The Frequency and Outcome of Acute Kidney Injury in a Tertiary Hospital: Which Factors Affect Mortality?

Acute kidney injury (AKI) is a major cause of mortality and morbidity in hospitalized patients. Incidence and mortality rates vary from country to country, and according to different in-hospital monitoring units and definitions of AKI. The aim of this study was to determine factors affecting frequency of AKI and mortality in our hospital. We retrospectively evaluated data for 1550 patients diagnosed with AKI and 788 patients meeting the Kidney Disease: Improving Global Outcomes (KDIGO) guideline AKI criteria out of a total of 174 852 patients hospitalized in our institution between January 1, 2007 and December 31, 2012. Staging was performed based on KDIGO Clinical Practice for Acute Kidney Injury and RIFLE (Risk, Injury, Failure, Loss of kidney function and End-stage renal failure). Demographic and biochemical data were recorded and correlations with mortality were assessed. The frequency of AKI in our hospital was 0.9%, with an in-hospital mortality rate of 34.6%. At multivariate analysis, diastolic blood pressure (OR 0.89, 95% CI 0.87-0.92; P < 0.001), monitoring in the intensive care unit (OR 0.18, 95% CI 0.09-0.38; P < 0.001), urine output (OR 4.00, 95% CI 2.03-7.89; P < 0.001), duration of oliguria (OR 1.51, 95% CI 1.34-1.69; P < 0.001), length of hospitalization (OR 0.83, 95% CI 0.79-0.88; P < 0.001), dialysis requirement (OR 2.30, 95% CI 1.12-4.71; P < 0.05), APACHE II score (OR 1.16, 95% CI 1.09-1.24; P < 0.001), and albumin level (OR 0.32, 95% CI 0.21-0.50; P < 0.001) were identified as independent determinants affecting mortality. Frequency of AKI and associated mortality rates in our regional reference hospital were compatible with those in the literature. This study shows that KDIGO criteria are more sensitive in determining AKI. Mortality was not correlated with staging based on RIFLE or KDIGO. Nonetheless, our identification of urine output as one of the independent determinants of mortality suggests that this parameter should be used in assessing the correlation between staging and mortality.

Poststreptococcal glomerulonephritis in a patient with essential thrombocytosis.

In addition to being the main cause of glomerulonephritis in children, poststreptococcal glomerulonephritis (PSGN) has recently been shown in older patients, especially those with malignancy or diabetes mellitus. The pathogenesis of PSGN has been ascribed to activation of complement 3 (C3) of the alternative complement cascade which, along with immunoglobulin (Ig) G and IgM deposits, is observed in renal tissue. Our aim here is to discuss the probable causes of PSGN developing with isolated IgM deposition in a 52-year-old patient with essential thrombocytosis followed-up over the previous 3.5 years. These characteristics make our case the first to be reported in the literature.

Is there any interaction of resistin and adiponectin levels with protein-energy wasting among patients with chronic kidney disease.

The aim of this study was to evaluate the effects of adipocytokines including adiponectin, leptin, resistin, neuropeptide Y and ghrelin in chronic kidney disease (CKD) patients on appearance of protein-energy wasting (PEW). One hundred fifty patients with mean age of 45.4 ± 15.9 years, without active infections or chronic inflammatory conditions were recruited into the study. Study groups were control group (consisting of 30 healthy volunteers with normal kidney functions), hemodialysis group, predialysis group, peritoneal dialysis group and kidney transplant group. Fasting morning serum leptin, ghrelin, acylated ghrelin, neuropeptide Y, adiponectin, resistin levels of all of the groups were measured. Anthropometric and nutritional assessments of all patients were obtained. Diagnosis of PEW was made according to definition recommended by the International Society of Renal Nutrition and Metabolism. Presence of PEW in hemodialysis (23.3%) and peritoneal dialysis (26.7%) groups were significantly higher than those of predialysis (3.3%), and transplantation (0%) groups. Adiponectin and resistin levels in predialysis, peritoneal dialysis and hemodialysis patients were significantly higher than control group (p: 0.0001). This study had given significant positive correlations between presence of PEW and serum resistin (r: 0.267, p: 0.001), and serum adiponectin levels (r: 0.349, p: 0.0001). There were no relationship between presence of PEW and ghrelin, acylated-ghrelin, neuropeptide Y, and leptin levels of the groups. CKD patients except transplant patients had higher adiponectin and resistin levels than control group. PEW was found to be linearly correlated with resistin and adiponectin. High serum resistin and adiponectin levels might have a role in development of PEW among dialysis patients.

