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1.
American Journal of Transplantation ; 22(Supplement 3):1051, 2022.
Article in English | EMBASE | ID: covidwho-2063478

ABSTRACT

Purpose: Although, much has been written about COVID risk and immunization efficacy in transplant recipients, there is little data on the impact of COVID on transplant professionalism. Method(s): A survey about the impact of COVID on professional development was sent to transplant providers. There were 138 responses (10% response rate) with equal representation from transplant nephrologists, pulmonologists, surgeons, cardiologists and advanced practice providers. Responses were evenly divided between gender and across regions of the US. Result(s): 75% of respondents reported that COVID has had a negative impact on their own education with the primary reasons given being 'virtual fatigue' and not taking time off to attend virtual meetings leading to lack of engagement. 40% of respondents reported that staffing shortages made it difficult to attend virtual meetings. When asked about any positive impact of COVID on their education 43% said the ability to view sessions on their own time without travel requirements was positive. The impact of COVID on fellows' education was seen with reduced disease specific education due to focus on COVID and reduced fellow time on the wards (55% & 48% respectively).74% of respondents reported a negative impact on their professional relationships within their own center. The primary reasons were physical and emotional fatigue (43%) and staffing shortages (37%). The inability to socialize outside the work setting also had a significant impact. Fortunately, few had family or colleagues ill with COVID, but 3 reported death of co-workers or family members. Though most reported no positive impact on their work relationships (62%), "bunker mentality" and increased patience with colleagues were reported by 35%. 64% of respondents reported fatigue and lack of opportunity to see colleagues outside their own institution as a negative impact on those relationships. 76% described no positive impact on those relationships. 60% of respondents related a negative impact on their own research as there was no time to focus on research and/or most non-COVID research stopped, leading to lack of connection with research colleagues. 81% of respondents reported 'burnout' and 18% reported Post Traumatic Stress Syndrome (PTSD). When asked what the most significant impact of COVD on professionalism the overwhelming responses were emotional and physical fatigue and isolation from colleagues. The emotional stress of family and colleagues ill and sometimes dying from COVID takes a toll. Conclusion(s): In summary, in addition to the stress and physical toll the pandemic created for health care providers, transplant professionals reported a loss of ability to advance the field of transplantation due to the inability to attend professional meetings, participate in transplant-related research, and network with colleagues on topics other than COVID related care.

2.
American Journal of Transplantation ; 22(Supplement 3):706, 2022.
Article in English | EMBASE | ID: covidwho-2063463

ABSTRACT

Purpose: This study aimed to characterize the management and impact of respiratory viral infections on pediatric kidney transplantation waitlisted candidates. Method(s): An IRB-approved, anonymous REDCap survey was distributed to pediatric transplant nephrologist and infectious diseases practitioners from November 2021-January 2022 to members of the Pediatric Nephrology Research Consortium and the Pediatric Infectious Diseases Society via email. If multiple providers from the same center responded, questions related to center-wide practices were combined. Result(s): Sixty-six providers, 65 physicians and 1 nurse practitioner, responded to the survey from forty-eight different institutions (47 centers were in the United States). Providers estimated that respiratory viral infections were the most common cause of delays in transplant due to recipient infection. This fact has been highlighted during the pandemic with 46% of centers reporting they had delayed transplants for institutional reasons related to the pandemic and 38% had delayed transplants for active SARS-CoV-2 infection in a recipient, even before the omicron surge. Despite the impact of respiratory viral detection in waitlisted patients, over 80% of centers did not have a policy regarding delays for respiratory viral infections including SARS-CoV-2. Pre-transplant recipient screening for non-SARS-CoV-2 viral infections was not routine in 77% of centers but 45% of providers indicated they would delay a living donor transplant if they knew the recipient had an asymptomatic respiratory viral infection. For recipients with symptomatic respiratory viral infection, 95% and 87% of providers would delay transplant (living donor and deceased donor transplants respectively). Fifty-nine percent of providers indicated they would proceed with transplant after a waiting period ranging from one week to two months. Conclusion(s): Providers recognize that respiratory viral infections, not limited to SARS-CoV-2, are a common cause of pediatric kidney transplant delay. Most centers do not have defined approaches to screening and management of non-SARS CoV-2. Prospective studies and policies for screening and management of respiratory viral infections in waitlisted pediatric kidney transplant should be considered.

3.
American Journal of Transplantation ; 22(Supplement 3):795-796, 2022.
Article in English | EMBASE | ID: covidwho-2063407

ABSTRACT

Purpose: Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine has the potential to facilitate care delivery/ coordination for donors. We aimed to understand center practices and provider attitudes and perceived barriers of telemedicine services for living kidney donation. Method(s): We conducted a national survey of multidisciplinary providers from 194 U.S. active adult living donor kidney transplant centers in 2020. The survey was distributed with an online link from 2/18/2021 to 5/13/2021, and up to two reminders were provided. The target population included nephrologists, surgeons, nurse coordinators, social workers or independent living donor advocates, and psychiatrists or psychologists. We used descriptive statistics and analysis of variance. Result(s): Two hundred ninety-three providers from 128 unique centers responded to the survey, a center representation rate of 66.0%, reflecting 82.9% of U.S. practice by donor volume and 91.5% of U.S. states/territories. Most centers (70.3%) will continue using telemedicine beyond the COVID-19 pandemic. Video only was mostly used for donor evaluation by nephrologists, surgeons, psychiatrists or psychologists. Telephone and video were mostly used by social workers, while no mutual modality was used by coordinators. Vital signs and weight were obtained largely using self-reported measures or a local provider/primary care physician, and a physical exam was mostly completed at a subsequent in-person visit to the transplant center. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation for potential donors. These attitudes were consistent across provider roles (p>0.05). Providers were favorably disposed to use telemedicine beyond the pandemic for donor evaluation and followup care. Out-of-state licensing and reimbursements were key regulatory barriers. Conclusion(s): These findings help inform clinical practice and policy expanding telemedicine services to enhance access to living donation and may be extended to other medical specialties.

