Retrospective analysis of nontraumatic subdural hematoma incidence and outcomes in Egyptian patients with end-stage renal disease on hemodialysis.

BACKGROUND: The incidence of subdural hematoma (SDH) in chronic maintenance hemodialysis (CMH) patients may change over time, along with the evolving characteristics of the underlying populations. METHODS: We conducted a retrospective, single-center study at Cairo University hospitals, assessing the incidence, associated risk factors, and outcomes of nontraumatic SDH in CMH patients between January 2006 and January 2019. RESULTS: Out of 1217 CMH patients, nontraumatic SDH was diagnosed in 41 (3.37%) during the study, increasing with the enrollees' age but stable over the observation period and translating into an annual incidence rate of 28 per 1000 patients per year. SDH patients were likely to use central venous catheters, reported pruritis and history of bone fractures, and had higher phosphorus, parathyroid hormone, and alkaline phosphatase values (p < 0.001); however, there was no association with atrial fibrillation or use of anticoagulants. In the SDH cohort (n = 41), six patients did not need surgical intervention and 13 patients died before becoming surgically fit for intervention; mortality correlated with ischemic heart disease (p = 0.033) and the presence of atrial fibrillation or chronic anticoagulation with warfarin (p < 0.0001 for both), among others. Twenty-two patients received surgical operations and of these 2 died postoperatively; overall patient mortality was 12/41 (29.27%) at 30 days and 15/41 (36.59%) at 1 year. CONCLUSION: Our study demonstrated a striking enrichment for underlying comorbidities in those patients developing SDH and a high risk of immediate mortality. The benefit of chronic anticoagulation therapy should be carefully weighed against the risk of CNS bleed in MHD patients.

Benefits, challenges, and opportunities using home hemodialysis with a focus on Mississippi, a rural southern state.

The prevalence of end-stage renal disease continues to increase in the United States with commensurate need for renal replacement therapies. Hemodialysis continues to be the predominant modality, though less than 2% of these patients will receive hemodialysis in their own home. While home modalities utilizing peritoneal dialysis have been growing, home hemodialysis (HHD) remains underutilized despite studies showing regression in left ventricular mass, improved quality of life, reduced depressive symptoms, and decreased postdialysis recovery time. To increase penetration of HHD will require a proactive approach from both physicians and dialysis networks to address barriers both in the system and on the level of the patients and families. We are reviewing these issues with a focus on the state of Mississippi.

Aminoglycoside impregnated cement spacer precipitating acute kidney injury requiring hemodialysis.

The current standard of care for prosthetic joint infection includes two-stage arthroplasty, with antibiotic-impregnated cement spacers (ACS) utilized between the stages. We report a 75-year-old woman with previously normal renal function, who developed acute kidney injury (AKI) secondary to biopsy-proven acute tubular necrosis and acute interstitial nephritis after ACS placement containing tobramycin and vancomycin. Peak tobramycin level measured 25.3 mcg/mL, the highest value reported in the literature after ACS placement. Intermittent hemodialysis was initiated with subsequent full recovery of renal function. This paper reviews the published literature regarding the accumulation, toxicity and removal dynamics of aminoglycoside (AG) antibiotics and vancomycin in renal patients. Obtaining serum AG level should be strongly considered in patients experiencing AKI after ACS. Renal replacement therapy may assist in reducing toxic AG levels.

Baclofen-induced neurotoxicity in patients with compromised renal function: Review.

