Prerenal Failure Research Articles

P-83 Primary thyroid lymphoma presented with hypercalcemia and rapidly growing neck mass

Abstract Introduction Primary thyroid lymphoma is an uncommon malignancy, accounting for 1% to 2% of extranodal lymphomas and 1% to 5% of thyroid malignancies. Large B-cell lymphoma is the most prevalent form of primary thyroid lymphoma. Here, we present a patient with hypercalcemia and a rapidly growing neck lesion who was diagnosed with diffuse large B-cell lymphoma of the thyroid gland. Clinical Case A 75-year-old patient presented to the emergency room with loss of appetite and decreased oral intake over the previous five days, as well as abdominal pain and inability to pass gas and feces. The nausea and vomiting symptoms began simultaneously with the abdominal discomfort. Inspection revealed a distinct, palpable, and erythematous mass in the patient's neck, which the patient reported developing within the previous three months. After noticing the growing mass and consulting her primary care physician, she was referred to an ENT specialist; a biopsy was conducted and the results were pending. Her preliminary laboratory results revealed hypercalcemia and renal failure with depressed parathyroid hormone levels. The following were the initial laboratory results: creatinine 2,14 mg/dL, Ca 13,5 mg/dL, Albumin: 4,2 g/dL, P 2,9 mg/dL, Mg:1 mg/dl, parathormone 11.6 ng/dL procalcitonin 0.04% ng/mL and hemoglobin 10.2% g/dl. Abdominal CT revealed a contracted gallbladder with stone formations in the lumen, but no other abnormalities. The patient was admitted to the internal medicine ward with an initial diagnosis of hypercalcemia and prerenal acute kidney failure as a result of decreased oral intake. The patient's hypercalcemia was determined to be PTH-independent, and malignancy was suspected due to a 4-month history of progressive neck lesion. The thyroid gland was 49×40×87mm in the right and 38×40×62mm in the left, and the isthmus was 50mm thick with lobulated outlines on contrast enhanced cervical MR. The signal intensity of parenchyma was heterogeneous. 18F-FDG PET/CT uncovered a bilateral, distinct increase in the size of the thyroid gland with protrusions to the hyoid bone in superior sequences. The solid mass was found to have diffusely increased FDG uptake and a hypermetabolic pattern, both of which are indicative of malignant characteristics. The lesions encompass the trachea and there are reports of invasion of the cricoid cartilage and thyroid cartilage. A second main malignant disease concern was raised when small intestine FDG uptake and wall thickening suggested malignancy. The patient was re-evaluated by the endocrinology clinic, and additional workup tests were ordered due to the suspicion of Riedel Struma, which was based on the control sedimentation rate of 93 mm/h and the firmness of the gland upon palpation. An open surgical biopsy was performed. The pathology report concluded that it is consistent with diffuse large B-cell lymphoma that is CD20-positive. The hematology department has scheduled chemotherapy treatment for the patient.

Acute Diarrhea in Early Post-Transplant Period in Living Donor Kidney Transplant Recipients

