A Novel cause of abdominal pain presenting with anuria and renal failure

A girl in early adolescence with autism presented with 3 months of abdominal pain and 36 hours of anuria. She had recently received treatment for urinary tract infections, anxiety and menorrhagia (she had undergone menarche a few months earlier). Due to the pain, she had pulled out an incisor. Bladder scan showed 923 mL, creatinine was 829 mmol/L but urethral catheter insertion did not drain urine. An unenhanced CT scan revealed an absent left kidney, didelphys uterus and right-sided hydroureteronephrosis caused by haematocolpos in keeping with a diagnosis of OHVIRA syndrome and ureteric obstruction of a single kidney causing acute renal failure. She underwent vaginal septoplasty, drainage of the haematocolpos and right ureteric stent.

Outcomes of two-stage type II hybrid aortic arch repair in elderly patients with acute type A aortic dissection

Acute type A aortic dissection (a-TAAD) is a severe disease characterized by high mortality, which can be fatal in elderly patients. The objective of this study was to investigate the safety and efficacy of two-stage type II hybrid aortic arch repair (HAR) in elderly patients with acute type A aortic dissection (a-TAAD). This was a single-center, retrospective study involving 119 patients with a-TAAD, including 82 males and 37 females, aged 22-81 years old. Eighty-eight patients underwent total aortic arch replacement (TAR) with frozen elephant trunk (FET) implantation (TAR with FET group) and 31 patients underwent two-stage type II HAR (HAR group). Propensity score matching was applied to adjust for preoperative data, and match 25 pairs. The preoperative, perioperative, postoperative and follow-up data were recorded. Fifteen patients died during the perioperative period; 13 cases were in the TAR with FET group and 2 cases were in the HAR group. The age, body mass index, cerebral infarction, renal insufficiency were significantly higher, and the 24-h fluid drainage, the incidence of acute liver injury, acute kidney injury and pulmonary infection were lower in the HAR group (all P < 0.05). Moreover, the mechanical ventilation time, intensive care unit time, hospital stay time were shorter in the HAR group (all P < 0.05). The follow-up period ranged from 12 to 54 months, with 7 deaths (9.3%) in the TAR with FET group and 2 deaths (6.9%) in the HAR group. The true lumen of the aortic arch and the middle descending thoracic aorta were larger and the false lumen thrombosis rates of the middle descending thoracic aorta and renal artery level were higher in the HAR group (all P < 0.05). Two-stage type II HAR is a safe and effective method for the treatment of elderly patients with a-TAAD. It may be a good choice for elderly patients with a-TAAD and comorbidities.

Waitlist and post-transplant outcomes among candidates listed for liver transplant: Liver alone versus simultaneous liver kidney listings

BACKGROUND

Data comparing waitlist and post-transplant outcomes of liver transplantation (LT) alone (LTA) versus simultaneous liver kidney (SLK) listings are limited.

AIM

To examine 90-days waitlist and 1-year post-transplant outcomes of LT listings since Organ Procurement Transplant Network (OPTN) policy for SLK, who had cirrhosis with eGFR <30 mL/min or on dialysis at listing.

METHODS

Adults (08/2017-03/2021) with first LT listing (2628 SLK) were stratified on renal function from listing: acute kidney injury (AKI): rise of serum creatinine by ≥0.3 mg/dL or <42 days hemodialysis; chronic kidney disease (CKD): eGFR <60 mL/min for ≥90 days or ≥42 days hemodialysis.

RESULTS

Among 7094 adults analyzed, 90-days competing cumulative waitlist mortality was 18.2% in LTA + CKD (n = 37), 15.3% in LTA + AKI (n = 3337), 15% in SLK + AKI (n = 2070), and 11% in SLK + CKD (n = 403), p < 0.001. On fine and gray model, compared to SLK + CKD, LTA + AKI had 1.4-fold waitlist mortality. On a median post-transplant follow up of 1 year, patient survival was similar comparing LTA versus SLK for AKI (89% each, p = 0.83), for CKD (93 vs. 86%, p = 0.55), but lower in recipients listed for SLK with no AKI or CKD (93 vs. 88%, p = 0.02), adjusted hazard ratio (95% CI) of 0.7 (0.4-1.2). Among 1024 LTA recipients without AKI or CKD from listing, 117 were listed for SLK, and their 1-year survival was poorer compared to LT alone listings (79 vs. 95%, p < 0.002, adjusted HR 3.6 (1.3-10.3); p = 0.015).

CONCLUSIONS

Among candidates with renal dysfunction at listing for LT, those listed for LT alone should receive transplant promptly to optimise waitlist outcomes. Those listed for SLK should wait to receive both organs to optimise post-transplant outcomes.

Implications of Renal Disease in Patients Undergoing Structural Interventions

Percutaneous structural interventions have a major impact on the morbidity, mortality, and quality of life of patients by providing a lower-risk alternative to cardiac surgery. However, renal disease has a significant impact on outcomes of these interventions. This review explores the incidence, outcomes, pathophysiology, and preventative measures of acute kidney injury and chronic kidney disease on transcatheter aortic valve replacement, transcatheter mitral valve repair, and percutaneous balloon mitral valvuloplasty. Given the expanding indications for percutaneous structural interventions, further research is needed to identify ideal patients with chronic kidney disease or end-stage renal disease who would benefit from intervention.

Successful transplantation of four kidney grafts from two small pediatric donors with anuric acute renal failure into adult recipients

BACKGROUND

Kidneys from infants with anuric acute kidney injury (AKI) only rarely get accepted for transplantation despite encouraging data that such kidneys can have very good long-term outcome.

METHODS

We report the transplantation of four kidney grafts from two pediatric donors (3 and 4 years) with anuric acute kidney injury as single kidneys into four adult recipients.

RESULTS

All grafts gained function within 14 days posttransplantation, only one recipient needed dialysis after transplantation. None of the recipients suffered from surgical complications. One month after transplantation, all recipients were free of dialysis. Estimated glomerular filtration rates (eGFR) 3 months after transplantation were 37, 40, 50, and 83 mL/min/1.73 m2 . eGFR increased further through month 6, reaching 45, 50, 58, and 89 mL/min/1.73 m2 .

CONCLUSION

These cases highlight the feasibility of successful transplantation of single pediatric kidney grafts into adult recipients despite anuric AKI of the donor.

Opinion: on the importance of maintaining the functional form of explanatory variables

In medical research, continuous variables are often categorised into two or more groups before being included in the analysis; this practice often comes with a cost, such as loss of power in analysis, less reliable estimates, and can often leave residual confounding in the results. In this research report, we show this by way of estimates from a regression analysis looking at the association between acute kidney injury and post-operative mortality in a sample of 194 neonates who underwent the Norwood operation. Two models were developed, one using a continuous measure of renal function as the main explanatory variable and second using a categorised version of the same variable. A continuous measure of renal function is more likely to yield reliable estimates and also maintains more statistical power in the analysis to detect a relation between the exposure and outcome. It also reveals the true biological relationship between the exposure and outcome. Categorising a continuous variable may not only miss an important message, it can also get it wrong. Additionally, given a non-linear relationship is commonly encountered between the exposure and outcome variable, investigators are advised to retain a predictor with a linear term only when supported by data. All of this is particularly important in small data sets which account for the majority of clinical research studies.

