Partial Renal Recovery Research Articles

Immune checkpoint inhibitor-associated nephritis-treatment standard.

Over the last 13 years, the use of immune checkpoint inhibitor (ICI) therapy has grown remarkably, owing to their unprecedented anti-tumor efficacy in certain tumor groups. With increased use of ICIs, we are seeing immune-related adverse events (irAEs) more frequently. Renal irAEs, such as ICI-associated acute kidney injury (ICI-AKI), are reported in 2%-5% of patients treated with ICIs, with acute tubulointerstitial nephritis (ATIN) as the most common histopathologic lesion, though various forms of glomerulonephritis have also been reported. Modifiable risk factors for ICI-AKI include concurrent use of ATIN-associated drugs, like proton pump inhibitors, non-steroidal anti-inflammatory drugs and antibiotics, and dual ICI therapy with both Cytotoxic T-lymphocyte Associated Protein 4 (CTLA-4) and Programmed Cell Death Protein 1 and its ligand (PD1/PDL-1) blockade. Kidney biopsies remain the diagnostic modality of choice, though several promising non-invasive biomarkers, which have not yet been broadly clinically validated have emerged. The treatment of ICI-AKI involves holding ICIs, discontinuation of ATIN-associated drugs and initiation of immunosuppression with corticosteroids as first-line therapy. With prompt treatment initiation, most patients achieve full or partial renal recovery, allowing for re-challenge with ICI. However, a subset of patients will require additional steroid-sparing therapies for corticosteroid-dependent or refractory ICI-AKI. Here we review developments in our understanding of the pathophysiology of ICI-AKI, the approach to diagnosis (with a focus on the emergence of novel diagnostic tools), prognostic factors and the current evidence for establishing treatment standards for ICI-AKI. As the evidence base remains largely retrospective, we identify questions that would benefit from future prospective studies in the diagnosis, management and prognostication of ICI-AKI.

Colistin-Induced Acute Kidney Injury in the Treatment of Extensively Drug-Resistant Klebsiella Pneumoniae: A Case Report

This case report describes a 59-year-old male with uncontrolled type 2 diabetes mellitus who presented with recurrent urinary tract infections caused by multi-drug resistant Klebsiella pneumoniae. The patient's condition progressed from initial sensitivity to ceftazidime-avibactam to eventual resistance, leaving colistin as the only effective antibiotic. During the 19-day course of colistin therapy (900 mg daily), the patient developed severe acute kidney injury, with serum creatinine rising from 1.3 to 10.1 mg/dL, and colistin-induced peripheral neuropathy. Following discontinuation of colistin, partial renal recovery was observed, with creatinine decreasing to 2.5 mg/dL. This case highlights the challenges in managing extensively drug-resistant infections, the limited treatment options available, and the significant adverse effects associated with last-resort antibiotics like colistin. It underscores the urgent need for new antimicrobial strategies and emphasizes the importance of careful monitoring during treatment with potentially toxic antibiotics.

#2172 Maternal, obstetric and perinatal outcomes in pregnant women with lupus nephritis: experience of a tertiary center

Abstract Background and Aims Pregnant patients with systemic lupus erythematosus (SLE) and lupus nephritis (LN) are at particular risk for unfavourable maternal, obstetric and perinatal outcomes, especially if the disease is active. Thus, it is of paramount importance that LN patients have preconceptional counseling in order to optimize care and define the best moment to conceive. Method Observational retrospective study based on the review of medical records of pregnant women with lupus nephritis surveilled at our multidisciplinary maternal-fetal clinic from 2011 to 2023. Results We evaluated 26 gestations in 24 patients. Mean age was 30,8 years (19-40), 21 women were Caucasian, 2 black African, 1 Asian; 10/24 were nulliparous and 6/24 had chronic hypertension (HTUN). Mean baseline SCr was 0,79 mg/dl (0.5-3.5), baseline proteinuria > 1 g/day or <0,5 g/day was present in 3/26 and 22/26 gestations, respectively. Chronic kidney disease (CKD) stage 2, 3 and 5 was present in 1, 2 and 1 gestation respectively; 5/24 patients were APL positive; positive dsDNA and complement consumption at baseline were present in 4/26 and 12/26 gestations, with most patients previously having class IV LN (15/23). Active lupus nephritis during pregnancy occurred in 3 patients: 2 were submitted to medical termination of pregnancy (due to severe pulmonary HTN and renal function deterioration) and 1 was successfully treated with tacrolimus, azathioprine and prednisolone from week 28, and biopsied postpartum. Exposure to teratogenic therapy during the 1st trimester occurred in 3/26 gestations with a mean exposure of 8,5 weeks. Worsening kidney function occurred in 3/24 patients due to PE (1/26 CKD stage 3)/LN (1/26 stage CKD3)/pregnancy hyperfiltration (1/26 CKD stage CKD5), with partial and full renal recovery in 2 CKD stage 3 patients and dialysis initiation in the CKD stage 5 patient at 19 weeks (urea levels > 100 mg/dL). De novo proteinuria occurred in 3/24 patients (due to LN) and worsening proteinuria in 6/24 patients (PE 2/6; pregnancy hyperfiltration 4/6). De novo or worsening HTN occurred in 3/26 gestations. Immunosuppression during pregnancy consisted on azathioprine, prednisolone and hydroxychloroquine. SLE Flares occurred in 7/26 (27%) patients, with minor relapses in 4/6 gestations (hepatic, skin and articular involvement) and major renal flares in 3/6 gestations. All renal relapses occurred in patients with no preconception counseling nor immunosuppressive therapy. PE occurred in 2/26 (7,6%) gestations. Abortion occurred in 6/26 pregnancies (3 spontaneous abortions, 2MTP, 1 voluntary interruption). Cesarean (C) rate was 34,6%. Mean gestation age at delivery was 37±3 (28-40) weeks. Mean birth weight was 2789±859 mg (800-4175), 4 newborns were low birth weight (<2500 g). Apgar scores at 5/10 minutes were 10/10, respectively. Neonatal intensive care (NICU) was needed in 5 newborns. Conclusion In our series of SLE patients with LN, worsening kidney function only occurred in patients with advanced CDK, and renal flares in patients without preconceptional counseling nor immunosuppressive therapy, which underlines the importance of careful pregnancy planning. One patient with proliferative LN was successfully treated with tacrolimus associated to azathioprine and prednisolone during pregnancy, being a valuable therapeutic option in these situations. Although SLE patients with LN can have safe pregnancies, we still found an increased incidence of maternal, obstetric and perinatal complications, namely HTN, PE, C, low birth weight and the need of NICU.