Background: Acute diarrhea is common in Myanmar. People are so used to diarrhea at least once a year that they do not think diarrhea as an important problem. Acute diarrhea in early post-operative period in renal transplant recipient may result in pre-renal failure and delay graft function. This study aimed to identify the prevalence of diarrhea, its severity and response to treatment in early post-operative period (3 weeks after transplant) in living donor kidney transplant (LDKT) recipients. Patients and Methods: LDKT recipients having acute diarrhea in early post-transplant period at two transplant centers (Mingaladon and Nay Pyi Taw) in Myanmar were analyzed over 10 years period; from 2013 to 2023 September. Acute diarrhea is defined as three or more semisolid or liquid stools per day for a minimum of 1 day duration. It was a hospital based observational study. After obtaining diet history and physical examination, laboratory tests were done. Clinical parameters (diet, fever, features of oral candidiasis, features of dehydration, examination of abdomen), stool examination (stool inspection, stool examination for ova and cyst, stool for Clostridium difficle toxin, stool culture), blood tests (total WBC count, serum creatinine, liver function tests) and blood trough level for Tacrolimus and mycophenolate mofetil were done. Management was given according to algorithm and their response to treatment was recorded. Dose modification of immunosuppressants were done depending on full blood count and blood level of them. Results: A total of 230 LDKT recipients were observed; among them, thirteen percent (30/230) of recipients developed acute diarrhea in early post-operative period. The age ranged from 14 to 73 years. A majority of them had mild form; mild dehydration without significant changes in hemodynamic status. The peak onset of diarrhea was 4 to 5 days after transplant; majority resolved over one week. They did not have oral candidiasis. Abdominal examination was normal except mild tenderness over grafted kidney in all of them. Total WBC count and platelet count were normal except in two cases. Stool examination did not show trophozoite or cyst. Stool for Clostridium difficile toxin was not identified. With dietary modification and oral rehydration solution, their motion was back to normal in sixteen percent (5/30). Folic acid therapy with or without probiotics made resolution of diarrhea in 33.3% (10/30). Anti-infective therapy was given in 10% (3/30) of cases; norfloxacin to 2 cases. Intravenous colistin to one case as he had enterocolitis and septicemia due to Klebsiella pneumonia. His stool culture as well as blood culture showed Carbepenem resistant Klebsiella pneumonia; he was known case of myelodysplastic syndrome. Blood level of mycophenolate mofetil was normal; however, the dose was reduced in 2 cases owing to leucopenia or thrombocytopenia. Blood tacrolimus trough level was normal in two-third (20/30); and, it was high in one-third of them (20/30). They passed formed stool 24 - 48 hours after dose reduction of tacrolimus. Conclusion: In this study, 13% of the LDKT recipients had acute diarrhea in early post-operative period. Majority of them had mild form. Half of them recovered with oral rehydration solution, diet modification, folic acid and probiotics. Only one tenth of them had infective in origin and responded to anti-infective therapy. Raised blood tacrolimus trough level was found in one third of LDKT recipients with acute diarrhea; diarrhea improved dramatically after reduction of tacrolimus dose.

Morpho-functional aspects of various parts of the intestine and risk factors associated with the preventive ileostomy (review)

Currently, there is no clear answer which option of preventive intestinal stoma should be preferrable after low anterior resection for rectal cancer. The aim of this review was to search predictors of complications of preventive ileostomy. The disorders occur after ileostomy like dehydration, loss of electrolytes, and prerenal acute renal failure, are due to a deficiency of microvilli remaining in the digestion of the small intestine, as well as the inability of the intestine to adapt to new conditions.

EGFRcystatinC/eGFRcreatinine ratio < 0.6 in patients with SARS-CoV-2 pneumonia: a prospective cohort study

BackgroundShrunken Pore Syndrome (SPS), defined as a reduced ratio between two estimated filtration rates (based on cystatin C and creatinine) is an increasingly recognized risk factor for long-term mortality. Although some patients with other conditions might be erroneously identified as SPS. Our aim was to bring the focus on possible pathophysiologic mechanisms influencing the ratio in the setting of SARS-CoV-2 pneumonia and acute kidney injury.MethodsA single-centered prospective cohort study was conducted to investigate biomarkers in symptomatic COVID-19 pneumonia patients admitted to a hospital in Latvia. Nineteen biomarkers were measured in blood and three in urine samples. Associations were sought between these biomarkers, chronic diseases and the estimated GFRcystatinC/eGFRcreatinine ratio < 0.6, mortality rates, and acute kidney injury development. Data analysis was performed using SPSS Statistics, with significance set at p < 0.05.ResultsWe included 59 patients (average age 65.5 years, 45.8% female) admitted with COVID-19. Acute kidney injury occurred in 27.1%, and 25.4% died. Ratio < 0.6 was seen in 38.6%, associated with female sex, diabetes, hypothyroidism, and higher age. Ratio < 0.6 group had mortality notably higher − 40.9% vs. 16.2% and more cases of acute kidney injury (40.9% vs. 18.9%). Cystatin C showed strong associations with the ratio < 0.6 compared to creatinine. Urea levels and urea/creatinine ratio were higher in the ratio < 0.6 group. After excluding acute kidney injury patients, ratio < 0.6 remained associated with higher cystatin C and urea levels. Other biomarkers linked to a kidney injury as NGAL, and proteinuria did not differ.ConclusionWe prove that reduced ratio is common in hospitalized patients with SARS-CoV-2 pneumonia and is associated with increased mortality during hospitalization. Factors that influence this ratio are complex and, in addition to the possible shrinkage of pores, other conditions such as thickening of glomerular basal membrane, comorbidities, prerenal kidney failure and others may play an important role and should be addressed when diagnosing SPS. We highlight the need for additional diagnostic criteria for SPS and larger studies to better understand its implications in acute COVID-19 settings.

