A Prospective Study of the Effect of Gastroduodenal Artery Reconstruction on Duodenal Oxygenation and Enzyme Content After Pancreas Transplantation.

BACKGROUND: Whole pancreas transplantation provides durable glycemic control and can improve survival rate; however, it can carry an increased risk of surgical complications. One devastating complication is a duodenal leak at the site of enteroenteric anastomosis. The gastroduodenal artery (GDA) supplies blood to the donor duodenum and pancreas but is commonly ligated during procurement. Since we have not had expressive changes in pancreatic back table surgical techniques in the recent decades, we hypothesized whether back table GDA reconstruction, improving perfusion of the donor duodenum and head of the pancreas, could lead to fewer surgical complications in simultaneous pancreas-kidney (SPK) transplants. MATERIAL AND METHODS: Between 2017 and 2021, we evaluated demographic information, postoperative complications, intraoperative donor duodenum, recipient bowel O2 tissue saturation, and patient morbidity through the Comprehensive Complication Index (CCI®). RESULTS: A total of 26 patients were included: 13 underwent GDA reconstruction (GDA-R), and 13 had GDA ligation (GDA-L). There were no pancreatic leaks in the GR group compared to 38% (5/13) in the GDA-L group (p = 0.03913). Intraoperative tissue oxygen saturation was higher in the GDA-R group than in the GDA-L (95.18 vs.76.88%, p < 0,001). We observed an increase in transfusion rate in GDA-R (p < 0.05), which did not result in a higher rate of exploration (p = 0.38). CCI® patient morbidity was also significantly lower in the GDA-R group (s < 0.05). CONCLUSIONS: This study identified improved intraoperative duodenal tissue oxygen saturation in the GDA-R group with an associated reduction in pancreatic leaks and CCI® morbidity risk. A larger prospective multicenter study comparing the two methods is warranted.

Chronic stress physically spares but functionally impairs innate-like invariant T cells.

The deleterious effects of psychological stress on mainstream T lymphocytes are well documented. However, how stress impacts innate-like T cells is unclear. We report that long-term stress surprisingly abrogates both T helper 1 (TH1)- and TH2-type responses orchestrated by invariant natural killer T (iNKT) cells. This is not due to iNKT cell death because these cells are unusually refractory to stress-inflicted apoptosis. Activated iNKT cells in stressed mice exhibit a "split" inflammatory signature and trigger sudden serum interleukin-10 (IL-10), IL-23, and IL-27 spikes. iNKT cell dysregulation is mediated by cell-autonomous glucocorticoid receptor signaling and corrected upon habituation to predictable stressors. Importantly, under stress, iNKT cells fail to potentiate cytotoxicity against lymphoma or to reduce the burden of metastatic melanoma. Finally, stress physically spares mouse mucosa-associated invariant T (MAIT) cells but hinders their TH1-/TH2-type responses. The above findings are corroborated in human peripheral blood and hepatic iNKT/MAIT cell cultures. Our work uncovers a mechanism of stress-induced immunosuppression.

Autoantibodies to LG3 are associated with poor long-term survival after liver retransplantation.

Autoantibodies are detrimental to the survival of organ transplantation. We demonstrated that Angiotensin II Type I Receptor agonistic autoantibodies (AT1R-AA) were associated with poor outcomes after liver retransplantation. To examine the effect of other autoantibodies, we studied a retrospective cohort of 93 patients who received a second liver transplant. Pre-retransplant sera were tested with Luminex-based solid-phase assays. Among 33 tested autoantibodies, 15 were significantly higher in 48 patients who lost their regrafts than 45 patients whose regrafts were still functioning. Specifically, patients with autoantibodies to the C-terminal laminin-like globular domain of Perlecan (LG3) experienced significantly worse regraft survival (p = .002) than those with negative LG3 autoantibodies (LG3-A). In multivariate analysis, LG3-A (HR = 2.35 [1.11-4.98], p = .027) and AT1R-AA (HR = 2.09 [1.07-4.10], p = .032) remained significant predictors of regraft loss after adjusting for recipient age and sex. There were synergistic deleterious effects on regraft survival in patients who were double-positive for LG3-A and donor-specific antibody (DSA) (HR = 5.26 [2.15-12.88], p = .001), or LG3-A and AT1R-AA (HR = 3.23 [1.37-7.66], p = .008). All six double-positive patients lost their liver regrafts. In conclusion, LG3-A is associated with inferior long-term outcomes of a second liver transplant. Screening anti-HLA antibodies and autoantibodies such as LG3-A/AT1R-AA identifies patients with a higher risk for liver transplantation.

