Review on Kidney-Liver Crosstalk: Pathophysiology of Their Disorders

Kidney-liver crosstalk plays a crucial role in normal and certain pathological conditions. In pathologic states, both renal-induced liver damage and liver-induced kidney diseases may happen through these kidney-liver interactions. This bidirectional crosstalk takes place through the systemic conditions that mutually influence both the liver and kidneys. Ischemia and reperfusion, cytokine release and pro-inflammatory signaling pathways, metabolic acidosis, oxidative stress, and altered enzyme activity and metabolic pathways establish the base of this interaction between the kidneys and liver. In these concomitant kidney-liver diseases, the survival rates strongly correlate with early intervention and treatment of organ dysfunction. Proper care of a nephrologist and hepatologist and the identification of pathological conditions using biomarkers at early stages are necessary to prevent the complications induced by this complex and potentially vicious cycle. Therefore, understanding the characteristics of this crosstalk is essential for better management. In this review, we discussed the available literature concerning the detrimental effects of kidney failure on liver functions and liver-induced kidney diseases.

Patients With Acute-on-Chronic Liver Failure Have Greater Healthcare Resource Utilization After Liver Transplantation

BACKGROUND & AIMS

Although liver transplantation (LT) has been demonstrated to provide survival benefit for patients with acute-on-chronic liver failure (ACLF), data are lacking regarding resource utilization for this population after LT.

METHODS

We retrospectively reviewed data from 10 centers in North America of patients transplanted between 2018 and 2019. ACLF was identified by using the European Association for the Study of the Liver-Chronic Liver Failure criteria.

RESULTS

We studied 318 patients of whom 106 patients (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Healthcare resource utilization after LT was greater among recipients with ACLF compared with patients without ACLF regarding median post-LT length of hospital stay (LOS) (P < .001), length of post-LT dialysis (P < .001), discharge to a rehabilitation center (P < .001), and 30-day readmission rates (P = .042). Multivariable negative binomial regression analysis demonstrated a significantly longer LOS for patients with ACLF-1 (1.9 days; 95% confidence interval [CI], 0.82-7.51), ACLF-2 (6.7 days; 95% CI, 2.5-24.3), and ACLF-3 (19.3 days; 95% CI, 1.2-39.7), compared with recipients without ACLF. Presence of ACLF-3 at LT was also associated with longer length of dialysis after LT (9.7 days; 95% CI, 4.6-48.8) relative to lower grades. Multivariable logistic regression analysis revealed greater likelihood of discharge to a rehabilitation center among recipients with ACLF-1 (odds ratio [OR], 1.79; 95% CI, 1.09-4.54), ACLF-2 (OR, 2.23; 95% CI, 1.12-5.01), and ACLF-3 (OR, 2.23; 95% CI, 1.40-5.73). Development of bacterial infection after LT also predicted LOS (20.9 days; 95% CI, 6.1-38.5) and 30-day readmissions (OR, 1.39; 95% CI, 1.17-2.25).

CONCLUSIONS

Patients with ACLF at LT, particularly ACLF-3, have greater post-transplant healthcare resource utilization.

Causes of chronic kidney disease in the general population of Iran: A systematic review and meta-analysis

Chronic kidney disease is a significant public health problem worldwide. However, the causes of chronic kidney disease in Iran are unclear. This systematic review and meta-analysis identified the causes of chronic kidney disease in the general population of Iran. International databases (PubMed, Web of Science, Scopus, and Google Scholar) and national databases (Scientific Information Database and Magiran) were searched for studies published until March 1, 2018. The quality of the studies was assessed using the checklist developed by Hoy et al. Of 2518 retrieved studies, 26 studies involving 34,683 patients with chronic kidney disease stages 1 to 5 were included in the meta-analysis. The mean age of the cohort was 53.6±15.02 years. The results of the random-effects model showed that the three leading causes of chronic kidney disease were diabetes, hypertension, and glomerulonephritis, with an overall prevalence of 27.7%, 27.6%, and 6.4%, respectively. These results indicate the importance of addressing these risk factors at the national level to reduce disease prevalence.

Rapid Development of Diffuse Myocardial Calcification in a Patient after Recovery from Sepsis and Renal Failure: A Case Report

Myocardial calcification can develop owing to several conditions. It is a rare complication following sepsis and renal failure. We report a case of rapid development of left ventricular mid-wall calcification observed using CT and cardiac MRI in a patient after recovery from sepsis and acute renal failure.

