Normal Serum Creatinine Levels Research Articles

Long-term Efficacy of Repeat Incisions of Bladder Neck/External Sphincter in Patients With Spinal Cord Injury

To evaluate the efficacy of repeat bladder neck incision (BNI), with or without external sphincterotomy (ES). BNI/ES has been commonly used for management of neurogenic bladder in spinal cord injury (SCI) patients. This was a retrospective review of institutional review board-approved SCI database. A total of 97 patients underwent BNI/ES over a period of 40 years. During the period reviewed, a solitary redo BNI/ES was done in 46 patients, a second redo BNI/ES was done in 23 patients, and a third redo BNI/ES was done in 7 patients with success rates of 50%, 68.2%, and 85.7%, respectively. The most common indications for surgery failure and need for repeat surgery were elevated residual for the first repeat BNI/ES, recurrent urinary tract infections for the second, and elevated residual for the third repeat BNI/ES. All patients had a normal serum creatinine level at the end of the follow-up. Mean elapsed follow-up after the last redo BNI/ES was 119 months (range, 6-408 months) for all patients evaluated. Mean durability of successful redo BNI/ES was 109.1 months, which was significantly longer than mean durability of failed redo BNI/ES at 69.4 months (P <.05). SCI patients undergoing BNI/ES may require repeat BNI/ES to optimize lower urinary tract management. The success rate ranges from 50% to 85.7% after 3 repeat BNI/ES procedures with acceptable long-term durability and low perioperative complication rates.

Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report.

Vascularized composite allotransplantation (VCA) has emerged as a limb replacement strategy for selected patients.Rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy.Calcineurin inhibitors (CNIs) have served as the centerpiece agent in all reported cases,and CNI-associated complications are the most reported.Belatacept was approved in kidney transplantation,but to date,its use in VCA has not been reported.Herein,we report on a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant CNI nephrotoxicity,all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. Methods.A 21-year-old female received a unilateral hand transplant.Panel reactive antibody testing was 0% for Class I and Class II. The patient was CMV+ and EBV+. She received induction with rabbit antithymocyte globulin followed by tacrolimus, mycophenolate mofetil and steroids.At the one-year visit she was diagnosed with Banff I, C4d- skin rejection.HLA antibodies identified at this date were HLA-B*48, 60, 61 and 81 utilizing a LuminexTM-based microparticle assay,which,while not directly donor specific,likely recognize a shared epitope expressed by the donor's mismatched HLA-B* locus antigens.Creatinine increased to 2.08 mg/dl despite multiple attempts to lower her tacrolimus dose.The patient was treated for antibody mediated rejection and was started on belatacept and sirolimus.Tacrolimus and MMF were discontinued. Results.After 18-months on belatacept,the patient's renal function has returned toward normal serum creatinine levels,her skin biopsies have been free from rejection,and her quantitative upper extremity function test has improved from 21/99 to 42/99. Summary. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for non-life threatening conditions typically treated by VCA.

Warfarin-associated calciphylaxis in a patient with normal renal function

A 61-year-old woman with a history of diabetes and hypothyroidism presented with extensive necrotic skin lesions that had started as tender subcutaneous nodules in her thighs, buttocks, distal legs, and abdominal wall 5 months prior to presentation and 15 months after having been started on warfarin for pulmonary hypertension. The nodules had become confluent and ulcerated, with black eschar formation and intermittent pus drainage (Panel A). Warfarininduced skin necrosis had initially been suspected and warfarin was discontinued 3 months prior to presentation; however, the ulcers continued to worsen over this period. She later developed necrotic lesions in her fingertips, and hand radiographs revealed extensive arterial calcification (Panel B). A deep excisional biopsy of a subcutaneous nodule in the abdominal wall showed extensive fat necrosis and marked calcium deposition in the walls of multiple arterioles (Panel C). Vessel lumen were narrowed or occluded by endothelial cell proliferation and fibrin thrombi. No vasculitic changes or extravascular calcium deposition were present. Laboratory investigation revealed normal levels of serum creatinine (estimated glomerular filtration rate ≥60 mL/min), calcium, phosphorus, parathyroid hormone, and vitamin D. An extensive thrombophilia work-up was negative. A diagnosis of calciphylaxis was made. Calciphylaxis is an uncommon condition characterized by calcification of small arterioles that can lead to luminal obstruction and skin ischemia with ulcerations and necrosis. This case is unusual in that calciphylaxis usually occurs in the setting of end-stage renal disease and hyperparathyroidism. It can be triggered or worsened by vitamin K antagonist therapy, possibly due to a decrease in the vitamin K-dependent gamma-carboxylation of matrix Images in Vascular Medicine

