Normal Urine Output Research Articles

The combination of kidney function variables with cell cycle arrest biomarkers identifies distinct subphenotypes of sepsis-associated acute kidney injury: a post-hoc analysis (the PHENAKI study)

Background The severity and course of sepsis-associated acute kidney injury (SA-AKI) are correlated with the mortality rate. Early detection of SA-AKI subphenotypes might facilitate the rapid provision of individualized care. Patients and methods In this post-hoc analysis of a multicenter prospective study, we combined conventional kidney function variables with serial measurements of urine (tissue inhibitor of metalloproteinase-2 [TIMP-2])* (insulin-like growth factor-binding protein [IGFBP7]) at 0, 6, 12, and 24 h) and then using an unsupervised hierarchical clustering of principal components (HCPC) approach to identify different phenotypes of SA-AKI. We then compared the subphenotypes with regard to a composite outcome of in-hospital death or the initiation of renal replacement therapy (RRT). Results We included 184 patients presenting SA-AKI within 6 h of the initiation of catecholamines. Three distinct subphenotypes were identified: subphenotype A (99 patients) was characterized by a normal urine output (UO), a low SCr and a low [TIMP-2]*[IGFBP7] level; subphenotype B (74 patients) was characterized by existing chronic kidney disease (CKD), a higher SCr, a low UO, and an intermediate [TIMP-2]*[IGFBP7] level; and subphenotype C was characterized by very low UO, a very high [TIMP-2]*[IGFBP7] level, and an intermediate SCr level. With subphenotype A as the reference, the adjusted hazard ratio (aHR) [95%CI] for the composite outcome was 3.77 [1.92–7.42] (p < 0.001) for subphenotype B and 4.80 [1.67–13.82] (p = 0.004) for subphenotype C. Conclusions Combining conventional kidney function variables with urine measurements of [TIMP-2]*[IGFBP7] might help to identify distinct SA-AKI subphenotypes with different short-term courses and survival rates.

A Case Series of Bile Cast Nephropathy-induced Rapidly Progressive Renal Failure

Abstract A 45-year-old male presented to the hospital with symptoms of left inguinal swelling, which showed granulomatous adenitis on fine-needle aspiration cytology. He was diagnosed with tuberculous adenitis, for which he was started on antitubercular treatment. After 15 days of antitubercular treatment, the patient developed deranged renal parameters, with serum creatinine of 8.8 mg/dL while serum bilirubin rose to 7.4 mg/dL. The patient was oliguric and underwent four sessions of hemodialysis. Following this, a renal biopsy was done, which showed normal glomeruli with tubular casts that were pigmented, consistent with acute tubular injury secondary to bile cast nephropathy. The patient’s condition improved with one more session of hemodialysis and conservative management. Serum creatinine declined to 1.2 mg/dL, at the time of discharge, with normal urine output. This case illustrates features of bile cast nephropathy presenting as rapidly progressive renal failure secondary to antitubercular treatment.

Kidney injury molecule type-1, interleukin-18, and insulin-like growth factor binding protein 7 levels in urine to predict acute kidney injury in pediatric sepsis.

This study aimed to observe the role of urinary kidney injury molecule (KIM-1), interleukin (IL-18), and insulin-like growth factor-binding protein 7 (IGFBP-7) levels in predicting acute kidney injury (AKI) in children with sepsis. This prospective cohort observational study was conducted at Dr. RSUP. Wahidin Sudirohusodo, Makassar, South Sulawesi, from January to December 2021. Inclusion criteria were septic patients treated in the pediatric intensive care unit (PICU) aged 1 month to 18 years with normal serum creatinine or normal urine output (>5 ml/kg/body weight (BW)/h in 6-12 h). Patients with a history of kidney disease, prior urinary tract infection, or history of using nephrotoxic drugs were excluded. There was a significant difference in urinary KIM-1, IL-18, and IGFBP-7 levels between septic patients with and without AKI. The cut-off point for urinary KIM-1 level in sepsis with and without AKI was 1.666 ng/ml, with sensitivity of 82.5%, specificity of 82.2%, and a relative risk (RR) [95% confidence interval (CI)] of 6.866 (95% CI, 3.329-14.165). The cut-off point for urinary IL-18 levels was 3.868 ng/ml, with sensitivity of 92.50%, specificity of 91.78%, and RR of 20.078 (95%CI, 6.593-61.142). The cut-off point for urinary IGFBP-7 levels was ≥0.906 ng/ml with a sensitivity of 75.00%, specificity of 75.34%, and RR of 4.063 (95% CI, 2.206-7.483). Urinary KIM-1, IL-8, and IGFBP-7 levels could be used to predict AKI in septic patients. Urinary IL-8 has a higher sensitivity and specificity as a predictor of AKI in patients with sepsis.

