Incidence and Outcomes of Acute Kidney Injury in Critically Ill Patients with Coronavirus Disease 2019.

Patients with more severe cases of coronavirus disease-19 (COVID-19) may be at greater risk for developing acute kidney injury (AKI). The aim of our study was to analyze incidence and outcomes of AKI in critically ill patients with COVID-19. Our study prospectively followed about 198 patients with COVID-19 admitted to intensive care unit (ICU), Al Adan Hospital, Kuwait, for developing AKI and outcomes. Age, gender, nationality, history of hypertension, diabetes mellitus, ischemic heart disease, congestive heart failure, bronchial asthma, and chronic obstructive pulmonary disease were analyzed. The need for mechanical ventilation (MV), extracorporeal membrane oxygenation, inotropes, and medications was recorded. Causes of AKI, indication of dialysis, dialysis modality, dialysis outcomes, and mortality were analyzed. Our study reported that61 out of 198 (30.8%) ICU patients positive for COVID-19, developed AKI according to the Kidney Disease Improving Global Outcomes definition of AKI. Forty-eight out of 61 (79%) patients need continuous renal replacement therapy using continuous venovenous hemodiafiltration. Thirty-seven (61%) out of 61 patients were with severe sepsis syndrome. The most common cause of AKI was sepsis, cytokine storm, hypovolemia, heart failure, MV, and nephrotoxic drugs. Twenty-four patients (39%) out of 61 patients died, and the most common cause of death was sepsis, cytokine storm with respiratory failure, heart failure, and AKI. The outcome of AKI was as follows: six patients (10%) had complete recovery, five patients had partial recovery (8%), and 26 (43%) patients became dialysis dependent. Incidence of AKI is high in ICU COVID-19 patients and is associated with poor outcomes and high mortality. Early detection and specific therapy of kidney changes, including adequate hemodynamic support and avoidance of nephrotoxic drugs, may help to improve critically ill patients with COVID-19.

Analysis of histopathological pattern of kidney biopsy specimens in Kuwait: A single-center, five-year prospective study.

Glomerulonephritis (GN) varies in incidence in different geographical areas due to different socioeconomic conditions and ethnicity, genetic variability and environmental factors. Our study is aimed to determine the histopathological pattern of kidney biopsies in Kuwait over the preceding five years. In a prospective study, we analyzed the clinical and pathological data of 214 kidney biopsies that were performed during the period from November 2009 to November 2014 at the Al-Khezam Dialysis Center, Al-Adan Hospital, Kuwait. Kidney biopsies were performed percutaneously using an automated gun guided by ultrasound. The biopsy samples were processed for light microscopy and immunofluorescence. Electron microscopy was performed only in selected cases. Age, gender, serum creatinine, 24-h urinary protein, virology, immunology profiles, indication for renal biopsy and histopathological findings were recorded for analysis. Primary GN was reported in 46.7%, secondary GN was reported in 42.9% and tubulointerstitial disease was reported in 10.3% of the 214 kidney biopsies studied. Among primary GN, membranous GN (MGN) was the most common lesion (12.1%), followed by immunoglobulin A nephropathy (IgAN, 11.7%), minimal change disease (9.8%), focal and segmental glomerulosclerosis (9.3%), membranoproliferative GN (1.9%), Alport's syndrome (1.4%) and fibrillary GN (0.46%). Among biopsies that showed secondary GN, lupus nephritis was the most common (11.7%), followed by hypertensive glomerulosclerosis (10.3%), crescentic GN (7.1%), diabetic nephropathy (3.3%), thrombotic microangiopathy (2.3%), amyloidosis (2.3%), post-infectious GN (1.4%) and myeloma kidney (0.9%). Among biopsies that showed tubulointerstitial disease, acute interstitial nephritis was the most common lesion (6.1%), followed by chronic interstitial nephritis (2.8%) and acute tubular necrosis (1.4%). Our study indicates that MGN was the most common primary GN, followed by IgAN, while lupus nephritis was the most common secondary GN, followed by hypertensive glomerulosclerosis.

Novel troponin-like biomarkers of acute kidney injury.

