胆汁性肾病麻醉与术后急性肾功能衰竭的关系

报道梗阻性黄鱼合并胆汁性肾病（ＣＮ）３４例，术后死亡率２９．４％，急性肾功能衰竭（ＡＲＦ）发 生率４１．２％，ＡＲＦ死亡率为７１．４％。作者探讨了ＣＮ患者麻醉处理与术后ＡＲＦ关系，认为ＣＮ是术后 ＡＲＦ发生率和死亡率增高的病理基础，肾功能处于ＡＲＦ的前兆，麻醉手术有一定的危险性，ＡＲＦ发生 率与黄疸程度、麻醉方法和低血压持续时间有关。ＣＮ患者选择全麻优于连续硬膜外阻滞，对于重度黄疸 （和）或伴有感染性休克者应首选全麻。正确的麻醉处理是防止和减少术后ＡＲＦ的关键。     

An exceptional case of acute renal failure: is there a renal toxicity of Artemisia herba-alba?

A 59-year-old diabetic man was admitted for severe acute renal failure. Clinical signs were compatible with an acute tubular necrosis but no etiology was found. Kidney biopsy showed an osmotic nephrosis. Resumption of interrogatoire reveals consumption of Artemisia herba-alba accused in very few experimental studies to cause a lesion indicative of osmotic nephrosis.     

Renal transplants from non-heart beating paracetamol overdose donors

INTRODUCTION: Non-heart beating donors (NHBD) are widely encouraged to avert the critical shortage in the kidney donor pool. Ischaemic injury at the time of cardiac arrest in the NHBD is more pronounced and therefore the kidneys resulting are considered marginal. This review describes our experience with four kidneys from two controlled NHBDs who were exposed to paracetamol intoxication and subsequently were treated with mannitol prior to organ donation. MATERIALS AND METHOD: Two patients with fulminant liver failure following paracetamol overdose were referred as 'withdrawal of treatment' NHBD. As the two patients had developed hepatic encephalopathy they were treated with mannitol to reduce intra-cerebral oedema. The two donors were oligoanuric for at least 24 h prior to cardiac arrest. Following cardiac arrest, in situ perfusion was carried out and the kidneys were removed. One pair of kidneys were machine perfused while the second pair of kidneys were cold stored prior to transplantation. RESULTS: Pre-transplant assessment of NHBD kidneys resulted in three of four kidneys being transplanted. The NHBD kidneys exhibited a period of delayed graft function (DGF). The early transplant biopsies showed evidence of diffuse cytoplasmic vacuolation. These histological features disappeared with time and the renal function improved until the time of discharge. DISCUSSION: Non-heart beating donor kidneys are considered marginal and the effect of mannitol and paracetamol drug intoxication will induce reversible sub-lethal injury. A period of dialysis is inevitable in clearing the reactive intermediates of mannitol and paracetamol. The kidneys behaved as traditional controlled NHBD at time of discharge.     

有机溶剂相关性肾病综合征患者的护理

目的总结有机溶剂相关性肾病综合征患者的护理,为临床护理工作提供参考。方法对57例经肾活检明确诊断为有机溶剂相关性肾病综合征患者行免疫抑制剂和对症治疗,并针对性进行水肿护理、肾功能不全的护理、血栓及感染的预防指导等。结果 57例中4例患者转变为慢性肾功能不全,进行常规保肾治疗,另53例采用免疫抑制剂治疗。患者住院6~11 d,平均8.4 d出院。出院后随访1~73个月,5例患者死亡,死因为严重感染和尿毒症高钾血症;52例继续治疗中。结论有机溶剂相关性肾病综合征病情发展迅速,预后极差,在临床上除对症治疗护理外,还应注意预防感染、血栓等严重并发症,以改善预后,提高患者生活质量。     

Postpartum acute kidney injury: a review of 99 cases

Postpartum acute kidney injury (PPAKI) constitutes an important cause of obstetric AKI. It is associated with high maternal and fetal mortality in developing nations. The aim of this study is to survey the etiology and outcomes of PPAKI in a tertiary care Indian hospital. Ninety-nine patients, without prior comorbidities, treated for PPAKI, between 2005–2014 at M.S. Ramaiah Medical College, were included for analysis in this retrospective, observational study. AKI was analyzed in terms of maximal stage of renal injury attained as per RIFLE criteria. Outcomes included requirement for renal replacement therapy (RRT), maternal and fetal outcomes. PPAKI constituted 60% of all obstetric AKI cases. Median maternal age was 23 years and 52% of patients were primigravidas. Mean serum creatinine was 4.1?mg/dL. Failure (33%) and injury (31%) were the major categories as per RIFLE criteria. Thirty-nine percent of cases required RRT. Sepsis, particularly puerperal sepsis, was the leading causes of PPAKI (75% of cases) and maternal mortality (94% of deaths). Maternal and fetal mortality were 19% and 22% respectively. The incidence of cortical necrosis was 10.3%. Three patients required long-term RRT. In conclusion, consistent with other Indian literature, we report a high incidence of PPAKI. We found incremental mortality on moving from “Risk” to “Failure” category of RIFLE. PPAKI was associated with high maternal and fetal mortality with sepsis being the leading cause. Our study highlights the need for provision of better quality of maternal care and fetal monitoring to decrease mortality associated with PPAKI in developing countries.     