PMON79 Supraphysiologic vasopressin-induced receptor desensitization; a case report

Abstract Background Arginine vasopressin (AVP) is a nonapeptide released from the neurohypophysis in response to increases in plasma osmolality, hypovolemia, hypotension, and angiotensin II. V2 receptors, expressed on the basolateral membrane of the renal collecting ducts coupled to the adenylyl cyclase-cyclic adenosine monophosphate (cAMP)-protein kinase A (PKA) pathway. PKA increases the synthesis and shuttling of aquaporin 2 water channel containing vesicles (AQMCV) from cytoplasmic vesicles to the luminal surface of the renal collecting ducts (and inhibits the endocytosis of the vesicles), where they are inserted into the apical cell membrane. As a result, AVP increases free water reabsorption from the filtrate and decreases serum osmolality. There are different protocols for CDI management in post neurosurgical patient, including IV or SQ injections as well as continuous vasopressin drip. Here we discussed a case where prolonged IV drip could probably have caused loss of response to IV DDAVP injections. Case Patient is a 46-year-old male admitted with AMS with imaging revealed ruptured anterior communicating artery aneurysm associated with subarachnoid and intra parenchymal hemorrhage. The patient underwent emergent aneurysm coiling and EVD placed. The patient was subsequently started on heparin infusion due to a large frontal lobe clot which was found on cerebral angiogram. The next day, the patient developed acute diabetes insipidus with hypernatremia and polyuria. Repeat head CT demonstrated increased cerebral edema around the frontal clot. The patient underwent right frontal craniotomy for clot evacuation. He patient was subsequently started on vasopressin infusion (ranging from 0.5-6 units/hour) by neurosurgery team for urinary output less than 200 mL/hour. ​Urinary output and sodium level improved and remained stable on infusion. When endocrinology attempted transition to DDAVP IV injections patient responded with severe polyuria to initial 0.5 mcg injection. Eventually patient required 1 mcg IV every 4 hours dosing to maintain normal urine output and required a slow wean off to the standard dose of 0.5 mcg every 8 hours over 14 days. Discussion we are presenting a case of CDI associated to SAH who was started on IV infusion of vasopressin, required slow weaning. phenomenon called for slow re-sensitization of the receptors with gradual decreasing of DDAVP dosing. Animal studies have shown that V1 and V2 receptors levels are sensitive to hormone-induced downregulation of hormone receptors. Hypervasopressinemia in rats whose blood vasopressin concentration was experimentally elevated by IV infusion to extraphysiologic levels caused significant desensitization of kidney vasopressin receptors. In another study, IM injection of DDAVP to rats led to a total loss of kidney V receptors. Thus, it is likely that administration of high dose DDAVP IV in this patient induced downregulation of kidney V2 receptors. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PMON79 Supraphysiologic Vasopressin-Induced Receptor Desensitization: A Case Report

Abstract Background Arginine vasopressin (AVP) is a nonapeptide released from the neurohypophysis in response to increases in plasma osmolality, hypovolemia, hypotension, and angiotensin II. V2 receptors, expressed on the basolateral membrane of the renal collecting ducts coupled to the adenylyl cyclase-cyclic adenosine monophosphate (cAMP)-protein kinase A (PKA) pathway. PKA increases the synthesis and shuttling of aquaporin 2 water channel containing vesicles (AQMCV) from cytoplasmic vesicles to the luminal surface of the renal collecting ducts (and inhibits the endocytosis of the vesicles), where they are inserted into the apical cell membrane. As a result, AVP increases free water reabsorption from the filtrate and decreases serum osmolality. There are different protocols for CDI management in post neurosurgical patient, including IV or SQ injections as well as continuous vasopressin drip. Here we discussed a case where prolonged IV drip could probably have caused loss of response to IV DDAVP injections. Case Patient is a 46-year-old male admitted with AMS with imaging revealed ruptured anterior communicating artery aneurysm associated with subarachnoid and intra parenchymal hemorrhage. The patient underwent emergent aneurysm coiling and EVD placed. The patient was subsequently started on heparin infusion due to a large frontal lobe clot which was found on cerebral angiogram. The next day, the patient developed acute diabetes insipidus with hypernatremia and polyuria. Repeat head CT demonstrated increased cerebral edema around the frontal clot. The patient underwent right frontal craniotomy for clot evacuation. He patient was subsequently started on vasopressin infusion (ranging from 0.5-6 units/hour) by neurosurgery team for urinary output less than 200 mL/hour. ​Urinary output and sodium level improved and remained stable on infusion. When endocrinology attempted transition to DDAVP IV injections patient responded with severe polyuria to initial 0.5 mcg injection. Eventually patient required 1 mcg IV every 4 hours dosing to maintain normal urine output and required a slow wean off to the standard dose of 0.5 mcg every 8 hours over 14 days. Discussion we are presenting a case of CDI associated to SAH who was started on IV infusion of vasopressin, required slow weaning. phenomenon called for slow re-sensitization of the receptors with gradual decreasing of DDAVP dosing. Animal studies have shown that V1 and V2 receptors levels are sensitive to hormone-induced downregulation of hormone receptors. Hypervasopressinemia in rats whose blood vasopressin concentration was experimentally elevated by IV infusion to extraphysiologic levels caused significant desensitization of kidney vasopressin receptors. In another study, IM injection of DDAVP to rats led to a total loss of kidney V receptors. Thus, it is likely that administration of high dose DDAVP IV in this patient induced downregulation of kidney V2 receptors. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.

Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.

Masked diabetes insipidus in pituitary metastasis from breast cancer after thalamic biopsy: a case report

BackgroundSymptomatic pituitary metastasis is rare; furthermore, it can result in diabetes insipidus and panhypopituitarism. Since diabetes insipidus is masked by concurrent panhypopituitarism, it can impede the diagnosis of pituitary dysfunction.Case presentationA 68-year-old Japanese female suffering from pituitary and thalamic metastases caused by untreated breast cancer, underwent a biopsy targeting the thalamus, not the pituitary. She lacked prebiopsy pituitary dysfunction symptoms; however, these symptoms unexpectedly occurred after biopsy. Diabetes insipidus was masked by corticosteroid insufficiency, and she showed normal urinary output and plasma sodium levels. Upon commencement of glucocorticoid replacement therapy, the symptoms of diabetes insipidus appeared.ConclusionsIn this case, thalamic biopsy, as opposed to pituitary biopsy, was performed to preserve pituitary function. However, pituitary dysfunction could not be avoided. Caution is necessary for asymptomatic patients with pituitary metastases as invasive interventions, such as surgery, may induce pituitary dysfunction. Moreover, with respect to masked diabetes insipidus, there is a need to carefully consider pituitary dysfunction to avoid misdiagnosis and delayed treatment.

Трансплантация почки от Covid-19-инфицированного трупного донора: каковы последствия для реципиентов?

In recent months, with the spread of COVID 19, the number of kidney transplants from deceased donors has declined significantly in most countries. One of the reasons is the possibility of infection of the recipient with SARS-CoV-2. Determining the risk of transmission of COVID 19 with a donor organ is very important for developing a kidney transplantation policy during a pandemic.We present cases of kidney transplantation from COVID 19 positive deceased donor to two dialysis patients in single center. Deceased donor: a 45 years old man with diabetes, who had a major hemorrhagic stroke resulting in brain death. He had normal urine output and serum creatinine level for last 24 hours before kidney harvesting. For a few hours after organ harvesting, the donor was diagnosed COVID 19 (retrospective nasopharyngeal swab rRT-PCR which was confirmed by morphological examination and RNA-PCR of specimens from the trachea and bronchus). Recipient 1: a 49 years old man with polycystic kidney disease had been on hemodialysis for 28 months. He was in urgent list because of problems with vascular access. So non identical ABO (0-donor, B-recipient) kidney transplantation from this deceased donor was done in May 2020. Recipient 2: a 45 years old man with polycystic kidney disease on continuous ambulatory peritoneal dialysis (CAPD). was registered on urgent waiting list because of low transport capacity of peritoneum. Kidney transplantation from the same deceased donor was done at the same time. In both cases we completely abandoned any antilymphocytic agents for induction, despite non ABO identical transplantation in one of the recipients and the delayed graft function. Both patients received only basic immunosuppression, including tacrolimus, methylprednisolone and a mycophenolic acid.In first case cold ischemia time was 22 hours. The recipient had delayed graft function with increasing of urine output on day 8 post-transplant. No other deviations from the usual course were seen during hospital stay. The patient was discharge from hospital with serum creatinine level 122 mkmol/L. The cold ischemia time was 21 hours in another patient. Graft function was immediate with a decrease serum creatinine to 92.5 mkmol/L at discharge. Both patients had no febrile and no other symptoms of acute respiratory disease during all hospital stay. No abnormalities on chest X-ray were seen. No serum anti-SARS-CoV-2 IgM and IgG were detected before and during 6 weeks after surgery. Repeated nasopharyngeal swabs rRT-PCR were negative during all the period. Both recipients were discharged for 5 weeks after surgery to prevent out-of-hospital contamination of COVID 19, which would be difficult to differentiate from transmission infection. After 9 months both patients are doing well with no clinical or laboratory signs of COVID-19.Today we have no evidence of the possibility of transmission of COVID-19 from a SARS-Cov-2 positive donor to a kidney recipient. We also have no reason to suspect kidney damage by COVID-19 in a deceased donor at normal serum creatinine level. Avoiding the use of anti-lymphocyte drugs for induction of immunosuppression may also reduce the risk of developing COVID19 after transplantation. A careful collection and analysis of such dates is necessary to develop modern practical recommendations for transplant centers.