TCTAP A-186 Prognostic Significance of Normal Serum Creatinine Level and Reduced Estimated Glomerular Filtration Rate in Patients Receiving Coronary Revascularization

TCTAP A-186 Prognostic Significance of Normal Serum Creatinine Level and Reduced Estimated Glomerular Filtration Rate in Patients Receiving Coronary Revascularization

Effect of Multiple Access Tracts During Percutaneous Nephrolithotomy on Renal Function: Evaluation of Risk Factors for Renal Function Deterioration

To assess the impact of multiple access tracts during percutaneous nephrolithotomy (PCNL) on short- and midterm renal function, and to determine risk factors predicting renal function deterioration and/or recoverability. Patients undergoing PCNL with multiple punctures were prospectively enrolled. Preoperative evaluation included dimercaptosuccinic acid and diethylenetriaminepentaacetic acid renography. Patients were classified according to baseline renal function into patients with normal (<1.4 mg/dL) serum creatinine (group A) and patients with elevated (≥1.4 mg/dL) serum creatinine (group B). Patients were followed with serial serum creatinine evaluations and a repeated renography at 12 months. Factors evaluated for possible impact on renal function changes included preoperative renal function, number of access tracts, hypertension, and diabetes mellitus. There were 102 patients 21 to 65 (mean 39.9) years who completed the study. Fifty patients (group A) had normal preoperative serum creatinine levels and glomerular filtration rate (GFR), which showed no statistically significant change 12 months after PCNL. Fifty-two patients had baseline renal impairment (group B), and they experienced statistically significant worsening of the serum creatinine level and GFR at 12 months postoperatively (P<0.001). Ten (19.23%) patients in group B had a significant deterioration of GFR more than 25%. Independent risk factors for this poor outcome were elevated (≥1.4 mg/dL) preoperative serum creatinine level, diabetes, and hypertension. PCNL with multiple tracts carries a risk of adversely affecting renal function. Preoperative baseline renal impairment, diabetes, and hypertension are risk factors for significant renal function deterioration after the procedure.

Colectomy and acute renal failure: a case report with unusual presentation.

Surgery is the only curative modality but occasionally it can have some long term complication such as short bowel syndrome. We presented a case reporting a 63-year-old man who had subtotal colectomy with liver metastasectomy according to the colon adenocarcinoma, following the couple of months of surgery; he had acute kidney injury without any end-organ damage while he had a regular diet and nutrition. Following the regular treatment of renal failure, colorectal cancer recurrence was excluded and then he was discharged from the hospital with a normal serum creatinine level. The patient was admitted to the nephrology clinic again for acute renal failure within 3 weeks of last admission to the hospital. He also denied the insufficient oral water intake and nutrition, but laboratory examination revealed acute renal failure. We suspected for short bowel syndrome (SBS). Following the hydration, loperamide hydrochloride 10 mg/day was started and the patient was followed up with normal serum creatinine and uric acid levels. To the best of our knowledge, this is the first case report, in which a patient with short bowel syndrome presented with prerenal acute renal failure even though he had sufficient oral intake and nutrition and can be treated with hydration and loperamide hydrochloride.

