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A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay. [ABSTRACT FROM AUTHOR]

A 41-year-old woman presented by ambulance with a 1-day history of new-onset paralysis and nausea and vomiting ongoing for 48 hours. She had no history of any similar episodes. Biochemical analysis showed profound hypokalaemia with a non-anion gap metabolic acidosis. Her initial serum chloride was within the normal range. She had significant electrocardiographic changes on admission with ST depression, U waves and a prolonged QT interval. Urinary anion gap supported the diagnosis of a distal renal tubular acidosis. Subsequent connective tissue disease serology confirmed previously undiagnosed Sjogren’s syndrome. Successful recovery for this patient required multidisciplinary input from the intensive care, nephrology and neurology teams. [ABSTRACT FROM AUTHOR]

Background: Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking.Objective: To assess novel metrics of e-consult appropriateness and utility.Design: Retrospective cohort study.Setting: Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system.Participants: Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018.Measurements: The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days.Results: Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%).Limitation: Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record.Conclusion: Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Renal replacement therapy (RRT) in the setting of acute kidney injury (AKI) is generally provided by either tunneled or nontunneled dialysis catheters (TDCs or NTDCs), used immediately after insertion. Current consensus guidelines suggest using NTDCs rather than TDCs for vascular access in AKI primarily for logistical reasons, including ease of insertion and timeliness. However, there is increasing evidence that, compared to NTDCs, TDCs are associated with fewer complications (mechanical and infectious) and better dialysis delivery. Nevertheless, this evidence must be balanced by the feasibility and practicality of implementing a "TDC-first approach." In this paper, we assess the current evidence base for vascular access choice for AKI requiring RRT. We make the case for increased use of TDCs as first-line vascular access given growing observational evidence for improved patient outcomes; including decreased risk of infection and thrombosis, increased blood flow rates and decreased treatment interruptions, compared to NDTCs. We advocate for further research to test the feasibility and outcomes associated with a TDC-first approach to AKI-RRT access. A TDC-first approach has the potential to improve RRT clinical outcomes and reduce resource utilization and cost. [ABSTRACT FROM AUTHOR]

There is wide variation in clinical practice regarding timing of discontinuation of renal replacement therapy (RRT) in patients with acute kidney injury (AKI). Prolonged, unnecessary RRT treatment can contribute to length of stay, overall hospital costs, and risk of complications associated with RRT. In addition, prolonged RRT can paradoxically lengthen the time for which the patient remains dialysis-dependent. Well-designed, randomized clinical trials have utilized varied discontinuation criteria specifically related to urine output and creatinine clearance, which impedes the comparison of outcomes from such studies. Other observational studies have attempted to assess the sensitivity and specificity of various criteria for discontinuation of RRT. Whether diuretics influence renal recovery has not been fully elucidated as well. In this article, we propose a starting framework for RRT discontinuation criteria to guide clinicians and clinical researchers. We emphasize the importance of frequent clinical assessment while considering discontinuation of RRT for AKI patients with a creatinine clearance >15 mL/min on a timed urine collection and/or a urine output >400 mL/24 h without diuretics, or >2000 mL/24 h with diuretics. We also discuss newer biomarkers, methods of GFR estimation, and imaging techniques that may play a greater role in the future. Clinical trials objectively comparing the success of RRT discontinuation criteria will be required to provide high-quality evidence for our proposed guidelines. [ABSTRACT FROM AUTHOR]

Hyperoxaluria is an important and underrecognized cause for allograft dysfunction and loss after transplantation. It is potentially treatable if recognized in a timely fashion. Research is ongoing to expand the array of therapeutic options available to treat this. We present a case of a 59-year-old gentleman who underwent deceased donor renal transplantation that was complicated by delayed graft function necessitating continuation of renal replacement therapy. His initial biopsy showed extensive acute tubular necrosis with associated peritubular capillaritis and interstitial nephritis and oxalate crystals in several tubules. Despite receiving methylprednisolone to treat moderate acute cellular rejection, he remained dialysis dependent with minimal urine output. An interval renal allograft biopsy revealed residual acute tubular necrosis with extensive oxalate crystals now visible in many tubules. His plasma oxalate level was concurrently elevated to 19.3 μmol/L (reference range ≤ 1.9 μmol/L). He commenced calcium citrate to manage his hyperoxaluria and ultimately became dialysis independent at 3 weeks after transplantation. This case provides an important example of accelerated oxalate nephropathy as an underappreciated contributor to delayed graft function after renal transplantation. Our accompanying discussion provides an update on current therapeutic measures for managing this challenging condition. [ABSTRACT FROM AUTHOR]

