Recurrent arteriovenous graft thrombosis in COVID-19 positive patient.

Hypercoagulability is one of the common complications seen in COVID-19. It can lead to multiple thromboembolic complications. Recurrent arteriovenous graft thrombosis can be one of complications from this pathophysiology.

Severe nonbacterial preseptal cellulitis from adenovirus detected via pooled meta-genomic testing.

Preseptal cellulitis is a serious diagnosis that can progress to postseptal cellulitis leading to grave consequences. Clinically, viral and bacterial cellulitis can be indistinguishable from each other. Using rapid DNA/RNA sequencing can be helpful.

Role of renin-angiotensin-aldosterone system inhibitors in heart failure and chronic kidney disease.

Renin-angiotensin-aldosterone system (RAAS) inhibitors are the key medications for patients with heart failure and chronic kidney disease. Multiple randomized controlled trials have demonstrated their benefits in an outpatient setting for the treatment of chronic heart failure. Additional advantages in acute heart failure treatment during inpatient hospitalization are less clear but a small number of non-randomized studies have favored their use. Conditions that result in stoppage of RAAS inhibitors during inpatient stay are an increase in serum creatinine, hyperkalemia, and hemodynamic instability such as hypotension. The role of RAAS inhibitors in chronic kidney disease has also been documented in multiple randomized controlled trials, with their use in hypertension and proteinuria being unambiguous. This narrative review summarizes the role of RAAS inhibitors in acute and chronic heart failure and chronic kidney disease.

Acute interstitial nephritis with only three doses of pantoprazole.

Several antibiotics, proton pump inhibitors, and nonsteroidal anti-inflammatory drugs can cause acute interstitial nephritis. This is not dose-dependent, and recurrence can occur with a second exposure of the same drug. Stopping the culprit is critical for successful management.

Current Overview on Hypercoagulability in COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has brought many unique pathologies, such as coagulopathy, prompting a desperate need for effective management. COVID-19-associated coagulopathy (CAC) can cause various thromboembolic complications, especially in critically ill patients. The pathogenesis is likely due to endothelial injury, immobilization, and an increase in circulating prothrombotic factors. Data on treatment are limited, although prophylactic anticoagulation is advised in all hospitalized patients. Herein, we have comprehensively reviewed the current literature available on CAC and highlight the pathogenesis, clinical features, and management of CAC.

Old Era Continues in Modern World: A Case Report of Scurvy Induced Myopathy in Patient with Chronic Alcoholism.

We report a case of myopathy in a chronic alcoholic patient with scurvy who presented with generalized weakness, myalgias, and arthralgia. Our case raises awareness regarding rare interaction between vitamin C deficiency and myopathy which is seen more commonly in patients with history of chronic alcoholism and low socioeconomic status. Early treatment with vitamin C replacement is helpful in treatment of the disease and its complications.

Membranous nephropathy associated with profound hypothyroidism.

Membranous nephropathy can be primary or secondary. Although common causes of secondary MN are malignancy and lupus, hypothyroidism was rarely reported. Providers should check thyroid function tests in patients with unexplained nephrotic proteinuria.

Natriuretic peptides in acute kidney injury - A sojourn on parallel tracks?

OBJECTIVE: The focus of this review was to elicit the mechanistic logic of the experimental and clinical study designs of natriuretic peptides (NP) in acute kidney injury (AKI) and to understand their respective outcomes. METHODS: Online search of PubMed and manual review of articles. Randomized trials, observational and physiologic studies of NPs and AKI were extracted. Rationale, design and study outcomes were analyzed. RESULTS: In experimental models of AKI, infusion of NP prevented post-ischemic fall in renal blood flow (RBF) or improvement in RBF, GFR, diuresis and natriuresis and demonstrated anti-inflammatory properties. NPs were most effective in the early stages of AKI, also in established phase of AKI but their effectiveness were limited to the time of infusion. Hypotension was a major side-effect. Based on these observations, preliminary clinical studies were performed which demonstrated improved urine output, RBF and GFR and reduced need for dialysis. However, randomized, controlled trials failed to demonstrate improvement in dialysis-free survival in different cohorts and study designs. Although NPs reduced the incidence of AKI in the postoperative period in cardiac surgery, it was not associated with improved long-term survival. In contrast to randomized trials, meta-analysis reported favorable results. CONCLUSIONS: Reasons for the divergence of experimental and clinical outcomes of NPs in AKI are discussed in this review article.

