Pre-existing Renal Insufficiency Research Articles

Nephrotoxic drug burden and predictors of exposure among patients with renal impairment in Ethiopia: A multi-center study

BackgroundNephrotoxic drugs may hasten the decline in kidney function and worsen the progression of renal impairment as a result; these drugs should be avoided or used with caution in patients with pre-existing renal insufficiency. The purpose of this study was to assess the burden of nephrotoxic medication use and its predictors among patients with underlying renal impairment. MethodsA multicenter, institution-based, cross-sectional study was conducted from May 30, 2021 to July 30, 2021, at medical wards. Renal impaired patients admitted during the data collection period who took at least one medication were enrolled in the study. A simple random sampling technique was used to select the study participants. Data was collected through an interview and a medical card review. Both bivariable and multivariable binary logistic regression analyses were fitted to identify factors associated with nephrotoxic drug use. ResultsAmong the 422 participants, more than half of them (53.6 %) were male. The mean patient's age was 47.5 (±16.7) years. A total of 1310 drugs were prescribed for 422 patients with renal impairment, of which 80.15 % were nephrotoxic. Nephrotoxic drugs were prescribed for 66.4 % of patients. The burden of nephrotoxic medication prescription was significantly associated with variables like the presence of comorbidity (AOR = 6.31, 95 % CI: 2.01–19.79), the number of medications prescribed (AOR = 1.43, 95 % CI: 1.05–1.93), and the age of participants (AOR = 1.12, 95 % CI: 1.07–1.17). ConclusionThe present study demonstrated that two-third of the patients with renal impairment were exposed to nephrotoxic medications. Furosemide, Enalapril, and vancomycin were the most frequently prescribed nephrotoxic medications. The study suggests that prescribers need to give special attention to older patients who have underlying renal insufficiency, a comorbid condition, and polypharmacy regarding exposure to contraindicated nephrotoxic medication.

Examination about clinical efficacy and safety of active use of tolvaptan for decompensated congestive heart failure cases

Abstract Background In Japan, Tolvaptan is approved for use as a potent oral diuretic, mainly for severe congestive heart failure. However, over time since the launch of Tolvaptan, there have been many reports of its usefulness when used earlier in milder cases. Based on this background, in August 2015, our facility introduced a clinical pathway (PATH) for acute care for cases with decompensated congestive heart failure (DCHF), in which immediate use of tolvaptan with conventional diuretics ware stipulated to keep patient’s activity by early diuresis. Purpose In this study, we verified the clinical usefulness and safety of PATH for DCHF that prescribes the active use of tolvaptan. Methods From April 2014 to July 2022, 846 DCHF cases admitted to our hospital for the first time were included. They were divided into two groups, N-group(154 cases before introduction of PATH) and P-group(692 cases introduced PATH and prescribed Tolvaptan as stipulated). We investigated their implementation status of each medical treatment in acute phase and hospitalization period(HP), and compared the difference between the two groups. And in P-group, we investigated the occurrence of adverse event(AE), deterioration of renal function (R-event) and hypernatremia (N-event) that required unplanned discontinuation of tolvaptan use, and we investigated the clinical features about the cases with each adverse event. Results There was almost no difference in the patient background before admission or the patient's condition at admission. In P-group, the performance rate of each acute medical care for DCHF was lower and their performance period was shorter compared in N-group. The performance rate of cardiac rehabilitation was higher and its starting time was earlier in P-group. (Figure 1) As a result, HP was significantly shorter in P-group. AE incidence in P-group were 2.2%(R-event) and 4.8%(N-event). Mean age tended to be higher and cognitive function was lower in both AE cases. Cases with R-event were more likely to have pre-existing renal insufficiency. In N-event cases, their activity level before admission was lower and blood sodium level at admission was higher. Most of the N-event(85%) occurred within 7 days.(Figure 2) Conclusions With the introduction of unique clinical pathway that stipulates the active use of tolvaptan, the acute care of cases with decompensated congestive heart failure had been greatly simplified and streamlined, and the hospitalization period had been shortened. Although it is unlikely that all the results were due to the medicinal effects of Tolvaptan, it was thought that the realization of early mobilization due to its strong diuretic effect was linked to these results. A certain rate of feared adverse events, especially hypernatremia, was found to occur, but the rate appeared to be acceptable. However, in elderly and cognitively impaired cases, special caution seemed to be required for several days after the start of tolvaptan use.Figure 1Figure 2

629. Vancomycin AUC:MIC-Based Dosing is Associated with Significantly Less Acute Kidney Injury in Patients Admitted to a Burn Intensive Care Unit