Special Considerations for Supportive Care and Management of Complications in Elderly Patients With Multiple Myeloma

Multiple myeloma is a progressive and incurable hematologic malignancy. It is predominantly a disease of older individuals, with a third of these patients considered to be elderly. In recent years, there has been a focus and emphasis on identifying and stratifying patients based on their functional status and frailty. There are several hallmark complications of the disease-hypercalcemia, renal insufficiency, anemia, bone pain-along with thromboembolism and compromised immunity that are common in patients with multiple myeloma. Due to the wide range of patient ages and functional status, there are, accordingly, different considerations for management of the above complications based on numerous factors, including frailty status. This review focuses on considerations and management of common complications of multiple myeloma in elderly patients. These include renal failure, skeletal complications, anemia, thromboembolism, and infectious complications.

Severe Leptospirosis in a Mexican Woman

OBJECTIVE

To describe a severe case of infection by Leptospira in a woman in the northwest of Mexico.

CASE REPORT

A 55-yearold woman from Sonora, México arrived at the Intensive Care Unit due to severe multiple organ failure primarily affecting the respiratory, renal and hepatic systems. Diagnostic tests were performed, and they were positive for anti-Leptospira antibodies, IgM and IgG; and spirochetes were observed on dark field microscopy and confirmed by Polymerase Chain Reaction (PCR). Doxycycline and platelet apheresis transfusion were used as treatment, which led to a very slow recovery.

CONCLUSION

The information presented in this study may help in the identification of pathology caused by spirochetes. This case report is the first to present a case of severe leptospirosis in Sonora, México.

AL type cardiac amyloidosis: a devastating fatal disease

Introduction

Cardiac amyloidosis is a rare entity with a grave prognosis. Due to the low index of suspicion secondary to non-specific symptoms, it is often diagnosed at an advanced stage with multi-organ involvement.

Methods

We report a case of systemic AL amyloidosis with predominant cardiac and renal involvement associated with multiple myeloma.

Case Summary

A 60-year-old male presented with progressive anasarca, orthopnea and weight gain over 8 months. On clinical examination, 3+ pitting edema was found in bilateral extremities and scrotum. Serum N-type proBNP and troponin T were elevated, and EKG showed diffuse low voltage QRS, right axis deviation, and 1^st degree AV block. Echocardiography revealed granular myocardium, biventricular hypertrophy, bi-atrial dilation and apical sparing pattern on global longitudinal strain which was suggestive of cardiac amyloidosis. Light chain assessment showed elevated kappa and lambda chains with kappa to lambda ratio of 16.2. Endomyocardial biopsy revealed AL type cardiac amyloidosis, and bone marrow biopsy confirmed the diagnosis of multiple myeloma. He received six cycles of bortezomib, cyclophosphamide, and dexamethasone but continued to deteriorate. He experienced an episode of cardiac arrest following which he had a return of spontaneous circulation but due to poor prognosis, the family opted for pursuing comfort measures only.

Conclusions

Cardiac involvement in AL type amyloidosis imparts significant morbidity and mortality. The management of cardiac amyloidosis entails a multidisciplinary approach with an emphasis on cardiology and oncology. Despite the novel diagnostic modalities and treatment regimens, the outcome for AL-type cardiac amyloidosis remains poor.

Evaluating the Effect of Acetazolamide on the Prevention of Post-operative Acute Kidney Injury after Coronary Artery Bypass Grafting Surgery: A Randomized, Open-labeled Clinical Trial

Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) surgery and can be linked to the increased morbidity and mortality. Therefore, in the present study, the effect of preoperative administration of acetazolamide was evaluated to investigate whether it could prevent occurrence of post-operative AKI after CABG surgery. In this randomized controlled clinical trial, 130 patients who were candidates to undergo elective CABG surgery from January 21, 2020 to February 8, 2021 were randomly allocated to intervention group (receiving 500 mg of acetazolamide orally 2 h preoperatively) and control group. The patients were evaluated for AKI based on the kidney disease- improving global outcomes (KDIGO) criteria based on their serum creatinine (SCr) level and urine output until 7 days postoperatively. There was no significant difference in baseline demographics between the two groups. The total incidence of AKI was measured as 43%. Analysis of post-operative AKI incidence showed no statistically significant difference between the two groups (P = 0.860). Mean post-operative SCr level on day 1 was significantly higher in the acetazolamide group (P = 0.036). A significant difference was found in length of hospitalization stay between the groups, which was higher in the control group (P = 0.006). Our results did not demonstrate a significant protective effect of acetazolamide on incidence of post-operative AKI in the patients undergone elective on-pump CABG surgery.

Acute Kidney Injuries in Children with Severe Malaria: A comparative study of diagnostic criteria based on serum cystatin C and creatinine levels

Objectives

Serum creatinine levels are often used to diagnose acute kidney injury (AKI), but may not necessarily accurately reflect changes in glomerular filtration rate (GFR). This study aimed to compare the prevalence of AKI in children with severe malaria using diagnostic criteria based on creatinine values in contrast to cystatin C.

