Association of genotypes at rs438228855 in bovine SLC35A3 receptor gene of Pakistani cattle with the susceptibility to develop complex vertebral malformation.

The aim of this study was to report the genotype and allelic frequency at rs438228855 (G > T) in SLC35A3 receptor gene and its association with a complex vertebral malformation (CMV) in the enrolled Pakistani cattle. Our results indicated that allelic and genotype frequency at rs438228855 varied non-significantly (p > .05) among the three enrolled cattle breeds. GT (heterozygous) genotype was most abundant (0.54) followed by GG (wild type) genotype (0.45) while the mutant genotype (TT) was not observed among the enrolled cattle. It was observed that the Holstein Friesian breed had more GG (wild) than GT (heterozygous) genotypes while Sahiwal and cross cattle breed had more heterozygous (GT) combination at rs438228855 than the wild (GG) genotype. Significant variations in white blood cell count, % lymphocytes, red blood cell count, % monocytes, haemoglobin, mean corpuscular volume and mean corpuscular haemoglobin concentration were observed when compared between the enrolled cattle breeds. Most of the studied haematological parameters showed no association with the genotype at rs438228855. In conclusion, the heterozygosity at rs438228855 is not limited to the Holstein Friesian breed as local Sahiwal and crossbred cattle had also higher heterozygosity at rs438228855. We recommend that animals must be genotyped for rs438228855 before their selection as breeders to prevent economic losses.

Quantum inspired community detection for analysis of biodiversity change driven by land-use conversion and climate change.

Community detection remains little explored in the analysis of biodiversity change. The challenges linked with global biodiversity change have also multiplied manifold in the past few decades. Moreover, most studies concerning biodiversity change lack the quantitative treatment central to species distribution modeling. Empirical analysis of species distribution and abundance is thus integral to the study of biodiversity loss and biodiversity alterations. Community detection is therefore expected to efficiently model the topological aspect of biodiversity change driven by land-use conversion and climate change; given that it has already proven superior for diverse problems in the domain of social network analysis and subgroup discovery in complex systems. Thus, quantum inspired community detection is proposed as a novel technique to predict biodiversity change considering tiger population in eighteen states of India; leading to benchmarking of two novel datasets. Elements of land-use conversion and climate change are explored to design these datasets viz.-Landscape based distribution and Number of tiger reserves based distribution respectively; for predicting regions expected to maximize Tiger population growth. Furthermore, validation of the proposed framework on the said datasets is performed using standard community detection metrics like-Modularity, Normalized Mutual Information (NMI), Adjusted Rand Index (ARI), Degree distribution, Degree centrality and Edge-betweenness centrality. Quantum inspired community detection has also been successful in demonstrating an association between biodiversity change, land-use conversion and climate change; validated statistically by Pearson's correlation coefficient and p value test. Finally, modularity distribution based on parameter tuning establishes the superiority of the second dataset based on the number of Tiger reserves-in predicting regions maximizing Tiger population growth fostering species distribution and abundance; apart from scripting a stronger correlation of biodiversity change with land-use conversion.

Retrospective study of ovarian malignancy managed in surgical unit at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore.

OBJECTIVE: To determine the oncological outcome and pattern of ovarian tumours in patients who underwent surgical management. METHODS: The retrospective, descriptive hospital-based study was conducted at Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, and comprised data of all patients who underwent surgical intervention for ovarian cancer between January 2010 and December 2015. Data was retrieved from the hospital database and analysed using SPSS 20. RESULTS: Of the 236 patients, 203(86%) had undergone open surgery, while 33(14%) had had laparoscopic surgery. Neo-adjuvant chemotherapy was given in 60(25.42%) cases and adjuvant chemotherapy in 102(43.22%). Epithelial ovarian cancer in 201(85.16%) cases was the most common tumour type. Mortality was recorded in 36(15.5%) cases, while 41(19.9%) were lost to follow-up. CONCLUSIONS: Ovarian tumours were found to be difficult to treat and were associated with frequent recurrence.

Is it necessary to measure hepatic venous pressure gradient before liver resection in cirrhotic patients? A single center audit.

