Acute renal failure of leptospirosis: nonoliguric and hypokalemic forms

Acute renal failure induced by leptospirosis was studied in 56 patients. A higher frequency of nonoliguric renal failure was observed with lower morbidity and mortality rates than in oliguric forms. In addition, 45% of the patients in this series were hypokalemic, and no hyperkalemic patients were seen. A prospective study in 11 patients showed an initially elevated urinary fractional potassium excretion that fell simultaneously with the high urinary fractional sodium excretion and the urinary K/Na ratio, suggesting an increased distal potassium secretion due to an increased distal sodium delivery consequent to functional impairment of the proximal reabsorption of sodium.     

Acute renal failure after nonmyeloablative hematopoietic cell transplantation

Acute renal failure (ARF) is a common life-threatening complication after myeloablative allogeneic hematopoietic cell transplantation (HCT). Nonmyeloablative HCT aims to eradicate the malignancy with graft-versus-tumor effect, rather than with high doses of chemoradiotherapy. It may be anticipated that a lower risk of ARF exists in nonmyeloablative HCT as a result of the milder preconditioning regimen. However, the patients who receive the nonmyeloablative HCT are older individuals who are not eligible for the more toxic allogeneic myeloablative procedure. The goal of this study was to evaluate ARF in a large group of patients who received nonmyeloablative HCT. This cohort study enrolled patients who were undergoing nonmyeloablative HCT at four major centers from 1998 to 2001. Conditioning therapy involved total body irradiation 2 Gy +/- fludarabine 30 mg/m2. Posttransplantation immunosuppression consisted of cyclosporine or tacrolimus and mycophenolate mofetil. ARF was classified into four grades, similar to previous studies in the literature. Collectively, 253 patients were recruited into this study. ARF (>50% decrease in GFR) occurred in 40.4% of patients over a 3-mo period, with 4.4% of patients requiring dialysis. The overall mortality in the study population was 34% at 1 yr. The mortality increased with worsening grade of ARF. The combined need for dialysis and artificial ventilation was associated with a mortality exceeding 80%. Although the number of patients who develop ARF is significant, the risk of developing ARF that requires dialysis after nonmyeloablative HCT is infrequent despite the older age of the patients. The data are also suggestive that ARF may contribute to mortality after nonmyeloablative HCT.     

Acute hyperuricemic nephropathy and renal failure after transplantation

This report describes a patient who was treated for rejection of a cadaveric renal allograft with a variety of drugs, including the continuous administration of ciclosporin over a period of 16 months. The patient developed hyperuricemia, attacks of gout and finally a rapidly progressing renal failure 17 months after transplantation. The removed transplanted kidney showed extensive tubular dilatation, intratubular deposits of uric acid crystals and characteristic granulomas. There was also morphologic evidence of transplant glomerulopathy, as well as scattered linear parenchymal (cortical?) scars of the type seen in mild chronic ciclosporin toxicity. Both of these changes undoubtedly contributed to the reduction of renal reserve. However, we propose that prolonged continuous use of ciclosporin was the main factor in the development of hyperuricemia and obstructive hyperuricemic nephropathy and renal failure in this patient. To our knowledge cases of this nature have not been previously reported.     