Elevated C-peptide Levels Are Associated With Acute Rejection in Kidney Pancreas Transplantation.

BACKGROUND: We assessed whether allograft rejection or failure can be predicted by an acute increase in C-peptide production from the transplanted pancreas. METHODS: Patients with a minimum of 5 years of follow-up post simultaneous pancreas-kidney transplant were identified. C-peptide levels were obtained during clinic visits routinely. Graft failure was defined as return to dependence on insulin therapy or return to dialysis for pancreas and kidney grafts, respectively. Protocol kidney allograft biopsies were performed at 3 and 12 months. For-cause biopsies were also performed. RESULTS: Acute rejections were detected in 11 patients on biopsy results of the renal allograft. C-peptide levels drawn prior to documented rejections were significantly higher in patients with acute rejection than patients with borderline or no rejection (P = .006). Receiver operating characteristics curves for C-peptide indicated greater accuracy in predicting rejection than simultaneously drawn serum creatinine or lipase. CONCLUSIONS: Higher C-peptide levels in simultaneous pancreas-kidney recipients is associated with acute rejection vs nonrejection.

Angiotensin II type I receptor agonistic autoantibodies are associated with poor allograft survival in liver retransplantation.

Angiotensin II type I receptor (AT1R) agonistic autoantibodies (AT1R-AA) are detrimental to kidney transplantation. Early studies suggested a similar negative effect in primary liver transplantation. Here, we studied AT1R-AA in a retrospective cohort of 94 patients who received a second liver transplant to determine their prevalence and effects. The concentrations of preformed AT1R-AA before transplantation were higher (P = .019) in the 48 patients who lost their liver grafts than in the 46 patients whose grafts survived. About half (48/94, 51.1%) of the patients were positive for AT1R-AA >17 U/mL before the second liver transplantation. In 22 (23.4%) patients, strong positive AT1R-AA (defined as >40 U/mL) were detected, of whom 16 (72.7%) patients lost their grafts. Based on Kaplan-Meier analysis, patients with strong positive AT1R-AA had significantly worse graft survival than those with AT1R-AA <40 U/mL (P = .035). In multivariate Cox models that included confounders such as sex and age, either AT1R-AA >40 U/mL (HR = 1.999 [1.085-3.682], P = .026) or increased concentrations of AT1R-AA (HR = 1.003 [1.001-1.006] per incremental U/mL, P = .019) were significantly associated with elevated risk for graft loss. In conclusion, our data indicate that there is a high prevalence of AT1R-AA in candidates for second liver transplantation and that their presence is associated with inferior long-term outcomes of the second graft.

The impact of alloantibodies directed against the second donor on long-term outcomes of repeat liver transplantation.

BACKGROUND: Despite reports that associate donor specific antibody (DSA) with rejection after liver transplantation, grafts are still allocated according to blood group (ABO) but not human leukocyte antigen (HLA) compatibility, possibly due to the absence of an easily discernible clinical association between adverse recipient outcome and DSA. Re-transplantation provides a test environment where the presence of preformed DSA is prevalent and its effect on outcome should be apparent. METHODS: All patients undergoing a second liver transplantation with available pre-operative serum were included with the exception of ABO incompatible or multiple organ transplants. Banked sera were tested for anti-HLA antibodies with Luminex-based solid phase assays. Anti-HLA antibodies to the second donor (D2SA) were determined using antibodies specificity and HLA typing of 2nd liver donor. RESULTS: Preformed HLA antibodies directed to second liver transplantation (D2SA) were found in 31 (39%) of the 79 patients that were included in the study. Primary and re-transplantation characteristics were similar in both subgroups except first graft survival which was significantly shorter in recipients who are negative for D2SA. Mean survival of the second graft was similar in D2SA+ and D2SA- cohorts [8.55 (range, 0.01-24.74) vs. 7.56 (range, 0-23.53) years respectively, P=0.574]. Mean patient survival after 2nd liver transplantation was similar in D2SA+ and D2SA- cohorts [9.11 (range, 0.01-24.74) vs. 8.10 (range, 0-23.53) years respectively, P=0.504]. Subgroup univariate analysis demonstrated no detrimental effect of class, locus, or strength of D2SA on survival of the second liver transplant. In multivariate cox regression model, neither class I D2DSA (HR =1.101, P=0.92) nor class II D2SA (HR =1.74, P=0.359) were significant risks of graft failure. CONCLUSIONS: Presence of D2SA was not found to be associated with inferior outcomes in this retrospective cohort study of liver re-transplantation suggesting that changes to the allocation system are not required.

