Association between volume status assessed by bioelectrical impedance analysis, lung ultrasound, or weight change and mortality in patients with sepsisassociated acute kidney injury receiving continuous kidney replacement therapy

Fluid overload is an independent risk factor of mortality in patients with acute kidney injury (AKI) receiving continuous kidney replacement therapy (CKRT). However, the association between fluid status, as assessed by bioelectrical impedance analysis (BIA) or lung ultrasound, and survival in patients with AKI requiring CKRT has not been established. Methods: We analyzed 36 participants with sepsis-associated AKI who received CKRT at a tertiary hospital. The main exposures were volume surrogates: 1) overhydration normalized by extracellular water (OH/ECW, L/L) assessed by BIA, 2) the number of B-lines measured by lung ultrasound, and 3) weight change ([body weight at CKRT initiation – body weight at admission] × 100/body weight at admission). The primary outcome was the 28-day mortality. Results: Seventeen participants (47.2%) died within 28 days. There were no significant correlations between OH/ECW and weight change (R2 = 0.040, p = 0.24), number of B-lines and OH/ECW (R2 = 0.056, p = 0.16), or weight change and number of B-lines (R2 = 0.014, p = 0.49). Kaplan-Meier analyses revealed that patients in the highest tertile of OH/ECW showed a significantly lower cumulative 28-day survival probability than the others (the lowest + middle tertiles). The survival probability of participants in the highest tertile of the number of B-lines or weight change did not differ from that of their counterparts. In a multivariate Cox proportional hazard model, the hazard ratio for the highest tertile of OH/ECW was 3.83 (95% confidence interval, 1.04–14.03). Conclusion: Volume overload assessed using BIA (OH/ECW) was associated with the 28-day survival rate in patients with sepsis-associated AKI who received CKRT.

Fatty liver associated with metabolic derangement in patients with chronic kidney disease: A controlled attenuation parameter study

BACKGROUND: Hepatic steatosis measured with controlled attenuation parameter (CAP) using transient elastography predicts metabolic syndrome in the general population. We investigated whether CAP predicted metabolic syndrome in chronic kidney disease patients. METHODS: CAP was measured with transient elastography in 465 predialysis chronic kidney disease patients (mean age, 57.5 years). RESULTS: The median CAP value was 239 (202–274) dB/m. In 195 (41.9%) patients with metabolic syndrome, diabetes mellitus was more prevalent (105 [53.8%] vs. 71 [26.3%], P < 0.001), with significantly increased urine albumin-to-creatinine ratio (184 [38–706] vs. 56 [16–408] mg/g Cr, P = 0.003), high sensitivity C-reactive protein levels (5.4 [1.4–28.2] vs. 1.7 [0.6–9.9] mg/L, P < 0.001), and CAP (248 [210–302] vs. 226 [196–259] dB/m, P < 0.001). In multiple linear regression analysis, CAP was independently related to body mass index (β = 0.742, P < 0.001), triglyceride levels (β = 2.034, P < 0.001), estimated glomerular filtration rate (β = 0.316, P = 0.001), serum albumin (β = 1.386, P < 0.001), alanine aminotransferase (β = 0.064, P = 0.029), and total bilirubin (β = −0.881, P = 0.009). In multiple logistic regression analysis, increased CAP was independently associated with increased metabolic syndrome risk (per 10 dB/m increase; odds ratio, 1.093; 95% confidence interval, 1.009–1.183; P = 0.029) even after adjusting for multiple confounding factors. CONCLUSION: Increased CAP measured with transient elastography significantly correlated with and could predict increased metabolic syndrome risk in chronic kidney disease patients.

Renal Parenchymal Malakoplakia with Acute Interstitial Nephritis Presented with Acute Kidney Injury / 이화의대지

Malakoplakia is an uncommon chronic granulomatous inflammatory disease which is associated with immunocompromised conditions such as malignancy, autoimmune disease, chronic alcohol intake, poorly controlled diabetes and long-term steroid use. Malakoplakia can occur at various sites, most commonly in the genitourinary tract including urinary bladder and the ureter. Renal parenchymal involvement is relatively uncommon, accounting for 15% of all malakoplakia. A few cases of renal malakoplakia have been reported in Korea, and only one case was accompanied by acute kidney injury. Here we report an 80-year-old female patient with renal parenchymal malakoplakia and acute interstitial nephritis presented as acute kidney injury with literature review.

