Prolonged Renal Replacement Therapy Research Articles

Donor plasma VEGF-A as a biomarker for myocardial injury and primary graft dysfunction after heart transplantation

BackgroundVascular endothelial growth factor (VEGF)-A is an angiogenic and proinflammatory cytokine with profound effects on microvascular permeability and vasodilation. Several processes may induce VEGF-A expression in brain-dead organ donors. However, it remains unclear whether donor VEGF-A is linked to adverse outcomes after heart transplantation. MethodsWe examined plasma VEGF-A levels from 83 heart transplant donors as well as the clinical data of these donors and their respective recipients operated between 2010 and 2016. The donor plasma was analyzed using Luminex-based Multiplex and confirmed with a single-target ELISA. Based on donor VEGF-A plasma levels, the recipients were divided into three equal-sized groups (low VEGF <500 ng/L, n=28; moderate VEGF 500-3000 ng/L, n=28; and high VEGF >3000 ng/L, n=27). Biochemical and clinical parameters of myocardial injury as well as heart transplant and kidney function were followed-up for one year, while rejection episodes, development of cardiac allograft vasculopathy, and mortality were monitored for five years. ResultsBaseline parameters were comparable between the donor groups, except for age, where median ages of 40, 45, and 50 were observed for low, moderate, and high donor plasma VEGF levels groups, respectively, and therefore donor age was included as a confounding factor. High donor plasma VEGF-A levels were associated with pronounced myocardial injury (TnT and TnI), a higher inotrope score, and a higher incidence of primary graft dysfunction in the recipient after heart transplantation. Furthermore, recipients with allografts from donors with high plasma VEGF-A levels had a longer length of stay in the intensive care unit and the hospital, and an increased likelihood for prolonged renal replacement therapy. ConclusionsOur findings suggest that elevated donor plasma VEGF-A levels were associated with adverse outcomes in heart transplant recipients, particularly in terms of myocardial injury, primary graft dysfunction, and long-term renal complications. Donor VEGF-A may serve as a potential biomarker for predicting these adverse outcomes and identifying extended donor criteria.

Prediction of successful weaning from renal replacement therapy in critically ill patients based on machine learning

Background Predicting the successful weaning of acute kidney injury (AKI) patients from renal replacement therapy (RRT) has emerged as a research focus, and we successfully built predictive models for RRT withdrawal in patients with severe AKI by machine learning. Methods This retrospective single-center study utilized data from our general intensive care unit (ICU) Database, focusing on patients diagnosed with severe AKI who underwent RRT. We evaluated RRT weaning success based on patients being free of RRT in the subsequent week and their overall survival. Multiple logistic regression (MLR) and machine learning algorithms were adopted to construct the prediction models. Results A total of 976 patients were included, with 349 patients successfully weaned off RRT. Longer RRT duration (7.0 vs. 9.6 d, p = 0.002, OR = 0.94), higher serum cystatin C levels (1.2 vs. 3.2 mg/L, p < 0.001, OR = 0.46), and the presence of septic shock (28.1% vs. 41.5%, p < 0.001, OR = 0.63) were associated with reduced likelihood of RRT weaning. Conversely, a positive furosemide stress test (FST) (60.2% vs. 40.7%, p < 0.001, OR = 2.75) and higher total urine volume 3 d before RRT withdrawal (755 vs. 125 mL/d, p < 0.001, OR = 2.12) were associated with an increased likelihood of successful weaning from RRT. Next, we demonstrated that machine learning models, especially Random Forest and XGBoost, achieving an AUROC of 0.95. The XGBoost model exhibited superior accuracy, yielding an AUROC of 0.849. Conclusion High-risk factors for unsuccessful RRT weaning in severe AKI patients include prolonged RRT duration. Machine learning prediction models, when compared to models based on multivariate logistic regression using these indicators, offer distinct advantages in predictive accuracy.

