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Acute tubular necrosis [keywords]
- Expression of fibrosis-related genes in human renal allografts with interstitial fibrosis and tubular atrophy. [JOURNAL ARTICLE]
- J Nephrol 2013 Apr 29.:0.
Background:Gene expression analysis of fibrosis-related genes may became useful for the early identification of fibrosis processes. We quantitatively assessed messenger RNA transcripts of the CTGF, TGF-β and KIM-1 genes, in biopsy samples from renal transplant recipients with graft dysfunction, to test the hypothesis that in patients with chronic disease of the renal transplant, these molecules could be markers of the development and severity of graft fibrosis.
Methods:Ninety-six kidney transplant recipients who undertook 121 indication graft biopsies between January 2008 and December 2009 were included. Patients and biopsies were classified into 4 major diagnostic groups according to the Banff 2007 classification: acute tubular necrosis (ATN; n = 20), acute rejection (AR; n = 58), acute calcineurin inhibitor nephrotoxicity (CIN; n = 13) and interstitial fibrosis and tubular atrophy (IF/TA; n = 30).
Results:Messenger RNA transcripts of the CTGF and TGF-β genes were significantly higher in IF/TA compared with all other conditions. Messenger RNA transcripts of the KIM-1 gene in the IF/TA group were higher than in the CIN group. In addition, it was observed that gene expression of CTGF, TGF-β and KIM-1 increased with severity of fibrosis observed in the pathological examinations.
Conclusions:Gene expression evaluation of the kidney graft tissue may be used to improve pathological diagnosis and perhaps for the future development of noninvasive biomarkers.
- CT perfusion technique for assessment of early kidney allograft dysfunction: preliminary results. [JOURNAL ARTICLE]
- Eur Radiol 2013 May 10.
OBJECTIVES:To assess the benefit of quantitative computed tomography (CT) perfusion for differentiating acute tubular necrosis (ATN) and acute rejection (AR) in kidney allografts.
METHODS:Twenty-two patients with acute kidney allograft dysfunction caused by either AR (n = 6) or ATN (n = 16) were retrospectively included in the study. All patients initially underwent a multiphase CT angiography (CTA) protocol (12 phases, one phase every 3.5 s) covering the whole graft to exclude acute postoperative complications. Multiphase CT dataset and dedicated software were used to calculate renal blood flow. Renal biopsy or clinical course of disease served as the standard of reference. Mean effective radiation dose and mean amount of contrast media were calculated.
RESULTS:Renal blood flow values were significantly lower (P = 0.001) in allografts undergoing AR (48.3 ± 21 ml/100 ml/min) compared with those with ATN (77.5 ± 21 ml/100 ml/min). No significant difference (P = 0.71) was observed regarding creatinine level with 5.65 ± 3.1 mg/dl in AR and 5.3 ± 1.9 mg/dl in ATN. The mean effective radiation dose of the CT perfusion protocol was 13.6 ± 5.2 mSv; the mean amount of contrast media applied was 34.5 ± 5.1 ml. All examinations were performed without complications.
CONCLUSION:CT perfusion of kidney allografts may help to differentiate between ATN and rejection. KEY POINTS: • Quantitative CT perfusion of renal transplants is feasible. • CT perfusion could help to non-invasively differentiate AR from ATN. • CT perfusion might make some renal biopsies unnecessary.
- Urinalysis and pre-renal acute kidney injury: time to move on. [EDITORIAL]
- Crit Care 2013 May 7; 17(3):141.
Urinary indices are classically believed to allow differentiation of transient (or pre-renal) acute kidney injury (AKI) from persistent (or acute tubular necrosis) AKI. However, the data validating urinalysis in critically ill patients are weak. In the previous issue of Critical Care, Pons and colleagues demonstrate in a multicenter observational study that sodium and urea excretion fractions as well as urinary over plasma ratios performed poorly as diagnostic tests to separate such entities. This study confirms the limited diagnostic and prognostic ability of urine testing. Together with other studies, this study raises more fundamental questions about the value, meaning and pathophysiologic validity of the pre-renal AKI paradigm and suggests that AKI (like all other forms of organ injury) is a continuum of injury that cannot be neatly divided into functional (pre-renal or transient) or structural (acute tubular necrosis or persistent).
