Nontypical presentation of a common disease: a case report

Background Kawasaki disease is an idiopathic medium-sized vasculitis that occurs primarily in infants and children younger than 5 years of age. Atypical Kawasaki disease applies to patients who do not fulfill the complete criteria of fever of 5 days or more with at least four of five features: bilateral conjunctival injection, changes in the lips and oral cavity, cervical lymphadenopathy, extremity changes, and polymorphous rash. Acute kidney injury is defined as a sudden decline in kidney function within hours, including structural injuries and loss of function. Acute kidney injury is extremely common in hospitalized pediatric patients. However, it is rarely documented in Kawasaki disease. Acute kidney injury is underestimated in Kawasaki disease due to the lack of a clear definition of age-specific normal serum creatinine levels and routine renal functions. This report describes a case who presented with clinical features suggestive of atypical Kawasaki disease and developed acute kidney injury. Case presentation A 2-year-old Saudi girl had a history of high-grade fever for 5 days, moderate dehydration, dry cracked lips, poor appetite, and generalized erythematous rash; therefore, she was diagnosed to have incomplete Kawasaki disease. Laboratory investigations revealed normochromic normocytic anemia, leukocytosis, thrombocytosis, high inflammatory markers, and acute kidney injury stage III. An echocardiogram showed a 4-mm dilatation on the left main coronary artery and a 3-mm dilatation on the right. A renal biopsy was not performed to identify the cause of the injury as it showed improvements after the start of the specific therapy for Kawasaki disease; intravenous immune globulin at a dose of 2 g/kg, aspirin at a high dosage of 80 mg/kg/day, and prednisolone at 2 mg/kg. In addition to the acute kidney injury management, normal saline boluses were followed by furosemide at a 2 mg/kg dose. Her urine output increased, and her renal functions normalized. She was discharged in good condition after 10 days. Conclusions It is valuable to check renal function tests in a confirmed case of Kawasaki disease to reduce the negative consequences of late acute kidney injury discovery. Early detection and intervention make a substantial difference in acute kidney injury management.

Extubation in the operating room results in fewer composite mechanical ventilation-related adverse outcomes in patients after liver transplantation: a retrospective cohort study

Background To investigate the effect of extubation in the operating room (OR) on mechanical ventilation-related adverse outcomes in patients who undergo liver transplantation. Methods Patients who underwent liver transplantation between January 2016 and December 2019 were included. According to the timing of extubation, patients were divided into OR extubation group and intensive care unit (ICU) extubation group. The propensity score was used to match OR extubation group and ICU extubation group at a 1:2 ratio by demographical and clinical covariates. The primary outcome was a composite of mechanical ventilation-related adverse outcomes, including 30-day all-cause mortality, in-hospital acute kidney injury (stage 2 or 3), and in-hospital moderate to severe pulmonary complications. Secondary outcomes included in-hospital moderate to severe infectious complications, unplanned reintubation rates, ICU and postoperative hospital lengths of stay, and total hospital cost. Results A total of 438 patients were enrolled. After propensity score matching, 94 patients were in OR extubation group and 148 patients were in ICU extubation group. Incidence of the composite mechanical ventilation-related adverse outcomes was significantly lower in OR extubation group than ICU extubation group, even after adjusting for confounding factors (19.1% vs. 31.8%; Odds Ratio, 0.509; 95% Confidence Index [CI], 0.274-0.946; P=0.031). The duration of ICU stay was much shorter in OR extubation group than ICU extubation group (median 4, Interquartile range [IQR] (3 ~ 6) vs. median 6, IQR (4 ~ 8); P<0.001). Meanwhile, extubation in the OR led to a significant reduction of total hospital cost compared with extubation in the ICU (median 3.9, IQR (3.5 ~ 4.6) 10000 US dollars vs. median 4.1, IQR (3.8 ~ 5.1) 10000 US dollars; P=0.021). However, there were no statistically significant differences in moderate to severe infectious complications, unplanned reintubation rates, and the length of postoperative hospital stay between groups. Conclusions Among patients who underwent liver transplantation, extubation in the OR compared with extubation in the ICU, significantly reduced the primary composite outcome of 30-day all-cause mortality, in-hospital acute kidney injury (stage 2 or 3), or in-hospital moderate to severe pulmonary complications. Trial registration The trial was registered at www.clinicaltrials.gov with registration number NCT04261816. Retrospectively registered on 1st February 2020.

