Nephrology Consultation Research Articles

The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis.

This systematic review aims to evaluate the effect of the COVID-19 pandemic on access to health care for patients with CKD. MEDLINE and EMBASE databases were searched up to July 2021 (PROSPERO CRD42021230831). Data relevant to access to health care before and during the COVID-19 pandemic were extracted, including outcomes related to access to general nephrology consultations, telehealth, dialysis services and kidney transplantations. Relative and absolute effects were pooled using a random effects model to account for between-study heterogeneity. Risk of bias was assessed using a modified Quality in Prognostic Studies tool. The certainty of the evidence was rated using the GRADE approach. Twenty-three studies across five WHO regions were identified. Reductions in transplantation surgeries were observed during the COVID-19 pandemic compared with the pre-COVID-19 era (risk ratio=2.15, 95%CI=1.51-3.06, I2 = 90%, p< .001). Additionally, six studies reported increased use of telehealth services compared with pre-COVID-19 times. Four studies found reduced access to in-person general nephrology services and six studies reported interruptions to dialysis services during the COVID-19 pandemic. Our findings suggest COVID-19 pandemic may have led to reductions in access to kidney transplantation, dialysis and in-person nephrology care. Meanwhile, whilst the use of telehealth has emerged as a promising alternate mode of health care delivery, its utility during the pandemic warrants further investigation. This study has highlighted major barriers to accessing care in a highly vulnerable chronic disease group.

Improvement in Kidney Function after Discontinuation of Fenofibrate in Outpatient Nephrology Consultation for Chronic Kidney Disease

Background: It has been noted in observational and interventional studies that individuals exposed to fenofibrate can exhibit a rise in serum creatinine (sCr) concentration. However, it is not known to what extent this phenomenon impacts kidney function in patients who are referred to a nephrology clinic for consultation for chronic kidney disease (CKD). Methods: We conducted a prospective observational study of patients referred to our nephrology clinic for a new evaluation of a rise in sCr or worsening CKD and who were on fenofibrate therapy. We examined the effect of discontinuation of fenofibrate on kidney function, change in sCr, and estimated glomerular filtration (eGFR) at 3, 6, and 12 months. Results: A total of 22 patients (59% women, 86% White, 59% with type 2 diabetes, and 18% with peripheral arterial disease) were captured over 2.5 years. Median sCr at the time of fenofibrate discontinuation was 1.9 (1.1–3.3) mg/dL and eGFR, 32 (17–57) mL/min; proteinuria was absent in 17 (77%). Upon discontinuation of fenofibrate, median sCr decreased to 1.5 (0.9–2.4), 1.4 (1.0–2.5), and 1.4 (1.0–2.3) mg/dL at 3, 6, and 12 months, respectively (p < 0.05); whereas median eGFR increased to 44 (27–71), 45 (23–71), and 42 (21–71) mL/min, respectively (p < 0.05). A ≥30% rise in eGFR was observed in 59% of the patients at 3 months, and it persisted in 45% and 50% of patients at 6 and 12 months, respectively. Conclusion: Discontinuation of fenofibrate in patients referred for CKD evaluation can result in sustained reduction in sCr in about half of the patients and for up to 1 year. There is a need to raise awareness among primary practitioners about this phenomenon. Recognition of fenofibrate as a cause of rise in sCr could reduce unnecessary nephrology consultation and resource utilization.

Clinical Implementation of NGAL Testing to Improve Diagnostic Assessment of AKI Episodes in a Canadian Center.

