Anuria after kidney transplantation diagnosed as early recurrence of focal segmental glomerulosclerosis combined with acute calcineurin inhibitor nephrotoxicity: a case report and literature review.

BACKGROUND: Primary focal segmental glomerulosclerosis (FSGS) is a glomerular disease that sometimes recurs in patients after kidney transplantation (KT) and increases the risk of graft loss. Proteinuria is a common early sign of recurrent FSGS, but an abrupt decrease in urine volume is rare. Herein, we report a patient with early recurrence of FSGS with anuria following KT. CASE PRESENTATION: A 55-year-old man with end-stage kidney disease caused by primary FSGS experienced anuria on postoperative day 2 following deceased donor KT. Laboratory results revealed that serum tacrolimus trough levels were consistently elevated at the time of anuria. At first, we considered acute calcineurin inhibitor (CNI) nephrotoxicity based on graft biopsy on light microscopy, laboratory findings, and clinical courses. However, the allograft function did not recover even after discontinuation of CNI, and recurrent FSGS was diagnosed 2 weeks later on electron microscopy. A total of 13 sessions of plasmapheresis and two administrations of rituximab (375 mg/m2) were required to treat recurrent FSGS. The patient achieved a partial response, and the spot urine protein-to-creatinine ratio decreased from 15.5 g/g creatinine to 5.2 g/g creatinine. At 5 months following KT, the serum creatinine level was stable at 1.15 mg/dL. CONCLUSIONS: These findings highlight that anuria can occur in cases of early recurrence of FSGS combined with acute CNI nephrotoxicity.

Cystinuria Complicated by Anuria From Bilateral Obstructing Stones Requiring Bilateral Mini Percutaneous Nephrolithotomy in a 22-Month-Old.

Pediatric nephrolithiasis is increasing in incidence and presents differently compared to adults. We report a case of nephrolithiasis in a pediatric patient, presenting with complaints of emesis, anuria, hematuria, and abdominal distension, leading to a diagnosis of bilateral obstructing cystine stones requiring bilateral percutaneous nephrolithotomy. Pediatric patients with anuria should be evaluated for bilateral nephrolithiasis as an etiology. Calculous anuria requires prompt recognition of the pathologic process and relief of the obstruction with close follow-up and supportive care until definitive stone management. Bilateral percutaneous nephrolithotomy can provide definitive surgical intervention without significant morbidity.

A Novel cause of abdominal pain presenting with anuria and renal failure.

A girl in early adolescence with autism presented with 3 months of abdominal pain and 36 hours of anuria. She had recently received treatment for urinary tract infections, anxiety and menorrhagia (she had undergone menarche a few months earlier). Due to the pain, she had pulled out an incisor. Bladder scan showed 923 mL, creatinine was 829 mmol/L but urethral catheter insertion did not drain urine. An unenhanced CT scan revealed an absent left kidney, didelphys uterus and right-sided hydroureteronephrosis caused by haematocolpos in keeping with a diagnosis of OHVIRA syndrome and ureteric obstruction of a single kidney causing acute renal failure. She underwent vaginal septoplasty, drainage of the haematocolpos and right ureteric stent.

Dying with end stage kidney disease: factors associated with place of death on a palliative care program.

INTRODUCTION: End of life care of patients with end-stage kidney disease (ESKD) may be particularly challenging and requires the intervention of a specialized palliative care team (PCT). OBJECTIVE: To characterize the population of ESKD patients referred to a PCT and evaluate the determinants of planned dying at home. METHODS: We performed a retrospective observational cohort study of all patients with ESKD referred to our PCT between January 2014 and December 2021 (n = 60) and further characterized those with previously known ESKD regarding place of death (n = 53). RESULTS: The majority of the patients were female and the median age was 84 years. Half of the patients were on conservative treatment, 43% were on chronic hemodialysis, and the remainder underwent hemodialysis on a trial basis and were subsequently suspended. Of those with previously known ESKD, 18% died at home and neither gender, age, cognition, performance status, comorbidities, CKD etiology, or treatment modality were associated with place of death. Anuria was significantly associated with dying at the hospital as was shorter time from dialysis suspension and death. Although not reaching statistical significance, we found a tendency towards a longer duration of palliative care follow-up in those dying at home. CONCLUSION: Dying at home is possible in a palliative domiciliary program regardless of age, gender, etiology of CKD, major comorbidities, and treatment modality. Anuria and shorter survival from RRT withdrawal may be limiting factors for planned dying at home. A longer follow-up by palliative care may favor dying at home.