Serum sodium trajectory during AKI and mortality risk

Introduction: Kidneys play a primary role in electrolyte homeostasis. The association between serum sodium level and mortality or the need for kidney replacement therapy during acute kidney injury has not been adequately explored. Methods: In this prospective cohort study, we enrolled patients admitted to the Civil Hospital of Guadalajara from August 2017 to March 2020. We divided patients into five groups based on the serum sodium level trajectories up to ten days following hospitalization, 1) stable normonatremia (serum sodium 135 and 145 mEq/L), 2) fluctuating serum sodium levels (increased/decreased in and out of normonatremia), 3) uncorrected hyponatremia, 4) corrected hyponatremia, and 5) uncorrected hypernatremia. We assessed the association of serum sodium trajectories with mortality and the need for kidney replacement therapy (secondary objective). Results: A total of 288 patients were included. The mean age was 55±18 years, and 175 (60.7%) were male. Acute kidney injury stage 3 was present in 145 (51%). Kidney replacement therapy started in 72 (25%) patients, and 45 (15.6%) died. After adjusting for confounders, 10-day hospital mortality was significantly higher in group 5 (HR, 3.12; 95% CI, 1.05 to 9.24, p = 0.03), and kidney replacement therapy initiation was higher in group 3 (HR, 2.44; 95% CI, 1.04 to 5.70, p = 0.03) compared with group 1. Conclusion: In our prospective cohort, most patients with acute kidney injury had alterations in serum sodium. Uncorrected hypernatremia was associated with death, and uncorrected hyponatremia was correlated with the need for kidney replacement therapy.

Comparison of Efficacy of First Haemodialysis Session for Correction of Metabolic Disturbances in Acute Kidney Injury and Chronic Kidney Disease in Children

Introduction: Acute kidney injury and chronic kidney disease present with various complications like electrolyte disturbances, metabolic acidosis and fluid overload in children. The objective of the study was to compare the efficacy of the first session of haemodialysis in children with acute kidney injury stage 3 and chronic kidney disease G5 treated by dialysis for immediate recovery of renal functions in terms of reduction in the level of azotemia, correction of fluid and electrolyte imbalances, metabolic acidosis, and improvement in clinical status. Methods: This was a cross-sectional comparative observational study conducted on 13 patients of acute kidney injury stage 3 and 46 patients with chronic kidney disease G5, who required haemodialysis. Their clinical assessment, fluid status, renal function tests, electrolyte, bicarbonate were done at admission and completion of the first session of heamodialysis. Results: The age group of children was six to 16 years (median 11.4 years). There were six males (46%) and seven females (54%) in the acute kidney injury group and 29 (63%) males and 17 (37%) females in chronic kidney disease G5 groups. Sepsis (31%) and glomerulonephritis (31%) were common etiologies detected for acute kidney injury while in chronic kidney disease G5, congenital anomalies of the kidney and the urinary tract were the commonest (50%). There were significant reductions in the levels of serum urea and creatinine and a rise in blood pH, bicarbonate level, and base excess following the first session of haemodialysis in comparison to pre-dialysis values in both AKI and CKD. Conclusions: The study demonstrated improvement in the clinical parameters and biochemical parameters equally after the first dialysis sessions in both groups. This is one of the effective renal replacement therapy and should be instituted wherever indicated to improve the immediate outcome of the patients.

Machine Learning to Predict Post-Operative Acute Kidney Injury Stage 3 After Heart Transplantation

Background Acute kidney injury (AKI) stage 3, one of the most severe complications in patients with heart transplantation (HT), is associated with substantial morbidity and mortality. We aimed to develop a machine learning (ML) model to predict post-transplant AKI stage 3 based on preoperative and perioperative features. Methods Data from 107 consecutive HT recipients in the provincial center between 2018 and 2020 were included for analysis. Logistic regression with L2 regularization was used for the ML model building. The predictive performance of the ML model was assessed using the area under the curve (AUC) in 10-fold stratified cross-validation and was compared with that of the existing clinical metrics. Results Post-transplant AKI occurred in 71 (66.3%) patients including 13 (12.1%) stage 1, 13 (12.1%) stage 2, and 45 (42.1%) stage 3 cases. The top four features selected for the ML model to predicate AKI stage 3 were serum cystatin C, estimated glomerular filtration rate (eGFR), right atrial long-axis dimension, and serum creatinine (SCr). The predictive performance of the ML model (AUC: 0.828; 95% confidence interval [CI]: 0.745–0.913) was significantly higher compared with that of the existing clinical metrics including eGFR (AUC: 0.694; 95%[CI]: 0.594–0.795, p < 0.05) and SCr (AUC: 0.525; 95%[CI]: 0.411–0.636), p < 0.001). Conclusions The ML model, which achieved an effective predictive performance for post-transplant AKI stage 3, may be helpful for timely intervention to improve the patient’s prognosis.