Prenatal Diagnosis of Severe Fetal Renal Pelvic Dilatation and Treatment with Double Pig Tail Catheter

Introduction: Fetal urinary tract obstructions require feto-amniotic shunting with percutaneous vesico centesis or Double Pig Tail Catheter (DPTC) draining fetal urine to the amnion, mainly used to treat low urinary tract obstructions and though is associated to high morbidity; if it is early applied maintains permeable the urinary tract, prolongs fetal life and prevents maternal complications. There are few fetal patients with upper urinary tract obstructions treated by DPTC reported. We report a fetal patient with severe upper urinary obstruction due to ureteric-pelvic stenosis, derived to amnion with a DPTC. Case: A 19 years old women with 30 weeks of gestation was sent with diagnosis of an abdominal giant cystic in the fetus. The Ultrasound (US) confirmed the presence of a cystic abdominal mass of 10 cm by 10 cm, associated to left renal dilatation, the right kidney was ectopic and dilated forming the cystic mass secondary to an upper urinary tract obstruction, the bladder was normal displaced to the left. An US guided insertion of a DPTC was successfully done at 32 weeks of gestation. The pregnancy ended at 37 weeks with a 2,600 g female newborn, without abdominal cyst and normal creatinine. A follow up by the Pediatric Surgical Department until 18 months old observed normal serum creatinine levels. Conclusion: A successful installation of a DPTC in a 32 weeks of gestation fetus released a severe upper urinary tract obstruction maintaining permeable after borne.

Childhood-onset dense deposit disease: a rare cause of proteinuria

IntroductionDense deposit disease (DDD) is a rare renal disease related to the dysregulation of the alternative pathway of the complement cascade, caused by several factors including the presence of an autoantibody to C3 nephritic factor, mutations in factor H and autoantibodies to this protein. DDD is characterized by C3 accumulation with absent or scanty immunoglobulin deposition.Case PresentationHerein we report the case of a child with benign course of DDD, who presented with moderate proteinuria and lack of clinical symptoms without immunosuppressive treatment. Laboratory testing revealed moderate proteinuria, normal serum creatinine, total protein, and albumin levels, but significantly decreased serum C3 level. The results of renal biopsy were consistent with DDD. Genetic analysis revealed that the patient carried one copy of the H402 risk allele of factor H. The level of proteinuria did not change during the follow-up period and no nephrotic syndrome signs occurred. Renal function was stable.Conclusion In conclusion, a program of urine screening for asymptomatic proteinuria and hematuria to detect children with kidney disease before they experience loss of kidney functions should be considered. Children diagnosed with DDD should have the opportunity to get treatment early on and to be followed very closely.

Identification Of aHUS and Complement Mutations In Patients Presenting With Acute Thrombotic Microangiopathy