Abstract Background Vancomycin is often used for empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin is well known to cause acute kidney injury (AKI), which can be detrimental to patients in the intensive care unit (ICU) setting. In 2020, the American Society of Health-systems Pharmacists updated their vancomycin dosing guidelines to target an area under the plasma concentration-time curve to minimum inhibitory concentration ratio (AUC:MIC) of 400-600 mg*h/L, a change from targeting a trough concentration of 10-20 mg/L. This suggests that vancomycin toxicity is likely minimized using the AUC:MIC ratio. Methods This retrospective cohort study compares the incidence of AKI in patients admitted to the burn ICU dosed to achieve a target to those dosed to achieve an AUC:MIC goal. Incidence of AKI, per the AKIN criteria, was recorded. Known risk factors such as history of hypertension, concomitant furosemide use, pre-existing renal insufficiency, and other concomitant nephrotoxins were considered. All data collected were previously obtained as a part of usual practice. Results Two hundred thirty-six subjects who received 317 courses of vancomycin were included. One hundred twenty courses were dosed to achieve an AUC goal, and 197 courses were dosed to achieve a trough goal. In the AUC group, 49 (57.7%) subjects were admitted for burns, 21 (24.7%) were admitted for necrotizing soft tissue infection (NSTI), and 15 (17.7%) were admitted for other reasons. In the trough group, 97 (64.7%) were admitted for burns, 22 (18.7%) for NSTI, and 25 (16.7%) for other reasons. Demographics were similar between the two groups. The incidence of AKI was 10.3% in the AUC group, as compared to 20.3% in the trough group (p=0.0171). Patients in the AUC group received significantly less vancomycin than in the trough group (3524 ± 1551 vs 3145 ± 1491, p=0.0315). Risk factors for AKI were similar between the two groups (55.6% vs 52.8%, p=0.6347), and concomitant nephrotoxin exposure was similar (52.6% vs 42.7%, p=0.0924). Conclusion Using AUC:MIC-based dosing was associated with a decreased incidence of AKI than trough-based dosing in patients admitted to the burn ICU. Disclosures All Authors: No reported disclosures.

Renal Function After Transcatheter Piccolo Patent Ductus Arteriosus Closure With Contrast Angiography in Extremely Premature Infants

Transcatheter patent ductus arteriosus (PDA) device closure is increasingly performed in extremely premature infants. Contrast angiography improves the procedural safety and effectiveness by precise anatomic delineation. Contrast nephropathy is a concern in clinically ill premature infants, especially with the presence of renal insufficiency. We hypothesized that the benefit of transcatheter PDA closure outweighs the harm of contrast nephropathy in extremely premature infants. A total of 160 infants underwent successful transcatheter (n=59) and surgical (n=101) PDA closure at a median age of 26 (7 to 78) days. The surgical group had a lower procedural weight (870 vs 960 g, p=0.014). In the transcatheter group, serum creatinine decreased from 0.48 to 0.45 mg/100 ml at 24 hours (p=0.003, n=59) and decreased further to 0.37 mg/100 ml at 5 to 7 days after closure (p <0.001). Median contrast amount was 1.9 ml/kg (0.6 to 6.1). In 8 infants with pre-existing renal insufficiency who underwent transcatheter closure, serum creatine significantly improved from 1.44 to 1.36 mg/100 ml at 24 hours and 0.79 mg/100 ml at 5 to 7 days after closure (p <0.001). There was no difference in improvement of serum creatinine between transcatheter and surgical closure groups. In conclusion, despite the use of contrast, serum creatinine significantly improved with transcatheter PDA closure even in infants with pre-existing renal insufficiency. Contrast angiography should not be discouraged for transcatheter PDA closure because of the concern for contrast nephropathy in extremely premature infants.

Drug-Induced Nephrotoxicity: A Review

Background: Nephrotoxicity is referred to as rapid degeneration in kidney functioning due to the toxic effects of medications. The glomerulus and proximal renal tubule are the fundamental portions of the nephron to be affected by drugs leading to nephrotoxicity. Prescribed medications like antibiotics (aminoglycoside, and vancomycin), amphotericin B, antidepressants (amitriptyline, fluoxetine), acyclovir, angiotensin-converting enzyme inhibitors, Angiotensin receptor blockers, non-steroidal anti-inflammatory drugs, cocaine, statins, antihistamines (Diphenhydramine), and sulfonamides can result in specific outcomes relative to nephrotoxicity, such as renal injury, inflammation, platelet aggregation, cell cytotoxicity, thrombosis, reduced renal blood flow, and crystal precipitation result in nephrotoxicity. Objective: we aimed to review the various pathogenic mechanisms responsible for drug-induced nephrotoxicity including, altered intra-glomerular hemodynamics, tubular cell toxicity, renal inflammation, crystal nephropathy, rhabdomyolysis, and thrombotic microangiopathy. The review also highlights risk factors related to the patient and the drugs being prescribed. The majority of the nephrotoxicity risk factors depend on the patients' age, gender, pre-existing renal insufficiency, drug dosage, and hypersensitivity to drug toxicity. Methods: We have searched the different databases to recruit published material mainly focusing on Pubmed, GoogleScholars, and Iraqi Virtual Science Library. Conclusion: To sum up, the review explains the necessity of evaluating nephrotoxicity, drug dosage, and risk factors as primary preventive measures to avoid drug-induced Nephrotoxicity.