Methods

This prospective cross-sectional study was performed between June 2016 and May 2017 at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. A total of 170 children aged 0.5–14 years old with severe malaria were included. Serum cystatin C levels were determined using a particle-enhanced immunoturbidmetric assay method, while creatinine levels were measured using the Jaffe reaction. Renal function assessed using cystatin C-derived estimated GFR (eGFR) was compared to that measured using three sets of criteria based on creatinine values including the Kidney Disease: Improved Global Outcomes (KDIGO) and World Health Organization (WHO) criteria as well as an absolute creatinine cut-off value of >1.5 mg/dL.

Results

Mean serum cystatin C and creatinine levels were 1.77 ± 1.37 mg/L and 1.23 ± 1.80 mg/dL, respectively (P = 0.002). According to the KDIGO, WHO and absolute creatinine criteria, the frequency of AKI was 32.4%, 7.6% and 16.5%, respectively. In contrast, the incidence of AKI based on cystatin C-derived eGFR was 51.8%. Overall, the rate of detection of AKI was significantly higher using cystatin C compared to the KDIGO, WHO and absolute creatinine criteria (P = 0.003, <0.001 and <0.001, respectively).

Conclusion

Diagnostic criteria for AKI based on creatinine values may not indicate the actual burden of disease in children with severe malaria.

Conservative management of bladder endometriosis with acute renal failure

Endometriosis involving the bladder is rare, but generally has a severe presentation with prominent lower urinary tract symptoms and can progress to renal failure. As endometriosis has a significant effect on quality of life and fertility, treatment plans must be centered on the patient's symptoms, expectations, and priorities. We present a case of a 37-year-old African American female with advanced bladder endometriosis and consequent renal failure, who desired to avoid extensive surgery and maintain her fertility. This case highlights the importance of shared decision making in balancing disease management with patient autonomy.

The Treatment of Metabolic Acidosis: An Interactive Case-Based Learning Activity

Introduction

Metabolic acidosis is a dangerous and potentially life-threatening condition encountered in the inpatient and emergency department setting. Metabolic acidoses due to renal failure, bicarbonate losses, or lactic acidosis are common conditions, and the appropriate medical management of each is relevant to any inpatient medical provider. Therefore, we created a learning activity that utilizes blackboard-style videos followed by an interactive case-based learning session to help the medical student recognize, diagnose, and manage common causes of metabolic acidosis.

Methods

We organized this learning activity by assigning digital videos, followed by application in an interactive team-based format. We created electronic blackboard-style videos and a quiz to assess medical knowledge related to concepts discussed in the videos. Next, we created case resources that facilitate an interactive case-based teaching session so the learners could apply their knowledge and simulate the management of metabolic acidosis.

Results

We implemented this activity for 34 medical students. All students viewed the videos prior to the in-class session. In a pre/post assessment of medical knowledge, we observed a significant improvement in quiz scores. Next, we successfully facilitated the case-based active learning session, allowing the assessment of higher-order cognitive skills related to management of patients with metabolic acidosis. Our medical students felt highly satisfied and competent at the completion of our course.

Discussion

Our medical students rated this as an excellent learning activity. Others may find this activity useful within the context of any course or rotation related to patients with metabolic acidosis.

The Role of Qutenza® (Topical Capsaicin 8%) in Treating Neuropathic Pain from Critical Ischemia in Patients with End-Stage Renal Disease: An Observational Cohort Study

Objective

Current treatment strategies for painful critical ischemia in patients with end-stage renal disease (ESRD) are suboptimal. A drug that is non-renally excreted has minimal systemic absorption and does not require dose adjustment in renal failure is attractive. The aim of this study was to evaluate the safety and efficacy of Qutenza® (topical capsaicin 8%) for chronic neuropathic pain from critical ischemia in patients with ESRD.

Design and Setting

A prospective cohort study was conducted in a single-center, university teaching hospital.

Patients

Twenty patients with ESRD were treated with Qutenza® for neuropathic pain from critical limb ischemia.

Methods

Patients were followed-up at 1, 6 and 12 weeks post-treatment. The primary end point was the difference in visual analog scale (VAS) between baseline and week 12. Secondary end points were Brief Pain Inventory questionnaire (BPI) scores, quality of life assessment (EQ-5D) and patient global impression of change (PGIC). Safety and tolerability data were also collected. The trial was prospectively registered with clinical trials databases (EudraCT: 2012-001586-32; NCT01704313).

Results

There was significant reduction in VAS from baseline to week 12 (-20+/-7%; P = 0.02). There was a significant reduction in all seven domains of the BPI. Quality of life also improved at 12 weeks following treatment in two of the EQ-5D domains (mobility and pain). Qutenza® was well tolerated with no significant side effects in this patient cohort, which included 20% diabetics.

Conclusions

In this small, observational study Qutenza® treatment has been shown to be effective and well-tolerated to treat neuropathic pain from critical ischemia in patients with ESRD.