Follow-up of perfusion index and inferior vena cava collapsibility index in fluid therapy in prerenal acute renal failure

IntroductionAcute renal failure (ARF), which may occur as a result of hypovolemia, is frequently diagnosed in emergency departments. It is essential to determine these patients' volume status and fluid requirement. The aim of this study was to examine the change in the inferior vena cava (IVC) collapsibility index and perfusion index (PI) in order to evaluate fluid deficit, volume status, and response to fluid therapy in patients with prerenal ARF who presented with signs of hypovolemia. Materials and methodsThe study sample included 104 patients diagnosed with prerenal ARF due to hypovolemia in our emergency department. After obtaining informed consent from the patients, intravenous (IV) fluid therapy (20 cc/kg IV infusion of 0.9% sodium chloride solution for 30 min) was initiated. The PI and IVC collapsibility index were measured before and after the treatment. ResultsOf the patients included in this study, 56.7% were women. The mean age was 76.06 years. Of the patients, 46.2% had a history of multiple diseases. Avoidant/restrictive food intake disorder was the most common complaint (28.8%). The mean PI of the patients was 2.20 at admission, which increased to 3.27 after treatment. The mean IVC collapsibility index was 38.39 at admission, which decreased to 29.36 after treatment. There was a significant and negative correlation between the PI and IVC collapsibility index of the patients. ConclusionsEarly diagnosis and treatment of ARF in emergency departments are critical. Serial measurements of the IVC collapsibility index and PI are helpful in monitoring patients’ response to fluid therapy.

Post-obstructive polyuria. Pathophysiological analysis of a case

The relief of the impediment to urinary flow is the treatment of acute kidney failure due to urinary tract obstruction. However, there is a risk of inducing massive polyuria, which can be self-limited or produce severe contraction of the intravascular volume with pre-renal acute kidney failure and alterations in the internal environment. Polyuria, urine output > 3 L/d or > 200 mL/min for more than 2 hours, can have multiple causes, and can be classified as osmotic, aqueous or mixed. Post-obstructive polyuria obeys different pathogenic mechanisms, which overlap and vary during a patient's evolution. Initially, there is a decrease in vasoconstrictor factors and an increase in renal blood flow, which, added to the excess of urea accumulated, will cause intense osmotic diuresis (osmotic polyuria due to urea). Added to these factors are the positive sodium and water balance during acute renal failure, plus the contributions of crystalloid solutions to replace diuresis (ionic osmotic polyuria). Finally, there may be tubular dysfunction and decreased solutes in the renal medullary interstitium, adding resistance to the action of vasopressin. The latter causes a loss of free water (mixed polyuria). We present the case of a patient with post-obstructive polyuria where, by analyzing the clinical symptoms and laboratory alterations, it was possible to interpret the mechanisms of polyuria and administer appropriate treatment for the pathogenic mechanism.

Analysis of causes of graft loss in 135 kidney transplant recipients

To investigate the causes of graft loss in kidney transplant recipients. We retrospectively analyzed the clinical data of 135 recipients with graft loss after renal transplantation in the Eighth Medical Center of Chinese PLA General Hospital from January 1, 2002 to January 1, 2022. A total of 135 kidney transplant recipients experienced graft failure. The causes of graft loss included graft rejection (70 cases, 51.8%), death of the recipients with functional graft (37 cases, 27.4%), surgical complications (12 cases, 8.9%), drug toxicity (4 cases, 3.0%), carbapenem-resistant Klebsiella pneumoniae infection (4 cases, 3.0%), polyoma BK virus-related nephropathy (3 cases, 2.2%), primary nonfunctioning kidney (2 cases, 1.5%), recurrence of primary disease (2 cases, 1.5%), and prerenal acute renal failure (1 case, 0.7%). The main cause of graft loss after renal transplantation is graft rejection, and the secondary cause is death of the recipient with functional graft, and other reasons can be rare.