Increasing understanding of abnormalities within the alternative complement pathway in atypical hemolytic uremic syndrome (aHUS) is changing the way the disease is both diagnosed and treated. It is rarely possible to definitively diagnose aHUS at the time of initial acute presentation and treatment, with plasma exchange, is initiated on clinical grounds. With the risk of further acute episodes and increasing availability of terminal complement inhibitors accurate molecular diagnosis is imperative. Aimto determine the clinical phenotype and nature of complement abnormalities within a cohort of aHUS patients referred to a large thrombotic thrombocytopenic purpura (TTP) referral centre. Patients and methodsData from 14 patients with a clinical diagnosis of aHUS was retrospectively analysed. 13 patients were referred with thrombotic microangiopathy not initially requiring renal replacement therapy (RRT). 1 patient presented to another institution requiring urgent RRT and was subsequently transferred to our care following recovery of renal function. All patients had ADAMTS13 levels above 30% and negative anti-ADAMTS13 antibody levels at presentation to exclude a diagnosis of TTP. 3 patients had diarrhoea at presentation; all were enterotoxin negative. Patients were subsequently assessed for mutations within complement factors H (CFH), I (CFI), B (CFB), C3 and membrane cofactor protein (MCP), at risk haplotypes and CFH antibodies. A control group of 14 acute acquired TTP patients with confirmed ADAMTS13 levels <5% were assessed for the same abnormalities within complement regulatory proteins. ResultsIn the aHUS cohort, the median age of presentation was 25.5 years (11 months to 72 years). The median serum creatinine was 275 µmol/l (range 79-1812 µmol/l), platelet count 27 x109/l (10-115) and LDH was 2016 IU (342-4621). In the TTP group, presenting creatinine was 106 µmol/l (61-353) µmol/l, platelets 13 x109/l (5-74) and LDH 1954 IU (756-3518). aHUS precipitants at initial presentation or relapse included pregnancy (n=2), upper respiratory tract infection (n=6), vaccination (n=1), abdominal sepsis (n=4). In 3 cases, there was no identified trigger. Headache was a common presenting symptom; only one hypertensive patient (72 years) had a transient ischemic attack; no other neurological events were documented in the aHUS group.In 57% (8/14 patients) variants of the alternative complement pathway were identified; 5 with MCP mutations, encoding p.R59X, p.C157Y (present in 2 brothers), p.C64F and c.286+2T>C/c.286+2T>G (both present in the same patient); 2 with CFH mutations, encoding c.3134-5T>C and p.R1215X; and 1 with a CFB mutation (p.D371G). All of the mutations identified, except CFH c.3134-5T>C, are of clear functional significance. 2 of the patients with MCP mutations had a normal serum creatinine at presentation. C3/4 levels were low in 3/8 patients. In the control group of TTP patients with ADAMTS13 <5% no complement mutations were identified.13/14 aHUS patients were treated initially with plasma exchange; 1 received eculizumab subsequently. 3 patients required temporary RRT and 1 died within 24 hours of presentation with progressive cardiorespiratory failure. At follow-up, all patients had platelet counts >150 x109/l and 12/13 had normal serum creatinine levels; one patient had a creatinine of 122 µmol/l. 5/13 patients had recurrent episodes, 4 of whom had confirmed complement pathway abnormalities (3 MCP mutated, 1 CFB mutated). None required long-term RRT or progressed to end-stage renal failure (ESRD) at a median follow-up of 2 years (range 0.25-28 years). ConclusionsThis aHUS cohort, without ESRD, demonstrates the difficulty in clinically differentiating TTP from complement mediated TMAs. We demonstrate that diagnostic differentiation based on platelet count, renal function and serum C3/C4 levels is insufficient to predict an underlying complement mutation. This distinction is increasingly important with the proven efficacy of complement inhibitor therapy in targeting complement activation in aHUS. Specifically, we demonstrate a very high frequency of functionally significant MCP mutations which mimic relapsing/remitting TTP. An ADAMTS13 activity >5% in a patient with a TMA should necessitate genetic screening for complement gene mutations prior to consideration of complement inhibitor therapy. Disclosures:No relevant conflicts of interest to declare.

Kidney injury molecule-1 expression is closely associated with renal allograft damage

The aim of our study was to investigate the expression of kidney injury molecule-1 (KIM-1) in renal allograft biopsy samples and assess the clinical significance of its use as a biomarker for tissue damage. A total of 69 renal allograft biopsy samples from 17 patients with normal serum creatinine and 52 cases of increased serum creatinine were collected. They were divided into different groups according to the Banff 2007 diagnostic criteria. KIM-1 expression was detected by immunohistochemical methods and the association of KIM-1 and blood biochemical indexes was analyzed. KIM-1 expression increased as Banff 2007 classification grade increased and was positively correlated with tubular inflammation severity in the acute T-cell rejection group. Moreover, KIM-1 expression was strongly positive in the chronic active antibody-mediated rejection group. Interestingly, KIM-1 was weakly positive in the normal group without obvious acute rejection and injury of immunosuppressant toxicity. In this group, 27.3% (3/11) of the cases with normal serum creatinine level showed weakly positive KIM-1 expression in their renal tissues. KIM-1 expression level is positively correlated with renal allograft damage and tubular cell injury. KIM-1 is expressed in tubular epithelial cells before blood biochemical indexes become elevated and morphological changes occur. KIM-1 expression is an early, sensitive, and specific biomarker to determine renal tubular epithelial cell injury in renal allograft tissue.

