Prognostic models to predict complete resolution of hypertension after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis.

Complete resolution of hypertension (CRH) after adrenalectomy for primary aldosteronism is far from a certainty. Although several prognostic models have been proposed to predict outcome after adrenalectomy, studies have not clarified which of the available models can be used reliably in clinical practice. To identify, describe and appraise all prognostic models developed to predict CRH, and meta-analyse their predictive performances. We searched MEDLINE, Embase and Web of Science for development and validation studies of prognostic models. After selection, we extracted descriptive statistics and aggregated area under the receiver operator curve (AUC) using meta-analysis. From 25 eligible studies, we identified 12 prognostic models used for predicting CRH after total adrenalectomy in primary aldosteronism. We report the results for 3 models that had available data from at least 3 external validation studies: the primary aldosteronism surgical outcome (PASO) score (AUC: 0.81; 95% confidence interval [CI]: 0.74-0.86; 95% predictive interval [PI]: 0.04-1.00), Utsumi nomogram (AUC: 0.79; 95% CI: 0.72-0.85; 95% PI: 0.03-1.00) and the aldosteronoma resolution score (ARS) model (AUC: 0.77; 95% CI: 0.74-0.80; 95% PI: 0.59-0.86 for all studies and AUC: 0.80; 95% CI: 0.75-0.85; 95% PI: 0.57-0.93 for the studies with the same adrenal vein sampling-guided adrenalectomy rate compared to the models meta-analysed). The PASO score, Utsumi nomogram and ARS model showed comparable discrimination performance to predict CRH in primary aldosteronism. Unlike the ARS model, the number of external validation studies for the PASO score and the Utsumi nomogram was relatively low to draw definite conclusions.

Point of Care Ultrasound Training in Nephrology: Twitter Poll as a Modern Tool for Development of an Effective Curriculum.

INTRODUCTION: Point of care ultrasonography (POCUS) is being increasingly recognized as an adjunct to physical examination in the field of nephrology. However, paucity of trained faculty and standardized curricula remain key barriers to widespread adoption of this skill as well as development of reliable quality assessment programs at the institutional level. Herein, we sought to explore the utility of Twitter polls to gain insights into knowledge deficits of the learners for making curricular improvements while simultaneously disseminating POCUS pearls and pitfalls. METHODS: A series of 57 single-question polls were tweeted over a 12-month period, each containing an ultrasound image or a video asking for correct interpretation. These were sent out from the Twitter handle of NephroPOCUS.com (@NephroP), an online POCUS education tool. The answer and a brief explanation were shared in a subsequent tweet at the end of the voting period. Information on the percentage of correct answers, Tweet impressions, and engagements was collected and analyzed by the pre-determined difficulty level (I-III) and the organ/learning objective being tested. RESULTS: The number of responses per poll was 228 ± 94.6 (mean ± SD), and the percentage of correct responses was 57.9 ± 17.5 (mean ± SD). 16 (of 57) polls received less than 50% correct responses, of which 8 belonged to level III difficulty. The learning objectives that received the least number of correct responses in the kidney, cardiac, lung, vascular, and other categories were identification of end-stage kidney (16.2% correct answers), right pleural effusion on the parasternal short axis view of the heart (29%), right pleural effusion from the subxiphoid window (39%), grading of systemic venous congestion (27.3%), and identification of ascites on the right lateral chest window (15%), respectively. The overall engagement rate was 6.96%, which was above the median for health and higher education-related tweets on Twitter. Targeted didactic material was developed based on these results, published on various open-access nephrology education platforms. CONCLUSIONS: Twitter polls aid in identifying the knowledge gaps among POCUS learners. Information obtained from the polls can be used to improve POCUS-related curricula and develop targeted educational material to facilitate remote learning.

Multi-Organ Point-Of-Care Ultrasound in Acute Kidney Injury.

