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Pless-Petig G, Walter B, Bienholz A, Rauen U. Mitochondrial Impairment as a Key Factor for the Lack of Attachment after Cold Storage of Hepatocyte Suspensions. Cell Transplant 2018; 26:1855-1867. [PMID: 29390882 PMCID: PMC5802638 DOI: 10.1177/0963689717743254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Isolated primary hepatocytes, which are widely used for pharmacological and clinical purposes, usually undergo certain periods of cold storage in suspension during processing. While adherent hepatocytes were shown previously to suffer iron-dependent cell death during cold (4 °C) storage and early rewarming, we previously found little iron-dependent hepatocyte death in suspension but severely decreased attachment ability unless iron chelators were added. Here, we focus on the role of mitochondrial impairment in this nonattachment of hepatocyte suspensions. Rat hepatocyte suspensions were stored in a chloride-poor, glycine-containing cold storage solution with and without iron chelators at 4 °C. After 1 wk of cold storage in the basic cold storage solution, cell viability in suspension was unchanged, while cell attachment was decreased by >80%. In the stored cells, a loss of mitochondrial membrane potential (MMP), a decrease in adenosine triphosphate (ATP) content (2 ± 2 nmol/106 cells after cold storage, 5 ± 3 nmol/106 cells after rewarming vs. control 29 ± 6 nmol/106 cells), and a decrease in oxygen consumption (101 ± 59 pmol sec-1 per 106 cells after rewarming vs. control 232 ± 83 pmol sec-1 per 106 cells) were observed. Addition of iron chelators to the cold storage solution increased cell attachment to 53% ± 20% and protected against loss of MMP, and cells were able to partially regenerate ATP during rewarming (15 ± 10 nmol/106 cells). Increased attachment could also be achieved by addition of the inhibitor combination of mitochondrial permeability transition, trifluoperazine + fructose. Attached hepatocytes displayed normal MMP and mitochondrial morphology. Additional experiments with freshly isolated hepatocytes confirmed that impaired energy production-as elicited by an inhibitor of the respiratory chain, antimycin A-can decrease cell attachment without decreasing viability. Taken together, these results suggest that mitochondrial impairment with subsequent energy deficiency is a key factor for the lack of attachment of cold-stored hepatocyte suspensions.
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Affiliation(s)
- Gesine Pless-Petig
- 1 Institut für Physiologische Chemie, Universitätsklinikum Essen, Essen, Germany
| | - Björn Walter
- 1 Institut für Physiologische Chemie, Universitätsklinikum Essen, Essen, Germany
| | - Anja Bienholz
- 2 Klinik für Nephrologie, Universitätsklinikum Essen, Essen, Germany
| | - Ursula Rauen
- 1 Institut für Physiologische Chemie, Universitätsklinikum Essen, Essen, Germany
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Guberina H, da Silva Nardi F, Michita RT, Dolff S, Bienholz A, Heinemann FM, Wilde B, Trilling M, Horn PA, Kribben A, Witzke O, Rebmann V. Susceptibility of HLA-E*01:03 Allele Carriers to Develop Cytomegalovirus Replication After Living-Donor Kidney Transplantation. J Infect Dis 2018; 217:1918-1922. [PMID: 29228302 DOI: 10.1093/infdis/jix638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/06/2017] [Indexed: 11/12/2022] Open
Abstract
Cytomegalovirus (CMV) causes serious complications among solid organ transplant recipients. We report the positive correlation between the presence of the HLA-E*01:03 allele in living-donor kidney recipients and CMV reactivation during the first year after transplantation. Thus, HLA-E genotyping may help identify CMV replication-prone patients who require individualized patient-based CMV management.
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Affiliation(s)
- Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Fabiola da Silva Nardi
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Germany
| | - Rafael Tomoya Michita
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Falko M Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Mirko Trilling
- Institute for Virology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Peter A Horn
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Vera Rebmann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Germany
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Korth J, Widera M, Dolff S, Guberina H, Bienholz A, Brinkhoff A, Anastasiou OE, Kribben A, Dittmer U, Verheyen J, Wilde B, Witzke O. Impact of low-level BK polyomavirus viremia on intermediate-term renal allograft function. Transpl Infect Dis 2018; 20. [PMID: 29156086 DOI: 10.1111/tid.12817] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/10/2017] [Accepted: 08/13/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND BK polyomavirus (BKPyV)-associated nephropathy (PyVAN) is a significant cause of premature renal transplant failure. High-level BKPyV viremia is predictive for PyVAN; however, low-level BKPyV viremia does not necessarily exclude the presence of PyVAN. As data are limited regarding whether or not low-level BKPyV viremia has an effect on intermediate-term graft outcome, this study analyzes the impact of low-level BKPyV viremia on intermediate-term graft function and outcome compared with high-level viremia and non-viremic patients. METHODS All renal transplant patients received follow-up examinations at the Department of Nephrology, University Hospital Essen. Patients were screened for BKPyV viremia and stratified into three groups according to their maximum BKPyV load in serum (low-level viremia, high-level viremia, and no viremia). RESULTS In 142 of 213 (67%) patients, BKPyV was never detected in serum; 42 of 213 (20%) patients were found positive for low-level viremia (≤104 copies/mL); and 29 of 213 (13%) patients showed high-level viremia (>104 copies/mL). No significant differences regarding transplant function and graft failure were observed between patients without BKPyV viremia (delta estimated glomerular filtration rate [eGFR] +0.1 mL/min [month 1 vs last visit at month 44]) and patients with low-level BKPyV viremia (delta eGFR -1.7 mL/min). In patients with high-level viremia, transplant function was significantly restricted (delta eGFR -6.5 mL/min) compared with low-level viremia until the last visit at 44 ± 9.7 months after transplantation. Although the graft function and graft loss were worse in the high-level viremia group compared with no viremia (eGFR 37 vs 45 mL/min), the difference was not significant. CONCLUSIONS High-level viremia was associated with impaired graft function. In contrast, low-level BKPyV viremia had no significant impact on intermediate-term graft function.
