers for the assessment of renal integrity in patients undergoing knee arthroplasty \u2013 a pilot study

BackgroundThe feasibility of novel kidney injury biomarkers in consecutive patients having total knee arthroplasty with local infiltration analgesia was evaluated.MethodsWe enrolled 30 patients scheduled for elective unilateral total knee arthroplasty. Paired plasma and urine samples were taken before surgery and at 4 h, 24 h and 48 h after surgery to measure creatinine, cystatin C, neutrophil gelatinase associated lipocalin, kidney injury molecule-1, interleukin-18 and liver-type fatty acid-binding protein.ResultsAt baseline, 13 subjects had normal kidney function, 15 had mild and two had moderate kidney failure evaluated by calculated glomerular filtration rate. None of the subjects had all measured novel renal markers below proposed cut-off concentrations. Altogether 28/30 subjects had one (n = 3), two (n = 7) or three (n = 18) plasma neutrophil gelatinase associated lipocalin values above normal. In seven of these 28 subjects plasma creatinine, calculated glomerular filtration rate and plasma cystatin C were within the reference values. Five subjects had a low urine output, < 0.5 mL/h, indicating transient acute kidney injury, four of these had high plasma neutrophil gelatinase associated lipocalin and one high plasma cystatin C.ConclusionsIn the present study plasma neutrophil gelatinase associated lipocalin was elevated in most subjects with total knee arthroplasty and local infiltration analgesia as a marker of possible renal proximal tubular injury. Five subjects had transient low urine output, but none developed renal deterioration requiring treatment.

Impact of postoperative intravenous fluid administration on complications following elective hepato-pancreato-biliary surgery

BackgroundThe impact of perioperative intravenous fluid administration on surgical outcomes has been documented in literature, but not specifically studied in the context of hepato-pancreato-biliary (HPB) surgery. This study aimed to investigate the impact of postoperative intravenous fluid administration on intensive care unit (ICU), in this subgroup of patients. MethodsA single-center retrospective cohort of 241 HPB patients was assessed, focusing on intravenous fluid administration in ICU, during the first 24 h. Intravenous fluid variables were compared to hospital stay and postoperative complications. Data were assessed using Spearman's correlation test for bivariate correlations and logistic regression for multivariate analysis. ResultsThe median volume of intravenous fluid administered in the first 24 h postoperatively was 4380 mL, of which 2200 mL was crystalloid, 1500 mL colloid and 680 mL “other” fluid. Patients with one or more complications had a higher median total intravenous fluid input (4790 vs. 4300 mL), higher colloid volume (2000 vs. 1500 mL), lower urine output (1595 vs. 1900 mL) and greater overall fluid balance (+3040 vs.+2553 mL) than those without complications. There were correlations between total intravenous fluid volume administered (r = 0.278, P < 0.001), intravenous colloid input (r = 0.278, P < 0.001), urine output (r = -0.295, P < 0.001), positive fluid balance (r = 0.344, P < 0.001) and length of hospital stay. Logistic regression model was constructed to predict the occurrence of one or more complications; total intravenous fluid volume and overall fluid balance were both independent significant predictors (OR = 2.463, P = 0.007; OR = 1.001, P = 0.011; respectively). ConclusionsAdministration of high volumes of intravenous fluids in the first 24 hours post-HPB surgery, along with higher positive fluid balance is associated with a higher rate of complications and longer hospital stay. Moreover, lower urine output is associated with longer hospital stay. Whether these are the cause of complications or the result of them remains unclear.

Self-reported depression symptoms in haemodialysis patients: Bi-factor structures of two common measures and their association with clinical factors.