The role of adipocytokines on depressive symptoms of patients with chronic kidney disease.

OBJECTIVE: The aim of this study is to evaluate depression and anxiety scores among chronic kidney disease (CKD) patients and to search the changes of serum concentrations of adipokines with respect to emotional disturbances of CKD patients. PATIENTS AND METHODS: 150 patients recruited into this cross-sectional analytic study. Study groups were control, hemodialysis, predialysis, peritoneal dialysis and kidney transplantation groups. Fasting morning serum leptin, ghrelin, acylated ghrelin, neuropeptide Y, adiponectin, resistin levels of all of the groups were measured using ELISA (Sandwich) method. A screening interview based on the Structured Clinical Interview for DSM-IV and self-report scales (The Beck Depression [BDI] and The Beck Anxiety Inventory [BAI] and Brief Symptom Inventory [BSI] which is self report scales) were administered and conducted by a trained interviewer. RESULTS: BDI scores were significantly higher in hemodialysis and predialysis groups compared to control group (p = 0.009). Somatization sub scores of BSI were significantly higher in hemodialysis and peritoneal dialysis groups compared to control group (p = 0.041). Also positive symptom distress index scores of BSI were significantly higher in hemodialysis and transplantation groups compared to control group (p = 0.047). BDI score were significantly negatively correlated with duration of education (r = -0.165, p = 0.045), positively correlated with presence of protein energy wasting (r = 0.198, p = 0.016), and resistin levels (r = 0.233, p = 0.004). CONCLUSION: CKD patients had higher BDI, BSI-somatization, BSI-positive symptom distress index scores compared to control group. High serum resistin levels, presence of protein energy wasting might have a role in development of depressive disorders of patients with chronic kidney disease.

New marker of platelet activation, SCUBE1, is elevated in hypertensive patients.

BACKGROUND: Hypertension is associated with an increase in platelet activation and endothelial dysfunction and leads to a tendency to cardiovascular events (CVEs). Signal peptide-CUB-EGF domain-containing protein 1 (SCUBE1) is a novel platelet activation marker. There are currently no studies showing the level of SCUBE1 in hypertensive patients. The purpose of this study was to determine the level of SCUBE1 in this patient group and to investigate the parameters affecting that level. METHODS: Forty-five newly diagnosed, untreated, stage 1 hypertensive patients and 21 healthy individuals were included. Blood specimens were collected to determine SCUBE1, soluble CD40 ligand, prothrombin time, partial thromboplastin time, fibrinogen, D dimer, hemogram, lipid parameters, blood urea nitrogen, creatinine, and uric acid levels. The relation between SCUBE1 level and demographic data and biochemical parameters was then investigated. RESULTS: SCUBE1 and sCD40L levels obtained from plasma specimens from the hypertensive group were significantly higher than those of the control group (P < 0.001; P < 0.05, respectively). Hypertensive group blood pressure (BP) values and uric acid, low-density lipoprotein, total cholesterol, and triglyceride levels were also statistically higher than those of the control group. Parameters affecting SCUBE1 levels were systolic and diastolic BP, sCD40L, lipid parameters, and uric acid levels. CONCLUSIONS: We show elevated levels of SCUBE1, a novel platelet activation marker, in primary hypertensive patients. We think that, when supported by further clinical studies, this newly described marker may be useful in the monitoring of CVEs in this patient group, in which platelet activation is known to be associated with such events.