4.
American Journal of Kidney Diseases ; 79(4):S37-S38, 2022.
Article in English | EMBASE | ID: covidwho-1996885

ABSTRACT

Cocaine is one of the most used illicit drugs. Cocaine induced toxicity can result in hepatotoxicity, pulmonary toxicity, and renal dysfunction. Acute kidney injury (AKI) is an emergent complication in cocaine abusers. Rhabdomyolysis and vasoconstrictions mechanism are well known cause of AKI, cocaine induce thrombotic microangiopathy (TMA) is rarely reported. Cocaine is widely used in the United States, we report a case of Cocaine induced TMA in a cocaine abuser. We chronicle a case of a 42-Year-old male cocaine abuser, who presented to ED with complaints of Dyspnea, cough, anorexia and chest tightness for two days. He attributed to inhaling ammonia from cat urine along with cocaine abuse. No prior history of kidney disease or any other chronic illness. On examination, the patient appeared malnourished and cachectic. He was normotensive, lethargic and oriented. There were crackles at the lung bases. Blood tests revealed serum creatinine 18.0 mg/dL, blood urea nitrogen 150 mg/dL, hemoglobin 8.2 g/dL, platelets 173000/mm3, Retics count 8 %, LDH 1120 (84–246 IU/L) and haptoglobin < 8 (30–200mg/dL). A blood film revealed occasional schistocytes. Urinalysis showed proteinuria and microscopic hematuria. Urine toxicology revealed cocaine. Routine blood and urine cultures showed no growth. Serologic tests showed reduced complement C3 level of 40 (82-185 mg/dL) and normal C4 level of 32 (10–53mg/dL). There were no antibodies against HIV 1/2 and Covid 19. His ADAMTS-13 results showed 0.61 and 0.63 (0.68 to 1.63). Renal Ultrasound was unremarkable. Patient was intubated and ventilated in ICU;he was initiated on hemodialysis. He was provided four sessions of plasma exchanges till his ADAMTS-13 result came back near normal that was indicative of Cocaine induce TMA. Cocaine abuse is a global issue with increasing number of cases in the USA. It can cause AKI due to well-known etiologies like Rhabdomyolysis, Vasculitis, Acute interstitial Nephritis and Renal Infarction. However, Clinicians and nephrologists should also consider rare causes like TMA as a possible differential cause of AKI in the setting of cocaine abuse.

5.
American Journal of Kidney Diseases ; 79(4):S37, 2022.
Article in English | EMBASE | ID: covidwho-1996884

ABSTRACT

Immunization with COVID-19 mRNA vaccines has been associated with new-onset and relapse of glomerulonephritis (GN)1,2. We present a case of new onset, seronegative, full-house immune-complex GN after mRNA COVID-19 vaccination. A 24-year-old male with history of idiopathic portal vein thrombosis in childhood, portal hypertension post splenorenal shunt and splenectomy 5 years prior presented with 9 weeks of progressive edema, ascites, and foamy urine. His symptoms started then worsened after his 1st and 2nd doses of the mRNA- 1273 COVID-19 vaccination (Moderna). Cr peaked at 3.04mg/dl (baseline 0.7) and UPCR at 50.52 g/g. Serum albumin 0.9 g/dl. Complements were low. ANA and anti-DS DNA were negative as were other serologies. Infectious work up was also negative. Kidney biopsy showed membranoproliferative pattern of injury on light microscopy with one fibrocellular crescent and without IFTA. IF revealed “full house” staining and EM showed severe subepithelial deposits with subendothelial and mesangial deposits. No tubuloreticular inclusions were present (Figure 1). The patient received cyclophosphamide 750 mg and high dose steroids. One month after treatment, Cr improved to 0.92 and proteinuria fell to 6.05g/g. Complements returned to normal. The high potency of mRNA COVID-19 vaccine can induce a robust immune response which may incite or unmask GNs2. Our patient had a rapid and robust response to immunosuppression. Seronegative full-house immune complex GN may occur after receiving mRNA SARS-CoV-2 vaccination and nephrologists should be aware of potential association. Prompt recognition and treatment may lead to favorable outcomes. (Figure Presented)

6.
Cytotherapy ; 24(5):S50-S51, 2022.
Article in English | EMBASE | ID: covidwho-1996714

ABSTRACT

Background & Aim: Funded in 2015, the NEPHSTROM EU-H2020 consortium aimed to translate pre-clinical evidence of efficacy of “off-the-shelf” intravenous (i.v.) allogeneic mesenchymal stromal cells (allo-MSC) in diabetic nephropathy to early-phase clinical investigation in patients with progressive diabetic kidney disease (DKD). Methods, Results & Conclusion: Methods: The trial IMP, NEPHSTROM ORBCEL-M, consists of cryopreserved, CD362-selected bone marrow allo-MSCs or matching placebo (cryopreservation fluid). The protocol for a multi-site, randomised, placebo-controlled, double- blind, dose-escalation phase-1b clinical trial in adults with DKD due to type 2 diabetes was designed collaboratively by a group of academic nephrologists and cell therapy specialists from Italy, the UK, Ireland and the Netherlands. Inclusion criteria included age 40-85 yrs and type 2 diabetes with evidence of progressive DKD [eGFR 25- 55mL/min/1.73m2, urine albumin creatinine ratio >88mg/g and rapid eGFR decline or ≥15% risk of ESRD within 5 years]. Three dose cohorts were planned, each with n=12 NEPHSTROM ORBCEL-M recipients + n=4 Placebo recipients and 18 months follow-up. Results: Following regulatory approval of the trial dossier through the EMA’s Voluntary Harmonisation Procedure and ethical approvals at the Sponsor site (Bergamo, Italy) and three other sites (Galway, Ireland;Birmingham and Belfast, UK), the NEPHSTROM trial (NCT02585622) opened March 2018. To date, 27 patients have been treated and 14 have completed the trial protocol. We report here our (as-yet blinded) experiences with the first fixed-dose cohort (80x10e6 cells/placebo i.v.), consisting of 16 subjects enrolled at 3 sites and followed for 18 months. The trial intervention proved safe, with one quickly-resolved infusion reaction and no subsequent SAEs ascribed to the IMP. Two patients died of unrelated causes between 12 and 18 months. Serial serum assays for anti-HLA antibodies indicated no persistent allo-immune sensitisation. NEPHSTROM ORBCEL-M effects on trends in eGFR, true GFR (iohexol clearance), albuminuria, serum/plasma inflammatory biomarkers and immune cell profiles will be analysed after unblinding. Following DSMB approval and COVID-19-related trial pauses, 11 second dose cohort subjects (160x10e6 cells/placebo i.v.) have been treated and are undergoing follow-up with no IMP-related adverse events to date. Conclusion: A novel, off-the-shelf, i.v. allo-MSC IMP has thus far proven safe and feasible in adults with progressive DKD.