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Affiliation(s)
- Johannes Korth
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marek Widera
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alexandra Brinkhoff
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Olympia Evdoxia Anastasiou
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ulf Dittmer
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jens Verheyen
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Benkö T, Gottmann M, Radunz S, Bienholz A, Saner FH, Treckmann JW, Paul A, Hoyer DP. One-year Allograft and Patient Survival in Renal Transplant Recipients Receiving Antiplatelet Therapy at the Time of Transplantation. Int J Organ Transplant Med 2018; 9. [PMID: 29531642 PMCID: PMC5839625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antiplatelet therapy is common in patients on the waiting list for kidney transplantation. OBJECTIVE To evaluate the incidence of post-operative bleeding in patients with antiplatelet therapy undergoing kidney transplantation and analyze the impact on the outcome. METHODS We studied all patients with concomitant antiplatelet therapy undergoing kidney transplantation in our center from January 2007 to June 2012. Data were collected by chart review. Univariate and multivariate logistic regression and Cox proportional hazard model were used to identify risk factors for the long-term outcome. RESULTS Of 744 kidney transplant recipients during the study period, 161 received oral antiplatelet therapy and were included in the study. One-third of the patients demonstrated signs of bleeding, half of which requiring surgical treatment. Coronary artery disease, deceased donor kidney transplantation, and dual antiplatelet medication were independent risk factors for post-operative bleeding. One-year allograft survival was significantly better in the non-bleeding group (91.4% vs 75.9%, p=0.023). Multivariable analysis found that post-operative bleeding, recipient age, and biopsy-proven rejection were independent risk factors for graft survival. Recipient age and biopsy-proven rejection were also identified as independent risk factors for patient survival. CONCLUSION This analysis indicated a high risk for post-operative bleeding in renal transplant patients under antiplatelet therapy. The associated negative effect on allograft survival underscored the need to reduce any risk factors for post-operative bleeding.
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Affiliation(s)
- T. Benkö
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany,Correspondence: Tamas Benkö, MD, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45127 Essen, Germany, Tel: +49-201-723-1101, E-mail:
| | - M. Gottmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - S. Radunz
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - A. Bienholz
- Department of Nephrology, University Hospital Essen, University Essen-Duisburg, Germany
| | - F. H. Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - J. W. Treckmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - A. Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - D. P. Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Germany
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Bienholz A, Mae Pang R, Guberina H, Rauen U, Witzke O, Wilde B, Petrat F, Feldkamp T, Kribben A. Resveratrol Does Not Protect from Ischemia-Induced Acute Kidney Injury in an in Vivo Rat Model. Kidney Blood Press Res 2017; 42:1090-1103. [PMID: 29207388 DOI: 10.1159/000485606] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The natural polyphenol resveratrol (RSV) has been shown to ameliorate ischemia/reperfusion (I/R)-induced damage. Therefore, a rat model of I/R-induced AKI equipped with intensive monitoring was utilized to examine direct renal protection by RSV in vivo. METHODS AKI was induced by bilateral renal clamping (45 min) followed by reperfusion (3 h). Solvent-free RSV was continuously infused intravenously (0.056 and 0.28 mg/kg) in a total volume of 7 ml/kg/h starting from 30 min before renal clamping. At a mean arterial blood pressure below 70 mmHg for more than 5 min, bolus injections of 0.5 ml 0.9% NaCl solution were administered repetitively (max. 5 ml/kg/h). RESULTS No differences could be found between normoxic control groups with/without RSV. Bilateral renal clamping and subsequent reperfusion caused a progressive rise in creatinine, cystatin C, and CK, a decrease in cellular ATP content and diuresis. Infusion of RSV increased sirtuin 1 expression after ischemia/reperfusion and was associated with decreased blood pressure during ischemia and early reperfusion accompanied by an increased requirement of bolus injections as well as with increased expression of TNFα. CONCLUSION RSV did not exert protective effects on I/R-induced AKI in the present short-term in vivo rat model. The lack of protection is potentially connected to aggravation of blood pressure instability.
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Affiliation(s)
- Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rahel Mae Pang
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Duisburg-Essen, Essen, Germany
| | - Ursula Rauen
- Institute of Physiological Chemistry, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Duisburg-Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Frank Petrat
- Institute of Physiological Chemistry, University Duisburg-Essen, Essen, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, Christian-Albrechts-University, Kiel, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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6
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Guberina H, Tomoya Michita R, Dolff S, Bienholz A, Trilling M, Heinemann FM, Horn PA, Kribben A, Witzke O, Rebmann V. Recipient HLA-G +3142 CC Genotype and Concentrations of Soluble HLA-G Impact on Occurrence of CMV Infection after Living-Donor Kidney Transplantation. Int J Mol Sci 2017; 18:ijms18112338. [PMID: 29113092 PMCID: PMC5713307 DOI: 10.3390/ijms18112338] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/29/2017] [Accepted: 10/31/2017] [Indexed: 11/26/2022] Open
Abstract
The expression modulation of the immunosuppressive non-classical Human leukocyte antigen-G (HLA-G) molecule and its soluble isoforms is an immune evasion strategy being deployed by cytomegalovirus (CMV). The +3142 C>G single nucleotide polymorphism (SNP) located within the 3′ untranslated region (3′UTR) is of crucial importance for the regulation of HLA-G expression. Therefore, we analyzed the influence of the +3142 C>G HLA-G SNP on the occurrence of CMV infection in a cohort of 178 living-donor kidney recipients and their 178 corresponding donors. In addition, soluble HLA-G (sHLA-G) levels were quantified before and after transplantation. The presence of the HLA-G +3142 CC genotype in recipients, but not donors of our cohort as along with elevated sHLA-G levels (≥6.1 ng/mL) were associated with higher susceptibility to CMV infection after transplantation. Our results provided evidence that (i) HLA-G is implicated in the establishment of CMV after living-donor kidney transplantation and (ii) recipient HLA-G +3142 CC genotype and sHLA-G concentration levels could represent important predictive risk markers for CMV infection.
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Affiliation(s)
- Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Rafael Tomoya Michita
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Mirko Trilling
- Institute for Virology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Falko M Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Peter A Horn
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
| | - Vera Rebmann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany.
