Polyuria due to Pressure Natriuresis in Venoarterial Extracorporeal Membrane Oxygenation.

We report a case of a 40-year-old woman who developed profound polyuria (>25 L urine output) immediately after initiation of venoarterial (VA) extracorporeal membrane oxygenation (ECMO). Investigations into the cause determined the polyuria was due to marked natriuresis (>85 g of sodium excreted in 1 day). This natriuresis persisted despite low cardiac filling pressures and high-negative ECMO venous pressures, suggesting clinical hypovolemia due to pressure natriuresis from locally high pressures at the renal artery due to arterial ECMO inflow. As ECMO flows were decreased, polyuria and natriuresis resolved. To our knowledge, this is the first description of VA-ECMO-associated salt wasting.

Ethylene Glycol Intoxication Requiring ECMO Support.

Ethylene glycol is commonly used in antifreeze, and ingestion of even a small amount can result in acute kidney injury, severe metabolic acidosis, and neurological injury. When cases are recognized early, treatment involves administration of alcohol dehydrogenase inhibitors to prevent conversion to toxic metabolites of glycolate, glyoxolate, and oxalate. In later presentations with more severe renal injury, hemodialysis may be required for clearance of toxic metabolites and supportive care for renal failure. We present the first reported case of severe ethylene glycol intoxication requiring support of extracorporeal membrane oxygenation (ECMO) due to refractory cardiopulmonary collapse.

Acute Hyponatremia After a Religious Fast.

OBJECTIVE: Our objective is to describe how polydipsia and intake of nonsteroidal anti-inflammatory drugs (NSAIDs) after fasting while breastfeeding may result in acute symptomatic hyponatremia. CASE REPORT: We present the case of a 24-year-old woman at 4 weeks postpartum who engaged in a 20-hour fast from both eating and drinking, during which she continued to breastfeed her newborn child. After ending her fast, she noted decreased milk supply. Attributing her decreased milk supply to dehydration, she then consumed 4 L of water with little salt and also took NSAIDs for a headache, which continued to worsen. Upon presentation to the emergency department, she was found to have a sodium level of 124 mEq/L (normal, 135-145 mEq/L) and a urine specific gravity of 1.015 (normal, 1.005 - 1.030). Thyroid function and cortisol level test results were normal. She was diagnosed with acute symptomatic hypovolemic hyponatremia. After 1 L of normal saline her sodium rapidly corrected to normal and her symptoms resolved. At 2 months of follow-up she was asymptomatic and had no further episodes of hyponatremia. DISCUSSION: Due to the patient's gender and small body size, 4 L of water was sufficient to lower her serum sodium rapidly from normal to 124 mEq/L. She was unable to excrete this water due to a combination of hypovolemia-mediated arginine vasopressin and NSAID use. CONCLUSION: Clinicians should be cognizant that reproductive-age women are uniquely susceptible to hyponatremia and dangerous sequelae therein. They should counsel fasting individuals, particularly lactating women, to consume solute as well as fluid after fasting.

The genetic architecture of membranous nephropathy and its potential to improve non-invasive diagnosis.

Membranous Nephropathy (MN) is a rare autoimmune cause of kidney failure. Here we report a genome-wide association study (GWAS) for primary MN in 3,782 cases and 9,038 controls of East Asian and European ancestries. We discover two previously unreported loci, NFKB1 (rs230540, OR = 1.25, P = 3.4 × 10-12) and IRF4 (rs9405192, OR = 1.29, P = 1.4 × 10-14), fine-map the PLA2R1 locus (rs17831251, OR = 2.25, P = 4.7 × 10-103) and report ancestry-specific effects of three classical HLA alleles: DRB1*1501 in East Asians (OR = 3.81, P = 2.0 × 10-49), DQA1*0501 in Europeans (OR = 2.88, P = 5.7 × 10-93), and DRB1*0301 in both ethnicities (OR = 3.50, P = 9.2 × 10-23 and OR = 3.39, P = 5.2 × 10-82, respectively). GWAS loci explain 32% of disease risk in East Asians and 25% in Europeans, and correctly re-classify 20-37% of the cases in validation cohorts that are antibody-negative by the serum anti-PLA2R ELISA diagnostic test. Our findings highlight an unusual genetic architecture of MN, with four loci and their interactions accounting for nearly one-third of the disease risk.

Reproducibility of Deceased Donor Kidney Procurement Biopsies.