Acute Kidney Injury and Associated Factors in Intensive Care Units at a Tertiary Hospital in Northern Tanzania

Background: Acute kidney injury (AKI) is a recognized complication in critically ill patients. The epidemiology of AKI varies worldwide, depending on the diagnostic criteria used and the setting. The International Society of Nephrology has called for a reduction in preventable deaths from AKI to zero by the year 2025. It is suspected that the majority of AKI cases are in limited-resource countries, but the true burden of AKI in these settings remains unknown. Objective: We aimed to determine, using standardized KDIGO (Kidney Disease Improving Global Outcomes) criteria, the prevalence of AKI, associated factors, and clinical characteristics of adult (≥18 years) patients admitted to intensive care units (ICUs) at a tertiary hospital in Tanzania. Design: Prospective observational study from November 2017 to May 2018. Methods: In all, 320 patients admitted to medical and surgical ICUs were consecutively enrolled. Baseline, clinical, and laboratory data were collected on admission and during their ICU stay. Serum creatinine and urine output were measured, and KDIGO criteria were used to determine AKI status. Results: More than half (55.3%) of ICU patients were diagnosed with AKI. Of these, 80% were diagnosed within 24 hours of admission. Acute kidney injury stage 3 accounted for 35% of patients with AKI. Patients with AKI were older, more likely to have cardiovascular comorbidities, and with higher baseline serum levels of creatinine, potassium, universal vital assessment admission scores, and total white cell count ≥12. Sepsis (odds ratio [OR] = 3.81; confidence interval [CI] = 1.21-11.99), diabetes (OR = 2.54; CI = 1.24-5.17), and use of vasopressors (OR = 3.78; CI = 1.36-10.54) were independently associated with AKI in multivariable logistic regression. Less than one-third of those who needed dialysis received it. There was 100% mortality in those who needed dialysis but did not receive (n = 19). Limitations: Being based at a referral center, the findings do not represent the true burden of AKI in the community. Conclusion: The prevalence of AKI was very high in ICUs in Northern Tanzania. The majority of patients presented with AKI and were severely ill, suggesting late presentation, underscoring the importance of prioritizing prevention and early intervention. Further studies should explore locally suitable AKI risk scores that could be used to identify high-risk patients in the community health centers from where patients are referred.

Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

Background The postoperative period is critical for a patient’s recovery, and postoperative hypotension, specifically, is associated with adverse clinical outcomes and significant harm to the patient. However, little is known about the association between postoperative hypotension in patients in the intensive care unit (ICU) after non-cardiac surgery, and morbidity and mortality, specifically among patients who did not experience intraoperative hypotension. The goal of this study was to assess the impact of postoperative hypotension at various absolute hemodynamic thresholds (≤ 75, ≤ 65 and ≤ 55 mmHg), in the absence of intraoperative hypotension (≤ 65 mmHg), on outcomes among patients in the ICU following non-cardiac surgery. Methods This multi-center retrospective cohort study included specific patient procedures from Optum® healthcare database for patients without intraoperative hypotension (MAP ≤ 65 mmHg) discharged to the ICU for ≥ 48 h after non-cardiac surgery with valid mean arterial pressure (MAP) readings. A total of 3185 procedures were included in the final cohort, and the association between postoperative hypotension and the primary outcome, 30-day major adverse cardiac or cerebrovascular events, was assessed. Secondary outcomes examined included all-cause 30- and 90-day mortality, 30-day acute myocardial infarction, 30-day acute ischemic stroke, 7-day acute kidney injury stage II/III and 7-day continuous renal replacement therapy/dialysis. Results Postoperative hypotension in the ICU was associated with an increased risk of 30-day major adverse cardiac or cerebrovascular events at MAP ≤ 65 mmHg (hazard ratio [HR] 1.52; 98.4% confidence interval [CI] 1.17–1.96) and ≤ 55 mmHg (HR 2.02, 98.4% CI 1.50–2.72). Mean arterial pressures of ≤ 65 mmHg and ≤ 55 mmHg were also associated with higher 30-day mortality (MAP ≤ 65 mmHg, [HR 1.56, 98.4% CI 1.22–2.00]; MAP ≤ 55 mmHg, [HR 1.97, 98.4% CI 1.48–2.60]) and 90-day mortality (MAP ≤ 65 mmHg, [HR 1.49, 98.4% CI 1.20–1.87]; MAP ≤ 55 mmHg, [HR 1.78, 98.4% CI 1.38–2.31]). Furthermore, we found an association between postoperative hypotension with MAP ≤ 55 mmHg and acute kidney injury stage II/III (HR 1.68, 98.4% CI 1.02–2.77). No associations were seen between postoperative hypotension and 30-day readmissions, 30-day acute myocardial infarction, 30-day acute ischemic stroke and 7-day continuous renal replacement therapy/dialysis for any MAP threshold. Conclusions Postoperative hypotension in critical care patients with MAP ≤ 65 mmHg is associated with adverse events even without experiencing intraoperative hypotension.