A case of recurrent episodes of acute renal allograft failure caused by renal pedicle tortion.

BACKGROUND: Acute allograft failure which occur intermittently after renal transplantation caused by graft tortion is a very rare entity. We here report highly unusual case of recurrent episodes of acute allograft dysfunction two years after kidney transplantation secondary to ischemic tubular necrosis caused by tortion of renal pedicle due to rotation of the allograft with body movements. CASE PRESENTATION: A 55 year-old male patient with living unrelated kidney transplantation for chronic renal failure caused by autosomal dominant polycystic kidney disease had presented recurrent acute deteriorations in renal functions. All laboratory values were within normal limits except elevated serum creatinine levels, acute tubular necrosis in graft biopsy, and detection of pelvic dilatation in renal ultrasonography from time to time. Changes in axis of graft in nuclear medicine scans taken at different times during the same study made us bring to mind the diagnosis of renal pedicle tortion. Renal blood flow measurements with Doppler ultrasonography in different body positions helped to reach the final diagnosis of mobile kidney right on time. The patient is now well after prompt surgical treatment with nephropexy. DISCUSSION: Unfortunately, tortion of allograft once occurred is associated with very high rate of graft loss due to arterial compromise and infarction and it is very difficult to diagnose without high level of suspicion. We discuss the causes of renal allograft tortion and the measures to prevent its occurrence and the methods to diagnose.

Rhabdomyolysis and severe muscle weakness secondary to colistin therapy.

Rhabdomyolysis is a clinical condition that causes renal failure up to 40%. Rhabdomyolysis may be traumatic or nontraumatic. Colistin (polymyxin E) is an effective antibiotic. Nephrotoxicity is a frequently encountered side effect. The nephrotoxic effect of colistin is thought to be associated with increased membrane permeability, cell swelling and lysis, and the development of acute tubular necrosis. Here, we report a case of nontraumatic rhabdomyolysis associated with the use of colistin. There is only one report of rhabdomyolysis secondary to colistin in the literature, and there is no report of a case developing severe tetraparesis, as in our case.

Is there any way to protect from tacrolimus-induced renal and pancreas injury?

BACKGROUND: The aim of this study was to explore effects of erythropoietin and pentoxifylline in tacrolimus-induced pancreatic beta cell and renal injury in rats. METHODS: Rats in group I were given saline; rats in group II were injected with tacrolimus; rats in group III were received erythropoietin (Epo) and tacrolimus; while rats in group IV were injected pentoxifylline (Ptx) plus tacrolimus for nine d. On 10th day, blood and tissue samples were taken for biochemical and pathological evaluations. RESULTS: Tacrolimus-injected animals exhibited significant elevation in blood urea nitrogen (BUN), and serum BUN levels were improved in rats pretreated with Ptx. Significantly more apoptotic nuclei were observed in kidneys of tacrolimus group. In rats subjected to tacrolimus and pretreated with Epo, there was significant decrease in apoptotic nuclei staining than those in tacrolimus group. Blood trough levels of tacrolimus were significantly higher in erythropoietin-pretreated group, although same amount of tacrolimus was injected with other groups. CONCLUSION: Results of our study demonstrated significant antiapoptotic effects of erythropoietin on renal tubules, increasing effect of erythropoietin on tacrolimus blood levels, and insignificant antioxidant effects of both erythropoietin and pentoxifylline on renal and pancreas tissues. Study with clinically greater tacrolimus levels may be useful to confirm these findings.

Role of erythropoietin in prevention of amikacin-induced nephropathy.