Information Technology and Acute Kidney Injury: Alerts, Alarms, Bells, and Whistles

The goal of this review is to describe the rationale for alerting systems for acute kidney injury, the challenges associated with alert implementation, and the efficacy (or lack thereof) of acute kidney injury alerts to date.

Delayed Diagnosis of Falciparum Malaria with Acute Kidney Injury

Prompt malaria diagnosis is crucial so antimalarial drugs and supportive care can then be rapidly initiated. A 15-year-old boy who had traveled to Africa (South Africa, Kenya, and Nigeria between January 3 and 25, 2011) presented with fever persisting over 5 days, headache, diarrhea, and dysuria, approximately 17 days after his return from the journey. Urinalysis showed pyuria and hematuria. Blood examination showed hemolytic anemia, thrombocytopenia, disseminated intravascular coagulation, and hyperbilirubinemia. Plasmapheresis and hemodialysis were performed for 19 hospital days. Falciparum malaria was then confirmed by peripheral blood smear, and antimalarial medications were initiated. The patient's condition and laboratory results were quickly normalized. We report a case of severe acute renal failure associated with delayed diagnosis of falciparum malaria, and primary use of supportive treatment rather than antimalarial medicine. The present case suggests that early diagnosis and treatment is important because untreated tropical malaria can be associated with severe acute renal failure and fatality. Physicians must be alert for correct diagnosis and proper management of imported tropical malaria when patients have travel history of endemic areas.

The protective effect of Nigella sativa against cisplatin-induced nephrotoxicity in rats

OBJECTIVE

The clinical use of cisplatin is highly restricted, because of its nephrotoxicity. In this study the protective effect of Nigella sativa (N. sativa) against cisplatin-induced nephrotoxicity was investigated in rats.

MATERIALS AND METHODS

In the current study, the effects of the administration of aqueous-ethanolic extract of N. sativa (100 and 200 mg/kg, BW) and vitamin E (100 mg/kg, BW) against blood and urine biochemical alterations and kidney function in rats treated with cisplatin were investigated. Cisplatin was injected at a dose of 6 mg/kg, BW, on the sixth day of the experiment.

RESULTS

The results indicated significant changes in serum urea and creatinine concentration, urine glucose concentration, and urine output in cisplatin group compared with control group. Serum urea and creatinine concentration in preventive and preventive+treatment vitamin E and preventive+treatment N. sativa (200 mg/kg, BW) groups and also serum creatinine concentration in preventive+treatment N. sativa (100 mg/kg, BW) group significantly decreased compared with cisplatin group. Urine glucose concentration in preventive and preventive+treatment N. sativa groups and urine output in preventive and preventive+treatment N. sativa (200 mg/kg, BW) groups significantly decreased compared with cisplatin group.Osmolarity excretion rate in preventive and preventive+treatment vitamin E and preventive N. sativa groups was significantly higher than control group.

CONCLUSIONS

The current study suggests that N. sativa extract and vitamin E in a dose- and time-dependent manner improved the serum and urine biochemical parameters and kidney function in cisplatin-induced nephrotoxicity in rats. However, it needs more investigations to determine the mechanism of N. sativa action on cisplatin-induced kidney toxicity.

Shock duration after resuscitation is associated with occurrence of post-cardiac arrest acute kidney injury

This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.

A rapidly fatal sepsis caused by listeria monocytogenes type-4b in a patient with chronic renal failure

INTRODUCTION

Listeria monocytogenes is a significant zoonosis causing invasive infections in the susceptible persons. The current paper presented a patient who died due to a rapidly-progressing multiple organ failure (MOF) as a result of severe sepsis caused by L. monocytogenes.

CASE PRESENTATION

A 70-years-old patient with chronic renal failure was admitted to the infectious diseases clinic due to diarrhea for one day. He was hospitalized and the body fluid samples were collected for laboratory analyses. Within few hours, his vital findings worsened, and he developed respiratory arrest. Ceftriaxone and gentamycin were administrated. However, he died due to disseminated intravascular coagulation, septic shock and meningoencephalitis at the 22nd hour of admission. Causative agent was identified as L. monocytogenes serotype-4b in post-mortem period.

DISCUSSION

L. monocytogenes can cause progressive and rapidly fatal infections in the vulnerable persons, with multisystem involvement. Since this bacterium is not susceptible to cephalosporines, it will be better to consider effective antimicrobials in the treatment of the possible cases.

A study of the efficacy of furosemide as a prophylaxis of acute renal failure in coronary artery bypass grafting patients: A clinical trial

BACKGROUND

Renal failure is a frequent event after coronary artery bypass grafting (CABG). Hemodynamic alterations during surgery as well as the underlying disease are the predisposing factors. We aimed to study intermittent furosemide therapy in the prevention of renal failure in patients undergoing CABG.