Acute kidney injury (AKI) is a clinical syndrome caused by a multitude of hemodynamic, toxic, and structural insults to the kidney, and portends worse patient outcomes. Despite careful history taking, physical examination, and analysis of laboratory data, a void is evident in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at bedside as an adjunct to physical examination. Growing body of evidence points to POCUS as a powerful tool in a variety of clinical settings. Herein, we discuss how nephrologist-performed POCUS has the potential to provide answers to focused questions that we encounter in diagnosis and management of patients with AKI. From excluding hydronephrosis to providing real-time insights into hemodynamics, incorporation of POCUS helps integrate all the pieces of patient data and formulate individualized treatment plans. Future studies are needed to evaluate the impact of multi-organ POCUS on AKI-related pragmatic patient outcomes, the potential of this technique to stratify the risk and to identify patients with different levels of severity of AKI and different pathophysiological signatures.

The dynamic relationship between serum chloride and cardiorenal syndrome.

Low serum sodium concentration has long been recognized as an established marker of short- and long-term morbidity and mortality in patients with heart failure (HF), and is commonly included in various risk prediction models. Mechanisms leading to hyponatremia (e.g. maladaptive neurohormonal activation) could also lead to concurrent decline in serum chloride levels. Besides, chloride has distinct biological roles (e.g. modulation of renal tubular sodium transporters) that are relevant to the pathophysiology and therapy of HF, making it a potent cardiorenal connector. Several clinical studies have recently reported on a potentially overlooked link between low serum chloride levels and adverse outcomes in patients with a wide variety of HF syndromes, which could indeed be stronger than that of sodium. While evidence on predictive value of chloride is accumulating in various patient populations and settings, the limited available interventional studies have so far yielded conflicting results. It remains to be elucidated whether hypochloremia represents a marker of disease severity and prognosis, or it is an actual pathogenetic mechanism, hence being a potential novel target of therapy. Current ongoing studies are designed to better understand the mechanistic aspects of the role of hypochloremia in HF and shed light on its clinical applicability.

Preventive care for patients with end-stage kidney disease: crossroads between nephrology and primary care.

Patients with end-stage kidney disease (ESKD) undergoing maintenance hemodialysis (HD) might expect their nephrologists to coordinate all their healthcare needs. We performed a survey among adult patients with ESKD undergoing HD in two outpatient dialysis centers at the University of Florida to identify differences in characteristics between patients with and without primary care providers (PCP) and to explore the association of PCP utilization with adherence to preventive health measures. Of the 132 participants, 89.4% reported having a PCP. This group was more likely to be female, older, and with higher education level. Having a PCP was associated with influenza, pneumococcal, and tetanus/Tdap vaccinations as well as screening for tuberculosis, depression, hypertension, and dyslipidemia. The PCP group had statistically significant higher rates of influenza immunization (89.8% vs 71.4%, P = .04) as well as screening for hypertension (93.2% vs 64.3%, P = .04) and depression (78.8% vs 42.9%, P = .004), compared to the group without PCP, in the multivariable analysis. Having a PCP is associated with higher rates of influenza vaccination and screening for depression and hypertension. These findings could have important implications as far as identifying patients with ESKD at risk for fragmented care and potential gaps in optimal preventive care.

Emergence of Chloride as an Overlooked Cardiorenal Connector in Heart Failure.

Several studies have recently challenged the sodium-centric view that has been dominating the field of heart failure (HF) and cardiorenal syndrome. The previously observed benefits of severe dietary restriction of salt do not seem to be consistently reproduced by contemporary studies. Moreover, there is evidence that too low intake may paradoxically lead to adverse outcomes in more advanced stages of HF. Facing the escalating controversy, investigators have shifted their focus from sodium to its often overlooked counter ion in salt, the chloride. Emerging data suggest that serum chloride levels could portend robust independent prognostic value in a wide range of HF syndromes possibly stronger than that of sodium. The untoward impact of hypochloremia on the outcomes could be mechanistically linked to renal tubular regulatory pathways, neurohormonal activation, and diuretic resistance. As such, it can be a potential target of therapy in this setting. In this article, the authors provide a brief overview of the role of serum chloride as a cardiorenal connector and explore the context in which the contemporary data should be interpreted. Implementation of predictive and therapeutic strategies incorporating the emerging evidence would be refined through discussion of nuances of such findings as well as their biological and clinical relevance.