The incidence, risk factors and outcomes of acute kidney injury in critically ill patients undergoing emergency surgery: a prospective observational study

BACKGROUND

Without sufficient evidence in postoperative acute kidney injury (AKI) in critically ill patients undergoing emergency surgery, it is meaningful to explore the incidence, risk factors, and prognosis of postoperative AKI.

METHODS

A prospective observational study was conducted in the general intensive care units (ICUs) from January 2014 to March 2018. Variables about preoperation, intraoperation and postoperation were collected. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria.

RESULTS

Among 383 critically ill patients undergoing emergency surgery, 151 (39.4%) patients developed postoperative AKI. Postoperative reoperation, postoperative Acute Physiology and Chronic Health Evaluation (APACHE II) score, and postoperative serum lactic acid (LAC) were independent risk factors for postoperative AKI, with the adjusted odds ratio (ORadj) of 1.854 (95% confidence interval [CI], 1.091-3.152), 1.059 (95%CI, 1.018-1.102), and 1.239 (95%CI, 1.047-1.467), respectively. Compared with the non-AKI group, duration of mechanical ventilation, renal replacement therapy, ICU and hospital mortality, ICU and hospital length of stay, total ICU and hospital costs were higher in the AKI group.

CONCLUSIONS

Postoperative reoperation, postoperative APACHE II score, and postoperative LAC were independent risk factors of postoperative AKI in critically ill patients undergoing emergency surgery.

Association between Ureteral Clamping Time and Acute Kidney Injury during Robot-Assisted Radical Cystectomy

Robot-assisted radical cystectomy (RARC) is replacing open radical cystectomy (ORC) and requires clamping of the ureters, resulting in a predisposition to postrenal acute kidney injury (AKI). We investigated the association between ureteral clamping or its duration and acute/chronic postoperative kidney function. Patients who underwent radical cystectomy (robotic or open) at two tertiary institutions during 2002-2021 were retrospectively enrolled. In those who underwent RARC, the maximum postoperative percentage serum creatinine level (%sCre) change was plotted against ureteral clamping duration. They were divided into two groups using the median clamping time (210 min), and the maximum %sCre change and percentage estimated glomerular filtration rate (%eGFR) change at 3-6 months (chronic) were compared between the ORC (no clamp), RARC < 210, and RARC ≥ 210 groups. In 44 RARC patients, a weak correlation was observed between the duration of ureteral clamping and %Cre change (R2 = 0.22, p = 0.001). Baseline serum creatinine levels were comparable between the groups. However, %sCre change was significantly larger in the RARC ≥ 210 group (N = 17, +32.1%) than those in the RARC < 210 (N = 27, +6.1%) and ORC (N = 76, +9.5%) groups (both, p < 0.001). Chronic %eGFR change was comparable between the groups. Longer clamping of the ureter during RARC may precipitate AKI; therefore, the clamping duration should be minimized.

Outcomes and factors leading to graft failure in kidney transplants from deceased donors with acute kidney injury-A retrospective cohort study

Due to shortage of donor, kidney transplants (KTs) from donors with acute kidney injury (AKI) are expanding. Although previous studies comparing clinical outcomes between AKI and non-AKI donors in KTs have shown comparable results, data on high-volume analysis of KTs outcomes with AKI donors are limited. This study aimed to analyze the selection trends of AKI donors and investigate the impact of AKI on graft failure using the United states cohort data. We analyzed a total 52,757 KTs collected in the Scientific Registry of Transplant Recipient (SRTR) from 2010 to 2015. The sample included 4,962 (9.4%) cases of KTs with AKI donors (creatinine ≥ 2 mg/dL). Clinical characteristics of AKI and non-AKI donors were analyzed and outcomes of both groups were compared. We also analyzed risk factors for graft failure in AKI donor KTs. Although the incidence of delayed graft function was higher in recipients of AKI donors compared to non-AKI donors, graft and patient survival were not significantly different between the two groups. We found donor hypertension, cold ischemic time, the proportion of African American donors, and high KDPI were risk factors for graft failure in AKI donor KTs. KTs from deceased donor with AKI showed comparable outcomes. Thus, donors with AKI need to be considered more actively to expand donor pool. Caution is still needed when donors have additional risk factors of graft failure.

Kidney Transplantation in the Times of COVID-19 - A Literature Review

Kidney transplantation at the time of the COVID-19 pandemic is challenging. Modifying the immunosuppression protocols is controversial and not evidence based. In this study, we aim to review the published literature of kidney transplant recipients who encountered COVID-19. A literature review was performed using PubMed, ScienceDirect, and World Health Organization databases to identify relevant English-language articles published up to May 7, 2020. There were 24 articles that reported 129 kidney transplant recipients who encountered COVID-19. The age mean was 54.2 years with 73.7% as males. The most commonly reported presentations in order were fever (82.3%), cough (58%), shortness of breath (33.2%), and fatigue (30.7%). Acute kidney injury was observed in 34.1% of patients. Kidney transplant patients encountered COVID-19 were maintained on tacrolimus (Tac, 92%), mycophenolate mofetil (MMF, 78.8%), and prednisone (Pred, 77%) and were manage by holding MMF in 79.1% of patients and holding Tac in 34.4% of patients. In all, 20% of patients needed Intensive Care Unit (ICU) admission and 24.6% of patients required mechanical ventilation. In all, 18.8% of patients had died compared to the reported general population COVID-19 mortality of 3.4%. The clinical presentation of COVID-19 in kidney transplant recipients may be different from the general population with a higher rate of severe disease, complications including renal failure, and mortality.

Mitochondrial transplantation ameliorates ischemia/reperfusion-induced kidney injury in rat

No real therapeutic modality is currently available for Acute kidney injury (AKI) and if any, they are mainly supportive in nature. Therefore, developing a new therapeutic strategy is crucial. Mitochondrial dysfunction proved to be a key contributor to renal tubular cell death during AKI. Thus, replacement or augmentation of damaged mitochondria could be a proper target in AKI treatment. Here, in an animal model of AKI, we auto-transplanted normal mitochondria isolated from healthy muscle cells to injured kidney cells through injection to renal artery. The mitochondria transplantation prevented renal tubular cell death, restored renal function, ameliorated kidney damage, improved regenerative potential of renal tubules, and decreased ischemia/reperfusion-induced apoptosis. Although further studies including clinical trials are required in this regard, our findings suggest a novel therapeutic strategy for treatment of AKI. Improved quality of life of patients suffering from renal failure and decreased morbidity and mortality rates would be the potential advantages of this therapeutic strategy.