Mortality in Elderly Patients with Acute Renal Failure

In a retrospective study, we identified 55 elderly patients with acute renal failure (ARF) admitted to our hospital during an 8-year period from 1985 to 1993. Information about the etiology, complications, laboratory data, and treatment course were obtained from the clinical history. Of the 200 patients with ARF admitted to the hospital during this period, 28% were patients more than 60 years old (41 male and 14 female) with an average age of 68.5 ± 7 years. The main causes of ARF were sepsis, volume depletion, low cardiac output, arterial hypotension, nephrotoxicity by antibiotics, and obstructive uropathy. The global mortality of elderly patients with ARF was 53%. The mortality rate of the different types of the ARF were: prerenal 35%, intrinsic 64% (oliguric 76%, nonoliguric 50%), and postrenal 40%. Mortality as a result of sepsis occurred in 18 patients (62%), by cardiovascular disease in 4 patients (13%), by acute respiratory failure in 2 patients (7%), and by other causes in 5 patients (18%). In the cases of sepsis, Pseudomonas was detected in 7 cases (39%), Escherichia coli in 2 cases (11%), Gram-negative nonspecific in 3 cases (17%), Klebsiella in 1 case (5%), and in 5 cases (16%), the hemoculture was negative. The patient survival rate was 47% (26 of 55 patients). Of these patients, 19 recovered their normal renal function (73%), but 7 patients remained with renal failure (27%). In conclusion, the global mortality in the elderly patients without considering the types of ARF was 53%. The oliguric form had the highest mortality rate with 76%. The main causes for mortality were sepsis with 62%, cardiovascular disease with 13%, and other causes 18%.     

Osmotic Nephropathy Resulting from Maltose-Based Intravenous Immunoglobulin Therapy

Intravenous immunoglobulin preparations are being used for an increasing number of indications. To minimize adverse reactions, sugar additives such as sucrose, maltose, and glycine are added to some preparations to serve as stabilizing agents. Intravenous immunoglobulin infusion induces acute renal failure (ARF) via a mechanism of osmotic nephrosis. Most reported cases are related to the use of sucrose-based intravenous immunoglobulin. Herein, we describe a patient with lupus nephritis treated with an immunoglobulin preparation containing maltose who developed ARF with histologic changes characterized by vacuolization and swelling of renal proximal tubular cells. Our case draws nephrologists' attention to the potential of maltose-based immunoglobulin in producing renal failure. Awareness and exercising caution in high-risk groups is elementary to the prevention of this condition.     

Does Early Initiation of Continuous Renal Replacement Therapy Affect Outcome: Experience in a Tertiary Care Center

Abstract

Background: Acute kidney injury (AKI) requiring dialysis commonly occurs in critically ill patients and is associated with high mortality. Factors impacting outcomes of individuals with AKI who underwent continuous renal replacement therapy (CRRT), including early versus late initiation and duration of CRRT, were examined. Methods: Survival and recovery of renal function for patients with AKI in the intensive care unit were retrospectively examined over a 7-year period. Factors associated with mortality and renal recovery were analyzed based on severity of illness as defined by Cleveland Clinic Foundation (CCF) score. Univariate and multivariate logistic regression analysis with backward elimination was performed to determine the most significant risk factors. Results: Of patients who underwent CRRT, 230/330 met inclusion criteria. During index admission 112/230 (48.7%) patients died. Median survival was 15.5 days [95% confidence interval (12.0, 18.0)]. Among survivors, renal recovery occurred in 84/118 (71.2%). Renal recovery overall was observed in 90/230 subjects (39.13%). A higher baseline CCF score correlated with higher mortality and lower probability of renal recovery. Patients initiated on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared with those initiated earlier (odds ratio = 11.66, p = 0.0305). Patients receiving CRRT >10 days had a higher mortality rate compared with those with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012). Conclusions: CRRT remains an important dialysis modality in hemodynamically unstable patients with AKI. Mortality in these patients continues to be high. Renal recovery is high in survivors. Delay in initiation and length of CRRT exposure may portend poorer prognosis.     