- Results of pretransplant treatment of hepatorenal syndrome with terlipressin. [Journal Article]
- Curr Opin Organ Transplant 2013 Jun; 18(3):265-70.
Hepatorenal syndrome (HRS) is a dreaded complication of end-stage liver disease. The best treatment option for HRS is liver transplantation (LT) in suitable candidates. Pretransplant care of HRS is of utmost importance in order to secure a good posttransplant outcome. We review the advances during the last year in the diagnosis and management of HRS in candidates who are awaiting liver transplantation.New attempts at defining renal failure in cirrhosis using the Acute Kidney Injury (AKI) definition have been proposed, as this definition has the potential advantage of detecting earlier phases of kidney dysfunction. Patients who undergo liver transplantation with acute tubular necrosis recover renal function more slowly than those with HRS and have a higher incidence of chronic kidney disease at all time points after liver transplantation. Vasoconstrictor drugs, particularly terlipressin, are effective for the management of HRS; however, noradrenaline is a good choice if terlipressin is not available. Long-term treatment of HRS with vasoconstrictors until liver transplantation in those patients with HRS recurrence after the first treatment is beneficial as a bridge to liver transplantation. Data from the cohorts of patients treated with vasoconstrictors (terlipressin and midodrine) indicate that liver transplantation offers a clear survival benefit to patients with HRS regardless of prior therapy with these drugs.Ongoing advances in the management of patients with HRS before liver transplantation indicate that vasoconstrictors plus albumin should be offered to all suitable candidates. Liver transplantation remains the best treatment option for HRS.
- Acute renal failure associated with acute non-fulminant hepatitis B. [Journal Article]
- World J Hepatol 2013 Feb 27; 5(2):82-5.
A 38-year-old female presenting with a high fever of 39 °C developed severe liver dysfunction and acute renal failure (ARF). In tests for a hepatitis associated virus, an Immunoglobulin M-anti-hepatitis B virus core antibody was the only positive finding. Moreover, the progression of ARF coincided with the pole period of liver damage and all the other assumed causes for the ARF were unlikely. Therefore, this case was diagnosed as ARF caused by acute hepatitis B. ARF associated with non-fulminant hepatitis has been infrequently reported, usually in association with acute hepatitis A. This case is considered to be an extremely rare and interesting case.
- Renoprotective effect of Alpiniae oxyphyllae Fructus on ischemia/reperfusion-induced acute renal failure. [JOURNAL ARTICLE]
- Arch Pharm Res 2013 May 4.
The present study was designed to examine whether water extract of Alpiniae oxyphyllae Fructus (AAO) has an effect on renal functional parameters in association with the expression of water channels and sodium potassium pump in ischemia/reperfusion-induced acute renal failure (ARF). Polyuria caused by down-regulation of renal AQP-2, 3 in the ischemia/reperfusion-induced ARF rats was markedly restored by administration of AAO (200 mg/kg/day p.o.) with restoring expression of AQP-2, 3 in the kidney. The expression of Na,K-ATPase α1 subunit was also restored in the ischemia/reperfusion-induced ARF rat by administration of AAO. The renal functional parameters including urinary sodium excretion, urinary osmolality, and solute-free reabsorption were also markedly restored in ischemia-ARF rats by administration of AAO. In histopathologic study, administration of AAO improved tubular damage such as necrosis of tubular segment. Ischemia/reperfusion-induced ARF decreased the expressions of AQP-2, 3, and Na,K-ATPase in renal medulla. However, administration of AAO markedly restored the expression levels of AQP-2, 3 and Na,K-ATPase. Taken together, the present study suggested that A. oxyphyllae ameliorates the urine concentration and renal functions in ischemia/reperfusion-induced ARF, through the restoring of AQP-2, 3 and Na,K-ATPase.
