Anti-Tumor Necrosis Factor Therapy and Risk of Kidney Function Decline and Mortality in Inflammatory Bowel Disease.

Importance: Inflammatory bowel disease (IBD) is associated with adverse clinical outcomes, including chronic kidney disease and mortality, due in part to chronic inflammation. Little is known about the effects of anti-tumor necrosis factor (TNF) therapy on kidney disease progression and mortality among patients with new-onset IBD. Objective: To examine the association of incident use of TNF inhibitors with subsequent decline in kidney function and risk of all-cause mortality. Design, Setting, and Participants: This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants were US veterans with new-onset IBD enrolled from October 1, 2004, through September 30, 2019. Data were analyzed from December 2022 to February 2024. Exposures: Incident use of TNF inhibitors. Main Outcomes and Measures: The main outcomes were at least 30% decline in estimated glomerular filtration rate (eGFR) and all-cause mortality. Results: Among 10 689 patients (mean [SD] age, 67.4 [12.3] years; 9999 [93.5%] male) with incident IBD, 3353 (31.4%) had diabetes, the mean (SD) baseline eGFR was 77.2 (19.2) mL/min/1.73 m2, and 1515 (14.2%) were newly initiated on anti-TNF therapy. During a median (IQR) follow-up of 4.1 (1.9-7.0) years, 3367 patients experienced at least 30% decline in eGFR, and over a median (IQR) follow-up of 5.0 (2.5-8.0) years, 2502 patients died. After multivariable adjustments, incident use (vs nonuse) of TNF inhibitors was significantly associated with higher risk of decline in eGFR (adjusted hazard ratio [HR], 1.34 [95% CI, 1.18-1.52]) but was not associated with risk of all-cause mortality (adjusted HR, 1.02 [95% CI, 0.86-1.21]). Similar results were observed in sensitivity analyses. Conclusions and Relevance: In this cohort study of US veterans with incident IBD, incident use (vs nonuse) of TNF inhibitors was independently associated with higher risk of progressive eGFR decline but was not associated with risk of all-cause mortality. Further studies are needed to elucidate potentially distinct pathophysiologic contributions of TNF inhibitor use to kidney and nonkidney outcomes in patients with IBD.

Primary Aldosteronism: Diagnosis and Management.

Primary aldosteronism (PA) is an important and commonly unrecognized cause of secondary hypertension. Idiopathic hyperaldosteronism and aldosterone-producing adenomas account for more than 95% of PA and are characterized, respectively, by bilateral or unilateral involvement of the adrenal glands. When there is suspicion for the presence of PA, a plasma aldosterone to renin ratio should be obtained initially. Localization to determine adrenal gland involvement is done by imaging, with computerized tomography or magnetic resonance imaging. After imaging, adrenal vein sampling is done to establish treatment options. Patients with unilateral disease, who are good surgical candidates, are most appropriately managed with adrenalectomy. A biochemical cure is almost certain following adrenalectomy; however, only 30-50% of patients would show adequate blood pressure improvement. Patients with bilateral adrenal disease and those believed not to be surgical candidates are managed with mineralocorticoid antagonists.

"Black"-Appearing Peritoneal Effluent.

When encountering unusually appearing dialysate effluent from a patient doing peri- toneal dialysis, it is important to review the patient's recent exposures. In the case of "black"-appearing dialysate effluent, consideration needs to be given to the possibility of someone having undergone a colonoscopy and having tattooing with India ink. Nephrology nurses are frequently the first to be notified when there has been a change in the character of a patient's peritoneal dialysis dialysate effluent. This article describes a case of "black"-appearing dialysate and includes some of the potential differentials that were considered in the evaluation process. Even though "black"-appearing dialysate is a rare occurrence, nephrology nurses need to be aware of some of the potential etiologies, including exposure to India ink.

Safety and diagnostic yield of transjugular renal biopsy.