Anti-donor immunoglobulin G subclass in liver transplantation.

Immunoglobulin G (IgG) subclasses in human health and immunity have only be sporadically studied in the half century since their discovery. Different patterns of IgG subclass production are seen if the immune response is deviated towards type 1 versus type 2. The current state of our knowledge of IgG subclasses in liver transplantation is reviewed here. While several studies have been conducted in liver disease, only four relatively small studies have been undertaken in liver transplant recipients. Total IgG4 elevation in serum is related to sclerosing pancreatico-cholangiopathy that is sensitive to treatment with steroids. Conventional immunosuppressive regimes, especially with a combination of tacrolimus and sirolimus, reduce the production of all IgG subclasses after transplantation but it is not known if they deviate the immune response. Presence of anti-donor IgG3 before transplantation, or its expansion after transplantation, has been associated with rejection and liver graft loss. Anti-GSTT1 IgG4 production after transplantation is associated with de-novo immune hepatitis. Greater knowledge of anti-donor IgG subclass responses after transplantation will allow us tailor novel treatments for greater effect.

The effectiveness of junctional tourniquets: A systematic review and meta-analysis.

BACKGROUND: Junctional tourniquets have been incorporated into tactical combat casualty care for junctional vascular trauma. They apply external compression to stop blood flow in the groin and axilla. OBJECTIVES: The primary outcome was effectiveness in achieving arterial occlusion. Secondary outcomes included time to application and pain scores. DATA SOURCES: Medline and EMBASE databases were searched. STUDY APPRAISAL AND SYNTHESIS METHODS: A random-effects meta-analysis was conducted to estimate the average effectiveness and time to effective application for each device. RESULTS: Eight studies reported the effectiveness of junctional tourniquets in healthy volunteers. The average effectiveness was 52% (95% confidence interval [CI], 15-87%) for the abdominal application of the abdominal aortic and junctional tourniquet (AAJT), 83% (95% CI, 73-89%; 26%) for the junctional Emergency Treatment Tool, 87% (95% CI, 79-92%; 15%) for the SAM junctional tourniquet (SJT), and 95% (95% CI, 90-98%) for the Combat Ready Clamp. The groin application of the AAJT was studied in two articles with 100% in both studies. The average time to application was 101 seconds for the SAM junctional tourniquet (95% CI, 50-152 seconds) and the Combat Ready Clamp (95% CI, 63-139 seconds), while it was 130 seconds (95% CI, 85-176 seconds) for the Junctional Emergency Treatment Tool. The abdominal application of AAJT had an average time to application of 92 and 171 seconds in two studies. LIMITATIONS: All studies were conducted in healthy volunteers. CONCLUSION AND IMPLICATIONS: Junctional tourniquets may meet a medical need in combat, and in the civilian environment, to control hemorrhage from these difficult injuries. All four Food and Drug Administration-approved devices demonstrate the ability to achieve vascular occlusion in healthy volunteers; however, effectiveness in patient transport has not been evaluated, and outcomes of their use in the field need to be captured and reported. LEVEL OF EVIDENCE: Systematic review, level III.

After the war is over: the role of General Sir Arthur Currie in the development of academic medicine in Canada

Summary: Canadian universities faced a challenge with the return of a large cohort of battle-hardened students and faculty from the First World War. General Sir Arthur Currie, considered one of the few successful generals of the war, returned to a welcome of silence in Canada. McGill University exploited the opportunity to recruit him as its president. Currie oversaw a campaign of building construction and faculty development at McGill that also had a significant effect on the rest of Canada. Through his fostering of the Montreal Neurological Institute and the recruitment of Dr. Wilder Penfield, Currie facilitated the development of multidisciplinary medicine, which integrates clinical care with research ­ an aspiration still held by specialty medicine in Canada today.