Point-of-Care Ultrasonography for Objective Volume Management in End-Stage Renal Disease.

Focused ultrasonography or point-of-care ultrasonography (POCUS) is increasingly considered as an essential bedside diagnostic tool. In patients with end-stage renal disease (ESRD) treated with hemodialysis, it can be used as an adjunct to physical examination to objectively assess the volume status and guide the rate and amount of ultrafiltration. Herein, we describe the case of an ESRD patient presenting with hypertensive urgency where POCUS disclosed the presence of hypervolemia despite unremarkable physical examination. The sonographic findings of the inferior vena cava, heart, and lungs guided fluid extraction during hemodialysis therapy, and the actual ultrafiltration volume was significantly higher than what was anticipated based on clinical findings. This case highlights the importance of using -POCUS as a tool for objective and precise assessment of volume status in patients with ESRD.

Left Ventricular Assist Device and the Kidney: Getting to the Heart of the Matter.

Left ventricular assist devices (LVADs) are increasingly used for the management of patients with advanced heart failure (AHF) due to their established salutary impact on hemodynamic status and survival benefit. Impairment in kidney function is common in the setting of AHF and is associated with adverse impact on the outcomes. Cardiorenal interactions represent a complex pattern in these patients rendering their care a challenge that needs to be addressed by multidisciplinary approaches. Following LVAD implantation, AHF patients have the potential to achieve marked improvement in kidney function due to increased cardiac output and kidney perfusion as well as reduction in renal venous congestion. However, a subset of these patients is also at risk for acute kidney injury and resurgence of kidney dysfunction on continued mechanical circulatory support. Herein, we provide an overview of various aspects of changes in kidney function pre- and post-LVAD implantation, review potential underlying pathophysiologic mechanisms, and the impact on the outcomes. Moreover, the currently available data on renal replacement therapy of LVAD-treated patients, whether in the acute setting or as a maintenance therapy, are discussed in detail along with areas of high clinical relevance where a clear gap in knowledge exists.

Expanding the Boundaries of Combined Renal Replacement Therapy for Non-Renal Indications.

Over the last decades, there have been major advancements in the field of renal replacement therapy (RRT) with utilization of newer technologies and advent of various modalities. Once exclusively used for treatment of renal failure and its metabolic consequences, the science of RRT has expanded to include non-renal indications such as treatment of fluid overload in patients with refractory heart failure. Hepatic encephalopathy due to sudden rise in serum ammonia level in the setting of acute liver failure represents an underexplored area in which RRT can potentially be helpful. While the key role of hyperammonemia in the pathogenesis of hepatic encephalopathy in patients with liver failure is well established, emerging data points to distinct pathophysiologic mechanisms underlying chronic alterations in neural metabolic functions and acute changes in cerebral perfusion. In the acute setting, ammonia can cross the blood-brain barrier at high levels leading to sudden formation of strong osmolytes, significant transcellular shift of water, and cerebral edema. Herein, we provide a brief overview of the role of RRT in management of acute hyperammonemia in the setting of acute liver failure and discuss the practical aspects of the available therapeutic modalities. Larger studies are needed to shed light on a number of clinical aspects such as the impact on the outcomes, criteria for selection of the patients that would benefit most from this therapeutic approach, optimal timing of initiation of RRT, and the most appropriate modality.

Are We Barking Up the Wrong Tree? Rise in Serum Creatinine and Heart Failure.

A significant subset of patients with heart failure (HF) experience small to moderate rise in serum creatinine (RSC) in the setting of otherwise beneficial therapies such as aggressive diuresis or renin-angiotensin-aldosterone system (RAAS) inhibition. Accumulating data suggest that RSC in this setting is dissimilar from conventional causes of renal insult in that it has a negligible impact on the outcomes. There is also emerging evidence on the lack of association between biomarkers of renal injury and RSC in the setting of aggressive diuresis. A similar pattern has been observed in recent hypertension trials where the RSC in patients with intensive blood pressure control has not been associated with biomarker evidence of renal injury or adverse outcomes. Based on these findings, RSC, rather than acute kidney injury, appears to be the preferred terminology in HF (and possibly in hypertension) because of its purely descriptive nature that lacks any potentially inaccurate implication of mechanistic or prognostic reference. From a pragmatic viewpoint, we believe that small to moderate RSC is to be anticipated and tolerated with RAAS inhibition and/or aggressive diuresis in acute or chronic HF and should not prompt discontinuation of the therapy unless complications such as hypotension and severe hyperkalemia develop.

