Severe Chronic Renal Insufficiency Research Articles

Carbon dioxide cone-beam computed tomography for the technical assessment of endovascular aortic intervention

Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

Use of an Extremely Biodiverse Probiotic and a Supplement Based on Microbial Chondroitin Sulfate is Associated with a Significant Decrease of Serum Free Kappa Light Chains as well as a Trend Toward Normalization of Kappa/Lambda Ratio and of Plasma Cell Bone Marrow Infiltration in a Case of Multiple Myeloma

We describe the case of a 71-year-old woman with multiple myeloma associated with severe chronic renal insufficiency who, since October 2018, assumed a novel, extremely biodiverse, probiotic and a supplement based on microbial chondroitin sulfate, vitamin D3 and ultrapure phosphatidylcholine; such a nutritional regimen was associated with a dramatic decrease of serum free Kappa light chains (from 2,190 to a minimum of 119.40 mg/L) as well as a trend toward normalization of Kappa/Lambda ratio (from 187 to a minimum of 3.16) and of plasma cell bone marrow infiltration (from 20 to 5%).

Endothelin A receptor blocker and calcimimetic in the adenine rat model of chronic renal insufficiency

BackgroundWe studied whether endothelin receptor antagonist and calcimimetic treatments influence renal damage and kidney renin-angiotensin (RA) components in adenine-induced chronic renal insufficiency (CRI).MethodsMale Wistar rats (n = 80) were divided into 5 groups for 12 weeks: control (n = 12), 0.3% adenine (Ade; n = 20), Ade + 50 mg/kg/day sitaxentan (n = 16), Ade + 20 mg/kg/day cinacalcet (n = 16), and Ade + sitaxentan + cinacalcet (n = 16). Blood pressure (BP) was measured using tail-cuff, kidney histology was examined, and RA components measured using RT-qPCR.ResultsAdenine caused tubulointerstitial damage with severe CRI, anemia, hyperphosphatemia, 1.8-fold increase in urinary calcium excretion, and 3.5-fold and 18-fold increases in plasma creatinine and PTH, respectively. Sitaxentan alleviated tubular atrophy, while sitaxentan + cinacalcet combination reduced interstitial inflammation, tubular dilatation and atrophy in adenine-rats. Adenine diet did not influence kidney angiotensin converting enzyme (ACE) and AT4 receptor mRNA, but reduced mRNA of renin, AT1a, AT2, (pro)renin receptor and Mas to 40–60%, and suppressed ACE2 to 6% of that in controls. Sitaxentan reduced BP by 8 mmHg, creatinine, urea, and phosphate concentrations by 16–24%, and PTH by 42%. Cinacalcet did not influence BP or creatinine, but reduced PTH by 84%, and increased hemoglobin by 28% in adenine-rats. The treatments further reduced renin mRNA by 40%, while combined treatment normalized plasma PTH, urinary calcium, and increased ACE2 mRNA 2.5-fold versus the Ade group (p < 0.001).ConclusionsIn adenine-induced interstitial nephritis, sitaxentan improved renal function and tubular atrophy. Sitaxentan and cinacalcet reduced kidney renin mRNA by 40%, while their combination alleviated tubulointerstitial damage and urinary calcium loss, and increased kidney tissue ACE2 mRNA.

Su1435 - The Incidence and Risk Factors for the Development of Moderate to Severe Chronic Renal Insufficiency Inpatients Undergoing Liver Transplantation for Nonalcoholic Steatohepatitis Cirrhosis

Su1435 - The Incidence and Risk Factors for the Development of Moderate to Severe Chronic Renal Insufficiency Inpatients Undergoing Liver Transplantation for Nonalcoholic Steatohepatitis Cirrhosis

A Risk Score Model to Characterize Predictors of Survival After Elective Endovascular Abdominal Aortic Aneurysm Repair