Characteristics and outcome of pregnancy-related acute kidney injury in a teaching hospital in a low-resource setting: a five-year retrospective review.

Pregnancy-related kidney injury contributes to a high burden of acute kidney injury in low-resource settings and causes maternal and perinatal morbidity and mortality. Few studies have examined the impact of acute kidney injury in resource-limited countries, with very limited research on pregnancy-specific disorders in Ethiopia. This study aimed to determine the characteristics of pregnancy-related acute kidney injury, outcomes and associated factors. A retrospective study was conducted to evaluate the clinical profile and maternal-fetal outcome of pregnancy-related acute kidney injury at Ayder Comprehensive Specialized Hospital in Tigray, Ethiopia, from January 1, 2017, to December 31, 2021. Maternal and fetal outcomes were analyzed using descriptive statistics. Multivariate logistic regression was used to determine the association between the dependent and independent variables. Of 27,350 mothers who delivered at Ayder Comprehensive Specialized Hospital between January 1, 2017, and December 31, 2021, a total of 187 women developed pregnancy-related acute kidney injury, a prevalence rate of 68 per 100,000 births. Preeclampsia, sepsis and pre-renal causes due to dehydration and hemorrhage were the most common causes of pregnancy-related acute kidney injury in this study. Hemodialysis was needed in 8.6% (n = 16) of patients. Of the 187 pregnancy-related acute kidney injuries, 143 (76.5%) recovered completely and 30 (16%) partially. The mortality rate was 7.5%. Preexisting chronic kidney disease (AOR = 30.13; 95% CI: 2.92, 310.84), use of vasoactive agents (AOR = 5.77; 95% CI: 1.47, 22.67), increase in creatinine per unit (AOR = 1.65; 95% CI: 1.11, 2.45) and complications related to acute kidney injury (AOR = 5.26; 95% CI: 1.73, 16.00) were determinants of the composite endpoints (partial renal recovery and death). This study emphasizes acute kidney injury in resource-limited settings is a significant cause of maternal and fetal morbidity and mortality. The vast majority of patients with pregnancy-related acute kidney injury recovered completely from kidney injury. The main causes of pregnancy-related acute kidney injury were preeclampsia, sepsis and pre-renal associated with hemorrhage and dehydration. Preexisting renal disease, use of vasopressors, increase in creatinine per unit and complications associated with acute kidney injury were determining factors for concomitant fetomaternal mortality. Appropriate preventive strategies during prenatal care and prompt treatment are needed for pregnancy-related acute kidney injury.

Risk factors and fetomaternal outcome in pregnancy-related acute kidney injury.

Pregnancy-related acute kidney injury (PRAKI) is acute kidney injury (AKI) occurring during pregnancy, labor, and postpartum period. AKI is defined as suddenly impaired kidney function with the retention of nitrogenous and other waste products. In high population country like India, not all deliveries are done tertiary care. Even not all are registered one if delivery is conducted at a hospital setup. The majority of patients are being managed by available obstetrician at local places. Early diagnosis and timely management of complications related to pregnancy are very important to avoid PRAKI. We aim to study maternal risk factors and fetomaternal outcome in PRAKI. A prospective study is conducted between 2021 and 2022 in the Department of Obstetrics and Gynaecology, VMMC, and Safdarjung Hospital, New Delhi. For antenatal and delivered women up to 6 weeks, 50 patients were recruited according to KDIGO (Kidney Disease International Global Outcomes) criteria. Patients were followed with CBC, serum electrolytes, serial KFT, urine input/output monitoring, and USG-KUB. Dialysis was done if indicated. Complete renal recovery was considered if S.Cr ≤1.0 mg/dl within 6 weeks of diagnosis of AKI. For statistical significance, a P value of less than 0.05 was considered. The majority of patients were unbooked, 21-25 years of age, and belonged to lower socioeconomic status (54%). Risk factors were: preeclampsia (28%), puerperal sepsis (24%), PPH (20%), abruption (14%), pyelonephritis (4%), acute gastroenteritis (4%), gestational hypertension with superimposed preeclampsia (2%), antepartum eclampsia (2%), and thrombotic microangiopathy (2%). Hemodialysis is required in 23 (46%). Complete renal recovery was seen in 40 (80%) and partial renal recovery in 3 (6%). Maternal mortality was 14% and causes were: puerperal sepsis (57%), preeclampsia with severe features with MODS (29%), and antepartum eclampsia with hepatorenal failure (14%). Fetal outcome: 76% live birth, 24% intrauterine death, and 16% early neonatal death. Most common risk factors for PRAKI are preeclampsia followed by puerperal sepsis and PPH where all are preventable causes.