Prognostic factors of dehydration and renal damage in patients with formed preventive ileostomy during rectal resection for cancer

To determine the potential prognostic factors of complications associated with ileostomy dysfunction in patients who have undergone rectal resection for cancer. We retrospectively analyzed patients over the age of 18 who underwent open and laparoscopic resection of the rectum with the formation of a preventive ileostomy from January 2015 to May 2022. To determine the influence of potential predictors on the frequency of complications associated with large ileostomy losses, a single-factor logistic regression analysis was used. Complications associated with large ileostomy losses were primarily water-electrolyte disorders, dehydration and acute renal failure, which required intensive therapy and re-hospitalization. Of the 120 patients included in the study, 26 (21.7%) suffered complications associated with large losses of fluid and electrolytes in the stoma. In this group of patients, at least one repeated emergency hospitalization to a medical institution was required (average value 1.6). Factors associated with ileostomy dysfunction in a single-factor analysis were: the presence of signs of intestinal obstruction (OR=2.6; p=0.047), the development of postoperative complications (OR=3; p=0.024), steroid use (OR=4.3; p=0.010), smoking (OR=4.8; p=0.017) the average amount of discharge from the stoma at discharge is more than 1000 ml/24 h (OR=3.2; p=0.016) and the need for Loperamide at the time of discharge (OR=2.8; p=0.032). Multivariate logistic regression analysis revealed an independent risk factor for complications leading to re-hospitalization: ileostomy losses at discharge ≥1000 ml/24 h (OR=3.3 (1.18-9.37); p=0.023). In our study, those patients whose ileostomy discharge exceeded 1000 ml/24 h at discharge were at increased risk of dehydration, hypokalemia, hypocalcemia, acute prerenal renal failure, which led to repeated hospitalization to correct these disorders, sometimes in the intensive care unit.

Return to Work in Driver with Diabetes Mellitus Type 2 on Oral Anti Diabetic with a History of Hypoglycaemia

Background: Patients with type 2 diabetes might be vulnerable to hypoglycemia, especially those treated with insulin secretagogues such as sulfonylurea and glinide, or insulin. Hypoglycemia compromises driving performance, causes slower response times, and reduces cognitive function. A return-to-work assessment needs to be done after a history of severe hypoglycemia or intractable episodes requiring hospitalization before resuming driving.Case presentation: A-44-year-old man, a commercial vehicle driver with a history of Oral antidiabetic drugs (OAD), was admitted to the hospital with severe hypoglycemia and pre-renal acute kidney failure. After being hospitalized for seven days, the patient was planned to be discharged and intended to return to work as a driver in a car rental company after recovery.Discussion: In determining return-to-work status, a proper analysis is needed in the form of seven steps to establish the return-to-work status. Job description, job demand, current medical status, disability, risk, and tolerance must be discussed before determining fit to work status. References related to how severe hypoglycemia relates to driving tasks could be valuable information in deciding fit-to-work status.Conclusion: Return-to-work assessment has concluded that the patient is temporarily unfit as a commercial vehicle driver for six weeks. Education regarding hypoglycemia, including recognizing symptoms early, how to treat promptly, and avoid further devastating accident should be discussed thoroughly between patient and physician. Close monitoring by Occupational Medicine Specialists in hypoglycemia state and symptoms as a return-to-work- program would be a valuable step.

MULTISYSTEM-INFLAMMATORY SYNDROME (MIS-C) IN NEONATE ASSOCIATED WITH SARS-COVID19

Background: Multisystem-Inflammatory Syndrome in Children (MIS-C) is a rare complication of COVID-19 infection in the pediatric population which greatly enhances the risk for thrombotic complications including disseminated intravascular coagulation (DIC). Furthermore, treating complications of DIC is complex as treating one complication can exacerbate the other, and the underlying COVID-19 infection and MIS-C as a whole. This makes choosing the most appropriate treatment difficult.Aim: To report on case of MIS-C in neonate who developed DIC with multiple thrombotic and hemorrhagic events.Methods: In our study, we analyzed a clinical case of a neonate diagnosed with MIS-C who developed DIC with damage to the heart, kidneys, lungs, liver and adrenal glands.Results: After infection with SARS-CoV2, MIS-C developed which led to systemic inflammation that triggered DIC, as proven by laboratory markers. DIC led to thrombotic and hemorrhagic events that affected multiple organs, which led to the following: Pre-renal Acute Kidney Injury-renal failure, acute adrenal insufficiency (Waterhouse-Friderichsen syndrome), ileofemoral thrombosis, right atrial thrombosis, Left ventricle thrombosis and fixed aortic thrombosis. Furthermore, the treatment of MIS-C and that of the complications of DIC were contraindicated on several occasions.Conclusion: This case demonstrated that MIS-C and DIC modulated each other which worsened the prognosis for this neonate initially. With many critical comorbidities the treatment for this case became complex, treating one complication would exacerbate the other, especially noted when the neonate suffered adrenal hemorrhage. Although prognosis was poor, the neonate recovered due to precise control of treatment tactics by the multidisciplinary team.