Baclofen is a centrally-acting γ-amino butyric acid agonist used mainly in the symptomatic management of spasticity originating from the spinal cord. It is absorbed completely from the gastrointestinal tract, metabolized by the liver to a minor degree, and excreted unchanged by the kidneys. Baclofen is moderately lipophilic and can cross the blood-brain barrier easily. At the usual dosage, it acts mainly at the spinal level without central nervous system (CNS) side effects. During renal failure, however, the elimination of the drug will decrease with a prolonged half-life, resulting in a larger area-under-the-curve exposure and disproportionate CNS toxicity. Clinically, these patients with renal failure may present with a variety of toxic symptoms manifesting at therapeutic/sub-therapeutic doses of baclofen. In cases of unexplained mental status changes in a patient receiving baclofen therapy, a careful assessment of renal function and a high suspicion of baclofen-induced encephalopathy will be key to the diagnosis.
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Upward trend of dapsone-induced methemoglobinemia in renal transplant community
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Dapsone, a sulfone antibiotic, is used for prophylaxis of Pneumocystis jirovecii pneumonia in patients with documented sulfa allergy. Acquired methemoglobinemia caused by dapsone is not uncommon in patients with normal glucose-6-phosphate dehydrogenase (G6PD) levels. Discrepancy between oxygen saturation measured by pulse oximetry and arterial oxygen saturation (SpO2) readings, a phenomenon known as "saturation gap," is noted with cases of methemoglobinemia. Although its prevalence in renal transplant patients is poorly described, there is evidence that its incidence is increasing. Here we describe a case series of 4 patients who were switched from trimethoprim-sulfamethoxazole (TMP-SMX) to dapsone and subsequently developed methemoglobinemia. Symptoms occur at varying methemoglobin levels and are more severe in patients with pre-existing coronary disease or chronic lung disease. Early recognition and cessation of dapsone is imperative, especially in renal transplant.
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Successful Peritoneal Dialysis in Large-Weight Subjects: Clinical Features and Comparisons with Normal-Weight Subjects.

Peritoneal dialysis (PD) obviates the need for temporary vascular access in end-stage renal disease; however, extremely heavy weight has been viewed as a relative contraindication to PD.We performed a cross-sectional review of multiple clinical and laboratory variables for 75 current or past PD patients (vintage > 6 months), comparing dialysis adequacy parameters for those with a large body weight (>100 kg, LWS group) and with a normal body weight (<75 kg, NWS group).In the LWS group (n = 17), mean weight was 117.2 ± 15.7 kg, and mean body mass index (BMI) was 37.2 ± 6.3 kg/m2; in the NWS group (n = 33), mean weight was 63.2 ± 9.2 kg, and mean BMI was 25.3 ± 4.5 kg/m2. Despite the marked differences in weight and BMI between the groups (both p < 0.0001), achieved Kt/V was adequate, although marginally less, in large subjects (1.96 ± 0.29 for the LWS group vs. 2.22 ± 0.47 for the NWS group, p = 0.022), and weekly global creatinine clearance was significantly better in the LWS group (92.5 ± 43.5 L/1.73 m2 vs. 62.2 ± 27.5 L/1.73 m2, p = 0.016). The total daily exchange volume was approximately 30% higher in the LWS group (12.8 ± 2.5 L vs. 9.9 ± 2.2 L, p < 0.0001). Residual creatinine clearance (p = 0.224) and residual urine output (p = 0.125) were similar and did not seem to influence the results. Compared with their LWS counterparts, members of the NWS group were more likely to have higher iron saturation (p = 0.053) and serum ferritin (p = 0.004), but lower achieved hemoglobin (p = 0.055).Successful PD is feasible in larger-weight individuals; however, given the retrospective nature of the present study, prospective trials are needed to confirm that observation.

Clinical Characteristics and Predictors of Mortality in Obese African-Americans with COVID-19: a Single-Center Retrospective Study.

BACKGROUND: This study aims to add to the body of evidence linking obesity as an established risk factor for COVID-19 infection and also look at predictors of mortality for COVID-19 in the African-Americans (AA) population. METHODS: A retrospective cohort study of patients with confirmed COVID-19 infection was done in a community hospital in New York City. The cohort was divided into two groups, with the non-obese group having a BMI < 30 kg/m2 and the obese group with a BMI ≥ 30 kg/m2. Clinical predictors of mortality were assessed using multivariate regression analysis. RESULTS: Among the 469 (AA) patients included in the study, 56.3% (n = 264) had a BMI < 30 kg/m2 and 43.7% (n = 205) had a BMI ≥ 30 kg/m2. Most common comorbidities were hypertension (n = 304, 64.8%), diabetes (n = 200, 42.6%), and dyslipidemia (n = 74, 15.8%). Cough, fever/chills, and shortness of breath had a higher percentage of occurring in the obese group (67.8 vs. 55.7%, p = 0.008; 58.0 vs. 46.2%, p = 0.011; 72.2 vs. 59.8%, p = 0.005, respectively). In-hospital mortality (41.5 vs. 25.4%, p < 0.001) and mechanical ventilation rates (34.6 vs. 22.7%, p = 0.004) were also greater for the obese group. Advanced age (p = 0.034), elevated sodium levels (p = 0.04), and elevated levels of AST (0.012) were associated with an increase in likelihood of in-hospital mortality in obese group. CONCLUSIONS: Our results show that having a BMI that is ≥ 30 kg/m2 is a significant risk factor in COVID-19 morbidity and mortality. These results highlight the need for caution when managing obese individuals.