OBJECTIVE: To determine whether routine preoperative hepatic venous pressure gradient measurements are necessary in child's-A cirrhotic patients undergoing liver resection for hepatocellular carcinoma, and to assess immediate post-operative liver dysfunction and 30-day mortality in such cases. METHODS: The 3-year audit was done at Shuakat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data from January 1, 2015, to December 31, 2017, of all Child's class "A" patients with hepatocellular carcinoma without any clinical signs of portal hypertension who had preoperative hepatic venous pressure gradient measurements done. A proforma was used to collect the required data from patient files. Data was analysed using SPSS 21. RESULTS: Of the 20 patients, 11(55%) were males. The overall mean age was 60.6±7.4 years. Only 2(10%) patients had raised hepatic venous pressure gradient. Of the total, 14(70%) patients underwent surgery. Mean duration of surgery was 222±82.5 minutes and mean hospital stay was 6.8±3.2 days. None of the patients had deranged prothrombin-time or bilirubin on postoperative day 5. CONCLUSIONS: The incidence of subclinical portal hypertension was very low. Hepatic venous pressure gradient measurement can be avoided in early stage hepatocellular carcinoma for child's A cirrhotic patients undergoing liver resection.

Primary hepatic neuroendocrine tumour: A rare entity - multimodal approach for diagnosis and management.

Neuroendocrine tumours (NETs) of the liver are generally metastatic lesions from broncho-pulmonary or gastrointestinal primary lesions. Liver is an unusual primary site for a NET with only 150 reported cases in literature. We encountered two cases of primary hepatic NET (PHNET) at the Shaukat Khanum Memorial Cancer Hospital, Lahore. Both the patients had abdominal pain and hepatomegaly. Imaging revealed a large mass in the right lobe of the liver in both the cases. The tru-cut biopsy showed neuroendocrine tumour. Extensive workup to look for primary lesion elsewhere in the body turned out to be negative. One patient received neo-adjuvant chemotherapy along with right main portal vein embolisation. Once adequate future liver remnant was achieved, the patient underwent right hepatic trisectionectomy. In the other patient, anticipated future liver remnant was sufficient and underwent surgery without portal vein embolization. No immediate postoperative complication was observed, and both the patients were followed for more than one year.

An Extremely Rare Case of Anomalous Left Main Coronary Artery Originating From Single Right Coronary Ostium Managed Using Heart Team Approach.

Anomalies of coronary artery origin are rare, difficult to diagnose using conventional testing methods and extremely challenging to eventually manage once diagnosed. The risk of adverse outcomes increases as such patients age and develop atherosclerosis in such vessels. A comprehensive and multidisciplinary approach may be required to best manage such difficult cases.  We present a case of a 65-year-old female with symptoms of chest pain concerning for unstable angina. She also complained of occasional diaphoresis and dizziness. Physical examination revealed a regular heart rhythm with no vascular bruits. An electrocardiogram (EKG) only showed normal sinus rhythm and left axis deviation. Non-invasive testing included an echocardiogram, which showed multiple wall motion abnormalities. A diagnostic cardiac catheterization via right radial artery approach was performed to delineate her coronary anatomy and rule out ischemic etiology. This led to diagnosis of anomalous coronary anatomy with an anomalous left main coronary artery from single right coronary ostium. Furthermore, it showed significant obstructive multi-vessel coronary artery disease involving distal left main artery, proximal left anterior descending artery, left circumflex and right coronary arteries. The patient had a right dominant system with absent left coronary cusp. Percutaneous vs surgical revascularization options were considered. Given high Syntax score and acceptable Society of Thoracic Surgeons (STS) risk, Heart Team approach was pursued and the patient was referred for multi-vessel surgical revascularization.

Prophylactic Antibiotics for Reducing Central Line-associated Blood Stream Infection in Children with Totally Implantable Venous Access Devices.