Review of literature: Renal abnormalities in liver disease

Renal failure is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance. Patients with cirrhosis are more prone to developing acute kidney injury than the non-cirrhotic population. The differential diagnosis of renal dysfunction in advanced liver disease includes pre-renal failure, intrinsic renal failure and hepatorenal syndrome. Hepatorenal syndrome is a complication of advanced cirrhosis characterized by an abrupt deterioration in renal function. In cirrhosis with ascites, hepatorenal syndrome is a specific prerenal dysfunction. It is unresponsive to fluid volume expansion and is associated with an extremely poor prognosis. An accurate assessment of renal function is recommended in all patients with cirrhosis. Liver transplantation remains the definitive treatment for hepatorenal syndrome, but new treatment strategies can be utilized as a bridge to transplantation. This review provides an update on our present understanding of the underlying pathophysiological mechanisms involved, diagnostic criteria, different treatment approaches and strategies to prevent Hepatorenal Syndrome.

A Cross-Sectional Survey to Assess the Knowledge of Nurses Regarding Acute Kidney Injury in a Tertiary Care Hospital in Delhi

Background: Acute kidney injury (AKI) is growing as a serious manifestation of multiple etiologies globally. As majority of the admitted patients are in direct contact with nurses, nurses have a pivotal role in the early detection and management of AKI. Nurses must possess knowledge and information about AKI for its early detection and management. Aim: This study aimed to assess knowledge of nurses regarding AKI. Materials and Methods: This cross-sectional descriptive survey was carried out in the emergency department and outpatient departments of selected hospital, New Delhi, over a period of 5 months. Eligibility criteria for inclusion included nurses working in the emergency department and outpatient departments, who can understand or read either English or Hindi language; and were willing to participate in the study. Two hundred and forty-five nurses were recruited as study samples using total enumerative sampling technique. Results: The results of the study revealed that majority 77.1% of the subjects had good knowledge regarding AKI and only 22.9% of participants had poor knowledge regarding AKI. Majority (i.e., 69.4%, 64.1%, 77.1%, and 84.1%) of nurses were familiar with causes of prerenal failure, the various modalities of treatment of AKI, cases that require dialysis, and complications of AKI, respectively. However, only 20.4% of subjects were aware of RIFLE criteria for AKI. Conclusion: The study identified that most of the nurses carry good knowledge regarding AKI, however, still knowledge is lacking in few important aspects pertaining to assessment and management of AKI, which needs to be considered by nursing administrators while planning in-service and continuing education for nurses.

Changing serum creatinine in the detection of acute renal failure and recovery following radiocontrast studies among acutely ill inpatients: Reviewing insights regarding renal functional reserve gained by large-data analysis

A rise in serum creatinine (SCr) is widely used for the detection and definition of evolving acute kidney injury (AKI). Yet, it takes time for SCr to re-adjust in response to changes in glomerular filtration rate (GFR), and subtle transient changes in GFR may remain concealed. Additionally, it cannot differentiate altered glomerular hemodynamics and pre-renal failure from true renal tissue injury, necessitating additional clinical and laboratory diagnostic tools.While these features limit the usefulness of SCr and subsequently estimated GFR (eGFR) at a single time point for the individual patient, their overall pattern of changes along time in a large cohort of hospitalized patients may provide a powerful perspective regarding the detection and assessment of shifting kidney function in this population. Herein we review our experience running large data analyses, evaluating patterns of day-to-day changes in SCr among inpatients, occurring around the exposure to iodinated radiocontrast agents. These large data evaluations helped substantiating the existence of contrast-induced nephropathy in patients with advanced renal failure, underscoring the impact of predisposing and confounding factors. It also provides novel insights regarding a phenomenon of "acute kidney functional recovery” (AKR), and illustrate that the incidence of AKI and AKR along the scale of baseline kidney function co-associates and is inversely proportional to kidney function. This can be attributed to renal functional reserve, which serves as a buffer for up-and-down changes in GFR, forming the physiologic explanation for concealed subclinical AKI.

