Gender and kidney transplantation.

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

Validation of the STARZ neonatal acute kidney injury risk stratification score in an independent prospective cohort.

OBJECTIVE: A rapid AKI risk assessment score would allow for improving management and outcomes. STARZ (Sethi, Tibrewal, Agrawal, Raina, waZir) score was developed for acute kidney injury (AKI) risk stratification of critically ill neonates. This is the first independent validation for the novel score outside the original enrolled centres. STUDY DESIGN: 750 neonates were included in the study. The STARZ score was calculated after 12 hours of admission. Neonates admitted in NICU and receiving IV fluids for at least 48 hours were included. RESULTS: A total of 8.8% neonates had AKI in the first 7 days post admission. The duration of hospital stay was significantly higher among neonates with AKI [10.5 (7-19) vs. 7 (5-10) days; p < 0.001]. Mortality risk was 6.4 times higher among those with AKI [8 (12.1%) vs. 13 (1.9%); p < 0.001; RR (95% CI): 6.38 (2.74-14.83)]. In this study, the STARZ neonatal scoring model showed a sensitivity of 89.4% in detecting AKI with a 90.9% specificity and a high negative predictive value of 98.9%. The area under ROC was 0.958 (0.934-0981) - a high discriminative power. CONCLUSIONS: The STARZ score allows for AKI risk stratification, providing opportunity for therapeutic interventions which may improve outcomes in critically ill neonates.

Renal Outcomes in Neonates and Infants with Transposition Physiology Undergoing Arterial Switch Procedure.

Acute kidney injury (AKI) in children with Transposition of Great arteries (TGA) undergoing Arterial Switch operation (ASO) is an important complication in the post-operative period associated with worse outcomes. AKI in children post open cardiac surgery has been well studied, with lesser data in literature pertaining to TGA and its sub-types specifically. This was a prospective, observational study enrolling infants with TGA undergoing ASO at a single center over a span of a decade from January 2010 to December 2020. The infants were followed during the duration of ICU and hospital stay, with documentation of baseline and intraoperative parameters as well as post-operative course. Out of 145 infants enrolled in the study, 83.1% developed AKI with majority (83.9%) having stage 1 AKI. Higher odds of AKI were seen in infants requiring Norepinephrine [odds ratio - 16.76 (95% CI 2.19-128.2), p < 0.001] and those who developed gram-negative infections [2.81 (1.04-7.56), p - 0.036]. Infants with AKI had significantly higher vasoactive-inotropic support at day 1 than those without AKI [16 (12.5-21.50 vs 13 (10.25-15.75), p - 0.014]. Seventeen infants in the AKI group (14%) died as opposed to none in the non-AKI group (p = 0.076). Median hours of ventilator support required were significantly higher in those with AKI than those who did not develop AKI (48 vs 45.5 p = 0.015). The infants with ASO + ASD + PDA (53% of neonates who died) were younger, had less weight at admission, more gram-negative sepsis and need for dopamine, as compared to ASO + VSD + ASD (23.5% of mortality) and ASO + ASD + VSD + aortic arch repair (23.5% of mortality). AKI in infants with TGA undergoing ASO is common and associated with poorer outcomes. In this subpopulation, AKI development is associated most commonly with hemodynamic instability and infections. This is the first study, looking at outcomes of TGA depending on the sub-types of ASO surgeries done in the infants [ASO with ASD + PDA or ASD + VSD or ASD + VSD + Arch Repair].

Perioperative albuminuria and clinical model to predict acute kidney injury in paediatric cardiac surgery.

BACKGROUND: AKI is an important complication post cardiac surgery in children. An early diagnosis can help in mitigating complications and allow for prognostication. Urinary albumin:creatinine ratio (ACR) as a biomarker can provide a cheaper and more accessible AKI risk assessment and prediction. There is a paucity of paediatric literature regarding its utility. METHODS: This was a prospective observational study, enrolling all children aged 1 month to 18 years, who underwent cardiac surgery, with use of cardiopulmonary bypass. Cohort was divided into groups < 2 years and ≥ 2 years for analyses to account for differences in physiological albumin excretion with age. RESULTS: Of 143 children enrolled in the study, 36 developed AKI. In both age groups, the post-operative ACR was higher than pre-operative ACR among patients with and without AKI. In the group aged ≥ 2 years, the highest first post-operative ACR tertile (> 75.8 mg/g) predicted post-operative AKI after adjusting for clinical variables (adjusted RR, 11.71; 1.85-16.59). In the group aged < 2 years, the highest first post-operative ACR tertile (> 141.3 mg/g) predicted post-operative AKI in unadjusted analysis but not after adjusting for clinical variables (RR, 2.78; 0.70-6.65). For AKI risk prediction, AUC (95% CI) was highest after combining clinical model and pre-operative ACR for groups aged < 2 years [0.805 (0.713-0.896)] and ≥ 2 years [0.872 (0.772-0.973)]. CONCLUSIONS: This study provides evidence for use of albuminuria as a feasible biomarker in AKI prediction in children post cardiac surgery, especially when added to a clinical model. A higher resolution version of the Graphical abstract is available as Supplementary information.

Pulmonary Hypertension in Patients with End Stage Renal Disease on Maintenance Hemodialysis-A Cross-sectional Study.

BACKGROUND: Pulmonary Hypertension (PH) in End Stage Renal Disease (ESRD) on Maintenance Hemodialysis (HD) portends a poor outcome in patients undergoing dialysis. METHODS: 50 patients with ESRD undergoing regular hemodialysis for at least 3 months were included. Biochemical parameters- hemoglobin, urea, creatinine, albumin, calcium, phosphorus and PTH assessed post dialysis. All patients underwent 2D echocardiography one hour after dialysis to avoid overestimation of pulmonary artery pressures. Measurement of various parameters was carried out including right atrial and ventricular dimensions, tricuspid annular plane systolic excursion, flow across tricuspid and pulmonary valves and tissue doppler imaging of the annular plane. PH was defined as mean right ventricular systolic pressure ≥25 mmHg. Variables were compared between two groups- subjects with PH and Non-PH. RESULTS: Seventeen patients were detected to have PH. All baseline biochemical parameters did not show significant difference between two groups. On ECHO, right atrial and ventricular enlargement and pulmonary vascular resistance were significantly higher in PH group. LA vol index greater than 34ml/m2 was detected in 94.1% patients with PH as opposed to 51.5% in non PH. LVEDP was detected to be significantly higher in PH compared to Non PH (p=0.001; 94.1% vs 39.4%). Mean values of ejection fractions were also significantly different. CONCLUSION: This study suggests that up to one third of ESRD patients on HD develop PH. Echocardiography findings reveal a significant association between raised LVEDP and increased pulmonary artery pressures. Thus, volume overload and diastolic dysfunction (heart failure with preserved ejection fraction) appear to be the main contributors to development of PH.