METHODS

In a single-blind randomized controlled trial, 123 elective CABG patients, 18-75 years, entered the study. Clearance of creatinine, urea and water were measured. Patients were randomly assigned into three groups: furosemide in prime (0.3-0.4 mg/kg); intermittent furosemide during CABG (0.2 mg/kg, if there was a decrease in urinary excretion) and control (no furosemide).

RESULTS

There was a significant change in serum urea, sodium and fluid balance in "intermittent furosemide" group; other variables did not change significantly before or after the operation. Post-operative fluid balance was significantly higher in "intermittent furosemide" group (2573 ± 205 ml) compared to control (1574.0 ± 155.0 ml) (P < 0.010); also, fluid balance was higher in "intermittent furosemide" group (2573 ± 205 ml) compared to "furosemide in prime" group (1935.0 ± 169.00 ml) (P < 0.010).

CONCLUSION

The study demonstrated no benefit from intermittent furosemide in elective CABG compared to furosemide in prime volume or even placebo.

Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010

BACKGROUND & AIMS

It is not clear whether evidence-based recommendations for inpatient care of patients with cirrhosis are implemented widely or are effective in the community. We investigated changes in inpatient outcomes and associated features over time.

METHODS

By using the Healthcare Cost and Utilization Project, National Inpatient Sample, we analyzed 781,515 hospitalizations of patients with cirrhosis from 2002 through 2010. We compared data with those from equal numbers of hospitalizations of patients without cirrhosis and patients with congestive heart failure (CHF), matched for age, sex, and year of discharge. The primary outcome was a change in discharge status over time. Factors associated with outcomes were analyzed by Poisson modeling.

RESULTS

The mortality of patients with and without cirrhosis, and patients with CHF, decreased over time. The absolute decrease was significantly greater for patients with cirrhosis (from 9.1% to 5.4%) than for patients without cirrhosis (from 2.6% to 2.1%) or patients with CHF (from 2.5% to 1.4%) (P < .01). However, relative decreases were similar for patients with cirrhosis (41%) and patients with CHF (44%). For patients with cirrhosis, the independent mortality risk ratio decreased steadily to 0.50 by 2010 (95% confidence interval, 0.48-0.52), despite patients' increasing age and comorbidities. Hepatorenal syndrome, hepatocellular carcinoma, variceal bleeding, and spontaneous bacterial peritonitis were associated with a higher mortality rate, but the independent mortality risks for each decreased steadily. Sepsis was associated strongly with increased mortality, and the risk increased over time.

CONCLUSIONS

Among patients with cirrhosis in the United States, inpatient mortality decreased steadily from 2002 through 2010, despite increases in patient age and medical complexity. Improvements in cirrhosis care may have contributed to increases in patient survival beyond those attributable to general improvements in inpatient care. Further improvements might require an increased use of proven therapies and the development of new treatments-particularly for sepsis.

The effect of selenium supplementation on acute phase reactants and thyroid function tests in hemodialysis patients

BACKGROUND

Selenium deficiency is a common problem in patients with chronic kidney disease (CKD). This micronutrient has anti-inflammatory and anti-oxidant effects. Selenium is also found in high concentrations in the thyroid gland.

OBJECTIVES

To determine the effect of selenium supplementation on thyroid function tests and acute phase reactants in hemodialysis patients.

PATIENTS AND METHODS

In this double-blinded randomized clinical in 3 months, 64 hemodialysis patients with selenium deficiency were divided into experimental (received selenium supplementation; 32 cases) or control group (received placebo; 32 cases). Erythrocyte sedimentation rate (ESR), ferritin, quantitative C-reactive protein (CRP) and thyroid function tests (TFTs) including thyroid stimulating hormone (TSH), T3 resin uptake (T3RU), and free T4 were measured before and after the intervention and compared between experimental and control groups.

RESULTS

At baseline, no significant difference was found between experimental and control groups regarding CRP, ESR and ferritin serum levels. Likewise, after intervention, no significant difference was found between experimental and control groups for CRP (14.77 ± 17.93 vs. 18.29 ± 21.56 mg/L), ESR (32.90 ± 32.62 vs. 33.91 ± 31.15 mm/h) and ferritin (528.6 ± 423.07 vs. 519.52 ± 345.59 ng/mL). At baseline, no significant difference was found between experimental and control groups regarding TFTs. Likewise, after intervention, no significant difference was found between experimental and control groups for TSH (3.7 ± 2.22 vs. 2.84 ± 1.88 µU/mL), free T4 (7.19 ± 1.98 vs. 7.02 ± 1.87 µg/dL) and T3RU (30.04 ± 2.28% vs. 29.2 ± 1.98%).

CONCLUSIONS

Oral selenium supplementation for three months did not have any significant effect on thyroid function tests or acute phase reactants.

