Reduced Urine Output Research Articles

Clinicopathological biomarker patterns, venom detection and venom proteomics in canine Vipera berus envenomation

Vipera berus (V. berus) bites are associated with high morbidity, including kidney injury, in dogs. Although antivenom is often used and perceived effective to treat this type of snakebite, it is costly and associated with adverse events and specific diagnostics for this type of snakebite are lacking. We sought to improve diagnostics in V. berus envenomation by using currently available tools, including evaluating urinary albumin as a biomarker for snakebite-associated kidney injury. Additionally, we planned to adapt a method from human medicine for venom detection in clinical samples from bitten dogs and describe the composition of Norwegian V. berus venom. Serum biochemical analytes and urine albumin (ELISA) were measured in samples collected at 24 hours and two weeks after bite in 29 envenomated dogs. An adapted ELISA was applied to detect venom in urine and plasma collected from 25 cases between presentation and 24 hours after bite, using a commercial antivenom as the capture and detection antibody. Proteomic analysis of venom collected from 11 V. berus was performed using liquid chromatography-tandem mass spectrometry. Elevated serum C-reactive protein, creatine kinase, and aspartate aminotransferase were common for the case group. Although no case dogs showed acute kidney injury with azotemia and/or reduced urine output, elevated urinary albumin concentrations may indicate early or mild kidney injury in some case dogs. The venom ELISA detected positive signals in both plasma and urine for up to 24 hours after bite. However, with false positives detected in plasma, urine seemed to be the most appropriate body fluid for this assay. The venom proteome identified L-amino acid oxidases as the dominant component. In conclusion, serum biochemical and urinary albumin analyses are useful tools for evaluating canine V. berus envenomation. The venom ELISA is proposed as a promising tool for studies of V. berus envenomation and future diagnostic test development. Venom from the studied Norwegian V. berus was shown to differ considerably from previous reports from other countries, implying geographical variation in composition.

Short- and long-term outcomes in critically ill patients with primary glomerular disease: a case‒control study.

Glomerular diseases, encompassing primary and secondary forms, pose significant morbidity and mortality risks. Despite their impact, little is known about critically ill patients with primary glomerulopathy admitted to the intensive care unit (ICU). We conducted a case‒control study of patients with primary glomerulopathy using the Medical Information Mart for Intensive Care IV database. Demographic, clinical, and outcome data were collected. Logistic regression and mediation analysis were performed to identify predictors of hospital and long-term mortality. Among 50,920 patients, 307 with primary glomerulopathy were included. Infectious and cardiovascular-related causes were the main reasons for ICU admission, with sepsis being diagnosed in more than half of the patients during their ICU stay. The hospital mortality rate was similar to that of the control group, with a long-term mortality rate of 29.0% three years post-ICU discharge. Reduced urine output and serum albumin were identified as independent predictors of hospital mortality, while serum albumin and the Charlson comorbidity index were significantly associated with long-term mortality. Notably, although acute kidney injury was frequent, it was not significantly associated with mortality. Additionally, reduced urine output mediates nearly 25% of the association between serum albumin and hospital mortality. Critically ill patients with primary glomerulopathy exhibit unique characteristics and outcomes. Although hospital mortality was comparable to that of the control group, long-term mortality remained high. The serum albumin concentration and Charlson Comorbidity Index score emerged as robust predictors of long-term mortality, highlighting the importance of comprehensive risk assessment in this population. The lack of an association between acute kidney injury and mortality suggests the need for further research to understand the complex interplay of factors influencing outcomes in this patient population.

Assessing Clinical Outcomes and Treatment Efficacy in a Patient with Crescentic Glomerulonephritis (CGN)- A Case Report

Crescentic glomerulonephritis (CGN) is a rapidly progressive renal condition marked by crescent formation in the glomeruli, often resulting in end-stage renal disease (ESRD) if not promptly addressed. This case report examines a 54-year-old female with a sudden onset of generalized edema and reduced urine output, which led to her hospitalization. Laboratory evaluations revealed acute renal failure with markedly elevated serum creatinine levels. Despite a background of Antineutrophil Cytoplasmic Antibodies (ANCA)-associated vasculitis, her management was complicated by inconsistent adherence to immunosuppressive therapy. Notably, severe hypertension exacerbated her renal impairment, necessitating immediate intervention. The clinical progression of CGN highlights the critical importance of early diagnosis, continuous monitoring, and a multidisciplinary approach for effective management. Emphasizing patient education and lifestyle modifications, particularly in dietary habits and blood pressure control, can significantly influence treatment outcomes. This case illustrates the urgency of addressing CGN and the necessity of a collaborative healthcare strategy to improve prognosis and enhance the patient's quality of life.