Проблеми діагностики та лікування турнікетного синдрому при вогнепальних пораненнях верхніх і нижніх кінцівок

The article presents topical issues of diagnostic monitoring of changes in vascular status when using a tourniquet during a combat injury, diagnosis of tourniquet syndrome. An alternative diagnostic approach in the form of additional use of multifocal express muscle biopsy and dynamic digital thermography has been demonstrated. Purpose - to conduct an analysis of the problematic issues of diagnosis and treatment of tourniquet syndrome in gunshot wounds of the limbs in order to reduce the number of organizational and technical errors in wounds of the limbs where a tourniquet was used. Materials and methods. In the 16 months since the beginning of Russia’s full-scale aggression against Ukraine, 28 wounded people with tourniquet limb syndrome were treated in the Military Medical Clinical Center of the Northern Region (MMCC of the Northern Region). All the wounded were male, the average age was 34.2±0.6 years. The analysis of the following indicators was carried out: the timing of applying a tourniquet before arrival at ROLE 2, the localization of the tourniquet, the amount of surgical intervention at ROLE 2, the length of stay at ROLE 2, the amount of pre-operative examination in the MMCC of the NR, the amount of surgical interventions in the conditions of the MMCC of the NR, the number of cases of acute kidney injury, the need for renal replacement therapy, the average bed-day on ROLE 3, the level of mortality. Classical general clinical studies were carried out in combination with thermographic and histological research. Results. In terms of localization, in gunshot wounds with tourniquet syndrome, wounds of the lower extremities prevail 28 (82.4%) over the upper extremities 6 (17.6%). There were 12 (35.3%) cases of gunshot fractures in tourniquet syndrome. All (28 patients) injured people arrived with tourniquets on their limbs. The terms of applying a tourniquet before hospitalization on ROLE 3 - from 3 hours 10 minutes to 11 hours 25 minutes, on average - 5 hours 35 minutes ±20 minutes. In 5 (14.7%) cases, there were attempts to remove the tourniquet when it was applied for more than 3 hours at the ROLE 1 level. In 6 (21.4%) of the wounded, there were 2 tourniquets on one anatomical and functional site, which led to amputation on proximal level. The average length of stay at ROLE 2 with tourniquet syndrome was 60±10 hours. All wounded (28 patients) with tourniquet syndrome underwent 34 amputations. 16 (57.1%) wounded with tourniquet syndrome had acute kidney injury and were on prolonged renal replacement therapy. This category of wounded had a tourniquet syndrome at the level of the thigh. Polyfocal express muscle biopsy and dynamic digital thermography were used to diagnose tourniquet syndrome. Conclusions. Improving the training of combat medics will lead to a decrease in the number of organizational and technical errors in limb injuries where a tourniquet is used. A tourniquet applied for a long time leads to a high level of limb amputation in case of irreversible changes in the muscles. There is a need for further development of objective methods for the diagnosis of tourniquet syndrome. The proposed additional methods of diagnosis in the form of polyfocal express biopsy and thermography make it possible to objectify the extent of damage due to standing of the tourniquet. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Nutrients and micronutrients at risk during renal replacement therapy: a scoping review.

Purpose of reviewMalnutrition is frequent in patients with acute kidney injury. Nutrient clearance during renal replacement therapy (RRT) potentially contributes to this complication. Although losses of amino acid, trace elements and vitamins have been described, there is no clear guidance regarding the role of micronutrient supplementation.Recent findingsA scoping review was conducted with the aim to review the existing literature on micronutrients status during RRT: 35 publications including data on effluent losses and blood concentrations were considered relevant and analysed. For completeness, we also included data on amino acids. Among trace elements, negative balances have been shown for copper and selenium: low blood levels seem to indicate potential deficiency. Smaller size water soluble vitamins were found in the effluent, but not larger size liposoluble vitamins. Low blood values were frequently reported for thiamine, folate and vitamin C, as well as for carnitine. All amino acids were detectable in effluent fluid. Duration of RRT was associated with decreasing blood values.SummaryLosses of several micronutrients and amino acids associated with low blood levels represent a real risk of deficiency for vitamins B1 and C, copper and selenium: they should be monitored in prolonged RRT. Further Research is urgently required as the data are insufficient to generate strong conclusions and prescription recommendations for clinical practice.

Safety of bedside placement of tunneled dialysis catheter in COVID-19 patients.