Impact of acute kidney injury in elderly versus young deceased donors on post-transplant outcomes: A multicenter cohort study

We investigated the impact of acute kidney injury (AKI) in elderly deceased-donors (DDs) vs. AKI in young DDs on post-transplant clinical outcomes. A total of 709 kidney transplant recipients (KTRs) from 602 DDs at four transplant centers were enrolled. KTRs were divided into young-DDKT and elderly-DDKT groups according to the age of DD of 60 years. Both groups were subdivided into non-AKI-KT and AKI-KT subgroups according to AKI in DDs. We investigated short-term and long-term clinical outcomes of non-AKI-DDKT and AKI-DDKT subgroups within young-DDKT and elderly-DDKT groups. The incidence of DGF in the AKI-DDKT subgroup was higher and the allograft function within 12 months after KT in the AKI-DDKT subgroup was lower than those in the non-AKI-DDKT subgroup in both young-DDKT and elderly-DDKT groups. Death-censored allograft survival rate was significantly lower in the AKI-elderly-DDKT subgroup than that in the non-AKI-elderly-DDKT subgroup, but it did not differ between AKI-young-DDKT and non-AKI-young-DDKT subgroup. In multivariable analysis, AKI-elderly-DDKT was an independent risk factor for allograft failure (hazard ratio: 2.648, 95% CI: 1.170-5.994, p = 0.019) and a significant interaction between AKI and old age in DDs on allograft failure was observed (p = 0.001). AKI in elderly DDs, but not in young DDs, can significantly affect long-term allograft outcomes of KTRs.

[Acute kidney failure due to uterine prolapse]

BACKGROUND

Kidney failure due to uterine prolapse is rare, nonetheless, early recognition and treatment of this form of postrenal kidney failure are essential in order to prevent serious complications.

CASE DESCRIPTION

In this article we describe a 73-year-old woman and a 63-year-old-woman with severe kidney failure due to a uterine prolapse. Both patients were initially treated with a nephrostomy catheter to ensure the passage of urine from the kidneys, after which the uterus was repositioned using a vaginal ring.

CONCLUSION

Renal failure due to uterine prolapse can be easily diagnosed by physical examination. If uterine prolapse is diagnosed in a patient with renal failure, it is essential to quickly ensure the passage of urine in order to secure the function of the kidney.

Cause rare d’insuffisance rénale aigue: géant calcul de vessie chez une jeune femme

Giant urinary bladder stone is defined as a stone with a weight higher than 100 g. It is rare in women, accounting for approximately 2%. Its occurrence in the urinary bladder does not exceed 5% of the whole of the urinary tract. In women, the occurrence of urinary bladder stone is often secondary to a predisposing factor including intravesical foreign body, neurogenic bladder, repeated urinary infections, a history of surgery treating stress urinary incontinence. Therefore, there are some patients with a bladder stones without any obvious cause, such as primary idiopathic stone. We here report the case of a 31-year old patient with giant urinary bladder stone affecting the superior part of the urinary tract causing acute renal failure. The patient initially underwent bilateral nephrostomies to drain the superior part of the urinary tract; then giant urinary bladder stone was removed by open cystolithotomy. Etiological assessment didn't show any obvious cause.

[Recurrent atypical hemolytic uremic syndrome after renal transplantation: treatment with eculizumab]

Atypical hemolytic uremic syndrome (aHUS) is a rare entity. It is characterized by a thrombotic microangiopathy (nonimmune hemolytic anemia, thrombocytopenia, and acute renal failure), with a typical histopathology of thickening of capillary and arteriolar walls and an obstructive thrombosis of the vascular lumen. The syndrome is produced by a genetic or acquired deregulation of the alternative pathway of the complement system, with high rates of end stage renal disease, post-transplant recurrence, and high mortality. Mutations associated with factor H, factor B and complement C3 show the worst prognosis. Even though plasma therapy is occasionally useful, eculizumab is effective both for treatment and prevention of post-transplant recurrence. We describe here an adult case of congenital aHUS (C3 mutation) under preventive treatment with eculizumab after renal transplantation, with neither disease recurrence nor drug-related adverse events after a 36-months follow-up.

Unilateral nephrectomy diminishes ischemic acute kidney injury through enhanced perfusion and reduced pro-inflammatory and pro-fibrotic responses

While unilateral nephrectomy (UNx) is suggested to protect against ischemia-reperfusion injury (IRI) in the remaining kidney, the mechanisms underlying this protection remain to be elucidated. In this study, functional MRI was employed in a renal IRI rat model to reveal global and regional changes in renal filtration, perfusion, oxygenation and sodium handling, and microarray and pathway analyses were conducted to identify protective molecular mechanisms. Wistar rats were randomized to either UNx or sham UNx immediately prior to 37 minutes of unilateral renal artery clamping or sham operation under sevoflurane anesthesia. MRI was performed 24 hours after reperfusion. Blood and renal tissue were harvested. RNA was isolated for microarray analysis and QPCR validation of gene expression results. The perfusion (T1 value) was significantly enhanced in the medulla of the post-ischemic kidney following UNx. UNx decreased the expression of fibrogenic genes, i.a. Col1a1, Fn1 and Tgfb1 in the post-ischemic kidney. This was associated with a marked decrease in markers of activated myofibroblasts (Acta2/α-Sma and Cdh11) and macrophages (Ccr2). This was most likely facilitated by down-regulation of Pdgfra, thus inhibiting pericyte-myofibroblast differentiation, chemokine production (Ccl2/Mcp1) and macrophage infiltration. UNx reduced ischemic histopathologic injury. UNx may exert renoprotective effects against IRI through increased perfusion in the renal medulla and alleviation of the acute pro-inflammatory and pro-fibrotic responses possibly through decreased myofibroblast activation. The identified pathways involved may serve as potential therapeutic targets and should be taken into account in experimental models of IRI.

[Post-obstructive diuresis : diagnosis and management]

The syndrome of "post-obstructive diuresis" corresponds to a massive polyuria and natriuresis occurring after the drainage of an obstructive acute kidney injury. Such a complication needs to be readily detected and managed because of the significant risk for haemodynamic disorders. On the basis of a clinical observation, we describe the pathophysiology of post-obstructive diuresis, as well as its diagnostic and therapeutic management.

Long-term Graft Survival After Kidney Allograft Torsion: Rapid Diagnosis and Surgical Management Key to Reversibility of Injury

INTRODUCTION

Kidney allograft torsion (KAT) is a rare complication of kidney transplantation (KT) that occurs when the transplanted kidney rotates around its vascular pedicle, which may result in a catastrophic compromise of the graft's blood supply, deterioration of kidney function, and eventually premature graft death.

CASE REPORT

We report the case of a patient who had an acute kidney injury (AKI) episode from KAT. Her diagnosis was ascertained expeditiously and she had prompt surgical management. Five years after the KAT event, her baseline creatinine (Cr) stabilized around 1.6 mg/dL and she has achieved >8-year graft survival.

DISCUSSION

This case illustrates the reversibility of injury that can occur after a KAT event with a commensurate return to baseline kidney function when KAT is promptly diagnosed and treated. A high index of suspicion of this uncommon but catastrophic complication of KT must be maintained to achieve desirable long-term outcomes. A diagnosis of KAT must be considered when routine etiologies of an acute deterioration of kidney allograft function have been excluded. Finally, prophylactic nephropexy must be strongly considered with intraperitoneal placement of a kidney allograft to avoid KAT.