Vitamin B12 supplementation in end stage renal diseases: a systematic review

BACKGROUND

Hyperhomocysteinemia is a risk factor for cardiovascular disease particularly in patients with end stage renal disease (ESRD). Vitamin B12 supplementation on its own still remains as a controversial issue for clinicians in decreasing the level of homcysteine in this group of patients.

METHODS

Using all randomized controlled trials (RCTs), clinical trials and pre-post-trial studies found during January 1999 to March 2014, we conducted a systematic review which assessed the effects of vitamin B12 in decreasing homocysteine levels in patients with ESRD.

RESULTS

The findings of this study revealed that, overall, the greatest effect of B12 supplementation on decreasing homocysteine levels in patients with ESRDs occurred when it was combined with folate supplementation. It was also demonstrated that injection treatments might be more beneficial than oral intake treatments.

CONCLUSION

More rigorous studies are needed to draw a firm conclusion about B12 therapy and the level of homocyteine in patients with ESRD.

Importance of neutrophil gelatinase-associated lipocalin in differential diagnosis of acute and chronic renal failure

Background:

Neutrophil Gelatinase-associated Lipocalin (NGAL) protein is easily detected in the blood and urine soon after acute renal injury. NGAL gains features of an early, sensitive and noninvasive biomarker for acute renal injury. Recent evidences suggest that its expression is also increased in CRF reflecting the severity of disease.

Objectives:

In the present study, we aimed to investigate whether blood NGAL level plays a role in the differential diagnosis of acute and chronic renal failure.

Patients and Methods:

This was a prospective case-control study. Fifty patients presented to emergency department with acute renal failure (ARF), 30 with chronic renal failure (CRF) and 20 healthy individuals as control group were included in this study. Blood pH, HCO3^-, BUN, creatinine and potassium values were evaluated in all patients. Blood NGAL values were evaluated in all groups. BUN, serum creatinine and NGAL values were statistically compared between patients and controls.

Results:

Median NGAL levels in patients was 304.50 (29), and 60 (0) in control, which was statistically significant between the two groups (Z = -6.477, P < 0.001). The median NGAL values were 261.50 ± 291 in ARF group and 428.50 ± 294 in CRF group. There was a significant difference in NGAL level between ARF and CRF groups (Z = -2.52, P = 0.012). Median BUN values were 153.46 ± 82.47 in ARF group and 169.40 ± 93.94 in CRF group. There was no significant difference in BUN value between ARF and CRF groups (P > 0.05). Median creatinine values were 2.84 ± 2.95 in ARF group and 4.78 ± 4.32 in CRF group. In serum creatinine values, a significant difference was found between ARF and CRF groups (P < 0.05).

Conclusions:

Serum NGAL levels of ARF and CRF patients were significantly higher than healthy individuals. In addition, NGAL values of patients with CRF were significantly higher than those of ARF. Serum NGAL values can be used to detect renal injury and differentiate ARF and CRF.

Renal failure in a soldier taking N.O.-Xplode

INTRODUCTION

Dietary supplements are widely used but are unregulated by the US Food and Drug Administration. Presented here is a case of severe renal failure possibly associated with a dietary supplement, which demonstrates the need for improved patient-physician communication regarding the possible risks and lack of regulation of dietary supplements.

METHODS

A 26-year-old man presented with 3 days of flank pain. The patient had been taking a dietary supplement called N.O.-Xplode for 3 months. Initial laboratory tests revealed a creatinine value of 9.45 mg/dL. Extensive laboratory analysis and imaging revealed no underlying cause of his renal injury. Renal biopsy showed acute tubular necrosis with normal glomeruli. After discontinuing N.O.-Xplode, renal function returned to normal within 1 week.

CONCLUSIONS

This case demonstrates the need for improved patient-physician communication about dietary supplements. The patient had not consulted a physician before initiating use; the amount of each ingredient contained in the dietary supplement is unavailable; and there are no available data regarding safety or efficacy. It is critical that physicians are able and open to counseling patients on the inherent risks associated with dietary supplements, including their lack of regulation by the Food and Drug Administration, unknown efficacy, and possible serious adverse outcomes.

Antigen carbohydrate 125 and creatinine on admission for prediction of renal function response following loop diuretic administration in acute heart failure

BACKGROUND

The use of loop diuretics in acute heart failure (AHF) is largely empirical and has been associated with renal function impairment by reducing renal perfusion but also renal improvement by decreasing renal venous congestion. Antigen carbohydrate 125 (CA125) has emerged as a proxy for fluid overload. We sought to evaluate whether the early changes in creatinine (ΔCr) induced by intravenous furosemide doses (ivFD) differ among clinical groups defined by overload status (CA125) and creatinine on admission (Cr).