COVID-19 patients admitted to the ICU have high incidence of AKI requiring prolonged renal replacement therapy and often necessitate the placement of a tunneled dialysis catheter (TDC). We describe our experience with two cases of COVID-19 patients who underwent successful bedside placement of TDC under ultrasound guidance using anatomical landmarks without fluoroscopy guidance. Tunneled dialysis catheter placement under direct fluoroscopy remains the standard of care; but in well selected patients, placement of tunneled dialysis catheter at the bedside using anatomic landmarks without fluoroscopy can be safely and successfully performed without compromising the quality of care and avoid transfer of COVID-19 infected patients outside the ICU.

Laboratory criteria for the persistence of secondary hyperparathyroidism in patients with chronic kidney disease

Secondary hyperparathyroidism is a complication of chronic kidney disease in both the non-dialysis and dialysis stages. Even modern advances in drug therapy cannot change the fact that most CKD patients require surgical treatment. The purpose of the treatment of SHPT is to normalize mineral metabolism, prevent bone diseases and prevent extraosseous manifestations. One of the methods of surgical treatment is subtotal parathyroidectomy. Persistence or recurrence of the disease occurs in 5-30% of cases.Purpose of the study. To determine laboratory criteria for the persistence of SHPT in patients with chronic kidney disease on the second day after parathyroidectomy.Materials and methods. The study involved 118 patients with end-stage CKD with prolonged renal replacement therapy. All patients had clinical and laboratory signs of secondary hyperparathyroidism. In the period from 2009 to 2019, patients underwent subtotal parathyroidectomy. The patients were divided into two groups. This division was based on the presence of persistence or recurrence of the disease. The main group included 20 patients with laboratory signs of SHPT persistence; the comparison group included 98 patients without signs of disease’s persistence.Results. Analysis of changes in laboratory parameters in patients with persistence and in patients without signs of disease’s persistence revealed certain differences in their postoperative level. In all 118 cases, there was a significant decrease in PTH in the postoperative period - from 31.5 to 99.6%. Using ROC-analysis, a study was carried out of the possibility of using the degree of PTH reduction as a predictor of the persistent course of SHPT and the optimal cut-off thresholds were established. A decrease in the postoperative level of PTH by 90.9% or more indicates an effective PTE. The maximum value of the test specificity (1.000 (0.968; 1.000)) is achieved when the PTH reduction is 76.0%. At the same time, the maximum value - 1.000 (0.968; 1.000) - reaches the predictive value of a positive test result.Conclusions. Using the subtotal parathyroidectomy in our study, the persistent of SHPT occurred in 16.9% of cases. A decrease in PTH levels on the second day after surgery less than 76% comparatively to the preoperative level should be considered as a predictor of the development of disease persistence. A reduction in PTH of more than 90.9% may be an indication of sustained remission.

P1096SAFETY AND EFFICACY OF A NEW SIMPLIFIED REGIONAL CITRATE ANTICOAGULATION PROTOCOL FOR SUSTAINED LOW EFFICIENCY DIALYSIS FOCUSED ON PREVENTION OF RRT-INDUCED HYPOPHOSPHATEMIA IN CRITICALLY ILL RENAL PATIENTS