Estimated Glomerular Filtration Rate in Chronic Kidney Disease: A Critical Review of Estimate-Based Predictions of Individual Outcomes in Kidney Disease.

Chronic kidney disease (CKD) is generally regarded as a final common pathway of several renal diseases, often leading to end-stage kidney disease (ESKD) and a need for renal replacement therapy. Estimated GFR (eGFR) has been used to predict this outcome recognizing its robust association with renal disease progression and the eventual need for dialysis in large, mainly cross-sectional epidemiological studies. However, GFR is implicitly limited as follows: (1) GFR reflects only one of the many physiological functions of the kidney; (2) it is dependent on several non-renal factors; (3) it has intrinsic variability that is a function of dietary intake, fluid and cardiovascular status, and blood pressure especially with impaired autoregulation or medication use; (4) it has been shown to change with age with a unique non-linear pattern; and (5) eGFR may not correlate with GFR in certain conditions and disease states. Yet, many clinicians, especially our non-nephrologist colleagues, tend to regard eGFR obtained from a simple laboratory test as both a valid reflection of renal function and a reliable diagnostic tool in establishing the diagnosis of CKD. What is the validity of these beliefs? This review will critically reassess the limitations of such single-focused attention, with a particular focus on inter-individual variability. What does science actually tell us about the usefulness of eGFR in diagnosing CKD?

Rhabdomyolysis among hospitalized patients for salicylate intoxication in the United States: Nationwide inpatient sample 2003-2014.

INTRODUCTION: This study aimed to assess the risk factors and impact of rhabdomyolysis on treatments, outcomes, and resource utilization in hospitalized patients for salicylate intoxication in the United States. MATERIALS AND METHODS: The National Inpatient Sample was utilized to identify hospitalized patients with a primary diagnosis of salicylate intoxication from 2003-2014. Rhabdomyolysis was identified using hospital diagnosis code. We compared the clinical characteristics, in-hospital treatment, outcomes, and resource utilization between patients with and without rhabdomyolysis. RESULTS: A total of 13,805 hospital admissions for salicylate intoxication were studied. Of these, rhabdomyolysis developed in 258 (1.9%) admissions. The risk factors for rhabdomyolysis were age>20 years, male sex, volume depletion, hypokalemia, sepsis, and seizure. After adjustment for baseline clinical characteristics, salicylate intoxication patients with rhabdomyolysis required more invasive mechanical ventilation, and renal replacement therapy. Rhabdomyolysis was significantly associated with higher risk of failure of any organ systems, and in-hospital mortality. Length of hospital stay and hospitalization cost were higher when rhabdomyolysis occurred during hospital stay. CONCLUSIONS: Rhabdomyolysis was not common in hospitalized patients for salicylate intoxication but it was associated with increased morbidity, mortality, and resource utilization.

Use and outcomes of kidneys from donors with renal angiomyolipoma: A systematic review.

BACKGROUND: Renal angiomyolipoma (AML) is the most frequent mesenchymal tumor of the kidney. Although there is a rare possibility of malignant transformation of AML, this risk has not been studied in immunosuppressed patients. The safety of donors with AML and their kidney transplant recipients has not been well established. METHODS: A literature search was conducted utilizing MEDLINE, EMBASE, and Cochrane databases from inception through May 15, 2018 (updated on October 2019). We included studies that reported the outcomes of kidney donors with AML or recipients of donor with AML. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095157). RESULTS: Fourteen studies with a total of 16 donors with AML were identified. None of the donors had a diagnosis of tuberous sclerosis complex (TSC), pulmonary lymphangioleiomyomatosis (LAM), or epithelioid variant of AML. Donor age ranged from 35 to 77 years, and recipient age ranged from 27 to 62 years. Ninety-two percent of the donors were female. Only 8% were deceased donor renal transplant. The majority underwent ex vivo resection (65%) before transplantation, followed by no resection (18%), and the remaining had in vivo resection. Tumor size varied from 0.4 cm to 7 cm, and the majority (87%) were localized in the right kidney. Follow-up time ranged from 1 to 107 months. Donor creatinine prenephrectomy ranged 0.89-1.1 mg/dL and postnephrectomy creatinine 1.0-1.17 mg/dL. In those who did not have resection of the AML, tumor size remained stable. None of the donors with AML had end-stage renal disease or died at last follow-up. None of the recipients had malignant transformation of AML. CONCLUSION: These findings are reassuring for the safety of donors with AML (without TSC or LAM) as well as their recipients without evidence of malignant transformation of AML. As such, this can also positively impact the donor pool by increasing the number of available kidneys.