Background:The differential diagnosis of acute kidney injury (AKI) episodes is often challenging. Novel AKI biomarkers have shown their utility to improve prognostic prediction and diagnostic assessment in various research populations but their implementation in standard clinical practice is still rarely reported.Objective:To report the differential diagnostic ability and associated clinical utility of the neutrophil gelatinase-associated lipocalin (NGAL) testing in a real-life setting of a heterogeneous AKI population.Design:This is a retrospective cohort study combined with a clinical audit using questionnaires distributed to consultant nephrologists following NGAL results.Setting:The first 250 consecutive patients with a confirmed AKI where an NGAL test (plasma NGAL [pNGAL] or urine NGAL [uNGAL]) was ordered from a large academic center in Montreal, Canada from January 2021 to August 2021.Patients:Patients were classified into 3 groups based on the final AKI etiology category (functional, intrarenal, and postrenal) following definitive adjudication by 2 independent nephrologists.Methods:The ability of plasma NGAL (pNGAL), urine NGAL (uNGAL), and uNGAL-to-creatinine ratio (uNGAL/Cr) to discriminate intrarenal from functional AKI etiologies was compared to standard urine chemistry (FENa) and proteinuria. A logistic regression was used to evaluate the association between intrarenal AKI and increased biomarker levels. The overall clinical utility and appreciation of the NGAL test was evaluated using a questionnaire completed prospectively by the consultant nephrologist at the time of receiving the NGAL result. The NGAL results were prospectively available to clinicians with a median time of 2.9 (1.3-7.4) hours from the initial order.Results:A total of 214 uNGAL and 44 pNGAL were ordered from 100 functional, 139 intrarenal and 11 postrenal AKI episodes after final adjudication. The discriminative ability of FENa (AUC 0.68 [95% CI: 0.61-0.75]) was lower than uNGAL (AUC 0.80 [95% CI: 0.73-0.86]) and uNGAL/Cr (AUC 0.83 [95% CI: 0.77-0.88]) but better than pNGAL (AUC 0.66 [95% CI: 0.48-0.85]). According to consultant nephrologists, the NGAL testing has led to a change in clinical management in 42% of cases.Limitations:Data reported came from a single center and NGAL was reserved for more complex cases, which limits generalizability. No biopsy has been performed for most AKI cases as the final adjudication was based on a retrospective review of the hospitalization episode.Conclusions:Neutrophil gelatinase-associated lipocalin testing can be successfully integrated as part of the diagnostic workup for AKI in clinical practice. The integration of tubular damage biomarkers to functional biomarkers can further improve the differential diagnostic assessment. However, the impact of such biomarkers on AKI management and associated outcomes still needs further validation.

Shroom3, a Gene Associated with CKD, Modulates Epithelial Recovery after AKI.

Ischemia-induced AKI resulting in tubular damage can often progress to CKD and is a common cause of nephrology consultation. After renal tubular epithelial damage, molecular and cellular mechanisms are activated to repair and regenerate the damaged epithelium. If these mechanisms are impaired, AKI can progress to CKD. Even in patients whose kidney function returns to normal baseline are more likely to develop CKD. Genome-wide association studies have provided robust evidence that genetic variants in Shroom3, which encodes an actin-associated protein, are associated with CKD and poor outcomes in transplanted kidneys. Here, we sought to further understand the associations of Shroom3 in CKD. Kidney ischemia was induced in wild-type (WT) and Shroom3 heterozygous null mice (Shroom3Gt/+ ) and the mechanisms of cellular recovery and repair were examined. A 28-minute bilateral ischemia in Shroom3Gt/+ mice resulted in 100% mortality within 24 hours. After 22-minute ischemic injury, Shroom3Gt/+ mice had a 16% increased mortality, worsened kidney function, and significantly worse histopathology, apoptosis, proliferation, inflammation, and fibrosis after injury. The cortical tubular damage in Shroom3Gt/+ was associated with disrupted epithelial redifferentiation, disrupted Rho-kinase/myosin signaling, and disorganized apical F-actin. Analysis of MDCK cells showed the levels of Shroom3 are directly correlated to apical organization of actin and actomyosin regulators. These findings establish that Shroom3 is required for epithelial repair and redifferentiation through the organization of actomyosin regulators, and could explain why genetic variants in Shroom3 are associated with CKD and allograft rejection.

Nephrologists' Perspectives of the Potential Utilization of Home Hemodialysis in Saudi Arabia.