Determinants of Urine Output Using Advanced Hemodynamic Monitoring in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy.

INTRODUCTION: Low cardiac output and hypovolemia are candidate macrocirculatory mechanisms explanatory of de novo anuria in intensive care unit (ICU) patients undergoing continuous renal replacement therapy (CRRT). We aimed to determine the hemodynamic parameters and CRRT settings associated with the longitudinal course of UO during CRRT. METHODS: This is an ancillary analysis of the PRELOAD CRRT observational, single-center study (NCT03139123). Enrolled adult patients had severe acute kidney injury treated with CRRT for less than 24 h and were monitored with a calibrated continuous cardiac output monitoring device. Hemodynamics (including stroke volume index [SVI] and preload-dependence, identified by continuous cardiac index variation during postural maneuvers), net ultrafiltration (UFNET), and UO were reported 4-hourly, over 7 days. Two study groups were defined at inclusion: non-anuric participants if the cumulative 24 h UO at inclusion was ≥0.05 mL kg-1 h-1, and anuric otherwise. Quantitative data were reported by its median [interquartile range]. RESULTS: Forty-two patients (age 68 [58-76] years) were enrolled. At inclusion, 32 patients (76%) were not anuric. During follow-up, UO decreased significantly in non-anuric patients, with 25/32 (78%) progressing to anuria within 19 [10-50] hours. Mean arterial pressure (MAP) and UFNET did not significantly differ between study groups during follow-up, while SVI and preload-dependence were significantly associated with the interaction of study group and time since inclusion. Higher UFNET flow rates were significantly associated with higher systemic vascular resistances and lower cardiac output during follow-up. Multivariate analyses showed that (1) lower UO was significantly associated with lower SVI, lower MAP, and preload-independence; and (2) higher UFNET was significantly associated with lower UO. CONCLUSIONS: In ICU patients treated with CRRT, those without anuria showed a rapid loss of diuresis after CRRT initiation. Hemodynamic indicators of renal perfusion and effective volemia were the principal determinants of UO during follow-up, in relation with the hemodynamic impact of UFNET setting.

Pharmacokinetic analysis of ceftazidime and cefazolin in the treatment of continuous ambulatory peritoneal dialysis-related peritonitis.

