ABSTRACT
Introduction: Online hemodiafiltration (HDF) has been increasingly used for improved clearance of middle molecular weight toxins. The impact of this mode of clearance is unknown in critically ill patients. We aimed to determine whether the use of HDF in acute kidney injury (AKI) is associated with lower mortality and improved kidney recovery up to 90 days after initiation of therapy. Methods: Single-center retrospective cohort study using data from 2017 to 2020 of adults with AKI who initiated intermittent renal replacement therapy (IRRT) in the intensive care unit (ICU), using either hemodialysis (HD) or HDF depending on the maintenance status of the water system without regards for patient characteristics. We assessed association with patient-events and session-events using time-dependent Cox models and general estimating equations models, respectively. Results: We included 182 adults with AKI for whom 848 IRRT sessions were performed in the ICU. The 90-day mortality rate was 43 of 182 (24.6%). There was no significant association with the use of HDF and mortality (adjusted hazard ratio [aHR]: 0.85 (0.43; 1.67) P = 0.64), kidney recovery (aHR: 1.18 (0.76; 1.84) P = 0.47), or intradialytic hypotension (adjusted odds ratio [aOR]: 0.91 confidence interval [CI]: 0.64-1.28 P = 0.58). HDF treatment was associated with a lower rate of subsequent vasopressor use (aOR: 0.60 CI: 0.36-0.99 P = 0.047) and a greater reduction of the neutrophil-to-lymphocyte ratio (NLR) following the first session (-15.0% vs. +5.1%, P = 0.047) but was also associated with increased risk of filter thrombosis during treatment (aOR: 2.42 CI: 1.67-3.50 P < 0.001). Conclusion: The use of HDF in the setting of AKI was not associated with a differential risk of mortality or kidney recovery.
ABSTRACT
Primary membranous nephropathy (MN) and mucous membrane pemphigoid (MMP) are two autoimmune conditions with well-defined diagnostic and treatment guidelines. MN has been linked to bullous pemphigoid (BP) in certain case reports, though little is known regarding the association of MN and other bullous diseases. The association of MN and MMP has rarely been described, and very little data exist regarding the treatment of this association. We report a case of severe refractory membranous nephropathy secondary to mucous membrane pemphigoid successfully treated with rituximab. A 35-year-old woman with known MMP was referred to our clinic for new-onset generalized edema and proteinuria. MN was confirmed on renal biopsy. Despite therapy with high-dose systemic glucocorticoids, combined with mycophenolate mofetil, and later azathioprine, nephrotic-range proteinuria persisted even at a daily dose of prednisone of 40 mg. The patient was then started on rituximab infusions, which induced remission of both mucous membrane pemphigoid and membranous glomerulonephritis. This suggests that MN can be secondary to MMP, and rituximab may be useful induce remission in cases that are refractory to standard therapy.