Acute kidney injury in non-critical care setting: elaboration and validation of an in-hospital death prognosis score.

BACKGROUND: Acute kidney injury (AKI) is still characterized by a high mortality rate. While most patients with AKI are admitted in conventional medical units, current available data are still obtained from studies designed for patients admitted in intensive care units (ICU). Our study aimed to elaborate and validate an in-hospital death prognosis score for AKI admitted in conventional medical care units. METHODS: We included two prospective cohorts of consecutive patients with AKI admitted between 2001 and 2004 (elaboration cohort (EC)) and between 2010 and 2014 (validation cohort (VC)). We developed a scoring system from clinical and biological parameters recorded at admission from the EC to predict in-hospital mortality. This score was then tested for validation in the VC. RESULTS: Three-hundred and twenty-three and 534 patients were included in the EC and VC cohorts, respectively. The proportion of in-hospital death were 15.5% (EC) and 8.9% (VC), mainly due to sepsis. The parameters independently associated with the in-hospital death in the EC were Glasgow score, oxygen requirement, fluid overload, blood diastolic pressure, multiple myeloma and prothrombin time. The in-hospital death prognosis score AUC was 0.845 +/- 0.297 (p < 0.001) after validation in the VC. CONCLUSIONS: Our in-hospital death prognosis score is the first to be prospectively developed and validated for AKI admitted in a conventional medical care unit. Based on current parameters, easily collected at time of admission, this score could be a useful tool for physicians and nephrologists to determine the in-hospital death prognosis of this AKI population.

Team-Based Learning Activities for First-Year Medical Students: Perception of the Learners.

OBJECTIVES: Team-based learning (TBL) is an active learning strategy that is used increasingly in medical education to promote critical thinking, knowledge application, teamwork, and collaboration. The aim of this study was to assess the students' perspective on the utility of TBL compared with traditional lectures. METHODS: We used a validated TBL student assessment instrument comprising three subscales studying accountability, preference for lecture or TBL, and student satisfaction. First-year medical students enrolled at the University of Florida College of Medicine in spring semester 2016 were asked to complete the questionnaire. RESULTS: The response rate was 50% (70/138). Although 81% of students reported that they had to prepare before TBL and believed they had to contribute to the learning of their team, only 52% believed that they were accountable for team learning. The majority believed that TBL activities are an effective approach to learning (74%), with 78% agreeing that TBL activities helped them recall information. Fewer than half (45%), however, believed that TBL helped improve their grades. CONCLUSIONS: Students reported a preference and satisfaction with TBL over traditional lectures, but a mixed response was noted on the questions pertaining to accountability for team learning.

Extracorporeal Ultrafiltration for Acute Heart Failure: Lost Battle or Lasting Opportunity?

The negative prognostic impact of congestion and worsening renal function in patients with decompensated heart failure (HF) has been widely recognized. As diuretics are thought to provide suboptimal results and are associated with a number of adverse effects, a number of diuretic-sparing therapeutic strategies have been explored. Extracorporeal ultrafiltration (UF) represents an intriguing option that presumably lacks many of the untoward effects of diuretic-based regimens while portending several advantages. However, conflicting data have recently emerged in relation to some of its previously proposed beneficial effects possibly due to counterbalance of the underexplored mechanisms. Herein, the existing literature on the role of UF therapy for management of acute decompensated HF is briefly reviewed with special emphasis on its impact on surrogates of efficacy and safety such as excess fluid removal and renal function. A number of topics relevant to cardiorenal syndrome such as congestion and sodium removal are also discussed.

Chronic Kidney Disease in Pregnancy.

