Hospital mortality and prognostic factors in critically ill patients with acute kidney injury and cancer undergoing continuous renal replacement therapy

Whether continuous renal replacement therapy (CRRT) should be applied to critically ill patients with both acute kidney injury (AKI) and cancer remains controversial because of poor expected outcomes. The present study determined prognostic factors for all-cause in-hospital mortality in patients with AKI and cancer undergoing CRRT. Methods: We included 471 patients with AKI and cancer who underwent CRRT at the intensive care unit of a Korean tertiary hospital from 2013 to 2020, and classified them by malignancy type. The primary outcomes were 28-day all-cause mortality rate and prognostic factors for in-hospital mortality. The secondary outcome was renal replacement therapy (RRT) dependency at hospital discharge. Results: The 28-day mortality rates were 58.8% and 82% in the solid and hematologic malignancy groups, respectively. Body mass index (BMI), presence of oliguria, Sequential Organ Failure Assessment (SOFA) score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups. A high heart rate and the presence of severe acidosis were prognostic factors only in the solid malignancy group. Among the survivors, the proportion with RRT dependency was 25.0% and 33.3% in the solid and hematologic malignancy groups, respectively. Conclusion: The 28-day mortality rate of cancer patients with AKI undergoing CRRT was high in both the solid and hematologic malignancy groups. BMI, presence of oliguria, SOFA score, and albumin level were common predictors of 28-day mortality in the solid and hematologic malignancy groups, but a high heart rate and severe acidosis were prognostic factors only in the solid malignancy group.

Percutaneous peritoneal dialysis catheter implantation with no break-in period: a viable option for patients requiring unplanned urgent-start peritoneal dialysis

Background@#Urgent-start peritoneal dialysis (PD) is applied to patients who need PD within two weeks but are able to wait for more than 48 hours before starting PD. To evaluate the usefulness of percutaneous PD catheter insertion in urgent-start PD, we reviewed the clinical outcomes of percutaneous catheter insertion with immediate start PD and surgical insertion with longer break-in time in Pusan National University Hospital. @*Methods@#This study included 177 patients who underwent urgent-start PD. Based on the PD catheter insertion techniques, the patients with urgent-start PD were divided into percutaneous (n = 103) and surgical (n = 74) groups. For the percutaneous group, a modified Seldinger percutaneous catheter insertion with immediate initiation of continuous ambulatory PD was performed by nephrologists. @*Results@#The percutaneous group showed higher serum urea nitrogen, creatinine, and lower serum albumin compared with the surgical group (P < 0.05). Ninety-day infectious and mechanical complications showed no significant differences between the two groups. Ninety-day peritonitis in the percutaneous group was 9.7% compared to 5.4% in the surgical group (P = not significant [NS]). Major leakage was 3.9% in the percutaneous group compared to 1.4% in the surgical group (P = NS). Overall infectious and mechanical complication-free survival was not significantly different between the two groups. The percutaneous group and surgical group showed no statistical difference with respect to catheter survival over the entire observation period (P = NS). @*Conclusion@#This study suggests that urgent-start PD can be applied safely with percutaneous catheter insertion by nephrologists with no break-in period.

Erratum: Correction of Figure in the Article: Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

The present erratum notice corrects one figure of the article.

Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

BACKGROUND: Accurate volume measurement is important in the management of patients with congestive heart failure or renal insufficiency. A bioimpedance analyser can estimate total body water in litres and has been widely used in clinical practice due to its non-invasiveness and ease of results interpretation. To change impedance data to volumetric data, bioimpedance analysers use equations derived from data from healthy subjects, which may not apply to patients with other conditions. Bioelectrical impedance vector analysis (BIVA) was developed to overcome the dependence on those equations by constructing vector plots using raw impedance data. BIVA requires normal reference plots for the proper interpretation of individual vectors. The aim of this study was to construct normal reference vector plots of bioelectrical impedance for Koreans. METHODS: Bioelectrical impedance measurements were collected from apparently healthy subjects screened according to a comprehensive physical examination and medical history performed by trained physicians. Reference vector contours were plotted on the RXc graph using the probability density function of the bivariate normal distribution. We further compared them with those of other ethnic groups. RESULTS: A total of 242 healthy subjects aged 22 to 83 were recruited (137 men and 105 women) between December 2015 and November 2016. The centers of the tolerance ellipses were 306.3 Ω/m and 34.9 Ω/m for men and 425.6 Ω/m and 39.7 Ω/m for women. The ellipses were wider for women than for men. The confidence ellipses for Koreans were located between those for Americans and Spaniards without overlap for both genders. CONCLUSION: This study presented gender-specific normal reference BIVA plots and corresponding tolerance and confidence ellipses on the RXc graph, which is important for the interpretation of BIA-reported volume status in patients with congestive heart failure or renal insufficiency. There were noticeable differences in reference ellipses with regard to gender and ethnic groups.