Extraperitoneal cystectomy with ureterocutaneostomy derivation in fragile patients - should it be performed more often?

Radical cystectomy (RC) continues to be standard of care for muscle-invasive bladder cancer and recurrent or refractory nonmuscle invasive bladder cancer. Unfortunately, it has high rates of perioperative morbidity and mortality. One of the most important predictors of postoperative outcomes is frailty, while the majority of complications are diversion related. The aim of our study was to evaluate safety of extraperitoneal cystectomy with ureterocutaneostomy in patients considered as frail. We retrospectively collected data of frail patients who underwent extraperitoneal cystectomy with ureterocutaneostomy from October 2018 to August 2020 in a single center. We evaluated frailty by assessing patients' age, body mass index (BMI), nutritional status by Malnutrition Universal Screening Tool, overall health by RAI (Risk Analysis Index) and ASA (American Society of Anaesthesiologists) score, and laboratory analyses. We observed intraoperative outcomes and rates of perioperative (within 30 days) and early postoperative (within 90 days) complications (Clavien-Dindo classification). We defined extraperitoneal cystectomy with ureterocutaneostomy as safe if patients did not develop Clavien Dindo IIIb, or worse, complication. A total of 34 patients, 3 female and 31 male, were analyzed. The median age was 77, BMI 26, RAI 28, ASA 3 and the majority had preexisting renal insufficiency. Blood analyses revealed presence of severe preoperative hypoalbuminemia and anemia in half of our cohort. Intraoperative median blood loss was 250 cc, whilst operative time 245 min. During perioperative period 60% of our cohort developed Clavien Dindo II complication and during early postoperative period 32% of patients required readmission. One death occurred during early postoperative period (2.9%). After 12 months of follow-up, we observed stability of the renal function for most patients. We believe that extraperitoneal cystectomy with ureterocutaneostomy could be considered as a treatment option for elderly and/or frail patients.

The effect of suprarenal graft fixation during endovascular aneurysm repair on short- and long-term renal function

ObjectiveThe effect of suprarenal fixation (SR) compared with infrarenal fixation (IR) on renal function during endovascular aneurysm repair (EVAR) remains controversial. This study aims to compare the renal outcomes between fixation types in short- and long-term follow-up. MethodsPatients undergoing EVAR for infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. The estimated glomerular filtration rate (eGFR) was measured at baseline and during a follow-up of 5 years. A decline in renal function was defined as a 20% or greater decrease in the eGFR. Changes in the eGFR were compared between SR and IR groups at 1 to 7 days, 30 days, and 1 to 5 years postoperatively. Preoperative renal insufficiency was defined as an eGFR of less than 60 mL/min/1.73 m2, and those patients were included in the subanalyses. ResultsA total of 358 patients were included. Among these, 267 (74.6%) had SR and 91 (25.4%) had IR fixation. A decrease in renal function occurred more commonly after SR than after IR in 1 to 7 days postoperatively (P = .009), but no difference was noticed at 30 days and 1 to 5 years. Regardless of the fixation method, renal function steadily decreased steadily over time after EVAR (estimate –3.13 per a year; 95% confidence interval, –3.40 to –2.85; P < .001). Patients with preexisting renal insufficiency were included in subgroup analyses, and those with SR were more often found to have a decline in eGFR 5 years postoperatively than their counterparts with IR (59.5% vs 20.0%; P = .036). ConclusionsAn immediate postoperative decrease in renal function was seen more often after SR fixation than IR fixation but this difference was transient. SR fixation is a safe method for patients with normal renal function. Long-term results seems to favor IR over SR in patients with preexisting renal insufficiency.

Levetiracetam Induced Hyperkalemia – A Rare Side Effect in Elderly with Pre-Existing Subclinical Renal Insufficiency Presenting with Bradyarrhythmia

Levetiracetam is a commonly used drug in today’s world for long term management of partial as well as generalized seizures mainly due its major advantage that is has so few and non-threatening side effects[1].In the following case scenario, we show how a 70 years old male presented with severe hyperkalemia and after no other common culprits were seen, it was thought to be a side effect therapy with levetiracetam and after discontinuing it and managing hyperkalemia, the patient’s condition improved from a very critical state. We also show a rare form ECG presentation of severe hyperkalemia in the form of bradyarrhythmia with absent P waves. Our experience shows that unpredictable and rare side effects of new anti-epileptic drugs should be given attention and such cases often go undiagnosed.