7.
Journal of General Internal Medicine ; 37:S582, 2022.
Article in English | EMBASE | ID: covidwho-1995665

ABSTRACT

STATEMENT OF PROBLEM/QUESTION: With Chronic Kidney Disease (CKD) on the rise, Grady Health System (GHS) implemented a novel Electronic-Consultation (E-Consult) Service for outpatient Nephrology and we sought to determine the characteristics and outcomes of these patients to better recognize the utility in our new approach to kidney care. DESCRIPTION OF PROGRAM/INTERVENTION: The Nephrology EConsult service was launched in September 2020 across all primary care clinics at GHS, which is located in downtown Atlanta, GA, and serves a population of mainly Medicare/Medicaid and uninsured patients. With this service, Primary Care Providers (PCPs) submit an E- Consult and a single Nephrologist reviews the chart to communicate closed-loop recommendations via the patient's Electronic Health Record (EHR). If high-complexity factors are discovered (including nephrotic-range proteinuria, acute kidney injury (AKI), or CKD 4/5), the patient is scheduled for an in-person clinic visit with Nephrology. MEASURES OF SUCCESS: We retrospectively analyzed the charts of 200 randomly-selected E-Consults placed 09/2020-12/2021 to determine disease complexity, A1c and albuminuria screening rates, DM2 control, common comorbidities, renoprotective medication use, as well as the percentage of PCPs who completed the consultation recommendations. We identified the number of in-person Nephrology clinic visits that were prevented with this virtual service and compared waitlist times against a traditional referral to outpatient Nephrology. FINDINGS TO DATE: The majority of patients (55%) have low-complexity kidney disease, and nearly half of all E- Consults are managed entirely virtually, avoiding an in-person visit to Nephrology. Fewer E-Consults have high- complexity disease (45%), most of which involve AKI (60%) and/or CKD4 (35%), warranting an in-person Nephrology evaluation, and with this service an in-person visit occurs in 1/3 the time of traditionally-placed referrals. The most common comorbidities are hypertension (80%) and DM2 (51%), and interestingly, the majority of patients with DM2 have relative control of their disease with an A1c <7% (63%). However, the rate of screening A1c differs from albuminuria: most patients have a recent A1c (70%) while less than half of patients have a recent urine albumin. Very few patients are prescribed an SGLT2-inhibitor (5%) and more than a quarter of eligible patients are not on any renoprotective medications. Nearly a quarter of PCPs do not complete the e-consult recommendations, representing an area where EMR automatization may be useful. KEY LESSONS FOR DISSEMINATION: Our Nephrology E-Consult Service improves access to kidney care for all patients, reduces clinic wait times for those with high-complexity disease, and may play an important role during the Covid-19 pandemic by reducing healthcare-associated exposures. By providing a closed-loop method of communication between PCP and Nephrologist, guideline-based recommendations for routine screening and renoprotective strategies can be exchanged for the patient's benefit.

8.
Journal of Vascular Access ; 23(3):NP7, 2022.
Article in English | EMBASE | ID: covidwho-1968509

ABSTRACT

Introduction: Transplantation (KTx) is considered the best renal replacement therapy and improving its outcomes remains a primary challenge. KTx ureteral JJ stenting has been used to prevent urological complications, but there is no consensus about EJJR timing and literature regarding routine US imaging after EJJR to detect complications is lacking. Aim: Define the incidence of urological complications diagnosed by routine US after EJJR in KTx, determine US utility and best time interval to perform it. Methods: We retrospectively analysed all routine KTx US performed in our Unit from 2016 until 2020 by an experienced interventional nephrologist. US post EJJR findings were compared with previous patient US. KTx characteristics, treatment and outcomes were recorded. Results: - 345 KTx were done, 62.9% were male receptors, 81.7% had a first KTx and 91.5% were from a deceased donor. No routine US post EJJR was done in 20.9% due to the COVID pandemic. - Mean timing to elective JJ stent removal was 36.4 ± 25 days (SD). - Mean time from EJJR to US was 16.3 ± 28.8 days (SD). - Urinary tract (UT) ectasia (19.7%) and grade I UT dilatation (3.6%) were not considered pathological. - 47.3% (129) had a complication detected: 88.4% (114) had a collection, 8.5% (11) had UTD: 5.4% grade II and 3.1% grade III. 3% had other complications. Conclusion: Routine US after EJJR allowed a timely diagnosis and early treatment of urological complications, a key factor for successful transplantation. KTx US is a cost - effective and reproducible test that provides crucial information to guide clinical decisions, being most efficient when performed 10 days post removal. Interventional nephrologists could do this examination promptly.

