Onuigbo, Macaulay

In the cognate nephrology literature, a few recent publications from major academic centers in the United States have suggested that the incidence of contrast nephropathy was exaggerated and overstated. These investigators have concluded that intravenous contrast material administration was not associated with an increased risk of acute kidney injury (AKI), emergent dialysis, and short-term mortality in a cohort of patients with diminished renal function. As a contrarian opinion, we first describe a clear cut case of contrast-nephropathy resulting in AKI requiring hemodialysis treatment managed in the Renal Unit of the Mayo Clinic Health System, Northwestern Wisconsin, in the Spring of 2017. We subsequently revisit the overwhelming evidence-base in the English literature that supports the enormous impact of contrast-nephropathy as a clinical syndrome. We finally posit that these recent repudiations of the existence and significance of contrast-nephropathy as a significant clinical entity represent an overreach in statistical expertise. There is no basis for a requiem song over contrast-nephropathy

Background and objectives Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis. Design, setting, participants, & measurements We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization. Results Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4–11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P =0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P <0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P <0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P =0.02). Conclusions In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

AbstractIntroduction: We first described the syndrome of rapid onset end stage renal disease (SORO‐ESRD), acute yet irreversible renal failure, in 2010.Objective: The impact of SORO‐ESRD renal allograft survival remains speculative and we plan to study this question.Methods: A retrospective analysis of individual adult patient‐level serum creatinine trajectories of ESRD patients on maintenance hemodialysis for >90 days at Mayo Clinic, Rochester, 2001–2013.Results: Of 1461 ESRD patients, 149 (10%) patients including 13 renal transplant recipients (RTRs) satisfied the diagnosis of SORO‐ESRD ‐ 4 males, 9 females, 12 Caucasians/one other, age 45 (18–83) years. Serum creatinine was 1.4 (0.8–1.7) mg/dL in the last year before hemodialysis initiation. Initial hemodialysis access was a dialysis catheter in all 13 patients. AKI precipitating SORO‐ESRD followed acute rejection (4), postoperative (2), tubulo‐interstitial nephritis (2), unknown (2), infection/sepsis (1), contrast nephropathy (1), BKV nephropathy (1), and cardio‐renal syndrome (1). Renal allograft survival was 1469 (277–4939) days (4 years). Renal allograft biopsies were available in 9/14 (69%) RTRs ‐ Four showed acute rejection, two of which followed interruption of immunosuppression, three revealed acute tubular necrosis and four others also showed chronic transplant glomerulopathy. Time on hemodialysis was 856 (129–1630) days (2.4 years). 5/13 RTRs with SORO‐ESRD (38%) died ‐ 3 (60%) following cardiac arrest, 2 (40%) after stopping hemodialysis. 4/13 (31%) were re‐transplanted in the period of this study.Conclusion: SORO‐ESRD contributed significantly to late renal allograft loss and return to hemodialysis with 100% initial dialysis catheter rate. Potentially preventable causes of AKI leading to SORO‐ESRD were identified. The application of experience gained from such studies would help reduce late renal allograft loss and the need for re‐transplantation. This would further help reduce the yawning gap between need and availability of donor kidney organs both here in the United States and around the world. Larger studies are warranted.

There is mounting evidence that forward heart failure as manifested by low cardiac output alone does not define the degree of renal dysfunction in cardiorenal syndrome. As a result, the term “congestive renal failure” was coined in 2012 by Ross to depict the role of renal venous hypertension in type 1 acute cardiorenal syndrome. If so, aggressive decongestive therapies, either through mechanical ultrafiltration with dialysis machines or pharmacologic ultrafiltration with potent diuretics, would lead to improved cardio and renal outcomes. Nevertheless, as recently as 2012, a review of this literature had concluded that a renal venous hypertension-directed approach using diuretics to manage cardio-renal syndrome was yet to be fully investigated. We, in this review, with three consecutive case series, describe our experience with pharmacologic decongestive diuresis in this paradigm of care and argue for studies of such therapeutic interventions in the management of cardiorenal syndrome. Finally, based on our observations in the Renal Unit, Mayo Clinic Health System, in Northwestern Wisconsin, we have hypothesized that patients with cardiorenal syndrome presenting with accelerated rising Pro B Naturetic Peptide levels appear to represent a group that would have good cardio- and renal-outcomes with such decongestive pharmacologic therapies.

Renal transplantation is the sine qua non consummate form of renal replacement therapy (RRT) for end stage renal disease (ESRD). Despite the increasing ESRD burden worldwide, developing countries continue to experience a gross lack of RRT options for its teeming citizens with ESRD. This report is a demonstration of a nephrologist’s experience and dilemma trying to make sense of the yawning disparity between RRT options, especially renal transplantation, as it applies to the citizens of the USA versus the citizens of Nigeria. The limited three-year experience of renal transplantation at Garki Hospital, located in Abuja, the capital of Nigeria, which is one of the very few centers carrying out renal transplantation in Nigeria, was starkly contrasted with this author’s first-hand experience at the University of Maryland Medical School, in Baltimore, Maryland, USA, as a Nephrology Fellow between 2000 and 2002. The potential role of public-private partnership (PPP) ventures in developing countries is considered as a way to help bridge this gap.