BACKGROUND AND OBJECTIVES: Unfavorable histology on procurement biopsies is the most common reason for deceased donor kidney discard. We sought to assess the reproducibility of procurement biopsy findings. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compiled a continuous cohort of deceased donor kidneys transplanted at our institution from 1/1/2006 to 12/31/2016 that had at least one procurement biopsy performed, and excluded cases with missing biopsy reports and those used in multiorgan transplants. Suboptimal histology was defined as the presence of advanced sclerosis in greater than or equal to one biopsy compartment (glomeruli, tubules/interstitium, vessels). We calculated κ coefficients to assess agreement in optimal versus suboptimal classification between sequential biopsy reports for kidneys that underwent multiple procurement biopsies and used time-to-event analysis to evaluate the association between first versus second biopsies and patient and allograft survival. RESULTS: Of the 1011 kidneys included in our cohort, 606 (60%) had multiple procurement biopsies; 98% had first biopsy performed at another organ procurement organization and their second biopsy performed locally. Categorical agreement was highest for vascular disease (κ=0.17) followed by interstitial fibrosis and tubular atrophy (κ=0.12) and glomerulosclerosis (κ=0.12). Overall histologic agreement (optimal versus suboptimal) was κ=0.15. First biopsy histology had no association with allograft survival in unadjusted or adjusted analyses. However, second biopsy optimal histology was associated with a higher probability of death-censored allograft survival, even after adjusting for donor and recipient factors (adjusted hazard ratio, 0.50; 95% confidence interval, 0.34 to 0.75; P=0.001). CONCLUSIONS: Deceased donor kidneys that underwent multiple procurement biopsies often displayed substantial differences in histologic categorization in sequential biopsies, and there was no association between first biopsy findings and post-transplant outcomes.

Procurement Biopsies in the Evaluation of Deceased Donor Kidneys.

BACKGROUND AND OBJECTIVES: Biopsies taken at deceased donor kidney procurement continue to be cited as a leading reason for discard; however, the reproducibility and prognostic capability of these biopsies are controversial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compiled a retrospective, single-institution, continuous cohort of deceased donor kidney transplants performed from 2006 to 2009. Procurement biopsy information-percentage of glomerulosclerosis, interstitial fibrosis/tubular atrophy, and vascular disease-was obtained from the national transplant database. Using univariable, multivariable, and time-to-event analyses for death-censored graft survival, we compared procurement frozen section biopsy reports with reperfusion paraffin-embedded biopsies read by trained kidney pathologists (n=270). We also examined agreement for sequential procurement biopsies performed on the same kidney (n=116 kidneys). RESULTS: For kidneys on which more than one procurement biopsy was performed (n=116), category agreement was found in only 64% of cases (κ=0.14). For all kidneys (n=270), correlation between procurement and reperfusion biopsies was poor: overall, biopsies were classified into the same category (optimal versus suboptimal) in only 64% of cases (κ=0.25). This discrepancy was most pronounced when categorizing percentage of glomerulosclerosis, which had 63% agreement (κ=0.15). Interstitial fibrosis/tubular atrophy and vascular disease had agreement rates of 82% (κ=0.13) and 80% (κ=0.15), respectively. Ninety-eight (36%) recipients died, and 56 (21%) allografts failed by the end of follow-up. Reperfusion biopsies were more prognostic than procurement biopsies (hazard ratio for graft failure, 2.02; 95% confidence interval, 1.09 to 3.74 versus hazard ratio for graft failure, 1.30; 95% confidence interval, 0.61 to 2.76), with procurement biopsies not significantly associated with graft failure. CONCLUSIONS: We found that procurement biopsies are poorly reproducible, do not correlate well with paraffin-embedded reperfusion biopsies, and are not significantly associated with transplant outcomes.

Effect of implementing a computerized system for bone mineral density storage and report preparation on result turnaround time and savings in cost, time, and space.

OBJECTIVE: To evaluate whether introduction of a densitometry workflow, data-storage, and reporting software system would result in streamlined workflow with fewer expenses and quicker result turnaround time. METHODS: BoneStation was implemented March 30, 2009, in a large, urban, tertiary referral center performing more than 6000 bone mineral density studies annually at 3 different geographic sites. The times of scan acquisition, report preparation, and final signature in the online medical record were recorded, and the delays from scan to report and from scan to final signature in the online medical record were calculated for each patient during 2 representative weeks before (n = 274) and 2 weeks after (n = 235) implementation of BoneStation. RESULTS: Use of BoneStation reduced time from scan to report from 2.11 +/- 0.16 days to 0.46 +/- 0.05 days (P<.001). BoneStation saved our practice $8.94 per scan, while costing only $3 per scan, resulting in net savings. Considering that the total reimbursement from Medicare in 2010 for dual-energy x-ray absorptiometry is projected to be $55.44, this constitutes cost savings of 10.7% of the total reimbursement. CONCLUSION: The introduction of a specialized electronic medical system for data storage and reporting reduced costs and improved result turnaround time in a densitometry practice.