Home hemodialysis (HD) is an attractive renal replacement modality that has been shown to provide several benefits to the patient and health-care system. However, home HD programs have not been well-established in Saudi Arabia. We aimed to explore the perspectives of adult nephrology consultants in Saudi Arabia about the potential utilization of home HD via a survey-based cross-sectional study. The survey was distributed via email to all adult nephrology consultants practicing in Saudi Arabia and registered in the Saudi Society of Nephrology and Transplantation. Out of 236 invited consultants, 151 (64%) participated in the study. Half of the participants defined home HD as a trained patient who can independently perform his/her HD sessions at home. Eighty-one (54%) consultants have never managed a patient on home HD during their nephrology training period. More than 70% of participants believed that home HD provides advantages over in-center HD, and that its utilization in Saudi Arabia would be feasible. Although 40% of participants worked in centers with no accredited nephrology training program, most of the remaining participants believed that the local training program did not provide enough teaching about home HD to trainees. Patients' refusal, the nephrologists' lack of motivation and experience, a lack of administrative support, and the lack of infrastructure and nursing support were identified by most participants as the major barriers to the utilization of home HD in Saudi Arabia. Addressing these barriers would be the first step to facilitate initiatives aiming to establish home HD programs in this country.

Incorporación de la telemedicina al Servicio de Nefrología del Hospital Central de las fuerzas Armadas

Uno de los principales retos de los profesionales de la salud, es el desarrollo de habilidades en el uso de las Tecnologías de la Información y de la Comunicación; herramienta de apoyo en la prevención, diagnóstico y tratamiento, principalmente en patologías crónicas de alta prevalencia. La frecuencia de la Enfermedad Renal Crónica aumenta mundialmente. En Uruguay afecta al 7% de la población. Se recomienda asistencia de pacientes en etapas 1 a 3a en Atención Primaria de Salud mediante sistema de referencia/contrarreferencia con nefrólogo. Seguimiento de los estadios 3b a 5 por parte del nefrólogo. La atención nefrológica adecuada está limitada por falta de especialistas o su concentración en la capital. La Telemedicina incorpora conectividad digital a la especialidad, facilitando seguimiento a distancia y comunicación entre equipos de salud. Objetivo: mejorar la accesibilidad a la consulta nefrológica de pacientes del interior del país asistidos por médicos de Atención Primaria en Salud, usando la historia clínica electrónica y las Tecnologías de la Informática y la Comunicación. Metodología: seguimiento conjunto de pacientes del interior del país, por Nefrología y médicos de Atención Primaria en sistema de referencia-contrarreferencia, vía remota en modalidades sincrónica y asincrónica individualizándose por paciente control a seguir (presencial o remoto) y frecuencia. Se evaluó con la División Comunicaciones e Informática de la Dirección Nacional de Sanidad y la Dirección General de Atención Periférica la factibilidad del Proyecto. Conclusión: el Proyecto es factible mediante integración de recursos humanos y tecnológicos disponibles, asegurando la confidencialidad y protección de datos de pacientes según marco regulatorio legal vigente. Recibido para evaluación: Marzo 2021 Aceptado para publicación: Octubre 2021 Correspondencia: 8 de octubre 3020. C.P.11600. Montevideo, Uruguay. Tel.: (+598) 24876666 int. 1913. Contacto: mpinato@vera.com.uy

P053 Interstitial Nephritis from IBD: Complicated Conclusions.