To validate the factor structure of two common self-report depression tools in a large sample of haemodialysis (HD) patients and to examine their demographic and clinical correlates, including urine output, history of depression and transplantation. Factor structures of the Beck Depression Inventory (BDI-II) and Patient Health Questionnaire (PHQ-9) were evaluated using confirmatory factor analysis (CFA). Data was utilised from the screening phase (n = 709) of a placebo-controlled feasibility randomised control trial (RCT) of sertraline in HD patients with mild to moderate Major Depressive Disorder. Alternative factor models including bi-factor models for the BDI-II and PHQ-9 were evaluated. Coefficient omega and omega-hierarchical were calculated. For both measures, bi-factor measurement models had the overall best fit to the data, with dominant general depression factors. Omega-hierarchical for the general BDI-II and PHQ-9 factors was 0.94 and 0.88 respectively. Both general factors had high reliability (coefficient omega = 0.97 and 0.94 respectively) and explained over 85% of the explained common variance within their respective models. BDI-II and PHQ-9 general depression factors were negatively associated with age and urine output and positively with a history of depression, antidepressant use within the last 3 months and a history of failed transplantation. In adjusted regression models, age, urine output and a history of depression remained significant. These data suggest that both the BDI-II and PHQ-9 are sufficiently unidimensional to warrant the use of a total score. Younger age, lower urine output and a history of depression appear consistent correlates of depression severity among HD patients.

Early Postoperative Acute Kidney Injury Among Heart Transplant Recipients

Introduction Acute kidney injury (AKI) is a frequent complication of heart transplantation (HT) with a reported incidence of 14-76%. Data on the clinical consequences of AKI among HT recipients are scarce. The aim of this study was to investigate the incidence of AKI in the early postoperative period after HT and to find out its related risk factors and its impact on clinical consequences. Materials and Methods A single center retrospective evaluation of data from 83 HT recipients (age >14 years) was performed for the postoperative incidence of AKI as defined by the Kidney Disease Improving Global Outcome (KDIGO) criteria. Moreover, risk factors for developing AKI were also analyzed. The requirement of renal replacement therapy (RRT) and mortality were evaluated as secondary clinical consequences. Results At the time of HT, the mean age of the patients was 37.9 ± 15.5 y, and 75% of the patients were male. Postoperative AKI was seen in 53 recipients (63.9%) of which 19 (35.8%) had AKI stage I, 20 (37.8%) stage II, 14 (26.4%) stage III. Thirty-nine patients (73.6%) required RRT; continuous RRT in 30 (76.9%), intermittent hemodialysis in 9 (23.1%). The recipients who had AKI were significantly older (40.7 ± 14.5 vs 32.8 ± 16.3 y; p=.018), had higher body mass index (24.0 ± 5.3 vs 21.6 ± 4.2; p=.028) and more frequent history of coronary artery disease (43.4% vs 20%; p=.035) and higher EuroSCOREs (9.9±9.0 vs 5.3±4.9; p=.01). Higher pulmonary artery pressure and lower ejection fraction at the preoperative period; lower urine output, longer duration of cardiopulmonary bypass, higher doses of adrenaline requirement intraoperatively; and higher amount of erythrocyte, platelet and albumin infusion at the postoperative period were found in the recipients developing AKI when compared who did not (p<.05). EuroSCORE, low urine output during surgery, postoperative higher amount of platelet suspension and albumin infusion were found as independent risk factors for AKI (Table 1). One-year mortality was significantly higher among HT recipients with AKI (39% vs 13%: p=.02). Conclusion Our results demonstrated that the incidence of AKI in the early postoperative period after HT was 63.9%, and approximately two thirds required RRT. Among HT recipients, higher EuroSCORE, intraoperative low urine output, and postoperative higher amount of platelet suspension and albumin infusions were associated with AKI development.

Nutritional Status in the First 2 Years of Life in Cystic Fibrosis Diagnosed by Newborn Screening.