7227 Acute Hyponatremia Following Initiation of Antidepressant in Patient on Desmopressin Treatment for AVP Deficiency

Abstract Disclosure: M.E. Horowitz: None. Y. Gao: None. S.B. Abraham: None. P. Kishore: None. Introduction: Intranasal desmopressin (DDAVP) is indicated as antidiuretic replacement therapy in arginine vasopressin (AVP) deficiency. It increases water permeability in the distal nephron, reducing urine output, increasing urine osmolality, and decreasing serum osmolality. Treatment is titrated to normalize serum sodium and urine output (UOP). Initiation of medications affecting sodium balance or fluid status may lead to abnormalities in these markers. One of these is escitalopram, an antidepressant which can cause hyponatremia attributed to inappropriate AVP secretion. We report a case of acute hyponatremia in a patient with previously stable sodium on chronic DDAVP who was started on escitalopram. Clinical Case: A 44-year-old female with history of a craniopharyngioma resection in 2007 complicated by AVP deficiency on chronic DDAVP, bipolar disorder, and depression presented with nausea, vomiting, and dizziness for two days. Patient was found to be hyponatremic to 118 mEq/L (135-145 mEq/L). Sodium checked one month prior was 135 mEq/L, and historically was never less than 130 mEq/L since 2008. DDAVP was prescribed since resection with few dose changes, at this time four 10mcg sprays in each nostril three times daily since 2020. Escitalopram 5mg daily was initiated two months prior. Desmopressin was held in the setting of hyponatremia, which resolved appropriately to 135 mEq/L over the first five days. During this time, the patient complained of large volume diuresis at ∼three liters daily. On day six, sodium acutely increased to 146 mEq/L; subcutaneous (SC) DDAVP was given and sodium normalized. UOP decreased significantly over the next 24 hours, but large volume diuresis resumed thereafter. On day 10, DDAVP SC was given, again decreasing UOP for 24 hours. Psychiatry recommended continuing escitalopram given improvement in psychiatric symptoms since initiation. Upon discharge, the patient was prescribed DDAVP two 10mcg sprays in each nostril nightly, a significant reduction compared to her prior dose. Sodium rechecked one week later remained within normal limits. Clinical Lessons: This effect of combination DDAVP and escitalopram has not been reported previously. Prescribers should be aware of the potential for hyponatremia and the need to adjust DDAVP dose in combined use. To avoid these risks in patients on chronic DDAVP, the side effects of antidepressants and antipsychotics should be reviewed prior to initiation. Presentation: 6/2/2024

Risk factors for death among children with severe malaria, Ivukula sub-county, Namutumba district, Eastern Uganda, september 2021–february 2022