Vaginal hysterectomy in a 95-year-old woman a case report/ Histerectomia vaginal em mulher de 95 anos relato de caso

M.M, 95-year-old Japanese woman, 6 vaginal deliveries, presented a 20 days fetid vaginal smell/5 months mild vaginal bleeding. Well appearing, oriented and coherent. Physically active, having a controlled mild hypertension as the only comorbidity. Vaginal exame, identified a foul smelling from the cervix. A transvaginal ultrasound revealed anteverted/flexed uterus, and the endometrial cavity had cystic/solid content, without vascularity in doppler. Endometrial biopsy was performed and the hypothesis of neoplastic cells was discharged. It was indicated a total vaginal hysterectomy. There were no complications. The correct anesthetic dose provided lower risk and a better outcome. In the first 12 hours, a pre-renal acute renal failure was reversed. The hospital discharge was after 2 days, when the patient had no pain, was walking and urinating. Only dipyrone was used as analgesic and 14 days of clindamycin was prescribed. After a month, no complaints/pain were reported. The patient returned to her daily habits and to social contact in a short time, indicating a good evolution. The surgery highly improved the patient’s quality of life.

Renal manifestations of hepatitis E among immunocompetent and solid organ transplant recipients.

Hepatitis E virus (HEV) infections are generally self-limited. Rare cases of hepatitis E induced fulminant liver failure requiring liver transplantation are reported in the literature. Even though HEV infection is generally encountered among developing countries, a recent uptrend is reported in developed countries. Consumption of unprocessed meat and zoonosis are considered to be the likely transmission modalities in developed countries. Renal involvement of HEV generally holds a benign and self-limited course. Although rare cases of cryoglobulinemia are reported in immunocompetent patients, glomerular manifestations of HEV infection are frequently encountered in immunocompromised and solid organ transplant recipients. The spectrum of renal manifestations of HEV infection include pre-renal failure, glomerular disorders, tubular and interstitial injury. Kidney biopsy is the gold standard diagnostic test that confirms the pattern of injury. Management predominantly includes conservative approach. Reduction of immunosuppressive medications and ribavirin (for 3-6 mo) is considered among patients with solid organ transplants. Here we review the clinical course, pathogenesis, renal manifestations, and management of HEV among immunocompetent and solid organ transplant recipients.

Safety and Efficacy of Veverimer in Acidotic Patients With CKD and Heart Failure

Safety and Efficacy of Veverimer in Acidotic Patients With CKD and Heart Failure

Study of incidence of acute renal failure and its associated factors and complications amongst patients admitted in intensive care unit of a tertiary care teaching hospital

Background: Impairment of renal function is a serious complication in critically ill patients. Mortality of acute renal failure remains high ranging from 35% to 86% despite haemodialysis therapy and substantial improvement of dialysis techniques. Therefore attention must be paid to the conditions favouring deterioration of renal function in order to prevent acute renal failure or to intervene in an early phase when less invasive therapies might be even more promising. Methods: This prospective study was conducted in a tertiary care teaching hospital in Mumbai from 1st January 2006 to 31st December 2006. All patients consecutively admitted in intensive care unit were studied. Results: Total number of patients admitted during the said period to the Intensive care Unit was 406, of which 50 had evidence of acute renal failure. The incidence of acute renal failure in the critically ill patients included in our study was 12.31%. There was a statistically significant difference in the incidence of fluid overload, oliguria and hyperkalemia between the pre-renal and renal failure groups. Conclusion: The incidence of acute renal failure in the critically ill patients was 12.31% and commonest predisposing factors associated with acute renal failure were acute insults like hypotension, sepsis and risk factors like age &gt;50 years and pre-existing renal disease.

Central pontine myelinolysis during treatment of hyperglycemic hyperosmolar syndrome: a case report

