Resolution Of Acute Kidney Injury Research Articles

Comparative Study of Acute Kidney Injury in Liver Transplantation: Donation after Circulatory Death versus Brain Death.

BACKGROUND Acute kidney injury (AKI) after orthotopic liver transplantation (OLT) contributes to morbidity and mortality. Donation after circulatory death (DCD) has been established to increase the pool of organs. While surgical complications are reported to be comparable in DCD and donation after brain death (DBD) OLT, there is a knowledge gap concerning adverse kidney events in these 2 groups. MATERIAL AND METHODS In this retrospective cohort study, 154 patients received a DBD and 68 received a DCD organ (2016-2020). The primary outcome was a major adverse kidney event within 30 days (MAKE-30). The secondary outcome was dynamics of AKI and kidney replacement therapy (KRT) during the first postoperative week and on postoperative day 30. Incidence and resolution from AKI and KRT and patient survival (PS) 30 days after OLT were compared between the DCD and DBD recipients. RESULTS MAKE-30 incidence after OLT was comparable in DCD (n=27, 40%) vs DBD (n=41, 27%) recipients (risk ratio 1.49 [95% CI 1.01, 2.21], p=0.073). AKI incidence was comparable in DCD (n=58, 94%) vs DBD (n=95, 82%) recipients (risk ratio 1.14 [95% CI: 1.03, 1.27], P=0.057). Overall, 40% (n=88) of patients required KRT, with no difference between DCD (n=27, 40%) vs DBD (n=61, 40%) recipients (risk ratio 1.00 [95% CI 0.71, 1.43], P>0.999). Resolution of AKI by day 30 was lower in DCD (n=29, 50%) than in DBD (n=66, 69%) recipients (risk ratio 0.71 [95% CI: 0.53, 0.95], P=0.032). Survival after 30 days (DCD: n=64, 94% vs DBD: n=146, 95%, risk ratio 0.99 [95% CI 0.93, 1.06], P>0.999) was also comparable. CONCLUSIONS MAKE-30, short-term renal outcome, and survival did not significantly differ between DBD and DCD-OLT. Resolution of AKI by day 30 was lower in DCD than in DBD recipients.

#3033 IgA vasculitis: a unexpected diagnosis of pulmonary renal syndrome

Abstract Background IgA vasculitis is an inflammatory condition affecting blood vessels that poses a significant diagnostic and therapeutic challenge in clinical practice. Characterized by the deposition of immunoglobulin A (IgA) on vessel walls, this pathology can manifest in various ways, presenting a broad and sometimes complex clinical spectrum. Ninety percent of cases occur in the pediatric age group. Severe lung involvement, such as pulmonary hemorrhage, is rare in patients with IgAV. We present a case of a 33-year-old patient with pulmonary renal syndrome and without purpura, an atypical presentation of IgA vasculitis. Case Report We describe the case of a 33-year-old patient with no relevant medical history or regular medication, who presented to the emergency department in November 2022 with symptoms of hemoptysis, fatigue, myalgias, and pallor. On physical examination, the patient was conscious, cooperative, normotensive, tachycardic, afebrile, with bilateral axillary adenopathies, and scattered crackles on lung auscultation. Laboratory tests revealed anemia with a hemoglobin level of 5.8 g/dL, non-oliguric acute kidney injury with a creatinine level of 2.25 mg/dL, microscopic hematuria (>50/hpf), and proteinuria (UPCR of 2.8 mg/mg and UACR of 1.6 mg/mg). A chest CT scan showed bilateral and scattered ground-glass opacities consistent with alveolar hemorrhage. The patient was admitted to the Nephrology service, underwent 3 sessions of plasma exchange, and started therapy with methylprednisolone 1000 mg for 3 days. A renal biopsy revealed 24 glomeruli, with 3 showing segmental sclerosis and 1 with fibrocellular crescents, mild interstitial nephritis; immunofluorescence showed IgA+++, C3++, IgM, and IgG+- Oxford Classification: M1 E0 S1 T0 C1. Bronchofibroscopy showed a rosy bronchoalveolar lavage and macrophages with hemosiderin pigment deposition. The patient continued with prednisolone at 1 mg/kg. In January 2023 (after two months), there was a >25% reduction in albuminuria with resolution of acute kidney injury. A gradual reduction of prednisolone was initiated, and it was definitively discontinued in October 2023. In the last outpatient visit in January 2024, the patient maintained normal renal function, with no hematuria, UPCR of 100 mg/g, UACR of 70 mg/g, and no further episodes of alveolar hemorrhage. Conclusion This case stands out for its atypical presentation: an adult with alveolar hemorrhage and without other more classical manifestations of IgA vasculitis, such as purpura. This is yet another case that emphasizes the importance of the broad spectrum of diagnoses that a nephrologist should consider in the face of acute kidney injury.