MP28-05 PHENOTYPING MEN WITH BENIGN PROSTATIC HYPERPLASIA BASED ON LUTS QUESTIONNAIRES AND BLADDER DIARIES

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Epidemiology & Evaluation (MP28)1 Sep 2021MP28-05 PHENOTYPING MEN WITH BENIGN PROSTATIC HYPERPLASIA BASED ON LUTS QUESTIONNAIRES AND BLADDER DIARIES Lakshay Khosla, Philip Lee, Kevin Rychik, Max Edeson, Wade Bushman, and Jerry G Blaivas Lakshay KhoslaLakshay Khosla More articles by this author , Philip LeePhilip Lee More articles by this author , Kevin RychikKevin Rychik More articles by this author , Max EdesonMax Edeson More articles by this author , Wade BushmanWade Bushman More articles by this author , and Jerry G BlaivasJerry G Blaivas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002025.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Men with Benign Prostatic Hyperplasia (BPH) may exhibit normal urine output, oliguria, or polyuria. The etiologies of polyuria have been previously investigated. This study was done to quantify clinical differences based on urinary output and test whether oliguria results from a patient-directed effort to reduce fluid intake to ameliorate lower urinary tract symptoms (LUTS). Specifically, we postulated that oliguria would be associated with more severe LUTS scores. METHODS: A retrospective analysis was performed utilizing a database for patients who completed a 24-hour bladder diary (24HBD) and the LUTS questionnaire from 2015 through 2019. Data on clinical diagnosis, demographics, uroflow (Q), post-void residual urine (PVR), and prostate size was obtained from the EMR. Patients with a clinical diagnosis of BPH with complete data were included. Patients were divided into three urinary phenotypes based on urine output: normal (>1 - <2500 L/24 H), oliguria (<1 L/24 H), and polyuria (>2.5 L/24 H).The data was analyzed using SPSS statistics software by utilizing one-way MANOVA, one-way ANOVA and Tukey’s HSD post-hoc tests. RESULTS: Of the 139 men in the database with BPH, 124 (mean age ± SD, 65.3 ± 11.9 years) had complete data available. Of these, 85 had normal urine output (69%), 14 had oliguria (11%), and 25 had polyuria (20%). Prostate size data was available for 45 men. There was no difference in the LUTSS or any of its subscores amongst the 3 groups. However, compared to the polyuria group, the oliguria group exhibited lower mean 24 hour voided volumes (24H VV), max voided volumes (MVV), daytime voids, total voids, maximum flow rate (Qmax), voided volume at Qmax, and PVR (Table 1). CONCLUSIONS: Our hypothesis was rejected; LUTS scores amongst men with oliguria were no different from LUTS scores amongst men with polyuria or normal 24H VV. However, men with oliguria had lower 24H VV, MVV, total voids, Qmax and PVR compared to men with polyuria. Differences in parameters demonstrate a need for the development of precise nomenclature for BPH phenotypes. To determine whether oliguria in BPH results from a patient’s self-restriction of fluid intake to mitigate LUTS that would otherwise be present, the patient’s role in managing symptoms should be investigated. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e482-e482 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lakshay Khosla More articles by this author Philip Lee More articles by this author Kevin Rychik More articles by this author Max Edeson More articles by this author Wade Bushman More articles by this author Jerry G Blaivas More articles by this author Expand All Advertisement Loading ...

Does Pituitary Dysfunction Always Occur Following Penetrating Head Trauma?