BACKGROUND: Kidney injury in IBD is challenging. Tubulointerstitial nephritis (TIN) is linked to aminosalicylates, but also described in drug-naïve patients, suggesting that TIN may be a direct manifestation of IBD. We describe three cases of TIN in IBD to illustrate the challenges in determining the etiology of the injury. Case #1: 58-year-old male with a horseshoe kidney deformity, uncontrolled hypertension, GERD and small bowel stricturing Crohn's disease (CD), previously on mercaptopurine and allopurinol, subsequently transitioned to adalimumab, maintaining clinical and radiologic remission. Two years later, he developed acute kidney injury in setting of high fevers and sweats, with negative infectious evaluation. Medications included adalimumab, PPI, valacyclovir and torsemide. Renal biopsy revealed TIN with dense, zonal and focal granulomatous features suggestive of drug-induced hypersensitivity, chronic infection, sarcoidosis or an extra-intestinal manifestation of CD. Case #2: 45-year-old female with SLE, nephrolithiasis, GERD, hypertension and ulcerative colitis (UC), initially on mesalamine, then vedolizumab, with clinical and endoscopic remission. Her SCr increased at the time of her UC diagnosis, and worsened over 6 months while on mesalamine, vedolizumab, PPI and losartan. Renal biopsy demonstrated acute and chronic TIN with eosinophils raising concern for an allergic/drug-induced injury. Nephrology concluded that her TIN was secondary to either UC or one of her medications. Case #3: 33-year-old male with UC transitioned to vedolizumab, having failed budesonide and mesalamine. He had latent TB and received 9 months of isoniazid. While on mesalamine, vedolizumab and PPI, he developed fever, chills and night sweats, with an acute rise in SCr, prompting discontinuation of meds. Three months later, still in remission and with improved SCr, he restarted vedolizumab. A year later he developed low-grade fever with elevated SCr, prompting discontinuation. Renal biopsy revealed acute and chronic TIN with severe interstitial fibrosis, tubular atrophy and focal global glomerulosclerosis. He started prednisone and remained off other IBD therapy for 6 months, but repeat colonoscopy revealed mild colitis. He restarted mesalamine, but again developed elevated SCr 2 months later. Repeat renal biopsy revealed TIN with less interstitial fibrosis and focal global glomerulosclerosis, and nephrology suggested his interstitial nephritis was likely secondary to UC over his medications. He started azathioprine with significant improvement in SCr and clinical remission of UC. In all three cases, neither nephrology consultation nor renal biopsy helped distinguish the etiology of renal injury, defaulting to either the IBD meds or an extra-intestinal manifestation of IBD, and not accounting for the acute inflammatory symptoms in two of the cases. While literature review reveals several cases that allege kidney injury as an extra-intestinal target of IBD serious doubts remain. TIN secondary to aminosalicylates is well-documented, but there are few reports of adalimumab-induced granulomatous TIN and only one report of vedolizumab-induced TIN. Each of our patients had well-controlled IBD and multiple confounding variables that could impact kidney function or cause TIN, including hypertension and multiple potential culprit medications, illustrating the dilemma of determining the etiology of renal injury in IBD patients.

Acute kidney injury referred to the nephrologist: A single centre experience in a tertiary care hospital.

Acute kidney injury (AKI) shows an increasing incidence, accounting for a remarkable proportion of nephrology team in-hospital activity. The aim was to describe main features and outcomes of AKI observed in patients admitted to a tertiary care hospital. We conducted a retrospective analysis in all consecutive AKI patients referred for nephrology consultation (November 2018-February 2020) focusing on the factors associated with in-hospital mortality within 90 days and kidney function recovery (KFR) upon discharge. Demographic, clinical and laboratory data, as well as main features of AKI episodes, were collected from medical records of the entire hospital stay. AKI was defined according to KDIGO Clinical Practice Guideline. Among 1145 patients referred for nephrology consultation, 559 were evaluated for AKI (598 episodes). Pre-existing CKD was present in 54.7% of patients. In 69.2% of cases AKI was evaluated within 48 h from its onset. Most of the episodes (66.6%) were classified as KDIGO Stage 3. In-hospital mortality within 90 days since admission was 43.3%. Multivariate Cox regression analysis showed a higher mortality risk for advancing age (HR 1.02/unit, 95% CI 1.01-1.03) and oliguria (HR 1.91, 95% CI 1.45-2.52), while a higher eGFR (HR 0.72/unit, 95% CI 0.54-0.95) and KFR within 7 days (HR 0.62, 95% CI 0.41-0.94) were associated to a lower mortality. KFR was observed in 96.4% of survivors. In patients with partial KFR, the loss of eGFR was -29.2 ± 17.9 ml/min. KFR incidence rate was 6.79 per 100-person days (95% CI 6.72-6.87) in survivors and 2.30 (95% CI 2.25-2.35) in non-survivors. AKI-related nephrology activity accounts for most of the nephrologist workload as consultant. Referred AKI episodes are frequently severe and superimposed on CKD, carrying a relatively high mortality in a patient population developing AKI outside ICU. Early KFR appears strongly associated with a favourable impact upon in-hospital survival.