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Al-Rashid F, Bienholz A, Hildebrandt HA, Patsalis PC, Totzeck M, Kribben A, Wendt D, Jakob H, Lind A, Jánosi RA, Rassaf T, Kahlert P. Transfemoral transcatheter aortic valve implantation in patients with end-stage renal disease and kidney transplant recipients. Sci Rep 2017; 7:14397. [PMID: 29089579 PMCID: PMC5663698 DOI: 10.1038/s41598-017-14486-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 10/11/2017] [Indexed: 11/09/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has evolved to a treatment of choice in high-risk patients and is therefore ideal for patients with advanced chronic kidney disease, as patients with end-stage renal disease and kidney transplant recipients. Especially, outcome of this special patient group is very important. 22 patients with chronic kidney disease stage 5 undergoing intermittent hemodialysis treatment (CKD 5D) and 8 kidney transplant recipients (KT) with severe aortic valve stenosis underwent transfemoral TAVI. TAVI was successfully performed in all patients. Postinterventional acute kidney injury (AKI) occurred in four kidney transplant recipients (KDIGO grade 1: n = 3, grade 3: n = 1) but creatinine/eGFR returned to baseline values in all patients. Short-term (30-day) mortality was 3% (1 patient in CKD 5D group). KT had a higher 2-year mortality than CKD5D patients (31% vs. 53%; p = 0.309), and cause of death was non-cardiac because of sepsis in all cases. The amount of contrast medium during TAVI was not associated with the development of acute kidney injury. TAVI is feasible in patients with CKD5D and in KT. Postinterventional AKI in these patients is often mild and does not impact renal function at day 30, while infection/ sepsis is the leading cause of mid-term mortality.
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Affiliation(s)
- Fadi Al-Rashid
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany.
| | - Anja Bienholz
- The Department of Nephrology, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Heike Annelie Hildebrandt
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Polycarpos-Christos Patsalis
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Matthias Totzeck
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- The Department of Nephrology, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Daniel Wendt
- The Department of Cardiovascular Surgery of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Heinz Jakob
- The Department of Cardiovascular Surgery of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Alexander Lind
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Rolf Alexander Jánosi
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Philipp Kahlert
- The Department of Cardiology and Vascular Medicine of the West-German Heart and Vascular Center Essen, Essen University Hospital, University Duisburg-Essen, Essen, Germany
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Abstract
Acute kidney injury (AKI) is a clinical syndrome occurring in the context of multiple and diverse disease entities. Although the term AKI implies renal damage as well as functional impairment or a combination of both, diagnosis is solely based on the functional parameters serum creatinine and urine output. Independent of the underlying disease and even assuming full recovery of renal function, AKI is associated with increased morbidity and mortality not only during the acute situation, but also long term. Awareness of the individual risk profile of each patient and the variety of causes and clinical manifestations of AKI is pivotal for prophylaxis, diagnosis, and therapy. The complexity of the clinical syndrome in the context of sepsis, solid organ transplantation, malignancy, and autoimmune diseases requires differentiated diagnostic and therapeutic approaches and interdisciplinary care.
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Affiliation(s)
- A Bienholz
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - A Kribben
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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9
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Eisenberger U, Guberina H, Willuweit K, Bienholz A, Kribben A, Gerken G, Witzke O, Herzer K. Successful Treatment of Chronic Hepatitis C Virus Infection With Sofosbuvir and Ledipasvir in Renal Transplant Recipients. Transplantation 2017; 101:980-986. [PMID: 27495770 DOI: 10.1097/tp.0000000000001414] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Treatment of chronic hepatitis C virus (HCV) infection after renal allograft transplantation has been an obstacle because of contraindications associated with IFN-based therapies. Direct-acting antiviral agents are highly efficient treatment options that do not require IFN and may not require ribavirin. Therefore, we assessed the efficacy and safety of sofosbuvir and ledipasvir in renal transplant patients with chronic HCV infection. METHODS Fifteen renal allograft recipients with therapy-naive HCV genotype (GT) 1a, 1b, or 4 were treated with the combination of sofosbuvir and ledipasvir without ribavirin for 8 or 12 weeks. Clinical data were retrospectively analyzed for viral kinetics and for renal and liver function parameters. Patients were closely monitored for trough levels of immunosuppressive agents, laboratory values, and potential adverse effects. RESULTS Ten patients (66%) exhibited a rapid virologic response within 4 weeks (HCV GT1a, n = 4; HCV GT1b, n = 6). The other 5 patients exhibited a virologic response within 8 (HCV GT 1b, n = 4) or 12 weeks (HCV GT4, n = 1). One hundred percent of patients exhibited sustained virologic response at week 12 after the end of treatment. Clinical measures of liver function improved substantially for all patients. Adverse events were scarce; renal transplant function and proteinuria remained stable. Importantly, dose adjustments for tacrolimus were necessary for maintaining sufficient trough levels. CONCLUSIONS The described regimen appears to be safe and effective for patients after renal transplant and is a promising treatment regimen for eradicating HCV in this patient population.
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Affiliation(s)
- Ute Eisenberger
- 1 Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Germany. 2 Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Germany. 3 Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany. 4 Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Germany
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10
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Bienholz A, Walter B, Pless-Petig G, Guberina H, Kribben A, Witzke O, Rauen U. Characterization of injury in isolated rat proximal tubules during cold incubation and rewarming. PLoS One 2017; 12:e0180553. [PMID: 28672023 PMCID: PMC5495391 DOI: 10.1371/journal.pone.0180553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 06/16/2017] [Indexed: 01/27/2023] Open
Abstract
Organ shortage leads to an increased utilization of marginal organs which are particularly sensitive to storage-associated damage. Cold incubation and rewarming-induced injury is iron-dependent in many cell types. In addition, a chloride-dependent component of injury has been described. This work examines the injury induced by cold incubation and rewarming in isolated rat renal proximal tubules. The tissue storage solution TiProtec® and a chloride-poor modification, each with and without iron chelators, were used for cold incubation. Incubation was performed 4°C for up to 168 h, followed by rewarming in an extracellular buffer (3 h at 37°C). After 48, 120 and 168 h of cold incubation LDH release was lower in solutions containing iron chelators. After rewarming, injury increased especially after cold incubation in chelator-free solutions. Without addition of iron chelators LDH release showed a tendency to be higher in chloride-poor solutions. Following rewarming after 48 h of cold incubation lipid peroxidation was significantly decreased and metabolic activity was tendentially better in tubules incubated with iron chelators. Morphological alterations included mitochondrial swelling and fragmentation being partially reversible during rewarming. ATP content was better preserved in chloride-rich solutions. During rewarming, there was a further decline of ATP content in the so far best conditions and minor alterations under the other conditions, while oxygen consumption was not significantly different compared to non-stored control tubules. Results show an iron-dependent component of preservation injury during cold incubation and rewarming in rat proximal renal tubules and reveal a benefit of chloride for the maintenance of tubular energy state during cold incubation.