Epidemiology and outcome of acute kidney injury in hospitalized children: experience from a tertiary care hospital in Eastern India

Background: The aim of the study was to assess the etiology, clinical profile and short-term outcome of acute kidney injury in hospitalized children. Methods: A single centre prospective observational study conducted at a tertiary care hospital in eastern India. Consecutive hospitalized children aged between one month to twelve years who developed AKI according to AKIN criteria were included in the study. Relevant clinical and laboratory parameters as guide by clinical condition along with outcome of patients were recorded at the time of discharge and at one month and three months after discharge. Results: 116 hospitalized children who developed AKI were included in the study; 63 (54.3%) participants are above 5 years of age with male to female ratio of the study population was 1.07:1. Infections (46.5%), acute glomerulonephritis (19.8%), snake bite (11.2%) and post-surgery (8.6%) were the common causes of AKI. 43.1% of them had AKIN stage 3. 66.4% had oliguria, 33.6% had shock. 72.4% required admission at Pediatric Intensive Care Unit support, 32.4% required ionotrop support, 44.8% required mechaicanical ventilator support. Around 65% requrired dialysis support; of which 75% recieved hemodialysis and 25% requied peritoneal hemodialysis. Mortality rate was 44%. At discharge, 41.6% (n=27) of the patients had complete renal recovery from AKI. Percentage of partial renal recovery at the time of discharge, 1 month and 3 months after discharge were respectively 53.8%; 47.7% and 10%. 3 patients at the time of discharge and 2 patients after 3 months required persistent dialysis support. Number of factors are associated with poor outcome especially higher acute kidney injury state, critically ill patients and low serum albumin at admission. Conclusions: Infection is the leading cause of acute kidney injury in hospitalized children in this part of world. Mortality in critically ill children with acute kidney injury is high. Various clinical parameters at presentation are associated with poor short term renal outcome.

#4764 NEPHROTIC SYNDROME IN PREGNANT DIABETIC WOMEN: MATERNAL AND PERINATAL OUTCOMES AT A TERTIARY CENTER

Abstract Background and Aims Management of pregnant women with diabetic kidney disease and nephrotic range proteinuria or nephrotic syndrome constitute a challenge to clinicians. Maternal and perinatal outcomes, especially in patients with chronic kidney disease, remain poor. The authors describe the multidisciplinary approach and the outcomes of diabetic pregnant patients with nephrotic range proteinuria. Method Retrospective observational study in which the authors reviewed maternal, obstetric and perinatal outcomes in pregnant diabetic woman with nephrotic range proteinuria or nephrotic syndrome surveilled at our nephro-obstetric unit from 2011 until 2021. Results We evaluated 7 gestations in 6 patients. Mean age was 31.7±4.7 years (26-38), 5 were caucasian and 1 was black African, and 4 were nuliparas. They all had type 1 diabetes, with mean disease diagnosis at 9.9±5.9 years of age. All patients had chronic hypertension and 5/6 patients had poor glycemic control before pregnancy (mean HbA1c of 11.9%). Mean baseline SCr was 1.1±0.5 mg/dl (0.51-2.8) and mean baseline proteinuria was 3697.2±2301.4 mg/day (75-6326), with 1/1/3/2 patients being on CKD stage 1/2/3/4, before pregnancy, respectively. Exposure to teratogenic therapy during the first trimester occurred in 5/7 gestations with a mean exposure of 7.4 ± 3.1 weeks. Proteinuria increased in all patients and renal function deteriorated in 5/7 gestations (mean SCr of 2.5±1.2; 0.67-4.07 mg/dl) in association with pre-eclampsia in 2 patients and with pregnancy hyperfiltratrion and nephrotic syndrome in all gestations. One patient started dialysis at week 28, due to urea levels >100mg/dL. Partial renal recovery occurred in 2 patients. To date, 3/6 patients initiated PD 15 months (6-29 months) after gestation, 1 of which received a kidney-pancreas transplant. Hypertension aggravated in 6 gestations. Aspirin and low molecular weight heparin were initiated in 6 gestations and they were all treated with furosemide to control volume overload. Regarding fetal outcomes, severe fetal growth restriction was responsible for 1 still birth and 1 medical termination of pregnancy, both at 24 weeks. Cesarean was performed in 4/5 gestations (one is still undergoing) due to pre-eclampsia, renal function deterioration and/or fetal growth restriction. Mean gestation age at delivery was 29.5±4.7 weeks, mean birth weight was 1389 ±203.3 mg (1190-1665) and mean apgar scores at 1/5/10 minutes were 9/10/10 respectively. Neonatal intensive care was needed in 4 newborns. Conclusion This study reinforces the idea that diabetic women with nephrotic range proteinuria have an increased risk of complications and worse outcomes during pregnancy, namely pre-eclampsia, fetal growth restriction, preterm delivery and renal function deterioration. As such, glycemic and proteinuric control should be optimized and careful counseling regarding outcomes should be discussed before pregnancy. Management during gestation should involve an experienced multidisciplinary team including endocrinologist, nutritionist, nephrologist and obstetrician.

