Anaesthesia management in Chronic Kidney Disease (CKD) patient undergo repair pseudoaneurysms surgery: a case report

Introduction: Chronic kidney disease (CKD) is marked by the presence of kidney damage (usually defined as estimated GFR < 60 mL/ min/1.73 m2) for 3 or more months, and it may be caused by a multitude of disease processes. Management of patients with CKD includes aggressive treatment of the underlying cause, pharmacologic therapy to delay disease progression and prevent complications, and preparation for hemodialysis as ESRD ensues. Case presentation: In this case report, a 48-year-old man with a pseudoaneurysms due to the insertion of a vascular access for hemodialysis, undergo repair pseudoaneurysms surgery under general anesthesia, at the Sanglah General Hospital, October 2020. The patient came with fully awareness, blood pressure 145/95 mmHg, heart rate 85 times per minute regular and oxygen saturation 97% with room air. Conclusion: General anesthesia in patients with CKD requires an understanding of the pathologic changes that accompany renal disease, co-existing medical conditions, and the impact of reduced renal function on drug pharmacokinetics.

The acute impact of baseline renal function and contrast medium volume/estimated glomerular filtration rate ratio on reduced renal function following endovascular abdominal aortic aneurysm repair

Objective The aim of this study was to determine the acute impact of baseline serum creatinine, estimated glomerular filtration rate (eGFR), and contrast medium volume (CMV) on the incidence of reduced renal function (RRF) after endovascular abdominal aortic aneurysm repair (EVAR). We aimed to determine if the CMV/eGFR ratio was a predictor of RRF. Methods This study is a retrospective review of EVAR patients in the Society for Vascular Surgery/Vascular Quality Initiative (SVS/VQI) from January 2015 to August 2020. Reduced renal function was defined as > 0.3 mg/dl (26.5 μmol/L), 50% increase from baseline, and temporary or permanent dialysis. Receiver operator characteristic (ROC) curve analyses were conducted for serum creatinine, eGFR, contrast volume, fluid volume, and CMV/eGFR ratio. Two data sets (training and test) were developed followed by multivariate analyses. Results SVS/VQI data for EVAR contained 38,701 records, of which 30,539 were divided into training ( n = 18,283; 60%) and test ( n = 12,256; 40%) data sets. RRF rate for the training set was 3.6% ( n = 667) and 3.4% ( n = 420) for the test data. RRF patients included more females (29.4 vs 19.0%, p < 0.001), were older in age (75.6 + 8.4 vs 73.3 + 8.7 years), had more congestive heart failure (22.3 vs 12.2%, p < 0.001), and more COPD (42.0 vs 34.2%, p < 0.001). An ROC analysis revealed that eGRF, creatinine, contrast, intravenous fluid, and contrast medium volume (CMV)/eGFR ratio were all significantly ( p < 0.05) correlated with RRF. The eGFR and CMV/eGFR ratio had the largest area under the curve, (0.26) and (0.65), respectively, while fluid had the lowest (0.54). Negative predictive values were 93.7 (CMV/eGFR), 93.9 (creatinine), 94.2 (eGFR), 92.8 (contrast), and 92.6 (intravenous fluid). Multivariate analysis of the training data set resulted in the CMV/eGFR ratio as an independent predictor of RRF (odds ratio, OR: 1.9 with 95% CI: 1.6, 2.2, p < 0.015). For the test data, the CMV/eGFR ratio was an independent predictor of RRF (OR: 1.8, CI: 1.4 to 2.2, p < 0.001) as well as several other variables. Conclusion RRF after EVAR is a dreaded and potentially devastating complication. Baseline serum creatinine, eGFR, contrast medium volume, and the ratio (CMV/eGFR) were all significantly associated with RRF. The optimal cut-off value for the CMV/eGFR ratio, ≤ 2, provides an easy-to-use equation to provide a suggested contrast target based on initial renal function with caution applied for high-risk patients.