A Tissue Engineered Renovascular Graft Composed of Proteins, Polymers, Smooth Muscle and Endothelial Cells for Renal Artery Stenosis

Endarterectomy and bypass surgery to treat renal artery stenosis are increasingly shunned these days due to high risks of complications during and after the surgery. Striving to find a sound alternative solution, we pioneered the construction of a tissue engineered renovascular graft that could immediately restore the normal blood flow to kidneys and sustain renal functions without suffering restenosis after the surgery. A highly porous scaffold was first constructed by electrospinning polycaprolactone, poliglecaprone, gelatin and elastin, giving the vast majority of non-woven fibers in the scaffold a diameter below 1200 nm. To recapitulate the anatomical and functional signatures of renal arteries, a bi-layer vasculature comprising a smooth muscle layer topped by an endothelial layer was built on the scaffold. The vasculature witnessed a sustained proliferation for up to 10 days in vitro and robustly secreted prostacyclin and endothelin-1, evidencing that the vasculature was functionally comparable to native renal arteries. After 30 days as a renovascular graft in mice, the luminal diameter of the graft remained clear without a restenosis and an increased confluence of the endothelial layer was observed. The tensile test confirmed that the renovascular graft was mechanically superior to native renal arteries and retained this advantage within 30 days in vivo. Also, this renovascular graft sustained renal functions as evidenced by normal levels of serum creatinine, urine creatinine and serum urea nitrogen and the lack of edema in the kidney cortex. These results demonstrate that this renovascular graft holds a great therapeutic promise for renal artery stenosis.

Prognostic Factors And Mortality Rate In Neonates With Acute Renal Injury In Nicu

How to Cite This Article: Esfandiar N, MohkamM, Afjeii A, et al. Prognostic Factors and Mortality Rate in Neonates with Acute Renal Injury in NICU. J Ped. Nephrology 2013 July;1(1):32-36. Introduction: Acute Renal Injury (AKI) is a frequent clinical condition in the Neonatal Intensive Care Units (NICUs). Most AKI causes are preventable; performing rapid preventive, diagnostic, and therapeutic measures could prevent the potential complications. The present study was conducted to define the risk factors and mortality rates of neonates with and without AKI admitted in the NICU of a tertiary care hospital. Materials and Methods : Demographic and biochemical data of NICU of Mahdieh Hospital were collected and analyzed. More than twofold increase in normal serum creatinine level or >0.8 mg/dl (for infants > 4 days age) was defined as AKI. All newborns were divided into two groups: with and without AKI. Risk factors and mortality rates were compared in the 2 groups. Results: The mortality rate of newborns with AKI was 4.5%. The other risk factors for mortality in neonates with AKI were as follows: Hyaline Membrane Disease (HMD) (P 60 mmHg (P 1 mg/dl (P <0.003). ROC Curve revealed that low birth weight was the most significant risk factor for mortality of neonates with AKI admitted in the NICU. Conclusions: Mortality related to AKI was associated with HMD, using mechanical ventilation, the need to surfactant use, low Apgar score, high blood PCO2, high serum creatinine level, and low birth weight. Keywords : Acute Kidney Injury; Prognosis; Hospital mortality; Intensive Care Units; Neonate .