The expression of two isoforms of matrix metalloproteinase-2 in aged mouse models of diabetes mellitus and chronic kidney disease

BACKGROUND: This study was undertaken to explore the effects of aging on the kidneys in mouse models of diabetes and chronic kidney disease (CKD), and to compare the expression of two isoforms of matrix metalloproteinase-2 (MMP-2)–secretory full-length MMP-2 and intracellular N-terminal truncated MMP-2 (NTT-MMP-2)–in these models. METHODS: Two experimental ICR mouse models were used: a streptozotocin (STZ)-induced type 1 diabetes mellitus model and a 5/6 nephrectomized (5/6Nx) CKD model. The abundance of each isoform of MMP-2 was determined by quantitative polymerase chain reaction (qPCR), and functional analyses were conducted. Moreover, the protein levels of the two MMP-2 isoforms were determined semi-quantitatively by immunohistochemical staining, and their association with tissue damage was assessed. RESULTS: Both isoforms of MMP-2 were upregulated in the kidney tissues of STZ-induced diabetic mice and 5/6Nx mice, irrespective of age. Characteristically, NTT-MMP-2 protein expression was elevated in old control mice, in line with the qPCR results. NTT-MMP-2 expression was limited to the renal cortex, and to the tubulointerstitial area rather than the glomerular area. In terms of tissue damage, tubulointerstitial fibrosis was more severe in old 5/6Nx mice than in their young counterparts, whereas glomerulosclerosis was comparable in old and young 5/6Nx mice. CONCLUSION: The intracellular isoform of MMP-2 was induced by ageing, irrespective of the presence of diabetes or CKD, and its induction may be related to tubulointerstitial fibrosis in chronic kidney disease.

Unmasked chronic renal function deterioration after unilateral adrenalectomy in patients with primary aldosteronism

We report 2 cases of chronic estimated glomerular filtration rate (eGFR) decline after unilateral adrenalectomy due to primary aldosteronism. The patients were diagnosed with unilateral adrenal cortical adenoma releasing aldosterone. Two patients were examined for hypertension and hypokalemia. Unilateral laparoscopic adrenalectomy was performed in both cases, and pathology confirmed adrenal cortical adenoma. After adrenalectomy, hypertension and hypokalemia improved to within normal range. However, the eGFR decreased postoperatively, and abdominal computed tomography scan showed decreased kidney size compared to previous images. Kidney biopsy was performed to delineate the exact cause of renal function deterioration and revealed hypertensive changes with chronic interstitial changes, indicating that glomerular hyperfiltration with aldosterone excess masked renal function damage. Physicians have to consider the probability of postadrenalectomy eGFR decline related to chronic hypertensive change.

Severe Hypernatremia Caused by Acute Exogenous Salt Intake Combined with Primary Hypothyroidism

This report describes a case of severe hypernatremia with a serum sodium concentration of 188.1mmol/L caused by exogenous salt intake. A 26-year-old man diagnosed with Crohn's disease 5 years previously visited our clinic due to generalized edema and personality changes, with aggressive behavior. He had compulsively consumed salts, ingesting approximately 154 g of salt over the last 4 days. Despite careful fluid management that included not only hypotonic fluid therapy for 8 hours but also hypertonic saline administration, his serum sodium level decreased sharply at 40.6 mmol/L; however, it returned to normal within 72-hour of treatment without any neurological deficits. Primary hypothyroidism was also diagnosed. He was discharged after 9 days from admission, with a stable serum sodium level. We have described the possibility of successful treatment in a patient with hypernatremia caused by acute salt intoxication without sustained hypotonic fluid therapy.