The purpose of this study was to identify significant predictors of mortality after elective abdominal aortic aneurysm repair. We included all elective endovascular aneurysm repairs from 16 centers across the “Virginia's group” of the Society for Vascular Surgery Patient Safety Organization. Patients were classified into normal (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m2), moderate chronic renal insufficiency (eGFR 30-59), or severe chronic renal insufficiency (eGFR <30). Kaplan-Meier and Cox regression were used to measure and to determine the predictors of mortality. A score equation was developed to categorize patients into low, medium, and high mortality risk. A total of 5678 endovascular aneurysm repair patients were included with an age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were three deaths within 30 days (0.1%). Overall survival was 81.2% and 69.2% at 5 and 8 years, respectively. Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), on dialysis (HR, 3.7; P < .001), eGFR 80 (HR, 3.2; P < .001), age 75 to 79 years (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index of 25 to 35 were both found to be protective (HR, 0.78 [P = .017] and HR, 0.8 [P = .024], respectively. The 5- and 8-year survival rates for patients with low, medium, and high risk were 89.2%, 79.7%, and 80.7% and 68.9%, 64.1%, and 47.5%, respectively (P < .001). Survival for patients with high-risk score was 47.5% at 8 years. This risk score model offers an objective tool to better guide recommendations for interventions in this era of cost-effectiveness.

Medical Nutrition Therapy for Chronic Kidney Disease in Pregnancy: A Case Report

Medical Nutrition Therapy for Chronic Kidney Disease in Pregnancy: A Case Report

Preoperative 3D/3D MRI Fusion of Image in the Hybrid Room: Treatment of Aorto-Iliac Aneurysms in Patients with Renal Insufficiency

Severe chronic renal insufficiency is a major limitation for the endovascular treatment of aorto-iliac aneurysms (EVAR). MRI imaging can bring an important alternative to angio-CT. The aim of this study was to evaluate the feasibility of preoperative MRI and computer processing to minimize the use of iodized contrast during EVAR.

The effect of chronic renal insufficiency by use of glomerular filtration rate versus serum creatinine level on late clinical outcome of carotid endarterectomy

Several studies have reported mixed results after carotid endarterectomy (CEA) in patients with chronic renal insufficiency (CRI), and we previously reported the perioperative outcome in patients with CRI by use of serum creatinine (Cr) level and glomerular filtration rate (GFR). However, only a few of these studies used GFR by the Modification of Diet in Renal Disease equation in their analysis of long-term outcome. During the study period, 1000 CEAs (926 patients) were analyzed; 940 of these CEAs had Cr levels and 925 had GFR data. Patients were classified into normal (GFR ≥60 mL/min/1.73 m(2) or Cr <1.5 mg/dL), moderate CRI (GFR ≥30-59 or Cr ≥1.5-2.9), and severe CRI (GFR <30 or Cr ≥3). At a mean follow-up of 34.5 months and a median of 34 months (range, 1-53 months), combined stroke and death rates for Cr levels (867 patients) were 9%, 18%, and 44% for Cr <1.5, ≥1.5 to 2.9, and ≥3 (P = .0001) in contrast to 8%, 14%, and 26% for GFR (854 patients) of >60, ≥30 to 59, and <30, respectively (P = .0003). Combined stroke and death rates for asymptomatic patients were 8%, 17%, and 44% (P = .0001) for patients with Cr levels of <1.5, ≥1.5 to 2.9, and ≥3, respectively, vs 7%, 13%, and 24% for a GFR of ≥60, ≥30 to 59, and <30 (P = .0063). By Kaplan-Meier analysis, stroke-free survival rates at 1 year, 2 years, and 3 years were 97%, 94%, and 92% for Cr <1.5; 92%, 85%, and 81% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 93% for a GFR ≥60; 93%, 90%, and 86% for a GFR of ≥30 to 59; and 86%, 77%, and 73% for a GFR <30 (P < .0001). These rates for asymptomatic patients at 1 year, 2 years, and 3 years were 97%, 95%, and 93% for Cr <1.5; 94%, 87%, and 82% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 94% for a GFR ≥60; 95%, 91%, and 86% for a GFR of ≥30 to 59; and 84%, 80%, and 75% for a GFR <30 (P = .0026). A univariate regression analysis for asymptomatic patients showed that the hazard ratio (HR) of stroke and death was 6.5 (P = .0003) for a Cr ≥3 and 3.1 for a GFR <30 (P = .0089). A multivariate analysis showed that Cr ≥3 had an HR of stroke and death of 4.7 (P = .008), and GFR <30 had an HR of 2.2 (P = .097). Patients with severe CRI had higher rates of combined stroke/death. Therefore, CEA for these patients (particularly in asymptomatic patients) must be considered with caution.