#2564 Terlipressin given by continuous infusion versus boluses in the treatment of hepatorenal syndrome: a systematic review and meta-analysis

Abstract Background and Aims Hepatorenal syndrome (HRS) is one of the complications among patients with cirrhosis. Available guidelines recommended terlipressin with albumin as part of HRS management. To date there is no consensus on whether terlipressin should be given via bolus or continuous intravenous infusion. This study aims to compare the effectiveness and safety of continuous intravenous infusion versus intravenous boluses of terlipressin in the treatment of patients with HRS and cirrhosis. Method A comprehensive search for databases of randomized controlled trials (RCTs) comparing continuous intravenous infusion versus intravenous boluses of terlipressin among adult patients with hepatorenal syndrome was done. PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov were searched using relevant terms including hepatorenal syndrome, acute kidney injury, cirrhosis, terlipressin, bolus, and continuous infusion until December 2023. Response to therapy defined as decrease in serum creatinine or regression of acute kidney injury was the primary outcome of interest, while safety in terms of drug-related events, mortality, and transplant-free survival were the secondary outcomes. Data extraction was performed using a standardized data form. The reviewers independently screened the studies and assessed the methodological quality using the Cochrane Risk of Bias tool and any discrepancies were resolved by consensus among the authors. Random-effects meta-analysis was done using Review Manager 5.4. Results A total of three studies, one high quality and two moderate quality RCTs, were included in the review, involving a total of 240 patients. Pooled analysis showed that continuous infusion was as effective or better than bolus infusion in achieving the primary outcome (RR 1.12, 95% CI 0.95-1.32, I2 = 0%). In one study, 28- and 90-day mortality were not significantly different, while 90-day transplant-free survival was not significantly different between continuous and bolus groups from another trial (53% vs 69% p = 0.26). Higher incidence of adverse events were also reported in the bolus group, RR 0.37, 95% CI 0.13-1.04 (p = 0.06). Conclusion There is limited evidence to suggest that continuous infusion of terlipressin may demonstrate resolution of acute kidney injury more frequently than bolus infusion, and that continuous infusion is associated with decreased adverse events. Larger randomized controlled trials with higher quality are needed to ascertain the effects on mortality, need for renal replacement therapy, and transplant-free survival.

Profile of Acute Kidney Injury in the Pediatric Age Group in a Tertiary Care Hospital: A Prospective Observational Study.

Acute kidney injury (AKI) is a menace in the pediatric intensive care unit (PICU) and is responsible for significant morbidity and mortality all over the world. There are limited data available on pediatric AKI in central India. Our primary objective is to determine the clinical, etiological, and outcome profile of AKI in the pediatric age group of 3 months to 15 years admitted to the All India Institute of Medical Sciences (AIIMS), Raipur. The secondary objective(s) is to predict the association of mortality in children diagnosed with AKI and to estimate the number of patients developing chronic kidney disease (CKD) at three-month follow-up. This observational study was conducted in the Department of Pediatrics at AIIMS Raipur, Chhattisgarh, from September 2021 to February 2023. All patients aged 3 months to 15 years of age satisfying the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI and presenting to the hospital were included, and those refusing consent or having CKD stage ≥3 were excluded. A total of 66 children were assessed for eligibility. Out of these 66 patients, 2 were excluded as they had AKI on CKD, and a total of 64 patients were included. For all included patients, details of their demography, clinical features, etiology workup, and hospital stay were collected. Their outcome was observed and categorized into complete response, partial response, no response, left against medical advice (LAMA), or death. Patients who were discharged were followed up for three months and observed for the recovery or development of CKD. The incidence of AKI in the PICU was 15.48% (64/413). Ventricular septal defect with pneumonia and pneumonia (12.5%, 8/64 each) were the most common diagnoses at presentation, resulting in AKI. The most common clinical presentations were fever (54.7%, 35/64) and respiratory distress (43.8%, 28/64). Out of them, 73.4% (47/64) had sepsis, and 62.5% (40/64) had shock. About 56.2% (36/64) of children had non-oliguric AKI as compared to 43.8% (28/64) who had oliguric AKI. Among total children with AKI, 54.7% (35/64) of patients had prerenal AKI, 43.8% (28/64) had renal AKI, and 1.6% (1/64) had postrenal AKI. Of all the children included, 32.8% (21/64) experienced complete resolution of AKI, while 18.8% (12/64) showed partial resolution, and 1.6% (1/64) remained unresolved. Among them, 3.1% (2/64) LAMA, and 43.8% (28/64) died. The median duration of the hospital stay in our study was 16.5 days. Out of them, 59.4% (38/64) of patients required renal replacement therapy (60.5% required peritoneal dialysis (PD), 36.8% required hemodialysis (HD), and 2.6% required both). Among survivors, 19.35% (6/31) developed CKD on a three-month follow-up. The incidence of AKI was seen in critically ill children in the PICU, and it was associated with high mortality.