Acute renal failure after cadaveric related liver transplantation

Acute renal failure (ARF) is a frequent medical complication after liver transplantation (LT). We analyzed cadaveric related liver transplant recipients who had developed ARF early in the postoperative course. Between January 1982 and August 2003, a total of 67 patients underwent cadaveric related LT. Their mean age was 28.64 years at LT. The 67 recipients had the following indications: biliary atresia (n = 17), Wilson's disease (n = 15), hepatitis B-related liver cirrhosis (n = 14), hepatitis C-related liver cirrhosis (n = 4), primary biliary cirrhosis (n = 4), hepatitis B-related liver cirrhosis with hepatoma (n = 3), hepatitis C-related liver cirrhosis with hepatoma (n = 2), Budd-Chiari syndrome (n = 2), neonatal hepatitis (n = 1), choledochus cyst (n = 1), autoimmune cirrhosis (n = 1), neuroendocrine tumor (n = 1), and hemangioendothelioma (n = 1). Forty-nine patients received cyclosporine (CsA), azathioprine, and steroids and 18, a combination with tacrolimus (FK506). Eight (11.94%) patients developed ARF at a mean time of 17.25 days after LT. The mean peak serum creatinine was 2.24 mg%. Four of these patients had a diagnosis of hepatitis B-related liver cirrhosis; two, hepatitis C-related liver cirrhosis; one, primary biliary cirrhosis; and one, hepatitis B-related liver cirrhosis with hepatoma. The ARF etiology was multifactorial for the majority of patients. Eight ARF patients had a history of liver cirrhosis, which may be a risk factor for intraoperative ARF. ARF treatment included fluid replacement, decreased or altered immunosuppressive agents, avoiding exposure to nephrotoxic drugs, and adjusting antibiotic dosages. The majority of patients returned to normal renal function at 1 to 3 weeks after the diagnosis of ARF. No patient required dialysis and/or experienced a mortality. We conclude that the incidence of ARF is relatively low and with good outcomes. ARF etiology was multifactorial for the majority of patients, but eight patients had a history of liver cirrhosis, which may be a risk factor for intraoperative ARF. We suggest that in the early postoperative period of LT cases diagnosis and treatment of ARF are important.     

Acute renal failure requiring renal replacement therapy after orthotopic liver transplantation

OBJECTIVES: Acute renal failure (ARF) is a severe complication in patients undergoing orthotopic liver transplantation (OLT), which predicts a poor outcome. The aim of this study was to analyze risk factors for the development of ARF, including severity of illness, onset time of ARF prognostic factors of outcome, and mortality in a group of critically patients requiring renal replacement therapy (RRT). METHODS: Retrospective analysis of 240 consecutive liver transplant cases from 1999 to 2001 admitted to the intensive care unit (ICU) was performed to identify risk factors for ARF development after OLT. The analyzed factors were: age, sex, CrS, BUN, diuresis, sepsis, hypovolemia, cardiac failure, nephrotoxic drugs (cyclosporine or FK506, antibiotics), hyperbilirubinemia, associated diseases (DM, CRF), onset time of renal failure and progressiveness, timing of RRT, number of days of RRT, and mortality. We examined variables upon admission to the ICU, before the first RRT, and on the last ICU day before resignation or death. We used Students' t test. Quantitative parameters were expressed as mean values +/- SD. RESULTS: Of the 240 patients, 20 (8.3%) experienced ARF needing renal replacement therapy during the postoperative period. The results of our study suggested that ARF among patients undergoing RRT conferred an excessive risk of in-hospital death: eight patients died (40%). This increased risk cannot be explained solely by a more pronounced severity of illness. CONCLUSION: Our results provide strong evidence that ARF presents a specific, independent risk factor for a poor prognosis.     

Acute renal failure after liver transplantation in MELD era

Model for End-Stage Liver Disease (MELD) score was used in our center from 2003 to assess the position of orthotopic liver transplantation (OLT) candidates on a waiting list. A key component of MELD score in the assessment of the degree of the illness is renal function. In this study, we measured the effects of this new scoring system on renal function and therapeutic strategies. We evaluated the incidence of acute renal function (ARF) after OLT requiring renal replacement therapy (hemofiltration or hemodialysis) in two patient groups: 240 transplanted before MELD era and 224 after the introduction of this parameter to select candidates. ARF occurred in 8.3% of patients in the pre-MELD group versus 13% in the MELD group, while the mortality rates were 40% and 27%, respectively. The creatinine level before OLT seemed to be a good predictor of ARF (P < .001), and blood transfusion rates (P < .05) as well as intraoperative diuresis (P < .05). In our analysis we did not observe a correlation between MELD score and postoperative ARF.     