Background: Pituitary dysfunction and panhypopituitarism remain underdiagnosed in penetrating and blunt head trauma and can occur in both acute and chronic settings. Case: A 56 years old male with no significant PMH was admitted with a gunshot wound to the left T9 rib paraspinally with bullet deflection cranially along the left lung, left sternocleidomastoid, and resting anterior to the suprasellar cistern just above the midline of the sphenoid sinus close to the pituitary gland. Moderate volume pneumocephalus, chest hemopneumothorax, and sudden loss of right-sided vision required neurosurgical and pulmonary intervention. Endocrinology was consulted to evaluate pituitary function in the context of the bullet within the cranium. Physical examination showed intact mental status, non-focal exam, right-sided blindness, and foley catheter with normal urine output. Laboratory hormonal assessment for hypothalamic-pituitary axis (HPA) was performed consistent with normal sodium, potassium, FSH of 14.2 mIU/ml (1.0-13.0 mIU/ml), LH of 4.5 mIU/ml (1.0-9.0 mIU/ml), AM cortisol of 13.6 ug/dl (5-25 ug/dl), free cortisol of 2.06, ACTH of 10 pg/ml (10-60 pg/ml), IGF-1 of 80 ng/ml (78-220 ng/ml), TSH 1.93 mIU/L (0.5-5.0 mIU/L), FT4 1.05 ng/dl (0.8-1.8 ng/dl), Prolactin of 14.2 ng/ml (4-23 ng/ml) and HbA1c 5.1%. He reported no symptoms of adrenal insufficiency and remained hemodynamically stable. He was monitored for symptoms of pituitary insufficiency and suppression of the HPA axis along with urine output which remained normal and reassuring for the absence of central DI. The patient will continue outpatient endocrine surveillance. Discussion: The development of hormone deficiencies is directly related to the severity of head trauma. Mild traumatic brain injury (TBI) patients discharged from the ED, without loss of consciousness or post-traumatic amnesia less than 30 minutes do not require endocrine surveillance. Pituitary dysfunction occurs in 20-40% of patients with moderate to severe TBI. Pituitary ischemia leads to pituitary injury, due to changes in cerebral blood flow, cerebral hypoxia, and increased intracranial pressure. Compressive effects on the stalk from increased intracranial pressure is another indirect mechanism for pituitary dysfunction. Hospitalizations longer than 48 hours following TBI, require pituitary screening at 3-6 months. Chronic hypopituitarism develops in 15-20% of patients within 2-3 years with ACTH and GH deficiencies. Other changes in LH, FSH, TSH, and development of central diabetes insipidus can occur. However, despite severe TBI, acute pituitary hormonal involvement may not always occur, as in our patient.

The Sodium See-Saw: Prolonged Second Phase of Diabetes Insipidus and Complete Resolution Following Surgical Resection of a Supra-Sellar Meningioma

Abstract Background: Diabetes insipidus (DI) is a common occurrence after sellar/suprasellar surgery. However, signs of recovery after a few days should be treated with caution as this may precede a “triple response”, seen in 3.4% of the patients. In this response, initial postoperative DI gives way to a period of remission or clinically inappropriate antidiuresis before eventual recurrence of DI. Clinical Case: A 38-year-old Hispanic female was admitted to the hospital for elective transcranial resection of a suprasellar meningioma extending along the planus sphenoidale, measuring 23x19x17mm. Preoperatively, all pituitary hormones were in the normal range. On POD1, she was noted to have polyuria with urine output of &amp;gt;400ml/h, uptrending sodium levels (148, RR: 135-145mmol/L), low urine specific gravity (&amp;lt;1.005, RR:1.005-1.030) and low urine osmolality (82, RR:300-900mOsm/kg). She was diagnosed with DI and was treated with DDAVP over the following three days. Follow-up MRI was done. In addition to post-surgical changes, it showed acute ischemia in the region of the anterior commissure. After short-term improvement in her clinical status, she was noted to have decreased thirst and decreased urine output on POD6. Sodium was low at 132mmol/L. Urine specific gravity was 1.017. Serum osmolality was 258 mOsm/kg (RR:279-300 mOsm/kg). There was concern for developing SIADH vs concurrent adrenal insufficiency. Patient had received methylprednisolone perioperatively, hence AM cortisol testing would have been inaccurate. Fluid restriction, along with empiric glucocorticoid replacement, was initiated. Sodium continued to worsen with nadir of 122mmol/L and patient reported new onset headache. She was started on 3% (hypertonic) saline continuous infusion and salt tablets. Hyponatremia gradually resolved by POD13, 7 days after onset of SIADH. Salt tablets and fluid restriction were discontinued. Patient was seen in clinic on POD17 and reported normal thirst and urine output. Sodium was noted to be 143mmol/L. Conclusion: This case highlights the rare presentation of a partial triphasic sodium imbalance after resection of a suprasellar mass, with a prolonged second phase lasting for 7 days. A few studies have reported that it may last longer when pituitary gland is not damaged preoperatively, as was the case in our patient. Similarly, complete recovery may also occur if the hypothalamus and pituitary are normal preoperatively. Postoperatively, patient was noted to have an anterior commissural ischemia. This could have contributed to the fluctuations in ADH secretion, due to the rostral proximity of the hypothalamus to the anterior commissure. Despite adequate measures, sodium may continue to drop dramatically in the second phase. Patients should be monitored for changes in thirst and normalization of urine output, as these may indicate early symptoms of impending SIADH before hyponatremia develops.