9.
European Journal of Clinical Pharmacology ; 78:S130, 2022.
Article in English | EMBASE | ID: covidwho-1955961

ABSTRACT

Introduction: Zolpidem and zopiclone are widely used for sleep disorders, yet their abuse and dependence potential has been underestimated. The electronic prescription of zolpidem/zopiclone became mandatory on 17.07.2019 in Greece. Objectives: To investigate descriptive characteristics of zolpidem/ zopiclone prescriptions and the impact of the mandatory electronic prescription mandate. Methods: Anonymized prescriptions of zopiclone (ATC: N05CF01) and/or zolpidem (ATC: NC05CF02) that were executed in pharmacies between 01.10.2018 and 01.10.2021 were obtained from the Greek nationwide prescription database. The database covers almost the entire Greek population and it is administrated by IDIKA of the Greek Ministry of Health. We investigated descriptive characteristics of prescriptions, and calculated themonthly number of prescriptions taking into consideration dates with potential impact, i.e., the date of the mandatory electronic prescription mandate (on 17.07.2019) and the date of the first case of COVID-19 in Greece (on 26.02.2020). Results and Conclusion: During the investigated period of three years, there were 1229842 executed prescriptions of zolpidem (89.4%), zopiclone (10.4%) or both (0.3%), considering 156554 unique patients. The patients weremainly elderly (73.1%were ≥ 65 years old) andwomen (64.5%). The majority of the prescription physicians (69.9%) were general practitioners or internists, followed by 17% psychiatrists or neurologists, 5.3% cardiologists, 4.5% physicians in specialty training, 1% nephrologists and 2.4% of physicians with another specialty. After the mandatory electronic prescription mandate and before COVID- 19 in Greece, i.e., between 08.2019 to 03.2020, there was a notable increase of prescriptions in comparison to the previous period from 10.2018 to 07.2019 (median 37267 vs median 34106;Mann-Whitney U=9, p-value=0.009). After COVID-19, the median monthly number of prescriptions was 36363, yet there were variations ranging from 16963 to 39956. In conclusion, the mandatory electronic prescription system could increase the surveillance of drugs with abuse potential such as zolpidem and zopiclone. Nevertheless, the large number of prescriptions in elderly patients and prescribed by primary care physicians is worrisome and warrants further investigation.

10.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i763-i765, 2022.
Article in English | EMBASE | ID: covidwho-1915809

ABSTRACT

BACKGROUND AND AIMS: Factors influencing dialysis choice are multifaceted. Detailed and unbiased information is pivotal in order to assist patients in making decisions. Hence, patient education is a cornerstone in the treatment of advanced chronic kidney disease. At the hospital of Southern Jutland, a kidney school has existed for more than 15 years teaching patients about their illness and treatment options at end-stage renal disease (ESRD). Due to the coronavirus disease (COVID-19) pandemic, an online kidney school (OKS) was established. We present the latest results of this ongoing study regarding the change of preferences of ESRD treatment options among patients after participation in online renal education. METHOD: The OKS consists of a 3-h synchronous class taught by a nephrologist and a dialysis nurse combined with asynchronous short films on treatment options and advice from a dietitian. The OKS has been held six times with 45 patients in total. A questionnaire was distributed to participants before and after the OKS. Patients were asked to choose between center haemodialysis, home haemodialysis, peritoneal dialysis, transplantation, maximal conservative medical treatment and 'not enough information to make the decision'. RESULTS: Out of the 45 patients, 36 patients answered the questionnaire before OKS and of those, 19 also answered the questionnaire after OKS. A total of 76% % of the participants were male, 52% answered the questionnaire on their own and 48% answered the questions together with a relative. The percentage of patients not feeling informed enough to make the decision decreased from 56% prior to participation in OKS in comparison to 32% following participation in OKS. The percentage of patients who prefer peritoneal dialysis as their ESRD treatment of choice increased from 6% to 32%. CONCLUSION: Online education on treatment choices for end-stage renal patients leads to change of treatment preferences. This is especially true for peritoneal dialysis. The OKS is designed to help patients make an informed decision on treatment options in ESRD. Although the number of patients feeling unsure about what kind of treatment to choose is decreased, the number of patients unsure about the best treatment option for them remains high. These patients require a follow-up consultation in order for them to make the final decision for ESRD treatment. The number of patients who answered the questionnaire prior to OKS is higher in comparison to after OKS. However, this is an ongoing study and we will be able to confirm or dismiss these preliminary findings at a later stage. (Figure Presented).

11.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i699-i700, 2022.
Article in English | EMBASE | ID: covidwho-1915793

ABSTRACT

BACKGROUND AND AIMS: Transplantation (KTx) is considered the best renal replacement therapy nephrologists can offer and improving its outcomes remains a primary challenge in our field. KTx ureteral JJ stenting has been used to prevent urological complications, but there is no consensus about its elective removal timing and literature regarding routine US imaging after EJJR to detect complications is lacking. Our aim was to define the incidence of urological complications diagnosed by routine US after EJJR in KTx, determine US utility and best time interval to perform it. METHOD: We retrospectively analyzed all routine KTx US performed in our Unit from 2016 until 2020 by an experienced interventional nephrologist. US post EJJR findings were compared with previous patient US. KTx characteristics, treatment and outcomes were recorded. RESULTS: • 345 KTx were done in the study period, 62.9% of receptors were male, 81.7% had a first KTx and 91.5% of organs were from a deceased donor. No routine US post EJJR was done in 20.9% due to the COVID pandemic. • Mean timing to elective JJ stent removal was 36.4 ± 25 days (SD). • Mean time from EJJR to US was 16.3 ± 28.8 days (SD). • Urinary tract (UT) ectasia (19.7%) and grade I UT dilatation (3.6%) were not considered pathological. • 47.3% (129) had a complication detected: 88.4% (114) had a collection, 8.5% (11) had UTD: 5.4% grade II and 3.1% grade III. 3% had other complications. • Table1 summarizes the outcomes of complications detected • Cumulative frequency analysis of complications post EJJR showed the highest diagnostic yield was around day 10 post removal (Figure 1). CONCLUSION: Routine US after EJJR allowed a timely diagnosis and early treatment of urological complications, a key factor for successful transplantation. KTx US is a cost-effective and reproducible test that provides crucial information to guide clinical decisions, being most efficient when performed 10 days post elective removal. Interventional nephrologists could do this examination promptly. (Table Presented).