Spleno-renal artery transposition in a solitary functioning kidney for treatment-resistant hypertension and acute kidney injury

Renal Artery Stenosis (RAS) is an important cause of treatment-resistant hypertension. Uncontrolled hypertension with RAS can cause progressive chronic kidney disease (CKD) leading to end-stage kidney disease. Therapeutic revascularisation can be helpful in appropriate circumstances where pharmaceutical intervention has failed and significant renovascular disease contributes to resistant hypertension. We present an interesting case of a Caucasian male with peripheral vasculopathy, abdominal aortic aneurysm (AAA), single functioning kidney and ostial RAS caused by stent struts from an endovascular AAA stent graft. He had escalating medications requirement, with repeated failed attempts at percutaneous radiological intervention that led to an episode of contrast-induced acute kidney injury (AKI), before undergoing successful surgical revascularisation by a splenic artery transposition graft to the left renal artery that was performed to improve kidney function and the blood pressure. This report highlights the challenges faced with regard to the management of severe hypertension and progressive CKD.

Acute Kidney Injury and In-Hospital Mortality after Coronary Artery Bypass Graft versus Percutaneous Coronary Intervention: A Nationwide Study

BACKGROUND

Post-procedural acute kidney injury (AKI) is associated with significantly increased short- and long-term mortalities, and renal loss. Few studies have compared the incidence of post-procedural AKI and in-hospital mortality between 2 major modalities of revascularization - coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) - and results have been inconsistent.

METHODS

We generated a propensity score-matched cohort that includes a total of 286,670 hospitalizations with multi-vessel coronary disease undergoing CABG or PCI (2004-2012) from the National Inpatient Sample database. We compared incidence of AKI, AKI requiring renal replacement therapy (RRT), in-hospital mortality, hospital stay, and charges between CABG and PCI groups.

RESULTS

The incidence of AKI after CABG was higher than PCI (8.9 vs. 4.5%, OR 2.05, 95% CI 1.99-2.12, p < 0.001). The incidence of AKI requiring RRT was also higher after CABG (1.1 vs. 0.5%, OR 2.14, 95% CI 1.96-2.34, p < 0.001). Likewise, in-hospital mortality was higher after CABG than PCI (2.0 vs. 1.4%, OR 1.44, 95% CI 1.35-1.52, p < 0.001). Among patients with pre-existing chronic kidney disease (stages I-IV), those undergoing CABG was associated with 2.0-2.3-fold higher odds of developing AKI than those undergoing PCI. The patients treated with CABG had a significantly longer hospital stay and higher hospital charges.

CONCLUSIONS

Patients undergoing CABG are associated with (1) increased risk of developing post-procedural AKI, (2) higher likelihood of receiving RRT, and (3) worse short-term survival. Long-term renal outcome remains to be studied.

Discoidin domain receptor 1 kinase activity is required for regulating collagen IV synthesis

Discoidin domain receptor 1 (DDR1) is a receptor tyrosine kinase that binds to and is activated by collagens. DDR1 expression increases following kidney injury and accumulating evidence suggests that it contributes to the progression of injury. To this end, deletion of DDR1 is beneficial in ameliorating kidney injury induced by angiotensin infusion, unilateral ureteral obstruction, or nephrotoxic nephritis. Most of the beneficial effects observed in the DDR1-null mice are attributed to reduced inflammatory cell infiltration to the site of injury, suggesting that DDR1 plays a pro-inflammatory effect. The goal of this study was to determine whether, in addition to its pro-inflammatory effect, DDR1 plays a deleterious effect in kidney injury by directly regulating extracellular matrix production. We show that DDR1-null mice have reduced deposition of glomerular collagens I and IV as well as decreased proteinuria following the partial renal ablation model of kidney injury. Using mesangial cells isolated from DDR1-null mice, we show that these cells produce significantly less collagen compared to DDR1-null cells reconstituted with wild type DDR1. Moreover, mutagenesis analysis revealed that mutations in the collagen binding site or in the kinase domain significantly reduce DDR1-mediated collagen production. Finally, we provide evidence that blocking DDR1 kinase activity with an ATP-competitive small molecule inhibitor reduces collagen production. In conclusion, our studies indicate that the kinase activity of DDR1 plays a key role in DDR1-induced collagen synthesis and suggest that blocking collagen-mediated DDR1 activation may be beneficial in fibrotic diseases.

Timing of Renal Replacement Therapy in Acute Kidney Injury

BACKGROUND

Renal replacement therapy (RRT) is commonly and increasingly utilized in critically ill patients with severe acute kidney injury (AKI). The issue of when to start RRT in a critically ill patient with AKI has long troubled clinicians.

SUMMARY

Currently, there is a paucity of high-quality evidence to guide clinician decision-making on the optimal time to start RRT. This lack of evidence has translated into wide variation in treatment patterns and practices. In patients developing life-threatening complications of AKI, the decision to start RRT is largely indisputable; however, in the absence of such complications, the optimal thresholds to start RRT that translates into improved outcomes for patients are unknown. Available evidence from observational studies and clinical trials have considerable limitations for translation to clinical practice due to their retrospective, post hoc secondary design, their small sample sizes, heterogeneity in study populations and illness severity, variation in the definitions of AKI and in the timing of or thresholds for starting RRT and the risk of residual confounding and bias related to the association between the timing of RRT and outcome.

KEY MESSAGES

Several large randomized trials are planned or ongoing, and the results of these trials will greatly inform best clinical practice and will help reduce unnecessary variation in the practice of RRT prescription. For now, the decision on the appropriate time to start RRT is naturally complex, integrating numerous variables, and should largely be individualized.

Comparison of Plasma and Urine Biomarker Performance in Acute Kidney Injury

Background

New renal biomarkers measured in urine promise to increase specificity for risk stratification and early diagnosis of acute kidney injury (AKI) but concomitantly may be altered by urine concentration effects and chronic renal insufficiency. This study therefore directly compared the performance of AKI biomarkers in urine and plasma.

Methods

This single-center, prospective cohort study included 110 unselected adults undergoing cardiac surgery with cardiopulmonary bypass between 2009 and 2010. Plasma and/or urine concentrations of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), liver fatty acid-binding protein (L-FABP), kidney injury molecule 1 (KIM1), and albumin as well as 15 additional biomarkers in plasma and urine were measured during the perioperative period. The primary outcome was AKI defined by AKIN serum creatinine criteria within 72 hours after surgery.

Results

Biomarkers in plasma showed markedly better discriminative performance for preoperative risk stratification and early postoperative (within 24h after surgery) detection of AKI than urine biomarkers. Discriminative power of urine biomarkers improved when concentrations were normalized to urinary creatinine, but urine biomarkers had still lower AUC values than plasma biomarkers. Best diagnostic performance 4h after surgery had plasma NGAL (AUC 0.83), cystatin C (0.76), MIG (0.74), and L-FAPB (0.73). Combinations of multiple biomarkers did not improve their diagnostic power. Preoperative clinical scoring systems (EuroSCORE and Cleveland Clinic Foundation Score) predicted the risk for AKI (AUC 0.76 and 0.71) and were not inferior to biomarkers. Preexisting chronic kidney disease limited the diagnostic performance of both plasma and urine biomarkers.