- Critical Care Management ofVerapamil and Diltiazem Overdose With a Focus on Vasopressors: A 25-Year Experience at a Single Center. [JOURNAL ARTICLE]
- Ann Emerg Med 2013 May 1.
STUDY OBJECTIVE:Verapamil or diltiazem overdose can cause severe morbidity and death, and there exist limited human data describing management and outcome of a large number of such patients. This article describes the management and outcome of patients with nondihydropyridine calcium-channel blocker overdose, with an emphasis on vasopressor dosing, at a single center.
METHODS:This study is a retrospective chart review of patients older than 14 years and admitted to the inpatient toxicology service of a single tertiary care medical center for treatment of verapamil or diltiazem overdose from 1987 through 2012, and who had the presence of either drug confirmed by urine drug screening. Patients were identified by review of patient encounter logs. Data abstracted from medical records included demographics, laboratory results, drugs used to support blood pressure, complications, and outcomes. A second group included patients with a reported calcium channel blocker ingestion but for whom results of the urine drug testing were no longer available. In an effort to assess selection bias, this group was included to determine whether patients who were excluded from the primary group only because of unavailability of urine drug screen results had different outcomes.
RESULTS:During the study period, 48 patients met inclusion criteria. The median age was 45 years, with a range of 15 to 76 years, and 52% were male patients. Verapamil accounted for 24 of 48 (50%) ingestions. Vasopressors were administered to 33 of 48 (69%) patients. Maximal vasopressor infusion doses were epinephrine 150 μg/minute, dopamine 100 μg/kg per minute, dobutamine 245 μg/kg per minute, isoproterenol 60 μg/minute, phenylephrine 250 μg/minute, and norepinephrine 100 μg/minute. The use of multiple vasopressors was common. Hyperinsulinemic euglycemia was used in 3 patients who also received multiple vasopressors. Eight probable or possible ischemic complications were noted in 5 of 48 (10%) patients. Gastrointestinal bleeding occurred in 3 of 48 (6%) patients; a brain magnetic resonance imaging in 1 patient suggested mild ischemia, without clinical evidence of infarction; 1 patient had ischemic bowel; and 3 patients developed renal failure from acute tubular necrosis, which resolved in each case. Six of the 8 ischemic complications were evident before use of vasopressor therapy. Three patients sustained inhospital cardiac arrest before admission and were successfully resuscitated. Each of these arrests occurred before instituting vasopressor infusions. One patient experienced a late cardiac arrest from primary respiratory arrest from administration of sedatives, and multiple organ system failure followed resuscitation, with death occurring during manipulation of a pulmonary artery catheter. The remaining 47 patients recovered. There were 12 patients in the group of additional poisoned patients for whom results of urine drug screening were unavailable. Four patients were treated with vasopressors, 2 experienced acute tubular necrosis that was present before vasopressor use, and all recovered.
CONCLUSION:In our series of patients admitted with verapamil or diltiazem overdose, hypotension was common and managed with the use of multiple vasopressors and without hyperinsulinemic euglycemia in all but 3 cases. Despite high doses of vasopressors, ischemic complications were the exception and were usually present before use of vasopressors. Death occurred in a single patient whose death was not attributed directly to calcium-channel blocker toxicity. Vasopressor use after verapamil or diltiazem overdose was associated with good clinical outcomes without permanent sequelae.
- The outcome of living related kidney transplantation with multiple renal arteries. [Journal Article]
- Saudi J Kidney Dis Transpl 2013 May-Jun; 24(3):615-9.