AB0607 Heart Transplantation in 2 Patients with Systemic Sclerosis and Primary Cardiac Involvement

BackgroundThere is no specific treatment for primary cardiac involvement in systemic sclerosis (SSc). Even if heart transplantation is an option, only 1 case has been reported1.ObjectivesAnalyse data of patients with...

Impact of Chronic Renal Insufficiency on the Early and Late Clinical Outcomes of Carotid Artery Stenting Using Serum Creatinine vs Glomerular Filtration Rate

This study analyzed the impact of chronic renal insufficiency (CRI) on early and late clinical outcomes of carotid artery stenting (CAS) using serum creatinine and glomerular filtration rate (GFR). There were 313 CAS patients classified into 3 groups: normal (serum creatinine <1.5 mg/dL or GFR ≥ 60 mL/min/1.73 m(2)); moderate CRI, and severe CRI (serum creatinine ≥ 3 or GFR < 30 mL/min/1.73 m(2)). Major adverse events ([MAE] stroke, death, and myocardial infarction) were compared for all groups. Using serum creatinine, perioperative stroke rates for normal, moderate, and severe CRI were: 5%, 0%, and 25%, respectively, (p = 0.05) vs 4.6%, 3.7%, and 11.1%, respectively, (p = 0.44) using GFR. The perioperative MAE rates for symptomatic patients were 9.3% and 0% (p = 0.355) and 2% and 5.9% (p = 0.223) for asymptomatic patients for normal and moderate/severe CRI, respectively, using serum creatinine vs 8.1% and 7.8%, respectively, for symptomatic patients and 2.5% and 3%, respectively, for asymptomatic patients using GFR. At a mean follow-up of 21 months, late MAE rates in normal vs moderate/severe CRI patients were 8.2% and 14%, respectively, (p = 0.247) using serum creatinine vs 6.6% and 13.3%, respectively, (p = 0.05) using GFR. Late MAE rates for symptomatic patients in normal vs moderate/severe CRI were: 8.7% vs 27%, respectively, (p = 0.061) using serum creatinine and 5.7% vs 18.8%, respectively, (p = 0.026) using GFR. Late death rate was 0.55% in normal vs 7.6% (p = 0.002) for moderate/severe CRI. Freedom from MAE at 3 years in symptomatic patients was 81% in normal and 46% in moderate/severe CRI (p = 0.0198). A multivariate Cox regression analysis showed that a GFR of < 60 mL/min/1.73 m(2) had an odds ratio of 1.6 (p = 0.222) of having a MAE after CAS. The GFR was more sensitive in detecting late MAE after CAS. Carotid artery stenting in moderate CRI patients can be done with a satisfactory perioperative outcome; however, late death was significant.

Atrial natriuretic peptide as a predictor of atrial fibrillation in a male population study. The Study of Men Born in 1913 and 1923

BackgroundAtrial fibrillation is one of the most common arrhythmias in clinical practice and it is often diagnosed after a complication occurs. The study aimed to evaluate the predictive value of atrial natriuretic peptide (ANP) for atrial fibrillation in a male population-based study. Methods and resultsThis study is a part of the “Study of Men Born in 1913 and 1923”, a longitudinal prospective cohort study of men, living in the city of Gothenburg in Sweden. A population-based sample of 528 men was investigated in 1988 when they were aged 65years (n=134) and 75years (n=394), and they were followed up for 16years. Blood samples were collected from all 528 men at baseline and plasma ANP levels were analyzed by radioimmunoassay. Hazard ratios were estimated by competing-risk regression analysis.One hundred five participants were excluded because of a prior diagnosis of atrial fibrillation, congestive heart failure, severe hypertension, or severe chronic renal insufficiency. Of the remaining 423 participants, 90 men were diagnosed with atrial fibrillation over the 16-year follow-up. In multivariable analysis, men in the two highest quartiles of ANP levels had a significantly higher risk for atrial fibrillation compared with men in the lowest ANP quartile. The adjusted ratio was 3.14 (95% CI 1.59–6.20) for the third ANP quartile and 3.36 (95% CI 1.72–6.54) for the highest quartile of ANP level. ConclusionsIn this population-based longitudinal study, we found that elevated ANP levels at baseline predicted atrial fibrillation during a follow-up time of 16years.