To evaluate nutritional status and associated factors in a cystic fibrosis (CF) cohort diagnosed by newborn screening and followed up to month 24. A prospective longitudinal multicenter study assessing nutritional status according to pancreatic status, feeding modalities, prescriptions, pulmonary outcome, and biological nutritional parameters. One hundred and five infants were recruited and 99 completed the study. Nutritional care management prevented undernutrition and stunting in those with exocrine pancreatic sufficiency (EPS), but affected (13/87) 15% and (21/86) 24%, respectively, of infants with exocrine pancreatic insufficiency (EPI). The logistic regression model found a positive association between both weight and length z scores "at risk" at month 24, and initial pulmonary symptoms (odds ratio [OR] 0.06, P < 0.01 and OR 0.08, P < 0.01, respectively); these symptoms were less frequent when age at first visit was earlier than 1.2 months (33% vs 67%, P = 0.02); stunting was also associated with high-calorie density intake and Staphylococcus aureus (OR 0.05, P = 0.01 and OR 0.17, P < 0.01). Pulmonary outcome did not differ according to pancreatic status; breast-feeding for at least 3 months delayed first acquisition of Pseudomonas aeruginosa. Despite sodium and fat-soluble vitamin supplementation, half of both cohorts had low urinary sodium output and half of the EPI cohort had low vitamin D levels. Our data shed light on the fact that stunting was more frequent than undernutrition, while both parameters involved only patients with pancreatic insufficiency. Modalities of feeding were not associated with nutritional status; breast-feeding may provide some protection against acquisition of P aeruginosa.

Double trouble: managing diabetic emergencies in patients with heart failure

Double trouble: managing diabetic emergencies in patients with heart failure

Incidence of Acute Kidney Injury Following Liver Transplantation

Introduction Acute kidney injury (AKI) is a common postoperative complication following liver transplantation (LT) with an incidence ranging from 40% to 70%. The aim of this study was to analyze the incidence of AKI following LT by using KDIGO criteria and compare patients who developed AKI with those who did not. Materials and Methods We retrospectively analyzed the data of 65 consecutive patients who underwent LT in Baskent University Hospital between January 2015 to May 2017. Demographic, preoperative, and intraoperative data were collected. Results The median age of the overall population was 25±24 years and 12 (38%) of them were female. There were 34 pediatric patients younger than 18 years. This group had a median age of 64±72 months and 14 (41%) of them were female. AKI occurred in 16 (47%) pediatric patients during the first week following LT with stage 1, stage 2, and stage 3 AKI frequencies of 43.8%, 50 %, and 6.3%, respectively. When compared with those who developed AKI, the median age, body weight, MELD scores (model for end-stage liver disease), PELD scores (pediatric end-stage liver disease), graft recipient ratio were similar between the pediatric patients who did not develop AKI. Among living donors, significantly lower percentage of patients developed AKI (39% vs 61%, p=.018).There were also statistical differences between the two groups in terms of number of patients who had preoperative kidney dysfunction (80% vs 20%, p=.047) and mortality rates (31% vs 6 %, p=.047). Renal replacement therapy (RRT) was initiated in 18.8% of pediatric liver transplant recipients. The percentage of patients older than 18 years were 48% (n=31). This group had a median age of 46±17 years and 7 (23%) of them were female. AKI occurred in 15 (48%) adult patients during the first week following LT with stage 1, stage 2, and stage 3 AKI frequencies of 43%, 21%, and 21%, respectively. When compared with those who developed AKI, the median age, body weight, and MELD scores were similar between the pediatric patients who did not develop AKI. Compared with those who did not develop AKI postoperatively, those who did had significantly lower levels of creatinine (1.9±1.9 mg/dl vs 0.7±0.1 mg/dl, p=.013), given higher amounts of crystalloids (73±32 ml/kg vs 106±33 ml/kg, p=.018) and had lower urine output intraoperatively (11±9 ml/kg vs 20±9 ml/kg, p=.018). Requirement for RRT was seen in 43% of adult liver transplant recipients. There was a higher mortality rate in patients with AKI following LT (89% vs 11%, p=.003). Conclusion Our results indicates that AKI occurred in more than half of adult patients after LT and about half of pediatric liver transplant recipients according to KDIGO criteria in our cohort. Mortality of patients with AKI was significantly higher for both adult and pediatric groups.

Urinary Biochemistry in the Diagnosis of Acute Kidney Injury.