Maternal-Perinatal Variables in Patients with Severe Preeclampsia Who Develop Acute Kidney Injury.

Introduction: At present, we are witnessing an increase in preeclampsia, especially the most severe forms, which are associated with an increased risk of maternal-perinatal morbidity and mortality. As a severity criterion, acute kidney injury (AKI) has been associated with a worse prognosis, and for this reason, the maternal and perinatal variables associated with AKI in patients with severe preeclampsia (SP) were analysed in this study. Methods: An observational, retrospective, single-centre study of patients with SP treated at a tertiary hospital between January 2007 and December 2018 was conducted. The case criteria based on the criteria established by the ACOG Practice Guidelines for Gestational Hypertension and Preeclampsia. AKI is considered when serum creatinine exceeds 1.1 mg/dL in a pregnant woman with previously normal renal function. In patients with existing chronic kidney disease (CKD), it is referred to as AKI if the baseline serum creatinine increases by 1.5 fold. Pregestational, gestational and postpartum variables were analysed up to 12 weeks postpartum using univariate and multivariate logistic regression analysis. Results: During the study period, 76,828 births were attended, and 303 pregnant women were diagnosed with SP. The annual incidence of SP increased gradually throughout the study period, reaching 1.79/100 births/year in 2018. Acute kidney injury (AKI) occurred in 24.8% of the patients. The multivariate analysis revealed an increased association with a history of previous CKD, the use of assisted reproductive techniques and caesarean section. Uric acid and thrombotic microangiopathy (TMA) had a high correlation with AKI. Indications for caesarean section are associated with AKI in SP. Regarding perinatal outcomes in cases of AKI, there was a higher percentage of neonates who required foetal lung maturation with steroids and an increased need for NICU admission. No case of maternal death was recorded; however, an increase in neonatal mortality was found among patients who did not develop AKI. After 12 weeks postpartum, 72 patients were referred to the nephrology consultation for persistent hypertension, proteinuria or renal failure. Conclusions: In preeclampsia, AKI is a common complication, especially among patients with a history of CKD, those who became pregnant using assisted reproduction techniques and those who delivered via caesarean section. The perinatal impact of AKI is mainly centred on a higher rate of NICU admission and a lower mortality rate. Among biochemical and haematological markers, the uric acid level prior to renal failure has a direct and significant correlation with the risk of AKI, as does the development of TMA in patients with preeclampsia. Therefore, the monitoring of renal function in cases of preeclampsia should be strict, and referral for a nephrology consultation may be necessary in some cases.

Inferior vena cava thrombosis as a possible cause of nephrotic-range proteinuria: two case reports

BackgroundNephrotic-range proteinuria is a common reason for nephrological consultation in clinical practice. The differential diagnosis is wide, and generally focuses on different forms of glomerulonephritis, but other causes should not be overlooked, as illustrated in this article.Case presentationsWe report two female patients with nephrotic-range proteinuria. In the first case, a 46 year old Caucasian patient who suffered from extreme obesity (Body mass index (BMI) 77 kg/m2), acute kidney injury and nephrotic-range proteinuria were discovered during an emergency consultation for acute abdominal pain. The second patient (aged 52, also Caucasian) developed stage 4 chronic kidney disease and nephrotic proteinuria (protein/creatinine ratio 1821 g/mol) after accidental rupture of the inferior vena cava during a gastric bypass operation. On split-urine collection, both had a much higher degree of proteinuria during the day than during the night, compatible with orthostatic proteinuria. At further work-up, inferior vena cava thrombosis was diagnosed in both patients, whereas renal veins were patent.DiscussionAfter simple anticoagulation in the first case, and anticoagulation plus endovascular recanalization in the second, there was almost complete resolution of the orthostatic proteinuria and a strong improvement of the estimated glomerular filtration rate in both patients. These cases highlight that nephrotic-range proteinuria can be linked to inferior vena cava thrombosis, and that a split-urine collection may also be very useful in the diagnostic work-up of proteinuria in adults.