Acute kidney injury (AKI) is a common and serious condition in both the inpatient and outpatient settings, and its diagnosis depends on serum creatinine measurements. Unfortunately, creatinine is a delayed and unreliable indicator of AKI. The lack of early biomarkers has limited our ability to translate promising experimental therapies to human AKI. Fortunately, understanding the early stress response of the kidney to acute injuries has realized a number of potential biomarkers. For example, neutrophil gelatinase-associated lipocalin is emerging as an excellent stand alone troponin-like biomarker in the plasma and urine for predicting and monitoring clinical trials and in the prognosis of AKI. In recent years, a number of new biomarkers of AKI with more favorable test characteristics than creatinine have been identified and studied in a variety of experimental and clinical settings. This review will consider the most well-established biomarkers of AKI.

ANCA negative pulmonary renal syndrome with pathologic findings of thrombotic microangiopathy.

INTRODUCTION: Thrombotic microangiopathy (TMA) is characterized by aggregation of platelets in the renal and/or systemic circulation, thrombocytopenia and intravascular hemolysis. The syndrome classically spares the lung. The term pulmonary-renal syndrome describes a number of diseases in which pulmonary hemorrhages and glomerulopathy coexist. CASE REPORT: We report a 44-year-old man admitted to hospital because of chronic unexplained fever. Six days after admission he developed hemoptysis, respiratory distress and biochemical evidence of acute renal failure. High-resolution computed tomography scan of the chest demonstrated alveolar hemorrhages. The patient developed hypoxia and was shifted to the intensive care unit to be supported by mechanical ventilation. He also received two sessions of continuous veno-venous hemodiafiltration. Kidney biopsy revealed pathological findings of TMA. Serology for anti-neutrophil cytoplasmic antibodies, anti-cardiolipin antibodies and anti-glomerular basement membrane antibodies was negative. The patient was treated with pulse steroids followed by prednisolone with mild improvement. Seven days later, his condition deteriorated with an increase in serum creatinine and pulmonary hemorrhages. His hemoglobin level dropped and he developed features of intravascular hemolysis. A diagnosis of TMA was made and treatment with plasma exchange was initiated. The patient showed dramatic improvement and was discharged in good condition. He remained in remission throughout his subsequent follow up. CONCLUSION: TMA should be considered in the differential diagnosis of pulmonary renal syndromes, and can be successfully managed by corticosteriods combined with plasma exchange.

Clinical and histopathological spectrum of IgA nephropathy in Kuwait.

BACKGROUND: Little is known about the nature and the course of IgA nephropathy (IgAN) in Arab countries. The aim of this work was to study the spectrum of clinical presentation and histopathological findings at our institution. DESIGN AND SETTING: Retrospective review, all renal biopsies at the Mubarak Al Kabeer Hospital between January 2000 and December 2004. METHODS: Cases of IgA nephropathy were selected, and their medical records and biopsy findings were reviewed. RESULTS: Eighty patients (9.2% of all native kidney biopsies) were diagnosed to have IgAN nephropathy. Sixty-nine biopsies were included in the study;11 were excluded. Forty-three (62.3%) patients were male and 26 (37.7) patients were female. Fifty (72.5%) patients were below the age of 40 years. Mean (SD) duration of follow-up was 3.6 (1.3) years. The first presentation included nephritic-range proteinuria (49.3%) and renal impairment (50.7%). During the follow-up period, 56 (81.2%) patients were stable or improved. Hass classification of biopsies showed 36.2% had class I, 27.5% had class II, 13.0% had class III, 5.8% had class IV, and 17.4% had class V IgAN. Females had milder forms of the disease than males. Macroscopic hematuria and renal impairment at presentation were seen more in patients with class IV and V IgAN. The presenting serum creatinine and uric acid values were higher in those with Hass classes III to V. Deterioration of renal function during the follow-up period was more significant in the presence of hypertension, renal impairment, or macroscopic hematuria at the time of biopsy . CONCLUSION: The prevalence of IgAN in Kuwait is about 9.2%. Renal impairment or macroscopic hematuria at presentation was seen in patients with more aggressive renal lesions and contributed to poor outcome.

Can continuous venovenous hemofiltration prevent contrast-agent induced nephropathy in patients with advanced chronic kidney disease after coronary angiography?

