Ulinastatin for Aki: Should It Be in Our Care Bundle ?

Introduction: In critically ill patients with AKI, unacceptably high mortality rates reaching up to 50-80% in all dialyzed ICU patients are seen despite the availability of intensive renal support. At present there is no specific or targeted therapy for AKI. Pathophysiology of AKI is multifactorial. Systemic inflammation, mediated in part by cytokines, might be contributing majorly to the development of AKI. This mandates a multipronged approach to the treatment of AKI. There are hardly any studies on the use of ulinastatin in AKI. Our premise regarding the use of molecule in AKI was based on the fact that this molecule acts at multiple levels in the sepsis and can act to stop the cascade and thereby stop the "storm." Methods: We studied a total of 200 patients with AKI who needed ICU care in our hospital in the period between June 2017 - Jan 2020. Out of these, 100 patients received Injection ulinastatin 3 doses a day for 5 days, against a similar number of control patients. We included those patients with AKI who had SOFA scores more than 8. None of the patients had COVID 19 infection. We compared the same number of patients who had received ulinastatin with controls. Injection ulinastatin 1,50,000IU was given three times a day for 5 days. All the patients included had received dialytic therapy. We recorded the age of the patients, it varied from 11-94 years (mean age 52 years), > 60 % (120) of the patients being in the age group of 26-40 years. The ratio of males to females 1.8:1 (M: F 129:71). The etiologies were as follows: Malaria - complicated - P vivax, P falciparum (n= 76) 38% Enteric fever (n= 40) 20% UTI (n=30) 15% Post-partum (n=20) 10% Dengue (n = 14) 7% Acute gastroenteritis/diarrheal diseases (n= 12) 6% Pancreatitis (n= 6) 3% Obstructive uropathy (n= 3) 1.5% 33 % (n= 66) patients had diabetes as a co morbid condition. The renal function tests of all the patients along with liver function tests, sepsis parameters like d-dimer, serum procalcitonin levels, CRP-hs levels, coagulation tests, complete blood counts, and arterial blood gas analysis were done We recorded the length of stay, need and duration of renal replacement therapy, time to stoppage of renal replacement therapy, need for mechanical ventilation, mortality and post AKI recovery and progression to CKD. Result(s): The patients who received ulinastatin had a shorter stay in the ICU (p <0.01 vs control group);also, the time to stoppage of renal replacement therapy was shorter (p < 0.05). The recovery of renal function was seen in 84% (n=168). The progression to CKD was seen in 11% (n=22) of patients. The average number of sittings of dialysis needed were 11 (range3-20), lesser number of dialysis were needed in the ulinastatin group. The overall mortality was 36 %(n=72).The average follow up period post discharge has been 141 days (21 - 240 days) Conclusion(s): There definitely seem to be advantages in using ulinastatin and results look promising. But there are limitations to this study - this was a retrospective analysis hence not all the patients received ulinastatin. Moreover, the drug is expensive. This study was done in a semi urban set up where causes for AKI are predominantly infective. A larger prospective double-blind study will be needed to consider ulinastatin as a routine option for treating AKI. Till then preventing AKI should be the aim for us. No conflict of interestCopyright © 2023

EMPHYSEMATOUS PYELONEPHRITIS IN THE COVID & CANCER ERA- CASE SERIES FROM A TERTIARY CARE HOSPITAL IN CHENNAI, SOUTH INDIA