OBJECTIVE: Peritoneal dialysis-related peritonitis (PDRP) presents a significant challenge for nephrologists. Continuous intraperitoneal cefazolin and ceftazidime are recommended for the treatment of peritonitis. However, some pharmacokinetic studies have shown that doses of 15-20 mg/kg/d may not achieve sufficient therapeutic levels. In this study, we investigated the pharmacokinetics of ceftazidime and cefazolin in patients with continuous ambulatory peritoneal dialysis-related peritonitis and compared the pharmacokinetic characteristics between traditional and modified treatment groups. METHODS: From February 2017 to December 2019, 42 PDRP patients (17 males, 25 females; mean age: 50.7 ± 12.1 years; mean body weight: 60.9 ± 11.8 kg) were recruited for the study, all participants were anuric. Twenty patients were enrolled in the traditional group and treated with cefazolin (1.0 g) and ceftazidime (1.0 g) via intraperitoneal administration once daily for 14 days. Twenty-two patients were enrolled in the modified group and received the same dose of antibiotics twice daily for the initial five days, followed by once daily for the subsequent nine days. Serum and dialysate samples were collected after days 1, 2, 3, 5, 7, 10, and 14 and analyzed via liquid chromatography-mass spectrometry. RESULTS: In the traditional group, the highest and lowest serum concentrations of ceftazidime were 35.9 and 21.7 µg/mL, respectively. The highest concentration of cefazolin was 54.6 µg/mL on day 5 and the lowest concentration was 30.4 µg/mL on day 1. In the modified group, the highest and lowest serum concentrations of ceftazidime were 102.2 and 54.8 µg/mL, respectively. The highest concentration of cefazolin was 141.7 µg/mL and the lowest concentration was 79.8 µg/mL. All antibiotic concentrations were above the minimum inhibitory concentration (MIC) level (8 µg/mL of ceftazidime and 2 µg/mL of cefazolin) throughout the treatment period. However, on day 1, the concentration of ceftazidime in the third bag of dialysate effluent from the traditional group fell below the MIC level. Despite remaining above the MIC, cefazolin concentration was consistently lower in the third bag of dialysate effluent from the traditional group throughout the treatment period. CONCLUSIONS: Intraperitoneal administration of cefazolin and ceftazidime at a dose of 1 g twice daily for 5 days and then once daily for the rest of the treatment period ensured adequate therapeutic levels of antibiotics for treating anuric PDRP patients.

Clinical Profile and Treatment Outcomes of Patients with Malaria Complicated by Acute Kidney Injury.

As Odisha is an endemic region for malaria with many acute kidney injury (AKI) cases, this study evaluated the clinical profile and treatment outcomes of patients with malaria complicated by AKI. This prospective observational study was conducted between December 2015 and September 2017. Detailed histories and clinical examinations were recorded. On admission, tests for routine hematology, plasma glucose, liver function, renal function, serum electrolytes, thick smears, thin smears, and malarial parasites were performed. Of the 958 AKI malarial patients admitted, 202 (82.6 % males) were included in the study, with a mean age of 38.37 years. In total, 86.14%, 3.46%, and 10.39% of patients had Plasmodium falciparum, Plasmodium vivax, and mixed malaria, respectively. Headache and decreased urination (83.66% each) were the most common symptoms after fever (100%). Anuria and oliguria were reported in 5.95% and 67.82% of patients, respectively, whereas 26.23% reported a urine output of >400 mL/24 h. All patients had raised serum creatinine and urea levels, and >60% had anemia, proteinuria, and/or hyponatremia. Multiple organ dysfunction syndrome was observed in 62.87% of patients. Acute tubular necrosis was seen in 60% of renal biopsy specimens (n = 15). Of the 75.75% of patients requiring dialysis, 82.12% and 17.88% of patients required hemodialysis and peritoneal dialysis, respectively, during which 11 patients died. AKI, a serious complication of P. falciparum or P. vivax malaria, is a life-threatening condition. Fever, anemia, oligo/anuria, hepatic involvement, cerebral malaria, high serum creatinine and urea, and disseminated intravascular coagulation were the main predictors of mortality in our study.

Improvement of persistent anuria in severe myocardial infarction: the potential role of Impella 5.5 as a bridge to decision.

A man in his 40s with ST-segment elevation myocardial infarction complicating cardiogenic shock was transferred to our hospital. Emergent percutaneous coronary intervention for the left anterior descending and left circumflex arteries supported with Impella CP was performed. However, his cardiac function was severely impaired, and anuria developed, necessitating continuous renal replacement therapy (CRRT). After Impella CP was removed on day 6, the patient remained dependent on inotropes and CRRT. Following volume reduction to manage pulmonary congestion, symptoms of low perfusion appeared. Then, Impella 5.5 was inserted on day 38 as a bridge to decision. On day 52, the urine volume reached >2000 mL/day, and CRRT was discontinued. On day 56, the patient was transferred to a certified facility for left ventricular assist device implantation or heart transplantation. This case suggests the potential of Impella 5.5 as a bridge to decision in patients with organ failure caused by low cardiac output.