Acute pancreatitis after renal transplantation

Post-transplantation pancreatitis is an infrequent complication with a high risk of mortality. In a 7-year period, there were five patients who had documented pancreatitis out of a total of 488 renal homograft recipients, an incidence of 1 per cent. Two cases occurred in patients with an orthotopic transplant, one of them as a result of surgical injury of the pancreas and the other as a consequence of cytomegalovirus infection. The third case was an acute pancreatitis of hypercalcaemic origin, the fourth patient developed postoperative pancreatitis and acute acalculous cholecystitis, and the fifth had acute pancreatitis and sepsis associated with cytomegalovirus infection. Three patients died as a direct result of the complication. The mean incidence and mean mortality rate of post-transplantation pancreatitis, as determined from our review of the literature of the last 15 years, are 2.3 and 61.3 per cent, respectively; these are similar to the figures found up to 1970 of 1.7 and 52.2 per cent. A multiplicity of factors present in the uraemic patient may be responsible for the continued frequency of post-transplant pancreatitis despite advances in surgical technique and immunosuppressive therapy.     

Acute renal failure in hematopoietic cell transplantation

Hematopoietic cell transplantation is a common procedure for the treatment of malignancies and some non-malignant hematologic disorders. In addition to other transplant-related organ toxicities, acute renal failure is a common complication following transplantation. This review discusses the incidence, timing, etiologies, risk factors, and prognosis of renal failure associated with three commonly used transplantation procedures - myeloablative autologous, myeloablative allogeneic, and non-myeloablative allogeneic transplantation. It is important to note that the epidemiology and prognosis of renal failure are distinct with these three transplantation procedures. However, the common theme is that mortality increases with worsening renal failure with all three procedures. Moreover, mortality is >80% for patients with renal failure requiring dialysis. It also appears that surviving patients have an increased risk of chronic kidney disease after renal failure. The reduction of acute renal failure will have several advantages, including reducing mortality and the burden of chronic kidney disease following transplantation.     

Renal concentration defect following nonoliguric acute renal failure in the rat

The mechanism of impaired renal concentrating ability following nonoliguric ischemic acute renal failure was studied in the rat. Fifty min of complete occlusion of the renal artery and vein with contralateral nephrectomy resulted in reversible, nonoliguric acute renal failure. Eight days following induction of acute renal failure, a defect in 30 hr dehydration urine osmolality was present when experimental animals were compared with uninephrectomized controls (1,425 +/- 166 versus 2,267 +/- 127 mOsm/kg water respectively, P less than 0.001). Comparable postdehydration plasma vasopressin levels in experimental and control animals and an impaired hydro-osmotic response to exogenous vasopressin in experimental animals documented a nephrogenic origin of the defect in urine concentration. Lower urinary excretion of prostaglandin E2 in experimental animals and a failure of cyclo-oxygenase inhibition with 10 mg/kg of indomethacin to improve dehydration urine osmolality suggested that prostaglandin E2 antagonism of vasopressin action did not contribute to the concentration defect. Postdehydration inner medullary (papillary) interstitial tonicity was significantly reduced in experimental animals versus controls (870 +/- 85 versus 1,499 +/- 87 mOsm/kg water respectively, P less than 0.001). To determine if this decreased interstitial tonicity was due to vascular mechanisms, papillary plasma flow was measured and found to be equivalent in experimental and control animals. To examine a role for biochemical factors in the renal concentration defect, cyclic nucleotide levels were measured in cytosol and membrane fragments. A decrease in vasopressin and sodium fluoride-stimulated adenylate cyclase was found in outer medullary tissue of experimental animals. In contrast, vasopressin-stimulated adenylate cyclase activity was comparable in the inner medullary tissue of control and experimental animals. Our study suggests a defect in generation of renal inner medullary interstitial solute as a mechanism of the impaired urinary concentration observed in this model of acute renal failure.     