Large Right Ventricular Hemangioma Presented as Acute Pulmonary Embolism at Two Weeks Post-COVID19 Vaccination: A Case Report

Background: Right ventricular hemangioma is very rare. Corona Virus disease (COVID-19) and vaccination were documented to cause diverse thromboembolic phenomena. Case presentation: We report a large right ventricular hemangioma presented as acute pulmonary embolism two weeks after COVID-19 vaccination associated with acute kidney injury and significantly elevated Interleukin-6 (IL-6). There was no thrombocytopenia; therefore, the diagnosis of vaccine-induced immune thrombotic thrombocytopenia (VIIT) was deemed unlikely. The patient underwent emergency cardiac surgery. The mass was excised through a right atriotomy, and tricuspid annuloplasty was done. IL-6 normalized after six days with resolution of acute kidney injury. Conclusions: Pulmonary embolism is a rare presentation of the right ventricular hemangioma, and COVID-19 vaccination could play a role in this presentation. Cardiac hemangioma could be associated with high IL-6 that resolves with excision.

Diagnostic and prognostic performance of urinary neutrophil gelatinase-associated lipocalin in patients with cirrhosis and acute kidney injury.

Acute kidney injury (AKI) commonly occurs in patients with decompensated cirrhosis. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) could help discriminate between different etiologies of AKI. The aim of this study was to investigate the use of uNGAL in (1) the differential diagnosis of AKI, (2) predicting the response to terlipressin and albumin in patients with hepatorenal syndrome-AKI (HRS-AKI), and (3) predicting in-hospital mortality in patients with AKI. One hundred sixty-two consecutive patients with cirrhosis and AKI were included from 2015 to 2020 and followed until transplant, death, or 90 days. Standard urinary markers and uNGAL were measured. Data on treatment, type, and resolution of AKI were collected. Thirty-five patients (21.6%) had prerenal AKI, 64 (39.5%) HRS-AKI, 27 (16.7%) acute tubular necrosis-AKI (ATN-AKI), and 36 (22.2%) a mixed form of AKI. Mean values of uNGAL were significantly higher in ATN-AKI than in other types of AKI (1162 ng/ml [95% CI 423-2105 ng/ml] vs. 109 ng/ml [95% CI 52-192 ng/ml]; p < 0.001). uNGAL showed a high discrimination ability in predicting ATN-AKI (area under the receiver operating characteristic curve, 0.854; 95% CI 0.767-0.941; p < 0.001). The best-performing threshold was found to be 220 ng/ml (sensitivity, 89%; specificity, 78%). The same threshold was independently associated with a higher risk of nonresponse (adjusted OR [aOR], 6.17; 95% CI 1.41-27.03; p = 0.016). In multivariable analysis (adjusted for age, Model for End-Stage Liver Disease, acute-on-chronic liver failure, leukocytes, and type of AKI), uNGAL was an independent predictor of in-hospital mortality (aOR, 1.74; 95% CI 1.26-2.38; p = 0.001). uNGAL is an adequate biomarker for making a differential diagnosis of AKI in cirrhosis and predicting the response to terlipressin and albumin in patients with HRS-AKI. In addition, it is an independent predictor of in-hospital mortality.

Pregnancy Related Acute Kidney Injury: A Multicenter Prospective Observational Study From Bangladesh