METHODS AND RESULTS

We included 526 consecutive patients admitted for AHF. All patients received intravenous furosemide for the first 48 hours. CA125 and Cr were dichotomized at 35 U/ml and 1.4 mg/dl, respectively, and grouped as follows: C1 [Cr <1.4, CA125 ≤ 35 (n=151)]; C2 [Cr <1.4, CA125 >35 (n=241)]; C3 [Cr ≥ 1.4, CA125 ≤ 35 (n=45)]; and C4 [Cr ≥ 1.4, CA125 >35 (n=89)]. Clinicians in charge of the management of patients were blind to CA125 values. ΔCr was estimated as the absolute difference in Cr between admission and 48-72 hours. Multivariable linear regression analysis was used for modeling purposes. The adjusted analysis showed a differential effect of ivFD on ΔCr. Per increase in 20mg/day of ivFD, the mean ΔCr was 0.010 mg/dl (p=0.464) in C1, 0.002 mg/dl (p=0.831) in C2, 0.045 mg/dl (p=0.032) in C3, and -0.045 mg/dl (p<0.001) in C4 (omnibus p<0.001). A similar pattern of response was observed in a validation cohort.

CONCLUSIONS

In patients with AHF, the magnitude and direction of ΔCr attributable to ivFD were differentially associated with values of CA125 and Cr on admission.

A syndrome of congenital hyperinsulinism and rhabdomyolysis is caused by KCNJ11 mutation

BACKGROUND

Congenital hyperinsulinism is a genetically heterogeneous disorder, but mutations in the components of the ATP-sensitive potassium channel K(ATP) account for more than a third of all isolated congenital hyperinsulinism cases. The association between congenital hyperinsulinism and rhabdomyolysis has not been reported.

OBJECTIVE

To describe significant skeletal muscle manifestations in a family with a novel mutation in KCNJ11 (encoding the Kir6.2 component of K(ATP)).

METHODS

Cross-sectional analysis of members of a large multiplex consanguineous family with congenital hyperinsulinism and rhabdomyolysis using autozygosity mapping and exome sequencing.

RESULTS

Five affected members of an extended consanguineous Saudi family were recruited along with relevant unaffected relatives. We were able to map an apparently novel syndrome of congenital hyperinsulinism and severe rhabdomyolysis leading to acute renal failure to a single locus that harbours KCNJ11 in which we identified a novel homozygous mutation.

CONCLUSIONS

This study expands the phenotype associated with KCNJ11 loss of function in humans and calls for increased awareness of rhabdomyolysis as a potential late-onset life-threatening complication of KCNJ11-related congenital hyperinsulinism.

Metformin induced acute pancreatitis

Acute pancreatitis frequently presents with abdomen pain but may presents with various skin manifestations as rash and rarely, pancreatic panniculitis. Metformin, one of the most effective and valuable oral hypoglycemic agents in the biguanide class was linked to acute pancreatitis in few cases. Here, we report a case of metformin induce acute pancreatitis in young healthy man with normal renal function.

Comparison of oral lesion prevalence between renal transplant patients and dialysis patients

OBJECTIVE

Renal transplantation is performed in patients with end stage renal disease as the best treatment plan. However, different complications may occur in these patients due to the direct consequences of the renal disease or drug-induced suppression of the body immune system. The main objective of the present study was to compare different oral lesions in patients receiving renal transplantation with the patients undergoing dialysis referred to two hospitals in Tehran, Iran.

MATERIALS AND METHODS

In this cross-sectional study, 93 renal transplant patients who had received renal transplant at least 6 months prior to our study, were selected from their records at the hospitals. Furthermore, 93 candidates of renal transplantation were selected as the control group. The patients in both case and control groups underwent oral examinations and the results were analyzed by chi-square test and Spearman correlation coefficient.

RESULTS

At least one oral lesion was found in 30 (32.2%) patients in the renal transplant group and 8 (8.6%) patents in the control subjects. The difference between the two groups was statistically significant (p<0.0001). The most prevalent lesion was xerostomia observed in 20 patients of the renal transplant group and 4 patients in the control group. The odds ratio of cyclosporine and amlodipine and the effect of these in increasing the risk of oral lesions was 1.21 and 1.02, respectively in renal transplant recipients.

CONCLUSION

The results of the study showed that renal transplantation significantly increases the risk of related oral lesions. Therefore, renal transplant recipients must undergo regular oral examinations in order to find any suspicious lesion(s) as soon as possible to treat them.

An unforgettable concurrence: Successfully managed gallstone ileus accompanied by diabetic nephropathy

BACKGROUND

Gallstone ileus is an uncommon complication of gall stones associated with potentially serious morbidity and mortality.

CASE REPORT

We reported a 60-year-old male case who presented with renal failure and pain in right hypochondriac region. He also had a history of brain infarcts along with diabetes which is an additional factor for mortality. On Computed Tomography of the abdomen, he was diagnosed to have cholecystocholedochal fistula including air in the gall bladder and obstruction in the distal part of the ileum. Computed tomography plays an important role to make the proper diagnosis and in treatment.