Conclusions

In our cohort plasma biomarkers had higher discriminative power for risk stratification and early diagnosis of AKI than urine biomarkers. For preoperative risk stratification of AKI clinical models showed similar discriminative performance to biomarkers. The discriminative performance of both plasma and urine biomarkers was reduced by preexisting chronic kidney disease.

Obstruction of an ileal urinary conduit in an incarcerated right inguinal hernia

We present the case of a 72-year-old man with a history of anuria from his ileal conduit 15 months following its formation. That conduit had become incarcerated in a right-sided ingunial hernia. The patient presented with anuria and an acute kidney injury. A clincal diagnosis of an incarcerated hernia was made, and he was taken to theatre for reduction and repair of the hernia. On removal of the conduit from the hernial sac, it began to drain immediately. He made a full recovery, with normalisation of his renal function.

Accuracy of Urinary Neutrophil Gelatinase-Associated Lipocalin in Quantifying Acute Kidney Injury after Partial Nephrectomy in Patients with Normal Contralateral Kidney

BACKGROUND

To evaluate the efficacy of urinary neutrophil gelatinase-associated lipocalin (uNGAL) for predicting the degree of acute kidney injury (AKI) in patients following partial nephrectomy (PN).

METHODS

This prospective study included 176 patients who underwent open or laparoscopic PN for solid renal tumors between June 2013 and May 2014. Urine samples were collected preoperatively and at 3, 24, and 48 h after renal pedicle clamp removal. Changes in uNGAL levels were analyzed for all patients and between subgroups that were dichotomized based on preoperative eGFR values of <60 and ≥60 mL/min/1.73m2, open and laparoscopic surgery, and according to the onset of AKI. Linear mixed models were used to investigate preoperative and perioperative features associated with postoperative uNGAL and eGFR changes at 6 months postoperatively.

RESULTS

Among 146 patients included in the final analysis, 10 (6.8%) patients had preoperative eGFR <60 mL/min/1.73m2. In the overall group, uNGAL levels increased following PN. However, all subgroups demonstrated comparable changes in uNGAL levels over time. Multivariate analyses failed to reveal any correctable clinical features associated with postoperative uNGAL changes, whereas preoperative serum creatinine levels and the onset of AKI correlated with eGFR at 6 months postoperatively.

CONCLUSIONS

uNGAL levels may increase following PN. However, it does not appear to be a useful marker for quantifying the degree of AKI or predicting postoperative renal function in patients with normal contralateral kidney and relatively good preoperative renal function. Further analysis is necessary to assess the usefulness of uNGAL in patients with poor preoperative renal function.

Subclinical kidney injury before and 1 year after bariatric surgery among adolescents with severe obesity

OBJECTIVE

To assess subclinical kidney injury in adolescents with severe obesity by measuring biomarkers of early kidney disease and to assess changes in the levels of these biomarkers following bariatric procedures.

METHODS

Twenty-two adolescents undergoing bariatric surgery with no microalbuminuria and normal kidney function were selected. Urinary NGAL, IL-18, and KIM-1 were measured at baseline, 6 and 12 months postoperatively. Biomarker levels were compared to 44 age-gender-matched lean controls.

RESULTS

Subjects with obesity had a mean baseline BMI of 48 kg/m(2) that decreased by 34% at 1-year follow-up. Urine NGAL, IL-18, and KIM-1 were significantly elevated in subjects with obesity compared to lean controls at baseline. The obese cohort had a further significant increase in NGAL and KIM-1 at 6 months, followed by decline at 1 year. The overall change in levels of all three biomarkers through 1 year after surgery, however, was not significant compared to baseline.

CONCLUSIONS

Adolescent severe obesity is associated with increased urinary excretion of novel biomarkers of kidney injury, despite no microalbuminuria or decreased kidney function. This subclinical kidney injury persists 1 year after significant weight loss induced by bariatric surgery, suggesting that close, long-term follow-up of kidney status is warranted in these adolescents.

Acute cardiac tamponade: an unusual cause of acute renal failure in a renal transplant recipient

We report a case of slow graft function in a renal transplant recipient caused by uremic acute pericardial effusion with tamponade. Urgent pericardiocentesis was done with an improvement in blood pressure, immediate diuresis, and quick recovery of renal function back to baseline. Pericardial tamponade should be included in consideration of causes of type 1 cardiorenal syndrome in renal transplant recipients.

[Renal dysfunction in liver disease]

In patients with liver disease various acute and chronic kidney disorders may occur, the most severe being a hepatorenal syndrome. It is usually found in patients with decompensated cirrhosis and the only effective treatment is liver transplantation. The other common causes of renal dysfunction are: prerenal (dehydration, hypovolemia) and renal (ischemia or nephrotoxicity) acute kidney injury. The most frequent chronic nephropathies are: glomerulonephritis and mixed cryoglobinemia due to viral hepatitis C and B. Finally, chronic liver disease has been associated with an increased risk of diabetic nephropathy.

Performance of urinary NGAL and L-FABP in predicting acute kidney injury and subsequent renal recovery: a cohort study based on major surgeries

BACKGROUND

Acute kidney injury (AKI) is a frequent complication of major surgery. The current study evaluated the power of two biomarkers [urinary neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid binding protein (L-FABP)] to detect the occurrence of AKI and to predict the recovery from renal dysfunction in a major surgery cohort.

METHODS

In this prospective study, 199 patients undergoing major surgery were enrolled. Urinary samples collected from participants before surgery, and 0, 4, and 12 h and 1, 2, 7, and 14 days after surgery were tested for NGAL and L-FABP.

RESULTS

Thirty-seven (18.6%) subjects developed AKI. Urinary NGAL and L-FABP were significantly increased from the time surgery was completed (p<0.05). The peak levels of NGAL and L-FABP occurred 12 and 4 h postoperatively (16.4- and 172.0-fold compared to baseline) in AKI group, respectively. The area under the receiver operating characteristic (ROC) curve (AUC) in NGAL (at 12 h), L-FABP (at 4 h), the most predictive model (NGAL at 12 h+L-FABP at 4 h), and the best combination at the same time point (12 h) was 0.83 [95% confidence interval (CI), 0.74-0.91], 0.85 (95% CI 0.77-0.93), 0.94 (95% CI 0.89-0.98), and 0.91 (95% CI 0.85-0.97), respectively. However, the largest AUC of single and combined biomarkers for predicting non-recovery after AKI only reached 0.70.

CONCLUSIONS

Urinary NGAL and L-FABP can be used to detect AKI and combining NGAL and L-FABP may improve the diagnostic performance; however, NGAL and L-FABP may be poor predictors for renal recovery after AKI.