Prevalence and outcomes of hypothyroidism-induced acute kidneyinjury.

Hypothyroidism is an important reversible cause of acute kidney injury (AKI), acting through various mechanisms, including rhabdomyolysis, metabolic, and systemic effects. We screened all patients presenting with AKI for hypothyroidism, and suspected hypothyroid-induced AKI patients were followed up. The prevalence of hypothyroidism-induced AKI was 1.9%, with the commonest presenting symptom being pedal edema. The mean thyroid-stimulating hormone levels (mIU/L) and estimated glomerular filtration rate (eGFR) (mL/min/1.73m2) were 123.5 ± 22.32 and 29.4 ± 20.54, respectively, at presentation, and 3.28 ± 4.91 and 71.39 ± 40.28, respectively, at the end of 8 weeks. Creatine Phosphokinase (CPK) was significantly elevated in only 1 patient. One patient became dialysis-dependent (11.1%), 2 had partial renal recovery (22.2%), and 6 patients had complete renal recovery (66.7%). There was a significant positive correlation between renal recovery and CPK at admission, eGFR at admission, and hemoglobin, and a significant negative correlation with the presence of chronic kidney disease, urea at admission, and creatinine at admission. Thyroid hormones exert various effects on the kidney, and their imbalance can significantly alter renal function. Elevated creatinine with normal GFR can occur due to increased release of creatinine. Our study is the first published series of hypothyroid-associated AKI with follow-up data.

Relation of Mechanical Ventilation to Acute Kidney Injury in Myocardial Infarction Patients

Introduction: Acute kidney injury (AKI) is a common and serious complication in critically ill patients, particularly those with ST-elevation myocardial infarction (STEMI). Mechanical ventilation (MV) is often needed when respiratory deterioration occurs and is continuously associated with higher risk for AKI. Whether MV is an independent predictor for AKI in STEMI patients has not been evaluated before. We aimed to determine a potential association between MV and the occurrence of AKI in STEMI patients. Methods: A single-center retrospective cohort in a tertiary referral hospital. We evaluated consecutive patients that were admitted to the cardiac intensive care unit with acute STEMI between 2008 and 2019. Patients were divided into groups based on their need for MV upon admission. To minimize baseline differences between the two groups, propensity matching was performed. The primary outcome was the occurrence of AKI after intubation and secondary outcomes included severe AKI (>2 times the baseline creatinine) and renal recovery. Results: 2,929 patients were included and of them, 143 (5%) were intubated. After using the propensity matching, 138 pairs were available for analysis with similar demographic and clinical characteristics. MV was a predictor for AKI (Table 2, odds ratio [OR]: 3.3, 95% confidence interval [CI]: 1.9–5.6) and severe AKI (OR: 6.3, 95% CI: 2.5–16). These results remained significant after adjusting for the occurrence of a new heart failure and bleeding. Early or partial renal recovery was similar between the groups. Conclusion: MV is independently associated with the occurrence of AKI and severe AKI. The possible mechanism might be temporary, reflected by similar rates of renal recovery.

Causes and outcome of acute kidney injury amongst adults patients in two hospitals of different category in Cameroon; a 5 year retrospective comparative study

BackgroundAcute kidney injury (AKI) is an under-recognized disorder, which is associated with a high risk for mortality, development of chronic kidney disease (CKD).ObjectiveWe sought to describe and compare the causes and outcomes of AKI amongst adult patients in Douala general hospital (DGH) and Buea regional hospital (BRH).MethodsA hospital-based retrospective cohort analytic study was carried from February to April 2021. Convenience sampling was used. We included Patient’s files admitted from January 2016 to December 2020 aged > 18 years, with AKI diagnosed by a nephrologist and recorded values of serum creatinine (sCr) on admission and discharge. Data were analysed using SPSSv26. Chi-square, fisher, median mood’s and regression logistic test were used, values were considered significant at p < 0.05.ResultsOf the 349 files included 217 was from DGH and 132 from BRH. Community acquired AKI were more present in BRH 87.12% (n = 115) than DGH 84.79% (n = 184) (p = 0.001). Stage III AKI was the most common presentation in both hospital. Pre-renal AKI was more common (p = 0.013) in DGH (65.44%, n = 142) than BRH (46.97%, n = 62). Sepsis and volume depletion were more prevalent in urban area with (64.51 and 30.41% vs. 46.21 and 25.75%) while severe malaria was more present in Semi-urban area (8.33% vs. 1.84%, p = 0.011). Complete and partial renal recovery was 64.97% (n = 141) in DGH and 69.69% (n = 92) in BRH (p = 0.061). More patients had dialysis in BRH 73.07% (n = 57) than in DGH 23.33% (n = 21). More patient died in DGH 33.18% (n = 72) died than in BRH 19.70% (n = 26) (p = 0.007). Stage III was significantly associated with non-renal recovery in both DGH (p = 0.036) and BRH (p = 0.009) while acute tubular necrosis was associated with non-renal outcome in DGH (p = 0.037).ConclusionsAKI was mainly due to sepsis, volume depletion and nephrotoxicity. Complete and partial recovery of kidney function were high in both settings. Patient outcome was poorer in DGH.

Feto-maternal outcome of pregnancy related acute kidney injury in a North Indian population.