Proposed specifications of a mobile operating room for far-forward surgery

Summary: Provision of initial surgery to casualties within one hour of injury is associated with better survival. Where evacuation options are limited, surgery within the "golden hour" may have to occur close to the point of injury. Interventions close to the point of injury are limited by the adverse environment. Far-forward surgery has a long history going back to Dominique Larrey of the Napoleonic Army. We reviewed previous reports and used our own experience of far-forward surgery to describe the specifications of the ideal mobile operating room that would address some of these environmental barriers.

Care of victims of suicide bombing

Summary: Suicide bombers often target crowds. This commentary discusses the additional features required in a medical response beyond conventional mass casualty care, including forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling and postexposure prophylaxis. We propose a pathway for care of victims of a suicide bomb, adapting elements from protocols for child abuse, sexual assault and needle-stick exposure.

A novel REBOA system: prototype and proof of concept

Background: Lower torso hemorrhage is a significant cause of death from injuries in combat. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to rescue patients successfully in the hospital setting, but its prehospital use is controversial. We designed a device that would be easy to use, safer in injured vessels, migration-resistant and amenable to a prehospital environment. Methods: We designed a novel, balloon-led device using common commercial materials. Thin latex rubber was reassembled in cylindrical conformation aligned to the shape of the aorta and invaginated into vinyl tubing. The catheter is placed into the femoral vessel, followed by expression of the balloon with CO2 inflation in a proximal direction to navigate and treat damaged pelvic vasculature, occluding the distal aorta. The system was tested on model aortas (both intact and injured cadaveric porcine aorta) with inline fluid flow and pressure monitoring to determine the maximum pressure the balloons could occlude. The device was also tested on a perfused human cadaveric model. Results: Flow was occluded with the balloon up to an average of 561.1 ± 124.3 mm Hg. It always ruptured before causing damage to the porcine aorta and was able to occlude injured iliac vessels and proceed to occlude the distal aorta. The device was effective in occluding the distal aorta of a perfused human cadaver. Conclusion: This novel, high-volume, low-pressure device can occlude the distal aorta in a simulated human aorta model, cadaveric porcine model and perfused human cadaver. It can occlude fluid flow to supraphysiologic pressures. It is easy to use, migration-resistant, able to navigate and treat injured pelvic vessels, and amenable to prehospital care.

Contexte: L'hémorragie au bas du corps est une importante cause de décès suite aux blessures subies au combat. L'occlusion aortique endovasculaire par ballonnet a été utilisée avec succès comme mesure de réanimation chez des patients hospitalisés, mais son utilisation dans un contexte préhospitalier est controversée. Nous avons conçu un instrument qui serait facile à utiliser, plus sécuritaire en présence de vaisseaux lésés, peu sujet à migrer et adapté au contexte préhospitalier. Méthodes: Nous avons conçu un nouvel instrument guidé par ballonnet et fabriqué à l'aide de matériaux d'usage courant. Du caoutchouc de latex mince a été façonné en cylindre pour épouser la forme de l'aorte et introduit dans un tube de vinyle. Le cathéter est ensuite inséré dans la veine fémorale, après quoi il est gonflé avec du CO2 en direction proximale pour atteindre et traiter le réseau vasculaire pelvien et créer une occlusion aortique distale. Le système a été mis à l'essai sur des aortes modèles (aortes de cadavres de porcs intactes et lésées), avec surveillance interne du débit et de la pression pour déterminer la pression maximale contre laquelle le ballonnet est capable de créer l'occlusion. L'instrument a aussi été testé sur un modèle de cadavre humain perfusé. Résultats: Le ballonnet a permis l'occlusion à une pression moyenne pouvant atteindre 561,1 ± 124,3 mm Hg. Il s'est toujours rompu avant de pouvoir endommager l'aorte porcine et a permis l'occlusion des vaisseaux iliaques lésés et ensuite de l'aorte distale. L'instrument a permis l'occlusion efficace de l'aorte distale d'un cadavre humain perfusé. Conclusion: Ce nouvel instrument à fort volume et faible pression permet de créer l'occlusion de l'aorte distale dans un modèle simulé d'aorte humaine, dans un modèle de cadavre porcin et sur un cadavre humain perfusé. Il est facile à utiliser, peu susceptible de migrer; il se déploie et traite facilement les vaisseaux pelviens lésés et convient au contexte préhospitalier.

