Fluid Resuscitation Dilemma in End-stage Renal Disease Patients Presenting with Sepsis: A Systematic Review and Meta-analysis.

Background: This study aims to investigate the safety and efficacy of guideline-directed fluid resuscitation (GDFR) compared with conservative fluid management in end-stage renal disease (ESRD) patients with sepsis by evaluating 90-day mortality and intubation rate. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases using specific keywords and controlled vocabulary. The search strategy, implemented until October 1, 2023, aimed to identify studies examining fluid resuscitation in ESRD patients with sepsis. The review process was streamlined using Covidence software. A fourth reviewer resolved discrepancies in study inclusion. A random-effects model with the generic Mantel-Haenszel method was preferred for integrating odds ratios (ORs). Sensitivity analysis and publication bias analysis were performed. Results: Of the 1274 identified studies, 10 were selected for inclusion, examining 1184 patients, 593 of whom received GDFR. Four studies were selected to investigate the intubation rate, including 304 patients. No significant mortality or intubation rate difference was spotted between both groups [OR = 1.23; confidence interval (CI) = 0.92-1.65; I2 = 0% and OR = 1.91; CI = 0.91-4.04]. In most studies, sensitivity analysis using the leave-one-out approach revealed higher mortality and intubation rates. The Egger test results indicated no statistically significant publication bias across the included studies. Conclusion: Our research contradicts the common assumption about the effectiveness of GDFR for sepsis patients with ESRD. It suggests that this approach, while not superior to the conservative strategy, may potentially be harmful.

Systemic oncological therapy in breast cancer patients on dialysis.

The advancement of renal replacement therapy has significantly enhanced the survival rates of patients with end-stage renal disease (ESRD) over time. However, this prolonged survival has also been associated with a higher likelihood of cancer diagnoses among these patients including breast cancer. Breast cancer treatment typically involves surgery, radiation, and systemic therapies, with approaches tailored to cancer type, stage, and patient preferences. However, renal replacement therapy complicates systemic therapy due to altered drug clearance and the necessity for dialysis sessions. This review emphasizes the need for optimized dosing and administration strategies for systemic breast cancer treatments in dialysis patients, aiming to ensure both efficacy and safety. Additionally, challenges in breast cancer screening and diagnosis in this population, including soft-tissue calcifications, are highlighted.

Acute cardiovascular complications of disseminated intravascular coagulation in acute myeloid leukemia.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a common complication of all leukemia subtypes, but it is an especially prominent feature of Acute Myeloid Leukemias (AML). DIC complicating AML can lead to a variety of complications, however, its association with acute cardiovascular complications has not been reported before. METHODS: National Inpatient Sample Database was used to procure individuals with AML, and baseline demographics and comorbidities were collected using ICD-10-DM codes. Patients were stratified into those with and without DIC. Greedy propensity matching using R was performed to match the two cohorts in 1:1 ratio on age, gender, and fifteen other baseline comorbidities. Univariate analysis pre and post-match along with binary logistic regression analysis post-match were used to analyze outcomes. RESULTS: Out of a total of 37,344 patients with AML, 996 had DIC. DIC patients were younger, predominantly males, and had lower prevalence of baseline cardiovascular comorbidities. DIC patients had statistically significant higher mortality (30.2 % vs 7.8 %), acute myocardial infarction (5.1 % vs 1.8 %), acute pulmonary edema (2.3 % vs 0.7 %), cardiac arrest (6.4 % vs 0.9 %), and acute DVT/PE (6.6 % vs 2.7 %). Logistic regression model after matching showed similar outcomes along with significantly higher rates of acute heart failure in DIC patients. CONCLUSION: These findings highlight the importance of close cardiovascular monitoring and prompt recognition of complications in AML patients with DIC. The underlying mechanisms involve a complex interplay of procoagulant factors, cytokine release, and endothelial dysfunction. Further studies are needed to develop targeted interventions for prevention and management of these complications.

Risk of Nephrolithiasis in Patients with Inflammatory Bowel Disease Receiving Biologic Treatment.