Acute kidney injury (AKI) is a serious complication in pregnancy, resulting in significant maternal and fetal morbidity/mortality. The aim of this study was to evaluate the magnitude of pregnancy-related AKI (PRAKI) in a North Indian population, and its contributing factors. This prospective study was carried out at the department of obstetrics and gynecology in collaboration with the nephrology unit and internal medicine department at King George Medical University from June 2019 to October 2020. After informed consent and ethical clearance, a total of 150 PRAKI women were enrolled, and 98 women were subjected to renal replacement therapy as per Kidney Disease Improving Global Outcomes 2012 guideline and were followed for 3 months for renal and fetomaternal outcome. There was a high incidence (1.02%) of AKI during pregnancy and puerperium. Majority (57.3%) of the women were aged 26-30 years, and 93.3% had institutional deliveries. About 49% of the women suffering from PRAKI were multipara, and most were identified in the postpartum period (82%). Hypertensive disorder of pregnancy (48%), puerperal sepsis (45%), and hemorrhage (34%) were the associated causes for PRAKI. Stillbirth/intrauterine death (IUD) was higher in Stage II (53.8%) and Stage III AKI (37.7%) (none in Stage I AKI). The majority of the neonates were born with a birth weight of ≤2500 g irrespective of the stages of AKI. Preterm deliveries were significantly higher in Stage II AKI (53.8%) than in Stage I (33.3%) and Stage III (20.0%). Thirty-seven cases of PRAKI were managed conservatively, while 98 required dialysis. Complete recovery occurred in 27.3% and partial renal recovery in 31.3%. However, 3.3% progressed to chronic kidney disease, 34% expired, and 4% were lost to follow-up. High maternal mortality of 30.1% was observed in those dialyzed. AKI is associated with fetal growth restriction and preterm deliveries. Stillbirth/IUD is higher in Stage II and Stage III AKI.

Crescentic glomerulonephritis with anti-PR3 ANCA associated with Bartonella henselae infective endocarditis.

Abstract Bartonella henselae infective endocarditis complicated by glomerulonephritis is a rare diagnosis and requires a broad range differential diagnosis. ANCA PR-3 (Antineutrophil cytoplasmic antibodies directed to proteinase-3) is a frequent finding in this clinical setting. We report a patient with PR3-ANCA positive crescentic glomerulonephritis associated with Bartonella henselae infective endocarditis. Antibiotics and corticosteroids after achieving septic control resulted in partial renal recovery. This case underlines the need to exclude ANCA vasculitis in the setting of crescentic glomerulonephritis associated with infective endocarditis and emphasizes the potential role of immunosuppressive therapy after control of infection.

MO326: Factors Influencing Death Rate in COVID-19-Associated Acute Kidney Injury

BACKGROUND AND AIMSDuring a 2-year pandemic, COVID-19 proved to be a condition with a high potential to affect various organs other than the lungs. Acute kidney injury (AKI) in hospitalized COVID-19 patients is associated with a poor prognosis. The aim of this study was to identify factors influencing in-hospital mortality.METHODIn a retrospective analysis, we included 268 adult patients with RT-PCR-confirmed SARS-CoV-2 infection and AKI admitted to two Emergency University Hospitals during a 6-month period, between 1 November 2020 and 30 April 2021. Data were retrieved from the electronic databases of the two hospitals. We analysed kidney and patient outcomes at discharge and the potential risk factors for mortality in AKI patients. We defined and staged AKI according to KDIGO 2012 creatinine criteria.RESULTSIn our cohort the mean age was 72.28 years, 169 (63%) patients were men, and 111 (41.4%) had previously known chronic kidney disease. 81 patients were classified as having stage 1 AKI, 79 patients had stage 2 AKI and 108 had stage 3 AKI. A total of 135 (50.37%) patients died during hospitalization.Statistic analysis using the Mann–Whitney U-test revealed significant differences (P < .01) between survivors and non-survivors regarding peak values of serum urea (137.9 versus 190.9 mg/dL), creatinine (2.88 versus 3.94 mg/dL), procalcitonin (3.56 versus 15.86 ng/mL), C-reactive protein (92.32 versus 176.09 mg/L), interleukin-6 (243 versus 9552 pg/mL), ferritin (1331 versus 5189 ng/ml) and d-dimers (3.68 versus 6.88 mcg/ml). No significant differences were found between survivors and non-survivors regarding peak values of erythrocyte sedimentation rate (69 versus 71 mm/1 h; P = .35) and fibrinogen (629 versus 645 mg/dL; P = .24) and also regarding the lowest lymphocyte count during hospitalization (519 versus 649/mmc; P = .80).The analysis using Fisher’s exact test showed that deceased patients were significantly more associated with AKI KDIGO stage 2 or 3 (51.9%/63% versus 32.1%), with higher need for renal replacement theraphy (RRT) (68.8% versus 47.9%), with ICU (intensive care unit) admission (90.1% versus 22.3%) (Table 1). Moreover, death was associated more frequently with partial or absent renal function recovery (20%/50% versus 6.4%) (P < .05) (Table 1).In a logistic regression model (using KDIGO stages, serum urea and need for RRT), it was proved that only serum urea had a significant prediction power (P = .001): every increase of serum urea with 1 unit increases the risk of death by 1.007 times (95% confidence interval 1.003–1.011).CONCLUSIONMortality of COVID-19 patients associating AKI is proportionally augmented by both markers of severity of SarS-CoV-2 and also by severity of AKI. In our study, the peak value of serum urea during hospitalization was the best predictor for death in COVID-19.