The impact of race on hospitalization outcomes for goodpasture's syndrome in the United States: nationwide inpatient sample 2003-2014.

BACKGROUND: Goodpasture's syndrome is a rare and life-threatening autoimmune disease. While Goodpasture's syndrome is well described in Caucasian and Asian populations, its prevalence and outcomes among African American and Hispanic populations are unclear. We conducted this study to assess the impacts of race on hospital outcomes among patients with Goodpasture's syndrome. METHODS: The National Inpatient Sample database was used to identify hospitalized patients with a principal diagnosis of Goodpasture's syndrome from 2003 to 2014. Goodpasture's syndrome patients were grouped based on their race. The differences in-hospital supportive care for organ failure and outcomes between Caucasian, African American, and Hispanic Goodpasture's syndrome patients were assessed using logistic regression analysis. RESULTS: Nine hundred and sixty-four patients were hospitalized with a primary diagnosis of Goodpasture's syndrome. Of these, 786 were included in the analysis: 622 (79%) were Caucasian, 73 (9%) were African American, and 91 (12%) were Hispanic. Hispanics had significantly lower use of plasmapheresis. The use for mechanical ventilation, noninvasive ventilation support, and renal replacement therapy in African Americans and Hispanics were comparable to Caucasians. There was no significant difference in organ failure, sepsis, and in-hospital mortality between African Americans and Caucasians. In contrast, Hispanics had higher in-hospital mortality than Caucasians but similar risk of organ failure and sepsis. CONCLUSION: African American and Hispanic populations account for 9% and 12% of hospitalizations for Goodpasture's syndrome, respectively. While there is no significant difference in in-hospital mortality between African Americans and Caucasians, Hispanics with Goodpasture's syndrome carry a higher in-hospital mortality compared to Caucasians.

Comprehensive review of mask utility and challenges during the COVID-19 pandemic.

Masks are widely discussed during the course of the ongoing COVID-19 pandemic. Most hospitals have implemented universal masking for their healthcare workers, and the Center for Disease Control currently advises even the general public to wear cloth masks when outdoors. The pertinent need for masks arises from plausible dissemination of the SARS-CoV-2 through close contacts, as well as the possibility of virus transmission from asymptomatic, pre-symptomatic, and mildly symptomatic individuals. Given current global shortages in personal protective equipment, the efficacy of various types of masks: N95 respirators, surgical masks, and cloth masks are researched. To accommodate limited supplies, techniques for extended use, reuse, and sterilization of masks are strategized. However, masks alone may not greatly slow down the COVID-19 pandemic unless they are coupled with adequate social distancing, diligent hand hygiene, and other proven preventive measures.

COVID-19 disparity among racial and ethnic minorities in the US: A cross sectional analysis.

AIM: To analyze racial disparities in Coronavirus disease (COVID-19) cases in the United States of America and discuss possible reasons behind this inequality. SUBJECT AND METHODS: We obtained estimated case counts of African-American, Caucasian, Native American, Asian and Hispanic individuals with coronavirus disease (COVID-19)infection through May 5, 2020, from publicly available data on state departments of health websites. We calculated race-specific fractions as the percentage of the total population and analyzed the reasons behind this disparity. RESULTS: The incident rates of COVID-19 were higher among African Americans and among Latinos disproportionately higher than their representation in 14 states and 9 states, respectively. A similar observation was also reported for New York city. The percentage of deaths reported among African Americans was disproportionately higher than their represented share in the population in 23 out of 35 states. It was reported that 22.4% of COVID-19 deaths in the USA were African American, even though black people make up 13.4% of the USA population. CONCLUSIONS: The analysis shows the disparity of coronavirus disease outcomes by ethnicity and race. Additional research is needed to determine the factors behind this inequality.