High serum and urine neutrophil gelatinaseassociated lipocalin levels are independent predictors of renal progression in patients with immunoglobulin A nephropathy

BACKGROUND/AIMS: Tubulointerstitial injury plays an important role in the progression of immunoglobulin A nephropathy (IgAN), and neutrophil gelatinase-associated lipocalin (NGAL) is among the most sensitive tubular biomarkers. We investigated whether serum or urine NGAL predicts prognosis in patients with IgAN. METHODS: The present study enrolled patients with biopsy-proven IgAN from January 2005 to December 2010, whose serum and urine samples at the time of kidney biopsy were preserved by freezing. We retrospectively reviewed patient clinical data and followed patients until October 2012. Serum and urine NGAL levels were measured using an enzyme-linked immunosorbent assay kit. Renal progression was defined as an estimated glomerular filtration rate decline by > 50% or progression to end-stage renal disease. RESULTS: There were 121 patients enrolled in this study. During the median follow-up period of 41.49 months, renal progression was found in nine patients (7.4%). Serum or urine NGAL alone could not predict renal progression; however, when serum and urine NGAL levels were combined, belonging to the high NGAL group independently predicted renal progression (hazard ratio [HR], 5.56; 95% confidence interval [CI], 1.42 to 21.73; p = 0.014), along with tubular damage graded according to the Oxford classification as T2 (HR, 8.79; 95% CI, 2.01 to 38.51; p = 0.004). In addition, a Kaplan-Meier curve of renal survival showed significantly higher renal progression in patients in the high NGAL group (log rank, p = 0.004). CONCLUSIONS: In patients with IgAN, high serum and urine NGAL levels at the time of kidney biopsy predict renal progression.

Adrenocorticotropic hormone-independent macronodular adrenal hyperplasia with abnormal cortisol secretion mediated by catecholamines

No abstract available.

Significance of residual renal function for phosphate control in chronic hemodialysis patients

BACKGROUND: The aim of this study was to compare mineral metabolism between anuric and nonanuric chronic hemodialysis patients, and determine the differences in phosphate control between the two groups. METHODS: A total of 77 chronic hemodialysis patients were enrolled in this cross-sectional study from January 2012 to February 2012. Patient demographics, laboratory findings, medication histories, and vascular calcification scores were collected. We divided the patients into anuric and nonanuric groups according to the residual renal function and then compared their clinical features. Multivariate binary regression analysis was used in each group to determine the independent factors related to phosphate control. RESULTS: The mean patient age was 59.27+/-13.95 years, and 57.1% of patients were anuric. In anuric patients, dialysis vintage was significantly longer, but the mean Kt/V was not different between groups. Serum phosphate, fibroblast growth factor (FGF)-23, and Ca/P products were significantly higher, and 1,25(OH)2D3 levels were significantly lower in the anuric patients, although the intact parathyroid hormone and 25(OH)D levels were not different. In anuric patients, LnFGF-23 [hazard ratio (HR) 2.894, 95% confidence interval (CI) 1.294-6.474, P=0.010] was an independent factor predictive of phosphate control. However, in the nonanuric patients, glomerular filtration rate (HR 0.409, 95% CI 0.169-0.989, P=0.047) and blood urea nitrogen (HR 1.090, 95% CI 1.014-1.172, P=0.019) were independent factors predictive of phosphate control. CONCLUSION: In chronic hemodialysis patients, preservation of residual renal function is a significant determinant of phosphate control, and the factors associated with phosphate control is different depending on the residual renal function status. In the anuric patients, FGF-23 is most significantly associated with phosphate control; however, glomerular filtration rate and blood urea nitrogen are more important than FGF-23 in the nonanuric HD patients.

Pyeloduodenal Fistula Successfully Treated By Endoscopic Ligation without Surgical Nephrectomy: Case Report

A 74-yr-old woman presented with fever and abdominal discomfort. She was in a septic condition caused by urinary tract infection. Her computed tomogram of the abdomen revealed features of hydronephrosis with ureteral stones in both kidneys. During percutaneous nephrostomies, right pyeloduodenal fistula (PDF) was diagnosed. Elective surgery was originally planned but the patient was in a poor condition to undergo surgery. Instead, 2 times endoscopic clipping and ligation by endoloop were applied with parenteral antibiotics for the fistula lesion. On admission day 30, she was discharged from the hospital after confirmation of no more contrast leakage on fistulography. We reviewed the literature and discuss the etiologies, clinical presentations, diagnosis, and treatment of PDF.