Successful Use of Belatacept in Three Lung Transplant Recipients for Unique Indications

<h3>Introduction</h3> Belatacept is a selective costimulatory blocker approved for immunosuppression after kidney transplantation. Data for its use in other solid organ transplants shows mixed results. We present 3 cases of its efficacy in lung transplant as an alternative agent for maintenance therapy in unique contexts. <h3>Case Report</h3> Patient #1 is a 40 year old male who received bilateral lung transplant for ILD from scleroderma complicated by AKI requiring hemodialysis with partial renal recovery at discharge. Over the next 7 months, his renal function declined and with a creatinine of 3.9 mg/dL, belatacept was initiated in combination with a lowered tacrolimus goal of 5 - 6 ng/mL to minimize further nephrotoxicity. 2 months into this course, his creatinine improved to 3.2 mg/dL without untoward effect on the allograft. Patient #2 is a 47 year old female who underwent a third retransplant for CLAD. Prior to the third transplant, her immunosuppression consisted of sirolimus, tacrolimus, and prednisone. Mycophenolate mofetil was avoided due to prior skin cancer. Given her history of rejection and high PRA, she was started on belatacept to supplement tacrolimus and prednisone post-op. 22 months post-transplant she has low level DSA and normal cfDNA levels with a normally functioning graft. Patient #3 is a 66 year old male with a right lung transplant for IPF. His course was complicated by TTP and HUS secondary to calcineurin inhibitors, which reoccurred on rechallenge with mTOR inhibitors. He was subsequently started on belatacept along with mycophenolate mofetil and prednisone. He has been on this regimen for 2 years without recurrent side effects, cytopenia, or renal dysfunction. <h3>Summary</h3> Belatacept is renal sparing, which is beneficial as standard immunosuppression regimens include calcineurin inhibitors that are nephrotoxic. Its utility to prevent rejection was shown when evaluated by DSA and cfDNA levels. In the rare case of TTP and HUS, these phenomena did not reoccur. It is imperative to recognize the risks with this agent. PTLD has occurred in EBV-seronegative recipients. There has been an association of viral infections, including CMV. ACR has been documented in heart and kidney recipients. In conclusion, belatacept has a role as an alternative immunosuppressive component in the appropriate clinical context.

Glomerulonephritis with non-Randall-type, non-cryoglobulinaemic monoclonal immunoglobulin G deposits (PGNMID and ITG).

ABSTRACTBackgroundGlomerulonephritis (GN) with non-Randall-type, non-cryoglobulinaemic monoclonal immunoglobulin G deposits encompasses rare diseases [proliferative GN with non-organized deposits (PGNMID) and immunotactoid GN] that cannot be distinguished without ultrastructural analysis by electron microscopy (EM).MethodsHere, we report and analyse the prognosis of 41 EM-proven (PGNMID for 39/41) and 22 non-EM-proven/DNAJB9-negative cases, diagnosed between 2001 and 2019 in 12 French nephrology centres.ResultsMedian (interquartile range) serum creatinine (SCr) at presentation was 150 (92–256) µmol/L. The predominant histological pattern was membranoproliferative GN (79%), with IgG3 (74%) kappa (78%) deposits the most frequently observed. Disease presentation and patient management were similar between EM-proven and non-EM-proven cases. A serum monoclonal spike was detected for 21 patients and 10 had an underlying haematological malignancy. First-line therapy was mixed between clone-targeted therapy (n = 33), corticosteroids (n = 9) and RAAS inhibitors (n = 19). After 6 months, nine patients achieved complete and 23 partial renal recovery. In univariate analysis, renal recovery was associated with baseline SCr (odds ratio 0.70, P = 0.07). After a median follow-up of 52 (35–74) months, 38% of patients had progressed to end-stage kidney disease independently associated with baseline SCr [hazard ratio (HR) 1.41, P = 0.003] and glomerular crescentic proliferation (HR 4.38, P = 0.004).ConclusionsOur results confirm that non-cryoglobulinaemic and non-Randall GN with monoclonal IgG deposits are rarely associated with haematological malignancy. The prognosis is uncertain but may be improved by early introduction of a specific therapy.

Short- and Long-Term Recovery after Moderate/Severe AKI in Patients with and without COVID-19.

Severe AKI is strongly associated with poor outcomes in coronavirus disease 2019 (COVID-19), but data on renal recovery are lacking. We retrospectively analyzed these associations in 3299 hospitalized patients (1338 with COVID-19 and 1961 with acute respiratory illness but who tested negative for COVID-19). Uni- and multivariable analyses were used to study mortality and recovery after Kidney Disease Improving Global Outcomes Stages 2 and 3 AKI (AKI-2/3), and Machine Learning was used to predict AKI and recovery using admission data. Long-term renal function and other outcomes were studied in a subgroup of AKI-2/3 survivors. Among the 172 COVID-19-negative patients with AKI-2/3, 74% had partial and 44% complete renal recovery, whereas 12% died. Among 255 COVID-19 positive patients with AKI-2/3, lower recovery and higher mortality were noted (51% partial renal recovery, 25% complete renal recovery, 24% died). On multivariable analysis, intensive care unit admission and acute respiratory distress syndrome were associated with nonrecovery, and recovery was significantly associated with survival in COVID-19-positive patients. With Machine Learning, we were able to predict recovery from COVID-19-associated AKI-2/3 with an average precision of 0.62, and the strongest predictors of recovery were initial arterial partial pressure of oxygen and carbon dioxide, serum creatinine, potassium, lymphocyte count, and creatine phosphokinase. At 12-month follow-up, among 52 survivors with AKI-2/3, 26% COVID-19-positive and 24% COVID-19-negative patients had incident or progressive CKD. Recovery from COVID-19-associated moderate/severe AKI can be predicted using admission data and is associated with severity of respiratory disease and in-hospital death. The risk of CKD might be similar between COVID-19-positive and -negative patients.