Impact of occult renal impairment on early and late outcomes following coronary artery bypass grafting

High serum creatinine is considered an independent risk factor for poor outcomes following coronary artery bypass grafting (CABG). However, the impact of occult renal impairment (ORI), defined as an impaired glomerular filtration rate (GFR) with a normal serum creatinine (SCr) level, remains unclear. Thus, we sought to investigate the impact of ORI on outcomes after CABG. Among patients undergoing their first percutaneous coronary intervention (PCI) or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 1842 patients with normal SCr levels undergoing CABG were enrolled in the study. Patients were divided into two groups based on preoperative estimated GFR calculated by the Cockcroft-Gault equation: 1339 patients with estimated GFR of ≥ 60 ml/min/1.73 m(2) (normal group) and 503 with estimated GFR of <60 ml/min/1.73 m(2) (ORI group). Preoperative estimated GFR differed between the groups (51.3 ± 6.6 vs 85.8 ± 23.0 ml/min/1.73 m(2), P < 0.01). ORI was associated with high in-hospital mortality (3.2 vs 1.0%, P < 0.01) and need for dialysis (2.0 vs 0.2%, P < 0.01). In terms of long-term outcomes, ORI was associated with high mortality compared with the normal (hazard ratio [95% confidence interval]: 1.72 [1.16-2.54], P < 0.01) and high incidence of composite cardiovascular events (death, stroke or myocardial infarction: 1.53 [1.16-2.02], P < 0.01). ORI was an independent risk factor for early and late death as well as cardiovascular events in patients undergoing CABG with normal SCr levels. A more accurate evaluation of renal function through a combination of SCr and estimated GFR is needed in patients with normal SCr levels.

Rituximab in the treatment of resistant lupus nephritis: therapy failure in rapidly progressive crescentic lupus nephritis

The objective of this paper is to report the clinical outcome of B cell depletion therapy in 18 patients with refractory lupus nephritis (LN). Eighteen patients received rituximab on an open-label basis with prospective evaluations. All patients had renal disease refractory to conventional immunosuppressive therapy, including intravenous cyclophosphamide (CyC). All patients fulfilled the revised ACR classification criteria for SLE. Rituximab was given as 2 × 1 g infusions with 500 mg iv CyC and 500 mg iv methylprednisolone, two weeks apart. Complete remission (CR) of nephritis at six months was defined as normal serum creatinine and serum albumin levels, inactive urine sediment, and proteinuria < 0.5 g/day; partial remission (PR) was defined as a ≥50% improvement in all renal parameters that were abnormal at baseline. Clinical response was assessed by the British Isles Lupus Assessment Group (BILAG) score pre- and post-rituximab treatment, and efficacy was recorded by extent and duration of B lymphocyte depletion (normal range 0.100-0.500 × 10(9)/l). Follow-up data were collected at six months, one year post-treatment and at the most recent clinic visit. At six months, 11/18 patients reached renal CR and two of 18 PR. The mean global BILAG scores for responders decreased from 15 (SD 10) to 5 (SD 3), and a total of ten A scores disappeared. Five patients failed to show complete or partial renal response despite peripheral B lymphocyte count depletion, and progressed to end-stage renal failure (ESRF) and dialysis. Four of these patients had severe proliferative, crescentic nephritis, of whom three had Class IV-G, one Class III and one late membranous glomerulonephritis. One patient died six years after rituximab therapy from overwhelming sepsis while on long-term haemodialysis. Rituximab therapy achieved a response in 13/18 patients with refractory LN. However, in patients with rapidly progressive crescentic LN, when there is already evidence of significant renal impairment, rituximab therapy may not prevent progression to ESRF and dialysis. Our data also suggest that severe Class IV-G LN may be associated with a poor response to therapy.