Mesenchymal stem cells ameliorate rhabdomyolysis-induced acute kidney injury via the activation of M2 macrophages

INTRODUCTION

The mortality of rhabdomyolysis-induced acute kidney injury (AKI) is still high, as there is no effective therapy. It has been shown that bone marrow-derived mesenchymal stem cells (MSCs) can induce M2 macrophages, which mediate MSC protection in other experimental inflammation-related organ injury. This study was designed to investigate the protective effects of macrophage activation in MSC therapy of rhabdomyolysis-induced AKI.

METHODS

MSCs were injected into glycerol-induced rhabdomyolysis mice. Renal injury was evaluated using the serum creatinine, urea nitrogen, renal pathology and acute tubular necrosis score. The distribution of MSCs was detected using two-photon fluorescence confocal imaging. Immunofluorescence of anti-F4/80 and anti-CD206 was performed to determine macrophages and M2 macrophages in the tissues of the kidney, and M2 macrophage infiltration was also evaluated using western blotting analyses. After depletion of macrophages using clodronate liposomes at the phase of kidney repair, renal injury was re-evaluated. RAW 264.7 macrophages were incubated with lipopolysaccharide and co-cultured with MSCs and subsequently visualised using immunofluorescence staining and flow cytometry analysis. Finally, disparate phenotype macrophages, including normal macrophages (M0), lipopolysaccharide-stimulated macrophages (M1), and MSC-co-cultured macrophages (M2), were infused into mice with AKI, which were pre-treated with liposomal clodronate.

RESULTS

In vivo infusion of MSCs protected AKI mice from renal function impairment and severe tubular injury, which was accompanied by a time-dependent increase in CD206-positive M2 macrophage infiltration. In addition, depleting macrophages with clodronate delayed restoration of AKI. In vitro, macrophages co-cultured with MSCs acquired an anti-inflammatory M2 phenotype, which was characterised by an increased expression of CD206 and the secretory cytokine interleukin (IL)-10. The concentrations of IL-10, IL-6 and tumor necrosis factor α were evaluated using enzyme-linked immunosorbent assay. Furthermore, macrophage-depleted mice with intramuscular injection of glycerol were subjected to a single injection of different types of RAW 264.7 macrophages. Mice infused with M0 and M1 macrophages suffered a more severe histological and functional injury, while mice transfused with MSC-educated M2 macrophages showed reduced kidney injury.

CONCLUSIONS

Our findings suggested that MSCs can ameliorate rhabdomyolysis-induced AKI via the activation of macrophages to a trophic M2 phenotype, which supports the transition from tubule injury to tubule repair.

Retroperitoneal laparoscopic nephrectomy for acute blunt grade 4 renal injuries

OBJECTIVE

To first describe laparoscopic nephrectomy (LN) for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach.

PATIENTS AND METHODS

Three patients (2 males and 1 female) with acute blunt renal trauma underwent retroperitoneal LN successfully. The revised American Association for Surgery of Trauma grading system was used to grade renal injuries. All three patients with Grade 4 renal injuries required blood transfusions preoperatively and angiographic embolization because of hemodynamic instability. Given the severity of the renal injuries, failure of angiographic embolization, and persistent blood loss, surgical intervention was used. We performed retroperitoneal LN using four trocars within 24 hours after trauma for the patients.

RESULTS

Pure retroperitoneal LN was successfully performed in all 3 patients without requiring hand-assisted or open surgery. The renal hematoma dimension for the patients was 7.5, 8.4, and 9.2 cm, respectively. Operative time was 80, 110, and 130 minutes, respectively. Estimated blood loss was 100, 140, and 300 mL, respectively. The incision size was 4.2, 4.2, and 4.5 cm, respectively. The average hospital stay was 6 days. Pathology showed renal injuries without incidental renal tumors.

CONCLUSIONS

Despite the technical challenges, LN for patients with acute blunt Grade 4 renal injuries using a retroperitoneal approach is safe and feasible in carefully selected patients if conservative measures and angiographic embolization fail. However, it is important to note that one should keep a low threshold for open conversion or the hand-assisted approach whenever necessary.

Invariant natural killer T cells are depleted in renal impairment and recover after kidney transplantation

BACKGROUND

Altered immune function in patients with renal failure results in both susceptibility to infection and increased inflammatory response. Invariant natural killer T (iNKT) cells are a conserved, immunoregulatory T lymphocyte subset that responds to lipid antigens with near-immediate cytokine production and cytotoxicity. iNKT cells are required for the antibacterial host response. Whether renal failure and renal replacement therapy alter iNKT cell abundance or phenotype has not been investigated.

METHODS

iNKT cells were studied by flow cytometry in the peripheral blood of patients with acute renal failure, chronic haemo- and peritoneal dialysis (PD), chronic kidney disease and after renal transplantation.

RESULTS

A very marked reduction in iNKT lymphocytes was found in acute renal failure before the first haemodialysis (HD) session. iNKT cells were depleted in end-stage renal disease patients receiving either HD or PD. iNKT cell depletion was accentuated after an HD session. Lesser degrees were observed in patients with non-dialysis-dependent chronic kidney disease. CD56 and CD161 NK cell marker expression was decreased in renal impairment. CD56(+) and CD161(+) iNKT cells produced more interferon-γ than negative cells of the same donor. Within the first year after kidney transplantation, the decrease in iNKT cells and their NK cell markers was reverted.

CONCLUSIONS

We describe for the first time that iNKT lymphocytes are reduced in end-stage renal disease and further depleted by HD. iNKT cells are important for early host response including activation of other immune cells and their depletion may contribute to immune dysfunction in renal disease.

Emergency endovascular stent-grafting for acute type B aortic dissection with symptomatic malperfusion

AIM

The aim of this paper was to analyze the durability and efficacy of emergency thoracic endovascular aortic repair (TEVAR) for acute Stanford type B aortic dissection (TBAD) with malperfusion syndrome.

METHODS

A retrospective analysis of acute TBAD with spinal cord, kidney, viscera, and extremity malperfusion was performed. Emergency TEVAR to cover primary tear site by stent-graft was strongly suggested to included candidates. Computed tomography (CT) scans and clinical findings were carried out in diagnosis and follow-up.

RESULTS

One hundred twenty-seven TBAD patients (101 men, 46.1±11.4 year, range 34~76) who presented with acute end-organ malperfusion, including sudden paraplegia (N.=4), acute renal failure (N.=26), acute viscera ischemia (N.=61) and limb ischemia (N.=36), received aortic stent-grafting 2~48 hours after onset. Technical success was achieved in all primary TEVAR. The overall endoleak rate was 7.1% (9/127; typeI:3; typeII: 4; typeIV: 2). The 30-day mortality was 0.8% (2/127). 125 patients were followed for 19.1±14.5 (1~86) months, one patient died 50 days post-TEVAR due to myocardial infarction. Four patients required reintervention with additional stent grafts. Follow-up CT angiography showed enlargement of the true lumen and different degrees of thrombosis in the distal false lumen (complete thrombosis in 48, partial thrombosis in 52 and patency in 24).

CONCLUSION

Emergency TEVAR is an effective method to treat acute TBAD complicated with end-organ malperfusion. Covering of the proximal entry site of TBAD by stent-graft leads to flow increased in the true lumen and thrombosis of the false lumen of varying degree, which may improve end-organ perfusion and restore branch vessels patency.