BackgroundIn February 2022, the Ministry of Health received reports of more than 100 child deaths from a ‘strange disease’ in Namutumba District over a period of 6 months from politicians through the media. Preliminary investigations by the district rapid response team confirmed the strange disease to be severe malaria. The scope of severe malaria deaths was investigated, associated factors identified, and recommendations made for control measures to inform early malaria treatment strategies in Namutumba District.MethodsA retrospective study was conducted in March 2022 in the most affected subcounty (Ivukula Subcounty) involving cases and controls. A case was defined as a death with a positive malaria test, fever and any of the following: convulsions, difficulty breathing, yellowing of eyes or palms, tea-coloured urine, anaemia (evidenced by pale eyes or palms, or clinically-identified in medical records), loss of consciousness, or reduced urine output (very little or no urine in a day) in a child ≤ 12 years from September 2021 to February 2022 in Ivukula Subcounty, Namutumba District. Controls were survivors with the same signs and symptoms, recruited in a 2:1 ratio with cases. Cases and controls were actively searched using a door-to-door approach with the help of community health workers. Caretakers were interviewed to obtain data on signs and symptoms, socio-demographic information, health-seeking behaviours and health system risk factors. Drugs and bloodstock status information was obtained from health workers using an interview guide. Factors associated with death were identified using multivariate logistic regression and thematic analysis for qualitative data.ResultsAmong 46 cases, 29 (63%) were < 5 years, and 23 (50%) were female. Death among children with severe malaria was significantly associated with treatment non-completion (aOR = 9.7, 95%CI 1.8–53) and inability to receive blood transfusion for anaemic patients (aOR = 7.1, (95%CI 1.4–36). Healthcare workers reported that inability to reach referral sites due to transport costs, stockouts of anti-malarials and blood products at health facilities, and absence of integrated community case management of childhood illnesses (iCCM) contributed to deaths among children with severe malaria.ConclusionLack of access to anti-malarial treatment and to blood transfusions among anaemic patients due to stockouts were associated with severe malaria deaths among children ≤ 12 years in Ivukula Subcounty. Recommendations made were: accurate quantification of anti-malarials for health facilities, offering transport support to severe patients referred to higher-level facilities, and increasing access to blood products. Activation of iCCM could facilitate public health efforts against severe malaria in the district.

Aortic valve thrombosis in nephrotic syndrome: a case report.

We report a rare case of aortic valve thrombosis in a 55-year-old man. He had reduced urine output and generalized edema four days before admission. He felt sick and had chest pain on the day of admission. Severe hypoalbuminemia and massive proteinuria were present, and a diagnosis of nephrotic syndrome was made. An electrocardiogram showed findings suspicious for acute myocardial infarction, and emergency catheterization was performed. However, no coronary artery stenosis or occlusion was found at that time. A subsequent contrast-enhanced CT scan and transesophageal echocardiography revealed a thrombus in the aortic valve. The thrombus nearly occluded the left coronary artery. Emergency surgery was performed to remove the thrombus. His postoperative course was stable, but nephrotic syndrome persisted. A renal biopsy diagnosed minimal change disease. Treatment with 50mg/day of prednisolone induced remission, and he was discharged on day 43. There were no aortic valve abnormalities. Nephrotic syndrome was considered the main contributor to thrombus formation. Aortic valve thrombosis associated with nephrotic syndrome is a very rare but potentially fatal condition that requires attention.

The impact of pre-operative uric acid levels on post-operative renal outcomes in off-pump coronary artery bypass grafting patients

Background: Elevated pre-operative uric acid levels significantly impact post-operative renal outcomes in off-pump CABG patients, increasing the risk of acute kidney injury, as evidenced by higher serum creatinine and reduced urine output. Methods: This cross-sectional study was conducted in Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, Bangladesh from January 2021 to December 2022. Total 160 patients undergoing off pump CABG were divided into two groups, group A and group B, each containing 80 patients. In group A, uric acid level was &lt;7 mg/dl for male and &lt;6 mg/dl for female and in group B, it was &gt;7 mg/dl and &gt;6 mg/dL for female. Results: The demographic characteristics, pre-operative serum UA levels and serum creatinine levels between the two groups was not statistically significant. Group A had shorter operative times (mean 265.21±53.33 minutes) compared to Group B (mean 327.04±44.32 minutes), with more patients in Group-B undergoing longer surgeries (&gt;360 minutes). Group-B also had more grafts (mean 4.4 vs 3.6), higher serum creatinine (1.91 vs 1.17 mg/dl), bilirubin (0.8 vs 0.7 mg/dl), and lower urine output (mean 47.52 vs 95.37 ml/hour), all statistically significant (p&lt;0.001). Conclusions: This study concludes that there is significant impact of pre-operative uric acid levels on post-operative renal outcomes in off-pump CABG patients.