Sugammadex-Induced Anaphylactic Shock Reversed With Short-Term Continuous Veno-Venous Hemodiafiltration: A Case Report.

Anaphylaxis is a life-threatening, systemic, hypersensitivity reaction, manifested by urticaria, hypotension, and respiratory symptoms. Antigens that are cleared renally may have protracted exposure in patients with impaired renal function, resulting in prolonged and refractory anaphylactic shock. After administration of sugammadex, a 47-year-old man developed prolonged, refractory anaphylactic shock, with anuria due to acute kidney injury. The patient was treated with continuous, short-term, veno-venous hemodiafiltration. Initiating this therapy in patients with refractory anaphylactic shock and anuria due to an antigen that is excreted renally can expedite recovery.

2022 Recommendations of the AFU Lithiasis Committee: Specific cases - chronic kidney disease, bilateral stones, and solitary kidney.

Chronic kidney disease, diabetes and hypertension are risk factors of kidney function impairment. The relative risk of kidney failure is 1.52 in patients with urinary stone disease. The various techniques used to remove upper urinary tract stones generally do not alter kidney function in patients with normal kidney function and may sometimes improve kidney function or slow its deterioration in patients with kidney disease. Compared to the asynchronous treatment of bilateral renal and ureteral stones, concomitant treatment is associated with higher risk of anuria and the need of additional interventions, in the absence of postoperative stenting. For the treatment of solitary kidney stones, the absence of postoperative stenting increases the risk of postoperative anuria. Moreover, the multiplication of percutaneous nephrolithotomy access tracts increases the risk of bleeding and that of kidney function impairment. METHODOLOGY: These recommendations were developed according to two methods: the Clinical Practice Recommendations (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

Renal cortical necrosis - a rare manifestation of dengue fever: A case report.

RATIONALE: Dengue fever is a widespread mosquito-borne viral disease, most prevalent in the tropical and subtropical areas of the world. There has been a significant rise in the incidence and number of outbreaks of dengue in recent years, which has made it a matter of global concern. It may be associated with a number of renal complications, ranging from hematuria, proteinuria, glomerulonephritis, and acute tubular necrosis. However, renal cortical necrosis (RCN) is a rare renal complication of this disease. PATIENTS CONCERNS: We report the case of a young gentleman who presented with fever, vomiting, and anuria. On workup, he was found to be having complicated Dengue fever with RCN resulting in acute renal failure. DIAGNOSIS: To the best of our knowledge, RCN is not a reported renal complication of dengue fever. INTERVENTIONS AND OUTCOMES: Our report highlights the importance of early consideration of renal cortical necrosis in patients with dengue fever and persistent anuria. LESSON: This would allow for better disease prognostication while enabling physicians to develop more effective treatment strategies.

Fluid management protocols in hemodialysis patients using bioimpedance validation: time to look elsewhere?

The management of volume status in dialysis patients is an important determinant of the rate of decline of residual kidney function. The implementation of clinical protocols to guide volume management in the in-center hemodialysis unit resulted in comparable rates of development of anuria and decline in residual kidney function when compared with bioimpedance spectroscopy-guided volume management. Clinical judgment and experience are important drivers of patient outcomes. The importance and applicability of bioimpedance spectroscopy in other clinical settings, such as units without clear volume management protocols or in home dialysis units, remain to be seen.

Acute Kidney Injury as a Leading Cause of Papal Deaths in the Years 1277 to 2005: A Review of 21 Cases.