Toxicité rénale des produits de contraste radiologiques

The nephrotoxicity of iodinated contrast agent/media is defined by acute renal failure occurring within 48 to 72 hours after injection of iodized contrast product, in the absence of other etiology. The risk factors for contrast agent renal injury must systematically be sought before the exam. The presence of risk factors, including the existence of a renal failure defined by a creatinine clearance (eGFR) of less than 60 mL/min/1.73 m², requires to take prevention measures including hydration. If eGFR is less than 30 mL/min/1.73 m², the advice of a nephrologist is necessary.     

Early detection of acute kidney injury: emerging new biomarkers

SUMMARY:   Acute kidney injury (AKI) has recently become the preferred term to describe the syndrome of acute renal failure (ARF) with 'failure' or 'ARF' restricted to patients who have AKI and need renal replacement therapy. ¹ This allows capture of the broader clinical spectrum of modest reductions in creatinine, which are themselves known to be associated with major increases in both short- and long-term mortality risk. ^2–5 It is hoped that this change in nomenclature will facilitate an expansion of our understanding of the underlying pathophysiology and also facilitate definitions of AKI, which allow comparisons among clinical trials of patients with similar duration and severity of illness. This review will cover the need for early detection of AKI and the role of urinary and plasma biomarkers, including enzymuria. The primary message is that use of existing criteria to diagnose AKI, namely elevation of the serum creatinine with or without oliguria, results in identification that is too late to allow successful intervention. New biomarkers are essential to change the dire prognosis of this common condition.     

Acute Renal Disease, as Defined by the RIFLE Criteria, Post-Liver Transplantation

Acute renal failure (ARF) can complicate up to 60% of orthotopic liver transplants (OLT). The RIFLE criteria were developed to provide a consensus definition for acute renal disease in critically ill patients. Using the RIFLE criteria, we aimed to determine the incidence and risk factors for ARF and acute renal injury (ARI), and to evaluate the link with the outcomes, patient survival and length of hospital stay. Three hundred patients, who received 359 OLTs, were retrospectively analyzed. ARI and ARF occurred post 11.1 and 25.7% of OLTs, respectively. By multivariate analysis, ARI was associated with pre-OLT hypertension and alcoholic liver disease and ARF with higher pre-OLT creatinine, inotrope and aminoglycoside use. ARF, but not ARI, had an impact on 30-day and 1-year patient survival and longer length of hospital stay. ARI and ARF, as defined by the RIFLE criteria, are common complications of OLT, with distinct risk factors and ARF has serious clinical consequences. The development of a consensus definition is a welcome advance, however these criteria do need to be validated in large studies in a wide variety of patient populations.     

Osmotherapy for increased intracranial pressure: Comparison between mannitol and glycerol

Summary Osmotic agents are still the most common treatment for controlling intracranial hypertension (ICH). Mannitol, glycerol, sorbitol, and hypertonic serum saline are the agents currently available.This work was designed to compare mannitol and glycerol in a similar population of brain injured patients, randomly divided into two groups of eight. The following mean day parameters were obtained: number of infusions, hydric balance, mean arterial pressure (MAP), and intracranial pressure (ICP). Cerebral perfusion pressure (CPP) was calculated. Brain computed tomographies (CT) were obtained on arrival, at follow-up whenever justified and at discharge. For comparison of both groups a modified therapeutic intensity level (mTIL) was used.Both agents induced a statistically equally effective decrease on ICP and increase on CPP evaluated at one and two hours post infusion but the mean day mTIL showed a statistically significant difference in favour of glycerol. The possible explanations of this difference are discussed. According to our results mannitol would be most indicated as a bolus to control sudden rises in ICP whereas glycerol would be most indicated as a basal treatment.     

Mesangial IgA deposits with steroid responsive nephrotic syndrome: probable minimal lesion nephrosis

Two children presented with nephrotic syndrome. Renal biopsy demonstrated minimal lesion nephrosis with mesangial IgA deposits. Response to prednisone therapy was prompt in both cases. The clinical and histologic features of these and other reported cases suggested a diagnosis of minimal lesion nephrosis and not IgA nephropathy (Berger's disease).     