INTRODUCTION: Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract. Biologic drugs target specific molecules in the body's immune system to control inflammation. Recent studies have suggested a potential link between their use and an increased risk of nephrolithiasis. We conducted a study to further investigate this association. METHODS: The study used multiple logistic regression analysis to assess the association between the use of biologic drugs and nephrolithiasis. A p-value of <0.05 was considered statistically significant. SAS 9.4 was used for statistical analysis. RESULTS: The final sample consisted of 22,895 cases, among which 5603 (24.51%) were receiving at least one biologic drug. The biologic drugs received were as follows: Adalimumab 2437 (10.66%), Infliximab 1996 (8.73%), Vedolizumab 1397 (6.11%), Ustekinumab 1304 (5.70%); Tofacitinib, 308 (1.35%); Certolizumab, 248 (1.08%); and Golimumab, 121 (0.53%). There were 1780 (7.74%) patients with Nephrolithiasis: 438 (8.0%) patients were receiving biologic treatment. We found that the use of Vedolizumab (OR = 1.307, 95% CI 1.076-1.588, p = 0.0071) increased the odds of Nephrolithiasis by 31%. CONCLUSION: Vedolizumab use was associated with an increased risk of nephrolithiasis. The use of two or more biologic drugs also increased the risk compared to no biologic treatment.

Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib. METHODS: In this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant. RESULTS: Of the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (ß = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001). CONCLUSION: Apart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.

Underutilization of left heart catheterization in kidney transplant patients presenting with non-ST segment elevation myocardial infarction.

Background: Cardiovascular disease (CVD) is the leading cause of mortality in kidney transplant (KT) patients. The perceived risk of contrast-induced nephropathy (CIN) may create a reluctance to perform coronary angiography in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI). Methods: National Inpatient Sample (NIS) Database was used to sample individuals presenting with NSTEMI. Patients were stratified into KT and Non-KT cohorts. Outcomes included left heart catheterization rates, mortality, arrhythmias, acute kidney injury/acute renal failure (AKI/ARF), and extended length of hospital stay (ELOS) (>72 h). Propensity matching (1:1 ratio) and regression analyses were performed. Results: Out of 336,354 patients with NSTEMI, 742 patients were in the KT group. KT patients were less likely to have LHC relative to non-KT patients (22.0 % vs 18.3 %); a difference that persisted on post-match analysis (27.1 % vs 19.4 %). On pre-match analysis, KT transplant patients that underwent LHC had lower mortality (10.3 % vs 0.7 %), AKI/ARF (44.6 % vs 27.9 %), arrhythmias (30.4 % vs 20.6 %) and lower ELOS (58.6 % vs 41.9 %). Post-match, KT cohort patient that underwent LHC had lower arrhythmias (OR:0.60[0.38-0.96]), AKI/ARF (OR = 0.51[0.34-0.77]), ELOS (OR:0.49[0.34-0.73]). Conclusion: KT patients underwent LHC much less frequently than their non-KT counterparts for NSTEMI. Coronary angiography and subsequent revascularization were associated with a significant decrease in morbidity and mortality. This theorized risk of CIN should not outweigh the benefit of LHC in KT patients.

Aggressive versus conservative fluid resuscitation in septic hemodialysis patients.

PURPOSE: Sepsis and bacterial infections are common in patients with end-stage renal disease (ESRD). We aimed to compare patients with ESRD on hemodialysis presenting to hospital with severe sepsis or septic shock who received <20 ml/kg of intravenous fluid to those who received ≥20 ml/kg during initial resuscitation. MATERIALS AND METHODS: We conducted a retrospective chart review of adult patients with ICD codes for discharge diagnosis of sepsis, severe sepsis, septic shock, ESRD, and hemodialysis admitted to our institution between 2015 and 2018. RESULTS: We present outcomes for a total of 104 patients - 51 patients in conservative group and 53 in aggressive group. The mean age was 69.5 ± 11.2 years and 71 ± 11.5 years in the conservative group and aggressive group, respectively. There was no significant difference in the rate of ICU admission, and ICU or hospital length of stay between the two groups. Complications such as volume overload, rate of intubation, and urgent dialysis were not found to be significantly different. CONCLUSION: We found that aggressive fluid resuscitation with ≥20 ml/kg may not be detrimental in the initial resuscitation of ESRD patients with SeS or SS. However, a clinical decision of volume responsiveness should be made on a case-by-case basis rather than a universal approach for fluid resuscitation in ESRD patients.