Background: Acute kidney injury (AKI) is one of the most challenging and serious complications of pregnancy which imposes a heavy burden of maternal morbidity and mortality if its diagnosis and treatment are delayed. Objective: This prospective study intended to determine the frequency, etiology and outcomes of the patients of pregnancy related acute kidney injury (PRAKI) in different tertiary care hospitals in Bangladesh. Methods: This was a prospective study of patients with pregnancy related complications leading to acute kidney injury admitted in selected departments of different tertiary care hospitals in Bangladesh for a period of one year (October 2018 to September 2019). Patients were included in this study who were healthy previously and developed acute kidney injury (serum creatinine &gt;70.72 mmol/l) due to pregnancy related complications. Recruited patients were monitored after 3 months with a view to exclude chronic kidney disease. Result: A total of 351 patients with pregnancy and puerperium were observed, of these patients studied, 34 (9.2%) had pregnancy-related AKI. In 32 patients who completed the study, the mean age was 27.2±6.2 years. There were more subjects belonging to the rural area (68.8%) and nineteen (59.4%) of patients were below primary level of education. Most of the study subjects from lower socioeconomic status (56.2%). Twenty-one (65.5%) patients were multigravida, and mean parity of the patients included in this study was 1.7±0.8. Nineteen (59.4%) patients did not receive any antenatal care. PRAKI occurred during the post-partum period in 53.2% of the cases, 21.9% in third trimester, and 24.9% in first and 2nd trimester. The most common cause of PRAKI in our study was sepsis, occurring in about 15 patients (46.9%). Most common presentation of PRAKI was oliguria (87.5%) and edema (84.3%). Mean hemoglobin level was 7.8 ±1.7 gm/dl and creatinine level was 573±407 μmol/l. A majority of the patients (81.25%) underwent hemodialysis, while others were treated with conservative management only. At the three-month follow-up, complete resolution of AKI was observed in 62.5% patients, progressed to CKD in 25% whereas mortality occurred in 12.5% patients. In univariate analysis, inappropriate antenatal care (p- 0.0018), low mean platelet count (p-0.00001), higher serum creatinine (p-0.00004), dialysis at presentation (p-0.0154), and septicemia (p-0.0487), have significant effect. Conclusion: Pregnancy related AKI is still a critical situation in developing countries and rare entity in developed countries. Maternal mortality has decreased but sepsis still accounts for majority of cases of PRAKI. Therefore, early diagnosis and treatment is the need of the hour. J Dhaka Med Coll. 2021; 29(1): 76-81

Значение исследования напряжения кислорода в моче в характеристике острого повреждения почек у больных коронавирусной инфекцией COVID-19

Objective. To evaluate the diagnostic capabilities of the method of studying the voltage (partial pressure) of oxygen (pO2) in urine to characterize the state of the kidneys in COVID-19 infection. Patients and methods. The study is based on the results of continuous prospective (cohort) study organized in 2020-21 on the basis of the Republican Clinical Infectious Diseases Hospital in Izhevsk. The included patients were divided into 3 groups: I – 14 patients with signs of acute kidney injury (AKI), which resolved within the next 7 days (group of patients with AKI), II – 12 people whom AKI was not stopped within 7 days (group of patients with acute kidney disease (AKD)), III – 17 patients of the comparison group (patients without clinical and laboratory signs of AKI). Clinical and laboratory examination of patients, including the study of pO2 in urine, was carried out for 7 days daily. Results. With the development of AKI in COVID-19, a significant (p &lt; 0.001) decrease in pO2 in urine to 47.1 mmHg is observed. Increasing of pO2 in urine by 20% of the minimum value with 95% probability (p &lt; 0.05) may be the predictor of subsequent decreasing in urea and creatinine levels within 72 hours and with the probability of 72% (p &lt; 0.05) – a predictor of AKI resolution. Conclusion. The revealed correlations between the indicators of pO2 in urine with the parameters of the functional state of the kidneys indicate the possibility of their using in the diagnosis, assessment of the severity and dynamics of the condition of patients with AKI during COVID-19. Key words: COVID-19, oxygen tension in urine, acute kidney injury

Successful Use of Mycophenolate Mofetil as Adjunct to Prednisolone for Treatment of Acute Kidney Injury Secondary to Human Serum Albumin Administration in a Dog.

The use of human serum albumin (HSA) is described in dogs receiving critical care. However, despite the high degree of homology, anaphylactic and delayed hypersensitivity reactions are reported. Delayed type III hypersensitivity reactions can lead to glomerulonephritis and acute kidney injury (AKI). Undiluted 20% HSA was administered to a 4.8 yr old intact male Labrador Retriever with severe hypoalbuminemia, following surgical management of septic peritonitis of gastrointestinal origin. Nineteen days after HSA administration, the dog developed peracute high magnitude renal proteinuria and AKI. Rapid immunosuppression, using a combination of prednisolone and mycophenolate mofetil, resulted in full resolution of AKI, hypoalbuminemia, and proteinuria. Addition of mycophenolate mofetil may have resulted in the first documented case of full renal recovery from hypersensitivity-induced AKI caused by HSA administration.

Use of Aminophylline to Reverse Acute Kidney Injury in Pediatric Critical Care Patients.