Acute peritoneal dialysis is an efficient and reliable alternative therapy in preterm neonates with acute kidney injury.

BackgroundThis study aimed to assess the underlying causes and outcomes of acute peritoneal dialysis (APD) and the complications of PD procedure in preterm neonates with acute kidney injury (AKI).MethodsA retrospective study of 21 preterm neonates who underwent APD in a neonatal intensive care unit (NICU) in Peking University Third Hospital between 2016 and 2019 was conducted. The demographic, clinical, biochemistry, and PD procedure­-related information of the neonates was analyzed.ResultsOf the 21 preterm neonates, the average gestational age (GA) was 28.9±2.6 weeks, and the average birth weight was 1,226.7±495.3 g, and included 5 (23.8%) low-birth-weight infants (LBWIs), 7 (33.3%) very LBWIs (VLBWIs), and 9 (42.9%) extremely LBWIs (ELBWIs). The major underlying causes for APD were asphyxia (66.7%, n=14) and twin-twin transfusion syndrome (47.6%, n=10). PD procedure-related complications mainly involved inadequate drainage (n=5, 23.8%) and drainage infections (n=2, 9.5%). The median duration of PD was 3 days (range, 1 hour–20 days). Compared to pre-PD, blood urea nitrogen (BUN) and serum K+ levels were significantly decreased post-PD (P<0.05). After PD, edema disappeared in 77.8% (n=14/18) of patients, and 42.9% patients (n=9/21) gained normal urine output. Although 8 of the 21 (38.1%) patients died and 6 (29.6%) abandoned therapy, 7 (33.3%) patients including 1 VLBWI and 3 ELBWI survived.ConclusionsAPD is an efficient and reliable alternative route of renal replacement therapy particularly for reducing BUN and K+ levels in preterm neonates with AKI. APD is practicable in critically ill preterm neonates, even in LBWIs and ELBWIs.

Case Report and Supporting Documentation: Acute Kidney Injury Manifested as Oliguria Is Reduced by Intravenous Magnesium Before Cisplatin

After more than four decades of post-approval, cisplatin is still an important treatment for numerous cancers. However, acute kidney injury (AKI), defined as significant impairment of renal filtration as discussed below, is the major limiting side effect of cisplatin, occurring in approximately 30% of patients (25–33% after the first course). Cisplatin also damages the kidneys’ ability to reabsorb magnesium in 40–100% of patients, with collateral health risks due to subsequent hypomagnesemia. Multiple methods and drugs have been proposed for preventing cisplatin-induced AKI, including saline infusion with or without mannitol, which has not always prevented AKI and has been found to activate a cellular stress response in renal tubular cells. While numerous reports and trials, as well as the National Comprehensive Cancer Network (NCCN), support premedication with magnesium and hydration, this practice has not been universally accepted. Many clinics administer intravenous magnesium (IV) only after identification of hypomagnesemia post-cisplatin treatment, thus placing patients at risk for AKI and chronic renal loss of magnesium. We present the following case report and additional supporting evidence identifying the immediate effect of IV magnesium prior to intraperitoneal cisplatin for cycle 4 because of documented hypomagnesemia resulting in normalization of oliguria, which had been experienced for the first three cycles. The patient subsequently requested and received IV magnesium before cisplatin for the next two cycles with continuation of normal urinary output. The effect of pretreatment with IV magnesium on urine output following cisplatin has not been previously reported and further supports pre-cisplatin administration. In addition, two recent meta-analyses of clinical trials and pre-clinical research are reviewed that demonstrate effectiveness of magnesium pretreatment to preventing AKI without reducing its chemotherapeutic efficacy. This case report with additional evidence supports the adoption of administration of 1–3 g IV magnesium before cisplatin as best practice to prevent cisplatin induced AKI and hypomagnesemia regardless of patient baseline serum magnesium levels.

Infant With Inconsolable Cryinge

A healthy 9-month-old female infant presented to the emergency department with inconsolable crying and consciousness fluctuation of 2 hours’ duration. She had no fever, had regular oral intake, and had normal urine and stool output, without rectal bleeding. Neurologic examination result was unremarkable. The abdomen was soft, but the baby experienced discomfort during abdominal examination. All blood test results were unremarkable. Ultrasonography showed an undefined image at the mesenteric root (Figure 1), without a clear image of intussusception.

Urethroplasty with balloon catheterization in fetal lower urinary tract obstruction: observational study of 10 fetuses.