Effect of novel vitamin D receptor activator paricalcitol on renal ischaemia/reperfusion injury in rats

INTRODUCTION

Despite the developments in modern medicine, acute renal injury is still a challenging and common health problem. It is well known that ischaemia and reperfusion takes place in pathological mechanisms. Efforts to clarify the pathophysiology and interventions to improve outcomes are essential. Our study aimed to investigate whether the prophylactic use of paricalcitol is beneficial in renal ischaemia/reperfusion (I/R) injury.

METHODS

Twenty-four Wistar albino rats were assigned randomly to four groups. Right nephrectomies were performed at the time of renal arterial clamping. Sham surgery was performed on the rats in group 1. For the rats in group 2, the left renal artery was clamped for 45 minutes. The rats in group 3 received paricalcitol for seven days (0.2μg/kg/day); following this, a right nephrectomy and left renal arterial clamping were not performed. The rats in group 4 received paricalcitol for seven days (0.2μg/kg/day); following this, a right nephrectomy and left renal arterial clamping for 45 minutes were performed. Tissue thiobarbituric acid reactive substances (TBARS), superoxide dismutase, sulfhydryl groups as well as nitric oxide metabolites, serum urea and creatinine levels were measured for all four groups.

RESULTS

In group 4, there were some improvements in terms of TBARS, nitrite, nitrate, superoxide dismutase and creatinine levels. In the histopathological evaluation, paricalcitol therapy improved tubular necrosis and medullar congestion but there was no significant difference in terms of tubular cell swelling, cellular vacuolisation or general damage. Immunohistopathological examination revealed lower scores for vascular endothelial growth factor in the group 4 rats than in group 2.

CONCLUSIONS

Paricalcitol therapy improved renal I/R injury in terms of serum and histopathological parameters. These potential beneficial effects need to be further investigated.

Crossed renal ectopia presenting with suprapubic swelling and acute renal failure

A 17-year-old male was admitted with a fluctuant suprapubic mass. A bladder scan demonstrated > 999 ml filling so he was catheterised. However, only 75ml of urine was drained. He was in acute renal failure with serum potassium of 6.5mmol/l. Computerised tomography (CT) scan showed a large midline 'cystic mass' separate from the bladder compressing the left ureter, causing left-sided hydronephrosis. Right kidney was not visualised. Percutaneous aspiration of the 'cyst' yielded 2000ml of straw-coloured fluid high in creatinine, urea and electrolytes indicating that it was urine. Having relieved the left ureter, the patient was subsequently diuresed, and renal function returned to normal. A CT urogram showed contrast uptake with renal parenchyma in the "cyst". Consequently, a diagnosis of right-sided crossed renal ectopia was made. Bilateral ureteric stents were inserted, and later a right-sided nephrectomy was performed. The patient made a full recovery. To the best of our knowledge, this is the only reported case of crossed renal ectopia causing obstruction of the normal ureter, resulting in acute renal failure.The role of modern imaging in the management of this condition is also highlighted in this report.

Hypoxic preconditioning with cobalt of bone marrow mesenchymal stem cells improves cell migration and enhances therapy for treatment of ischemic acute kidney injury

Mesenchymal stem cell (MSC) administration is known to enhance the recovery of the kidney following injury. Here we tested the potential of hypoxic-preconditioned-MSC transplantation to enhance the efficacy of cell therapy on acute kidney injury (AKI) by improving MSC migration to the injured kidney. Cobalt was used as hypoxia mimetic preconditioning (HMP). MSC were subjected to HMP through 24 h culture in 200 µmol/L cobalt. Compared to normoxia cultured MSC (NP-MSC), HMP significantly increased the expression of HIF-1α and CXCR4 in MSC and enhanced the migration of MSC in vitro. This effect was lost when MSC were treated with siRNA targeting HIF-1α or CXCR4 antagonist. SPIO labeled MSC were administered to rats with I/R injury followed immediately by magnetic resonance imaging. Imaging clearly showed that HMP-MSC exhibited greater migration and a longer retention time in the ischemic kidney than NP-MSC. Histological evaluation showed more HMP-MSC in the glomerular capillaries of ischemic kidneys than in the kidneys receiving NP-MSC. Occasional tubules showed iron labeling in the HMP group, while no tubules had iron labeling in NP group, indicating the possibility of tubular transdifferentiation after HMP. These results were also confirmed by fluorescence microscopy study using CM-DiI labeling. The increased recruitment of HMP-MSC was associated with reduced kidney injury and enhanced functional recovery. This effect was also related to the increased paracrine action by HMP-MSC. Thus we suggest that by enhancing MSC migration and prolonging kidney retention, hypoxic preconditioning of MSC may be a useful approach for developing AKI cell therapy.

The role of urinary liver-type fatty acid-binding protein in critically ill patients

Although several urinary biomarkers have been validated as early diagnostic markers of acute kidney injury (AKI), their usefulness as outcome predictors is not well established. This study aimed to determine the diagnostic and prognostic abilities of urinary liver-type fatty acid-binding protein (L-FABP) in heterogeneous critically ill patients. We prospectively collected data on patients admitted to medical and surgical intensive care units (ICUs) from July 2010 to June 2011. Urine neutrophil gelatinase-associated lipocalin (NGAL) and L-FABP at the time of ICU admission were quantitated. Of the 145 patients, 54 (37.2%) had AKI defined by the Acute Kidney Injury Network (AKIN) criteria. AKI patients showed significantly higher level of urinary NGAL and L-FABP and also higher mortality than non-AKI patients. The diagnostic performances, assessed by the area under the ROC curve, were 0.773 for NGAL and 0.780 for L-FABP, demonstrating their usefulness in diagnosing AKI. In multivariate Cox analysis, urinary L-FABP was an independent predictor for 90-day mortality. Urinary L-FABP seems to be promising both for the diagnosis of AKI and for the prediction of prognosis in heterogeneous ICU patients. It needs to be further validated for clinical utility.

[Early markers of acute kidney injury in newborns]

The incidence of acute kidney injury (AKI) at neonatal intensive care units (NICU) is estimated as 6-24%. Traditional AKI markers i.e. serum creatinine (SCr) concentration, fractional sodium exertion, urine sodium concentration and renal failure index--are low sensitivity and low specificity markers but beside remain very late ones. Serum creatinine concentration arises 48 hours after renal tissue damage. The paper presents contemporary knowledge concerning concentration reference ranges of some early AKI biomarkers (NGAL, hKIM1, OPN, IL18)--either in term or preterm newborns. The most current reports about chosen AKI biomarkers in newborns with uncomplicated clinical course and in children with AKI within the course of sepsis or after cardiopulmonary bypass surgery--were discussed. Disposing of the reliable clinical data referring to early AKI biomarkers constitutes a valuable aid for clinicians who having got to know about the actual risk possess the time for proper clinical interventions.