Predictors of 15-Day Survival for the Intensive Care Unit Patient on Continuous Renal Replacement Therapy: A Retrospective Analysis.

Purpose In the intensive care unit (ICU), acute renal failure is mostly part of multiple organ dysfunction syndromes with mortality ranging from 28%-90%, continuous renal replacement therapy (CRRT) is the predominant mode of RRT used in ICU. The main objective of the study was to evaluate the outcomes in patients with acute kidney injury (AKI) on CRRT in the ICU. Methods A retrospective chart review was conducted for all ICU patients with acute renal failure on CRRT in a tertiary care teaching hospital. A subgroup analysis was conducted between 15 days in hospital survivors and non-survivors to look for predictors of survival for patients on CRRT. Results Two-hundred twenty-six patients underwent CRRT from January 2007 to December 2013. The overall in-hospital mortality was 84.1%. Fifty-six patients (24.77%) survived to the 15-day post-CRRT mark. Acute respiratory failure requiring mechanical ventilation was associated with significantly increased mortality; 89.2% vs. 97.6% (P=0.008), ICU length of stay was significantly longer in the survivor group than the nonsurvivor group. Median±IQR; {20±24 vs 6±7(P: <0.0001)} and so were the ventilator-associated days {16±24 vs 4±6.5 (P: <0.0001)} and duration of CRRT {4.5±5.5 vs 2±2.0(P: <0.0001)}. Patients who survived had a lower incidence of metabolic acidosis {44.6% vs 62.9% (P: 0. 016)} and uremic encephalopathy {12.5% vs 26.5%; (P: 0.031)} but a greater incidence of volume overload {28.6% vs 15.9% (P: 0.031)} as compared to the non-survivor. Acute Physiology And Chronic Health Evaluation II (APACHE II) scores were significantly higher in the non-survivor group (mean SD) 26.9±28.0 vs. 23.9±25.8 (P: 0.0136). Conclusions This observational study in patients undergoing CRRT in an ICU setting revealed that the overall mortality was 84.1%. Fluid overload as an indication of CRRT was associated with improved 15 days' survival whereas higher APACHE II scores and the use of mechanical ventilation were associated with reduced 15 days' survival.

Knowledge, Perceptions, and Attitudes of Medical Residents Towards Nanomedicine: Defining the Gap.

Even though the general public opinion towards nanotechnology applications to health has been studied, medical residents' opinions remain unknown. The purpose of this study was to evaluate the perception, knowledge, and attitude of medical residents towards nanomedicine using a 35-item questionnaire. Correlations between intrinsic factors, heuristics, and attitude towards nanomedicine were analyzed using the χ 2 test. Seventy medical residents participated. Nanomedicine was perceived as a developing field in its clinical trial stages. Responsibility for nanomedicine was attributed to scientists, whereas its ethical responsibility to physicians. The majority reported not having adequate access to information. A positive attitude towards nanomedicine was correlated with higher willingness to use nanomedicine to diagnose and treat patients (p < 0.05). Medical residents had a positive attitude towards nanomedicine. However, they lacked accurate knowledge in the field. Participants might have relied on availability heuristics to form their opinion. Formal education for the "handlers" of nanomedicine seems to be needed.

Fluid resuscitation in patients with end-stage renal disease on hemodialysis presenting with severe sepsis or septic shock: A case control study.