Acute kidney injury (AKI) is a complication encountered in 18% to 51% of pediatric critical care patients admitted for treatment of other primary diagnoses and is an independent risk factor for increased morbidity and mortality. Aminophylline has shown promise as a medication to treat AKI, but published studies have shown conflicting results. Our study seeks to assess the reversal of AKI following the administration of aminophylline in critically ill pediatric patients. We performed a single-institution retrospective chart review of pediatric inpatients who were diagnosed with AKI and subsequently treated with non-continuous dose aminophylline between January 2016 and December 2018. Data were collected beginning 2 days prior to the initial dose of aminophylline through completion of the 5-day aminophylline course. Nineteen therapies among 17 patients were included in analysis. Twelve of the therapies resulted in resolution of AKI during the study period. We observed urine output increase of 19% (p = 0.0063) on the day following initiation of aminophylline therapy in the subset of patients whose AKI resolved. Trends toward decreased serum creatinine and lower inotropic support were also noted. Based on these findings, aminophylline could be considered a potentially effective medication for use as rescue therapy in critically ill children with AKI. Limitations include small study population and retrospective nature. Further research in this area with a larger study population and a randomized control trial would allow for better characterization of the efficacy of aminophylline in reversal of AKI.

S1322 Large Volume Paracentesis in Cirrhotic Patients With Acute Kidney Injury Is Not Associated With Worsening of Renal Function; Analysis of a Multi-Institutional Cohort

Introduction: Effect of large volume paracentesis on renal function in cirrhotic patients with ongoing acute kidney injury has not been studied in detail, and large volume paracentesis (LVP) is often avoided in these patients due to concerns of worsening renal injury. We studied the association between volume removed on paracentesis and outcomes of acute kidney injury. Methods: We performed a retrospective cohort study of patients at two institutions. IRB approval was obtained at both institutions. Patients with acute kidney injury at the time of paracentesis were included in the study. A retrospective chart review was then performed, and variables of interest were collected. Data was then de-identified and then pooled for analysis. Results: One-hundred and sixty-two patients were included in the final cohort. The mean age of study participants was 61.10 years (SD: ±11.70); the population was predominantly male (63.6%). Alcohol was the most common etiology (43%), followed by NASH (30%). One hundred and eleven patients had Child C cirrhosis (68.5%). Pre-renal acute kidney injury was the most common etiology prior to paracentesis (51%); eighty-six patients had KDIGO stage 1 acute kidney injury while 37 patients and 39 patients had Stage 2 and Stage 3 respectively. Forty-eight participants (29.6%) experienced a worsening of creatinine after paracentesis. Large volume paracentesis (4L or greater) was performed on 81 patients while the rest had less than 4L removed; the groups were well matched with no statistically significant difference in baseline characteristics. There was no difference in the proportion of patients experiencing worsening of renal function after paracentesis, in the proportion of patients who experienced eventual complete resolution of acute kidney injury (p-value = 0.55), or in the proportion of patients that requirement renal replacement therapy (p-value = 0.51). Multivariable regression analysis was conducted incorporating age, gender, CKD, MELD-Na score, albumin administration, and amount of volume removed during paracentesis, revealing CKD as the only covariate significantly associated with worsening renal function after paracentesis (p-value = 0.003). Large volume removal during paracentesis was not associated with worsening of renal function (p-value = 0.61). Conclusion: Large volume paracentesis is not associated with worsening renal function, when compared to small volume paracentesis, in cirrhotic patients with pre-existing acute kidney injury.

P271 A masquerading case of Cryptococcus neoformans

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMIntroductionCryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutaneous tropism is not uncommon. Here we describe an HIV-negative immunocompromised patient who developed disseminated cryptococcosis with the predominant presentation being painful thigh lesions.Case DetailsA 56-year-old lady presented with skin lesions and burning pain over both thighs for 1 month and a high-grade fever for 15 days. Her thigh lesions were initially treated elsewhere as tinea corporis. Her previous medical history was significant for poorly controlled diabetes, and chronic liver disease (secondary to autoimmune hepatitis or AIH). Her ongoing medications included prednisolone, anti-diabetics, and tenofovir. At presentation, the only significant physical findings were large irregular areas of central hypo-pigmentation with peripheral hyper-pigmentation and superficial small blisters over both thighs. These areas showed signs of inflammation. The empiric antimicrobial therapy included piperacillin-tazobactam and fluconazole (in view of prior urine culture growing Candida species). Over the next 48 h, fever continued, thigh pain worsened and the lesions on thighs blistered with violaceous discoloration. Her blood cultures sent at admission grew Candida kruzei, resistant to fluconazole, sensitive to voriconazole, amphotericin and echinocandins. Beta-D Glucan was also elevated. Fluconazole was discontinued, and anidulafungin was initiated. A repeat culture (prior to the start of anidulafungin) was still positive for C. krusei, but a subsequent blood culture (after the start of anidulafungin) was negative. Echocardiography did not show features of endocarditis. After a transient improvement, she worsened again with breakthrough fever, hypotension, and worsening of thigh lesions with eschar formation. Wound debridement was done, and antibiotics were escalated to carbapenem and polymyxins. Tissue cultures (sent during wound debridement) grew carbapenem-resistant klebsiella pneumonia. With these, the fever and her wounds were better; but the fever still persisted and she described a persisting severe burning pain over both the thigh wounds which did not respond to several analgesics.A few days later, the fever worsened, and she had hypotension and disorientation. Blood and urine cultures were repeated. Repeat Serum beta D glucan levels were elevated. CSF examination was not possible in view of severe coagulopathy. The blood and wound cultures both grew C. neoformans (confirmed on MaldiTOFF). Antibiotics and anidulafungin were discontinued; liposomal amphotericin and flucytosine were started. Patient had significant improvement in sensorium, fever, and thigh pains within the next 72 h. Later, liposomal amphotericin was switched to conventional amphotericin because of financial constraints. This was followed by acute kidney injury and a flare of AIH. Amphotericin and flucytosine were withheld for a few days; a pulse of methylprednisolone was needed for AIH. Following resolution of acute kidney injury and AIH flare, conventional amphotericin B and flucytosine were restarted (and given for cumulative 3 weeks). This was followed by fluconazole consolidation. At hospital discharge, although there were raw areas over the thighs, these were healthy and she was otherwise well. A total of 3 months later, skin grafting was successfully performed.Conclusions Cryptococcus can be a great masquerader, and can mimic a variety of conditions. A high index of suspicion is required to clinch the diagnosis.