Decreased Renal Function Is an Independent Predictor of Severity of Coronary Artery Disease: An Application of Gensini Score

Coronary artery disease (CAD) is the leading cause of death in patients with chronic kidney disease (CKD).Although many studies have shown a higher prevalence of CAD among these patients, the association between the spectrum of renal dysfunction and severity of CAD remains unclear. In this study, we investigate the association between renal function and the severity of CAD. We retrospectively reviewed the medical records of 1,192 patients who underwent elective coronary angiography (CAG). The severity of CAD was evaluated by Gensini score according to the degree of luminal narrowing and location(s) of obstruction in the involved main coronary artery. In all patients, the estimated glomerular filtration rate (eGFR) was independently associated with Gensini score (beta=-0.27, P < 0.001) in addition to diabetes mellitus (beta=0.07, P = 0.02), hypertension (beta=0.12, P < 0.001), low density lipoprotein (LDL)-cholesterol (beta=0.08, P = 0.003), and hemoglobin (beta=-0.07, P = 0.03) after controlling for other confounding factors. The result of this study demonstrates that decreased renal function is associated not only with the prevalence, but also the severity, of CAD.

Influence of Left Ventricular Diastolic Dysfunction on Ischemic Heart Disease in Patients with Chronic Kidney Disease / 대한내과학회지

BACKGROUND/AIMS: Cardiovascular complications are commonly seen in patients with chronic kidney disease (CKD). Recently, the prevalence of left ventricular diastolic dysfunction (LVDD) has increased, and the importance of LVDD has emerged in patients with CKD. The objectives of this study were to identify diagnostic criteria for LVDD related to ischemic heart disease (IHD) and evaluate the prognostic impact of diastolic dysfunction in patients with CKD. METHODS: A total of 71 patients with CKD who were evaluated between January 2005 and May 2010 were included in this study. These patients were evaluated by conventional echocardiography and tissue Doppler imaging (TDI) for diastolic dysfunction. RESULTS: Diagnostic cutoff values for LVDD related to IHD were E/E' = 15.55 (sensitivity: 100%, specificity: 64.7%, p = 0.005) and E/A = 0.79 (sensitivity: 84.6%, specificity: 55.9%, p = 0.006). Group I consisted of 19 patients with an E/E' > 15.55 and E/A > 0.79. Group II consisted of the remaining patients. Factors contributing to LVDD were age, history of ischemic heart disease, anemia, and high low-density lipoprotein (LDL) level. Factors contributing to IHD were LVDD, smoking, high LDL level, and high parathyroid hormone (PTH) level. The disease-free survival for IHD was significantly lower in group I compared to group II (p = 0.001). However, there was no significant difference in overall survival between groups I and II (p = 0.177). CONCLUSIONS: Our study showed that moderate LVDD (E/E' > 15.55 and E/A > 0.79) in patients with CKD is positively associated with IHD.

A Case of Severe Acute Kidney Injury by Near-Drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.

Clinical Features of 11 Patients with Xanthogranulomatous Pyelonephritis / 대한내과학회지

BACKGROUND/AIMS: Because preoperative diagnosis of xanthogranulomatous pyelonephritis (XGP) is difficult, due to its similarities to other renal diseases, the diagnosis is made postoperatively in most cases. The purpose of this study was to describe the clinical findings in 11 patients with histologically documented XGP. METHODS: We retrospectively reviewed the characteristics, laboratory and radiological findings, preoperative diagnoses and operative methods of 11 patients with XGP, who underwent a surgical procedure or percutaneous renal biopsy. RESULTS: Among eleven patients, nine had flank pain and six had anemia. Preoperatively, three patients were diagnosed as XGP, two with renal cell carcinoma, two with renal tuberculosis, one with renal abscess, one with perirenal abscess, one with renal staghorn calculi with non-functioning kidney, and one with pyelonephrosis. On the basis of the computed tomography (CT) features, the diffuse or global forms (70.0%) were more common than the localized or focal forms (30.0%). One patient diagnosed with renal cell carcinoma preoperatively was diagnosed as XGP through an intraoperative frozen section renal tissue biopsy and underwent partial nephrectomy. One patient diagnosed as focal XGP underwent percutaneous biopsy of the renal mass, which confirmed the diagnosis. This patient received treatment with only antibiotic therapy. CONCLUSIONS: CT can be considered the preferred diagnostic tool for the evaluation of XGP; however, percutaneous renal biopsy seems to be valuable in selected cases for differential diagnosis of renal malignancy.