Abstract Background and Aims Sustained-Low Efficiency Dialysis (SLED) is a hybrid Renal Replacement Therapy (RRT) increasingly used in critically ill patients with Acute Kidney Injury (AKI). Usually lasting 8-12 hours, this modality combines several advantages of both intermittent and continuous RRT (CRRT). Regional citrate anticoagulation (RCA) represents the most adequate anticoagulation strategy to avoid the extracorporeal circuit clotting. Hypophosphatemia (serum phosphorus, s-P, levels ≤ 2.5 mg/dl) is a common electrolyte disorder in critically ills, with an increased incidence in course of prolonged RRTs, especially when standard dialysis/replacement solutions and highly intensive modalities are employed. Given the potentially negative impact of hypophosphatemia on patients’ outcomes, strategies aimed at preventing its onset should be appropriately implemented. This pilot study is aimed at evaluation of safety and efficacy of a simplified RCA protocol for SLED, based on the combination of a low-concentrated citrate solution with a phosphate-containing solution. Methods a prospective observational study was conducted on critically ill patients with AKI requiring RRT or End Stage Renal Disease (ESRD) previously on RRT admitted to our renal Intensive Care Unit (ICU). SLED was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 haemofilters (ST 150, 1.5 m2, Baxter). 8-hours SLED sessions were prescribed, in the SLED-f variant, by using a 18 mmol/l pre-dilution trisodium citrate solution (Regiocit 18/0, Baxter) combined with a phosphate-containing solution acting as dialysate (Ca2+ 0, HPO42- 1, Mg2+ 0.75, HCO3- 22 mmol/l; Biphozyl, Baxter) and a standard RRT solution acting as post-dilution replacement fluid (Prismasol 4, Baxter). Calcium chloride (CaCl 10%) was infused in a separate central venous line to maintain the systemic Ca2+ (s-Ca2+) within a normal range. Each patient underwent three consecutive daily SLED sessions. The activated coagulation time (ACT), acid–base parameters, s-Ca2+ and potassium were measured at SLED start and every 2 h. Phosphorus and magnesium losses with RRT were replaced, when needed, with sodium glycerophosphate pentahydrate (GlycophosTM 20 mmol/20 ml, Fresenius Kabi Norge AS, Halden, Norvegia) and magnesium sulphate. Results a total of 60 SLED-f sessions were performed in 20 ICU patients. At ICU admission, the average APACHE II score was 21.8 and half of patients were mechanically ventilated. Many of them showed hemodynamic instability and AKI was oliguric in 90% of cases. No premature interruptions for irreversible filter clotting occurred and the prescribed dialysis dose was delivered in 95% of cases. No statistically significant differences were observed between systemic ACT at SLED start and during RRT sessions, and no major hemorrhagic events were observed. Regarding RCA, no clinically relevant episode of hypo or hypercalcemia was observed, and calcium infusion rate remained constant in course of treatments. Acid-base status was effectively maintained during the entire period of treatment and no episodes of clinically relevant metabolic acidosis or alkalosis were registered. The analysis of the main laboratory variables at SLED start, in course and after 24 h of treatment did not show statistically significant differences. Regardless of starting values, s-P and s-Mg were progressively corrected and maintained within the normality range, limiting the need for exogenous supplementations. Conclusions These preliminary data suggest that our simplified RCA protocol for SLED, combining a low-citrate solution with a phosphate-containing solution, is safe and efficacious allowing to optimizing acid-base balance and to preventing RRT-related hypophosphatemia.

Usefulness of prolonged renal replacement therapy in patients with acute kidney injury requiring dialysis

Acute kidney injury (AKI) requiring dialysis is becoming more common. Several types of renal replacement therapies have been used, including continuous, intermittent, and prolonged intermittent renal replacement therapy (PIRRT). There is no clear difference between those therapies in terms of patient survival. The aim of this study was to describe a form of PIRRT (shift continuous veno-venous hemodialysis [CVVHD]) and the results of this technique in a population of patients with AKI requiring dialysis in a tertiary care center. We studied 302 patients with AKI requiring dialysis over a 3-year period. All patients were treated in the intensive care unit. There were 1709 treatments in the study. Shift CVVHD was done for 8 h daily using NxStage machines, with a bicarbonate base dialysate at a rate of 5 L/h. Demographics and laboratory data were obtained from the electronic medical record. Dialysis data were obtained from the dialysis run sheets. Patient mortality was 51.3%.The dialysis time was close to 8 h and the blood flow was 310 (± 43) mL/min. The mean arterial pressure was stable before and after the dialysis. The total ultrafiltration averaged 2934 mL per treatment; the ultrafiltration rate was 4.1 (± 3.1) mL/kg/h, and the ultrafiltration per hour was 359 (± 257.8) mL/h. The average dialysate potassium used was 2.9 mEq/L. The dose of dialysis was 57 (± 19) mL/kg/h. The urea reduction ratio was 48% (± 15%), the standardized KT/V (a measure of dialysis dose obtained by urea kinetic modeling) was 3.5 (± 0.9), and the equivalent renal urea clearance (EKR) was 9.8 (± 4.1) mL/min. The method produced a consistent reduction in the levels of blood urea nitrogen, creatinine, potassium, and phosphorous. The delivered dose of dialysis was stable during the observation period. In conclusion, shift CVVHD is effective in treating patients with AKI requiring dialysis and has a survival similar to that of continuous therapies with less intensive use of resources.