Impact of Chronic Renal Insufficiency Using Serum Creatinine vs Glomerular Filtration Rate on Perioperative Clinical Outcomes of Carotid Endarterectomy

Several studies have reported conflicting results after carotid endarterectomy in patients with chronic renal insufficiency (CRI). However, only a few used glomerular filtration rate (GFR) (Modification of Diet in Renal Disease) in their analysis. Nine hundred and forty carotid endarterectomies that had serum creatinine and GFR were analyzed. Patients were classified as normal (creatinine <1.5 mg/dL or GFR ≥60 mL/min/1.73 m(2)); moderate CRI (creatinine ≥1.5 to 2.9 mg/dL or GFR ≥30 to 59 mL/min/1.73 m(2)), and severe CRI (creatinine ≥3 mg/dL or GFR <30 mL/min/1.73 m(2)). Using creatinine, perioperative stroke and major adverse event rates for normal, moderate CRI, and severe CRI were 2%, 3.5%, and 11.1% (p = 0.091) and 2.4%, 4.4%, and 11.1% (p = 0.089) vs 1.1%, 3.7%, and 5.4% (p = 0.018) and 1.8%, 4%, and 5.4% (p = 0.086) using GFR. Univariate logistic regression analysis showed that creatinine ≥1.5 mg/dL had an odds ratio of 2.1 for having early stroke/death vs an odds ratio of 3.5 (p = 0.009) for GFR <60 mL/min/1.73 m(2). A multivariate analysis showed that GFR <60 mL/min/1.73 m(2) had an odds ratio for early stroke/death of 3.7 (p = 0.013). Using creatinine, perioperative stroke rates for symptomatic patients were 2.8%, 2.6%, and 0% and 1.6%, 4.1%, and 11.1% (p = 0.045) for asymptomatic patients with normal, moderate CRI, and severe CRI vs 1.6%, 4.7%, and 9.1% for symptomatic patients (p = 0.09) and 1%, 3.2%, and 3.9% for asymptomatic patients (p = 0.074) using GFR. Perioperative major adverse event rates for symptomatic patients using creatinine were 3.2%, 2.6%, and 0%, and for asymptomatic patients 2.1%, 5.4%, and 11.1% (p = 0.048) vs 2.1%, 4.7%, and 9.1% for symptomatic patients and 1.7%, 3.7%, and 7.7% (p = 0.193) for asymptomatic patients using GFR. Moderate/severe CRI also had more cardiac (5.7% vs 2.4%; p = 0.072) and respiratory complications (2.5% vs 0.2%; p = 0.018). Glomerular filtration rate (Modification of Diet in Renal Disease) was more sensitive in detecting perioperative stroke/death after carotid endarterectomy in patients with CRI. Patients with moderate/severe CRI had more major adverse events than normal patients.

P-1347 - Reboxetine-treated narcolepsy: case report

Narcolepsy is a disabling sleep disorder affecting 0.02% of adults worldwide. It is characterized by irresistible daytime sleepiness, catalepsy and can be associated with sleep paralysis, and hipnagogic hallucinations. The treatment is essentially symptomatic with stimulant drugs (mostly dopaminergic) for daytime sleepiness and sleep attacks, antidepressants (mostly noradrenergic) for catalepsy and hypnotics for disturbed night-time sleep. Special care must be taken, with close blood monitoring for toxicity, in the prescription of these drugs to patients with concurrent renal or hepatic disease. The authors present a case of a 72 year-old female patient with the diagnoses of narcolepsy and conjoint severe chronic renal and hepatic insufficiency, with intolerance for most of the recommended treatments for her sleep disorder. The patient is observed in a psychiatric consultation after several bone fractures due to cataleptic phenomena. We describe a successful therapeutical approach with reboxetine, with a significant improvement in daytime sleepiness, reflected by a decrease of 52% on the Epworth Sleepiness Scale. Furthermore, a significant reduction in the cataplexy subscore of the Ullanlinna Narcolepsy Scale was also found. Consequently, this treatment led to a decrease in the frequency of catalepsy attacks and secondary traumatic injuries and an increase in the Global Assessment of Functioning scale.

