The duration of hypotension determines the evolution of bacteremia-induced acute kidney injury in the intensive care unit.

BACKGROUND: Exploration of the impact of severe hypotension on the evolution of acute kidney injury in septic patients. METHODS AND RESULTS: We reviewed the hemodynamic parameters of 137 adults with septic shock and proven blood stream infection in the ICU. Severe hypotension was defined as a mean arterial blood pressure (MAP) ≤65 mmHg. The influence of the duration of severe hypotension on the evolution of acute kidney injury was evaluated according to the RIFLE classification, with day 0 defined as the day of a positive blood stream infection. After bloodstream infection, the probability for a patient to be in Failure was significantly higher than before blood stream infection (OR = 1.94, p = 0.0276). Patients have a significantly higher risk of evolving to Failure if the duration of severe hypotension is longer (OR = 1.02 for each 10 minutes increase in duration of a MAP <65 mmHg, p = 0.0472). A cut-off of at least 51 minutes of severe hypotension (<65 mmHg) or at least 5.5 periods of severe hypotension within 1 day identified patients with increased risk to evolve to Failure. CONCLUSIONS: There is a significant influence of both the duration and the number of periods of severe hypotension on the evolution to Failure. Blood stream infection has a significantly negative effect on the relationship between severe hypotension and Failure.

Determining factors predictive of CD34+ cell collection efficiency in an effort to avoid extended and repeated apheresis sessions.

INTRODUCTION: Collection efficiency (CE) is a reflection of the proportion of cells passing through a cell separator that is harvested. The aim of our study was to evaluate which factors influence CE independently in order to find ways to improve CE and therefore minimize the costs and risks of leukapheresis and graft processing. MATERIALS AND METHODS: A total of 206 consecutive apheresis procedures performed on 128 donors/patients were studied retrospectively. We explored the association between CE and the following factors: age, sex, weight, mobilization (granulocyte-colony-stimulating factor with or without chemotherapy), collection type (autologous versus allogeneic), venous access (peripheral versus central), total processed blood volume (TPV), hematocrit, white blood cell (WBC) count, thrombocyte count, and peripheral blood CD34+ cell concentration (PBCD34+). RESULTS: Stepwise multiple regression analysis showed WBC count to be the single best predictor of CE, accompanied by TPV. When performing subgroup analysis for autologous apheresis procedures, the inverse correlation of WBC count and TPV with CE becomes stronger (r = -0.563 with P < 0.001 and r = -0.198 with P = 0.020 respectively), whereas those correlations disappear when analyzing only allogeneic apheresis procedures. CONCLUSION: The negative correlation between TPV and CE present only in autologous collection procedures can be explained by the limited intra-apheresis recruitment of CD34+ cells into the blood which is negatively influenced by extensive pre-treatment. As a result of this study we decided to limit TPV to a maximum of three times the patient's blood volume in autologous apheresis procedures at our center.

Trends in therapeutic plasma exchange: a single-center evaluation.

PURPOSE: The quality of evidence supporting the use of therapeutic plasma exchange (TPE) in the treatment of individual diseases and disorders is often limited. Since we have experienced a growing variety of indications in our center we decided to make an inventory of our TPE population. METHODS: Single-center retrospective inventory of adult TPE-patients during a 7-year period to determine the evolution of indications for TPE, the response to treatment, and the existing evidence supporting TPE in specified settings. RESULTS: During a period of 84 months, 72 patients underwent 638 sessions of TPE in 91 episodes. There was no shift in frequency of TPE or level of indication. Our population consisted of 69 patients. A level I indication was seen in 41 patients (59.4%), while 14 (20.3%) had a level II indication, 8 (11.6%) had a level III indication, one had a level IV indication (1.4%) and 5 patients suffered from a condition not mentioned in the guidelines (7.2%). The response rate was inversely correlated with the level of evidence after exclusion of these 5 patients (category I 97.6%, category II 71.4%, category III 50%, category IV 0% response, p<0.01). CONCLUSIONS: There was no shift in frequency of TPE or level of indication in our center. Controversial indications should be carefully evaluated on an individual basis and a trial of TPE cannot be solely ruled out because of lack of evidence.

Complement factor H mutation associated with membranoproliferative glomerulonephritis with transformation to atypical haemolytic uraemic syndrome.

A patient with a history of haemolytic anaemia and membranoproliferative glomerulonephritis type 1 since childhood developed relapsing atypical haemolytic uraemic syndrome (aHUS) at the age of 18. Despite several episodes of relapsing aHUS, she was successfully treated with plasmapheresis. aHUS is strongly associated with disorders of the complement pathway. Diagnostic work-up of the patient revealed normal serum values of complement factor H, I, B and membrane cofactor protein (MCP). Genetic analysis showed a homozygous mutation in the factor H gene. Extraordinarily, the homozygous mutation in this patient causes a normal amount but hypothetically functionally defective factor H in the plasma.

Maximal conservative therapy of calcific uremic ateriolopathy.