Continuous Urine Output-Based Alert Identifies Cardiac Surgery–associated Acute Kidney Injury Earlier Than Serum Creatinine: A Prospective and Retrospective Observational Study

Objective(s)Acute kidney injury (AKI) is defined and staged by reduced urine output (UO) and increased serum creatinine (SCr). UO is typically measured manually and documented in the electronic health record, making early and reliable detection of oliguria-based AKI and electronic data extraction challenging. We investigated the diagnostic performance of continuous UO, enabled by active drain line clearance, based alerts (Accuryn AKI Alert), compared to AKI stage 2 SCr criteria and their association to length of stay (LOS), need for continuous renal replacement therapy (CRRT), and 30-day mortality. DesignProspective and retrospective observational study. SettingNine tertiary centers. ParticipantsCardiac surgery patients. InterventionsNone. Measurements and Main Results522 patients were analyzed. AKI stages 1, 2, and 3 were diagnosed in 32.18%, 30.46%, and 3.64% of patients based on UO compared to 33.72%, 4.60%, and 3.26% of patients using SCr, respectively. Continuous UO-based alerts diagnosed stage ≥1 AKI 33.6 (IQR= [15.43, 95.68]) hours before stage ≥2 identified by SCr. A SCr-based diagnosis of AKI stage ≥2 has been designated a Hospital Harm by the Centers for Medicare & Medicaid Services. Using this criterion as a benchmark, AKI alerts had a discriminative power of 0.78. AKI Alert stage 1 was significantly associated with increased ICU and hospital LOS and CRRT, and stage ≥2 alert with mortality. ConclusionsAKI Alert based on continuous UO, enabled by active drain line clearance, detected AKI stages 1 and 2 before SCr. Early AKI detection allows for early kidney optimization, potentially improving patient outcomes.

Averaged versus Persistent Reduction in Urine Output to Define Oliguria in Critically Ill Patients: An Observational Study.

Key Points When assessing urine output, consideration of an average or persistent value below a threshold has important diagnostic and prognostic implicationsSeventy-three percent (95% confidence interval, 72.3 to 73.7) of patients had oliguria by the average method versus 54.3% (53.5 to 55.1) by the persistent method. Background Oliguria is defined as a urine output (UO) of &lt;0.5 ml/kg per hour over 6 hours. There is no consensus as per whether an average or persistent value should be considered. Methods We analyzed all adults admitted to a tertiary intensive care unit between 2010 and 2020, except those on chronic dialysis or who declined consent. We extracted hourly UO and, across 6-hour sliding time windows, assessed for the presence of oliguria according to the average (mean UO below threshold) and persistent (all measurements below a threshold) methods. For both methods, we compared oliguria's incidence and association with 90-day mortality and acute kidney disease at hospital discharge. Results Among 15,253 patients, the average method identified oliguria more often than the persistent method (73% [95% confidence interval, 72.3 to 73.7] versus 54.3% [53.5 to 55.1]). It displayed a higher sensitivity for the prediction of 90-day mortality (85% [83.6 to 86.4] versus 70.3% [68.5 to 72]) and acute kidney disease at hospital discharge (85.6% [84.2 to 87] versus 71.8% [70 to 73.6]). However, its specificity was lower for both outcomes (29.8% [28.9 to 30.6] versus 49.4% [48.5 to 50.3] and 29.8% [29 to 30.7] versus 49.8% [48.9 to 50.7]). After adjusting for illness severity, comorbidities, age, admission year, weight, sex, and AKI on admission, the absolute difference in mortality attributable to oliguria at the population level was similar with both methods (5%). Similar results were obtained when analyses were restricted to patients without AKI on admission, with documented body weight, with presence of indwelling catheter throughout stay, and who did not receive KRT or diuretics. Conclusions The assessment method of oliguria has major diagnostic and prognostic implications. Its definition should be standardized.

A case of suicide secondary to diethylene glycol intentional ingestion.