Renal Recovery after the Implementation of an Electronic Alert and Biomarker-Guided Kidney-Protection Strategy following Major Surgery.

Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by >25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p < 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery.

Looking Beyond the Allograft Survival: Long-Term, 5-Year Renal Outcome in Lung Transplant Recipients

With the increased incidence and survival of lung transplant (LTx) recipients, the risk for chronic sequelae such as chronic kidney disease (CKD) is on the rise. Data on the long-term renal outcome are scarce. We performed a retrospective chart review of 171 adults with LTx from January 1, 2014, to January 1, 2019. Primary outcomes were prevalence of CKD/end-stage renal disease, acute kidney injury (AKI) as a risk factor for future CKD, and all-cause mortality in recipients with CKD compared with the non-CKD group. Secondary outcomes were frequency of utilization of modalities for CKD (urinalysis, imaging, biopsy, nephrology consultations). Baseline median creatinine and estimated glomerular filtration rate (eGFR) were 0.8 mg/dL and 90 mL/min/1.73 m2, respectively. Of the participants, 60% (96 of 161), 67% (102 of 153), 79% (37 of 47), 86% (10 of 12) had CKD at the end of 6, 12, 36, and 60 months, respectively, and 16% were on dialysis at the end of the study period; 3% received a subsequent renal transplant, and 27% mortality was noted over a 5-year follow-up period. The odds of CKD development in patients with an AKI during index hospitalization vs no AKI was 6.22 (2.87 to 13.06, P < .0001). The odds ratio of all-cause mortality in patients with CKD compared with non-CKD was 3.36 (95% confidence interval, 1.44-8.64, P=.005). Measurement of hematuria/proteinuria, imaging, and renal biopsy were infrequently used. Given the high prevalence of AKI and CKD in this population, a multidisciplinary team approach with an early nephrology consultation will be key to improve the overall and renal outcomes in LTx recipients.

Analysis of clinical manifestations, risk factors and diagnostic procedures in children with urolithiasis

The incidence of urolithiasis in the paediatric population has grown in recent years. Aim: The aim of this study was to analyse clinical symptoms, risk factors and diagnostic procedures in children with urolithiasis. Materials and methods: We conducted a questionnaire study (supplemented with an analysis of medical records) in a group of 49 children diagnosed with urolithiasis, including 17 patients from the department of paediatrics at the time of the first metabolic evaluation, and 32 patients hospitalised in a one-day department of paediatric urology prior to extracorporeal shock wave lithotripsy. Results: Urolithiasis occurred in children in the study group at the age of 9.3 ± 4.9 years and manifested with abdominal pain (69.4%), vomiting (18.4%) and haematuria (10.2%); urolithiasis was diagnosed accidentally in 14.3% of patients. All patients developed renal stones (bilateral in 20.4%); 28.6% of patients additionally presented with ureteral stones, and 6.1% with bladder stones. Urolithiasis was accompanied by urinary tract infection in 44.9% of patients. The most common risk factors for urolithiasis included positive family history (75.5%), low fluid intake (51%), urinary tract infection (42.9%) and overweight/obesity (28.6%). Among patients admitted for extracorporeal shock wave lithotripsy, only 65.6% of children underwent nephrological consultation. Slightly more than a half of these patients underwent metabolic diagnosis, with exhausted evaluation in 7 cases and incomplete metabolic assessment in 5 cases. The chemical composition of stones was analysed in 22.4% of patients. Conclusions: Abdominal pain and vomiting are the most common clinical symptoms in children with urolithiasis. The paper presents modifiable risk factors and shows the need for improvement in metabolic evaluation of urolithiasis.

The Case | Isolated microscopic hematuria: a diagnostic journey

Following discovery of microscopic hematuria at a medical appointment for French army enrollment, a 20-year-old Caucasian man was referred for a nephrology consultation. He had no medical or surgical history, was not taking any medication, and did not smoke, but he had travelled to Mali in the previous 6 months. Notably, his mother had recently experienced microscopic hematuria. There was no other urological or nephrological family history, and no consanguinity. The patient had not experienced any episodes of macroscopic hematuria, urinary tract infection, or renal colic.