Long-Term Effects of Conversion From Cyclosporine to Rapamycin on Testicular Function and Morphology in a Rat Transplantation Model

PurposeThe purpose of this study was to investigate the long-term effects of conversion from cyclosporine (CsA) to rapamycin on testicular function and morphology in a rat transplantation model compared with the continuous administration of CsA. MethodsFisher 344 kidneys were orthotopically transplanted into Lewis recipients. Four Fisher 344 to Lewis allograft groups were treated posttransplantation as follows: Group 1, CsA treatment to week 8 followed by rapamycin from week 8–24; Group 2, CsA from transplantation to week 24; Group 3, CsA from transplantation to week 8 then vehicle from weeks 8–24, and Group 4, control vehicle from transplantation to week 24. A fifth group (Group 5) underwent syngeneic isografts (Lewis to Lewis) with no drug treatment. At 24 week, we measured serum creatinine and sex hormones and harvested the right testis for histological analysis. ResultsAll rats showed normal serum creatinine levels. Testosterone was significantly lower in Group 1 versus Group 5 (0.85 ± 0.09 vs 1.05 ± 0.17 ng/mL; P = .008). Groups 2, 3 and 4 displayed higher testosterone values than Group 1 but lower than Group 5. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were also higher in Group 1 versus the other groups, but the differences were not significant. The histological damage score was significantly higher in Groups 1, 2, 3, and 4 versus Group 5 (1.8 ± 0.8), but the highest one was observed in Group 1 (8.3 ± 1.6). Electron microscopy showed more severe testicular ultrastructural damage in Group 1. ConclusionConversion from CsA to rapamycin resulted in more severe damage to testicular function and structure than the continuous use of CsA in a rat kidney transplantation model.

Serum cystatin C as a marker of renal function in detection of early acute kidney injury

In patients with acute kidney injury (AKI), serum creatinine level does not increase until moderate to severe reduction in glomerular filtration rate (GFR) occurs. Thus its use for estimating GFR in early AKI delays detection of kidney damage and making important therapeutic decisions. Moreover, serum cystatin C is not affected by gender, age, race, and muscle mass and also does not suffer from lag period for its rise in early AKI. We studied 200 healthy subjects and 130 AKI patients over a period of 2 years at a tertiary care hospital. Serum creatinine and serum cystatin C were studied and analyzed in relevance to early AKI. We found that 56.2% of patients of AKI group had normal levels of serum creatinine in early phase, while all patients had elevated serum cystatin C at same time. Multiple logistic regression analysis revealed cystatin C-based GFR reflecting decline in GFR with worsening AKI in better than creatinine-based GFR. Serum cystatin C is a better marker of renal function in early stages of AKI and is less affected by age, gender, muscle mass, and ethnicity. Its use helps in early therapeutic intervention and possibly favorable outcome.

Evaluation of renal functions using isotopic renogram and biochemical tests

Introduction: Radionuclide renography is now very important diagnostic tool comparable to other diagnostic modalities for the evaluation of renal diseases. Aim: This study was carried out to assess the role of radionuclide renography and biochemical test in the evaluation of the renal function. Materials and Methods: A total of 50 samples with a history of renal disease were included in this study. Out of a total 50, 31 were males and 19 were females, their age ranged between 9 and 79 years and most of the patients were in the age group above 46 years, weight ranged from 22 to 97 kg, mean (standard deviation [SD]) 67.32 (17.203). Height ranged from 125 to 185 cm, mean (SD) 163.07 (12.573). Radionuclide renography and biochemical test were done for all patients in the Radiation and Isotope Center of Khartoum in the period from March 2011 to October 2011. Results: In case of radionuclide renography, total glomerular filtration rate (GFR) ranged from 6.64 to 130.70, mean (SD) 65.87 (31.30) and the biochemical test showed that (10%) of patients with abnormal serum creatinine level and (12%) with abnormal serum urea level. The serum urea level was normal in 44 patients, but in the renogram 19 patients were abnormal (both kidneys GFR), 14 patients were abnormal (right kidney GFR) and 8 patients were abnormal (left kidney GFR). A total of 45 patients had normal serum creatinine level, but in the renogram 18 patients were abnormal (both kidneys GFR), 16 patients were abnormal (right kidney GFR) and 8 patients were abnormal (left kidney GFR). Conclusion: It is concluded that both isotopes renogram technique and biochemical test are very important in the evaluation of renal function.