OBJECTIVE: To analyse the need of prophylactic antibiotic before the insertion of totally implantable venous access devices (TIVADs) in terms of preventing central line-associated blood stream infection (CLABSI) in early postoperative period in pediatric oncology patients. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore from January 2005 to June 2016. METHODOLOGY: A total of 645 consecutive children with malignancy, who were implanted with TIVAD, were included in the study. The data were collected retrospectively and divided into two groups on the basis of prophylactic antibiotic administration (Group A) received the antibiotic; and Group B did not receive the antibiotic. Both the groups were compared in terms of positive central blood cultures in the absence of any other clinical source of infection during the early postoperative period of 30 days. RESULTS: The overall infection rate was 12.54% (35 out of 279) in Group B (did not receive prophylactic antibiotic) and 11.68% (41 out of 351) in Group A (received prophylactic antibiotic) without any significant difference (p = 0.741). CONCLUSION: There was no advantage of the use of prophylactic antibiotic before TIVAD insertion in preventing early postoperative CLABSI.

Prognostic significance of pre- and post-operative serum carcinoembryonic antigen levels in patients presented with rectal carcinoma; an experience from Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore.

OBJECTIVE: To explore the importance of serum carcinoembryonic antigen level as a tumour marker in rectal carcinoma. METHODS: The retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, and comprised data of patients with rectal carcinoma from January 1996 to December 2015. Serum carcinoembryonic antigen levels were analysed using immulite@2000 system analyser. On the basis of serum carcinoembryonic antigen levels, data of patients was divided into four groups. Group A had normal serum levels both before and after surgical resection; Group B had normal levels pre-surgery but post-surgery levels were raised; Group C had raised levels pre-surgery that went down to normal post-surgery; and Group D had raised levels both before and after surgery. SPSS 23 was used for data analysis. RESULTS: Of the 401 patients, 267(66.6%) were males, and 204(50.9%) were aged <50 years. Group A had 267(66.6%) patients, Group B 26(6.5%), Group C 79(`9.7) and Group D had 29(7.2%) patients. Stage III disease was the most common 343(85.5%) and it was true across the groups. Overall recurrence was in 141(35.2%) patients. Group D had the highest recurrence rate 26(89.7%), while Group C had the lowest 18(22.8%). CONCLUSIONS: Fluctuating levels of carcinoembryonic antigen affected post-operative outcome.

Risk factors and patterns of recurrence after curative resection in Gastroesophageal Junction Adenocarcinoma.

OBJECTIVES: We looked at risk factors and patterns of recurrence following surgical treatment of Gastro-Oesophageal Junction carcinoma (GOJC). METHODS: Electronic medical records of patients with GOJC undergoing resection with curative intent between Jan 2009 and June 2017 at Shaukat Khanum Memorial Cancer Hospital were reviewed. GOJ cancer was classified as per Siewert classification. Clinical and operative details were studied and data was analysed using SPSS 20. RESULTS: During the study period, we identified 78 patients with GOJ adenocarcinoma (38 patients with GOJ Type-I, 16 with Type-II tumors and 24 patients with GOJ Type-III tumors). Median age was 56 years ± 1.1. Male to female distribution was 72 versus 28%. Carbo-Pacli /5-FU based XRT verses Magic protocol (p<0.015) and advanced pathological T.-stage (p-value<0.032) were found to be statistically significant risk factors for recurrence. After a median follow up of 17.8 months+/- 1.5, 20 patients developed recurrence of which five had local recurrence, three had regional recurrence, eight had distant metastases and four had both local and distant metastases. CONCLUSION: The incidence of recurrence following curative resection of GOJC is 25%. Type of neoadjuvant treatment, waiting time for surgery and advanced T-stage are a risk factor for recurrence.

Radiological Parameters to Predict Hemorrhagic Progression of Traumatic Contusional Brain Injury.

INTRODUCTION: Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC). MATERIALS AND METHODS: Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the "ABC/2" technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC. RESULTS: HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00-5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08-8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87-13.13), frontal location (RR: 1.42, 95% CL: 1.08-3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51-10.01, subdural-RR: 2.91, 95% CL: 1.26-6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01-5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789-32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114-0.860). CONCLUSION: Initial computed tomography scan is a good predictor of high-risk group for HPC.