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Affiliation(s)
- Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- * E-mail:
| | - Björn Walter
- Institute of Physiological Chemistry, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Gesine Pless-Petig
- Institute of Physiological Chemistry, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ursula Rauen
- Institute of Physiological Chemistry, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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11
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Korth J, Kukalla J, Rath PM, Dolff S, Krull M, Guberina H, Bienholz A, Wilde B, Becker S, Ross B, Anastasiou OE, Kribben A, Witzke O. Increased resistance of gram-negative urinary pathogens after kidney transplantation. BMC Nephrol 2017; 18:164. [PMID: 28525997 PMCID: PMC5437586 DOI: 10.1186/s12882-017-0580-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 05/11/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Urinary tract infection is the most common complication after kidney transplantation. It can cause severe sepsis and transplant loss. Emergence of drug resistance among gram-negative urinary pathogens is the current challenge for urinary tract infection treatment after kidney transplantation. METHODS This study analyzes the antimicrobial susceptibility of gram-negative urinary pathogens after kidney transplantation from 2009 to 2012 at the Transplant Outpatient Clinic of the University Hospital Essen, Germany. Kidney transplant patients at the University Hospital Essen receive regular follow up examinations after transplantation. Midstream urines were examined for bacteriuria at each follow up visit. RESULTS From 2009 to 2012 15.741 urine samples were obtained from 859 patients. In 2985 (19%) samples bacterial growth was detected. The most frequently detected gram-negative bacteria were E.coli 1109 (37%), Klebsiella spp. 242 (8%) and Pseudomonas aeruginosa 136 (4.5%). Klebsiella spp. showed a significant increase of resistance to trimethoprim-sulfamethoxazole by 19% (p = 0.02), ciprofloxacin by 15% (p = 0.01) and ceftazidime by 17% (p = 0.004). E.coli and P. aeruginosa isolates presented no significant differences of antimicrobial susceptibility to the analyzed antibiotics. CONCLUSIONS Antimicrobial resistance of Klebsiella spp. increased significant to trimethoprim-sulfamethoxazole, ciprofloxacin and ceftazidime from 2009 to 2012.
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Affiliation(s)
- Johannes Korth
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Julia Kukalla
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Peter-Michael Rath
- Institute for Medical Microbiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Marco Krull
- Institute of Hygiene, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Stefan Becker
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Birgit Ross
- Institute of Hygiene, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Olympia Evdoxia Anastasiou
- Department of Gastroenterology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
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12
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Bienholz A, Reis J, Sanli P, de Groot H, Petrat F, Guberina H, Wilde B, Witzke O, Saner FH, Kribben A, Weinberg JM, Feldkamp T. Citrate shows protective effects on cardiovascular and renal function in ischemia-induced acute kidney injury. BMC Nephrol 2017; 18:130. [PMID: 28395656 PMCID: PMC5387390 DOI: 10.1186/s12882-017-0546-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/01/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Ischemia and reperfusion (I/R) is one of the major causes of acute kidney injury (AKI). Citrate reduces hypoxia-induced mitochondrial energetic deficits in isolated proximal tubules. Moreover, citrate anticoagulation is now frequently used in renal replacement therapy. In the present study a rat model of I/R-induced AKI was utilized to examine renal protection by citrate in vivo. METHODS AKI was induced by bilateral renal clamping (40 min) followed by reperfusion (3 h). Citrate was infused at three different concentrations (0.3 mmol/kg/h; 0.6 mmol/kg/h and 1.0 mmol/kg/h) continuously for 60 min before and 45 min after ischemia. Plasma calcium concentrations were kept stable by infusion of calcium gluconate. The effect of citrate was evaluated by biomonitoring, blood and plasma parameters, histopathology and tissue ATP content. RESULTS In comparison to the normoxic control group bilateral renal ischemia led to an increase of creatinine and lactate dehydrogenase activity and a decrease in tissue ATP content and was accompanied by a drop in mean arterial blood pressure. Infusion of 1.0 mmol/kg/h citrate led to lower creatinine and reduced LDH activity compared to the I/R control group and a tendency for higher tissue ATP content. Pre-ischemic infusion of 1.0 mmol/kg/h citrate stabilized blood pressure during ischemia. CONCLUSIONS Citrate has a protective effect during I/R-induced AKI, possibly by limiting the mitochondrial deficit as well as by beneficial cardiovascular effects. This strengthens the rationale of using citrate in continuous renal replacement therapy and encourages consideration of citrate infusion as a therapeutic treatment for AKI in humans.
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Affiliation(s)
- Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Jonas Reis
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Pinar Sanli
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Herbert de Groot
- Institute of Physiological Chemistry, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Frank Petrat
- Institute of Physiological Chemistry, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Joel M Weinberg
- Department of Internal Medicine, Division of Nephrology, V.A. Ann Arbor Health System and University of Michigan, 1150 W. Medical Center Drive, 1560C MSRB II, Ann Arbor, MI, 48109-5676, USA
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Schittenhelmstr. 12, 24105, Kiel, Germany
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13
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Guberina H, Rebmann V, Wagner B, da Silva Nardi F, Dziallas P, Dolff S, Bienholz A, Wohlschlaeger J, Bankfalvi A, Heinemann FM, Witzke O, Zoet YM, Claas FHJ, Horn PA, Kribben A, Doxiadis IIN. Association of high HLA-E expression during acute cellular rejection and numbers of HLA class I leader peptide mismatches with reduced renal allograft survival. Immunobiology 2017; 222:536-543. [PMID: 27871782 DOI: 10.1016/j.imbio.2016.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 10/15/2016] [Indexed: 01/15/2023]
Abstract
Non-classical Human Leukocyte Antigen (HLA)-E preferentially presents leader peptides derived from classical HLA-class I molecules. HLA-E can trigger opposed immune responses by interacting with inhibitory NKG2A or by activating NKG2C receptors on NK and T-cells. We studied the impact of HLA-E on renal allograft survival during acute cellular rejection. HLA-E expression was up-regulated in acute cellular rejection (ACR) biopsies (n=12) compared to biopsies from 13 renal allografts with no rejection-signs. HLA-E up-regulation was correlated with numbers of HLA-class I leader peptide mismatches (p=0.04). CD8+ and CD56+ infiltrating cells correlated with HLA-E expression (p<0.0001 and p=0.0009, respectively). Activating NKG2C receptor dominated on effector cells in biopsies and peripheral blood during ACR potentially allowing HLA-E-mediated immune activation. Moreover, HLA-E expression correlated with deterioration in renal allograft function (p<0.008) and reduced allograft survival (p=0.002). Our findings provide evidence that during renal allograft rejection HLA-E along with high numbers of mismatched HLA-class I leader peptides might represent additional targets for immune-activating responses.