MO382POTASSIUM DISTURBANCES AND CHARACTERISTICS OF RENAL RECOVERY IN 1519 CONSECUTIVE PATIENTS WITH ACUTE KIDNEY INJURY

Abstract Background and Aims Acute kidney injury (AKI) is a common condition occurring in about 15% of hospitalized patients, often complicated by hyperkalemia causing increased risk for adverse cardiovascular events. The level of AKI (prerenal, renal or postrenal), is of importance as both pathophysiology and prognosis differ. Although early recovery from AKI is associated with less morbidity and mortality, patients with a history of AKI have a higher long-term risk of end-stage kidney disease and death. Most AKI studies include critically ill patients treated at intensive care units; less is known about AKI patients in general. The aim of this large single-center study was to report potassium disturbances and short-term hospital outcomes in 1519 consecutive patients with AKI admitted to a nephrology department. Methods All patients diagnosed with AKI between 2009 and 2018 and admitted to the nephrology department at Danderyd University Hospital, Stockholm, Sweden, were screened. Patients who fulfilled the KDIGO 2012 definition of AKI, a sCreatinine (sCr) &amp;gt;1.5 times baseline or increase by &amp;gt;0.3 mg/dL (&amp;gt;26.5 mmol/L), were included. Potassium levels at admission were classified into hypokalemia (&amp;lt;3.5 mmol/L), normokalemia (3.5-4.9 mmol/L), mild hyperkalemia (5-5.4 mmol/L), moderate (5.5-5.9 mmol/L) and severe hyperkalemia (≥6 mmol/L). Partial recovery was defined as an in-hospital sCr decrease by at least 30% while modest recovery was defined as s sCr decrease by at least 50%. Using logistic regression with conditional backward selection, we determined which variables that were associated with a partial recovery or a hyperkalemia (&amp;gt;5 mmol/L). Patients on dialysis treatment were excluded. Patients were followed until either discharge or death, whichever came first. Results In 1519 patients with AKI, the majority (n=687 (45%)) had prerenal AKI, followed by AKI on chronic (defined as chronic kidney disease combined with any type of AKI) (n=536 (35%)), renal (n=166 (11%)) and postrenal AKI (n=130 (9%)). At admission, 30% of patients had any hyperkalemia, whereas 7% had severe hyperkalemia. Normokalemia was seen in 60% of the patients while 10.5% had hypokalemia. The more hyperkalemia, the higher level of sCr at admission, the more acidosis and the less proteinuria. Proteinuria was most pronounced in patients with mild hyperkalemia and normokalemia. In-hospital partial renal recovery was seen in 63% of the patients, while 38% had a modest recovery. Mortality during hospitalization was 4%; most of these patients had normokalemia (58%), followed by mild (18%) and moderate hyperkalemia (15%). In the prerenal and postrenal groups, most patients had a partial renal recovery (76% and 73% respectively). In patients with renal and AKI on chronic the proportions were lower (40% and 51%, respectively). Conclusion This study provides data from a large, contemporary AKI patient cohort under nephrology care. Severe potassium disturbances are common and short-term outcomes differ substantially in patients of variable AKI level and etiology. These findings have important implications for prognostic evaluation upon admission and further resource planning.

MO376CLINICAL OUTCOMES OF ACUTE KIDNEY INJURY FOLLOWING SNAKE BITE INJURIES

Abstract Background and Aims Snakebite is a common animal bite injury in tropical countries. Acute kidney injury (AKI) is an important complication in snakebite patients. This study aimed to comprehensively investigate the clinical profiles and outcomes of patients following hematotoxin-related snakebite associated with kidney impairment. Method We conducted a hospital-based, cross-sectional study of 238 patients with hematotoxin-related snakebite injuries. Data were retrieved from the King Narai Hospital Registry from October 2014 to August 2020. The prevalence of complications associated with snakebite injuries, including acute kidney injury (AKI) and its severity, was determined. Univariate and Multivariate predictors of AKI diagnosis were evaluated using binary logistic regression analysis Results A total of 238 patients, with 63.4% men, median (IQR) age 49.8 (39-61) years and median duration from injury to a hospital arrival of 1 hour (0.5-2) hours, were injured by Green pit viper (85.7%), Russell’s viper (12.6%) and Malayan pit viper (1.7%). AKI mostly occurred in Russell’s viper group 66.7%. An AKI was reported in thirty (12.6%, 95% CI: 8.7 % - 17.5%) patients, with the severity of 66.7% stage one, 6.7% stage two, 26.6% stage three by KDIGO classifications, and 13.3% requiring hemodialysis. Complete renal recovery was seen in twenty-two patients (73.3%), while partial renal recovery was 23.3%. Other complications included 84.4 % limb cellulitis, 4.6% significantly bleeding, 2.5% hypotension, 25.6% prolonged venous clotting time (VCT), 46.7% prolonged prothrombin time (PT), and 14.3% prolonged partial thromboplastin time (PTT). Of total patients, 60.1% were treated with anti-venom. Mortality was relatively low (0.4%). In multivariable logistic regression analyses, AKI was significantly associated with time to hospital arrival more than 3 hours (p = 0.04), Russell’s viper bitten (p = 0.01), clinical bleeding (p = 0.01), and prolonged PT (p &amp;lt; 0.01). Conclusion The prevalence of AKI in patients bitten by hematotoxin snakes was 12.6%, mostly from Russell’s viper. Factors associated with AKI outcomes were time to hospital arrival more than 3 hours, Russell’s viper bitten, clinical bleeding, and prolonged PT. Besides, one-fourth of AKI patients turned to chronic kidney disease.