Due to the potential risk of volume overload, physicians are hesitant to aggressively fluid-resuscitate septic patients with end-stage renal disease (ESRD) on hemodialysis (HD). Primary objective: To calculate the percentage of ESRD patients on HD (Case) who received ≥30 mL/Kg fluid resuscitation within the first 6 h compared to non-ESRD patients (Control) that presented with severe sepsis (SeS) or septic shock (SS). Secondary objectives: Effect of fluid resuscitation on intubation rate, need for urgent dialysis, hospital length of stay (LOS), intensive care unit (ICU) admission and LOS, need for vasopressors, and hospital mortality. Medical records of 715 patients with sepsis, SeS, SS, and ESRD were reviewed. We identified 104 Case and 111 Control patients. In the Case group, 23% of patients received ≥30 mL/Kg fluids compared to 60% in the Control group (p < 0.001). There was no significant difference in in-hospital mortality, need for urgent dialysis, intubation rates, ICU LOS, or hospital LOS between the two groups. Subgroup analysis between ESRD patients who received ≥30 mL/Kg (N = 80) vs those who received <30 mL/Kg (N = 24) showed no significant difference in any of the secondary outcomes. Compliance with 30 mL/Kg fluids was low for all patients but significantly lower for ESRD patients. Aggressive fluid resuscitation appears to be safe in ESRD patients.

The Value of Adding Red Cell Distribution Width to Mehran Risk Score to Predict Contrast-induced Acute Kidney Injury in Patients with Acute Coronary Syndrome.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a relatively reversible cause of acute kidney injury (AKI) that occurs after radiocontrast media administration. It is a common complication after percutaneous coronary intervention, especially in patients with acute coronary syndrome (ACS). The aim of this study is to determine the utility of red cell distribution width (RDW) in predicting CI-AKI in patients with ACS and to determine the value of adding RDW to the Mehran risk score (MRS) on admission. METHODS: A total of 161 patients who presented with ST-elevation myocardial infarction (STEMI) or non-STEMI were identified retrospectively between January 2015 and December 2016. Patients were divided into two groups, those who developed CI-AKI after percutaneous coronary intervention (PCI) and those who did not. RESULTS: A total of 161 patients were analyzed. Of them, 12 developed CI-AKI (eight presented with STEMI and four presented with non-STEMI). RDW did not correlate with the development of CI-AKI (14.55 ± 1.48 vs 14.83 ± 1.21; p = 0.072). The areas under the receiver operating characteristic curves (ROCs) for RDW, MRS, and the combined model (MRS and RDW) for the prediction of CI-AKI were 0.721 (95% confidence interval (CI), 0.645 to 0.788; p=0.0024), 0.885 (95% CI, 0.825 to 0.930; p<0.0001), 0.890 (95% CI, 0.831 to 0.933; p<0.0001), respectively. Pairwise comparisons between ROCs for MRS vs the combined model yielded a non-significant p-value of 0.49. This signifies no added benefit for RDW to MRS for predicting CI-AKI. CONCLUSION: RDW does not correlate with the development of CI-AKI in patients with ACS. The Mehran risk score remains a better indicator of CI-AKI risk assessment with no role for the addition of RDW to it. Further studies are needed to better assess predictors of CI-AKI in patients undergoing percutaneous coronary intervention.

Relevance of B-Lines on Lung Ultrasound in Volume Overload and Pulmonary Congestion: Clinical Correlations and Outcomes in Patients on Hemodialysis.