CONCLUSIONS

As in our case, diagnosis was challengeable because of renal failure,diabetes, septicaemia and intestinal obstruction (peritonitis). We did surgery on the basis of peritonitis which remains the only choice in such cases. In follow- up of 1 month patient was doing well and asymptomatic.

Postoperative outcomes in patients with chronic renal failure undergoing coronary artery bypass grafting in madani heart center: 2000-2010

INTRODUCTION

Renal failure predisposes patients to adverse outcome after coronary artery bypass grafting (CABG). Renal dysfunction is a predictor of increased morbidity and mortality after CABG, whether it is dialysis-dependent or not.

METHODS

In a retrospective study from April 2000 to December 2010, seventy-six patients (60 male and 16 female with the mean age of 58.57±7.93 years) with different categories of chronic renal failure undergoing CABG in Shahid Madani Hospital, were studied. The cardiac disease leading to the operation was coronary artery disease (CAD) in all patients. Patients demographic, surgical and laboratory data were gathered from hospital records. Data were then analyzed.

RESULTS

Mean hospital stay was 10.16±7.16 days. The preoperative mortality rate was 10.5% (15% in non dialysis and 5.6% in dialysis dependant patients with no significant difference). Morbidity rate was 28.9% (respectively 30% and 27.8% in dialysis and non dialysis patients with no significant difference) including in-hospital myocardial infarction (MI) (10.5%), in-hospital stroke (2.6%), in-hospital bleeding (21.1%) and in-hospital infection, pneumonia, (5.3%). Mean creatinine and blood urea nitrogen (BUN) levels were significantly increased after surgery (p<0.001). Postoperative hemodialysis rate was 33.3%.

CONCLUSION

Chronic renal failure whether dialysis-dependant or not increases in-hospital mortality and morbidity in patients undergoing CABG. For CRF patients not on dialysis with a creatinine 2.5 gm/dL, there is a strong likelihood of postoperative dialysis.

Short- and long-term results of triple valve surgery: a single center experience

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital's experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.

Leukocyte-Aprotinin Atrial Fibrillation Study (LAFFS): Impact of Aprotinin and Leukofiltration on Atrial Fibrillation, Renal Insufficiency and Encephalopathy Post-Cardiopulmonary Bypass

Purpose: Atrial fibrillation remains the leading postoperative complication following cardiopulmonary bypass. A randomized trial was undertaken to evaluate the effectiveness of leukocyte filtration and aprotinin, applied separately and in combination, on the incidence of post-operative atrial fibrillation. A secondary component of the study was the impact of these adjunct interventions on post-surgical renal and neurological dysfunction. Methods: A total of 1,220 patients undergoing primary isolated coronary artery bypass grafting were randomly assigned to one of four treatment groups. The control group (305 patients) received standard cardiopulmonary bypass with moderately hypothermic (34ºC) cardioplegic arrest. In the filtration group (310 patients) leukocyte reducing filters were incorporated into the bypass circuit and deployed strategically. The aprotinin group (285 patients) received full Hammersmith dose aprotinin. The combination therapy group (320 patients) received both aprotinin and leukocyte filtration. Results: The incidences of atrial fibrillation were 25% in the control group, 16% in the filtration group, 19% in the aprotinin group and 10% in the combination therapy group (P < 0.001). Renal dysfunction was detected in 3% of the control group, 2% of the filtration group, 8% of the aprotinin group, and 5% of the combination group (P < 0.005). Neurological dysfunction occurred in 2% of the control group, 2% of the filtration group, 1% of the aprotinin group, and 2% of the combination group (P = n.s.). Conclusions: Combination therapy with aprotinin and leukocyte filtration markedly reduced atrial fibrillation post-cardiopulmonary bypass, and was more effective than the individual treatments. Aprotinin treatment increased the incidence of renal dysfunction, and the addition of leukocyte filtration partially mitigated this detrimental effect of aprotinin. Thus, strategic leukocyte filtration augments aprotinin's anti-arrhythmic effects while suppressing its nephrotoxic sequelae.

RENAL TRANSPLANTATION - AN EARLY EXPERIENCE

Renal transplant (RT) is now a therapy of choice for end stage renal disease (ESRD). The Nephrology Unit, Asvini started functioning in Dec 90 and to date 1298 sittings of hemodialysis have been given to 45 patients. Of these, 35 were in ESRD and 11 patients underwent renal transplantation at this hospital during the period Jan 91 - Dec 93. One patient expired after 18 months of transplantation due to infection. Early experience in screening patients for RT, use of immunosuppression, management of rejection episodes and protocol are presented with special emphasis on its relevance to the Armed Forces.