Calcitriol loading before total parathyroidectomy with autotransplant in patients with end-stage kidney disease: does it prevent postoperative hypocalcaemia?

Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre-operative strategy for prevention. The primary aims were to examine the incidence of HBS with pre-operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end-stage kidney disease population. We performed a retrospective study from 2011 to 2018 on 45 patients with end-stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales. 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre-operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024). HBS remains a common complication of parathyroidectomy, even with prolonged high-dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy.

Transitional care program to facilitate recovery following severe acute kidney injury.

Patients with acute kidney injury needing prolonged renal replacement therapy (AKI-RRT) may benefit from a structured care process in form of an AKI transitional care program (ATCP), to facilitate RRT weaning and recovery. We examined outcomes following ATCP implementation in adults with AKI-RRT from a tertiary institution (versus pre-ATCP controls), including mortality, cumulative hospital days, and renal function over one year; RRT and haemodialysis catheter days in initial 90days. We studied 89 patients with age 62 ( ± 15) years. 47% had septic AKI, 20% cardiorenal syndrome, and 29% had baseline eGFR < 30mL/min/1.73 m2. Comparing 45 ATCP patients with 44 controls: 64% and 45% received continuous RRT (CRRT) (p = 0.07), with comparable rates of heart failure (24% versus 25%), ICU care (67% versus 70%), RRT successfully weaned (71% versus 75%), respectively; corresponding mortality rates were 24% and 32% (p = 0.44), hospital days of 205 (197-213) and 223 (215-232) per 1000 patient-days alive over one year (p = 0.002); with comparable RRT and catheter days. Serial serum creatinine in months following RRT cessation were comparable between either survivor-group. On multivariate analysis, heart failure or having received CRRT independently predicted mortality and longer hospital days (p < 0.05); ATCP was independently associated with reduced hospital days (p < 0.001). 17 ATCP patients and 14 controls required outpatient RRT weaning, with catheter days of 607 (568-648) and 683 (638-731) per 1000 patient-days in initial 90days, respectively (p = 0.01). Implementing a structured care pathway in patients with AKI-RRT may help reduce hospitalization, and reduce haemodialysis catheter days in the subgroup for outpatient RRT weaning.

Impact of Hemolysis on Acute Kidney Injury and Mortality in Children Supported with Cardiac Extracorporeal Membrane Oxygenation

Intravascular hemolysis with elevated plasma-free hemoglobin (PFH) complicates extracorporeal membrane oxygenation (ECMO). In 50 consecutive pediatric cardiac patients requiring ECMO, we sought to describe the relationship between PFH and clinical outcomes; primary outcomes were acute kidney injury (AKI) and prolonged (&gt;14 days) renal replacement therapy (RRT). Median age was 35 days, median weight 3.9 kg, and median ECMO duration 4.2 days. Seventy-eight percent (39/50) weaned off ECMO; survival to discharge was 50% (25/50). Seventy percent (35/50) had AKI on ECMO. Seventy-seven percent (30/39) required RRT post-ECMO; median duration was 5.2 days (0, 14.2). Prolonged RRT was associated with higher daily PFH (67.5 mg/dL [54.1, 102.5] vs. 46.7 mg/dL [40, 72.6],p= .025) and higher peak PFH (120 mg/dL [90, 200] vs. 60 mg/dL [40, 135],p= .016). After adjusting for ECMO duration and oliguria/elevated creatinine on ECMO day 0, peak PFH &gt;90 mg/dL was associated with prolonged RRT (operating room [OR] = 18, confidence interval [CI] 1.9–167.8). Patients who died had higher daily PFH (65 mg/dL [51.6, 111.7] vs. 42.5 mg/dL [37.5, 60],p= .0040). Adjusting for ECMO duration and blood product administration, daily PFH &gt;53 mg/dL was associated with mortality (OR 4.8, CI 1.01–23.3). Elevated PFH during pediatric cardiac ECMO is associated with prolonged RRT and non-survival to discharge. Initiatives to decrease PFH burden may improve clinical outcomes.