The aim of our study was to compare the surgical complications and short-term outcome of renal transplants with single and multiple renal artery grafts. We reviewed the records of 105 kidney transplantations performed consecutively at our institution from July 2006 to May 2010. The data of 33 (31.4%) renal transplants with multiple arteries were compared with the 72 transplants with single artery (68.6%), and the incidence of surgical complications, post-transplant hypertension, acute tubular necrosis, acute graft rejection, mean creatinine level, and patient and graft survival was analyzed. We further subdivided the study recipients into three groups: group A (n = 72) with one-renal-artery allografts and one-artery anastomosis, group B (n = 6) with mul-tiple-artery allografts with single-artery anastomosis, and group C (n = 27) with multiple-artery allografts with multiple arterial anasatomosis, and compared their outcome. No significant diffe-rences were observed among the recipients of all the three groups regarding early vascular and urological complications, post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine level, and graft and patient survival. The mean cold ischemia time in groups B and C was significantly higher (P <0.05). One patient in group A developed renal vein thrombosis resulting in graft nephrectomy. None of the patients with multiple renal arteries developed either vascular or urological complications. In conclusion, kidney transplantation using grafts with mul-tiple renal arteries is equally safe as using grafts with single renal artery, regarding vascular, urological complications, as well as patient and graft survival.
- [Acetaminophen (paracetamol) causing renal failure: Report on 3 pediatric cases.] [JOURNAL ARTICLE]
- Arch Pediatr 2013 Apr 26.
Renal failure secondary to acetaminophen poisoning is rare and occurs in approximately 1-2 % of patients with acetaminophen overdose. The pathophysiology is still being debated, and renal acetaminophen toxicity consists of acute tubular necrosis, without complication if treated promptly. Renal involvement can sometimes occur without prior liver disease, and early renal manifestations usually occur between the 2nd and 7th day after the acute acetaminophen poisoning. While therapy is exclusively symptomatic, sometimes serious metabolic complications can be observed. The monitoring of renal function should therefore be considered as an integral part of the management of children with acute, severe acetaminophen intoxication. We report 3 cases of adolescents who presented with acute renal failure as a result of voluntary drug intoxication with acetaminophen. One of these 3 girls developed severe renal injury without elevated hepatic transaminases. None of the 3 girls' renal function required hemodialysis, but one of the 3 patients had metabolic complications after her acetaminophen poisoning.
- The Relationship Between N-acetylcysteine, Hyperbaric Oxygen, and Inflammation in a Rat Model of Acetaminophen-induced Nephrotoxicity. [JOURNAL ARTICLE]
- Inflammation 2013 Apr 28.
An overdose of acetaminophen (APAP) produces acute tubular necrosis. The aim of this study was to observe the effects of hyperbaric oxygen (HBO) only and combined with N-acetylcysteine (NAC) on inflammatory cytokines in kidney. Thirty-two male Sprague-Dawley rats were divided into four groups: sham, control (APAP), NAC, and NAC + HBO. In the APAP, NAC, and NAC + HBO groups, renal injury was induced by oral administration of 1 g/kg APAP. The NAC group received NAC (100 mg/kg/day). NAC + HBO group received NAC (100 mg/kg/day) intraperitoneally and HBO underwent at 2.8 ATA pressure with 100 % oxygen inhalation for 90 min every 12 h for 5 days. Rats in the sham group received distilled water only by gastric tube. All animals were killed on 6 days after APAP or distilled water administration. Creatinine, urea, neopterin, tumor necrosis factor-α (TNF-α), and interleukin (IL)-6 levels were measured in sera. There was a significant increase in serum creatinine and urea levels in the control group compared to the sham group (in both, p = 0.001). NAC and NAC + HBO significantly decreased serum neopterin, TNF-α, and IL-6 levels compared to control group. APAP administration caused tubular necrosis in the renal. NAC and NAC + HBO treatments significantly reduced APAP-induced renal damage. The results of this study showed that renal dysfunction in APAP toxicity was attenuated by the use of HBO and NAC treatments. The combination of NAC and HBO treatments might be recommended as an effective treatment modality for APAP-induced nephrotoxicity.