Acute and chronic renal failure in liver transplantation

We have performed a retrospective review of the incidence and etiologies of acute renal failure (ARF) in 105 adult patients receiving liver transplants. The prevalence of chronic renal failure was also determined. ARF occurred in 94.2% of these patients. Acute tubular necrosis was the leading cause of ARF and was associated with the highest mortality. Factors associated with increased mortality included: (1) peak serum creatinine greater than 3 mg/dl, (2) multiple liver transplants and (3) the need for dialysis. Pretransplant renal failure did not increase mortality. Chronic renal failure developed in 83% of patients at latest follow-up (mean: 30.5 +/- 7.9 months).     

Acute renal failure requiring hemodialysis immediately after heart transplantation portends a poor outcome

BACKGROUND: Previous studies have not provided a definite clarification for the predictive value of pretransplant renal indices on postcardiac transplant patient outcome. Therefore, the purpose of this study was to investigate the interaction between pretransplant renal function and recovery after heart transplantation. METHODS: The study group consisted of 199 consecutive patients who underwent heart transplantation between 1973 and 1994. For better comparison, patients were arbitrarily divided into three different groups based on the year of the transplant operation: Group I- before 1985 (n=13), Group II- between 1985 and 1989 (n=68) and Group III- between 1990 and 1994 (n=118). Values for serum creatinine (Cr), blood urea nitrogen (BUN), urea/creatinine ratio (U/Cr), creatinine clearance (Cr(cl)), length of hospital stay (LOS), early (30-day) mortality, and survival at 1-year and at 5-year were collected for each patient. The data was analyzed by the use of univariate log-rank test with forward stepwise procedure. RESULTS: Postcardiac transplant LOS in the hospital or survival was unaffected by the pretransplant renal indices except the U/Cr ratio (p>0.05). When adjusted for the time, the U/Cr ratio was also insignificant (p=0.1349). The use of hemodialysis was necessary in 9 patients (4.5%) for treatment of acute renal failure manifested immediately after the transplant operation. Early mortality was 44% for these 9 cardiac transplant recipients who required the use of hemodialysis: 0% (0/3) in the 1985-1989 period and 67% (4/6) in the 1990-1994 period. CONCLUSIONS: Pretransplant renal indices have no predictive value on outcome after a heart transplant operation, however, postcardiac transplant acute renal failure necessitating hemodialysis portends a poor outcome.     

Acute renal failure early after heart transplantation: risk factors and clinical consequences

Gude E, Andreassen AK, Arora S, Gullestad L, Grov I, Hartmann A, Leivestad T, Fiane AE, Geiran OR, Vardal M, Simonsen S. Acute renal failure early after heart transplantation: risk factors and clinical consequences.
Clin Transplant 2010: 24: E207–E213. © 2010 John Wiley & Sons A/S. Abstract: Limited information exists about acute renal failure (ARF) early after heart transplantation (HTx). We correlated pre‐, per‐, and post‐operative patient and donor parameters to the risk of developing ARF. We also analyzed the consequences of ARF on kidney function after HTx, risk of later need for chronic dialysis or kidney transplantation, and mortality. In a retrospective study from 1983 to 2007, 145 (25%) of 585 HTx recipients developed ARF, defined as ≥26.4 micromol/L or ≥50% increase in serum creatinine from pre‐operatively to the seventh day post‐HTx and/or the need of early post‐operative dialysis. Independent risk factors for ARF were intravenous cyclosporine immediately post‐operatively (odds ratio [OR] 2.16, 95% CI 1.34–3.50, p = 0.02), donor age (OR 1.02, 95% CI 1.00–1.04, p = 0.02), and pre‐operative cardiac output (OR 1.38, 95% CI 1.12–1.71, p = 0.003). The development of ARF was a predictor for short‐term survival (≤3 months) ranging from 98% for patients who improved their creatinine after HTx vs. 79% for those in need of dialysis (p < 0.001). However, ARF did not predict subsequent end stage renal disease in need of dialysis or renal transplantation. ARF is a common complication post‐HTx. As ARF is associated with short‐term survival, post‐operative strategies of preserving renal function have the potential of reducing mortality. Of avoidable risk factors, the use of intravenous CsA should be discouraged.     