To present the preliminary outcomes of fetal urethroplasty using a coronary angioplasty balloon catheter in lower urinary tract obstruction (LUTO). We included 10 consecutive male fetuses diagnosed with LUTO caused by presumed isolated posterior urethral valves (PUVs), who underwent urethroplasty with a balloon catheter in our center between 2015 and 2018. During urethroplasty, the fetal urethra was dilated using a balloon catheter (diameter, 0.014 inches; balloon size, 2 × 9 mm) inserted under ultrasonographic guidance via an 18-gauge needle introduced into the fetal bladder. Mean gestational age at the time of urethroplasty was 17.8 (range, 16.5-20.4) weeks. All fetuses survived the procedure without any complications and there was no case of preterm prelabor rupture of the membranes. The procedure was successful in 5/10 (50%) fetuses, while in the other five (50%), we were unable to insert the balloon catheter into the urethra. In the five successfully treated cases, mean gestational age at delivery was 38 (range, 36-40) weeks and presence of PUVs was confirmed after birth. All five neonates micturated spontaneously and presented with normal urine output after birth. During the follow-up period, the parameters of kidney function were within normal limits in two neonates, whereas signs of impaired renal function were seen in another two. The other was diagnosed with renal insufficiency and required kidney transplant with bladder sparing at 2 years of age. Urethroplasty with a balloon catheter is a new prenatal treatment option for fetuses with PUVs. By restoring fetal micturition, the procedure can preserve normal urinary bladder and kidney function. Although data on its efficacy and potential to differentiate the etiology of LUTO are sparse, a significant advantage of this method is its safety for the fetus and the mother. Even if the neonates develop renal insufficiency, they may be eligible for kidney transplant with connection to their own bladder, without the need for urostomy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Effect of Implementing Nursing Intervention Program about Early Detection and Prevention of Acute Kidney Injury on Critically Ill Patients’ Clinical Outcome

Acute Kidney Injury is considered as a life threatening condition that affects critically ill patients. It is associated with high morbidity and mortality rate.. Aim: evaluate the effect of implementing nursing intervention program about early detection and prevention of acute kidney injury on critically ill patient's clinical outcome. Design: A quasi experimental research design was utilized. Subjects: convenience sample of 60 adult patients at the anesthesia Intensive Care Unit of Tanta University Hospital, divided into two groups (control and study group) 30 patients in each. Results: The majority (96.7%) of patients in both control and study group had high level of National early warning sign score (NEWS) on admission. There was a significant difference between control and study patients in relation to renal recovery, referred to nephrologists, Patients who received RRT and hospital mortality with P= 0.004. More than half (53.3%) of the study group had normal urine output ≥0.5 mL/kg per hour for >6 hours after one week compared to low percentage of patients (6.7%) in control group. There was a significant difference between control and study sample to length of hospital stay and status on discharge after one week with p= (0.000 and 0.015) respectively. Conclusion: improved patient' clinical outcome in study sample compared with control group. Recommendations: Integrating nursing intervention program into plan of care to replace the traditional nursing care plan.

Eye Discharge in a 9-day-old Twin Boy.

1. Eleanor A. Sharp, MD* 2. Jessica L. Garrison, MD* 1. *Paul C. Gaffney Division of Pediatric Hospital Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA A 9-day-old infant boy presents to the emergency department with a 1-day history of bilateral eye redness and yellow discharge. The morning before presentation, his mother noted his right eye to be crusted shut with dried yellow discharge. She applied a warm compress that removed the discharge and allowed him to open his eye normally. However, over the next several hours he developed bilateral eyelid swelling and yellow drainage from both eyes. He seemed to be trying to rub his eyes and was fussier than usual. The day of presentation, his mother noted both his eyes were red, swollen, and draining yellow fluid, so she brought him to the emergency department for evaluation. The patient has not been breastfeeding as long or as frequently as usual over the past day but has still had normal stool and urine output. The patient has not had fever, nasal congestion, rhinorrhea, rash, or sick contacts. His twin sister is asymptomatic. The patient was born full term via spontaneous vaginal delivery. He was the firstborn twin. The mother received routine prenatal care, and both the pregnancy and delivery were uncomplicated. Maternal screening for gonorrhea and chlamydia at the first prenatal visit was negative, and the patient received ophthalmic erythromycin after delivery. In the emergency department, the infant is afebrile with normal vital signs for age. He is fussy but consolable. He has periorbital swelling with overlying erythema, conjunctival injection, and mucopurulent discharge from both eyes, right worse than left. The reminder of his examination is unremarkable. Due to his age, evaluation for possible serious bacterial infection is completed. His white blood cell count is …

Activated Factor Seven (aFVII) versus Aminocaproic Acid for Treatment of Traumatic Retro-Peritoneal Hematoma