Introduction: Emphysematous pyelonephritis (EPN) is a rare yet life threatening, necrotizing renal parenchymal infection with a mortality rate of 20-25%. With advent of CT, early goal directed therapy with antibiotics, aggressive treatment of sepsis and percutaneous drainage techniques, the mortality and morbidity rates are not as grim as earlier reports. Nephrectomy, treatment of the past has been replaced with nephron sparing surgery with better patient outcomes. A retrospective study was conducted at Government Kilpauk Medical College Hospital between January 2020 and April 2022. Diabetes, obstructive uropathy, structural abnormalities of the urinary tract and immunosuppression are well known risk factors for EPN. Malignancy and associated chemotherapy can make the vulnerable even more susceptible to EPN. The COVID19 pandemic, which was rampant for the past two years, with steroids being the cornerstone of management of COVID pneumonia also contributed to significant immunosuppression and poor glycemic control in many. This study wants to highlight along with traditional risk factors, the impact of COVID19 and Cancer on EPN. Methods: Demographic, clinical, radiological, and microbiological data of 33 patients were recorded. The data were analyzed to study risk factors, treatment modalities, need for hemodialysis, prognostic factors contributing to morbidity and mortality and patient outcome.The initial diagnosis of EPN at presentation was made by ultrasound evidence of gas in renal parenchyma, which was confirmed by CT imaging. Results: Out of a total 33 patients, 64% were females and the median age was 57.5 years. At presentation, common symptoms were abdominal pain (93%), renal angle tenderness (87%), fever (82%), vomiting (75%), dysuria (74%) and oliguria (65.9%). 81.8% (n=27) patients were diabetic. Urinary tract obstruction was present in 33.3% (n=11), Solid organ malignancy related EPN in 21.2% (n=7), with cancers involving kidney and urinary tract predominantly, concomitant COVID infection in 18.2% (n=6) patients, renal transplant EPN in 9% (n=3) of patients respectively. Most common organism was E.coli (60%) followed by Klebsiella spp.(10%), Pseudomonas (8%), Candida spp. (5.6%), Proteus mirabilis (1.4%) and culture negative EPN (15%). CT scoring was done by Huang and Tseng classification. Class I was documented in 28%, Class 2 in 58.8%, Class 3 in 11.8% and Class 4 in 2% of patients. DJ stenting was done in 55% of patients, percutaneous nephrostomy in 3% and the remaining patients improved with antibiotics alone. 35.7% (n=12) required dialysis,10.7% (n=4) were dialysis dependent at the end of three months with 9%(n=3) requiring dialysis indefinitely. Gender, glycemic status or uremic symptoms showed no statistical significance. Sepsis, shock, altered sensorium, higher serum creatinine and hemodialysis dependency had significant impact on patient's outcome. Conclusions: Early diagnosis and treatment with broad-spectrum antibiotics and properly timed interventions decreased mortality. Abdominal pain, renal angle tenderness and fever were the most common symptoms. E. coli was the commonest organism encountered. Solid organ malignancy contributed to a sizable portion of EPN in our study secondary to susceptibility to infections and obstruction. COVID19 infection is a risk factor for EPN due to worsening glycemic status and immunosuppression caused by steroid administration. No conflict of interest

THE TIME TO NEGATIVE CONVERSION AMONG ADULT COVID-19 PATIENTS ON CHRONIC HEMODIALYSIS ADMITTED AT THE PHILIPPINE GENERAL HOSPITAL

BACKGROUND AND AIMS: In the Philippines, the shortage of dialysis centers that cater to ESKD individuals who tested positive for COVID-19 uniquely presents a logistic challenge, as these patients remain admitted in COVID-19 hospitals with hemodialysis units despite the clinical resolution of their disease. The majority of free-standing hemodialysis units require proof of negative conversion despite recommendations from local guidelines. As proof of negative conversion remains important in many practical settings, the negative conversion rate of SARS-CoV-2 infection has been the subject of several investigations. However, negative conversion rates particularly for ESKD patients with COVID-19 infection are lacking. Hence, this study aims to determine the time to negative conversion of COVID-19 RT-PCR testing among adult COVID-19 patients on chronic hemodialysis admitted at the Philippine General Hospital (PGH), a tertiary government hospital assigned as one of the COVID-19 referral centers in the country. This knowledge will allow for a more systematic and evidence-based implementation of the test-based approach, ultimately determining whether such an approach can be shifted to a symptom or time-based procedure in order to shorten the isolation period and conserve resources, especially in resource-limited settings. METHOD: This is a retrospective cohort study. All adult patients on chronic hemodialysis who were admitted at PGH after the diagnosis of COVID-19 by RTPCR between March 2020 and February 2021 were included. Patients who were asymptomatic for COVID-19, whose charts could not be retrieved, whose COVID-19 RT-PCR results were missing and those who died or got discharged without having a negative COVID-19 RT-PCR result were excluded in this study. Descriptive statistics were used in summarizing the data. Time to negative conversion is the primary outcome measure. RESULTS: A total of 90 patients who were on chronic hemodialysis and tested positive for COVID-19 via RT-PCR admitted at PGH at the specified time period met the inclusion and exclusion criteria. A total of 60% were males and the median age was 55 years old. The mean HD vintage was 2.95 years. Among the causes of ESKD, 46% was from hypertension, 31% was due to diabetes mellitus, 15% due to chronic hemodialysis, 0.80% was caused by autosomal polycystic kidney disease, 2.50% was due to obstructive uropathy and the remaining 4.0% of patients with ESKD were due to other causes such as NSAID nephropathy, gouty nephropathy, etc. Of these, 17% had mild, 53% had moderate, 18% had severe and 12% had critical COVID-19. The mean number of days from the onset of symptoms to clinical recovery is 22.48 days;the median was 18 days. One patient had clinical recovery only after 84 days. The median time to first negative conversion was 24.5 days, with a mean of 26.65 days. There were 6.67% who achieved negative conversion on the first week;15.56% on the second week;24.44% on the third week;26.67% on the fourth week;8.89% on the fifth week;6.67% on the sixth week;4.44% on the seventh week;5.56% on the eighth week;and 1.11% on the ninth week. After 28 days, 90% of the patients had clinical recovery, but 15% of them still had positive RT-PCR results. CONCLUSION: Among adult patients on chronic hemodialysis who were admitted at PGH after the diagnosis of COVID-19 by RT-PCR between March 2020 and February 2021, the median time to negative conversion was 24.5 days.