[Acute renal failure and chronic diarrhea: McKittrick-Wheelock syndrome]

In 1954, McKittrick and Wheelock described for the first time a syndrome presenting chronic lost of fluid and electrolytes secondary to chronic diarrhea, associated to large rectal villous adenomas. We report a case of a 75-year-old female who presented chronic diarrhea (3 to 4 depositions per day in the last year), accompanied by acute renal failure. In the rectal tact, we objective the presence of a mass of soft consistency with an irregular surface, occupying approximately two thirds of the circumference, at about 3 cm from the anal margin. It was confirmed by the colonoscopy and the patology was informed as villous adenoma, producing chronic diarrhea or McKittrick-Wheelock syndrome. We decide the surgical approach after the normalization of patient's general status and a proctectomy with coloanal anastomosis was performed. We conclude that we must think about this syndrome in aged patients with chronic diarrhea, alterations of the electrolyte balance and presence of renal failure. Surgery treatment after the replacement of water and electrolytes is the unique curative treatment. The absence of this can cause the death of these patients.

Microvasculopathy in ischemic acute kidney injury: consequences and therapeutic implications

Ischemic acute kidney injury (iAKI) is the most frequent type of hospital-aquired acute renal failure (ARF). Mortality of ARF still ranges between 30% and 50%. Although acute renal ischemia significantly affects function and structure of the tubular epithelium, postischemic interstitial inflammation and microvasculopathy both contribute to ongoing renal dysfunction. The renal vasculature shows a highly specialized architecture. Renal ischemia induces severe alterations of the endothelium in small peritubular arterioles and capillaries. Investigations performed in recent years point towards a new therapeutic approach in iAKI, that is to target postischemic endothelial dysfunction by administering cells of the endothelial lineage. With regard to endothelial-type cells, new perspectives are offered with the identificaton of endothelial progenitor cells (EPCs). Although heterogenous in nature, EPCs can be employed for anti-ischemic treatment in different situations. Meanwhile the cells have been shown to protect mice from iAKI and several strategies have been established in order to increase the renoprotective capacity of EPCs. Further investigations will help to clarify whether EPCs not only protect the kidney in the short- but also in the long-term.

Surgical rescue and restoration of renal function in a post-hysterectomy anuric patient--a case report

The recovery of renal function following release of urinary tract obstruction with advanced azotemia determines both the need for emergency dialysis in the early postoperative period and the long term planning for chronic kidney disease management.

METHOD AND RESULTS

The case of a 60-year-old woman with a anuria following a Total Abdominal Hysterectomy done in a peripheral hospital presenting in the emergency unit two weeks after the surgery is presented. Her management and subsequent restoration of renal function are discussed.

CONCLUSION

This report highlights the need to intervene early restore renal function in patients with bilateral urete obstruction.

Bilateral renal malakoplakia with acute renal failure: a case report and literature review

Malakoplakia involving the genitourinary tract is a rare inflammatory disorder that presents a diagnostic challenge. Renal parenchymal involvement is particularly uncommon. We report a case of bilateral renal malakoplakia that presented with acute renal failure and simulated xanthogranulomatous pyelonephritis (XGP). The etiology, clinical course, and management of malakoplakia are reviewed, emphasizing the distinct characteristics of the disease that lead to its accurate diagnosis.

Intramural dissection of the renal collecting system during percutaneous nephrostomy: computed tomography findings of a rare complication

Intramural dissection of the renal collecting system during percutaneous nephrostomy (PCN) is a rare complication that can be challenging to diagnose. In this report, we describe the computed tomography (CT) and fluoroscopic findings of urothelial dissection during CT-guided PCN in a 65-year old patient with an obstructed congenital solitary left kidney due to an urinary bladder carcinoma. To our knowledge, CT findings of urothelial dissection have not yet been described.

Outcomes of fasciotomy in patients with crush-induced acute kidney injury after Bam earthquake

INTRODUCTION. Fasciotomy may increase the morbidity and mortality in patients with crush-induced acute kidney injury (AKI), by creating an open wound, increasing the risk of bleeding, coagulopathy, and potentially fatal sepsis. This study evaluates the outcomes of fasciotomy in these patients after Bam earthquake in Iran. MATERIALS AND METHODS. We reviewed medical records of victims of Bam earthquake complicated with crush-induced AKI. Demographic, biochemical, and clinical data of patients who underwent fasciotomy were evaluated and compared with other patients with AKI. RESULTS. Fasciotomy was performed for 70 of 200 patients with crush-induced AKI (35.0%). There were no significant differences regarding sex, age, time under the rubble, and muscle enzymes level between these patients and those without fasciotomy. They did not experience higher rates of disseminated intravascular coagulopathy, sepsis, adult respiratory distress syndrome, amputation, and dialysis session. Neither did they have a longer hospitalization period or higher death rate. CONCLUSIONS. This study showed that fasciotomy did not have any deteriorating effect on morbidity and mortality of patients with crush-induced AKI after Bam earthquake.

Testing and management of thrombocytopenia and coagulopathy in the pre- and postliver transplant patient

Caring for patients with advanced liver disease and acute liver failure requires a thorough understanding of the profound coagulation changes that occur in these conditions. Due to the unique nature of the pathophysiologic changes from hepatic dysfunction, effective interpretation and management of coagulopathy and thrombocytopenia with blood products are important clinical skills, and are likewise required in the post transplant period. Acute superimposed complications such as sepsis and renal dysfunction present additional challenges. The aim of this review was to describe the coagulation changes in liver disease, appropriate coagulation testing, and management strategies in the pre- and post-transplant period.

Stem cell technology for the treatment of acute and chronic renal failure

Acute and chronic renal failure are disorders with high rates of morbidity and mortality. Current treatment is based upon conventional dialysis to provide volume regulation and small solute clearance. There is growing recognition that renal failure is a complex disease state requiring a multifactorial therapy to address the short-comings of the conventional monofactorial approach. Kidney transplantation remains the most effective treatment, however, organ availability lags far behind demand. Many key kidney functions including gluconeogenesis, ammoniagenesis, metabolism of glutathione, catabolism of important peptide hormones, growth factors, and cytokines critical to multiorgan homeostasis and immunomodulation are provided by renal tubule cells. Therefore, cell-based therapies are promising multifactorial treatment approaches. In this review, current stem cell technologies including adult stem cells, embryonic stem cells and induced pluripotent stem cells will be discussed as cell sources for the treatment of acute and chronic renal failure.

A successfully treated case of hyperosmolar hyperglycemic state complicated with rhabdomyolysis, acute kidney injury, and ischemic colitis

A 48-year-old Japanese male was admitted to our hospital due to hyperosmolar hyperglycemic state (HHS), combined with rhabdomyolysis and acute kidney injury. His blood sugar levels were gradually decreased by fluid resuscitation and insulin infusion; however, his renal function worsened, and he developed bloody stools. He required continuous hemodiafiltration to improve his hemodynamics. As colonoscopy revealed longitudinal ulcers, ischemic colitis was diagnosed. We treated him conservatively at first, but when we found the ulceration of the sigmoid colon had penetrated the mesenterium, colectomy was indicated. After surgery, his general condition improved. Careful monitoring of complications related to HHS is important.