Troponin Elevation on Admission Along With Dynamic Changes and Their Association With Hemorrhagic Transformation After Thrombolysis.

Background: Hemorrhagic transformation (HT) is a common complication of intravenous thrombolysis with alteplase. Cardiac troponin has been found to be associated with poor prognosis and cognitive impairment in acute ischemic stroke. But studies on the relationship between troponin and HT after thrombolysis are scarce.Methods: This study retrospectively analyzed thrombolytic patients from June 2015 to June 2021 in the Second Affiliated Hospital of Wenzhou Medical University. Cardiac troponin I were measured on admission and on following days to determine the presence of elevation and dynamic changes. HT within 24–36 h after treatment was identified by cranial computed tomography (CT). Besides, a score on the modified Rankin Scale (mRS) > 2 at discharge was defined as unfavorable outcome. Univariate analysis was used to explore the factors related to the troponin elevation on admission and troponin dynamic changes. Multivariate logistic regression model was used to investigated the association between troponin elevation on admission, troponin dynamic changes and HT after thrombolysis, respectively.Results: Troponin levels on admission were measured in 377 patients, and follow-up assay was performed in 292 patients (77.5%). 39 patients (10.3%) had troponin elevation on admission, and 66 patients (22.6%) had troponin dynamic changes comprising rising and falling pattern. The pre-existing heart disease, renal insufficiency and higher stroke severity are related to both troponin elevation on admission and the subsequent troponin dynamic changes. After adjusting the potential confounding factors, logistic regression model showed that patients with troponin elevation on admission had insignificant trend to develop HT (OR 2.23, 95%CI 0.96–5.21, p = 0.063), while patients with troponin dynamic changes had significantly higher risk of HT (OR 2.27, 95%CI 1.06–4.85, p = 0.034). Compared to the troponin elevation, a statistically stronger association was present between rising troponin dynamic changes and unfavorable outcome (OR 2.20, 95%CI 1.05–4.60, p = 0.037).Conclusion: Troponin dynamic changes are associated with HT after thrombolysis. Serial measurements are quite necessary in thrombolytic patients with risk factors associated with troponin dynamic changes (e.g., advanced age, pre-existing heart disease, higher NIHSS score, and troponin elevation on admission).

Parenchymal Volume Replacement by Renal Cell Carcinoma Prior to Intervention: Predictive Factors and Functional Implications

ObjectiveTo analyze predictors, extent and functional implications associated with renal parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) prior to intervention. This phenomenon is well-recognized yet not adequately studied, and, if severe, can influence management. Materials and MethodsA retrospective review was performed of partial nephrectomy (PN) and radical nephrectomy (RN) patients with available preoperative nuclear-renal-scan and imaging demonstrating solitary RCC with normal contralateral kidney. Normal renal parenchymal volume of each kidney was measured by free-hand scripting from preoperative axial images. Primary endpoint was percent PVR which was estimated assuming that the contralateral-kidney serves as a control: PVR = (volume contralateral kidney – volume ipsilateral kidney) normalized by volume contralateral kidney. Multivariable linear-regression analysis assessed factors associated with preoperative PVR. Further analysis evaluated the functional effect of PVR prior to surgery. Results146 PN and 136 RN patients with necessary studies were analyzed. For RN, the median PVR was 15% and a quarter of patients had PVR ≥27%. In contrast, PVR was negligible in PN patients for whom median preoperative parenchymal volumes were nearly identical in the ipsilateral/contralateral kidneys (179/180cc, respectively). PVR inversely correlated with preoperative renal function in the ipsilateral kidney (P <.01). Tumor-size (P <.01), stage (P = .03), and endophytic properties (P = .03) associated with PVR on multivariable-analysis. ConclusionOur data suggest that substantial replacement of normal parenchyma by RCC occurs in many patients selected for RN and can contribute to preexisting renal-insufficiency. PVR prior to intervention is mainly driven by tumor characteristics in RN patients, but is negligible in most PN patients.

The Dilemma after Sealing an Endovascular Aortic Aneurysm - Three Ways Out.