Antifungal Dosing in Dialysis and Continuous Renal Replacement Therapy

Appropriate dosing of antifungal drugs is crucial to achieving favorable outcomes in patients with invasive fungal infections. The use of various types of renal replacement therapy (RRT) in patients with severe acute or chronic renal insufficiency adds another level of complexity to the already challenging use of these drugs. The medical literature provides only a limited number of studies specifically addressing the use of antifungal agents in patients receiving RRT, and there are a number of inherent difficulties in interpreting and applying these studies of drug dosing during RRT to individual patients. This article briefly reviews recent studies examining the dosing of antifungal agents during RRT, and also briefly reviews device-related and drug-related factors that determine the removal of drugs during RRT. Finally, this article summarizes current recommendations for dosing of antifungal agents in patients receiving RRT and highlights areas for future study.

Aortic Root Pseudoaneurysm 1 Year After Transapical Aortic Valve Implantation

An 84-year-old woman was admitted to our institution for transapical aortic valve implantation (TAVI) because of severe aortic stenosis coexisting with high-risk clinical conditions. She had a past history of type 2 diabetes mellitus, hypertension, intrinsic asthma, moderate to severe chronic renal insufficiency (Modification of Diet in Renal Disease glomerular filtration rate, 36 mL/min per 1.73 m2), and peripheral atherosclerotic vascular disease involving both iliofemoral arteries. Eighteen months before, she had suffered a non–ST-segment elevation myocardial infarction and was treated with 2 bare metal stents on the middle segment of the left anterior descending coronary artery and the very proximal or ostial segment of the right coronary artery. Aortic stenosis was evaluated as moderate. After 5 months, she developed advanced Mobitz II–type atrioventricular block, and a permanent sequential atrial synchronous ventricular inhibited pacemarker was indicated. Progression of the aortic valve disease was not noted. More recently, she was admitted to another hospital with severe dyspnea, showing signs of acute heart failure on physical examination. Urgent transthoracic echocardiogram disclosed a normal left ventricle with preserved ejection fraction and progression of the severity of the aortic valve stenosis. Because of the very high operative risk, conventional on-pump aortic valve replacement was dismissed. …

Fibrocystic disease of liver and pancreas; under‐recognized features of the X‐linked ciliopathy oral‐facial‐digital syndrome type 1 (OFD I)

OFD I is an X-linked dominant male-lethal ciliopathy characterized by prominent external features including oral clefts, hamartomas or cysts of the tongue, and digital anomalies. Although these external features are easy to recognize and often lead to diagnosis in early childhood, visceral findings in OFD I, especially the fibrocystic liver and pancreas disease, are under-recognized. In addition, while the occurrence of polycystic kidney disease (PKD) in OFD I is well known, few patients are evaluated and monitored for this complication. We report on two adult females diagnosed with OFD I in infancy, but not evaluated for visceral involvement. In adulthood, they were incidentally found to have severe hypertension and chronic renal insufficiency due to undiagnosed PKD. A pancreatic cystic lesion, also discovered incidentally, was thought to be malignant and led to consideration of major surgery. We present NIH evaluations, including documentation of OFD I mutations, extreme beading of the intrahepatic bile ducts, pancreatic cysts, and tabulate features of reported OFD I cases having hepatic, pancreatic, and renal cystic disease. Liver and pancreas are not routinely evaluated in OFD I patients. Increased awareness and lifelong monitoring of visceral complications, particularly involving the liver, pancreas, and kidney, are essential for timely and accurate treatment.

Progression of Renal Insufficiency in Children and Adolescents With Neuropathic Bladder is Not Accelerated by Lower Urinary Tract Reconstruction

Children with chronic renal insufficiency and neuropathic bladder resistant to medical management may require lower urinary tract reconstruction before renal transplantation. A low pressure urinary reservoir optimizes the chance of graft survival and may slow native kidney death. We evaluated whether the renal deterioration rate is affected by augmentation cystoplasty. We performed a retrospective cohort study in children who presented to our institution with chronic renal insufficiency and neuropathic bladders from 2005 to 2009. Chronic renal insufficiency was defined as a glomerular filtration rate of less than 60 ml per minute. As a surrogate for renal function change, we used the inverse creatinine trend with respect to time to determine the progression rate of renal insufficiency before and after augmentation. A total of 11 patients with a mean glomerular filtration rate of 34 ml per minute per 1.73 m(2), mean bladder capacity 168 ml and mean compliance 3.5 ml/cm H(2)O met study inclusion criteria. Bladder augmentation or replacement was done at a mean age of 9.7 years with a resultant mean capacity of 486 ml and compliance of 14.7 ml/cm H(2)O. Mean followup was 4 years before and 1.9 years after augmentation. There was no statistically significant difference between the preoperative and postoperative slopes of inverse creatinine in 8 of 11 patients (73%). Two of the 3 patients (18%) with different preoperative and postoperative slopes had improving renal function after surgery. There was no statistically significant difference in slopes across all patients. In our series bladder augmentation did not appear to hasten progression to end stage renal disease in patients with severe chronic renal insufficiency and neuropathic bladder.