We aimed to describe a case of acute kidney injury (AKI) with an uncommon case. We described a previously health 24 years old male that presented acute kidney injury associated with neurological and respiratory symptoms. He was initially admitted at the hospital with nausea, vomiting, blurred vision, and reduced urine output. The patient's condition got worse approximately in one week. Laboratory tests revealed high levels of nitrogenous waste, hyponatremia, metabolic acidosis with an increased anion gap, and the presence of proteinuria and hematuria. The patient experienced paresthesia, seizures, respiratory alterations, and altered consciousness. The initial diagnostic hypothesis of rapidly progressive glomerulonephritis was not confirmed. A deeper investigation of the case exposed that it could have occurred an intentional exogenous poisoning with diethylene glycol (DEG). Renal biopsy unveil findings suggestive of poison-induced nephrotoxicity, which corroborated the suspicion. Despite therapeutic efforts, the patient died due to pulmonary complications. This case report shows the need to consider DEG poisoning as a etiology of AKI, especially in patients with neurological symptoms. Laboratory and histopathological analysis were crucial for the diagnosis.

The interaction of net ultrafiltration rate with urine output and fluid balance after continuous renal replacement therapy initiation: A multi-Centre study.

PurposeDuring continuous renal replacement therapy (CRRT), a high net ultrafiltration rate (NUF) may worsen the decrease in urine output (UO) associated with starting CRRT. However, fluid balance (FB) may modulate this association. We aimed to examine the relationship between NUF, UO and FB at the start of CRRT. MethodsA retrospective cohort study of 1030 CRRT-treated patients admitted to two tertiary ICUs. ResultsMedian age was 60 years (IQR, 48–70), median APACHE III was 94 (IQR, 76–114) and median NUF rate was 0.7 mL/kg/h. In the 24 h after CRRT started, the mean hourly UO decreased from 25.5 mL to 11.9 mL (P < 0.001). Moreover, after adjusting for multiple confounders on multivariable analysis, a higher NUF was not significantly associated with a lower UO (−1.5 mL/kg for every 1 mL/kg/h increase in NUF; 95% CI -3.1 to 0.04; p = 0.064). In addition, pre-CRRT FB did not modulate the above relationship between higher NUF and lower UO. ConclusionA higher NUF rate was not significantly associated with a greater immediate and sustained reduction in UO after CRRT commencement. FB before CRRT was also not associated with a greater reduction in UO. These findings do not provide evidence for an effect of NUF on renal function.

Rhabdomyolysis Associated with Sedentary Lifestyle, Strenuous Exercise, and Vitamin D3 Deficiency: A Rare Case Report

Rhabdomyolysis can lead to variable clinical presentation and complications putting life at risk. Patients with preexisting low serum 25(OH) Vitamin D are at high risk of exertional rhabdomyolysis during strenuous activities. This aimed to study the pathophysiology of rhabdomyolysis associated with sedentary lifestyle, strenuous exercise, and Vitamin D3 deficiency. A 26-year-old male with chief complaints of cramps in thigh muscles, reduced urine output, and dark coffee-colored urine was presented at Bawa Hospital, Ludhiana. The patient has a history of strenuous exercise and Vitamin D deficiency. Serum creatinine kinase, liver enzymes, and myoglobin in urine were evaluated. The patient was treated with intravenous fluids, sodium bicarbonate, and diuretic. The case was diagnosed as rhabdomyolysis and was treated accordingly. The recovery after 5 days was good following early treatment with fluids and forced alkaline diuresis. The kidney function tests remained normal throughout the treatment period. Aggressive fluid resuscitation is the key management for rhabdomyolysis.

Evaluation of renal sodium handling in heart failure with preserved ejection fraction: A pilot study.

The pathophysiology behind sodium retention in heart failure with preserved ejection fraction (HFpEF) remains poorly understood. We hypothesized that patients with HFpEF have impaired natriuresis and diuresis in response to volume expansion and diuretic challenge, which is associated with renal hypo-responsiveness to endogenous natriuretic peptides. Nine HFpEF patients and five controls received saline infusion (0.25 mL/kg/min for 60 min) followed by intravenous furosemide (20 mg or home dose) 2 h after the infusion. Blood and urine samples were collected at baseline, 2 h after saline infusion, and 2 h after furosemide administration; urinary volumes were recorded. The urinary cyclic guanosine monophosphate (ucGMP)/plasma B-type NP (BNP) ratio was calculated as a measure of renal response to endogenous BNP. Wilcoxon rank-sum test was used to compare the groups. Compared to controls, HFpEF patients had reduced urine output (2480 vs.3541 mL; p = 0.028), lower urinary sodium excretion over 2 h after saline infusion (the percentage of infused sodium excreted 12% vs. 47%; p = 0.003), and a lower baseline ucGMP/plasma BNP ratio (0.7 vs. 7.3 (pmol/mL)/(mg/dL)/(pg/mL); p = 0.014). Patients with HFpEF had impaired natriuretic response to intravenous saline and furosemide administration and lower baseline ucGMP/plasma BNP ratios indicating renal hypo-responsiveness to NPs.