Utilization profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability

Background: The Canadian Armed Forces deployed a Role 2 Medical Treatment Facility (R2MTF) to Iraq in November 2016 as part of Operation IMPACT. We compared the multinational interoperability required of this R2MTF with that of similar facilities previously deployed by Canada or other nations. Methods: We reviewed data (Nov. 4, 2016, to Oct. 3, 2017) from the electronic Disease and Injury Surveillance Report and the Daily Medical Situation Report. Clinical activity was stratified by Global Burden of Diseases category, ICD-10 code, mechanism of injury, services used, encounter type, nationality and blood product usage. We reviewed the literature to identify utilization profiles for other MTFs over the last 20 years. Results: In total, 1487 patients were assessed. Of these, 5.0% had battle injuries requiring damage-control resuscitation and/or damage-control surgery, with 55 casualties requiring medical evacuation after stabilization. Trauma and disease non-battle injuries accounted for 44% and 51% of patient encounters, respectively. Other than dental conditions, musculoskeletal disorders accounted for most presentations. Fifty-seven units of fresh frozen plasma and 64 units of packed red blood cells were used, and the walking blood bank was activated 7 times. Mass casualty activations involved coordination of health care and logistical resources from more than 12 countries. In addition to host nation military and civilian casualties, patients from 15 different countries were treated with similar frequency. Conclusion: The experience of the Canadian R2MTF in Iraq demonstrates the importance of multinational interoperability in providing cohesive medical care in coalition surgical facilities. Multinational interoperability derives from a unique relationship between higher medical command collaboration, international training and adherence to common standards for equipment and clinical practice.

Contexte: Les Forces armées canadiennes ont déployé une installation de traitement médical de rôle 2 (ITMR2) en Iraq en novembre 2016 dans le cadre de l'opération IMPACT. Nous avons comparé l'interopérabilité multinationale requise par cette ITMR2 à celle d'installations semblables déjà déployées par le Canada ou d'autres pays. Méthodes: Nous avons examiné les données (du 4 novembre 2016 au 3 octobre 2017) du rapport électronique de surveillance des maladies et des blessures et du rapport quotidien sur la situation médicale. L'activité clinique a été stratifiée selon la catégorie du fardeau mondial des maladies, le code de la CIM­10, le mécanisme de traumatisme, les services utilisés, le type de contact, la nationalité et l'utilisation de produits sanguins. Enfin, nous avons aussi examiné la littérature pour déterminer les profils d'utilisation d'autres ITM au cours des 20 dernières années. Résultats: Au total, 1487 patients ont été évalués. De ce nombre, 5,0 % avaient subi des blessures au combat qui nécessitaient une réanimation ou une intervention chirurgicale de contrôle des dommages, ou les deux, et 55 blessés avaient eu besoin d'évacuation médicale après stabilisation. Les traumatismes et les maladies non liées au combat représentaient respectivement 44 % et 51 % des contacts avec les patients. Outre les troubles dentaires, les troubles musculosquelettiques étaient à l'origine de la plupart des présentations. Par ailleurs, 57 unités de plasma frais congelé et 64 unités de concentré de globules rouges ont été utilisées, et la banque de sang ambulante a été activée 7 fois. La mobilisation nécessaire pour traiter un nombre massif de victimes a nécessité la coordination des soins de santé et des ressources logistiques de plus de 12 pays. En plus des victimes militaires et civiles du pays hôte, des patients de 15 pays différents ont été traités à une fréquence semblable. Conclusion: L'expérience de l'ITMR2 canadienne en Iraq démontre l'importance de l'interopérabilité multinationale quant à la prestation de soins médicaux cohérents dans les installations chirurgicales de la coalition. L'interopérabilité multinationale découle d'une relation unique s'appuyant sur la collaboration des membres du commandement médical supérieur, de la formation internationale et le respect de normes communes pour l'équipement et la médecine clinique.