Endovascular aneurysm sealing (EVAS) was commercially introduced in 2013. The initial results of EVAS were positive, leading to its widespread use. The mid- and long-term reports showed greater than expected rates of migration, which led to a recall of the device. In the present article, we describe our experience in managing type Ia endoleaks and migration occurring with the Nellix system in three different ways: open repair with Nellix explantation, Nellix-in-Nellix application (NINA technique), and the use of the multibranched Colt device originally dedicated to the treatment of thoracoabdominal aneurysms. From February 2014 to June 2021, we performed 20 procedures for failed EVAS or ChEVAS (migration, type Ia endoleak, secondary aneurysm rupture). All patients treated for EVAS failure were male, aged 65 - 79. Seven Nellix explantations were performed. Three patients were admitted to our hospital with ruptured aneurysms that occurred 3 weeks to 4 years (mean 124 weeks) after EVAS, and another four with type Ia endoleak. In all but one case, removal of the Nellix system was easy. In two patients, tube grafts were implanted and in the remaining five cases, bifurcated grafts were implanted. In four patients, graft legs were anastomosed with the internal iliac arteries. One patient with secondary aneurysm rupture died from multiorgan failure on the 4th postoperative day. In two cases, transient renal failure was noticed in the perioperative period. All patients were admitted to the intensive care unit for 1 to 4 days (mean 2 days). The mean hospital stay was 9 days. All patients stayed in follow-up (3 - 56 months), but no other complications occurred. Eight patients were treated with the NINA technique: five for distal migration of the Nellix and three for failed ChEVAS. Four patients had a NINA procedure performed with three chimneys, three with two and one with one chimney. In one case, two iliac limbs were implanted to avoid kinking of the external iliac arteries. The median hospitalization time after the procedure was 9 days (range 3 - 12). Four patients developed transient acute renal insufficiency in the perioperative period. The follow-up ranged between 4 and 72 months. In one patient, deterioration of preexisting chronic renal insufficiency developed 5 months after the procedure, but dialysis was not required. One patient died from exacerbation of heart failure 7 months after the NINA procedure. The Colt device was implanted in five patients for the treatment of distal migration with type Ia endoleaks. None of the patients developed any signs of spinal cord ischemia. All patients were admitted to the intensive care unit for 1 or 2 days. In two cases, transient acute renal failure was noticed in the perioperative period. The mean hospital stay was 9 days. All patients remained in follow-up (6 - 22 months). In one case, the occlusion of the celiac trunk branch was found in contrast computed tomography 1 month after implantation of the Colt device, but without any symptoms. No other complications occurred. Normal strategies for the management of complications for late failure of EVAR, including stent-graft extensions, are not suitable after EVAS; therefore, alternatives are necessary. Conversion to open repair carries an extensive burden on the patient, so it is not recommended for patients with high surgical risk. The use of a Nellix-in-Nellix application to treat late failure of EVAS is not within the instructions for use but could be an effective strategy for a type Ia endoleak with or without migration. The use of this technique has been extremely limited since the Nellix system was recalled from the market. The use of the Colt multibranched device may be an alternative option, but due to the small number of patients, this method needs further evaluation.

Perioperative Management of Long-term Antidiabetic Therapy in Patients with Diabetes Mellitus

Drug therapy, as well as diabetes technology, e.g. insulin pumps or sensor glucose measurement, have developed enormously in recent years. Their use differs according to the type of diabetes, secondary or concomitant diseases, and individual factors and target values. In the perioperative phase, diabetic patients are generally at increased risk of complications, including a derailment of glucose metabolism, an increased rate of cardiovascular events, worsening of preexisting renal insufficiency, and increased incidence of wound infections. In addition, drug class-specific side effects of antidiabetic therapy may occur. The prevalence of diabetes patients in anesthesiology is high and will continue to increase. In Germany, more than 8 million people are estimated to live with diabetes mellitus. The rate of new cases is about 600 000 per year. The distinction between type 1 and type 2 diabetes mellitus is essential. Diabetes therapy is becoming increasingly individualized; combination therapies are becoming more common. Therefore, the management of long-term medication should also be individualized. Substance-specific side effects or adverse effects, especially of oral antidiabetic agents, must be considered in the care of patients, e.g. euglycemic diabetic ketoacidosis under SGLT-2 inhibitors is a relevant problem. Insulin therapy is also evolving; knowledge of new preparations and of insulin pump therapy facilitates perioperative management. Both hypoglycemia and hyperglycemia, possibly with ketoacidosis, must be avoided. The purpose of this article is to provide an overview of the management of long-term medication in patients with diabetes mellitus.

MESENCHYMAL STEM CELL-BASED THERAPY FOR CHRONIC KIDNEY FAILURE RELATING LUPUS ERYTHEMATOSUS - A CASE REPORT

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease, which is characterized by systemic multiple-organ involvement, relapses with large amount of autoantibodies. Their pathophysiology is multifaceted, involves complex hormonal-immunological-cellular interactions, and leads to damage in multiple cell types, which is often resistant to conventional therapy. Thus, novel strategies are needed to repair the renal parenchyma and preserve kidney function. Mesenchymal stem cells (MSC) confer renal protection through paracrine/endocrine effects, and to some degree possibly by direct engraftment. The patient was diagnosed with chronic kidney disease by standard methods for more than fifteen years. The patient agreed to the treatment of autologous adipose mesenchymal stem cell transplantation. The adipose mesenchymal stem cells were harvested by surgery, isolated with our enzyme protocol. The patient received one injection with 2,6x106 cells/kg for a total of 43kg of body weight. The patient with SLE do not receive prompt treatment, he get irreversible organ damage. After seven months, the preexisting renal insufficiency gradually ameliorated, including the decrease of creatinine and blood urea as well as the increase of estimated glomerular filtration rate. Lupus symptoms also reduced, followed by the improvement of body movement and medication reduction.There was insufficient evidence of the clinical setting to show the efficiency of mesenchymal stem cells on the lupus nephritis relating to chronic kidney disease. This clinical trial highlights the feasibility and safety of mesenchymal stem cell treatments in renal failure-associated- autoimmune diseases.

Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update.

Despite tremendous improvement in molecular properties over the last century, intravascular injection of iodinated contrast material may still have systemic and hemodynamic consequences. Patients with pre-existing renal insufficiency may be at risk for acute kidney injury, which may be associated with an increased risk of the need for dialysis and mortality in the long term. Many questions as to the physiological pathways, optimal definition, and incidence of contrast-induced acute kidney injury remain open. These uncertainties are reflected in the changing landscape of this field in terms of nomenclature, research, and clinical practice. Clinical practice guidelines for the prevention of post-contrast acute kidney injury all recommend giving prophylaxis in the form of intravenous hydration to high-risk patients. Solid evidence for this strategy is lacking. This article gives an overview of the changing landscape of post-contrast acute kidney injury and prophylactic intravenous hydration, with the aim of supporting informed decision-making in clinical practice. Recent data have caused a shift in guideline recommendations: 90 % of patients formerly considered high-risk for contrast-induced acute kidney injury no longer qualify for prophylaxis. The remaining high-risk patients, with severe chronic kidney disease, represent a vulnerable population for whom intravenous hydration may provide some benefits but also carries risk. Intravenous hydration may benefit 'new' high-risk patients. However, it also confers risk. A dual approach to screening patients will help avoid this risk in clinical practice. · Intravenous hydration is the cornerstone for preventing contrast-induced acute kidney injury. · Solid evidence is lacking; recent data caused a shift in guideline recommendations. · Intravenous hydration may benefit 'new' high-risk patients with severe chronic kidney disease; however, it also confers risk. · A dual approach to screening patients will help avoid this risk in clinical practice. · Nijssen E, Rennenberg R, Nelemans P et al. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. Fortschr Röntgenstr 2021; 193: 151 - 159.

Findings on intraprocedural non-contrast computed tomographic imaging following hepatic artery embolization are associated with development of contrast-induced nephropathy.

BACKGROUNDContrast-induced nephropathy (CIN) is a reversible form of acute kidney injury that occurs within 48-72 h of exposure to intravascular contrast material. CIN is the third leading cause of hospital-acquired acute kidney injury and accounts for 12% of such cases. Risk factors for CIN development can be divided into patient- and procedure-related. The former includes pre-existing chronic renal insufficiency and diabetes mellitus. The latter includes high contrast volume and repeated exposure over 72 h. The incidence of CIN is relatively low (up to 5%) in patients with intact renal function. However, in patients with known chronic renal insufficiency, the incidence can reach up to 27%.AIMTo examine the association between renal enhancement pattern on non-contrast enhanced computed tomographic (CT) images obtained immediately following hepatic artery embolization with development of CIN.METHODSRetrospective review of all patients who underwent hepatic artery embolization between 01/2010 and 01/2011 (n = 162) was performed. Patients without intraprocedural CT imaging (n = 51), combined embolization/ablation (n = 6) and those with chronic kidney disease (n = 21) were excluded. The study group comprised of 84 patients with 106 procedures. CIN was defined as 25% increase above baseline serum creatinine or absolute increase ≥ 0.5 mg/dL within 72 h post-embolization. Post-embolization CT was reviewed for renal enhancement patterns and presence of renal artery calcifications. The association between non-contrast CT findings and CIN development was examined by Fisher’s Exact Test.RESULTSCIN occurred in 11/106 (10.3%) procedures (Group A, n = 10). The renal enhancement pattern in patients who did not experience CIN (Group B, n = 74 with 95/106 procedures) was late excretory in 93/95 (98%) and early excretory (EE) in 2/95 (2%). However, in Group A, there was a significantly higher rate of EE pattern (6/11, 55%) compared to late excretory pattern (5/11) (P < 0.001). A significantly higher percentage of patients that developed CIN had renal artery calcifications (6/11 vs 20/95, 55% vs 21%, P = 0.02).CONCLUSIONA hyperdense renal parenchyma relative to surrounding skeletal muscle (EE pattern) and presence of renal artery calcifications on immediate post-HAE non-contrast CT images in patients with low risk for CIN are independently associated with CIN development.