In-hospital Major Clinical Outcomes in Patients With Chronic Renal Insufficiency Presenting With Acute Coronary Syndrome: Data From a Registry of 8176 Patients

To assess the impact of chronic renal insufficiency (CRI) on in-hospital major adverse cardiac events across the acute coronary syndrome (ACS) spectrum. From January 29, 2007, through July 29, 2007, 6 adjacent Middle Eastern countries participated in the Gulf Registry of Acute Coronary Events, a prospective, observational registry of 8176 patients. Patients were categorized according to estimated glomerular filtration rate into 4 groups: normal (>or=90 mL/min), mild (60-89 mL/min), moderate (30-59 mL/min), and severe CRI (<30 mL/min). Patients' characteristics and in-hospital major adverse cardiac events in the 4 groups were analyzed. Of 6518 consecutive patients with ACS, 2828 (43%) had mild CRI, 1304 (20%) had moderate CRI, and 345 (5%) had severe CRI. In CRI groups, patients were older and had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia. On admission, these patients had a higher resting heart rate and frequently had atypical and delayed presentations. Compared with the normal estimated glomerular filtration group, CRI groups were less likely to receive antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors, and statins and were less likely to undergo coronary angiography. In-hospital heart failure, cardiogenic shock, and major bleeding episodes were significantly higher in all CRI groups. In multivariate analysis, mild, moderate, and severe CRI were associated with a higher adjusted odds ratio (OR) of death (mild: OR, 2.1; 95% confidence interval [CI], 1.2-3.7; moderate: OR, 6.7; 95% CI, 3.9-11.5; and severe: OR, 12.0; 95% CI, 6.6-21.7). Across the ACS spectrum, patients with CRI had a worse risk profile, had more atypical and delayed presentations, and were less likely to receive evidence-based therapy. Chronic renal insufficiency of varying stages is an independent predictor of in-hospital morbidity and mortality.

Prevention of acute kidney injury and protection of renal function in the intensive care unit

Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system. Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest specific vasodilators [corrected] under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention. The online version of this article (doi:10.1007/s00134-009-1678-y) contains supplementary material, which is available to authorized users.

Nephrogenic Systemic Fibrosis and Its Impact on Abdominal Imaging

The objective of this article is to review the current knowledge about nephrogenic systemic fibrosis (NSF) and how to prevent it. More than 300 cases of NSF in patients with severe chronic renal insufficiency or acute renal failure or in patients undergoing dialysis have been reported in the peer-reviewed literature, with an overwhelming majority occurring within weeks to months after injection of a gadolinium-based contrast agent (GBCA). Because administration of a high dose of a GBCA is a primary risk factor and because most high-dose magnetic resonance (MR) imaging applications involve abdominal imaging (eg, liver and abdominal MR angiography), NSF cases have been associated with abdominal MR imaging. Additional major risk factors for developing NSF include proinflammatory conditions, failure to perform dialysis promptly after GBCA administration, use of nonionic linear contrast agents, hyperphosphatemia, and younger age. Recent recommendations to use GBCAs with caution in patients with acute renal failure, patients receiving dialysis, or patients with an estimated glomerular filtration rate of less than 30 mL/min have resulted in virtually no new NSF cases being reported with onset in 2008 or 2009 in spite of a high level of awareness about this entity. In conclusion, NSF has been virtually eliminated by using caution in administering GBCAs to patients known to have severe or acute renal failure. In these patients, avoid high doses; and for patients undergoing dialysis, schedule MR imaging to occur just before a dialysis session to ensure rapid elimination of gadolinium.