Central Inhibition of Antidiuretic Hormone by the Kappa Opioid Receptor Agonist Nalfurafine Prevents and Reverses Loop Diuretic Resistance

PURPOSE: Diuretic resistance is a failure to achieve a therapeutically desired increase in the renal excretion of sodium and water and reduction in edema despite a full dose of a loop diuretic. High levels of antidiuretic hormone (ADH) have been associated with reduced urine output in heart failure patients. However, ADH’s contribution to the development of diuretic resistance is not known. Assuming that ADH may be released in response to the diuresis produced by loop diuretics, we tested the premise that co-treatment of rats with nalfurafine, a centrally acting kappa opioid (KOR) agonist that inhibits the release of ADH would prevent and/or reverse diuretic resistance to the loop diuretic furosemide. METHODS: Changes in 5-hr urine output (metabolic cages; no water access during collection), urinary Na/K excretion, and osmolality were measured in male Sprague-Dawley rats administered twice-daily i.p. injections (9:00am, 2:00pm; n=6/group) for 11 days with 1) furosemide only (F, 10mg/kg, i.p.; days 1-11), 2) furosemide + nalfurafine (F+N, 10ug/kg, i.p.; days 1-11) or 3) F (days 1-5) followed by F+N (days 6-11). 5-hr urine collection was measured in between the morning and afternoon drug injections and rats were returned to home cages. Control 5-hr urine samples (saline, i.p.) were collected 2 days prior to beginning drug treatments. SUMMARY: Initial treatment (day 1) of rats with F alone and F+N markedly increased urine output. However, over days 6-10, urine output was significantly reduced (diuretic resistance) in rats that continued to receive F alone. Daily co-treatment of F+N beginning day 1 maintained a marked 5-hrdiuresis for all 11 days. Further, delaying addition of nalfurafine co-administration with F until day 6 reversed established diuretic resistance as noted by a marked increase in diuresis over days 6-10 with F+N cotreatment. Initial treatment (day 1) of rats with furosemide also produced a marked natriuresis and kaliuresis. However, on subsequent days (2-11) there was a significant decrease in the renal excretion of sodium and potassium that remained lower in all 3 treatment groups. In contrast, nalfurafine co-treatment beginning either day 1 (Group 2) or day 6 (Group 3) increased free-water clearance as compared to furosemide alone (Group 1). CONCLUSIONS: These results demonstrate that co-administration of the KOR agonist nalfurafine prevented and reversed diuretic resistance to furosemide without worsening electrolyte excretion. Further, these findings support the premise that in response to fluid loss caused by repeated loop diuretic administration, a compensatory release and renal action of ADH plays an important role in mediating loop diuretic resistance. NIH P30GM106392 (DK) LSUHSC REP243 (DK). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Differentiation Syndrome Presenting as Acute Kidney Injury in a Patient of Acute Promyelocytic Leukemia on All-trans Retinoic Acid and Arsenic Trioxide Regimen: A Case Report