Risk factors effecting development of metachronous liver metastasis in rectal cancer patients after curative surgical resection. Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore experience.

OBJECTIVE: To determine risk factors affecting development of metachronous liver metastasis in rectal cancer patients after curative surgical resection. METHODS: The retrospective cohort study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of patients with histologically proven rectal carcinoma admitted to the department of surgical oncology from January 2005 to December 2015. Clinical data of all patients, including age, gender, clinical presentation, clinical and pathological tumour-nodes-metastasis classification, neoadjuvant chemo-radiotherapy, surgery, adjuvant chemotherapy, pre- and postoperative carcinoembryonic antigen levels, histopathological findings and tumour recurrence were analysed. SPSS 23 was used for data analysis.. RESULTS: Of the 434 patients, 26(6%) developed liver metastasis. Of them, 18(69%) were male and 16(61.5%) were aged below 50 years. On clinical staging, 2(7.7%) patients had stage II disease, 22(84.6%) had stage III, and 2(7.7%) patients had stage IV disease. At last follow-up, 2(7.7%) patients were alive without disease, 7(27%) had expired, while 17(65.4%) were alive with disease.. CONCLUSIONS: Tumour depth, lymph node metastasis, postoperative carcinoembryonic antigen levels, complete tumour response on histopathology were found to beresponsible for metachronous liver metastases in rectal cancer patients following curative resection.

Risk Factors For Chyle Leak After Esophagectomy.

BACKGROUND: Chylothorax is an uncommon (3-8% risk) but potentially fatal complication of esophagectomy with poorly understood risk factors. It has a high morbidity due to loss of fluids, electrolytes, and other nutrients, loss of lymphocytes and immune dysfunction. METHODS: Retrospective chart review of adult patients who underwent esophagectomy between 2009 and 2016 was performed. Cases with chyle leak were identified according to a set criteria. Clinical features, operative findings and postoperative variables were recorded and predictors of chyle leak were analyzed. RESULTS: During the study period, a total of 193 adult patients underwent esophagectomy of which 186 received neo adjuvant chemotherapy. The mean age was 53 years with 118 males and 74 females. Type of procedure performed was 3-stage esophagectomy in 98, Transhiatal esophagectomy in 79 and Ivor-Lewis esophagectomy in 15 patients. Chyle leak was identified in 9 (4.6%) patients. There was no significant association of chyle leak with age, gender, co-morbid, level of tumor, Neoadjuvant therapy and Type of esophagectomy. Chest drain output on postoperative day 5 was significantly predictive of chyle leak (p-value<0.05). Drain output more than 1000 on day 4 was highly suggestive of chyle leak (p-value<0.05). Day on which chest drain was removed was also found to be significantly related to chyle leak (p-value <0.05). CONCLUSIONS: No significant preoperative risk factors were identified for chyle leak. High chest drain output on postoperative day 5 and drain output more than 1000 on day 4 are significant predictors of chyle leak.

Review of and Updates on Hypertension in Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a prevalent sleep disorder as is hypertension (HTN) in the 21st century with the rising incidence of obesity. Numerous studies have shown a strong association of OSA with cardiovascular morbidity and mortality. There is overwhelming evidence supporting the relationship between OSA and hypertension (HTN). The pathophysiology of HTN in OSA is complex and dependent on various factors such as sympathetic tone, renin-angiotensin-aldosterone system, endothelial dysfunction, and altered baroreceptor reflexes. The treatment of OSA is multifactorial ranging from CPAP to oral appliances to lifestyle modifications to antihypertensive drugs. OSA and HTN both need prompt diagnosis and treatment to help address the growing cardiovascular morbidity and mortality due to these two entities.

Bringing efficiency into practice: A quality improvement initiative to reduce operating room turnaround time.