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Affiliation(s)
- Hana Guberina
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Vera Rebmann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Bettina Wagner
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fabiola da Silva Nardi
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany; CAPES Foundation, Ministry of Education of Brazil, Brasília, DF 70.040-020, Brazil
| | - Phillip Dziallas
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jeremias Wohlschlaeger
- Institute for Pathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Agnes Bankfalvi
- Institute for Pathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Falko M Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Yvonne M Zoet
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands, Netherlands
| | - Frans H J Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands, Netherlands
| | - Peter A Horn
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ilias I N Doxiadis
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands, Netherlands
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14
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Angeli P, Bezinover D, Biancofiore G, Bienholz A, Findlay J, Paugam Burtz C, Reyntjens K, Sakai T, Saner FH, Tomescu D, Wagener G, Weiss E. Acute kidney injury in liver transplant candidates: a position paper on behalf of the Liver Intensive Care Group of Europe. Minerva Anestesiol 2016; 83:88-101. [PMID: 27759741 DOI: 10.23736/s0375-9393.16.11661-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Acute kidney injury is associated with high mortality in the perioperative period of liver transplantation. The aim of this position paper was to provide an up-to-date overview with special emphases on diagnosis, risk factors, and treatment. EVIDENCE ACQUISITION The Liver Intensive Care Group of Europe nominated a panel of recognized international experts who reviewed the available literature published from 1990 to January 2016 and produced clinical recommendations. The level of evidence and strength of recommendation were judged according to the Grading of Recommendations Assessment Development and Evaluation system. EVIDENCE SYNTHESIS Diagnosis of AKI should be based on the KDIGO criteria. The preoperative risk factors are more related to the patient's predisposing factors and post-operative risk factors tend to be difficult to control. Therefore, focusing on intra-operative risk factors it would be important to maintain an adequate hemodynamics and to keep inferior vena cava clamping as short as possible. Biomarkers to identify AKI at an early stage are available; however, there is a lack of robust data that indicates their true beneficial effect. Intraoperative renal replacement therapy may be beneficial in some selective cases whereas its postoperative timing is still under debate. CONCLUSIONS Perioperative liver transplant risk factors for acute kidney injury are difficult to control. Therefore, the focus should be on intra-operative hemodynamics and nephrotoxic drugs avoidance. Prospective randomized trials are needed to show the beneficial effect of early replacement therapy. In this context, the new biomarkers would be helpful in identifying kidney injury earlier.
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Affiliation(s)
- Paolo Angeli
- Department of Medicine, Hepatology Unit, University School of Medicine, Padova, Italy
| | - Dimitri Bezinover
- Department of Anesthesiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria, Pisa, Italy
| | - Anja Bienholz
- Department of Nephrology, University Duisburg-Essen, Essen, Germany
| | - James Findlay
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Catherine Paugam Burtz
- Department of Anesthesia and Critical Care, APHP Hopital Beaujon, Clichy, France.,University Paris Diderot-Paris 7, Paris, France
| | - Koen Reyntjens
- Department of Anesthesia, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, University Duisburg-Essen, Essen, Germany -
| | - Dana Tomescu
- Department of Anesthesiology and Critical Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Gebhard Wagener
- Department of Anesthesiology, University of Columbia, New York, NY, USA
| | - Emmanuel Weiss
- Department of Anesthesia and Critical Care, APHP Hopital Beaujon, Clichy, France.,University Paris Diderot-Paris 7, Paris, France
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15
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Wilde B, Jiqiao Z, Dolff S, Bienholz A, Kribben A, Cohen Tervaert JW, Witzke O. SP052GRANZYME B PRODUCING B-CELLS HAVE IMMUNOREGULATORY FUNCTION AND ARE DIMINISHED IN PATIENTS WITH ANCA-VASCULITIS. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw157.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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16
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Bienholz A, Jahn M, Kribben A. [Acute kidney injury: update 2016]. Dtsch Med Wochenschr 2016; 141:482-5. [PMID: 27031202 DOI: 10.1055/s-0042-102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute kidney injury is still defined by the functional parameters diuresis and serum creatinine. New biomarkers can be sensible additions for the detection of pathogenesis and prognosis. Risk stratification is also very useful for identification of patients at risk for the development of acute kidney injury. This is of increased importance as usual therapeutic treatments are rare and long-term effects are devastating.
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17
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Becker S, Walter S, Witzke O, Körber A, Bienholz A, Kottmann T, Kribben A, Kaiser G, Mitchell A. Edema, Hyperpigmentation, Induration: 3 Skin Signs Heralding Danger in Patients on Maintenance Hemodialysis. Medicine (Baltimore) 2016; 95:e3121. [PMID: 27015187 PMCID: PMC4998382 DOI: 10.1097/md.0000000000003121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Skin changes are common in patients on dialysis. This study focused on putative associations of specific skin findings with comorbidities and mortality.We performed a retrospective analysis of data from 508 patients on maintenance hemodialysis therapy in 7 centers in the German State of North Rhine Westphalia. Data had been collected by interview, from patient files, and from targeted physical examination in an earlier prospective study screening hemodialysis patients for the presence of nephrogenic systemic fibrosis. While on dialysis, patients' extremities had been examined for any of the following: edematous skin at the lower extremities, hyperpigmentation, induration, and xerosis cutis. Our present data analyses focused on associated mortality and comorbidities.Five hundred eight patients (median age 71 years, range 20.0-95.9; n = 292 men) had agreed to participate in the initial study: 48% (n = 243) were diabetics and 46% (n = 232) had been diagnosed with coronary heart disease. On examination, 86% of patients (n = 439) presented with at least 1 of the prespecified skin changes. Skin edema (n = 89; 18%), hyperpigmentation (n = 74; 15%), and induration (n = 9; 2%) were independently associated with increased mortality over 24 months (P < 0.002, P < 0.030, and P < 0.020, respectively).In our study, prespecified skin changes indicated an increased mortality risk in patients on chronic hemodialysis. Routinely assessing the skin of dialysis patients represents a simple, reliable, and cost effective means of identifying those at greatest risk.