IP257. Pediatric Blunt and Penetrating Abdominal Aortic Transections: Report of Two Cases

Noniatrogenic vascular injury accounts for <1% of pediatric trauma. With <4% of these involving the aorta, there is a paucity of reports describing aortic injury in the pediatric population. We present two extremely rare cases of traumatic abdominal aortic transection and report the management and outcomes of both an open and an endovascular repair. Review and surveillance of the cases of two pediatric aortic transection patients were conducted at a level 1 trauma center. During a 12-year period, two children with trauma-related aortic transections presented to the emergency department. Both were hemodynamically unstable and taken directly to the operating room. An 11-year-old boy presented with a stab wound to the left flank. Injuries included penetration of the left kidney, transection of the aorta at the level of the right accessory renal artery, and injury to the inferior vena cava. The patient underwent reconstruction of the aorta using a Dacron interposition graft. He required nephrectomy, cava repair, fasciotomy, colon resection, colostomy, and prolonged renal replacement therapy. He was discharged home on postinjury day 38 without adverse vascular sequelae or need for further dialysis and underwent colostomy reversal at 5 months. Aortic duplex ultrasound at 7 months demonstrated questionable slight decrease in diameter at graft anastomotic sites but with normal flow throughout and without defect or stenosis. A 10-year-old boy involved in a motor vehicle crash, restrained only by a lap belt, presented with aortic transection at the level of the inferior mesenteric artery; he sustained multiple mesenteric rents, bowel injury, and lumbar spine fractures. The patient underwent endovascular repair of the aorta, fasciotomy, bowel resection, and delayed fusion of the lumbar spine. The patient was discharged home on postinjury day 36. At 4-year follow-up, imaging demonstrated satisfactory endograft position without growth complications of the aorta or child. This is a rare report detailing the management of penetrating abdominal aortic transections in two children. Both endovascular and open repairs are described with outcomes and follow-up.

Renal dysfunction and cirrhosis.

Hepatorenal syndrome (HRS) does not represent the predominant phenotype of acute kidney injury (AKI) in cirrhosis. Early recognition of HRS helps initiate appropriate therapy. The aims of this review are to present redefinition of AKI, to list new biomarkers, to report recent data on vasopressors in HRS and to propose criteria for simultaneous liver and kidney transplantation (SLKT). Urine output, which was not part of the definition of AKI might be reconsidered as it has an independent prognostic value. Biomarkers (NGAL and IL-18) could help identify ATN. However, cut-off values have to be clarified. Vasopressors with albumin represent first option in HRS. Continuous infusion of terlipressin has a better safety profile than intravenous boluses. SLKT should be considered whenever native kidney recovery is unlikely [i.e. prolonged renal replacement therapy (RRT) and/or GFR less than 25 ml/min for 6 weeks prior to transplantation]. New definitions and recent biomarkers may help differentiate HRS from ATN at an earlier stage. Urine output should be reconsidered in the definitions. Even in patients who are not candidates for transplantation, a short trial of RRT is justified whenever needed. SLKT should be considered whenever posttransplant renal recovery is unlikely.

Cystatin C in the diagnostics of acute kidney injury after heart transplantation

Aim. To examine the assumption that significant concentrations of cystatin C in urine are the manifestation of the tubular necrosis and, respectively, the severity of kidney damage after heart transplantation (HTx).Materials and methods. In this study we evaluated 33 heart recipients (6 women and 27 men, aged from 24 to 68 years old) who had risk factors of acute kidney injury: serum creatinine level &gt;113 μmol/l and/or mechanical circulatory support requirement (20 patients, in 14 cases before HTx). Cystatin C concentration in serum and in urine was measured by DyaSis particle-enhanced immunoturbidimetric assay test «Cystatin C FS».Results. Recipients were divided into two groups according to the levels of cystatinuria. In the group with the significant (more than 0.18 mg/l) urinary cystatin C concentrations the requirement of renal replacement therapy (RRT) was 2.5-fold higher, and the mean duration of RRT was more than 10-fold longer. In 2 patients with the significant cystatinuria acute kidney injury (AKI) has transformed into end-stage renal disease (ESRD).Conclusion. Due to data obtained we may suppose that significant concentrations of cystatin C in urine are the marker of the tubular necrosis with the prolonged RRT requirement. Further studies are needed to justify this relationship.