We present the case of a 61-year- old female patient in long-term hemodialysis who developed calcific uremic arteriolopathy (CUA) upon administration of the oral calcimimetic agent cinacalcet for treatment of secondary hyperparathyroidism. In May 2009, the baseline serum values were parathormone (PTH) 310 pg/ml, calcium 9.1 mg/dl and phosphorous 6.9 mg/dl. Necrotic wounds in the suprapubic fat tissue were successfully treated first, by correcting the calcium phosphorous product; second, through treatment with sodium thiosulfate and third, through intensive wound care with hyperbaric oxygen therapy and vacuum-assisted closure therapy, with no need for parathyroidectomy. Multiple factors have been described to play a role in the development of CUA. Based on the findings of this case, the treatment of CUA should be aimed at correcting different causes simultaneously.

Retrospective evaluation of possible renal toxicity associated with continuous infusion of vancomycin in critically ill patients.

BACKGROUND: Continuous infusion of vancomycin is increasingly preferred as an alternative to intermittent administration in critically ill patients. Intermittent vancomycin treatment is associated with an increased occurrence of nephrotoxicity. This study was designed to determine the incidence and risk factors of acute kidney injury (AKI) during continuous infusion of vancomycin. METHODS: This was a retrospective, observational, two-center, cohort study in patients with microbiologically documented Gram-positive pneumonia and/or bacteremia and normal baseline renal function. Vancomycin dose was adjusted daily aiming at plateau concentrations of 15-25 µg/mL. AKI was defined as an increase in serum creatinine of 0.3 mg/dL or a 1.5 to 2 times increase from baseline on at least 2 consecutive days after the initiation of vancomycin. Primary data analysis compared patients with AKI with patients who did not develop AKI. A binary logistic regression analysis using the forward stepwise method was used to assess the risk factors associated with AKI. RESULTS: A total of 129 patients were studied of whom 38 (29.5%) developed AKI. Patients with AKI had higher body weight (77.3 ± 15 vs. 70.5 ± 15.2 kg; p = 0.02), more diabetes (79% vs. 54%; p = 0.01), and a higher vasopressor need (87% vs. 59%; p = 0.002). Serum vancomycin levels, body weight, and SAPS 3 score were identified as variables contributing to AKI. The incidence of AKI increased substantially when treatment duration was prolonged (14.9 ± 9.8 vs. 9.2 ± 4.9 days; p = 0.05) and plasma levels exceeded 30 µg/mL. CONCLUSIONS: AKI is frequently observed during continuous vancomycin infusion, particularly when conditions that cause acute (shock) or chronic (diabetes) renal dysfunction are present and vancomycin levels above target range are achieved. Although this study challenges the concept that continuous vancomycin infusion might alleviate the risk of nephrotoxicity in critically ill patients, a direct relationship between vancomycin and nephrotoxicity remains to be proven.

Treating humoral rejection after cardiac transplantation.

Whereas effective strategies are available to treat acute cellular cardiac rejection, humoral rejection, also called vascular or antibody-mediated rejection, is more difficult to manage. Antibody-mediated (non-cellular) rejections (AMR) are rare and few successfully treated cases have been described in the literature. We report on a female patient, diagnosed with humoral rejection, leading to severe ventricular dysfunction and haemodynamic compromise, two months after transplantation. The patient received a combination therapy, consisting of plasmapheresis and immunoglobulins, which resulted in complete resolution of immunohistochemical signs of AMR. In this report, we will overview AMR and discuss several treatment modalities.

Acute renal dysfunction in salmonella gastroenteritis.

GOALS: To determine the incidence of renal function deterioration in adult patients with Salmonella infection. BACKGROUND: Renal impairment has been described during severe Salmonella infection and is mainly due to shock, dehydration, or rhabdomyolysis. However, it is unclear whether less severe Salmonella infection also has an impact on kidney function. STUDY: We retrospectively reviewed over a 2-year period the data of all hospitalized adult patients with microbiologically proven gastrointestinal infection. Different biologic parameters were compared between patients infected with Salmonella and patients with other gastrointestinal infections. RESULTS: One hundred and seven patients with positive stool cultures were identified; 44 of them had proven Salmonella infection. Renal dysfunction, defined as an increase in serum creatinine above 1.5 mg/dL in men and above 1.3 mg/dL in women, was observed in 16 (36%) patients infected by Salmonella but only in 3 (5%) comparators (P<0.0001). Hydration status and creatine kinase levels were not different in patients affected by Salmonella as compared with other pathogens. Kidney function recovered in all but 1 patient. CONCLUSIONS: Salmonella gastroenteritis in adults is frequently accompanied by renal dysfunction that is caused by mechanisms other than dehydration or rhabdomyolysis.

Evaluation of functional and mental state and quality of life in chronic haemodialysis patients.

Progressive increase of old patients with end stage renal disease (ESRD) with a high mortality and morbidity rate, receiving haemodialysis, increases the impact of psychosocial factors on the outcome. Depression is the most prevalent psychological problem in patients in haemodialysis and is associated with a high mortality. The purpose of this study was to evaluate the functional (ADL, IADL), mental (MMSE, SDS) state and the Quality of Life (KDQOL) in the chronic haemodialysis patients. Old patients can be successfully treated by haemodialysis and therefore age may never be used as exclusion for initiative haemodialysis. Formal geriatric assessment should be imperative for the older person with end stage renal disease since all elderly patients become dependent. The high prevalence of depression in our haemodialysis population needs further investigation.