Operating room (OR) turnaround time (TAT) is the minimal essential time required for cleaning of OR and preparation for the next case. The TAT inversely affects OR efficiency. Several factors related to personnel, equipment and scheduling have been identified as causes of increased TAT. We conducted the study to identify factors that affect OR TAT and to propose recommendations for its reduction. The retrospective study, conducted at Aga Khan University Hospital, Karachi, comprised TAT records related to March 2014. Of the 88 cases, 22(25%) showed a delay. Upon Pareto analysis it was found that in 8(36.6%) cases there was a delay of 70% related to scheduling of OR list and 5(22.7%) related to movement of patients from wards to OR. As such, improvement in these two broad areas can take care of majority of delays. We also recommend documentation of all processes as part of continuous improvement.

Serum anti-mullerian hormone and all-cause mortality in men.

Several studies have examined an association of anti-mullerian hormone to various risk factors for mortality, however, to the best of our knowledge, no study has reported a direct relationship between anti-mullerian hormone and all-cause mortality. Therefore, we examined the relationship between baseline anti-mullerian hormone levels and subsequent all-cause mortality in men during median follow-up of 9.4 (range = 0-13) years. We used the continuous National Health and Nutrition Examination Surveys from 1999-2004 combined with National Death Index for vital status information through December 2011. Cox proportional hazard models were fit to estimate hazard ratios for all-cause mortality. Models were adjusted for age, ethnic background, body mass index, hypertension, diabetes, smoking status, c-reactive protein, total cholesterol, estimated glomerular filtration rate, serum estradiol, testosterone, sex hormone binding globulin, and androstenedione. Of the 989 men, 30 % were older than 65 years, 51 % were Caucasians, 33 % had hypertension, 27 % were active smokers, and 11 % had diabetes. Mean serum anti-mullerian hormone level of the population was 7.2 (6.3) ng/mL. During the 8943 person-years of follow-up, 164 (17 %) men died. In unadjusted analysis, each unit increase in serum anti-mullerian hormone level was associated with a 13 % lower risk of death (HR = 0.87; 95 %CI = 0.83-0.92). In multivariable models, the inverse association between serum anti-mullerian hormone levels and mortality remained significant (HR = 0.94; 95 %CI = 0.90-0.98) and was independent of confounding variables. Similarly, individuals in the highest quartile had significantly lower risk of death as compared to individuals in the lowest quartile (unadjusted HR = 0.13, 95 %CI = 0.07-0.25; adjusted HR = 0.36, 95 %CI = 0.16-0.81). We found an independent and inverse association between serum anti-mullerian hormone levels and all-cause mortality in men. The mechanism underlying this association is unknown. Further studies are needed to validate our findings in men and to examine this association in women.

Reproductive Endocrinology in Chronic Kidney Disease Patients: New Approaches to Old Challenges.

Sexual dysfunction is a common yet underreported problem among chronic kidney disease (CKD) patients. This article will review sexual dysfunction in both genders, pregnancy outcomes, and best practices for successful full-term pregnancy in patients with CKD, including those with dialysis dependence and kidney transplants.

Review of Hyperkalemia in End Stage Renal Disease.

Potassium balance is maintained in the body by balancing the intake with the excretion and the transcellular shifts of potassium. Excretion of potassium is mainly renal as the contribution of the colon to the net potassium secretion of the colon to the net potassium secretion is trivial in patients with normal renal function. As the majority of potassium excretion is renal, it is not surprising to note that patients with end stage renal disease (ESRD) are at an increased risk of developing hyperkalemia in ESRD patients has been estimated to be 3-5%. Maintenance of a stable serum potassium level in patients with ESRD is crucial. We will review the various measures for the management and prevention of hyperkalemia in ESRD patients such as dietary restrictions, dialysis and drugs enhancing extra renal elimination of potassium.

The Need to Emphasize Nephrology Knowledge in Residents-in-Training.