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Affiliation(s)
- Stefan Becker
- From the Departments of Nephrology (SB, SW, AB, AK, AM), Infectiology (OW), and Dermatology (AK), University Duisburg-Essen, Essen, Germany; Medical Statistics Hamm (TK), Hamm, Germany; and Department of General, Visceral and Transplantation Surgery (GK), University Duisburg-Essen, Essen, Germany
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18
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Bienholz A. Chronische Niereninsuffizienz: Vermindert eine schlechte Nierenfunktion das Hörvermögen? Dtsch Med Wochenschr 2015; 140:1648. [DOI: 10.1055/s-0041-106991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Anja Bienholz
- Klinik für Nephrologie, Universitätsklinikum Essen (AöR)
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19
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Bienholz A, Wilde B, Kribben A. From the nephrologist's point of view: diversity of causes and clinical features of acute kidney injury. Clin Kidney J 2015; 8:405-14. [PMID: 26251707 PMCID: PMC4515898 DOI: 10.1093/ckj/sfv043] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/19/2015] [Indexed: 12/19/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome with multiple entities. Although AKI implies renal damage, functional impairment or both, diagnosis is solely based on the functional parameters of serum creatinine and urine output. The latest definition was provided by the Kidney Disease Improving Global Outcomes (KDIGO) working group in 2012. Independent of the underlying disease, and even in the case of full recovery, AKI is associated with an increased morbidity and mortality. Awareness of the patient's individual risk profile and the diversity of causes and clinical features of AKI is pivotal for optimization of prophylaxes, diagnosis and therapy of each form of AKI. A differentiated and individualized approach is required to improve patient mortality, morbidity, long-term kidney function and eventually the quality of life. In this review, we provide an overview of the different clinical settings in which specific forms of AKI may occur and point out possible diagnostic as well as therapeutic approaches. Secifically AKI is discussed in the context of non-kidney organ failure, organ transplantation, sepsis, malignancy and autoimmune disease.
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Affiliation(s)
- Anja Bienholz
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Benjamin Wilde
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Andreas Kribben
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
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Abstract
Despite the advances in critical care medicine, the hospital mortality in patients with acute kidney injury (AKI) requiring dialysis remains high. Depending on the underlying disease the in-house mortality is reported to be up to 80%. Several observational studies demonstrated an association between mortality and fluid overload. A primary mechanism of interest is that fluid overload causes tissue edema and subsequent reduction of perfusion, oxygenation and nutrient delivery. This results in further renal damage. In addition, fluid overload-related dilution within the extracellular space causes artificially low serum creatinine, which masks AKI diagnosis. As a consequence, renal protective management strategies are deferred, which further aggravates kidney injury. This aggravation of renal damage subsequently increases the mortality. This review discusses the role of fluid overload for outcomes in critically ill patients as described in the current literature and assesses criteria for the initiation of renal replacement therapy in this critically ill population.
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Affiliation(s)
- Fuat H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen
| | | | | | | | - Thorsten Feldkamp
- Klinik für Nieren- und Hochdruckkrankheiten, Universitätsklinikum Kiel
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21
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Bienholz A, Canbay A, Saner FH. [Coagulation management in patients with liver disease]. Med Klin Intensivmed Notfmed 2015; 111:224-34. [PMID: 25939600 DOI: 10.1007/s00063-015-0027-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 01/19/2015] [Accepted: 02/18/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND End-stage liver disease is associated with complex alterations in hemostasis. Whereas prognosis is essentially affected by life-threatening bleeding complications in some patients, others, especially those with cholestatic liver diseases, suffer from thromboembolic complications. Standard laboratory values (SLVS; prothrombin time, activated partial thrombin time, platelet count) cannot sufficiently reflect the altered balance of pro- and anticoagulatory factors. Moreover, a couple of studies indicated that SLVS are not able to predict bleeding complications in patients with acute liver failure or decompensated liver cirrhosis. DIAGNOSIS AND THERAPY Use of bed-side coagulation diagnostics such as thrombelastometry/-graphy, detection of thrombocyte function by multiple electrode aggregometry and selective measurement of single factors allows a targeted and causal therapy of hepatic coagulopathies especially in the context of bleeding complications or surgical interventions. In recent years, coagulation management guided by these new devices has contributed to a reduction in transfusion of allogenic blood products, which may be associated with undesirable side effects. DISCUSSION The current review summarizes the complex pathophysiological alterations of hemostasis associated with advanced liver insufficiency and discusses recent upcoming diagnostics and coagulation management in this patient cohort.
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Affiliation(s)
- A Bienholz
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland. .,Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - A Canbay
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - F H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
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Eisenberger U, Farese S, Bergmann I, Bienholz A, Pasch A. FP883SERUM CALCIFICATION PROPENSITY IS ASSOCIATED WITH RENAL RESISTANCE INDEX AND MORTALITY AFTER RENAL TRANSPLANTATION. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv185.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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23
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Wilde B, Bienholz A, Witzke O, Kribben A. [Acute renal failure and vasculitis - when to consider it and what to do about it?]. Dtsch Med Wochenschr 2015; 140:256-60. [PMID: 25704521 DOI: 10.1055/s-0041-100519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Renal involvement in systemic autoimmune diseases such as ANCA-vasculitis is common. Acute kidney injury (AKI) limits the prognosis of the patient and needs to be detected early. However, AKI is in early phases clinically inapparent and at first contact with the patient, extra-renal symptoms may dominate the clinical presentation. Serum-Creatinine and urinary analysis provide useful information on the extent of renal involvement. A renal biopsy should confirm the diagnosis. Treatment needs to be adapted to the extent of ANCA-vasculitis and in cases with severe organ failure plasmapheresis should be performed. Maintenance immunosuppressive is necessary to prevent relapses and the patients should be monitored closely to detect renal flares early.