Risk factors, outcomes, and predictors of resolution of acute kidney injury in children with diabetic ketoacidosis.

Acute kidney injury (AKI) is a common complication in patients with diabetic ketoacidosis (DKA) (incidence 35-77%). AKI evolution during DKA treatment/recovery is poorly understood. Our aim was to assess children with DKA for prevalence, short-term kidney outcomes, severity, and predictors of AKI development and resolution. This retrospective cohort study included children aged 2-14years admitted with DKA between January 2016 and May 2020 in a Saudi tertiary care hospital. We defined AKI as an increase in serum creatinine of > 1.5 times baseline or > 3mg/dL (26mmol/L) within 48h. Of 213 patients admitted with DKA, 172 (80.75%) developed AKI: stage 1 in 83 (38.96%), stage 2 in 86 (40.37%), and stage 3 in 3 (1.4%). No patient required dialysis. Multivariate analysis showed an increased risk of developing AKI with male gender (OR = 2.85) and lower serum bicarbonate (OR = 0.83) when adjusted for initial heart rate, hematocrit, new onset diabetes, and recurrent AKI. The mean time to AKI resolution was 13.21 ± 6.78h. Factors leading to prolonged recovery from AKI in linear regression analysis were older age (B coefficient = 0.44, p = 0.01), recurrent DKA episodes (B coefficient = 3.70, p value 0.003), increased acidosis severity (B coefficient = - 0.44, p = 0.04), increased time to anion gap normalization (B coefficient = 0.44, p = 0.019), and increased initial glucose (B coefficient = 0.01, p = 0.011). In our cohort, AKI is a common, but mostly transient complication in children presenting with DKA, and its severity is associated with longer intensive care stays and time for acidosis resolution. AKI was associated with male gender, and lower serum bicarbonate. Proper consideration of such risk factors is needed for AKI assessment and management in future DKA clinical practice guidelines. A higher resolution version of the Graphical abstract is available as Supplementary information.

POS-457 DZNEP, A HISTONE MODIFICATION INHIBITOR, SUPPRESSES RENAL FIBROSIS BY INHIBITING HIF1Α BINDING TO TIMP2 GENE THROUGH REDUCING OPEN CHROMATIN AREA

Even after complete resolution of acute kidney injury (AKI), some patients develop chronic kidney disease (CKD) and end-stage renal failure. The mechanism of AKI to CKD is thought to be that transient AKI damage may cause the epigenetic changes, such as histone modification and DNA methylation, that lead to CKD progression. Our previous report showed that 3-Deazaneplanocin A (Dznep), a histone modification inhibitor, suppressed renal fibrosis and the expression of Tissue Inhibitor of Metalloproteinase 2 (TIMP2), which is thought to be a profibrotic factor, in ischemia-reperfusion mice.

Long-Term Follow up of Renal and Other Acute Organ Failure in Survivors of Critical Illness Due to Covid-19.