OBJECTIVES: This study was devised to investigate papal deaths due to acute kidney injury, a topic for which scarce data exist. MATERIALS AND METHODS: We studied all popes between John XXI, who died in 1277 of crush syndrome, and John Paul II, who died of anuria and urinary sepsis in 2005. RESULTS: Between pontification years from 1277 to 2005, 21 of 78 popes (26.9%) died of acute kidney injury. Sepsis was identified as the leading cause of acute kidney injury and death in 20 of 21 popes (95.2%). Mean ± SE age at death of the 21 popes was 69.4 ± 2.26 years. Six popes (28.6%) died of stroke. CONCLUSIONS: Sepsis-associated acute kidney injury, a syndrome with a complex pathogenesis and poor prognosis, which is far from being fully understood, contributed to a high number of papal deaths.

Bio-impedance spectroscopy added to a fluid management protocol does not improve preservation of residual kidney function in incident hemodialysis patients in a randomized controlled trial.

Avoiding excessive dialysis-associated volume depletion may help preserve residual kidney function (RKF). To establish whether knowledge of the estimated normally hydrated weight from bioimpedance measurements (BI-NHW) when setting the post-hemodialysis target weight (TW) might mitigate rate of loss of RKF, we undertook an open label, randomized controlled trial in incident patients receiving HD, with clinicians and patients blinded to bioimpedance readings in controls. A total of 439 patients with over 500 ml urine/day or residual GFR exceeding 3 ml/min/1.73m2 were recruited from 34 United Kingdom centers and randomized 1:1, stratified by center. Fluid assessments were made for up to 24 months using a standardized proforma in both groups, supplemented by availability of BI-NHW in the intervention group. Primary outcome was time to anuria, analyzed using competing-risk survival models adjusted for baseline characteristics, by intention to treat. Secondary outcomes included rate of RKF decline (mean urea and creatinine clearance), blood pressure and patient-reported outcomes. There were no group differences in cause-specific hazard rates of anuria (0.751; 95% confidence interval (0.459, 1.229)) or sub-distribution hazard rates (0.742 (0.453, 1.215)). RKF decline was markedly slower than anticipated, pooled linear rates in year 1: -0.178 (-0.196, -0.159)), year 2: -0.061 (-0.086, -0.036)) ml/min/1.73m2/month. Blood pressure and patient-reported outcomes did not differ by group. The mean difference agreement between TW and BI-NHW was similar for both groups, Bioimpedance: -0.04 kg; Control: -0.25 kg. Thus, use of a standardized clinical protocol for fluid assessment when setting TW is associated with excellent preservation of RKF. Hence, bioimpedance measurements are not necessary to achieve this.

Successful transplantation of four kidney grafts from two small pediatric donors with anuric acute renal failure into adult recipients.

BACKGROUND: Kidneys from infants with anuric acute kidney injury (AKI) only rarely get accepted for transplantation despite encouraging data that such kidneys can have very good long-term outcome. METHODS: We report the transplantation of four kidney grafts from two pediatric donors (3 and 4 years) with anuric acute kidney injury as single kidneys into four adult recipients. RESULTS: All grafts gained function within 14 days posttransplantation, only one recipient needed dialysis after transplantation. None of the recipients suffered from surgical complications. One month after transplantation, all recipients were free of dialysis. Estimated glomerular filtration rates (eGFR) 3 months after transplantation were 37, 40, 50, and 83 mL/min/1.73 m2 . eGFR increased further through month 6, reaching 45, 50, 58, and 89 mL/min/1.73 m2 . CONCLUSION: These cases highlight the feasibility of successful transplantation of single pediatric kidney grafts into adult recipients despite anuric AKI of the donor.

Calculus anuria: a urological emergency with an excellent outcome.