Acute kidney injury (AKI) is a common complication, impacting short- and long-term patient outcomes. Although the application of the classification systems for AKI has improved diagnosis, early clinical recognition of AKI is still challenging, as increments in serum creatinine may be late and low urine output is not always present. The role of urinary biochemistry has remained unclear, especially in critically ill patients. Differentiating between a transient and persistent acute kidney injury is of great need in clinical practice, and despite studies questioning their application in clinical practice, biochemistry indices continue to be used while we wait for a novel early injury biomarker. An ideal marker would provide more detailed information about the type, intensity, and location of the injury. In this review, we will discuss factors affecting the fractional excretion of sodium (FeNa) and fractional excretion of urea (FeU). We believe that the frequent assessment of urinary biochemistry and microscopy can be useful in evaluating the likelihood of AKI reversibility. The availability of early injury biomarkers could help guide clinical interventions.

Fungating Stage-4 Penile Squamous Cell Carcinoma

Clinical-medical Image The patient is a 46-year-old male with past medical history significant for stage-4 squamous cell carcinoma of the penis. He had been treated with multiple cycles of radiotherapy and chemotherapy with cisplatin for 3-4 weeks, with subsequent addition of 5-fluorouracil for better efficacy. Patient eventually became non-compliant with radiotherapy and chemotherapy, and decided to stop attending follow-up office visits with his oncologist. He had not been feeling any pain during the time of increasing growth of the cancer. He was admitted to the hospital for neutropenic fever with altered mental status and exhibited a sun downing effect consistent with delirium. Basic metabolic panel revealed hypercalcemia with normal sodium levels, implicating hypercalcemia of malignancy as the etiology of his confusion. His physical exam was remarkable for extension of the penile cancer deep into the pelvis with pelvic disfigurement, as well as dry oral mucosa, decreased skin turgor, sunken eyes, and low urine output. His mental status improved upon administration of IV normal saline, IV haloperidol, and reversal of sun downing through bright light therapy and music therapy. Given the poor prognosis of the patient, a discussion about hospice care took place, and the patient was agreeable to hospice care.

Routine double-J stenting for live related donor kidney transplant recipients: It doesn't serve the purpose, but does it serve a better purpose?

PurposeDespite meticulous techniques, surgical complications continue to be problematic in kidney transplant recipients. Role of routine stenting to reduce complications is controversial. In this study, we compare incidence of early urological complications, lymphoceles, urinary tract infections (UTI) and graft function; with or without double-J stenting.Materials and MethodsAll patients who underwent live related donor renal transplantation from February 2014 to February 2016 were included. Transplants prior to February 2015 were without routine stenting; subsequent transplants were with routine stenting. Patients with neurogenic bladder, previously operated bladder and delayed or low urinary output were excluded. Follow-up was for at least three months. Descriptive statistics was performed for all parameters. Chi square test and Fisher's Exact test were used for qualitative variables. For quantitative variables, Mann-Whitney test was used to test median difference and independent samples t-test for mean difference. The p-value ≤0.05 was considered significant.ResultsWe analysed 74 patients (34 stented and 40 non-stented). There was no difference in the incidence of urinary leak, anastomotic obstruction, lymphoceles or UTI (p>0.4 for all comparisons). However, mean estimated glomerular filtration rate at sixth day, 14th day, one month and two months were 76.1 vs. 61.5 (p=0.025), 72.1 vs. 56.6 (p=0.005), 79.4 vs. 63.1 (p=0.002) and 82.0 vs. 63.3 (p=0.001) in the stented versus non-stented groups.ConclusionsPlacement of ureteral stent in renal transplant does not significantly affect the incidence of early urinary complications or UTI. However, graft function is significantly better in stented recipients, at least in the short term.

Risk Factors for Short- and Long-Term Outcomes in Children With STEC-HUS/D+ HUS: A Single-Center Experience.