12.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i245-i246, 2022.
Article in English | EMBASE | ID: covidwho-1915712

ABSTRACT

BACKGROUND AND AIMS: Renal recovery (RR) after AKI is a determinant outcome of future comorbidity and mortality in critical care patients. Related predictive factors remain uncertain. METHOD: We retrospectively analyzed patients admitted to ICU between January 2020 and February 2021 from our critical nephrology database. We analyzed adult patients with diagnosis of AKI (KDIGO criteria) treated with renal replacement therapy (RRT) during ICU hospitalization. We excluded patients with dialysis support previous to the admission. The main outcomes we evaluated were (1) RR (successful suspension of RRT without hyperkalemia, increase in serum creatinine (SCr), hypervolemia or acidemia after 1 week without RRT, with urine volume > 500 mL/d without diuretic treatment or > 2000 mL/d with diuretics). (2) Mortality during hospitalization. RESULTS: We found 1442 patients were admitted to ICU, 418 presented AKI (29.8%), of them, 178 patients (64% male) required RRT (AKI-RRTd) in ICU during follow-up, with mean age of 66 year old (52.8% >65 year). Main comorbidity and demographic data are in Table 1. Mean time in ICU was 19 days (RIC 11-35). The most frequent admission cause was non-surgical pathologies (93%), 53% of admitted patients had COVID-19 as main diagnosis (95 patients). There was need of vasoactive support in 73.6%, ventilatory support (82.6) and 67.2% of patients had fluid overload. The indication of dialysis was determined by a nephrologist: mainly oliguria, acidosis, hyperkalemia, fluid overload and increase SCr. Mean SCR at admission was 2.5 mg/dL. There were missing data in 48% of basal SCr (known SCr between 1 and 12 months prior to admission). Total mortality in AKI-RRTd was 70.8% (126 patients). In COVID patients, was 77.9% (74 patients). We found renal recovery in 63.4% of total survivors (33/52 patients). When analyzing COVID, there were 21 survivors, and we found renal recovery in 80.9% of patients. Patients who did not achieved renal recovery had longer ICU stay (median: 20 days, RIC: 4-26) and inhospitalization (median: 41 days, RIC: 29-58). Those patients were older, and had higher morbidity (diabetes), higher SCr at ICU admission and lower urine output. Their fluid balance was higher at 48 h after CRRT initiation (OR 3.05, 95% CI 1.39-6.65, P <.01). In COVID population without renal recovery, there were more urgent dialysis onset (OR 8.33, 95% confidence interval (95% CI) 1.04-66.2;P = .04), age > 65 year (OR 6.48, 95% CI 1.94-21.6;P < .01), positive fluid balance at 48 h after RRT (OR 3.25;95% CI 1.09-9.69;P = .03). The risk factors for mortality, were age > 65 year (OR 4.14, 95% CI 2.05- 8.35;P < .01), mechanical ventilation (OR 3.28, 95% CI 1.48-7.30;P < .01), haemodynamic support (OR 4.37, 95% CI 2.14-8.92;P < .01). Otherwise, lower SCr at admission (OR 0.82, 95% CI 0.71-0.93;P < .01) and at instauration of RRT (OR 0.75, 95% CI 0.065-0.88;P < .01) were associated to lower mortality. In COVID patients, fluid overload at RRT initiation (OR 10.83, 95% CI 1.37-85.36;P = .02), age > 65 year old (OR 8.85, 95% CI 2.68-29.1;P < .01) and FiO2 > 50% at RRT start (OR 2.77, 95% CI 1.02-7.50;P = .04) were associated to higher mortality. CONCLUSION: In ICU patients with AKI-RRT dependence, negative fluid balance at 48 h after RRT onset and in COVID patients, age < 65 year old, negative fluid balance at 48 h after RRT onset and non-urgent onset of RRT were related with renal recovery. (Table Presented).

13.
Journal of Urology ; 207(SUPPL 5):e596, 2022.
Article in English | EMBASE | ID: covidwho-1886517

ABSTRACT

INTRODUCTION AND OBJECTIVE: Organs from deceaseddonors who tested positive for COVID-19 were thought to be ineligible for transplantation. Despite lack of evidence showing that COVID-19 can be transmitted through urine or blood. We began to transplant kidneys from COVID-positive deceased-donors in February 2021 and this report comprises our early outcomes in this patient cohort. METHODS: From Feb 2021 to Oct 2021, 55 patients underwent kidney transplantation from 34 COVID-19 positive donors. Prior to initiating this clinical practice, formalized selection criteria for organs from COVID-19 positive deceased-donors were adopted by transplant surgeons, transplant nephrologists, and infectious disease physicians. If a deceased-donor suited these pre-determined criteria, individual kidney selection followed our usual programmatic criteria. RESULTS: The mean donor age was 34±13.7 years with a mean kidney donor profile index (KDPI) of 36.9±22.7%. All donors had at least 1 positive COVID-19 test from the nasopharyngeal ribonucleic acid swab test within a median of 4 (0-76) days prior to declaration as a deceased-donor. Extracorporeal membrane oxygenation (ECMO) was used in 6 donors. The initial and terminal mean creatinine was 1.1±1.1 mg/dl and 1.0±0.4 mg/dL. This patient cohort includes 36 male recipients and 19 female recipients. Mean age among all recipients was 51.2±13.5 years. Thirty-seven recipients (66.7%) were dialysis dependent. A similar proportion (67.3%) had received both COVID-19 vaccine doses. Delayed graft function occurred in 19.6% of the recipients. No patient tested positive for COVID-19 after surgery. At a mean follow up duration of 3.5 months, all kidney allografts are functioning, with a mean serum creatinine of 1.6±0.7 mg/dl. One patient underwent allograft nephrectomy at 1.5 months post-transplant due to Pseudomonas aeruginosa vascular infection. CONCLUSIONS: Transplantation of kidneys from COVID-19 positive donors is safe. Outcomes are comparable to kidneys from regular donors.