Renin-Angiotensin-Aldosterone System Optimization for Acute Decompensated Heart Failure Patients (ROAD-HF): Rationale and Design.

INTRODUCTION: The long-term benefits of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on outcomes in patients with chronic congestive heart failure are well-known, making them one of the most widely prescribed medications. However, the administration of ACEIs/ARBs in acute decompensated heart failure (ADHF) can increase the risk of morbidity and mortality secondary to worsening renal function (WRF). A decrease in estimated glomerular filtration rate (eGFR) during the treatment of ADHF has been associated with an increase in mortality proportional to the degree of WRF. AIM: The aim of our study is to determine whether withholding ACEIs/ARBs during the initial 72 h of admission in patients with ADHF will prevent WRF and allow more effective diuresis. METHODS: Four hundred and thirty patients will be randomized to the intervention (withholding ACEIs/ARBs) or control (continue/start ACEIs/ARBs) arms for 72 h. Primary outcomes include rates of acute kidney injury (AKI), patient global assessment, and change in kinetic eGFR over 72 h, while secondary outcomes include change in weight, fluid balance, change in signs and symptoms of congestion, change in renal function, change in urinary biomarkers (tissue inhibitor of metalloproteinases 2 [TIMP-2] × insulin-like growth factor-binding protein 7 [IGFBP7]), patients experiencing treatment failure, hospital length of stay (LOS), cost analysis, mortality within 30 days, and hospital readmissions over 30 days and 1 year. CONCLUSION: This prospective clinical trial will prove if withholding ACEIs/ARBs will prevent AKI in ADHF. It will help us understand the complex interactions between the heart and kidney, and delineate the best treatment strategy for ADHF. Holding ACEIs/ARBs might help preserve renal function, and decrease hospital LOS, readmission rates, and cost of care in ADHF. REGISTRATION: ClinicalTrials.gov identifier: NCT03695120.

Do we care if you have a cat? Bartonella infection related glomerulonephritis with no endocarditis.

Bartonella infection has been associated with culture negative endocarditis and in rare cases immune complex medicated rapidly progressive glomerulonephritis (RPGN). Most of the previously reported cases of RPGN are associated with endocarditis. We report a case of RPGN with no endocarditis secondary to Bartonella infection. Good social history, high index of suspicion, diagnosis with polymerase chain reaction and treatment with antibiotics is the key for treatment.

Continuation of Chronic Heart Failure Therapies During Heart Failure Hospitalization - a Review.

Randomized controlled trials have demonstrated the benefits of guideline-directed medical therapy in the outpatient setting for treatment of chronic heart failure. However, the benefits of continuation (or discontinuation) of major chronic heart failure therapies when treating acute heart failure during hospitalization are less clear. Real and anticipated worsening renal function, hyperkalemia and hypotension are the three major reasons for discontinuation of renin-angiotensin-aldosterone system inhibitors during hospitalization, and a failure to resume renin-angiotensin-aldosterone system inhibitors before discharge could worsen cardiovascular outcomes. Available data, mostly observational, shows that continuation or initiation of renin-angiotensin-aldosterone system inhibitors appears efficacious, safe, and well tolerated in majority of acute heart failure patients during hospitalization. Worsening renal function portends poor prognosis only if associated with congestion in acute heart failure, and clinicians should not de-escalate diuretic therapy routinely for worsening renal function.

Static pressures, intra-access blood flow and dynamic Kt/V profiles in the prediction of dialysis access function.