Direct Reversible Kidney Injury in Familial Hemophagocytic Lymphohistiocytosis Type 3

Hemophagocytic lymphohistiocytosis is a hyperinflammatory disorder resulting from primary or secondary immune dysfunction. AKI is frequent in severe hemophagocytic lymphohistiocytosis and has been attributed to multiorgan failure or the use of nephrotoxic drugs, but AKI is rarely considered a direct consequence of the disease process. We describe a child with familial hemophagocytic lymphohistiocytosis type 3 who developed AKI requiring prolonged renal replacement therapy because of severe renal inflammation. There was massive infiltration of the renal parenchyma by activated macrophages and cytotoxic T cells, and acute tubular injury. The patient responded to high-dose intravenous methylprednisolone, which resulted in improvement of renal function and discontinuation of renal replacement therapy. This case confirms the occurrence of reversible AKI due to hemophagocytic lymphohistiocytosis-induced activated macrophage infiltration of the renal parenchyma and inflammation.

Invasive aspergillosis after kidney transplant: case-control study.

Transplant recipients are at risk for invasive aspergillosis (IA), associated with a significant mortality rate. Renal transplant-specific risk factors have not been established. Forty-one adult kidney transplant recipients diagnosed with proven or probable IA from 1995 through 2013 were identified by search of the computerized patient files in the University Hospitals Leuven. The control population in this 1:2 case-control study consisted of the 2 patients who received a kidney transplant immediately before and after each identified patient and did not develop IA (n = 82). Leukopenia after kidney transplant increased the risk of IA among all patients (odds ratio [OR], 2.345 [95% confidence interval {CI}, 1.084-5.071]). For early-onset infection (ie, occurred during the first 3 months after transplant), a longer duration of renal replacement therapy pretransplant and the occurrence of leukopenia were risk factors (OR per year, 1.192 [95% CI, 1.006-1.413] and OR, 3.346 [95% CI, 1.063-10.527], respectively), whereas donor cytomegalovirus seropositivity increased the risk for late-onset IA (ie, occurred >3 months after transplant) (OR, 3.677 [95% CI, 1.388-9.743]). Twelve-week mortality rate was 39%. Disseminated infection, leukopenia, and the height of the serum galactomannan index were associated with an increased risk of death (hazard ratio [HR], 5.080 [95% CI, 1.740-14.830]; HR, 3.198 [95% CI, 1.183-8.649]; and HR, 1.371 [95% CI, 1.123-1.674], respectively). Prolonged renal replacement therapy before kidney transplant increases the risk of IA early after transplant. The height of the serum galactomannan index predicts mortality.

PP028-MON: Massive Copper (CU) and Selenium (SE) Losses Cause Life Threatening Deficiencies During Prolonged Renal Replacement Therapy

PP028-MON: Massive Copper (CU) and Selenium (SE) Losses Cause Life Threatening Deficiencies During Prolonged Renal Replacement Therapy

A neonate with severe oligo-anuric renal failure during multi-organ failure survived with prolonged renal replacement therapy.