Haemolytic anaemia: a consequence of COVID-19

A man in his early 50s presented with jaundice, mild shortness of breath on exertion and dark urine. He had had coryzal symptoms 2 weeks prior to admission. Medical history included obstructive sleep apnoea and hypertension. His initial blood tests showed a mild hyperbilirubinaemia and acute kidney injury stage 1. Chest X-ray and CT pulmonary angiogram were negative for features suggestive of COVID-19. He later developed a drop in haemoglobin and repeat bloods showed markedly raised lactate dehydrogenase and positive direct antiglobulin test. These results were felt to be consistent with a haemolytic anaemia. A nasopharyngeal swab came back positive for COVID-19. We suspect the cause of his symptoms was an autoimmune haemolytic anaemia secondary to COVID-19 which has recently been described in European cohorts.

Age-related clinical and hemodynamic outcome following transcatheter aortic valve replacement: a swiss TAVI registry analysis

Background Transcatheter aortic valve implantation (TA) is the preferred treatment modality for patients with severe aortic valve disease at high surgical risk and is expanding into lower risk populations. Therefore age range of treated patients is increasing. Purpose The aim of this study is to analyze age-related clinical and hemodynamic outcome of patients following TAVI in a nationwide, prospective, multicentre cohort (Swiss TAVI registry). Methods We retrospectively analyzed prospectively collected data from all patients included in the Swiss TAVI registry between February 2011 and December 2018. In an adjusted analysis, in-hospital, 30-days and 1-year outcome between four age groups were compared. Results Overall, 7097 patients underwent TAVI (&lt;70 years: n=324, 70–79 years: n=1913, 80–89 years: n=4353, 90–100 years n=507). Median STS risk score for mortality was 5.23±4.13% and differed significantly between age groups (3.46±4.10%, 3.97±3.73%, 5.57±3.97%, 8.22±4.74%; p=0.001). Valve predilatation was more often performed in older patients (54.3% vs. 54.3% vs. 60.7% vs. 69.6%; p≤0.001). Difference in hospital stay was statistically sigificant between age groups, numerically however not relevant (10.01±7.56 days vs. 9.25±6.38 days vs. 9.55±5.70 days vs 10.03±5.77 days; p=0.02). Post-procedural acute kidney injury stage 3 was highest in the youngest age group (3.4% vs. 1.6% vs. 1.1% vs. 1.0%; RR [95% CI] 0.65 (0.48–0.87); p=0,004) and rate of new pacemakers for conduction abnormalities increased significantly with age (10.2% vs. 13.7% vs. 17.1% vs. 18.7%; RR [95% CI] 1.22 (1.12–1.32); p&lt;0.001). There was no significant difference in life threatening/major bleeding (p=0.288/0.197) or major vascular complications (p=0.083). All-cause mortality and cardiovascular mortality in hospital, at 30 days and at 1 year were highest in nonagenarians and higher in the patients &lt;70 years compared to patients of 70–79 years: in hospital all-cause mortality 2.2% vs. 1.6% vs. 2.9% vs. 5.5% (RR [95% CI] 1.64 (1.28–2.10), p&lt;0.001); 30 day all-cause mortality 3.1% vs. 2.0% vs. 3.7% vs. 6.7%; (HR [95% CI] 1.59 (1.30–1.96); p&lt;0.0001); 1-year all-cause mortality 10.9% vs. 10.4% vs. 12% vs. 19.5% (HR [95% CI] 1.27 (1.14–1.41); p&lt;0.001); in hospital cardiovascular mortality 1.5% vs. 1.5% vs. 2.6% vs. 5.1% (RR [95% CI] 1.70 (1.31–2.20), p&lt;0.001); 30 day cardiovascular mortality 2.2% vs. 1.9% vs. 3.3% vs. 6.3%; (HR [95% CI] 1.68 (1.35–2.09); p&lt;0.001); 1-year cardiovascular mortality 7.2% vs. 6.9% vs. 8.3% vs. 15.3% (HR [95% CI] 1.36 (1.19–1.55); p&lt;0.001). This held true, when hazard ratio was corrected for STS PROM score, femoral access vs other access and year of procedure. Conclusion In-hospital, 30-day and 1-year clinical outcome of nonagenarians undergoing TAVI are less favorable compared to lower age groups. Interestingly, clinical outcome of the patients group 70–79 years was the most favorable. Mortality at 30 according to age Funding Acknowledgement Type of funding source: None