Calculus anuria is a catastrophic condition with dire consequences if not treated promptly. The purpose of this study was to identify factors which influence the short-term outcome of patients with calculus anuria. A retrospective analysis was conducted from January 2016 to December 2021, in children up to the age of 18 years, who presented with calculus anuria and required emergency decompression at Sindh Institute of Urology and Transplantation, Pakistan. One hundred and twenty-five children were included. Majority were born to consanguineous parents and a few of them had positive family history of stone disease. Severe illness was found in 25 (20%) patients and among them 8 (32%) required hemodialysis. Decompression by double J stenting is the preferred intervention in our institute and was done in 106 (85%) children, followed by percutaneous nephrostomy tube in 10 (8%) successfully. A small number of patients, 9 (7%) required both procedures to relieve their obstruction. A significant number of patients, about 115 (92%), attained normal renal functions after intervention. No pertinent factors were identified, relating to incomplete renal recovery in nine (7%) of the patients who unfortunately progressed to chronic kidney disease.

The role of residual renal function on potassium intake and excretion in patients on peritoneal dialysis.

BACKGROUND: Patients on chronic dialysis are at increased risk of developing disorders in potassium balance. The preservation of residual renal function (RRF), frequently observed in patients on peritoneal dialysis (PD), may contribute to better control of serum potassium. This study aimed to investigate the role residual renal function on potassium intake and excretion in PD patients. METHODS: In this cross-sectional study, dietary potassium was evaluated by the 3-day food record. Potassium concentration was determined in serum, 24 h dialysate, stool ample, and 24 h urine of patients with diuresis > 200 mL/day, who were considered non-anuric. RESULTS: Fifty-two patients, 50% men, 52.6 ± 14.0 years, and PD vintage 19.5 [7.0-44.2] months, were enrolled. Compared to the anuric group (n = 17, 33%), the non-anuric group (n = 35, 67%) had lower dialysate potassium excretion (24.8 ± 5.3 vs 30.9 ± 5.9 mEq/d; p = 0.001), higher total potassium intake (44.5 ± 16.7 vs 35.1 ± 8.1 mEq/d; p = 0.009) and potassium intake from fruit (6.2 [2.4-14.7] vs 2.9 [0.0-6.0]mEq/d; p = 0.018), and no difference in serum potassium (4.8 ± 0.6 vs 4.8 ± 0.9 mEq/L; p = 0.799) and fecal potassium (2.2 ± 0.5 vs 2.1 ± 0.7 mEq/L; p = 0.712). In non-anuric patients, potassium intake correlated directly with urinary potassium (r = 0.40; p = 0.017), but not with serum, dialysate, or fecal potassium. In the anuric group, potassium intake tended to correlate positively with serum potassium (r = 0.48; p = 0.051) and there was no correlation with dialysate or fecal potassium. CONCLUSION: The presence of residual renal function constitutes an important factor in the excretion of potassium, which may allow the adoption of a less-restrictive diet.

Primary versus deferred ureteroscopy for the management of obstructive anuria secondary to ureteric urolithiasis in children: a prospective randomized study.

To compare the role of primary and deferred ureteroscopy (URS) in the management of obstructive anuria secondary to ureteric urolithiasis in pediatric patients. This prospective randomized study included 120 children aged ≤ 12 years who presented with obstructive anuria secondary to ureteric urolithiasis between March 2019 and January 2021. The children were subdivided into group A, which included children who had undergone primary URS without pre-stenting, and group B, which included children who had undergone URS after ureteric stenting. All children were clinically compensated and sepsis-free. Patients with underlying urological structural abnormalities were excluded. The operative time, improvement of renal functions, stone-free rate, and complications were compared between the two groups. At the 1-month follow-up, urine analysis; kidney, ureter, and bladder radiography; and ultrasonography were performed. The patient characteristics of both groups did not show any significant difference. Primary URS had failed in ten children (16.6%) in group A. Moreover, failure of stenting was noted in six patients (11%) in group B. The mean operative time for group B was significantly lower than that for group A (p ≤ 0.001). The stone-free rate was significantly higher in group B (p ≤ 0.001). The rate of overall complications was higher in group A. Deferred URS is preferable over primary URS in the management of obstructive anuria secondary to ureteric urolithiasis". In children because of the lower need for ureteric dilatation, higher stone- free rate, shorter procedure time, and lower complication rate.