Acute Kidney Injury Associated with Severe SARS-CoV-2 Infection: Risk Factors for Morbidity and Mortality and a Potential Benefit of Combined Therapy with Tocilizumab and Corticosteroids.

BACKGROUND: Acute kidney injury (AKI) is a common complication in patients with severe COVID-19. METHODS: We retrospectively reviewed 249 patients admitted to an intensive care unit (ICU) during the first wave of the pandemic to determine risk factors for AKI. Demographics, comorbidities, and clinical and outcome variables were obtained from electronic medical records. RESULTS: Univariate analysis revealed older age, higher admission serum creatinine, elevated Sequential Organ Failure Assessment (SOFA) score, elevated admission D-Dimer, elevated CRP on day 2, mechanical ventilation, vasopressor requirement, and azithromycin usage as significant risk factors for AKI. Multivariate analysis demonstrated that higher admission creatinine (p = 0.0001, OR = 2.41, 95% CI = 1.56-3.70), vasopressor requirement (p = 0.0001, OR = 3.20, 95% CI = 1.69-5.98), elevated admission D-Dimer (p = 0.008, OR = 1.0001, 95% CI = 1.000-1.001), and elevated C-reactive protein (CRP) on day 2 (p = 0.033, OR = 1.0001, 95% CI = 1.004-1.009) were independent risk factors. Conversely, the combined use of Tocilizumab and corticosteroids was independently associated with reduced AKI risk (p = 0.0009, OR = 0.437, 95% CI = 0.23-0.81). CONCLUSION: This study confirms the high rate of AKI and associated mortality among COVID-19 patients admitted to ICUs and suggests a role for inflammation and/or coagulopathy in AKI development. One should consider the possibility that early administration of anti-inflammatory agents, as is now routinely conducted in the management of COVID-19-associated acute respiratory distress syndrome, may improve clinical outcomes in patients with AKI.

Type 5 Cardiorenal Syndrome: An Underdiagnosed and Underrecognized Disease Process of the American Mother.

Cardiorenal syndrome (CRS) continues to be an area of concern due to the changing understanding of identification, pathophysiology and optimal management. Originally thought that diuretics were always the answer, recent literature has shed lights on the five major CRS subphenotypes, and while conceptual in their classifications, different strategies may be utilized to manage each type. The effect of CRS in pregnant women is largely under discussed and underappreciated as its own entity. Trials involving possible management, specifically utilizing serelaxin, a recombinant form of relaxin, have shown promising results but more data are needed to begin implementing it on a large scale.

Anti-MDA5 Associated Clinically Amyopathic Dermatomyositis With Rapidly Progressive Interstitial Lung Disease.

Anti-melanoma differentiation-associated protein 5 (anti-MDA5) associated clinically amyopathic dermatomyositis (CADM) is a rare entity that is frequently associated with rapidly progressive interstitial lung disease. The disease is characterized by its association with a distinct myositis specific antibody, the lack of muscle involvement seen with other inflammatory myopathies, and a strong correlation with the development of rapidly progressive interstitial lung disease. Diagnosis is based on clinical findings and the presence of autoantibodies. Management generally involves combination immunosuppression therapy. However, the disease course is often aggressive and lends a poor prognosis. We report a case of a healthy 55-year-old male who presented with dyspnea, dry cough, and joint pain for 1 month. The patient was diagnosed with anti-MDA5 associated CADM with interstitial lung disease after a complete rheumatological workup found elevated titers of MDA5 antibodies and computed tomography of the chest without contrast revealed radiographic evidence of interstitial lung involvement. Disease course was complicated by the development of Pneumocystis pneumonia as a result of profound immunosuppression from combination immunosuppressant therapy. Our patient eventually succumbed to his illness approximately 10 weeks following initial symptom onset. This case highlights the aggressive nature of the disease and the challenges in management. Further research is warranted to establish more effective therapeutic options.

Esophagopericardial Fistula and Pneumopericardium as a Complication of Pulmonary Vein Isolation in a 62-Year-Old Man with Atrial Fibrillation: A Case Report.

BACKGROUND Pulmonary vein isolation is a method of cardiac ablation therapy used to treat irregular heart rhythm, including atrial fibrillation (AF). This report presents a case of esophagopericardial fistula (EPF) and pneumopericardium as a complication of pulmonary vein isolation in a 62-year-old man with AF. CASE REPORT We report the rare case of a 62-year-old man with a medical history of persistent atrial fibrillation status after ablation 3 days prior to his initial Emergency Department visit for chest pain. Acute coronary syndrome was ruled out with normal electrocardiogram, echocardiography, and troponin tests. Fluid overload and sotalol adverse effects were presumed to be the cause of his symptoms. We discontinued sotalol with diuresis and he was discharged home when his chest pain subsided. Nine days later, he returned to the Emergency Department with worsening similar symptoms and was eventually diagnosed with EPF and pneumopericardium on a computed tomography scan of the chest with contrast. He was managed with esophagogastroduodenoscopy and stent placement along with subxiphoid pericardial window and pericardial drain placement. The patient was discharged in stable condition after removing the pericardial drain. At 10-day and 1-month follow-up, he had no recurrent symptoms. CONCLUSIONS This report shows that although EPF with pneumopericardium is a rare complication of pulmonary vein isolation, it should be rapidly diagnosed and treated as a life-threatening emergency.

Idiopathic Pleuroparenchymal Fibroelastosis.

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare form of idiopathic interstitial pneumonia. The disease is characterized by fibrosis of the pleura and subpleural lung parenchyma predominantly affecting the upper lobes. Various triggers have been proposed as inciting factors in the development of the disease. Diagnosis is made clinically in conjunction with radiographic findings and histopathology when available. There are no known effective treatment options and several cases of lung transplantation have been reported. We report a case of an 86-year-old female who presented to the emergency department with worsening dyspnea and hypoxia. She had a history of unexplained pneumomediastinum and a 20 - 25 pounds unintentional weight loss over 10 months. Computed tomography (CT) of the chest without contrast revealed radiographic evidence of IPPFE. Despite symptomatic management with antibiotics, diuretics, and steroids, her condition continued to deteriorate. Unfortunately, our patient was not a candidate for a lung transplant. She was transitioned to hospice care and succumbed to her disease. IPPFE is a rare disease with an unknown prevalence. It has a median survival rate of 2 years. Usually, there is an overlap with interstitial lung diseases, making it challenging to diagnose. There are only a few cases reported in the literature, and there are currently no guidelines available on the appropriate management of this debilitating disease. We recommend more cases be reported, and further research is done to establish better criteria for diagnosis and management.

Blood pressure control. Improving medication compliance among ESRD patients.

Medication compliance among individuals with hypertension symbolizes a growing concern within the medical community. It is said that roughly 50% of hypertensive patients in the United States do not comply with their medication regimen. Uncontrolled hypertension in turn can lead to kidney failure and other complications. Because compliance to medication regimens is complex and difficult to ascertain, solutions to this problem must be multifactorial.