BACKGROUND: Chronic kidney disease is an increasingly prevalent health problem with the potential for poor outcome of end-stage renal disease. Hospitalized critically ill patients are prone to acute renal injury from numerous factors such as poor renal perfusion secondary to ischemia and hypotension, nephrotoxin exposure, and intravenous contrast exposure. AIMS: We set to explore resident awareness and knowledge about chronic kidney disease management, timely nephrology referrals, preventing inadvertent acute kidney injury (AKI), and the understanding of basic electrolyte physiology. MATERIALS AND METHODS: We conducted a cross-sectional study using an online questionnaire survey of internal medicine, Medicine/Pediatrics and Family Medicine residents in the United States to determine the knowledge of residents during their training about nephrology. RESULTS: The survey questionnaire was sent out to 270 residents. Forty-seven (17%) respondents completed the survey. Out of them, 57% of the residents chose to refer a patient with an estimated glomerular filtration rate <30 mL/min/1.73 m(2) to a nephrologist; 66% felt that it was safe to use aspirin in stage IV chronic kidney disease; 82% did not want to use metformin or Lovenox in stage IV chronic kidney disease; 87% answered that they would make the patient resume angiotensin converting enzyme inhibitor or angiotensin II receptor blockers (ARBs) about 48-72 h after contrast exposure. Only 7.5% decided to hold angiotensin converting enzyme inhibitors/ARBs before contrast exposure. Meanwhile, 70% correctly identified the efferent arteriole as the site of action of angiotensin converting enzyme inhibitors/ARBs and 76% identified nitrofurantoin as a contraindication in renal insufficiency. CONCLUSION: Residency offers a golden opportunity for resident physicians to create a strong foundation of concepts in medicine. There are several basic areas in the field of nephrology that need to be further emphasized during residency training to help improve patient care and potentially decrease the incidence of AKI.

Hyperuricemia: An Early Marker for Severity of Illness in Sepsis.

Background. Uric acid can acutely activate various inflammatory transcription factors. Since high levels of oxyradicals and lower antioxidant levels in septic patients are believed to result in multiorgan failure, uric acid levels could be used as a marker of oxidative stress and poor prognosis in patients with sepsis. Design. We conducted a prospective cohort study on Medical Intensive Care Unit (MICU) patients and hypothesized that elevated uric acid in patients with sepsis is predictive of greater morbidity. The primary end point was the correlation between hyperuricemia and the morbidity rate. Secondary end points were Acute Kidney Injury (AKI), mortality, Acute Respiratory Distress Syndrome (ARDS), and duration of stay. Results. We enrolled 144 patients. 54 (37.5%) had the primary end point of hyperuricemia. The overall morbidity rate was 85.2%. The probability of having hyperuricemia along with AKI was 68.5% and without AKI was 31.5%. Meanwhile the probability of having a uric acid value <7 mg/dL along with AKI was 18.9% and without AKI was 81.1% (p value < 0.0001). Conclusion. We report that elevated uric acid levels on arrival to the MICU in patients with sepsis are associated with poor prognosis. These patients are at an increased risk for AKI and ARDS.

The ethics of offering dialysis for AKI to the older patient: time to re-evaluate?

Older patients are more susceptible to AKI. In the elderly, AKI has been associated with increased morbidity and mortality, and it is a significant risk factor for CKD and dialysis-dependent ESRD. There are now accumulating data that the start of dialysis for some older patients is associated with poor outcomes, such as high treatment intensity, suffering, and limited life prolongation, which occur at the expense of dignity and quality of life. The biomedicalization of aging is a relatively recent field of ethical inquiry with two directly relevant features to decisions about starting dialysis for older patients with AKI: (1) the routinization of geriatric clinical interventions, such as dialysis, which results in the overshadowing of patient choice, and (2) the transformation of the technological imperative into the moral imperative. A major consequence of the biomedicalization of aging is that societal expectations about standard medical care have resulted in the relatively unquestioned provision of dialysis for AKI to older patients. This paper calls for nephrologists to re-examine the data and their attitudes to offering dialysis to older patients with AKI, especially those patients with underlying CKD and significant comorbidities. Shared decision-making and the reinforcement of the right of the patient to make a choice need to slow down the otherwise ineluctable routinization of starting old and very sick patients on dialysis. In the process of shared decision-making, nephrologists should not automatically recommend dialysis for older patients; in those patients who can be predicted to do poorly, recommending against dialysis upholds the Hippocratic maxim to be of benefit and do no harm. This paper challenges the automatic transformation of the technological imperative into the moral imperative for older patients with AKI and points to the need for a re-evaluation of dialysis ethics in this population.