Acute kidney injury in children

Acute kidney injury (AKI) (previously called acute renal failure) is characterized by a reversible increase in the blood concentration of creatinine and nitrogenous waste products and by the inability of the kidney to regulate fluid and electrolyte homeostasis appropriately. The incidence of AKI in children appears to be increasing, and the etiology of AKI over the past decades has shifted from primary renal disease to multifactorial causes, particularly in hospitalized children. Genetic factors may predispose some children to AKI. Renal injury can be divided into pre-renal failure, intrinsic renal disease including vascular insults, and obstructive uropathies. The pathophysiology of hypoxia/ischemia-induced AKI is not well understood, but significant progress in elucidating the cellular, biochemical and molecular events has been made over the past several years. The history, physical examination, and laboratory studies, including urinalysis and radiographic studies, can establish the likely cause(s) of AKI. Many interventions such as ‘renal-dose dopamine’ and diuretic therapy have been shown not to alter the course of AKI. The prognosis of AKI is highly dependent on the underlying etiology of the AKI. Children who have suffered AKI from any cause are at risk for late development of kidney disease several years after the initial insult. Therapeutic interventions in AKI have been largely disappointing, likely due to the complex nature of the pathophysiology of AKI, the fact that the serum creatinine concentration is an insensitive measure of kidney function, and because of co-morbid factors in treated patients. Improved understanding of the pathophysiology of AKI, early biomarkers of AKI, and better classification of AKI are needed for the development of successful therapeutic strategies for the treatment of AKI.     

Regulated Cell Death in AKI

AKI is pathologically characterized by sublethal and lethal damage of renal tubules. Under these conditions, renal tubular cell death may occur by regulated necrosis (RN) or apoptosis. In the last two decades, tubular apoptosis has been shown in preclinical models and some clinical samples from patients with AKI. Mechanistically, apoptotic cell death in AKI may result from well described extrinsic and intrinsic pathways as well as ER stress. Central converging nodes of these pathways are mitochondria, which become fragmented and sensitized to membrane permeabilization in response to cellular stress, resulting in the release of cell death–inducing factors. Whereas apoptosis is known to be regulated, tubular necrosis was thought to occur by accident until recent work unveiled several RN subroutines, most prominently receptor-interacting protein kinase–dependent necroptosis and RN induced by mitochondrial permeability transition. Additionally, other cell death pathways, like pyroptosis and ferroptosis, may also be of pathophysiologic relevance in AKI. Combination therapy targeting multiple cell-death pathways may, therefore, provide maximal therapeutic benefits.     

Any heart failure treatments associated with worsening renal function in patients admitted due to acute heart failure?

BackgroundWorsening renal function (WRF) occurs in approximately 25% of acute heart failure patients, and both baseline characteristics and heart failure treatment may increase the risk of WRF. This study aimed to evaluate additional risk factors for WRF in acute heart failure, particularly those related to heart failure treatment.MethodsThis was a retrospective, observational, analytical study. The inclusion criteria were age 18 years or over, hospital admission due to acute heart failure, and having undergone at least two serum creatinine tests during admission. The eligible patients were classified into two groups: WRF and non-WRF. Predictors for WRF (including treatment parameters) were determined using logistic regression analysis.ResultsDuring the study period, there were 301 eligible patients who met the study criteria. Of those, 82 (27.24%) had WRF. There were two independent factors associated with WRF occurrence: baseline diastolic blood pressure and beta blocker treatment, with adjusted odds ratios (95% confidence interval) of 1.060 (1.008, 1.114) and 0.064 (0.006, 0.634), respectively. The Hosmer-Lemeshow Chi square for the final model was 6.11 (p = .634).  ConclusionsAfter examining several heart failure treatments and baseline factors, we found that beta blocker treatment results improvement in kidney function.     

Acute renal failure in children with idiopathic nephrotic syndrome

Acute renal failure (ARF) is an uncommon but alarming complication of idiopathic nephrotic syndrome. The renal failure could be secondary to causes evident from the history and evaluation, such as severe intravascular volume depletion, acute tubular necrosis, allergic interstitial nephritis, bilateral renal vein thrombosis, acute pyelonephritis, or rapid progression of the original glomerular disease. It may be termed idiopathic if the underlying cause is undetermined. We present three children with idiopathic nephrotic syndrome who were admitted with acute renal failure. One case was due to drug-induced allergic interstitial nephritis. The other two were idiopathic in nature. Improvement in renal function occurred in the three patients over a variable period of 10 days to 4 weeks. After careful exclusion of well-known causes of acute renal failure, idiopathic acute renal failure (IARF) should be considered as a diagnostic possibility in these patients. The exact pathophysiology of IARF is not understood. Possible proposed explanations include interstitial edema, tubular obstruction, altered glomerular permeability, and unrecognized hypovolemia.