Renal pelvic dilation

Renal pelvic dilation

Improving the identification of acute kidney injury in the neonatal ICU: three centers' experiences.

To describe three different standardized approaches to improving neonatal acute kidney injury (AKI) identification and the impact on AKI identification, incidence, and nephrology consultation and referral. A retrospective cohort study in three academic NICUs. We compared AKI identification, AKI incidence, nephrology consultation, and nephrology follow-up before and after implantation of local protocols to standardize neonatal AKI identification. Neonatal AKI identification improved in all three NICUs following protocol implementation (26-85%, P < 0.0001). Each center also saw increases in nephrology consultation (15-83%, P < 0.0001) and nephrology follow-up (7-73%, P < 0.0001). AKI incidence decreased significantly (21-12%, P < 0.0001). Multiple strategies can be successfully operationalized to improve neonatal AKI identification. While different in approach, each strategy resulted in increased AKI identification and nephrology involvement. This study emphasizes the importance of local standardized approaches to AKI to improve AKI identification and nephrology involvement in the NICU.

Clinical Implementation and Initial Experience of Neutrophil Gelatinase-Associated Lipocalin Testing for the Diagnostic and Prognostic Assessment of Acute Kidney Injury Events in Hospitalized Patients

Introduction: The use of novel kidney injury biomarkers has been shown to improve diagnostic assessment and prognostic prediction in various populations with acute kidney injury (AKI), but their use in a standard clinical practice have been rarely reported. Methods: We reported the clinical implementation of neutrophil gelatinase-associated lipocalin (NGAL) measurement for routine AKI diagnostic workup of patients receiving nephrology consultation in a tertiary academic centre. Specific focus was made on the diagnostic performance to discriminate functional (“pre-renal”) from intra-renal AKI and to predict AKI progression. Results: Forty-five urine NGAL (uNGAL) and 25 plasma NGAL (pNGAL) samples in the first 50 consecutive patients were analysed. KDIGO Stage 1, 2, 3 AKI, and renal replacement therapy occurred in 10%, 40%, 50%, and 24% of cases, respectively. The uNGAL was lower in patients with transient AKI (<48 h) and no sign of urinary tract infections (37 [25–167] ng/mL) than sustained or progressive AKI (298 [74–1,308] ng/mL) (p = 0.016), while pNGAL did not discriminate transient (264 [100–373] ng/mL) from persistent AKI (415 [220–816] ng/mL) (p = 0.137). The median uNGAL level was 63 (35–1,123) ng/mL for functional/pre-renal AKI and 451 (177–1,315) ng/mL for intra-renal AKI (p = 0.043), while the pNGAL was 264 (114–468) and 415 (230–816) ng/mL (p = 0.235), respectively. Conclusion: NGAL, as part of the routine workup, is useful for diagnostic and prognostic assessment of new-onset AKI in clinical practice. Interpretation of an increased NGAL level should be clinically evaluated in its clinical context, particularly considering concomitant infection (urinary or systemic). Clinical adoption of emerging AKI biomarkers as diagnostic tests in clinical practice should be further encouraged.

Risk stratification for hydronephrosis in the evaluation of acute kidney injury: a cross-sectional analysis

ObjectiveTo validate an existing clinical decision support tool to risk-stratify patients with acute kidney injury (AKI) for hydronephrosis and compare the risk stratification framework with nephrology consultant recommendations.SettingCross-sectional study of...