14.
Revue Medicale Suisse ; 16(691):842-844, 2020.
Article in French | EMBASE | ID: covidwho-1870378

ABSTRACT

During the actual pandemic of COVID-19, it has become clear that the virus causing this devastating disease, SARS-CoV2, targets not only the lungs but also other organs. In this article, we discuss the known or suspected interactions between the virus and the kidneys, as well as their clinical presentations. We also discuss how the pandemic has altered the activities of nephrologists and the logistics of a Swiss dialysis center.

15.
Journal of Clinical Urology ; 15(1):82, 2022.
Article in English | EMBASE | ID: covidwho-1869011

ABSTRACT

Introduction: Recent NHSEI policy and the COVID-19 pandemic are increasing the proportions of consultations occurring non-face-to-face (F2F). Here we describe a nurse-led non-F2F clinic for the metabolic assessment of kidney stone patients. Method: A metabolic assessment may be indicated in patients forming urate stones, CaPO4 stones, or recurrent stones or with clinical features suggesting a metabolic cause. In otherwise uncomplicated clinical scenarios, these patients are reviewed in a non-F2F clinic run by an endo-urological specialist nurse. A stone history is taken by telephone. Blood tests are arranged in primary care. A collapsible 24-hour urine collection container is posted to the patient and returned via the primary care sample collection service. The cases are reviewed at the Metabolic Stone MDT by the nurse, nephrologist and urologist. Results: A total of 145 patients were eligible with six DNAs, leaving 139 patients reviewed through the non-F2F clinic between March 2020 and June 2021. Demographics were 81 males: 58 females, age range 17-83. About 126 of 139 (91%) patients completed the tests, which is a significantly higher rate than completion rates typically reported. Stone analysis was also available in 97 patients (28 CaOx;54 CaPO4;15 urate). Around 102 patients (81%) were discharged with dietary advice, while 24 patients (19%) were referred for consultant review. Two patients had primary hyperparathyroidism. Nineteen patients had hypercalciuria, all requiring consultant review. Conclusion: Nurse-led non-F2F review streamlines the metabolic assessment of stone-formers, reducing the need for hospital attendances and reducing consultant workload.

16.
Paediatrics and Child Health (United Kingdom) ; 2022.
Article in English | EMBASE | ID: covidwho-1860007

ABSTRACT

Children with new-onset nephrotic syndrome invariably present to general paediatrics in the first instance. Many with known nephrotic syndrome under the care of a paediatric nephrologist will present to local services with complex relapses. Using a case-based approach, this review aims to equip the general paediatrician with the skills: to assess and manage a child with a new presentation of nephrotic syndrome, to identify the complications associated with the nephrotic state, to choose the most appropriate steroid regimen and to identify those patients who should be referred to a paediatric nephrologist. We focus on the management of steroid-sensitive nephrotic syndrome (SSNS), the most common diagnosis in children presenting with nephrotic syndrome. We also discuss aspects of management of nephrotic syndrome relevant to the COVID-19 pandemic. Additionally, by the end of the article, the reader should have a basic understanding of the underlying pathophysiology of nephrotic syndrome and its resultant complications.