Sir, Here, we report a neonate with severe oligo-anuric renal failure during multi-organ failure who survived with prolonged renal replacement therapy. A female neonate, born at a gestational age of 39 weeks and 3 days, weighing 2780 gram, presented cyanosis on Day 15. She developed anuria and respiratory arrest, requiring mechanical ventilation. Blood pressure was 39/24 mmHg. She was diagnosed as having interrupted aortic arch, requiring surgery (Figure 1). Serum creatinine increased from 0.34 to 1.26 mg/dL. Continuous-flow peritoneal dialysis (PD), using two catheters for dialysate infusion and drainage simultaneously, was started. She had septicemia, which was controlled with antibiotics. After surgery, chylous effusion occurred in the thorax, resulting in pleural effusion and edema. At ∼2 months, she passed small volumes of urine output with renal and dialytic clearances of 0.98 and 11.45 mL/min/1.73 m2, respectively. Ligation of the thoracic duct was performed at 2.5 months. Overfluid status continued till 3 months, requiring PD and mechanical ventilation. Fig. 1. Course of the illness in the neonate. Cdial, dialytic clearance; Cr, creatinine; Crenal, renal clearance; Inf, influenza A virus infection; PN, peritonitis; RS, respiratory syncytial virus infection; RV, rotavirus infection; UV, urine volume. Because of frequent vomiting, she was fed with an intestinal tube at 4.5 months, resulting in severe diarrhea for 1 month. She remained anuric at 5 months despite decreased serum creatinine (1.36 mg/dL) due to malnutrition. Renal clearance was 1.68 mL/min/1.73 m2 at 6 months when urine output was redetected. She had episodes of peritonitis and virus infections, resulting in pleural effusion, requiring antibiotics, supportive therapy and PD. Renal clearance increased to 8.44 mL/min/1.73 m2 at 8 months. Urine output increased with serum creatinine of 0.81–1.2 mg/dL and renal clearance of 10.4 mL/min/1.73 m2 at 10 months, representing almost 50% of total clearance. Dialysis was stopped 1 year after surgery. Her growth and development are normal with glomerular filtration rate of 24.7 mL/min/1.73 m2. Prolonged oligo-anuria correlates with the final outcome [1]. Renal function recovered after 6–14 months of oliguria in two children with hemolytic uremic syndrome (HUS), in whom plasma infusion prolonged acute renal failure (ARF) [2], and after 23 days of oliguria in an infant with HUS, at the age of 23 weeks [3]. Younger age is another poor prognostic factor of ARF [4]. Neonates have a decreased number and function of nephron, resulting in severe renal insult and poor outcome [5]. ARF occurs in 8% of neonates in the intensive care unit, and its mortality rate is 48% [4], depending on the underlying disease and prognostic factors, including respiratory support, hypotension, cardiac disorders, surgery, oliguria/anuria, need for vasopressor drugs or dialysis, sepsis or multi-organ failure [1]. Despite these factors, the renal function of our patient returned to an extent that allowed cessation of dialysis after many months although PD might have been stopped late. Our patient still has significant chronic kidney disease and will require renal replacement therapy again in the future. Our observation suggests that neonates with severe oligo-anuric renal failure during multi-organ failure may survive with prolonged renal replacement therapy.

Renal cell carcinoma co-existent with other renal disease: clinico-pathological features in pre-dialysis patients and those receiving dialysis or renal transplantation.

Patients on chronic dialysis are prone to developing acquired cystic kidney disease (ACKD), which may lead to the development of renal cell carcinoma (RCC). The risk factors for the development of RCC so far have not been determined in pre-dialysis patients with co-existent renal disease. The aim of this study was to evaluate the clinico-pathological features of RCC in pre-dialysis patients with associated renal diseases or in those undergoing chronic dialysis and renal transplantation. We studied 32 kidneys from 31 patients with RCC and associated renal diseases. Of those, 18 kidneys were from 17 patients not on renal replacement therapy (RRT) when diagnosed with RCC; 14 patients received dialysis or dialysis followed by renal transplantation. Several clinico-pathological features were analysed and compared between the two groups. Overall, there was a preponderance of males (75%); nephrosclerosis was the predominant co-existent disease (31%). The median intervals from renal disease to RCC in the dialysis and transplanted groups were significantly longer than in the pre-dialysis group (15.8+/-1.1 vs 2.4+/-0.7 years, P<0.0001). In contrast to pre-dialysis RCC, the dialysis and transplant RCC groups had greater frequency of ACKD (100 vs 28%, P<0.0001), papillary type RCC (43 vs 11%, P<0.05) and multifocal tumours (43 vs 5%, P<0.05). At the end of the study, 71% of dialysis and transplanted patients and 72% of pre-dialysis patients were alive. ACKD develops in dialysis patients, as it does in those with renal disease prior to RRT. The duration of renal disease, rather than the dialysis procedure itself, appears to be the main determinant of ACKD and RCC. The RCC occurring in patients with ACKD and prolonged RRT is more frequently of the papillary type and multifocal than the RCC occurring in patients with no or few acquired cysts and a short history of renal disease. Long-term outcomes did not differ between the two groups.