A Case of Rifampin-Induced Crescentic Glomerulonephritis / 대한내과학회지

A 56-year-old male with pulmonary tuberculosis was admitted to our hospital for evaluation of generalized edema. He began antituberculosis treatment with rifampin, isoniazid, ethambutol, and pyrazinamide. He experienced abnormal increments in weight and serum creatinine after 6 weeks. All serological findings, including anti-neutrophil cytoplasmic antibodies (ANCA), were negative. Rifampin was stopped because it might have caused the increase in creatinine. Renal biopsy was consistent with pauci-immune crescentic glomerulonephritis (CrGN). His renal function was improved by high-dose steroid treatment. Rifampin-induced, ANCA-negative pauci-immune CrGN is very rare; most cases of rifampin-induced acute renal failure are due to acute tubulointerstitial nephritis. We present here a case of rifampin-induced CrGN and pulmonary tuberculosis successfully treated with high-dose steroids and antituberculosis medications, excluding rifampin.

25-Hydroxyvitamin D Status Based on Estimated Glomerular Filtration Rate in Patients with Chronic Kidney Disease / 대한내과학회지

BACKGROUND/AIMS: Accumulating data suggest that vitamin D deficiency is prevalent in patients with chronic kidney disease (CKD). However, comprehensive data are lacking for Koreans. The aim of this study was to survey vitamin D deficiency among patients with CKD in Korea and to identify the relationships among various factors. METHODS: We conducted a retrospective cohort study of 444 patients who were divided into four subgroups by estimated glomerular filtration rate (eGFR) for comparisons of mean 25-hydroxyvitamin D [25(OH)D] level and other parameters. In addition, non-dialyzed patients were categorized into four groups based on 25(OH)D levels ( or =30 ng/mL), and risk factors for severe vitamin D deficiency ( or = 60 mL/min/1.73 m2, 43% (34/79) showed severe 25(OH)D deficiency, and the mean 25(OH)D level was 11.7 +/- 5.3 ng/mL. In CKD3 group, 53.2% (41/77) showed severe 25(OH)D deficiency, with a mean level of 11.3 +/- 7.2 ng/mL. In CKD4 group, 53.3% (49/92) had severe 25(OH)D deficiency, with a mean level of 11.0 +/- 6.2 ng/mL. Approximately 71% (139/196) of patients in CKD5 group showed severe deficiency, and the mean level was 9.2 +/- 5.9 ng/mL. Severe 25(OH)D deficiency was affected by winter season, renal function, diabetes, and low-density lipoprotein cholesterol. The serum parathyroid hormone level was inversely correlated with the 25(OH)D level, such that 25(OH)D <20 ng/mL were associated with a steep increase in parathyroid hormone. CONCLUSIONS: Vitamin D deficiency is highly prevalent in the Korean population. Few patients met a sufficient 25(OH)D concentration, even in the early stages of CKD. Our data suggest that 25(OH)D level of 20 ng/mL is a threshold for a rapid increase in parathyroid hormone levels.

A Case of Rifampin-Induced Crescentic Glomerulonephritis / 대한내과학회지

A 56-year-old male with pulmonary tuberculosis was admitted to our hospital for evaluation of generalized edema. He began antituberculosis treatment with rifampin, isoniazid, ethambutol, and pyrazinamide. He experienced abnormal increments in weight and serum creatinine after 6 weeks. All serological findings, including anti-neutrophil cytoplasmic antibodies (ANCA), were negative. Rifampin was stopped because it might have caused the increase in creatinine. Renal biopsy was consistent with pauci-immune crescentic glomerulonephritis (CrGN). His renal function was improved by high-dose steroid treatment. Rifampin-induced, ANCA-negative pauci-immune CrGN is very rare; most cases of rifampin-induced acute renal failure are due to acute tubulointerstitial nephritis. We present here a case of rifampin-induced CrGN and pulmonary tuberculosis successfully treated with high-dose steroids and antituberculosis medications, excluding rifampin.

A Case of Immunoglobulin G4-Related Tubulointerstitial Nephritis with Extrarenal Involvement / 대한신장학회지

Immunoglobulin G4-related sclerosing disease is a novel clinicopathological disease entity known to involve various organs including the pancreas, bile ducts, gall bladder, retroperitoneum, kidney, salivary gland, lung and prostate. The most common organ involved is the pancreas and cases without pancreatic involvement are uncommon. Positive response to steroids is an important characteristic of this disease and this enables early diagnosis, which is required for good prognosis. We demonstrate a case of immunoglobulin G4-related tubulointerstitial nephritis in a 59-year-old male accompanied by sclerosing cholangitis and sialadenitis without any evidence of pancreatic infiltration. The patient was treated with prednisolone and was fully recovered in 6 months.