BackgroundLittle is known about the long-term health sequelae and outcomes of various organ failures in ICU survivors of Covid-19. The aim of our research was to study the characteristics of 120-day ICU survivors of the initial pandemic surge and report their long term (>6 months) outcomes.MethodsWe conducted a telephone questionnaire-based follow up study of 120- day survivors of Covid-19 admitted to ICUs at Montefiore Medical Center, Bronx, NY from 3/10/2020 to 4/11/2020. The study period was 2 months (11/1/2020-12/31/2020).Results126 out of 300 (42%) survived to 120-days post-hospital discharge. The median age of survivors was 54 (47-61) years. Seventy-eight (62%) patients developed acute kidney injury (AKI); thirty-five (44.9%) of them required renal replacement therapy (RRT). One hundred-five (83.3%) required invasive mechanical ventilation; ten of them required tracheotomy. 103 (81.7%) completed the telephone questionnaire-based study, at a median (IQR) of 216.5 (200-234.5) days after hospital discharge. 29 (28.2%) patients reported persistent shortness of breath, 24, (23.3%) complained of persistent cough, and persistent anosmia in 9 (8.8%). AKI resolved completely in 58 (74.4%) patients. Of 35 AKI patients who required initiation of RRT during hospitalization, 27 (77%) were liberated from RRT and 20 (57%) had resolution of AKI. Of 20 patients without AKI resolution, 12 developed chronic kidney disease, whereas 8 still require RRT. Thirty-three (32.4%) patients developed post-traumatic stress disorder (PTSD) and 10 (11.8%) reported major depression. Many of the patients (68%) regained baseline functional status. Readmissions occurred in 22.3% patients within first 6 months after discharge.ConclusionPersistent symptoms of long Covid have been reported in ICU survivors of Covid-19 for extended durations. Outcomes of Covid-19 associated acute kidney injury are excellent. There is a high incidence of PTSD and depression in COVID-19 ICU survivors. Functional outcomes are good, but these patients remain at increased risk of hospital readmission.

Renal Inflammation and Innate Immune Activation Underlie the Transition From Gentamicin-Induced Acute Kidney Injury to Renal Fibrosis.

Subjects recovering from acute kidney injury (AKI) are at risk of developing chronic kidney disease (CKD). The mechanisms underlying this transition are unclear and may involve sustained activation of renal innate immunity, with resulting renal inflammation and fibrosis. We investigated whether the NF-κB system and/or the NLRP3 inflammasome pathway remain activated after the resolution of AKI induced by gentamicin (GT) treatment, thus favoring the development of CKD. Male Munich-Wistar rats received daily subcutaneous injections of GT, 80 mg/kg, for 9 days. Control rats received vehicle only (NC). Rats were studied at 1, 30, and 180 days after GT treatment was ceased. On Day 1, glomerular ischemia (ISCH), tubular necrosis, albuminuria, creatinine retention, and tubular dysfunction were noted, in association with prominent renal infiltration by macrophages and myofibroblasts, along with increased renal abundance of TLR4, IL-6, and IL1β. Regression of functional and structural changes occurred on Day 30. However, the renal content of IL-1β was still elevated at this time, while the local renin-angiotensin system remained activated, and interstitial fibrosis became evident. On Day 180, recurring albuminuria and mild glomerulosclerosis were seen, along with ISCH and unabated interstitial fibrosis, whereas macrophage infiltration was still evident. GT-induced AKI activates innate immunity and promotes renal inflammation. Persistence of these abnormalities provides a plausible explanation for the transition of AKI to CKD observed in a growing number of patients.

Evaluation of Aminophylline for the Treatment of Acute Kidney Injury in Pediatric Hematology/Oncology Patients.

The purpose of this study was to compare acute kidney injury (AKI)-related outcomes of patients who received aminophylline in addition to standard of care with matched historical controls who received standard of care alone. This was a single center, retrospective, historical control cohort study that included patients treated for AKI. Patients who received aminophylline from January 2017 to June 2018 were matched for age, sex, primary diagnosis, and hematopoietic cell transplant history in a 1:2 ratio to historical controls treated for AKI from July 2015 to September 2016. The primary outcome was improvement in AKI stage at 5 and 10 days from treatment initiation. Twenty-seven patients who received aminophylline were matched to 54 historical controls. Fifty-eight patients (72%) had recently undergone hematopoietic cell transplant. At day 5, improvement in AKI stage was observed in 56% of patients in each group (p = 1.0); at day 10, improvement in AKI stage was observed in 75% of patients in the aminophylline group vs 70% of historical controls (p = 0.76). By day 10, serum creatinine levels had returned to baseline in 21% of patients in the aminophylline group and 34% of patients in the control group (p = 0.37). Findings of this study demonstrated no difference in the rate of AKI resolution or in the proportion of patients with resolved AKI when aminophylline was added to standard of care for the treatment of AKI in this pediatric hematology/oncology population.

Fluid management in patients with acute kidney injury - A post-hoc analysis of the FINNAKI study.

Whether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized. This was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients. We matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0-15.2]L fluids and non-AKI patients 10.2 L [7.5-13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0-7.2]L and among non-AKI patients 5.8 L [4.1-8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [-0.2-6.0]L compared to 0.9 L [-1.4-3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88-0.93) and better fluid output (multivariable OR 1.12 (1.07-1.18)) associated with enhanced change of resolution of AKI. AKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery.