BACKGROUND: Hemodialysis machine-generated circuit pressures and clearance profiles are potential predictors of quality assurances. In our practice, we previously we observed that elevated static access pressures were associated with abnormal Kt/V values, high access recirculation and deviation of the Kt/V profile (Abnormal Kt/V profile) from normally expected values (Normal Kt/V profile). AIM: To hypothesize that static or derived access pressures would correlate with direct intra-access blood flow rates and that clearance (Kt/V) profiles would correlate with measured Kt/V values. METHODS: Static access pressures, real-time adequacy of dialysis and intra-access blood flow were investigated in end stage renal disease patients undergoing hemodialysis. Wilcoxon-Mann-Whitney test, chi-square test or Fisher's exact test was used to investigate differences between the groups; Spearman's rank correlation test to investigate relationships between static pressures, direct intra-access pressures and Kt/V profiles; and multinomial logistic regression models to identify the independent effect of selected variables on Kt/V profiles. Odds ratio were calculated to measure the association between the variables and Kt/V profiles. RESULTS: One hundred and seven patients were included for analysis. There were no significant differences between genders, and types of vascular access between the normal vs. abnormal clearance (Kt/V) profile groups. No significant correlation could be demonstrated between static access pressures and Kt/V profiles, static access pressures and intra-access blood flow, intra-access blood flow and Kt/V profiles, measured Kt/V and Kt/V profiles or recirculation and Kt/V profiles. CONCLUSION: In this study utilizing measured versus estimated data, we could not validate that dialysis machine generated elevated static pressures predict intra-access blood flow disturbances or that abnormal Kt/V profiles predict access recirculation or inadequate dialysis. These parameters, though useful estimates, cannot be accepted as quality assurance for dialysis adequacy or access function without further evidences.

Rationale for treatment of hepatitis C virus infection in end-stage renal disease patients who are not kidney transplant candidates.

Hepatitis C virus (HCV) infection is a common problem in patients treated with maintenance hemodialysis (HD) and is associated with an increased morbidity and mortality and lower quality of life. The major causes of HCV-associated mortality are liver and cardiovascular-related death. HCV-infected HD patients have a higher prevalence of inflammation-related metabolic and vascular diseases, leading to high rates of cardiovascular mortality in patients with end-stage renal disease. In the current era of highly effective direct-acting antiviral regimens, HCV treatment may also confer hepatic, cardiovascular and other morbidity and mortality benefits even to dialysis-dependent patients who do not qualify for kidney transplantation. Currently, the most accepted regimens in this patient population include elbasvir/grazoprevir and glecaprevir/pibrentasvir.

Office orthostatic blood pressure measurements and ambulatory blood pressure monitoring in the prediction of autonomic dysfunction.

BACKGROUND: In this retrospective analysis we investigated the predictive performance of orthostatic hypotension (OH) and ambulatory blood pressure monitoring (ABP) to predict autonomic dysfunction. METHODS: Statistical associations among the candidate variables were investigated and comparisons of predictive performances were performed using Receiver Operating Characteristics (ROC) curves. RESULTS: Ninety-four patients were included for analysis. No significant correlations could be demonstrated between OH and components of ABP (reversal of circadian pattern, postprandial hypotension and heart rate variability), nor between OH and autonomic reflex screen. Reversal of circadian pattern did not demonstrate significant correlation (r = 0.12, p = 0.237) with autonomic reflex screen, but postprandial hypotension (r = 0.39, p = 0.003) and heart rate variability (r = 0.27, p = 0.009) demonstrated significant correlations. Postprandial hypotension was associated with a five-fold (OR 4.83, CI95% 1.6-14.4, p = 0.005) increased risk and heart rate variability with a four-fold (OR 3.75, CI95% 1.3-10.6, p = 0.013) increased risk for autonomic dysfunction. Per ROC curves, heart rate variability (0.671, CI95% 0.53-0.81, p = 0.025) and postprandial hypotension (0.668, CI95% 0.52-0.72, p = 0.027) were among the best predictors of autonomic dysfunction in routine clinical practice. CONCLUSION: Postprandial hypotension and heart rate variability on ambulatory blood pressure monitoring are among the best predictors of autonomic dysfunction in routine clinical practice.