DON'T “MIS-C” THE CANCER: A CASE REPORT OF INCIDENTALLY DIAGNOSED WILMS TUMOR DURING ACUTE MIS-C

Background: Incidental diagnosis of malignancy during unrelated illness is challenging, both for diagnostic clarity and therapeutic decision-making. There are reported cases of incidental discovery of Wilms tumor (WT) in the setting of trauma, but there are none reported in the setting of acute inflammatory illness, such as Multisystem Inflammatory Syndrome in Children (MIS-C), and thus no guidance regarding timing of definitive therapy. Objectives: We describe a patient with MIS-C and incidentally diagnosed WT in order to inform the management of future patients with simultaneously diagnosed malignancy and acute inflammatory illness. Design/Method: Information was obtained by retrospective review of the electronic health record. Results: A healthy 5-year-old female presented with six days of fever, cervical lymphadenopathy, urinary symptoms, and rash. Labs showed acute kidney injury, prompting imaging that revealed a left-sided renal mass, most likely a WT. The constellation of signs and symptoms was initially suggestive of obstructive uropathy resulting in urinary tract infection. However, subsequent development of conjunctivitis and oral mucosal changes, positive SARS-CoV-2 nucleocapsid antibodies, rising inflammatory markers, and mild-moderate coronary artery dilation on echocardiogram, made MIS-C the most fitting diagnosis. The patient rapidly improved after initiation of aspirin, methylprednisolone, and intravenous immunoglobulin. Cross-sectional imaging showed no metastatic disease or local tumor invasion. A multidisciplinary team of pediatric subspecialists discussed appropriate timing for upfront resection and decided to defer surgery for at least two weeks while inflammation resolved. Unfortunately, the patient continued to have ongoing inflammation requiring a prolonged steroid course, and surgery was ultimately deferred until one month following diagnosis. Surgery was uncomplicated and pathology demonstrated stage II favorable histology WT. Chemotherapy began on post-operative day 9. Conclusion: The lack of published cases of malignancy incidentally discovered during acute illness, coupled with the rapidly rising rate of pediatric cases of COVID-19 and MIS-C, present a challenge for clinicians who must treat the concurrent conditions. This report highlights the complexities of managing a WT for which upfront resection is standard in the United States. Surgery is typically performed quickly due to the fast-growing nature and risk of rupture. Reports of paraneoplastic inflammatory syndromes (non-WT) suggest that tumor resection in the setting of acute inflammation is safe, but pediatric data remains scarce. This patient's multidisciplinary team chose to delay tumor resection given the potential morbidity of major surgery in the setting of a raging inflammatory state. The patient had a favorable clinical outcome both in terms of her MIS-C and WT.

A rare case of spontaneous parenchymal kidney explosion in a patient with ureteral obstruction caused by a single stone.

INTRODUCTION: Spontaneous rupture of kidney may involve collecting system or parenchyma. Parenchymal rupture usually occurs in patients with renal cell carcinoma, angiomyolipoma, renal cysts, arteriovenous malformation or vascular diseases such as periarteritis nodosa. Collecting system rupture is usually a rare complication of obstructive urolithiasis. We describe the unusual cases of spontaneous kidney rupture in patients with acute urinary obstruction. CASE PRESENTATION: The case report describes the left parenchymal kidney explosion related to ipsilateral ureteral obstruction caused by a single ureteral stone. The patient reached our emergency department with acute left flank pain and massive haematuria. At the moment of admission, the patient was in stage III hypovolemic shock and had a lower haematocrit (haemoglobin = 4.9 g/dL). Despite blood transfusions, emergency surgical exploration, extrafascial nephrectomy and intensive support care, the patient died twelve hours after surgery. CONCLUSIONS: Parenchymal renal rupture can be a life-threatening emergency. Despite its rarity, in the differential diagnosis of acute abdomen, parenchymal renal rupture should always be considered in patients with abdominal pain and an anamnesis or history of urinary stones, pointing out the need of early diagnosis also in benign urological conditions.