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Kribben A, Bienholz A, Becker S, Lütkes P, Feldkamp T. Akutes Nierenversagen. Dtsch Med Wochenschr 2014; 139:2010-2. [DOI: 10.1055/s-0034-1387307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A. Kribben
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen
| | - A. Bienholz
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen
| | - S. Becker
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen
| | - P. Lütkes
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen
| | - T. Feldkamp
- Klinik für Innere Medizin IV, Nieren- und Hochdruckkrankheiten, Universitätsklinikum Schleswig-Holstein, Christian-Albrechts-Universität Kiel
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Bienholz A, Al-Taweel A, Roeser NF, Kribben A, Feldkamp T, Weinberg JM. Substrate modulation of fatty acid effects on energization and respiration of kidney proximal tubules during hypoxia/reoxygenation. PLoS One 2014; 9:e94584. [PMID: 24728405 PMCID: PMC3984175 DOI: 10.1371/journal.pone.0094584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/17/2014] [Indexed: 12/03/2022] Open
Abstract
Kidney proximal tubules subjected to hypoxia/reoxygenation develop a nonesterified fatty acid-induced energetic deficit characterized by persistent partial mitochondrial deenergization that can be prevented and reversed by citric acid cycle substrates. To further assess the role of competition between fatty acids and substrates on inner membrane substrate carriers in the deenergization and the contribution to deenergization of fatty acid effects on respiratory function, digitonin-permeabilized rabbit and mouse tubules were studied using either addition of exogenous oleate after control normoxic incubation or increases of endogenous fatty acids produced by hypoxia/reoxygenation. The results demonstrated major effects of matrix oxaloacetate accumulation on succinate-supported energization and respiration and their modification by fatty acids. Improvements of energization in the presence of fatty acids by glutamate were shown to result predominantly from lowering matrix oxaloacetate rather than from amelioration of transmembrane cycling of fatty acids and uncoupling. Mouse tubules had 2.5 fold higher rates of succinate utilization, which resulted in stronger effects of oxaloacetate accumulation than rabbit tubules. Hypoxia/reoxygenation induced respiratory inhibition that was more severe for complex I-dependent substrates. Fatty acids themselves did not acutely contribute to this respiratory inhibition, but lowering them during 60 min. reoxygenation to allow recovery of ATP during that period alleviated it. These data clarify the basis for the nonesterified fatty acid-induced mitochondrial energetic deficit in kidney proximal tubules that impairs structural and functional recovery and provide insight into interactions that need to be considered in the design of substrate-based interventions to improve mitochondrial function.
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Affiliation(s)
- Anja Bienholz
- Division of Nephrology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Nephrology, Department of Internal Medicine, University Duisburg-Essen, Essen, Germany
| | - Ahmad Al-Taweel
- Division of Nephrology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, United States of America
| | - Nancy F. Roeser
- Division of Nephrology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, United States of America
| | - Andreas Kribben
- Division of Nephrology, Department of Internal Medicine, University Duisburg-Essen, Essen, Germany
| | - Thorsten Feldkamp
- Division of Nephrology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Nephrology, Department of Internal Medicine, University Duisburg-Essen, Essen, Germany
- Division of Nephrology and Hypertension, Department of Internal Medicine, Christian-Albrechts-University, Kiel, Germany
| | - Joel M. Weinberg
- Division of Nephrology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
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26
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Affiliation(s)
- A Bienholz
- Klinik für Nephrologie, Universität Duisburg-Essen, Universitätsklinikum Essen
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Bienholz A, Petrat F, Wenzel P, Ickerott P, Weinberg JM, Witzke O, Kribben A, de Groot H, Feldkamp T. Adverse effects of α-ketoglutarate/malate in a rat model of acute kidney injury. Am J Physiol Renal Physiol 2012; 303:F56-63. [PMID: 22513847 PMCID: PMC3431145 DOI: 10.1152/ajprenal.00070.2012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 04/11/2012] [Indexed: 01/22/2023] Open
Abstract
Acute kidney injury (AKI) is the most common kidney disease in hospitalized patients with high mortality. Ischemia and reperfusion (I/R) is one of the major causes of AKI. The combination of α-ketoglutarate+malate (αKG/MAL) showed the ability to reduce hypoxia-induced damage to isolated proximal tubules. The present study utilizes a rat model of I/R-induced AKI accompanied by intensive biomonitoring to examine whether αKG/MAL provides protection in vivo. AKI was induced in male Sprague-Dawley rats by bilateral renal clamping (40 min) followed by reperfusion (240 min). αKG/MAL was infused continuously for 60 min before and 45 min after ischemia. Normoxic and I/R control groups received 0.9% NaCl solution. The effect of αKG/MAL was evaluated by biomonitoring, blood and plasma parameters, histopathology, and immunohistochemical staining for kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL), as well as by determination of tissue ATP and nonesterified fatty acid concentrations. Intravenous infusion of αKG/MAL at a cumulative dose of 1 mmol/kg each (146 mg/kg αKG and 134 mg/kg MAL) did not prevent I/R-induced increases in plasma creatinine, histopathological alterations, or cortical ATP depletion. On the contrary, the most notable adverse affect in animals receiving αKG/MAL was the decrease in mean arterial blood pressure, which was also accompanied by a reduction in heart rate. Supplementation with αKG/MAL, which is very protective against hypoxia-induced injury in isolated proximal tubules, does not protect against I/R-induced renal injury in vivo, possibly due to cardiovascular depressive effects.
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Affiliation(s)
- Anja Bienholz
- Department of Nephrology, University Duisburg-Essen, Germany.