17.
Genetics in Medicine ; 24(3):S170-S171, 2022.
Article in English | EMBASE | ID: covidwho-1768092

ABSTRACT

Introduction: Chronic kidney disease (CKD) is a debilitating disorder associated with significant morbidity and mortality. CKD diagnoses can have overlapping, non-specific clinical symptoms and histology findings, and the underlying etiology can remain unknown. Recent studies have shown that 1 in 10 adults with CKD has a genetic component to their disease. However, genetic services are limited in this patient population and disproportionally impact those from medically underserved communities. Therefore, an adult kidney genetics clinic was developed within the Division of Nephrology at a large urban academic medical center to increase access to genetic services and testing in adults with kidney disease. Methods: In June 2019, the Division of Nephrology at Columbia University Irving Medical Center created a Kidney Genetics Clinic staffed by genetic counselors (GC) and nephrologists. Initially, appointments were held in-person but transitioned to telemedicine beginning in May 2020 due to the COVID-19 pandemic. The clinic utilized two appointment types: full genetic consults (staffed by a GC and nephrologist) and genetic counseling visits (staffed by a GC only). Genetic counselors implemented several genetic education initiatives to increase clinic referrals and increase provider interest. These included bi-monthly genetic case seminars, monthly genetic research sign-out rounds, a continuing education course focusing on clinical genetics, and genetic counseling student rotations. Results: Between June 2019 and June 2021, the clinic received 277 referrals, averaging 11 per month. Of those referred, 83% were scheduled, and 212 patients underwent genetic evaluation. The median wait time from referral to appointment was 37 days, and the no-show rate was 8%. The majority (89%) of appointments were via telehealth, either by phone or video, while the rest occurred in person. Genetic counseling visits accounted for 21% of patient appointments, and the remaining ones were full genetic consults. Most patients who attended their genetics appointment were in the NY tri-state area (87%), but 12% resided in nine additional states, three other countries, and one US territory. The primary insurance was Medicare in 10% of patients and Medicaid in 17%. Most patients described themselves as white (n=126), while 47 patients reported Hispanic or Latino ethnicity, 36 identified as Black, 15 Asian, and 4 Native Hawaiian or Pacific Islander. The average age of the patient population was 44 years old (ranging from 18 to 87). Patients seen in the genetics clinic were referred for a variety of indications and included several different kidney diagnoses, including: CAKUT (n=6), tubulointerstitial disease (n=26), suspected or clinical diagnosis of a collagenopathy (n=38), focal segmental glomerulosclerosis (FSGS) (n=28), tubulopathy or electrolyte disorder (n=16), cystic kidney disease (including PKD) (n=24), hematuria and/or proteinuria (n=31), complement dysregulation (n=8), tumor or cancer (n=4), and CKD of unknown etiology (n=23). Six patients had a known genetic diagnosis, and 23 were healthy relatives of individuals with a known genetic diagnosis or potential kidney donors. Of patients seen in the kidney genetics clinic, 42% reported a family history of CKD or a personal or family history of a genetic diagnosis. A total of 186 clinical genetic tests were ordered on 174 patients;nine tests still have results pending, and ten were canceled. Genetic tests that were ordered included: small (>50) and large gene panels (n=146), exome sequencing (n=6), microarrays (n=4), and single gene and targeted variant testing (n=20). In patients that did not undergo genetic testing, reasons included: not clinically indicated, testing already ordered, and financial concerns. A diagnostic or candidate diagnostic positive result was reported in 29% of patients, involving 18 different genes. Pathogenic or likely pathogenic variants were most common in COL4A4 (n=11), followed by PKD1 (n=8). Similarly, the highest diagnostic yield was in patients with a referral ndication of a suspected collagenopathy (diagnosis in 50%) or cystic disease (diagnosis in 50%). A non-diagnostic positive finding was identified in 9% of patients and included results such as secondary findings (n=1), carrier status (n=5), and risk factors, such as an APOL1 high-risk genotype (n=9). The identification of a genetic diagnosis in patients impacted several areas of clinical care, including referrals to specialists, kidney donor selection, clinical trial eligibility (for example, in patients with a genetic Alport diagnosis), and increased access to medications (such as tolvaptan in patients with PKD1 variants). In addition, those with non-diagnostic findings were referred to ongoing research studies at the medical center to elucidate the genetics of kidney disease. Conclusion: Here, we describe the successful creation and implementation of an adult kidney genetics clinic at a large medical center. By utilizing a combination of in-person appointments and telemedicine, the clinic was able to provide access to genomic services across a broad geographic region and to a diverse patient population of adults with kidney disease. Genetic education efforts were an integral component of the clinic's success, as it increased visibility and helped providers identify patients who would benefit from genetic services, as evidenced by the high percentage of referred patients scheduling appointments and high diagnostic yield in patients undergoing testing. Identifying genetic diagnoses in this patient population has several clinical implications, including changes in management, eligibility for genetically stratified clinical trials, and treatment decisions. Continued and ongoing access to genomic services is a fundamental component of patient care in adults with kidney disease.

18.
Kidney International Reports ; 7(2):S292, 2022.
Article in English | EMBASE | ID: covidwho-1707930

ABSTRACT

Introduction: In Malaysia, the overall prevalence of Chronic Kidney Disease (CKD) is 15.48%1. The incidence of patients with end-stage renal disease (ESRD) requiring dialysis has been growing rapidly in Malaysia from 18 per million population (PMP) in 1993 to 231 PMP in 20132. From 2007 to 2016, the acceptance rate for both hemodialysis and peritoneal dialysis nearly doubled while the prevalence rate had increased by more than two-fold.3Early observational studies reported lower peritonitis rates with double versus single-cuffed catheters.4However, Eklund B et al. showed that there is no significant difference in terms of catheter survival, exit site infection and peritonitis.5Exit-site infection (ESI) is a common complication of peritoneal dialysis (PD) and is one of the important risk factors in PD-related peritonitis and technical failure.6In addition, exit site infection is an independent risk factor for early onset peritonitis. Early onset peritonitis on the other hand, is identified as an independent risk factor for mortality and technique failure in PD patients.7 Our objective of this study is to identify the incidence of exit site infection and early onset peritonitis among patients whom had their tenckhoff catheter inserted in Hospital Sultanah Bahiyah from January 2021 till June 2021. Methods: This is a single centered, retrospective observational study which examines the incidence of early onset exit site infection in the first 3 months and early onset peritonitis in the first 3 months for patients on newly inserted single or double cuffed tenckhoff catheters. All patients had their tenckhoff catheter inserted from 1stof January 2021 till 31stof June 2021 were recruited. The catheters are inserted by Nephrologists under Y-Tech peritoneoscope guidance in the operation theatre. Coiled Dacron cuffed catheters were used. I-series coiled PD catheter from MEDCOMP USA was used for single cuffed catheter while Argyle Curl Cath Peritoneal Catheters from MEDTRONIC USA was used for double cuffed catheter. Results: A total of 62 patients were included, 35 patients had double cuffed catheter inserted while 27 patients had single cuffed catheter inserted. One patient who had single cuffed catheter inserted was excluded from this study due to malfunctioning of tenckhoff catheter postoperatively. The mean age for single cuffed catheter and double cuffed catheter patients were 50.3 and 55.8 years old respectively. Among the single cuffed catheter patients, 12(44%) were female while 15(56%) were male. Among the double cuffed catheter patients, 19(54%) were female while 16(46%)were male. The incidence of exit site infection for single cuffed catheter was 2(8%) while double cuffed catheter was 6(17%) The incidence of early onset peritonitis for single cuffed catheter and double cuffed catheter were 4(15%) and 11(31%) respectively. Conclusions: There is a higher incidence of early onset exit site infection and early onset peritonitis among patients with double cuffed tenckhoff catheter. Our study has limitation due to small sample size as the study being conducted during the height of COVID19 pandemic. Further study would be needed to recruit more patients over longer duration to ascertain late onset exit site infection, peritonitis and the long term catheter survival among single and double cuffed tenckhoff catheter. No conflict of interest