Introduction: Off-labelled use of activated Factor VII (aFVII) in severe traumatic bleeding has been used as an alternative to aminocaproic. Aim of Work: The aim of this study is to compare the efficacy of aFVII with aminocaproic acid in the medical treatment of retroperitoneal bleeding, treatment of hypovolemic shock and preventing complications of massive blood transfusion. Materials and Methods: 80 patients with traumatic retro-peritoneal hematoma were allocated into two groups of 40 patients each. Patients in Group A received aminocaproic acid, while patients of group B received aFVII. The number of packed RBCs given to achieve the target Hb level and time to get to this target Hb level (&gt;10 gm%) were recorded as indicators of control bleeding. Blood pressure, pulse, arterial blood gasses and urine output were recorded as indicators of successful treatment of hypovolemic shock. Hypoxic index, chest X-ray and coagulation profile were used as indicators for complications. Results: There was a significantly smaller number of packed RBCs given to patients of group B to achieve the target Hb level and this target Hb level was achieved in a shorter time. There was a significantly higher number of patients in group B compared to group A who had normal blood pressure, pulse and urine output, pH and bicarbonate concentration. There was a significantly smaller number of patients who developed DIC and TRALI in group B compared to group A. Conclusion: aFVII was more effective than aminocaproic acid and needed a shorter time to stop retroperitoneal bleeding, treat hypovolemic shock, restore adequate tissue perfusion and protect patients from complications of massive blood transfusion.

Case 4: Abdominal Distention in a 12-month-old Girl.

1. Courtney Brennan, MD* 2. Kathryn Pade, MD† 1. *Department of Emergency Medicine and Transport, Children’s Hospital Los Angeles, Los Angeles, CA 2. †Department of Emergency Medicine, Rady Children’s Hospital, San Diego, CA A 12-month-old previously healthy girl presents to the emergency department for 3 months of progressive abdominal distention. They note that her abdomen has seemed very firm in the past month and it seems to be causing her discomfort. Parents report that she has continued to breastfeed for 10 to 15 minutes at a time but will often fall asleep during feedings, and she has been refusing to eat solid foods in the past month. They deny any dysphagia. She has maintained her normal urine output, and they deny any vomiting or changes in her stooling. She had been meeting developmental milestones appropriately, but she has seemed more tired in the past 2 to 3 months and no longer wants to crawl or sit unassisted. Her verbal and fine motor skills have continued to progress. They deny any known changes to her growth parameters. She had an upper respiratory tract infection approximately 2 weeks earlier. Review of systems is otherwise negative. Physical examination reveals an alert, smiling, and interactive infant. Vital signs are significant for tachypnea (respiratory rate of 48 breaths/min) and initial hypertension (blood pressure of 110/98 mm Hg), but a normal temperature of 99.9°F (37.7°C), heart rate of 122 beats/min, and oxygen saturation of 97%. Her weight is at the 71st percentile for age. Her lungs are clear to auscultation, and her heart rate is regular …

Extracorporeal resection of renal artery aneurysm and separate autogenous vein graft repair of its branches in a patient with retroaortic renal vein

Autopsy and intravital studies have reported the incidence of renal artery aneurysms (RAA) in 0.01 to 0.97% of the population. Fibromuscular dysplasia (FMD) and atherosclerosis are the main etiological factors for the development of RAA. The presence of abnormalities of the veins such as a retroaortic renal vein can significantly complicate the implementation of surgical interventions. The main methods to treat RAA are RAA resection with prosthetic repair, embolization of aneurysm cavities, and placement of an endograph. When aneurysm spreads to involve the renal artery branches or RAA is located in the kidney gates, the extracorporeal renal artery reconstruction is the only method to restore the renal vessels and keep a kidney. The article provides a rare observation of a patient suffering from renal artery fibromuscular dysplasia, left renal artery aneurysm with the development of vasorenal hypertension. The features of this clinical observation were the retroaortic left renal vein and the renal artery aneurysm located in the kidney gates. The patient underwent ureter-sparing extracorporeal autogenous vein graft repair of left renal artery branches. The surgery was performed using custodial solution for kidney pharmaco-hypothermic protection. Renal artery aneurysm was resected with the creation of a common junction of the renal artery branches followed by autogenous vein graft repair. The two lower segmental branches of the renal artery were separately prosthetized using the reversed autovein sections. Parietal injury to the left ureter was diagnosed in the patient in the postoperative period. A percutaneous needle-guided urine drainage bag was superimposed under ultrasound guidance with the placement of an integral stent in the injury area. The patient was discharged to outpatient care on Day 11. The urine drainage bag was removed two months after the control CTA. The integral stent was removed a month later, normal urine output was restored in the upper urinary tract. After 6 months, the control CTA showed that all reconstructed renal artery branches were completely patent, and blood pressure readings were within normal range.