Abstract T4: Nox2-derived Reactive Oxygen Species Contribute To The Impaired Renal Function And Increased Maternal Mortality Observed In Dahl SS Rats Following Multiple Pregnancies

We recently demonstrated that female Dahl Salt-Sensitive (SS) rats develop significant proteinuria, reduced renal function, and increased mortality (greater than 50% compared to virgin controls) following multiple pregnancies while fed a low salt diet. While the mechanisms are unclear, it is proposed that reactive oxygen species (ROS) production contributes to this renal disease phenotype. Previous experiments demonstrated that NADPH oxidase (NOX) 2-derived ROS production mediates the development of maternal syndrome (hypertension and proteinuria) in Dahl SS rat during a singular pregnancy, yet the role of NOX 2-derived ROS on long term renal health and survival following multiple pregnancies has not been explored. Therefore, we tested the hypothesis that genetic deletion of the p67phox subunit of NOX2 (SS p67phox-/- ) will result in the protection from reduced renal function and maternal death following multiple pregnancies. There were no maternal deaths observed in the SS p67phox-/- virgin or mated rats (n=3-5/group) following three pregnancies, suggesting that the production of NOX2-derived ROS contributes to the increased mortality seen in the SS rats. In terms of renal damage, protein excretion levels were comparable at baseline between virgin and mated SS p67phox-/- rats (26.3±2.8 vs 19.6±3.8 mg/day, p >0.05). Unlike the SS rats that develop significant proteinuria at the end of three pregnancies (217±53 mg/day, n=7), the SS p67phox-/- rats do not develop a pregnancy-specific increase in proteinuria as they remain comparable to the virgin controls following three pregnancies (31.8±10 vs 50.7±14 mg/day, p >0.05). Furthermore, the mated SS p67phox-/- do not exhibit changes in creatinine clearance (0.65±0.1 vs 0.62±0.1 ml/min/g, p >0.05) or blood urea nitrogen (BUN) levels (16±2 vs 15.7±1.3 mg/dl, p >0.05) relative to virgin controls. In contrast, SS rats develop significant impairment in renal function (creatinine clearance: 0.39±0.06 ml/min/g and BUN: 26.9±2.9) following multiple pregnancies, suggesting that NOX2-derived ROS contribute to the significant renal damage phenotype observed in the SS rats. Further studies are necessary to identify the cell type responsible for producing the detrimental ROS contributing to this phenotype.

ACR management guidelines for the treatment of gout: What’s new and what’s controversial

The community of many national and international recommendations dedicated to the treatment of a specific disease, including gout, is fully justified, since it allows taking into account, for example, regional, ethnic characteristics of the manifestations of the disease, which can be important when choosing a therapy. However, this is often associated with dissonance regarding the solution of key issues facing the practitioner. The publication in 2020 of the updated American College of Rheumatology (ACR) guidelines for the management of gout revealed controversy with some of the previous version’s postulates, as well as with other similar work, for example, with the guidelines published in the same year and the French Association of Rheumatology. Among the controversial provisions of the new version of the ACR recommendations are the unified target level of uric acid for all patients, indications for drug therapy, the choice of a drug in patients with reduced renal function, prevention of arthritis attacks when starting uratelowering therapy. This article discusses these and other controversial issues in gout therapy based on an analysis of the latest ACR guidelines.

For Whom the Bell Tolls: Acute Kidney Injury and Electronic Alerts for the Pediatric Nephrologist

With the advent of the electronic medical record, automated alerts have allowed for improved recognition of patients with acute kidney injury (AKI). Pediatric patients have the opportunity to benefit from such alerts, as those with a diagnosis of AKI are at risk of developing long-term consequences including reduced renal function and hypertension. Despite extensive studies on the implementation of electronic alerts, their overall impact on clinical outcomes have been unclear. Understanding the results of these studies have helped define best practices in developing electronic alerts with the aim of improving their impact on patient care. As electronic alerts for AKI are applied to pediatric patients, identifying their strengths and limitations will allow for continued improvement in its use and efficacy.