19.
Kidney International Reports ; 7(2):S429, 2022.
Article in English | EMBASE | ID: covidwho-1705744

ABSTRACT

Introduction: It is known that the number of patients with end-stage renal failure in ASEAN countries will certainly increase in the near future. However, many of these patients cannot receive good quality hemodialysis (HD) or any HD at all, resulting in death. The HD skill in Japan is top level expertise throughout the world. Therefore, the staff of the Department of Nephrology and Hemodialysis Unit of National Center for Global Health and Medicine (NCGM) have set forth to instruct the HD staff and physicians of some HD facilities, first in Malaysia, on our good technique and method of HD, in collaboration with Tsukuba International University and other HD-related companies of Japan. This project was a part of “Projects for global growth of medical technologies, systems and services through human resource development” funded by the Ministry of Health, Labour and Welfare. Methods: 1) The staff of the Department of Nephrology and HD Unit of NCGM with the collaborators visited HD facilities in Malaysia, surveyed their level and HD technique, and instructed the staff on our HD method and technique. 2) We invited the staff of the National Kidney Foundation of Malaysia (NKF) and other staff of HD facilities to visit Japan to inspect the HD method at NCGM, Tsukuba International University and a few other exemplary HD facilities in Tokyo. Further, we discussed the differences in HD method and technique between Japan and Malaysia. 3) We proposed that the system of clinical engineers (CE) working in HD facilities, which has been successfully established in Japan, should be established to improve the skill of HD in Malaysia. 4) We produced online videos on the sophisticated HD management and practice to show staff of HD facilities in Malaysia, as we could not directly instruct them due to the COVID-19 pandemic in the recent 2 years. Results: 1) We visited various HD facilities, small and large, in Malaysia 5 times in 2016, 2017 and 2018. We not only surveyed the level and technique of HD but also gave lectures on the Japanese method of HD. 2) We invited the primary staff of NKF as well as nurses and medical staff of the HD facilities, that we visited, to come to Japan. The staff who visited Japan directly observed and inspected the method and setting of HD at NCGM, Tsukuba International University and a few other HD facilities in Tokyo. The visitors could visualize and understand the Japanese method of HD in the clinical setting, and they had good discussion with the Japanese participants. 3) We proposed to the president of NKF and other experienced nephrologists in Malaysia that it is reasonable to establish the system of CE to develop high-level HD. We also presented the necessity of CE in Malaysia at the 34th Congress of the Malaysian Society of Nephrology, 2018. 4) We produced 2 sets of videos showing lessons on dialysis machines and electrical safety, and more than 40 Malaysian staff from HD facilities of a private clinic and a university hospital viewed them. Now we are newly preparing videos on other themes which can be viewed by more HD staff working in Malaysia on demand. Conclusions: We could successfully start the spread of higher-level HD in Malaysia. We are considering appropriate strategy to further improve the technical level of HD in Malaysia via online teaching methods. Conflict of interest Potential conflict of interest: This project was funded by the Ministry of Health, Labour and Welfare.

20.
Kidney International Reports ; 7(2):S270, 2022.
Article in English | EMBASE | ID: covidwho-1705141

ABSTRACT

Introduction: Arteriovenous fistula (AVF) delivers the best treatment dose prescribed for hemodialysis. KDOQI guideline 2006 advocate the adoption of ultrasound mapping for pre access creation. However, this is not translated to routine practice due to scarce resources. In this study, we wish to study the efficiency of clinical assessment in determining the suitable vessels for AVF creation and the access survival. Methods: This is a single tertiary nephrology center, prospective study of a series of patients who were referred to our AVF outsource program that was funded by Ministry of Health. This program diverting non Covid-19 CKD 5 or new ESKD patients that have opted for hemodialysis to private facilities for AVF creation due to the limitation of available operating theatre slot in government hospital attributed by Covid-19 pandemic. Those assessed by our nephrologists and trainees in a specially created outsourcing clinic that deemed suitable for assess creation will be outsource to the private institutions. Clinician assessment of suitability of the vessels and the outcome of AVF creations at 6 months were captured and analyzed. Results: A total of 147 patients were identified, reviewed, and outsourced, with the mean age of 54-year-old, male predominant (n: 94). 65% of the cohort has diabetes mellitus as their primary disease followed by hypertension at 17%. 37.4% of the cohort are CKD 5 patients who are not on dialysis, while 10.8% on peritoneal dialysis and 51.7% were on hemodialysis. 87% of the patients were AVF naïve whereas 13% had prior history of failed AVF. Out these, 15.6% of patients did not have access created (1 passed away, 7 needed complex grafts, 13 have small vessels, 2 needed two stages surgeries). Of the remaining 124 patients (84.4%), 2 received AVGs and 122 received AVFs. From the first subsequent vascular review by the surgeons, the concordance for the vascular access creation suitability with our assessment was 91.1%. Subsequently, the concordance for vascular access that was successfully created was 84.3% with site of creation agreement at 61%. At 6 months post AV access creation, 13 patients (10.5%) have primary failures whereas 11 patients (9%) had secondary failure. 21 patients (17%) unfortunately passed away during the study period and were excluded. At 6 months, 60% of the patients have functional AV access. In addition, for the 26 patients that have deemed no suitable vessels for AV access creation from prior vascular review before referred to our program, 84.6% has AV access created subsequently. Their outcome in 6 months includes: 36.3% have functional AV access, 18% have primary failure, 22.7% have secondary failure and another 22.7% passed away. Conclusions: We have demonstrated a careful clinical assessment of a patient’s vascular access by a nephrologist led team provides a high and consistent level of accuracy as to successfulness of the vascular creation. The omittance of routine vascular mapping in our protocol provide considerable cost and time saving which echoes the latest guideline by KDOQI 2019. Patients who failed assessment prior still warrant a repeat clinical assessment if they are considering hemodialysis as the life plan of kidney replacement therapy. No conflict of interest

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