BACKGROUND: Volume overload in patients on hemodialysis (HD) is an independent risk factor for cardiovascular mortality. B-lines detected on lung ultrasound (BLUS) assess extravascular lung water. This raises interest in its utility for assessing volume status and cardiovascular outcomes. METHODS: End-stage renal disease patients on HD at the Island Rehab Center being older than 18 years were screened. Patients achieving their dry weight (DW) had a lung ultrasound in a supine position. Scores were classified as mild (0-14), moderate (15-30), and severe (>30) for pulmonary congestion. Patients with more than 60 were further classified as very severe. Patients were followed for cardiac events and death. RESULTS: 81 patients were recruited. 58 were males, with a mean age of 59.7 years. 44 had New York Heart Association (NYHA) class 1, 24 had class 2, and 13 had class 3. In univariate analysis, NYHA class was associated with B-line classes (<0.001) and diastolic dysfunction (0.002). In multivariate analysis, NYHA grade strongly correlated with B-line classification (0.01) but not with heart function (0.95). 71 subjects were followed for a mean duration of 1.19 years. 9 patients died and 20 had an incident cardiac event. A Kaplan-Meier survival analysis demonstrated an interval decrease in survival times in all-cause mortality and cardiac events with increased BLUS scores (p = 0.0049). Multivariate Cox regression analysis showed the independent predictive value of BLUS class for mortality and cardiac events with a heart rate of 2.98 and 7.98 in severe and very severe classes, respectively, compared to patients in the mild class (p = 0.025 and 0.013). CONCLUSION: At DW, BLUS is an independent risk factor for death and cardiovascular events in patients on HD.

Contrast media use in patients with chronic kidney disease undergoing coronary angiography: A systematic review and meta-analysis of randomized trials.

BACKGROUND: Patients with chronic kidney disease (CKD) undergoing coronary angiography (CA), adequate hydration and minimizing volume of contrast media (CM) are class 1b recommendations for preventing contrast induced nephropathy (CIN). Current data are insufficient to justify specific recommendations about isoosmolar vs. low-osmolar contrast media by the ACCF/AHA/SCAI guidelines. METHODS: Randomized trials comparing IOCM to LOCM in CKD stage 3 and above patients undergoing CA, and reporting incidence of CIN (defined by a rise in creatinine of 25% from baseline) were included in the analysis. The secondary outcome of the study was the incidence of serum creatinine increase by >1mg/dl. RESULTS: A total of 2839 patients were included in 10 trials, in which 1430 patients received IOCM and 1393 received LOCM. When compared to LOCM, IOCM was not associated with significant benefit in preventing CIN (OR=0.72, [CI: 0.50-1.04], P=0.08, I2=59%). Subgroup analysis revealed non-significant difference in incidence of CIN based on baseline use of N-acetylcystine (NAC), diabetes status, ejection fraction, and whether percutaneous coronary intervention vs coronary angiography alone was performed. The difference between IOCM and LOCM was further attenuated when restricted to studies with larger sample size (>250 patients) (OR=0.93; [CI: 0.66-1.30]) or when compared with non-ionic LOCM (OR=0.79, [CI: 0.52-1.21]). CONCLUSION: In patients with CKD stage 3 and above undergoing coronary angiography, use of IOCM showed overall non-significant difference in incidence of CIN compared to LOCM. The difference was further attenuated when IOCM was compared with non-ionic LOCM.

Acute kidney injury adjusted to volume status in critically ill patients: recognition of delayed diagnosis, restaging, and associated outcomes.

Critically ill patients receive a significant amount of fluids leading to a positive fluid balance; this dilutes serum creatinine resulting in an overestimated glomerular filtration rate. The goal of our study is to identify undiagnosed or underestimated acute kidney injury (AKI) in the intensive care unit (ICU). It will also identify the morbidity and mortality associated with an underestimated AKI. We reviewed records of patients admitted to our institution (Staten Island University Hospital) between 2012 and 2013 for more than 2 days. Patients with end stage renal disease were excluded. AKI was defined using the Acute Kidney Injury Network criteria. The following formula was used to identify and restage patients with AKI: adjusted creatinine = serum creatinine × [(hospital admission weight (kg) 0.6 + Σ (daily cumulative fluid balance (L))/hospital admission weight × 0.6]. The primary outcome identified newly diagnosed AKI and those who were restaged. The secondary outcome identified associated morbidities. Seven-hundred and thirty-three out of 1,982 ICU records reviewed, were used. Two-hundred and fifty-seven (mean age 69.8±14.9) had AKI, out of which 15.9% were restaged using the equation. Comparison of mean by Student's t-test showed no difference between patients who were restaged. Similarly, chi-square revealed no differences between both arms, except mean admission weight (lower in patients who were restaged), fluid balance on days 1, 2, and 3 (higher in the restaged arm), and the presence of congestive heart failure (more prevalent in the restaged arm). Of note, the mean cost of stay was US$150,562.82 vs $197,174.63 for same stage vs restaged, respectively, however, without statistical significance (P=0.74). Applying the adjustment equation showed a modest (15.9%) increase in the AKI staging slightly impacting outcomes (mortality, length, and cost of stay) without statistical significance.