Procedures in COVID-19 Patients: Part-II.

Critical care in the era of novel coronavirus disease-2019 (COVID-19) infection has multiple challenges including management of the patient, underlying comorbidities, and the complications. With no end in sight to the pandemic, intensive care unit (ICU) practitioners and hospital administrators have to join hands to prepare for the long battle ahead. Critically ill COVID-19 patients need imaging or image-guided interventions in one form or the other including X-rays, ultrasonography (USG), echocardiography (ECHO), and CT scan. These patients often require renal replacement therapy (RRT) for either the preexisting chronic renal insufficiency or acutely developing kidney injury. Another important component of care is transfer of the patient to and fro from the ICU or to higher care centers. Most of the ICUs are equipped with modern facilities but with increasing number of patients a large number of makeshift arrangements are being made for managing these patients. This position paper outlines important tips to formulate protocols and procedures for critically ill patients, who are managed in the ICU.How to cite this article: Pande RK, Bhalla A, Myatra SN, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-II. Indian J Crit Care Med 2020;24(Suppl 5):S272–S279.

Correlation of intraoperative renal near infrared spectroscopy with the development of acute kidney injury in adult patients undergoing cardiac surgery using cardiopulmonary bypass

Introduction: The present study aimed to correlate renal oximetry near-infrared spectroscopy (NIRS) values with conventional non-invasive biomarkers for the early detection of acute kidney injury (AKI) in adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Accordingly, renal NIRS can be employed as a trending device for the prevention of AKI development. Materials and methods: After institutional ethical committee approval, a number of 132 adult patients undergoing cardiac surgery with CPB were selected by consecutive consenting sampling method. Emergency surgery and patients with preexistent renal insufficiency were excluded. NIRS sensor was applied on either the right or the left side of the spine at the lower border of L-1 before starting the induction. A renal regional oxygen saturation (rSO2) score was calculated after recording the renal oximetry values intra- and postoperatively. Urine output and serum creatinine were measured at 24, 48, and 72 hours postoperatively. Results: Out of 132 patients, 22 cases (16.66 %) developed AKI according to Acute Kidney Injury Network (Akin) criteria± Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification. Among these AKI patients, three cases required dialysis, and one of these three patients died on the 21st day postsurgery. Renal rSO2 scores in the AKI group were measured at 535 and 912 minutes %, in comparison to 162 and 184 minutes % reported in the non-AKI group which was statistically significant (P< 0.05). Conclusion: As evidenced by the obtained results, there is a correlation between intraoperatively measured renal NIRS readings and the occurrence of AKI following adult cardiac surgery using CPB.

MON-334 Severe Hypercalcemia Following Hip Joint Implantation of Stimulan® Calcium Sulfate Antibiotic Beads

Introduction: The diagnosis and management of hypercalcemia in hospitalized patients can be challenging. Hypercalcemia is often associated with significant morbidity and end-organ damage which may delay a patient’s recovery. Case report: A 63-years-old female presented for evaluation of left hip pain and was found to have an infection of the prosthetic joint. Past medical history was significant for type 2 diabetes and atrial fibrillation. No known history of malignancy or excess calcium, vitamins A or D intake. Past surgical history was significant for multiple left hip fixation surgeries and a left hip arthroplasty 4 months prior. Patient’s serum calcium on admission was 8.4 mg/dL (corrected 9.5 mg/dL, range 9.5-10.5 mg/dL), serum creatinine 1.2 mg/dL (range, 0.5 - 1.2 mg/dL). Three days later, she underwent surgical irrigation and debridement of the left hip with placement of 30 cc STIMULAN® antibiotic beads with vancomycin. On postoperative day (POD) 5, patient was found to be confused. Laboratory workup revealed serum calcium 13 mg/dL, ionized calcium 1.91 mmol/L (range, 1.12-1.32 mmol/L), serum creatinine 1.6 mg/dL, intact PTH 10 (range, 15- 65 pg/mL), PTH-rp 15 pg/mL (range, 14-27 pg/mL), 25-OH-vitamin D 18 ng/mL (range, 30-60 ng/mL), 1,25-OH2-vitamin D <8 ng/mL (range, 18-72 ng/mL). Clinical challenge: The differential diagnosis of non-PTH mediated hypercalcemia includes malignancy, granulomatosis and/or excess calcium intake. The patient’s history and laboratory data were not consistent with these etiologies. The temporal nature of the hypercalcemia in relation to implantation of antibiotic beads suggest causality of exogenous calcium sulfate and development of the patient’s hypercalcemia. Mild renal insufficiency, as well as immobilization in the setting of surgery, were likely also contributory. Treatment and outcome: This patient was first treated with aggressive intravenous saline and calcitonin. Serum calcium rose to 13.7 mg/dL and pamidronate 30 mg was administered. Hypercalcemia resolved on POD 11 with improvement in patient functional status. Discussion: Hypercalcemia due to implanted calcium sulfate antibiotic beads is not well described outside of case reports. Kallala found hypercalcemia in less than 0.01% of patients who underwent bead implantation, with all the affected patients presenting with preoperative renal failure. Conclusion: Hypercalcemia in the setting of calcium sulfate antibiotic beads implantation may contribute to a patient’s confusion and increase length-of-stay. We recommend serum calcium and creatinine to be closely monitored during the perioperative period in patients who receive calcium sulfate antibiotic beads. Risk factors for the development of hypercalcemia require additional study, though patients with pre-existing renal insufficiency may not be good candidates for the mechanism of antibiotic administration.