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Kaynar K, Kaynar K, Ersoz S, Aliyazioglu R, Uzun A, Ulusoy S, Al S, Ozkan G, Cansiz M, Bertocchio JP, Lancon J, El Moghrabi S, Galmiche G, Duong Van Huyen JP, Rieu P, Jaisser F, Albertoni G, Andrade S, Barreto JA, Borges F, Schor N, Ho WY, Chen SH, Tseng CJ, Bienholz A, Feldkamp T, Weinberg JM, Suller Garcia J, Naves M, Borges F, Schor N, Borges F, Aparecida Reis L, Simoes MDJ, Schor N, S Almeida W, Moreau Longo V, Segreto HRC, Schor N, Ghoneim A, Elkholy A, Medhat Abbas T, El Hadeedy M, Elhusseini F, Elessawey B, Eltanaihy E, Lotfy A, Eldesoky S, Sheashaa H, Sobh M, Minning DM, Warnock D, Mohamed AS, Wirthlin JB, Chintalacharuvu SR, Boone L, Brenner RM, Borges F, Aparecida Reis L, Simoes MDJ, Schor N, Santina Christo J, Dos Santos Passos C, Aparecida Reis L, Rene de Alencar D, Suller Garcia J, Schor N, De Braganca AC, Canale D, Goncalves JG, Brandao TPB, Shimizu MHM, Volpini RA, Seguro AC, Andrade L, Canale D, De Braganca AC, Goncalves JG, Brandao TPB, Shimizu MHM, Volpini RA, Andrade L, Seguro AC, Lee JW, Kim HK, Cho WY, Jo SK, Cho E, Hocherl K, Schmidt C, Mulay SR, Kulkarni OP, Rupanagudi KV, Migliorini A, Liapis H, Anders HJ, Pevzner I, Chupyrkina A, Plotnikov E, Zorov D, Lopez-Novoa JM, Eleno N, Perez-Barriocanal F, Arevalo M, Docherty N, Castellano G, Divella C, Loverre A, Stasi A, Curci C, Rossini M, Ditonno P, Battaglia M, Daha MR, Van Kooten C, Gesualdo L, Schena FP, Grandaliano G, Tsuda H, Kawada N, Iwatani H, Moriyama T, Takahara S, Rakugi H, Isaka Y, Schley G, Kalucka J, Klanke B, Jantsch J, Olbrich S, Baumgartl J, Amann K, Eckardt KU, Weidemann A, Dolgolikova A, Pilotovich V, Ivanchik G, Shved I, Banki NF, Antal Z, Hosszu A, Koszegi S, Vannay A, Wagner L, Prokai A, Muller V, Szabo AJ, Fekete A, Farrag S, Abulasrar S, Salama ,M, Amin M, Ali A, Sheashaa H, Sobh M, Rubera I, Duranton C, Cougnon M, Melis N, Tauc M, Plotnikov E, Zorov D, Chupyrkina A, Jankauskas S, Morosanova M, Pevzner I, Pulkina N, Zorova L, Shin YT, Kim SS, Chang YK, Choi DE, Na KR, Lee KW, Choi JY, Jin DC, Cha JH, Schneider R, Betz B, Meusel M, Held C, Wanner C, Gekle M, Sauvant C, Pisani A, Rossano R, Mancini A, Arfian N, Yagi K, Nakayama K, Ali H, Mayasari DS, Purnomo E, Emoto N, Efrati S, Berman S, Abu Hamad R, Weissgarten J, Scherbaum CR, Allam R, Lichtnekert J, Darisipudi MN, Hagele H, Mulay SR, Rupanagudi KV, Hohenstein B, Hugo C, Schaefer L, Anders HJ, Corsi C, Ferramosca E, Grandi E, Pisoni L, Rivolta I, Dalpozzo B, Hoxha E, Severi S, Santoro A, Laurent M, Cedric R, Dominique C, Sophie V, Nochy D, Loic G, Patrice C, Chantal J, Marie-Christine V, Alexandre H, Eric R, Cantaluppi V, Medica D, Quercia AD, Figliolini F, Dellepiane S, Randone O, Segoloni GP, Camussi G, Shin YT, Choi DE, Na KR, Chang YK, Kim SS, Ahn BH, Kim SH, Lee KW, Yasue Saito Miyagi M, Camara N, Cerqueira Leite Seelaender M, Maceratesi Enjiu L, Estler Rocha Guilherme P, Pisciottano M, Hiyane M, Yuri Hayashida C, De Andrade Oliveira V, Olsen Saraiva Camara N, Tami Amano M, Sancho-Martinez SM, Sanchez-Juanes F, Vicente L, Gonzalez-Buitrago JM, Morales AI, Lopez-Novoa JM, Lopez-Hernandez FJ, Chen JS, Chang LC, Chen CC, Park MY, Choi SJ, Kim JG, Hwang SD, Vicente-Vicente L, Ferreira L, Prieto M, Garcia-Sanchez O, Sevilla MA, Lopez-Hernandez FJ, Lopez-Novoa JM, Morales AI, Vicente-Vicente L, Ferreira L, Gonzalez-Buitrago JM, Lopez-Novoa FJ, Lopez-Novoa JM, Morales AI, Christoph K, Kuper C, Maria-Luisa F, Franz-Xaver B, Neuhofer W, Vervaet B, Le Clef N, Verhulst A, D'haese P, Tanaka T, Yamaguchi J, Eto N, Kojima I, Fujita T, Nangaku M, Wystrychowski A, Wystrychowski G, Obuchowicz E, Grzeszczak W, Wiecek A, Esposito C, Torreggiani M, Castoldi F, Migotto C, Serpieri N, Grosjean F, Manini A, Pertile E, Dal Canton A. AKI - Experimental. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- A Bienholz
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Feldkamp T, Bienholz A, Kribben A. Urinary neutrophil gelatinase-associated lipocalin (NGAL) for the detection of acute kidney injury after orthotopic liver transplantation. Nephrol Dial Transplant 2011; 26:1456-8. [PMID: 21486868 DOI: 10.1093/ndt/gfr146] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abstract
New guidelines of the "Kidney Disease: Improving Global Outcome" (KDIGO) working group standardize the definition of acute kidney injury (AKI) and acute kidney disease (AKD) allowing the assessment of prognosis and efficacy of prophylactic and therapeutic measures in different patient cohorts. The degree of severity and the duration of acute kidney injury are critical factors for the development of chronic kidney disease and mortality. The achievement of optimal fluid volumes is a cornerstone in the treatment during the early phase of AKI, while volume overload should be avoided in the late phase of established AKI. Recently employed biomarkers are promising for the early detection and prognosis of AKI, but cannot yet be used as routine tests. Microscopic urinalysis, a very old and cost-effective diagnostic measure, provides valuable informations about the severity and the course of AKI.
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Affiliation(s)
- T Feldkamp
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, 45122 Essen.
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