The Effect of Specialized Continuous Renal Replacement Therapy Team in Acute Kidney Injury Patients Treatment

PURPOSE: Continuous renal replacement therapy (CRRT) has been established for critically ill acute kidney injury (AKI) patients. In addition, some centers consist of a specialized CRRT team (SCT) with physicians and nurses. To our best knowledge, however, ona a few studies have yet been carried out on the superiority of SCT management. MATERIALS AND METHODS: A total of 551 patients, who received CRRT between January 2008 and March 2009, were divided into two groups based on the controller of CRRT. The impact of the CRRT management on 28-day mortality was compared between two groups by Kaplan-Meier curve and Cox analysis. RESULTS: During the study period, the number of filters used, down-time per day, and intensive care unit length of day were significantly higher in non-SCT group than in SCT group (6.2 hrs vs. 5.0 hrs, p=0.042; 5.0 hrs vs. 3.8 hrs, p<0.001; 27.5 days vs. 21.1 days, p=0.027, respectively), while net ultrafiltration rate was significantly lower in non-SCT group than SCT group (28.0 mL/kg/hr vs. 29.5 mL/kg/hr, p=0.043, respectively). In addition, 28-day mortality rate was significantly lower in SCT group than with non-SCT group (p=0.031). Moreover, Cox regression analysis showed that 28-day mortality rate was significantly lower in SCT control group, even after adjusting for age, gender, severity scores, biomarkers, risk, injury, failure, loss, and end-stage renal disease, and contributing factors (hazard ratio 0.91, p=0.046). CONCLUSION: A well-trained CRRT team could be beneficial for mortality improvement of AKI patients requiring CRRT.

Insulin resistance is associated with new-onset cardiovascular events in nondiabetic patients undergoing peritoneal dialysis

BACKGROUND: Chronic exposure to high glucose-containing peritoneal dialysis solution and consequent abdominal obesity are potential sources of insulin resistance in patients requiring prevalent peritoneal dialysis. The aim of this study was to elucidate the prognostic values of insulin resistance on new-onset cardiovascular events in nondiabetic patients undergoing prevalent peritoneal dialysis. METHODS: A total of 201 nondiabetic patients undergoing prevalent peritoneal dialysis were recruited. Insulin resistance was assessed by homeostatic model assessment of insulin resistance (HOMA-IR). The primary outcome was new-onset cardiovascular events during the follow-up period. Cox proportional hazard analysis was performed to ascertain the independent prognostic value of HOMA-IR for the primary outcome. RESULTS: The mean age was 53.1 years and male was 49.3% (n=99). The mean HOMA-IR was 2.6+/-2.1. In multivariate linear regression, body mass index (beta=0.169, P=0.011), triglyceride level (beta=0.331, P<0.001), and previous cardiovascular diseases (beta=0.137, P=0.029) were still significantly associated with HOMA-IR. During a mean follow-up duration of 36.8+/-16.2 months, the primary outcome was observed in 36 patients (17.9%). When patients were divided into tertiles according to HOMA-IR, the highest tertile group showed a significantly higher incidence rate for new-onset cardiovascular events compared to the lower two tertile groups (P=0.029). Furthermore, multivariate Cox analysis revealed that HOMA-IR was an independent predictor of the primary outcome (hazard ratio=1.18, 95% confidence interval=1.03-1.35, P=0.014). CONCLUSION: Insulin resistance measured by HOMA-IR was an independent risk factor for new-onset cardiovascular events in nondiabetic patients undergoing prevalent peritoneal dialysis.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone after Lung Transplantation / 이화의대지

A 54-year-old man was diagnosed as syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 7 days after lung transplantation, whereas the preoperative serum sodium level was normal. Hypertonic saline infusion with furosemide did not improve hyponatremia, however, tolvaptan corrected his serum sodium levels from 123 mEq/L to 131 mEq/L. Seven days after maintenance of tolvaptan, this drug was discontinued and hyponatremia did not occur. Herein, we report a case of SIADH after lung transplantation treated with tolvaptan.

Etiologies and Underlying Diseases of Leg Edema in Elderly Patients

BACKGROUND: Leg edema is a common symptom among elderly patients with multiple underlying diseases. This study was aimed to investigate the etiologies and underlying diseases of leg edema in elderly patients. METHODS: We retrospectively reviewed medical records of 247 patients aged over 65, who visited an Emergency Department of a tertiary hospital due to leg edema from January 2010 to December 2012. RESULTS: A total of 226 patients with complete medical records were included. The most common cause of leg edema in elderly patients was renal failure (42 cases, 18.6%), followed by heart failure (37 cases, 16.4%), and deep vein thrombosis (32 cases, 14.2%). However, the etiologies were not established in 66 cases (29.2%). Patients with leg edema caused by renal and heart failure had renal (40 cases, 95.2%) and cardiovascular diseases (29 cases, 78.4%), respectively, while others had diabetes mellitus and trauma. Patients with leg edema caused by deep vein thrombosis had underlying conditions such as cancer (13 cases, 40.6%), trauma, surgery within 1 year, and diabetes mellitus. Overall, chronic bilateral edema (120 cases, 53.1%) was most commonly observed form of leg edema in elderly patients. Deep vein thrombosis, cellulitis, and lymphedema usually caused unilateral edema, whereas systemic diseases such as renal failure, heart failure, and liver cirrhosis caused bilateral edema. CONCLUSION: Leg edema in elderly patients is usually caused by systemic diseases such as renal and heart failure closely related to underlying diseases. Therefore, it is important to consider the variety of underlying diseases, when approaching the cause and treatment of leg edema in elderly patients.