BACKGROUND: Aminoglycoside antibiotics are widely used potent bactericidal drugs. However, nephrotoxicity side effects via oxidant injury limit their effectiveness. Erythropoietin (Epo) has been shown to exert pleiotropic effects besides promoting erythrocyte differentiation such as antiapoptotic, antioxidant functions in ischemic and toxic acute renal injury. Therefore we aimed to explore whether Epo is renoprotective in an amikacin-induced nephropathy model in rats. METHODS: Twenty-eight rats were distributed equally into 4 groups: (i) injected with saline, (ii) injected with amikacin (1.2 g/kg intraperitoneally [i.p.]), (iii) pretreated with Epo (2,000 IU/kg, i.p.) and amikacin (1.2 g/kg i.p.) and (iv) injected only with Epo (2,000 IU/kg, i.p.). Twenty-four hours after last injection, renal tissues were excised for histopathological examinations, and blood samples were collected for serum creatinine and blood urea nitrogen measurements. RESULTS: An approximately twofold elevation in blood urea nitrogen concentration in the amikacin group (26.6 ± 3.9 mg/dL) compared with saline group (13.1 ± 0.4 mg/dL) was found, reflecting a significant degree of renal dysfunction (p<0.01). Serum urea levels were significantly improved in rats pretreated with Epo (15.9 ± 0.9 mg/dL). The most severe and pronounced injuries based on tubular necrosis were observed in the amikacin group, while rats pretreated with Epo demonstrated marked reduction of the histological features of renal injury. CONCLUSION: As far as we know, the present results are the first to demonstrate a protective effect of exogenous Epo against experimental amikacin-induced renal injury. According to these results, Epo may improve the therapeutic potential of amikacin. More studies are needed for a final conclusion.

Treatment of a case of mesangioproliferative glomerulonephritis secondary to Echinococcus alveolaris with albendazole.

Parasitic infections lead to significant morbidity and mortality, especially in tropical regions. The renal damage caused by these infections occurs via various mechanisms. Two forms of parasitic echinococcus infection widely responsible for infection in humans are Echinococcus granulosus and Echinococcus multilocularis. E. multilocularis causes Alveolar echinococcus infection in humans. Alveolar echinococcus has high mortality, and the possible limits of surgery are generally exceeded by the time of diagnosis. The literature contains no case reports of comorbidity of alveolar echinococcus and glomerulonephritis. Here we discuss the treatment of a patient with comorbid mesangioproliferative glomerulonephritis and alveolar echinococcus, behaving like a tumor, using albendazole since there was no possibility of surgery. This is the first ever such case report.

Swine H1N1 infection in a renal transplant recipient.

Influenza pandemics have been observed in several periods throughout history. The first influenza pandemic of the 21st century began in Mexico in 2009 and has spread rapidly all over the world. Swine H1N1 has been officially declared a pandemic by the World Health Organization in June 2009. As has been observed in previous pandemics, pregnant women, adolescents, and immunosuppressed individuals are affected more severely in this pandemic. Despite several reports about the pandemic, there have not been any reports of swine H1N1 infection in individuals who underwent renal transplant. The aim of the current study was to present oseltamivir therapy in a swine H1N1-infected patient who underwent renal transplant 10 months earlier, and was thus under immunosuppressive treatment. To the best of our knowledge, this is the first case report of a swine H1N1 infection in a renal transplant recipient.

Absence of hypoalbuminemia despite nephrotic proteinuria in focal segmental glomerulosclerosis secondary to polycythemia vera.

In addition to displaying geographic variation, focal segmental glomerulosclerosis (FSGS) has become the commonest cause of the nephrotic syndrome seen in adults in recent years. Secondary FSGS in particular, is observed when glomerular workload is increased. Polycythemia vera (PV) is a hematological disease characterized by abnormal proliferation in the erythroid series. The number of case reports belonging to glomerulonephritis secondary to PV is limited. In the literature, there are few reports of FSGS. One study pointed out that the presence of normoalbuminemia was detected in patients with FSGS secondary to hyperfiltration when there was nephrotic proteinuria. Here, we report a case of FSGS following a course with normoalbuminemia despite nephrotic range proteinuria developing secondary to PV. Our case is the first report in the literature with thes characteristics.