Initial impact of COVID-19 on dialysis provision; review of international guidelines and adaptation of a hub unit's service.

The COVID-19 pandemic has put a strain on many aspects of health care including the provision of dialysis. Two categories of patients have had the greatest impact on dialysis capacity. Those with COVID-19-related acute kidney injury and those chronic dialysis patients who required isolation or cohort dialysis because of the pandemic. Limited information on incidence hampers capacity planning and the rapid change in demand provides further challenges. In the 4 weeks after our first patient, the incidence of confirmed infection in our dialysis population has been 5.1%. By the third week, hemodialysis had to be provided in critical care as the in-house capacity for hemofiltration had been overwhelmed. The interventions that enabled these needs to be met are detailed in this paper alongside a review of international recommendations and how they have been adapted to meet local pressures.

Survival akin to injury, hospitalized patients with acute kidney injury based on the AKIN classification.

INTRODUCTION: Acute kidney injury (AKI) is often associated with severe consequences. The aim of the study was to determine whether the acute kidney injury network classification predicts hospital stay, renal recovery and mortality. METHODS: Hospitalized patients who were referred to the nephrology service over 6 months were studied retrospective with further 12 months prospective follow up. Statistical analysis was performed on their demography and outcome. RESULTS: Among the 238 patients who were referred, 166 had AKI, median age 74 years and 32% were diabetics. 10% (n = 17) required acute renal replacement therapy. The overall all-cause mortality of AKI group (n = 166) compared to non-AKI group (n = 72) at 1 year was 55% as opposed to 27.8% (p < 0.001). There was a significant statistical difference in the composite outcome and survival between the AKI stages in terms of renal recovery (p = 0.018). The AKI group had a median 8 day increase in length of stay compared to the non-AKI group (20 vs. 12 days; p = 0.0175). However, there was no significant statistical difference between pre and post admission AKI (p value = 0.191). CONCLUSION: The AKIN staging of AKI predicts both early and late mortality. AKI has a major impact on inpatient and 1-year-survival, renal recovery and length of stay. AKI and renal recovery following the insult were independent prognosticators. Early identification and management of AKI cases can help to prevent progression of the severity of AKI and therefore, mandates timely referral to nephrology team to prevent progression of AKIN class and its consequences.

Effect of cytomegalovirus prophylaxis with acyclovir on renal transplant survival.

It is recognized that cytomegalovirus (CMV) infection in transplant recipients may lead to graft loss. Prophylaxis with acyclovir has therefore gained widespread acceptance, but the debate on whether this intervention improves long term graft survival continues. All patients who received renal grafts at the National Renal Transplant Centre, Dublin, between January 1992 and December 1999 were retrospectively analyzed. During this time period, patients who were CMV positive and/or had received grafts from CMV-positive donors were administered prophylactic oral acyclovir 800 mg thrice daily, adjusted for calculated creatinine clearance, from the first day post-transplantation. This treatment was continued for three months unless the graft failed or the patient developed CMV disease or died. Graft and patient outcomes were compared in recipients who received acyclovir with those who did not. Over the study period, 935 patients received renal transplants in our center, of whom 487 were administered acyclovir. The incidence of CMV disease was 3.3 cases per 100 patients per annum in those who required prophylaxis. Despite prophylaxis, graft outcomes were found to be significantly worse (p value < 0.001) in the group that qualified for acyclovir. We conclude that acyclovir provides incomplete protection from the negative impact of CMV on graft survival.

Cutaneous squamous carcinoma leading to acute abdomen after renal transplantation.

Skin carcinoma is the commonest malignant complication of renal transplantation. We report the first case of a renal transplant recipient who presented with ileal obstruction as a consequence of squamous cell carcinoma metastases to the small intestine. This complication highlights the unusual presentation of malignancies associated with prolonged exposure to immunosuppression and the need for extra vigilance in such cases.

Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature.

Acute renal failure is a rare but serious complication of pregnancy. We describe a 31-year-old woman with haemolytic anemia, elevated liver enzymes, low platelets (HELLP syndrome) who developed acute peripartum renal failure. Renal biopsy performed 2 weeks later because of persistent oliguria revealed thrombotic microangiopathy and acute tubular necrosis. This case highlights the probable pathogenesis of acute renal failure in HELLP patients and explains why it resolves in the majority of cases. A review of the literature that describes renal histology in HELLP patients is presented.

The effect of pre-existing ischaemic heart disease on renal dysfunction in cardiac transplant recipients.

Renal dysfunction is a recognized complication of cardiac transplantation and can impact on the life expectancy of an already fragile population. A large proportion of these patients require transplantation because of the consequences of ischaemic heart disease (IHD) which, in turn, is often associated with ischaemic nephropathy. We studied the effect of IHD, diagnosed prior to transplantation, on the renal function of recipients who survived more than 6months after surgery. Of the 168 patients transplanted in a single centre over 15 years, 132 were included in the study. Renal dysfunction was defined as a serum creatinine consistently above 200 micromol/L (2.26 mg/dL). Analysis confirmed that IHD was an independent risk factor for developing renal impairment. In transplant recipients with IHD, closer monitoring is warranted to detect and prevent renal dysfunction or to retard its progression.

Plasmapheresis as rescue therapy in accelerated acute humoral rejection.

Accelerated acute humoral rejection (AHR) continues to occur in renal transplantation despite improved crossmatching, with potentially devastating consequences. Between 1 June 1998 and 31 December 2000, 440 renal transplants were performed in our center. AHR was diagnosed by the demonstration of typical pathological features on renal histology and positive direct immunofluorescence or detection of anti-HLA antibodies in serum. AHR developed in 20 (4.5%) of our renal transplant recipients, nine male and eleven female at an average of 16.3 days post transplantation. All of these patients had a negative current cytotoxic crossmatch prior to transplantation. The median serum creatinine at diagnosis was 5.96 mg/dL, and 83% of these individuals developed oliguric renal failure requiring dialysis after having initially attained good graft function (median of best serum creatinine before AHR was 2.64 mg/dL). The 18 recipients who had not infarcted their grafts at the time of diagnosis of AHR received plasmapheresis in conjunction with intensification of their immunosuppressive regimen. This regimen was successful in reversing AHR in 78% of those treated with apheresis. In the 14 responders, graft survival at 6 months was 100% and at 12 months was 91%. Median serum creatinine at 6 and 12 months was 1.26 and 1.33 mg/dL, respectively. Patients received an average of 8.1 plasma exchanges. However, responders received a significantly higher frequency of plasmapheresis (P =.0053), despite undergoing a similar number of exchanges overall. Plasmapheresis appears to be an effective modality for reversing AHR and maintaining graft function.