Serum Klotho in Living Kidney Donors and Kidney Transplant Recipients: A Meta-Analysis.

α-Klotho is a known anti-aging protein that exerts diverse physiological effects, including phosphate homeostasis. Klotho expression occurs predominantly in the kidney and is significantly decreased in patients with chronic kidney disease. However, changes in serum klotho levels and impacts of klotho on outcomes among kidney transplant (KTx) recipients and kidney donors remain unclear. A literature search was conducted using MEDLINE, EMBASE, and Cochrane Database from inception through October 2019 to identify studies evaluating serum klotho levels and impacts of klotho on outcomes among KTx recipients and kidney donors. Study results were pooled and analyzed utilizing a random-effects model. Ten cohort studies with a total of 431 KTx recipients and 5 cohort studies with a total of 108 living kidney donors and were identified. After KTx, recipients had a significant increase in serum klotho levels (at 4 to 13 months post-KTx) with a mean difference (MD) of 243.11 pg/mL (three studies; 95% CI 67.41 to 418.81 pg/mL). Although KTx recipients had a lower serum klotho level with a MD of = -234.50 pg/mL (five studies; 95% CI -444.84 to -24.16 pg/mL) compared to healthy unmatched volunteers, one study demonstrated comparable klotho levels between KTx recipients and eGFR-matched controls. Among kidney donors, there was a significant decrease in serum klotho levels post-nephrectomy (day 3 to day 5) with a mean difference (MD) of -232.24 pg/mL (three studies; 95% CI -299.41 to -165.07 pg/mL). At one year following kidney donation, serum klotho levels remained lower than baseline before nephrectomy with a MD of = -110.80 pg/mL (two studies; 95% CI 166.35 to 55.24 pg/mL). Compared to healthy volunteers, living kidney donors had lower serum klotho levels with a MD of = -92.41 pg/mL (two studies; 95% CI -180.53 to -4.29 pg/mL). There is a significant reduction in serum klotho levels after living kidney donation and an increase in serum klotho levels after KTx. Future prospective studies are needed to assess the impact of changes in klotho on clinical outcomes in KTx recipients and living kidney donors.

Degree of Glomerulosclerosis in Procurement Kidney Biopsies from Marginal Donor Kidneys and Their Implications in Predicting Graft Outcomes.

Background: This study aimed to assess the association between the percentage of glomerulosclerosis (GS) in procurement allograft biopsies from high-risk deceased donor and graft outcomes in kidney transplant recipients. Methods: The UNOS database was used to identify deceased-donor kidneys with a kidney donor profile index (KDPI) score > 85% from 2005 to 2014. Deceased donor kidneys were categorized based on the percentage of GS: 0-10%, 11-20%, >20% and no biopsy performed. The outcome included death-censored graft survival, patient survival, rate of delayed graft function, and 1-year acute rejection. Results: Of 22,006 kidneys, 91.2% were biopsied showing 0-10% GS (58.0%), 11-20% GS (13.5%), >20% GS (19.7%); 8.8% were not biopsied. The rate of kidney discard was 48.5%; 33.6% in 0-10% GS, 68.9% in 11-20% GS, and 77.4% in >20% GS. 49.8% of kidneys were discarded in those that were not biopsied. Death-censored graft survival at 5 years was 75.8% for 0-10% GS, 70.9% for >10% GS, and 74.8% for the no biopsy group. Among kidneys with >10% GS, there was no significant difference in death-censored graft survival between 11-20% GS and >20% GS. Recipients with >10% GS had an increased risk of graft failure (HR = 1.27, p < 0.001), compared with 0-10% GS. There was no significant difference in patient survival, acute rejection at 1-year, and delayed graft function between 0% and 10% GS and >10% GS. Conclusion: In >85% KDPI kidneys, our study suggested that discard rates increased with higher percentages of GS, and GS >10% is an independent prognostic factor for graft failure. Due to organ shortage, future studies are needed to identify strategies to use these marginal kidneys safely and improve outcomes.

The Use of Donor-Derived Cell-Free DNA for Assessment of Allograft Rejection and Injury Status.