Management of Obstructive Renal Failure in Adults at the Sylvanus Olympio University Hospital

Background: Obstructive nephropathies are a topical issue in urology and nephrology consultations, but no study has yet been conducted on the subject in our country. Objective: Describe the epidemiological, clinical, therapeutic and evolutionary profile of obstructive nephropathies at the Sylvanus Olympio University hospital of Togo. Method: It was a descriptive and cross-sectional study with a collection of retrospective data over a period of 08 years (2012-2019) which focused on obstructive nephropathies in the Urology-Andrology, Nephrology and Internal Medicine departments at the medical clinic of CHU SO. The diagnosis of obstructive nephropathy is retained on the basis of radiological and medical imaging results. Results: The study population included 131 patients. The annual hospital frequency was 2.84 cases for 100 admissions. The mean age was 56.72 ± 17.76 years. These patients were mostly male (72.52%). The most frequent age group was 60 - 80 years. Common symptoms at presentation were loin pain (45.75%) and dysuria (25.95%). The average length of probable course of the disease before hospitalization was 636.94 ± 258.88 days (21 months). The etiologies of obstructive nephropathy were largely dominated by prostatic tumors in half of the cases (45.80%). Among these patients, 121 have presented renal failure (92.36%). The average serum creatinine at admission was 59.01 ± 21.56 mg/l. Of the 121 patients with obstructive nephropathy presenting renal failure, 54 (44.63%) had decreased their serum creatinine at the output of more than 25%. The open surgery (54.20%) was the main treatment. There was an improvement in kidney function in patients who had a shorter duration of disease progression and who did not have a history of loin pain, oliguria and that the etiologies of the disease were not tumors. Tumoral etiologies, the presence of a history of high blood pressure, oedema of the lower members, oliguria, and a longer duration of disease progression and sex were factors associated with the occurrence of end-stage renal disease. Conclusion: Renal failure is the main complication of obstructive nephropathy in Togo, hence the importance of an early diagnosis for better care.

Identifying patients with CKD risk at the time of nephrectomy: When to initiate nephrology consult

Introduction: The prevalence of chronic kidney disease (CKD) is high among kidney neoplasm patients because of the overlapping risk factors. Our purpose is to identify kidney cancer survivors with higher CKD risk. Methods: We studied a retrospective cohort of 361 kidney tumor patients with partial or radical nephrectomy. Linear mixed model was performed. Results: Of patients with follow-up &gt;3 months, 84% were identified retrospectively to fulfill criteria for CKD diagnosis, although CKD was documented in only 15%. Urinalysis was performed in 205 (57%) patients at the time of nephrectomy. Multivariate analysis showed interstitial fibrosis and tubular atrophy (IFTA) &gt;25% ( p = 0.005), severe arteriolar sclerosis ( p = 0.013), female gender ( p = 0.024), older age ( p = 0.012), BMI ⩾ 25 kg/m2 ( p &lt; 0.001), documented CKD ( p &lt; 0.001), baseline eGFR ⩽ 60 ml/min/1.73 m2 ( p &lt; 0.001), and radical nephrectomy ( p &lt; 0.001) were independent risk factors of lower eGFR at baseline and during follow-up. Average eGFR decreased within 3 months post nephrectomy. However, patients with different risk levels showed different eGFR time trend pattern at longer follow-ups. Multivariate analysis of time × risk factor interaction showed BMI, radical nephrectomy and baseline eGFR had time-dependent impact. BMI ⩾ 25 kg/m2 and radical nephrectomy were associated with steeper eGFR decrease slope. In baseline eGFR &gt; 90 ml/min/1.73 m2 group, eGFR rebounded to pre-nephrectomy levels during extended follow-up. In partial nephrectomy patients with baseline eGFR ⩾ 90 ml/min/1.73 m2 ( n = 61), proteinuria ( p &lt; 0.001) and BMI ( p &lt; 0.001) were independent risk factors of decreased eGFR during follow up. Conclusions: As have been suggested by others and confirmed by our study, proteinuria and CKD are greatly under-recognized. Although self-evident as a minimum workup for nephrectomy patients to include SCr, eGFR, urinalysis, and proteinuria, the need for uniform applications of this practice should be reinforced. Non-neoplastic histology evaluation is valuable and should include an estimate of global sclerosis% (GS) and IFTA%. Patients with any proteinuria and/or eGFR ⩽ 60 at the time of nephrectomy or in follow-up with urologists, and/or &gt;25% GS or IFTA, should be referred for early nephrology consultation.