Introduction: Acute promyelocytic leukemia (APL), classified as Subtype M3 of acute myeloid leukemia, is known for its relatively favorable prognosis, primarily due to the high effectiveness of all-trans retinoic acid (ATRA) in treating the maturation block. However, it is essential to be aware of potential complications such as ATRA syndrome, which can affect 5%–25% of patients and manifest with symptoms such as fever, interstitial pulmonary infiltration, pleural/pericardial effusion, and acute renal failure. Methods: We present the case of a 47-year-old female with a history of hypertension, who experienced rash, fever, and reduced urine output during the induction phase with ATRA. Her serum creatinine levels exhibited a rapid increase from 2.63 mg/dL on October 07, 2022, to 7 mg/dL on October 18, 2022, despite having normal-sized kidneys and normal corticomedullary differentiation. A renal biopsy conducted on October 20, 2022, revealed features consistent with active tubulointerstitial nephritis, with direct immunofluorescence showing no significant glomerular immune deposits. A total of 17 hemodialysis sessions were performed. Results: A subsequent bone marrow examination conducted on October 26, 2022, demonstrated a hypercellular aspirate with normal morphology. However, due to the persistence of renal failure, a repeat biopsy was performed, revealing severe acute tubular injury. Pulse steroids were initiated, and ATRA was discontinued, resulting in an improvement in renal function. Conclusion: This case highlights an instance of acute, early, and severe differentiation syndrome (DS) occurring after induction therapy in a patient with APL. The DS in this case was particularly severe, leading to renal failure necessitating hemodialysis. The prompt initiation of pulse steroids and discontinuation of ATRA proved to be effective in managing this complication. Clinicians should remain vigilant for DS and its potential complications, including acute kidney injury and acute tubulointerstitial nephritis, when treating patients with APL.

Machine learning-based prediction of in-hospital mortality for critically ill patients with sepsis-associated acute kidney injury

Objectives This study aims to develop and validate a prediction model in-hospital mortality in critically ill patients with sepsis-associated acute kidney injury (SA-AKI) based on machine learning algorithms. Methods Patients who met the criteria for inclusion were identified in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and divided according to the validation (n = 2440) and development (n = 9756, 80%) queues. Ensemble stepwise feature selection method was used to screen for effective features. The prediction models of short-term mortality were developed by seven machine learning algorithms. Ten-fold cross-validation was used to verify the performance of the algorithm in the development queue. The area under the receiver operating characteristic curve (ROC-AUC) was used to evaluate the differentiation accuracy and performance of the prediction model in the validation queue. The best-performing model was interpreted by Shapley additive explanations (SHAP). Results A total of 12,196 patients were enrolled in this study. Eleven variables were finally chosen to develop the prediction model. The AUC of the random forest (RF) model was the highest value both in the Ten-fold cross-validation and evaluation (AUC: 0.798, 95% CI: 0.774–0.821). According to the SHAP plots, old age, low Glasgow Coma Scale (GCS) score, high AKI stage, reduced urine output, high Simplified Acute Physiology Score (SAPS II), high respiratory rate, low temperature, low absolute lymphocyte count, high creatinine level, dysnatremia, and low body mass index (BMI) increased the risk of poor prognosis. Conclusions The RF model developed in this study is a good predictor of in-hospital mortality for patients with SA-AKI in the intensive care unit (ICU), which may have potential applications in mortality prediction.

Congenital neonatal hemochromatosis with recurrent neonatal deaths - a diagnostic nightmare: A case report

Background: Neonatal hemochromatosis (NH) is a rare disorder and the most common cause of acuteliver failure in neonates. NH is characterized by severe hepatic injury and iron overload with highperinatal mortality and morbidity. There is a high risk of recurrence in subsequent pregnancies of womenwho have had a child with neonatal hemochromatosis.Case presentation: A 40-year-old para 13 with one living child and three previous cesarian scarspresented at ten weeks with a history of recurrent neonatal deaths. Her last infant death was at fourmonths after she delivered a baby via cesarian birth at 36 weeks. The infant developed severe jaundicewith reduced urine output. Laboratory investigations revealed deranged liver function tests with elevatedserum ferritin levels. The infant received repeated exchange transfusions, immunoglobulin, anddexoferamine. However, she succumbed at four months. Her management for the current pregnancyrequired close follow-up and she delivered at 37 weeks gestation to a live male infant who is faring well.Discussion: The cause of NH is not fully understood. Significant evidence indicates that most cases ofneonatal hemochromatosis result from fetal liver disease due to maternal-fetal alloimmunity, a conditiontermed gestational alloimmune liver disease (GALD). In GALD, these antibodies bind to fetal liverantigen and activate the terminal complement cascade, resulting in hepatocyte injury and death.Conclusion: NH is the most common cause of neonatal acute liver injury and should be considered in allcases of severe fetal liver injury as well as in cases of stillbirth, fetal demise, and early postnatal death.