Background. Hemolytic uremic syndrome (HUS) is one of the common causes for acute kidney injury in childhood. Objective. The goals of our study were to identify risk factors for short-term complications and long-term outcomes of chronic kidney disease (CKD) in Shiga toxin–producing Escherichia coli (STEC)-HUS and other diarrhea positive (D+) HUS. Methods. Retrospective chart review was obtained of 58 pediatric patients treated for STEC-HUS and other D+ HUS between February 2002 and January 2011. Results. Thirty-three patients (56.9%) required dialysis. Dialysis was more likely initiated if a patient was a female (P < .012), oliguric (urine output < 0.5 mL/kg/h, P < .0005), or hemoglobin (HGB) level >10 g/dL (P = .009) at admission. Neurological complications developed only among 5 dialyzed patients (P < .042), and were more common if the patient received hemodialysis (HD) compared with peritoneal dialysis (P < .0005). CKD was noted during the subsequent follow-up clinic visits in 5 patients (8.6%). Those who developed CKD received HD (P = .002), dialysis for >10 days (P = .0004), or HGB level >10 g/dL (P = .034) at admission. Conclusions. Children with STEC-HUS/D+ HUS who may need dialysis are identified by female gender, lower urine output, higher serum creatinine level, and higher HGB at admission. They are at higher risk developing central nervous system complications especially if they needed HD. Children requiring >10 days of dialysis are at risk for development of CKD.

Chikungunya Viral Infection Requiring Intensive Care – Experience in a Tertiary Care Hospital in Bangladesh

Background: Chikungunya fever is a benign self-limiting viral illness. Although it is considered as a nonfatal disease but in elderly patients who have co-morbidities can present with atypical life threatening clinical menifestations which may cause significant morbidity and mortality.The Aim of this study is to observe atypical presentations ,various complications and outcome of chikungunya fever.Methods: This was a cross sectional observational study was carried out on 23 adult patients with chikungunya fever from 1st June to 31st July of 2017 in the Department of Critical Care Medicine of BIRDEM General Hospital, Dhaka, Bangladesh.Results: Total 23 patients were included in this study, male 83% and female 17%.From indoor 17(73.9%) patients got admitted in ICU, 3(13%) patients came directly from home and 3(13%) patients from another hospitals. Most of the patients were elderly having co-morbidities like diabetes, Hypertension, IHD and CKD. COPD and CVD were also present in a few numbers of patients. Most of the patients had fever , arthralgia and headache but respiratory distress (73.9%), altered mental status (56.5%), vomiting (21.7%), diarrhoea (17.3%) and low urine output (17.3%) are the causes of ICU admission. Major Organ involvement of the study subjects were respiratory system (52.1%), renal system (47.8%), CVS (34.7%) and nervous system (34.7%). Among 23, 16(70%) patients improved and 4(17%) patients died in ICU.Conclusion: This study highlights that though chikungunya fever is considered as a benign non-fatal disease it can produce life threatening clinical menifestations and serious complications requiring Intensive Care particularly in elderly comorbid patients and can cause high mortality.Birdem Med J 2018; 8(1): 16-20

Open Cardiac Surgery without Blood and Blood Products Transplantation.

Blood transfusions are the most common type of tissue and organ transplantation. Perioperative and postoperative transfusions may cause morbidity and mortality and transfusion should based on only hematocrit values but also on hemodynamic and clinical parameters of the patient, which cannot be ignored. A prospective study was conducted between January 2015 and October 2016 with adult patients undergoing elective open heart surgery. In these patients, a protocol was established, and patients were divided into two groups as transfusion (-) and transfusion (+). In the first 24 hours in the intensive care unit, patients' drainage, 24-hours urine output, awakening and extubation times, and lactate and bilirubin levels in arterial blood gases were recorded. Thirty-day mortality and morbidity, and hemodynamic and clinical data were compared between these two groups. We have performed a total of 138 cases; no blood and blood products were transfused in 71% (n = 98), and in 29.0% (n = 40) blood and blood products were transfused. Thirty-day mortality and morbidity (arrhythmia, infectious and pulmonary morbidity, myocardial infarction, cerebrovascular accident, renal dysfunction, sternal revision) were compared between these two groups and no statistically significant difference was observed. Patients' awakening, extubation time, cardiopulmonary bypass period, cross-clamp time, and days in intensive care unit and hospital were compared, and there was no statistically significant difference between the two groups.Conclusion: In this study, we conclude that open heart surgery without blood transfusion may be accomplished with decent peri/postoperative management. The patients who did not receive any blood or blood products were not compromised clinically or hemodynamically. No extra morbidity and mortality were seen in the non-transfusion group. Transfusion decision was based on clinical and hemodynamic parameters such as persistent hypotension or tachycardia, hyperlactatemia, low urine output, and anemic symptoms.