An Insight Into the Immunologic Events and Risk Assessment in Renal Transplantation.

Organ transplantation has always been considered to be the optimal therapeutic intervention in patients with end-stage organ failure. In the US, approximately 615,000 patients are diagnosed with end-stage renal disease and less than 30% have received a kidney transplant. One of the crucial drawbacks in successful renal transplantation is allograft rejection. Survival rates among transplant recipients have greatly improved due to better understanding of transplant biology and more effective immunosuppressive agents. Post-transplant immune monitoring and optimization of the immunosuppressive therapy using non-invasive biomarkers can effectively predict impending graft rejection and may spare the need for renal biopsy. This article provides an insight into the immunomodulations of renal transplant recipients. It depicts the immune system including several types of kidney rejection and reviews the biomarkers that may serve in near future, as surveillance tools for graft monitoring. Finally, a summary on the main immunosuppressive drugs used in kidney transplant both in the induction and maintenance phases is also covered.

Cryoglobulinemic Glomerulonephritis as a Presentation of Atypical Post-Infectious Glomerulonephritis.

Post-infectious glomerulonephritis (PIGN) usually occurs within few days to weeks following an infection. Clinical presentation is variable, but in general, it is considered a benign entity with good prognosis. It rarely requires kidney biopsy to confirm the diagnosis. We present a case of a 55-year-old, previously healthy, male who presented for worsening shortness of breath, persistent cough, and right-sided pleuritic chest pain. Initial workup revealed a right exudative effusion with empyema. Hospital course was complicated by acute kidney injury requiring renal replacement therapy with a peak creatinine of 10.2 mg/dL from a baseline of 1.18 mg/dL. On kidney biopsy, findings were compatible with a diagnosis of cryoglobulinemic glomerulonephritis or an atypical form of PIGN. While a wide variety of histopathological findings on renal biopsies have been described to complement the usual diffuse proliferative glomerulonephritis pattern, cryoglobulinemic features with negative cryoglobulin have never been reported. Our case is unique not only by having an atypical histological presentation but also by meeting the criteria of atypical PIGN with persistent hypertension and microscopic hematuria.

Pauci-Immune Crescentic Glomerulonephritis: An ANCA-Associated Vasculitis.

Rapidly progressive glomerulonephritis (RPGN) is a syndrome signified by a precipitous loss of renal function, with features of glomerulonephritis including dysmorphic erythrocyturia and glomerular proteinuria. RPGN is associated with extensive crescent formation, and, thus, the clinical term RPGN is often used interchangeably with the pathologic term crescentic glomerulonephritis (CGN). From an immunopathologic standpoint, primary RPGN is divided into pauci-immune GN (PICG), anti-GBM GN, and immune complex GN. PICG, the most common etiology of primary RPGN, refers to a necrotizing glomerulonephritis with few or no immune deposits by immunofluorescence (IF) or electron microscopy (EM). In most patients, pauci-immune CGN is a component of a systemic small vessel vasculitis such as granulomatosis with polyangiitis (GPA). Approximately 90% of patients with PICG have circulating ANCA antibodies, leading to the nomenclature ANCA-associated vasculitis (AAV). Recent research has identified several other antibodies associated with PICG, which is now understood to be a complex spectrum of disease with considerable overlap in terms of clinical phenotype and outcomes. In addition, several genetic and environmental factors have recently been implicated in the pathogenesis of this disorder. With new prognostic classifications, enhanced understanding of immunopathologic mechanisms, and novel treatment paradigms, clinical and experimental interest in PICG remains high.