#18: Brincidofovir for the Treatment of Disseminated Human Adenovirus Infection in Pediatric Solid-organ Transplant Recipients

Abstract Background Human adenovirus (HAdV) viremia can cause significant morbidity among pediatric patients undergoing solid-organ transplantation (SOT). Currently, there are no US Food and Drug Administration (FDA)-approved treatments for HAdV infections, and historically the mainstay of treatment has been decreasing immunosuppression with antiviral therapies reserved for those with severe disease. Brincidofovir (BCV) is an investigational antiviral drug with potency against HAdV. We describe four cases of disseminated HAdV infection treated with (BCV) among pediatric SOT patients. Methods We retrospectively reviewed 4 cases of severe disseminated HAdV infection, which occurred between 2018 and 2019, in a tertiary pediatric transplant center. HAdV infection was defined as a positive HAdV PCR from a clinical specimen. Baseline clinical characteristics, disease course, treatment, and outcomes were reviewed. Results Four pediatric SOT patients (2 kidneys, 1 dual kidney/liver, and 1 liver) ranging in age from 9 months to 19 years were diagnosed with HAdV infection (Table 1). Patients presented with varied symptoms from 12 to 912 days post-transplant. Peak HAdV viral load ranged from 37,000 to &amp;gt;1,000,000 copies/mL. All patients had disseminated disease with evidence of graft involvement and varying degrees of acute kidney injury (AKI) making them candidates for BCV therapy over cidofovir to avoid nephrotoxicity. Three out of four patients received cidofovir prior to conversion to BCV. IRB-approved compassionate use of BCV was dosed at 2 mg/kg (max 100 mg) twice weekly PO along with reduced immunosuppression. Resolution of symptoms and HAdV viremia was seen at a mean of 21.5 days (range 15–32) of therapy. All patients had resolution of AKI with a return to baseline creatinine after therapy. Conclusions Though HAdV infection in pediatric SOT patients is uncommon, a subset of patients experience severe disease, morbidity, and graft loss. Currently, HAdV is not routinely monitored in pediatric SOT transplant patients. Although supportive care and decreased immunosuppression remain as the most important component of therapy, BCV was well tolerated and efficacious in our series. Further research is needed to better understand risk factors for HAdV infection and potential antiviral treatment options to improve patient outcomes.

Outcome of Neonatal Acute Kidney Injury in a Special Care Baby Unit (SCABU)

Background: Acute kidney injury (AKI) is common in neonates admitted in Special Care Baby Unit (SCABU) with high morbidity and mortality.&#x0D; Objective: The present study was intended to see the immediate hospital outcome of neonatal acute kidney injury (AKI) in a Special Care Baby Unit (SCABU).&#x0D; Methods: This observational study was carried out in SCABU, in the Department of Paediatrics, Dhaka Medical College Hospital, from October 2013 to March 2014. A total of 44 neonates (from 3-28 days) with AKI were included in this study. AKI staging was done by using pediatric RIFLE criteria as Risk, Injury, Failure. Patients were managed conservatively and immediate hospital outcome was assessed by SCABU stay, multiorgan failure, resolution of AKI, mortality and dialysis as needed.&#x0D; Results: Demographic profile among the study population the neonate of d”7 days old comprised the main bulk. Majority of the neonates were of average birth weight. The diagnosis was based on estimated creatinine clearance(eCCL) criteria of pRIFLE showed that 40.9% neonates were at risk of AKI, 20.5% have had already injured. Higher proportions of neonates were classified as failure (38.6%).Outcome variables of neonatal AKI predicted by pRIFLE criteria was significantly higher in failure group in respect to SCABU stay (12.1+ 7.9) p value &lt; 0.001, multiorgan failure (41.2 %) p value 0.026 and dialysis needed (88.2 %) p value &lt; 0.001, resolution from AKI (47.1%) p value 0.885, Mortality (41.2%) p value 0.106. Here 43% neonates with AKI were improved with normal renal function and 29% improved with impaired renal function. Increased frequency of death (28%) in this series was due to multiorgan involvement and significantly higher in failure group with adequate dialysis support.&#x0D; Conclusion: From the findings of the study it can be concluded that immediate hospital outcome of neonatal AKI is worst even after adequate dialysis support. Multiorgan involvements, increase length of hospital stay at SCABU, increase need for dialysis, are the important cause of increase mortality and morbidity. So, early detection, prompt referral and immediate supportive therapy could improve the outcome of neonatal AKI.&#x0D; DS (Child) H J 2018; 34(1) : 5-10