MO221ONLY A SIMPLE CASE OF AKI IN AN ONCOLOGIC PATIENT?

Abstract Background Nivolumab is a drug belonging to the class of Immune Checkpoint Inhibitors (ICPI), the use of which has improved the prognosis for patients with various advanced malignancies. These agents are associated with several "immune-mediated" adverse effects, although the literature on Nivolumab renal toxicity is poor and anecdotal. A rare immune-mediated renal adverse event is acute interstitial nephritis (AIN) that often imposes Nivolumab suspension. Case report We present the case of a 75-year-old woman with stage IV melanoma (inguinal and external iliac lymph node metastases without localization of the primitive lesion). At diagnosis, renal function was normal by age (Creatinine 0.89 mg/dl; CKD EPI eGFR 71 ml/min/1.73 m2). After lymphadenectomy, an adjuvant treatment with Nivolumab was initiated. At 4-month follow-up, the patient was hospitalized for AKI (creatinine 2.6 mg/dl; eGFR 17,3 ml/min/1.73 m2). Although, renal function decline was not accompanied by signs of systemic immunoactivation, Nivolumab was suspended. In the following weeks, only a partial renal function recovery was observed, still limiting immunotherapy reintroduction. Thus, the patient was referred to our Onconephrology Outpatient Unit for a multidisciplinary approach. We performed a urinalysis with microscopy study of the sediment and observed rare dysmorphic red blood cells and leukocytes. To exclude a glomerulopathy, a comprehensive screening for autoimmune diseases and 24 hours proteinuria were also measured and found not significant (Table 1). Renal ultrasound did not show any relevant alteration. Based on our original suspicion of AIN, although in absence of an history of fever, rush or eosinophilia, we introduced Prednisone 25 mg/day. In the following weeks, blood and urine tests showed a significant improvement in renal function (serum creatinine 1.06 mg/dL, eGFR CKD-EPI 51 mL/min/1.73m2) and the absence of red blood cells, leukocytes and proteinuria in the urinalysis. Based on nephrologist advice, the patient was then able to resume the cancer treatment with a maintenance dose of prednisone equal to 5 mg/day. Conclusion AIN is a rare adverse effect of ICPIs that mandates the close monitoring of renal function in patients under immunotherapy with these agents. AKI occurrence in patients treated with ICPIs should always lead to investigate a possible AIN, even in the absence of the classic symptom set of fever, rush and eosinophilia and with minimal changes in urinalysis. Based on our single observation, and after an accurate literature review, we suggest the initiation of a corticosteroid treatment in oncologic patients on an ICPI complicated with AKI and with suspicion of AIN at urinalysis. Moreover, this case report thickens the importance of a multidisciplinary approach to oncologic patients not only when a conventional nephrotoxic chemotherapy has to be started, but also in case of ICIPs use. The nephrologist advice, in fact, could be useful in both preventing and treating severe renal complications such as AIN, also allowing the oncologic therapy maintenance.

Slowly progressive anti-neutrophil cytoplasmic antibody-associated renal vasculitis: clinico-pathological characterization and outcome.

BackgroundAlthough rapidly progressive glomerulonephritis is the main renal phenotype of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), slow renal disease progression is sometimes observed. These forms have been rarely discussed; we analysed their prevalence, clinico-pathological characteristics and outcome.MethodsWe screened patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis followed at seven referral centres and selected those with estimated glomerular filtration rate (eGFR) reduction <50% over a 6-month period preceding diagnosis. Data regarding patient features and response to treatment were retrieved.ResultsOf 856 patients, 41 (5%) had slowly progressive renal AAV. All had MPA and all but one was P-ANCA/myeloperoxidase (MPO) ANCA-positive. At diagnosis, the median age was 70 years [interquartile range (IQR) 64–78] and extra-renal manifestations were absent or subclinical (interstitial lung lesions in 10, 24%). The median (IQR) eGFR was 23 mL/min/1.73 m2 (15–35); six patients (15%) had started renal replacement therapy (RRT). All had proteinuria (median 1180 mg/24 h, IQR 670–2600) and micro-haematuria. Main histologic findings were extracapillary proliferation at chronic stages and glomerulosclerosis; following Berden’s classification, 6/28 biopsies (21%) were ‘focal’, 1/28 (4%) ‘crescentic’, 9/28 (32%) ‘mixed’ and 12/28 (43%) ‘sclerotic’. At last follow-up (median 32 months, IQR 12–52), 20/34 patients (59%) treated with immunosuppression had eGFR improvement >25% as compared with diagnosis, while 4/34 (12%) had started RRT.ConclusionsAAV may present with slow renal disease progression; this subset is hallmarked by advanced age at diagnosis, positive MPO-ANCA, subclinical interstitial lung lesions and chronic damage at kidney biopsy. Partial renal recovery may occur following immunosuppression.