急性肝功能衰竭患者肝移植术后急性肾功能衰竭的病因分析及综合治疗

目的 分析急性肝功能衰竭(acute liver failure,ALF)患者肝移植术后肾功能衰竭的原因,评价以持续肾脏替代治疗(continuous renal replacement therapy,CRRT)为基础的综合疗法的疗效.方法 回顾性分析2001年1月至2006年6月在我院施行的412例肝移植资料,根据UNOS肝功能分级标准筛选出54例ALF患者(UNOS1和2A),其中17例移植术后出现急性肾功能衰竭(acute renal failure,ARF).在CRRT治疗基础上,进行抗排斥、抗感染、营养支持等治疗,并对患者围手术期情况、术后并发症、死亡原因及随访结果进行了分析.结果 CRRT治疗过程中无并发症发生.无ARF组围手术期死亡率为5.4%,术后并发症发生率为35.1%,1、3年生存率分别为89.2%和81.1%.ARF组围手术期死亡率为58.8%,术后并发症发生率为100%,1、3年生存率分别为41.2%和41.2%.结论 肝移植效果主要取决于肝外器官功能和术前肝功能状态.ALF患者围手术期死亡率较高,其中术前血肌酐高术后出现ARF率高,死亡率更高.以CRRT为基础的综合疗法能有效治疗ARF患者.     

Acute renal failure following liver transplantation with induction therapy

AIMS: To identify the predictive factors for acute renal failure (ARF) in a retrospective study of 100 orthotopic liver transplantations (OLT) performed in 94 patients between 2000 and 2003. METHODS: Acute renal failure (ARF) was defined using the RIFLE criteria, i.e. injury when creatinine doubles or GFR halves, and failure when creatinine trebles or GFR decreases by > 75%. Patients on dialysis pre OLT (n = 3) were excluded from the study. Immunosuppression included steroids, calcineurin inhibitors (CNIs), with (n = 32) or without mycophenolate mofetil. A total of 85% of patients also received induction therapy with antithymocyte globulins (29%) or anti-CD25 monoclonal antibodies (56%). RESULTS: 39 patients (41.5%) and 21 (22.3%) patients developed injury, and failure, respectively. Of these, 10 (10.6%) underwent dialysis. Univariate analysis revealed that acute renal dysfunction with a RIFLE score > or = 3 was significantly associated with a pre-operative serum creatinine level of > 100 micromol/l, pre-operative creatinine clearance of < 75 ml/mn, need for a transfusion (> 10 red packed units), post-operative diuresis of < 100 ml/h, use of vasopressive drugs, times to aspartate (AST) and alanine (ALT) aminotransferase peaks of > 20 and > 24 hours, respectively, relaparotomy, CNIs transient discontinuation, and the use of lower daily dosage of CNIs at post-OLT Days 3, 5, 7 and 15. In multivariate analysis, failure was significantly associated with time to AST peak (> 20 h) (OR 6.35 (1.2 - 33.6), p = 0.029), post-operative diuresis (< 100 ml/h) (OR 9.8 (2.03 47.3), p = 0.004), post-operative use of vasopressive drugs (OR 9.91 (2.02 - 48.7), p = 0.004), and transient CNIs withdrawal (OR 51.08 (7.58-344.1), p < 0.0001). Finally, the occurrence of ARF was significantly associated with an increased number of days on mechanical ventilation, on stay-in intensive care unit (ICU), and on overall hospitalization time. CONCLUSION: ARF is quite common after OLT and significantly increases the post-operative time at the hospital, thereby increasing the OLT cost. Its independent predictive factors are mainly related to perioperative events.