Impact of traumatic upper-extremity amputation on the outcome of injury caused by an antipersonnel improvised explosive device

Background: We have previously reported a higher than expected rate of upper-extremity amputation (UEA) in victims of an antipersonnel improvised explosive device (AP-IED) compared with a similar cohort injured by antipersonnel mines (APM). The goal of this study was to describe the rate, severity and impact of UAE caused by an AP-IED. Methods: We analyzed a prospective database of 100 consecutive dismounted AP-IED victims with pattern 1 injuries to compare the outcomes of the cohort with UEA to that without. Results: We found that UEA (8 above elbow, 19 below elbow, 1 through elbow, 3 hand, 15 digit(s)) was much more prevalent with AP-IED than with APM (40% v. 6%, p < 0.001). In addition, UEA was associated with a higher rate of multiple amputations (39 [98%] v. 32 [53%], p < 0.001), bilateral lower-extremity amputation (LEA; 33 [82.5%] v. 30 [53.3%], p = 0.003) and facial injury (8 [20%] v. 4 [6.4%], p = 0.044), but not with pelvic disruption (10 [25%]), genitoperineal mutilation (19 [48%]), eye injury (6 [15%]), or skull fracture (6 [15%]). The fatality rate was higher in patients with UEA than in those without (12 [30%] v. 7 [12%], p = 0.022). Conclusion: Upper-extremity amputation is more prevalent with AP-IED than APM. Presence of UEA is associated with more severe injury and increased risk of death in AP-IED victims. Upper-limb injury has significant consequences for rehabilitation from LEA, which universally accompanies UEA in AP-IED victims. Upper-extremity injury should be amenable to prevention by innovative personal protective equipment designed to protect the flexed elbow.

Contexte: Nous avons déjà fait état d'un taux plus élevé que prévu d'amputations des membres supérieurs (AMS) chez les victimes d'engins explosifs artisanaux (EEA) comparativement à une cohorte similaire blessée par des mines antipersonnel (MAP). L'objectif de cette étude est de décrire le taux, la gravité et l'impact des AMS causées par des EEA. Méthodes: Nous avons analysé une base de données prospective de 100 victimes consécutives d'EEA alors qu'elles se trouvaient hors de leur véhicule et présentant des blessures de type 1 afin de comparer les résultats des cohortes ayant subi ou non des AMS. Résultats: Nous avons constaté que l'AMS (8 au-dessus du coude, 19 sous le coude, 1 au niveau du coude, 3 mains et 15 doigts) était beaucoup plus prévalente avec les EEA qu'avec les MAP (40 % c. 6 %, p < 0,001). De plus, l'AMS a été associée à un taux plus élevé d'amputations multiples (39 [98 %] c. 32 [53 %], p < 0,001), d'amputations bilatérales des membres inférieurs (AMI) (33 [82,5 %] c. 30 [53,3 %], p = 0,003) et de blessures au visage (8 [20 %] c. 4 [6,4 %], p = 0,044), mais non de blessures au bassin (10 [25%]), de mutilations génitopérinéales (19 [48 %]), de blessures oculaires (6 [15 %]), ou de fractures du crâne (6 [15 %]). Le taux de létalité a été plus élevé chez les patients ayant subi une AMS que chez ceux qui n'en ont pas subi (12 [30 %] c. 7 [12 %], p = 0,022). Conclusion: L'amputation des membres supérieurs est plus prévalente avec les EEA qu'avec les MAP. L'AMS est associée à des blessures plus graves et à un risque plus grand de décès chez les victimes d'un EEA. Les blessures aux membres supérieurs ont de graves conséquences sur la réadaptation nécessaire après l'AMI, qui accompagne presque toujours l'AMS chez les victimes d'un EEA. Les blessures aux membres supérieurs devraient pouvoir être évitées grâce à de l'équipement de protection individuelle novateur conçu pour protéger le coude fléchi.

Hyperkalemia and Dialysis in the Deployed Setting.

Acute kidney injury is a recognized complication of combat trauma. The complications associated with acute kidney injury, such as life-threatening hyperkalemia, are usually delayed in onset. In the recent conflicts, rapid evacuation of U.S. and coalition personnel generally resulted in these complications occurring at higher echelons of care where renal replacement therapies were available. In the future however, deployed providers may not have this luxury and should be prepared to temporize patients while they await transport. In this clinical practice guideline, recommendations are made for the management of patients with, or at risk for, acute kidney injury and hyperkalemia in the austere, deployed environment.