To determine whether contrast induced nephropathy (CIN) post coronary angio-graphy procedure can be prevented in chronic kidney disease (CKD) patients by continuous venovenous hemofiltration (CVVH), we evaluated 98 CKD patients [52 (53.1%) were males, the mean age was 60.7 ± 11.0 years] who underwent coronary angiography from January 2004 to December 2006. Serum creatinine (Cr) before the procedure was 411 ± 79.9 µmol/L and crea-tinine clearance (Cr Cl) was 18.04 ± 4.26 mL/min. All patients underwent post procedure CVVH for 21.34 ± 2.12 hours. The mean time interval between the procedure and the start of CVVH was 44.3 ± 18.8 min. The mean serum Cr at discharge was 403 ± 88.4 µmol/L (Cr Cl 18.5 ± 4.61 mL/min) and was 423 ± 88.9 µmol/L (Cr Cl17.6 ± 4.27 mL/min) 15 days after the procedure. One patient (1.02%) developed worsening of renal functions that required repeated CVVH during hospitalization and ended up on regular hemodialysis. There was no in-hospital mortality. We conclude that CVVH is effective in preventing CIN after coronary angiography in CKD patients.

Acute renal failure in pediatric patients: etiology and predictors of outcome.

Acute renal failure (ARF) is the acute loss of kidney function over hours or days, the etiology of which varies in different countries. The data on the etiology and outcome of ARF in Arab children is limited. Our objective was to define the causes and predictors of outcome of ARF in Kuwaiti children, and the variables determining their fitness for dialysis. A total of 32 children with ARF were evaluated regarding their demographic and clinical data, the cause of ARF and the co-morbidities. Data were analyzed to find the independent variables determining fitness for dia-lysis and outcome. Males comprised 62.5% of the study children; 46.9% of ARF cases were due to sepsis and 56.2% underwent renal replacement therapy (RRT). Univariate analysis showed that age, hemodynamic instability, use of vasopressors, multi-organ failure (MOF), and mechanical venti-lation contributed to fitness for dialysis. However, MOF was the only independent variable affecting fitness for dialysis. The overall mortality was 43.8%. Univariate analysis showed that age below 24-months, hemodynamic instability, use of vasopressors, fluid overload, need for mecha-nical ventilation, MOF and late referral to the nephrologist were associated with poor outcome. However, multivariate analysis documented MOF, and the time of nephrologists' intervention as independent prognostic indicators. Our study suggests that sepsis was the major cause of pediatric ARF. RRT is the optimal treatment, and the only factor determining child's fitness for dialysis is MOF.

Intravenous alfacalcidol once weekly suppresses parathyroid hormone in hemodialysis patients.

Management of secondary hyperparathyroidism is difficult because of the interrelationship of parathyroid hormone, calcium and phosphorus. This study was carried out to assess the efficacy of intravenous administration of alfacalcidol once weekly versus twice weekly in patients with severe hyperparathyroidism. Twenty-one hemodialysis patients with intact parathyroid hormone >88 pmol/L were divided into two groups. Eleven patients (Group 1) were given a once-weekly alfacalcidol intravenously for 12 weeks. The starting dose was 4 microg which was increased or decreased by 1 microg per week. Ten patients (Group 2) were given twice-weekly alfacalcidol intravenously for 12 weeks. The starting dose was 2 microg twice weekly which was increased or decreased by 0.5 microg/dose. The dose was increased or decreased according to serum calcium and phosphorus levels. Serum calcium, phosphorus and alkaline phosphatase levels were measured weekly and intact parathyroid hormone every 4 weeks. Intact parathyroid hormone reduced significantly (P = 0.0001) from 128.12 +/- 35.42 pmol/L to 82.93 +/- 65.20 pmol/L and from 113.74 +/- 40.83 pmol/L to 64.24 +/- 35.17 pmol/L after 4 weeks in Groups 1 and 2, respectively. After 4 weeks alkaline phosphatase declined significantly (P = 0.0001) from 146.0 +/- 57.3 IU/L to 116.0 +/- 45.6 IU/L in Group 1 and from 139.0 +/- 45.1 IU/L to 116.6 +/- 38 IU/L in Group 2. There were no significant differences in serum levels of calcium, phosphorous or their product. Interestingly, an adenoma disappeared in one patient from Group 1, and out of two adenomas, one disappeared from another patient in the same group. These results indicate that intravenous alfacalcidol once weekly is safe and effective in suppressing high parathyroid hormone in hemodialysis patients.