Patient monitoring after kidney transplantation (KT) for early detection of allograft rejection remains key in preventing allograft loss. Serum creatinine has poor predictive value to detect ongoing active rejection as its increase is not sensitive, nor specific for acute renal allograft rejection. Diagnosis of acute rejection requires allograft biopsy and histological assessment, which can be logistically challenging in some cases and carries inherent risk for complications related to procedure. Donor-derived cell-free DNA (dd-cfDNA), DNA of donor origin in the blood of KT recipient arising from cells undergoing injury and death, has been examined as a potential surrogate marker for allograft rejection. A rise in dd-cfDNA levels precedes changes in serum creatinine allows early detections and use as a screening tool for allograft rejection. In addition, when used in conjunction with donor-specific antibodies (DSA), it increases the pre-biopsy probability of antibody-mediated rejection (ABMR) aiding the decision-making process. Advancements in noninvasive biomarker assays such as dd-cfDNA may offer the opportunity to improve and expand the spectrum of available diagnostic tools to monitor and detect risk for rejection and positively impact outcomes for KT recipients. In this this article, we discussed the evolution of dd-cfDNA assays and recent evidence of assessment of allograft rejection and injury status of KT by the use of dd-cfDNA.

Impact of hospitalists on the efficiency of inpatient care and patient satisfaction: a systematic review and meta-analysis.

Background: Over the past 20 years, hospitalists have assumed a greater portion of healthcare service for hospitalized patients. This was mainly due to reducing the length of stay (LOS) and hospital costs shown by many studies. In contrast, other studies suggested increased cost and resources utilization associated with hospitalist-run care models. Aim: We aimed to provide class 1 evidence regarding the effect of hospitalist-run care models on the efficiency of care and patient satisfaction. Design: Meta-analysis. Methods: Four electronic medical databases were searched to retrieve all relevant studies. Two authors screened titles and abstracts of search results for eligibility according to predefined criteria. Initially eligible studies were screened for full text inclusion. Included studies were reviewed for data on LOS, hospital cost, readmission, mortality, and patient satisfaction. Available data were abstracted and analyzed using Comprehensive Meta-Analysis. Results: Sixty-one studies were included for analysis. The overall effect size favored hospitalist-run care models in terms of LOS (MD = -0.67 day, 95% CI [-0.78, -0.56], p < 0.001). There was no significant difference in terms of hospital cost (MD = $92.1, 95% CI [-910.4, 1094.6], p = 0.86) whereas patient satisfaction was similar or even better in hospitalist compared to non-hospitalist (NH) service. Conclusion: Our analysis showed that hospitalist care is associated with decreased LOS and increased patient satisfaction compared to NH. This indicates an increase in the efficiency of care that does not come at the expense of care quality.

Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis.

BACKGROUND: Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. METHODS: Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. RESULTS: All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). CONCLUSION: High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.

Acute Kidney Injury in Pediatric Patients on Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-analysis.

Background: Acute kidney injury (AKI) is a well-established complication of extra-corporal membrane oxygenation (ECMO) in the adult population. The data in the pediatric and neonatal population is still limited. Moreover, the mortality risk of AKI among pediatric patients requiring ECMO remains unclear. Thus, this meta-analysis aims to assess the incidence of AKI, AKI requiring renal replacement therapy and AKI associated mortality in pediatric/neonatal patients requiring ECMO. Methods: A literature search was performed utilizing MEDLINE, EMBASE, and the Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring renal replacement therapy (RRT) and the risk of mortality among pediatric patients on ECMO with AKI. Random-effects meta-analysis was used to calculate the pooled incidence of AKI and the odds ratios (OR) for mortality. Results: 13 studies with 3523 pediatric patients on ECMO were identified. Pooled incidence of AKI and AKI requiring RRT were 61.9% (95% confidence interval (CI): 39.0-80.4%) and 40.9% (95%CI: 31.2-51.4%), respectively. A meta-analysis limited to studies with standard AKI definitions showed a pooled estimated AKI incidence of 69.2% (95%CI: 59.7-77.3%). Compared with patients without AKI, those with AKI and AKI requiring RRT while on ECMO were associated with increased hospital mortality ORs of 1.70 (95% CI, 1.38-2.10) and 3.64 (95% CI: 2.02-6.55), respectively. Conclusions: The estimated incidence of AKI and severe AKI requiring RRT in pediatric patients receiving ECMO are high at 61.9% and 40.9%, respectively. AKI among pediatric patients on ECMO is significantly associated with reduced patient survival.