With the increasing prevalence of chronic kidney disease (CKD) worldwide, the number of pregnant women with various degrees of renal dysfunction is expected to increase. There is a bidirectional relation between CKD and pregnancy in which renal dysfunction negatively affects pregnancy outcomes, and the pregnancy can have a deleterious impact on various aspects of kidney disease. It has been shown that even mild renal dysfunction can increase considerably the risk of adverse maternal and fetal outcomes. Moreover, data suggest that a history of recovery from acute kidney injury is associated with adverse pregnancy outcomes. In addition to kidney dysfunction, maternal hypertension and proteinuria predispose women to negative outcomes and are important factors to consider in preconception counseling and the process of risk stratification. In this review, we provide an overview of the physiologic renal changes during pregnancy as well as available data regarding CKD and pregnancy outcomes. We also highlight the important management strategies in women with certain selected renal conditions that are seen commonly during the childbearing years. We call for future research on underexplored areas such as the concept of renal functional reserve to develop a potential clinical tool for prognostication and risk stratification of women at higher risk for complications during pregnancy.

"AVOID"ing harm by a double-edged sword: is there a role for ultrafiltration in heart failure?

Prior studies comparing ultrafiltration with medical management for acute decompensated heart failure have yielded conflicting results. The AVOID-HF trial was designed as a definitive comparison of optimal ultrafiltration versus optimal diuretic-based medical therapy; unfortunately, the trial was terminated prematurely because of slow recruitment. The results of AVOID-HF nevertheless provide a rationale for well-designed, adequately powered trials to determine whether ultrafiltration has a role in the routine management of acute decompensated heart failure.

Defining the role of ultrafiltration therapy in acute heart failure: a systematic review and meta-analysis.

Ultrafiltration (UF) has emerged as an alternative therapy for acute decompensated heart failure (ADHF) due to its physiological benefits such as improvement in neurohormonal activation. We performed a systematic review and a meta-analysis to evaluate the efficacy, safety, and the impact on outcomes for UF therapy as compared to conventional medical treatment. The PubMed and Cochrane databases were searched from inception to December 2015 for randomized controlled trials that examined UF therapy in ADHF and used diuretic-based regimens as the control group. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we explored the impact on weight change, fluid removal, renal function, rehospitalization rate, and mortality. Mantel-Haenszel odds ratio (OR) was calculated for dichotomous data and weighted mean difference (WMD) for continuous data. Seven studies with a total of 771 patients met our selection criteria. UF therapy led to greater weight loss (WMD 1.35, 95 % CI 0.49-2.21, p < 0.01) and fluid removal (WMD 1.81, 95 % CI 1.01-2.62, p = <0.01) while the impact of UF on renal function was comparable with medical treatment (WMD 0.06, 95 % CI -0.11 to 0.22, p = 0.48), UF decreased heart failure rehospitalization rate (OR 0.60, 95 % CI 0.37-0.98, p = 0.04) but did not change mortality (OR 1.03, 95 % CI 0.68-1.57, p = 0.89). Compared with diuretic-based medical treatment, UF therapy is more efficient in decongestion of patients with ADHF. It does not have a deleterious impact on renal function and can improve heart failure-related rehospitalization rate, albeit without conferring a survival benefit.

More Efficient Sodium Removal by Ultrafiltration Compared to Diuretics in Acute Heart Failure; Underexplored and Overstated.

Enhanced removal of sodium has often been cited as an advantage of ultrafiltration (UF) therapy over diuretic-based medical treatment in the management of acute decompensated heart failure. However, so far clinical studies have rarely evaluated the precise magnitude of sodium removal, and this assumption is largely based on the physiologic mechanisms and anecdotal observations that predate the contemporary management of heart failure. Recent data suggest that patients treated with UF experience substantial reduction in urinary sodium excretion possibly due to prolonged intravascular volume contraction. Consequently, the efficient sodium extraction through production of isotonic ultrafiltrate can be offset by urine hypotonicity. Based on the limited currently available data, it seems unlikely that the persistent benefits of UF could be solely explained by its greater efficiency in sodium removal. The design of the future studies should include frequent measurements of urine sodium to precisely compare the impact of UF and diuretics on sodium balance.