Cystatin C is a biomarker for predicting acute kidney injury in patients with acute-on-chronic liver failure

To investigate serum cystatin C level as an early biomarker for predicting acute kidney injury (AKI) in patients with acute-on-chronic liver failure (ACLF). Fifty-six consecutive patients with hepatitis B virus-related ACLF who had normal serum creatinine (Cr) level (< 1.2 mg/dL in men, or < 1.1 mg/dL in women) were enrolled in the Liver Failure Treatment and Research Center of Beijing 302 Hospital between August 2011 and October 2012. Thirty patients with chronic hepatitis B (CHB) and 30 healthy controls in the same study period were also included. Measurement of serum cystatin C (CysC) was performed by a particle-enhanced immunonephelometry assay using the BN Prospec nephelometer system. The ACLF patients were followed during their hospitalization period. In the ACLF group, serum level of CysC was 1.1 ± 0.4 mg/L, which was significantly higher (P < 0.01) than those in the healthy controls (0.6 ± 0.3 mg/L) and CHB patients (0.7 ± 0.2 mg/L). During the hospitalization period, eight ACLF patients developed AKI. Logistic regression analysis indicated that CysC level was an independent risk factor for AKI development (odds ratio = 1.8; 95%CI: 1.4-2.3, P = 0.021). The cutoff value of serum CysC for prediction of AKI in ACLF patients was 1.21 mg/L. The baseline CysC-based estimated glomerular filtration rate (eGFR(CysC)) was significantly lower than the creatinine-based eGFR (eGFR(CG) and eGFR(MDRD)) in ACLF patients with AKI, suggesting that baseline eGFR(CysC) represented early renal function in ACLF patients while the Cr levels were still within the normal ranges. Serum CysC provides early prediction of renal dysfunction in ACLF patients with a normal serum Cr level.

Early Posttransplant Nephrotic Range Proteinuria as a Presenting Feature of Minimal Change Disease and Acute T Cell–mediated Rejection

Early-onset nephrotic range proteinuria is an extremely rare presentation of an acute rejection episode. Herein, we have reported a patient who developed nephrotic range proteinuria 7 days after receiving a renal allograft from his sister despite minor changes in serum creatinine levels. A kidney biopsy spcimen revealed a T cell–mediated acute rejection process concomitant with minimal change disease (MCD). Proteinuria and renal dysfunction improved dramatically in response to corticosteroids. The possibility of acute cellular rejection and coexisting MCD should be considered in patients with early posttransplantation nephrosis and normal serum creatinine levels. The coexistence of these entities provides support for the role of T cells in the pathogenesis of MCD.

Managing type 1 diabetes mellitus in pregnancy—from planning to breastfeeding

Type 1 diabetes mellitus in pregnant women increases the risk of adverse outcomes for mother and offspring. Careful preconception counselling and screening is important, with particular focus on glycaemic control, indications for antihypertensive therapy, screening for diabetic nephropathy, diabetic retinopathy and thyroid dysfunction, as well as review of other medications. Supplementation with folic acid should be initiated before conception in order to minimize the risk of fetal malformations. Obtaining and maintaining tight control of blood glucose and blood pressure before and during pregnancy is crucial for optimizing outcomes; however, the risk of severe hypoglycaemia during pregnancy is a major obstacle. Although pregnancy does not result in deterioration of kidney function in women with diabetic nephropathy and normal serum creatinine levels, pregnancy complications such as pre-eclampsia and preterm delivery are more frequent in these women than in women with T1DM and normal kidney function. Rapid-acting insulin analogues are considered safe to use in pregnancy and studies on long-acting insulin analogues have provided reassuring results. Immediately after delivery the insulin requirement declines to approximately 60% of the prepregnancy dose, and remains 10% lower than before pregnancy during breastfeeding.