Beneficial effect of statin on preventing contrast-induced acute kidney injury in patients with renal insufficiency: A meta-analysis.

Renal insufficiency is an important predictor of contrast-induced acute kidney injury (CI-AKI). We performed a meta-analysis to examine the effects of short-term statin therapy on the incidence of CI-AKI, particularly in patients with renal insufficiency. A systematic search was conducted to retrieve randomized controlled trials (RCTs) that investigated the impact of statin pretreatment before administration of contrast media on the development of CI-AKI in patients with mild to moderate renal insufficiency. The primary outcome was development of CI-AKI. The secondary outcome was the incidence ofacute kidney injury requiring hemodialysis. Data analysis from 8 RCTs, which included a total of 2313 subjects in the statin-treated group and 2322 in the control group, showed that statin pretreatment was associated with significant reduction of the risk of CI-AKI (relative risk [RR] = 0.59; 95% confidential interval [CI] 0.44-0.79; P = .0003, I = 0%). A beneficial effect of statin on preventing CI-AKI was consistent, regardless of the dose of statin and use of N-acetylcysteine. In subgroup analysis based on baseline estimated glomerular filtration rate (eGFR), patients with baseline eGFR <60 mL/min/1.73 m (RR = 0.63; 95% CI 0.41-0.98; P = .04, I = 0%) and 30 < eGFR < 90 mL/min/1.73 m (RR = 0.56; 95% CI 0.39-0.82; P = .003, I = 0%) showed significant reduction of risk of CI-AKI. Statin pretreatment is effective at preventing CI-AKI and should be considered in patients with preexisting renal insufficiency.

Twenty-two Year Multicentre Experience of Late Open Conversions after Endovascular Abdominal Aneurysm Repair

The aim was to report indications, technical aspects, and outcomes of a multicentre experience of late open conversions (LOCs) after endovascular abdominal aneurysm repair (EVAR), in order to identify risk factors which may influence early morbidity and mortality rates, and long term survival. Ten vascular centres retrospectively reviewed all patients requiring LOC (≥30 days from initial EVAR, undergoing total or partial endograft explantation) from 1996 to 2017. Baseline characteristics, endograft data, indications, procedural details, post-operative outcomes, and follow up data were reviewed and analysed. Included patients totalled 232 (90.1% males, mean age 74.3±7.9 years). The number of LOC per year significantly increased during the study period, reaching 22 in 2017 (correlation r=0.867, p<.0001). Reasons for LOC were 80.2% endoleak (186/232), 15.5% endograft infection (36/232), and 9.9% endograft thrombosis (23/232). Sixty-nine patients (29.7%) were operated on urgently; rupture was present in 18.5% (43/232). Eighty-nine patients (38.4%) underwent endovascular re-interventions prior to LOC. The proximal aortic cross clamp site was infrarenal in 40.5% (94/232), suprarenal in 25.4% (59/232), supracoeliac in 32.8% (76/232), and thoracic in 1.3% (3/232). Endograft explantation was total in 164/232 patients (70.7%), and partial in the remaining 68/232 (29.3%). The overall 30 day mortality was 11.2% (26/232). Early mortality was significantly higher for patients operated on urgently (26.1% vs. 4.9%, p<.001). Suprarenal clamping (odds ratio (OR) 2.34, 95% CI 1.12-4.88) and pre-existing renal insufficiency (OR 2.11, 95% CI 1.03-4.31) were independent risk factors for post-operative renal failure on multivariable analysis. Median follow up was 24.1 months (IQR 4.4-60.6). The estimated overall one and five year survival rates were 79.7% and 58.6%, respectively. Survival estimates were significantly lower for patients with endograft infection (83.8% vs. 59% at one year, 65.2% vs. 28.9% at five years; log rank p=.005), as well as for urgent patients (87.2% vs. 62.1% at one year, 65.1% vs. 43.7% at five years; log rank p<.0001). The annual number of LOC increased over time. LOCs performed urgently or for endograft infection are associated with poor survival. Infrarenal aortic clamping has lower post-operative complication rates.