BackgroundCentral pontine myelinolysis (CPM) is a non-inflammatory demyelinating lesion of the pons. CPM and extrapontine demyelination (EPM) are together termed osmotic demyelination syndrome (ODS), a known and serious complication of acute correction of hyponatremia. Conversely, hyperglycemic hyperosmolarity syndrome (HHS) develops in patients with type 2 diabetes who still have some insulin secretory ability due to infection, non-compliance with treatment, drugs, and coexisting diseases, and is often accompanied by ketosis. HHS represents a life-threatening endocrine emergency (mortality rate, 10–50%) associated with marked hyperglycemia and severe dehydration. HHS may develop ODS, and some cases have been associated with hypernatremia.Case presentationThe patient was an 87-year-old woman with hyperglycemia, dehydration, malnutrition, and potential thrombus formation during long-term bed rest. HHS was suspected to have developed due to progression of hyperglycemia and dehydration caused by pneumonia. Furthermore, ketoacidosis developed from ketosis and prerenal renal failure associated with circulating hypovolemia shock, which was also associated with disseminated intravascular coagulation. Treatment was started with continuous intravenous injection of fast-acting insulin and low-sodium replacement fluid. In addition, ceftriaxone sodium hydrate, heparin sodium, thrombomodulin α, human serum albumin, and dopamine hydrochloride were administered. Blood glucose, serum sodium, serum osmolality, and general condition (including vital, infection/inflammatory findings, and disseminated intravascular coagulation) improved promptly, but improvements in disturbance of consciousness were poor. Diffusion-weighted imaging of the brain 72 h after starting treatment showed no obvious abnormalities, but high-intensity signals in the midline of the pons became apparent 30 days later, leading to definitive diagnosis of CPM.ConclusionsFluctuation of osmotic pressure by treatment from hyperosmolarity due to hyperglycemia and hypernatremia in the presence of risk factors such as malnutrition, severe illness, and metabolic disorders may be a cause of CPM onset. When treating HHS with risk factors, the possibility of progression to ODS needs to be kept in mind.

Hepatorenal syndrome in children: a review.

Hepatorenal syndrome (HRS) occurs in patients with cirrhosis or fulminant hepatic failure and is a kind of pre-renal failure due to intense reduction of kidney perfusion induced by severe hepatic injury. While other causes of pre-renal acute kidney injury (AKI) respond to fluid infusion, HRS does not. HRS incidence is 5% in children with chronic liver conditions before liver transplantation. Type 1 HRS is an acute and rapidly progressive form that often develops after a precipitating factor, including gastrointestinal bleeding or spontaneous bacterial peritonitis, while type 2 is considered a slowly progressive form of kidney failure that often occurs spontaneously in chronic ascites settings. HRS pathogenesis is multifactorial. Cirrhosis causes portal hypertension; therefore, stasis and release of vasodilator substances occur in the hepatic vascular bed, leading to vasodilatation of splanchnic arteries and systemic hypotension. Many mechanisms seem to work together to cause this imbalance: splanchnic vasodilatation; vasoactive mediators; hyperdynamic circulation states and subsequent cardiac dysfunction; neuro-hormonal mechanisms; changes in sympathetic nervous system, renin-angiotensin system, and vasopressin. In patients with AKI and cirrhosis, fluid expansion therapy needs to be initiated as soon as possible and nephrotoxic drugs discontinued. Once HRS is diagnosed, pharmacological treatment with vasoconstrictors, mainly terlipressin plus albumin, should be initiated. If there is no response, other options can include surgical venous shunts and kidney replacement therapy. In this regard, extracorporeal liver support can be a bridge for liver transplantation, which remains as the ideal treatment. Further studies are necessary to investigate early biomarkers and alternative treatments for HRS.

Scrub typhus leading to focal segmental glomerulosclerosis in a child due to genetic predisposition

Scrub typhus is a multisystem disease, caused by genera orientia tsutsugamushi and is currently endemic in India. In children, the disease may vary from a mild to a severe form. Complications include encephalitis, myocarditis, disseminated intravascular coagulation, acute kidney injury, atypical pneumonia, etc. The pathophysiologic mechanisms of renal involvement in scrub typhus include prerenal failure, septic shock, vasculitis, acute tubular injury and direct renal invasion by rickettsia. Here, authors present the case of a previously well 5-year old female child who was admitted to our hospital with a history of high-grade fever and pain abdomen. IgM scrub typhus turned out to be positive and she was adequately treated with doxycycline. She turned afebrile but then gradually developed anasarca, hematuria, proteinuria and persistent stage 2 hypertension. Kidney biopsy was done which revealed focal segmental glomerulosclerosis (FSGS). Further workup of the patient by whole exome sequencing revealed missense mutations in TBX18, INF2 and NPHS1 genes. Mutations in INF2 gene is a recently discovered cause of autosomal dominant FSGS. In our case, the scrub typhus mediated kidney injury probably acted as a trigger in unmasking FSGS in the already genetically susceptible child.