PURPOSE: To evaluate the safety and tissue acquisition with transjugular renal biopsy (TJRB) by using the Quick-Core method in patients who were at high risk for complications with percutaneous renal biopsy. MATERIALS AND METHODS: This was a retrospective study, and indication for the transjugular route, complications, clinical and laboratory data, and adequacy of samples were abstracted from patient records. TJRB was performed when the patient had thrombocytopenia or coagulopathy and was at high risk for bleeding from percutaneous renal biopsy. Follow-up images were available in 25 patients; nine underwent abdominal ultrasonography (US) and 17 underwent computed tomography (CT) (one patient underwent both US and CT). The hemoglobin level, prothrombin time, international normalized ratio (INR), partial thromboplastin time, platelet count, and serum creatinine level were obtained before and after biopsy, and these findings were correlated with clinical outcomes. RESULTS: Thirty-nine patients underwent 39 TJRB procedures and comprise the current study population. The procedure was technically successful in 38 of the 39 patients (97%). Twenty-four of 39 patients (63%) had a platelet count of less than or equal to 75 x 10(9)/L, 11 (29%) had an elevated INR of more than 1.4, and seven received therapeutic anticoagulation. Patients with a platelet count of less than or equal to 75 x 10(9)/L or those with an elevated INR of more than 1.4 after transfusion were not at increased risk of hematoma formation (P = not statistically significant). The mean serum creatinine level at biopsy was 283 mumol/L +/- 150. A mean of 1.8 cores +/- 1.1 were obtained, with 5.0 glomeruli +/- 3.8, 2.1 glomeruli +/- 2.8, and 2.4 glomeruli +/- 3 at light, immunofluorescence, and electron microscopy, respectively. The renal tissue was sufficient for diagnosis in 92% of patients. Major complications occurred in one patient (2.6%). Minor complications-primarily renal hematoma-occurred in 52% of the patients. Contrast medium-induced nephropathy occurred in three patients (7.8%), two of whom also had renal hematomas. CONCLUSIONS: TJRB is a relatively safe and effective diagnostic tool in high-risk patients with coagulopathy and thrombocytopenia who require renal tissue for accurate diagnosis.

Screening for microalbuminuria simplified by urine specific gravity.

BACKGROUND: The albumin-to-creatinine ratio and the 24-hour urine collection to measure microalbuminuria are inconvenient and expensive. The newer rapid and less expensive dipstick methods for screening of microalbuminuria estimate only albumin and are subject to errors caused by variation in volume. We determined the relation between urine-specific gravity (Usg) and urine creatinine (Ucr) so that Ucr can be derived from Usg to correct for albumin concentration in the urine which is influenced by urine volume. METHODS: We randomly included 42 consecutive patients from the primary care clinic, and 34 patients from the diabetic clinic. RESULTS: We found that a very good correlation existed between Usg and Ucr in the 42 patients from the primary care clinic (Ucr = 11.4 x Usg -11,509, r = 0.83, p < 0.001). Patients from the diabetic clinic who had well-controlled blood sugar (n = 21) showed a similar trend (Ucr = 10.82 x Usg -10,882, r = 0.87, p < 0.001). However, this was not the case with uncontrolled diabetics (Ucr = 2.53 x Usg -2,513, r = 0.26, NS). Using simple arithmetic, we derived a simplified formula where Ucr can be predicted from Usg. Using multiple regression to incorporate the urinary glucose level by dipstick, a more generic formula was obtained for estimating urinary creatinine. CONCLUSION: Usg can be used instead of Ucr to normalize for the varied urine concentration while screening for microalbuminuria. Poorly controlled diabetics should be screened after their blood sugars are well controlled or use the more generic formula that incorporates urinary glucose. Thus, by measuring spot urine albumin and specific gravity by dipsticks one gets an easy, immediate and accurate estimation of microalbuminuria in an office setting.

Acetaminophen toxicity: suicidal vs. accidental.

INTRODUCTION: Acetaminophen toxicity, which can lead to hepatotoxicity, is a burden on our health care system and contributes significantly to intensive care unit admissions and cost of hospitalization. The aim of our study was to determine the epidemiology of various types of acetaminophen poisoning and analyze their outcome compared with their admission characteristics. METHODS: We identified 93 consecutive patients, hospitalized for acetaminophen toxicity over a 52-month period from 1996 to 1999 in our urban county hospital. Retrospective case-control analysis was carried out using the data obtained from the medical records. RESULTS: Acetaminophen accounted for 7.5% of all cases of poisoning admitted during this period. Of the 93 patients, 80 were classified as suicidal and 13 had accidentally poisoned themselves in an attempt to relieve pain. The ratio of females to males was found to be 2:1. Of the 93 patients studied, 88 were admitted to the intensive care unit for initial 24-48 hours of monitoring. Peak acetaminophen levels were higher in the suicidal overdose group (mean 121.7 +/- 97.0 mg/l vs. 64.5 +/- 61.8 mg/l, P < 0.05) than in the accidental group. In spite of this, peak aminotransferase levels >1000 IU/l were more often seen in the latter (39% vs. 12%, P < 0.05). Hepatic coma and death were seen more often in the accidental overdose group (15% vs 0%, P < 0.05). Interestingly chronic alcohol abuse was also more frequent in the accidental overdose category (39% vs 18%, P = 0.05). DISCUSSION: Although the peak acetaminophen level in the suicidal group was significantly higher, cases of therapeutic misadventure had higher rates of morbidity and mortality. Peak acetaminophen levels correlate poorly with hepatic dysfunction, morbidity and mortality. CONCLUSION: We recommend that the patients with suicidal acetaminophen overdose, without any concomitant poisoning, can safely managed on the medical floors.