Acute kidney injury in neonates with hypoxic ischemic encephalopathy based on serum creatinine decline compared to KDIGO criteria.

Neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia (HIE + TH) are at risk for acute kidney injury (AKI). The standardized Kidney Disease Improving Global Outcomes (KDIGO) criteria identifies AKI based on a rise in serum creatinine (SCr) or reduced urine output. This definition is challenging to apply in neonates given the physiologic decline in SCr during the first week of life. Gupta et al. proposed alternative neonatal criteria centered on rate of SCr decline. This study aimed to compare the rate of AKI based on KDIGO and Gupta in neonates with HIE and to examine associations with mortality and morbidity. A retrospective review was performed of neonates with moderate to severe HIE + TH from 2008 to 2020 at a single center. AKI was assessed in the first 7days after birth by KDIGO and Gupta criteria. Mortality, brain MRI severity of injury, length of stay, and duration of respiratory support were compared between AKI groups. Among 225 neonates, 64 (28%) met KDIGO, 69 (31%) neonates met Gupta but not KDIGO, and 92 (41%) did not meet either definition. Both KDIGO-AKI and GuptaOnly-AKI groups had an increased risk of the composite mortality and/or moderate/severe brain MRI injury along with longer length of stay and prolonged duration of respiratory support compared to those without AKI. AKI in neonates with HIE + TH was common and varied by definition. The Gupta definition based on rate of SCr decline identified additional neonates not captured by KDIGO criteria who are at increased risk for adverse outcomes. Incorporating the rate of SCr decline into the neonatal AKI definition may increase identification of clinically relevant kidney injury in neonates with HIE + TH.

Assessing resuscitation in burn patients with varying degrees of liver disease

We find minimal literature and lack of consensus among burn practitioners over how to resuscitate thermally injured patients with pre-existing liver disease. Our objective was to assess burn severity in patients with a previous history of liver disease. We attempted to stratify resuscitation therapy utilised, using it as an indicator of burn shock severity. We hypothesized that as severity of liver disease increased, more fluid therapy is needed. We retrospectively studied adult patients with a total body surface area (TBSA) of burn greater than or equal to 20% (n = 314). We determined the severity of liver disease by calculating admission Model for End-Stage Liver Disease (MELD) scores and measured resuscitation adequacy via urine output within the first 24 h. We performed stepwise, multivariable linear regression with backward selection to test our hypothesis with α = 0.05 defined a priori. After controlling for important confounders including age, TBSA, baseline serum albumin, total crystalloids, colloids, blood products, diuretics, and steroids given in first 24 h, we found a statistically significant reduction in urine output as MELD score increased (p < 0.000). In our study, severity of liver disease correlated with declining urine output during first 24-hour resuscitation more so than burn size or burn depth. While resuscitation is standardized for all patients, lack of urine output with increased liver disease suggests a new strategy is of benefit. This may involve investigation of alternate markers of adequacy of resuscitation, or developing modified resuscitation protocols for use in patients with liver disease. More investigation is necessary into how resuscitation protocols may best be modified.

Severe Hypernatremic Dehydration in a Neonate

Hypernatremia, a rare condition in newborns, is marked by elevated plasma sodium levels exceeding 150 mEq/L. It is more common in newborns who are exclusively breastfed or with excessive weight loss. Hypernatremic dehydration (HD) presents severe risks, including cerebral edema and other neurological complications. A female newborn, 12 days old (birth weight: 2800g), was brought to the Emergency Department due to a 30% decrease in birth weight and reduced urine output. The newborn was solely breastfed every 2 hours, with a good notion of adequate reflexes and tolerance. Physical examination revealed a skeletal appearance, jaundice, sunken eyes and skin turgor. Blood pressure measurement was unsuccessful, while capillary blood glucose was 96g/dL. A saline bolus (10 mL/Kg)was administered. Venous blood gas analysis showed pH 7.39, lactate 4.3 mmol/L, HCO3-21.8 mmol/L, and Na+ 180 mEq/L.