Introduction:Alport syndrome is an inherited renal disease characterized by hematuria, renal failure, hearing loss and a lamellated glomerular basement membrane. Patients with Alport syndrome who undergo renal transplantation have been shown to have patient and graft survival rates similar to or better than those of patients with other renal diseases. Methods:In this national case series, based in Beaumont Hospital Dublin, we studied the cohort of patients who underwent renal transplantation over the past 33 years, recorded prospectively in the Irish Renal Transplant Registry, and categorized them according to the presence or absence of Alport syndrome. The main outcomes assessed were patient and renal allograft survival. Results:Fifty-one patients diagnosed with Alport syndrome in Beaumont Hospital received 62 transplants between 1982 and 2014. The comparison group of non-Alport patients comprised 3430 patients for 3865 transplants. Twenty-year Alport patient survival rate was 70.2%, compared to 44.8% for patients with other renal diseases (p = .01). Factors associated with patient survival included younger age at transplantation as well as differences in recipient sex, donor age, cold ischemia time, and episodes of acute rejection. Twenty-year graft survival was 46.8% for patients with Alport syndrome compared to 30.2% for those with non-Alport disease (p = .11). Conclusions:Adjusting for baseline differences between the groups, patients with end-stage kidney disease (ESKD) due to Alport syndrome have similar patient and graft survival to those with other causes of ESKD. This indicates that early diagnosis and management can lead to favorable outcomes for this patient cohort. [ABSTRACT FROM PUBLISHER]

Purpose: To compare hemodynamic instability during continuous, intermittent and hybrid renal replacement therapy (RRT) in critically ill patients, and its association with renal recovery and mortality., Materials and Methods: The search was conducted in accordance with the PRISMA guidelines which was registered at the PROSPERO Database (CRD42018086504). Randomized clinical trials (RCTs) involving critically ill patients with acute kidney injury (AKI) treated with continuous, intermittent or hybrid RRT were included. The search was performed using PubMed, Embase and Cochrane databases., Results: Out of 3442 citations retrieved, 12 RCTs were included in the systematic analysis, representing 1419 patients. Most studies (n = 8) did not report differences in hemodynamic parameters across different RTT modalities. The incidence of hypotensive episodes varied from 5 to 60% among the studies. Punctual differences on heart rate and blood pressure were observed among studies. However, studies presented high heterogeneity in terms of outcome definitions and measurement, thus making the conduction of meta-analysis impossible., Conclusions: There is very few information available regarding hemodynamic tolerance of renal replacement therapy methods. A better standardization of hemodynamic tolerance and further reports are needed before conclusions can be drawn., Competing Interests: Declaration of Competing Interest All authors read and approved the final version of the manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objectives: AKI requiring KRT is associated with high mortality and utilization. We evaluated the use of an AKI Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes, including mortality, hospital length of stay, and intensive care unit length of stay., Design, Setting, Participants, & Measurements: We conducted a 12-month controlled study in the intensive care units of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4- to 6-week blocks. The primary outcome was risk of inpatient mortality. Prespecified secondary outcomes included 30- and 60-day mortality, hospital length of stay, and intensive care unit length of stay. Generalized estimating equations were used to estimate the effect of the AKI-SCAMP on mortality and length of stay., Results: There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% versus 47% control). AKI-SCAMP use was associated with significantly reduced intensive care unit length of stay (mean, 8; 95% confidence interval, 8 to 9 days versus mean, 12; 95% confidence interval, 10 to 13 days; P <0.001) and hospital length of stay (mean, 25; 95% confidence interval, 22 to 29 days versus mean, 30; 95% confidence interval, 27 to 34 days; P =0.02). Patients in the AKI-SCAMP group were less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% versus 7%; P =0.003)., Conclusions: Use of the AKI-SCAMP tool for AKI KRT was not significantly associated with inpatient mortality, but was associated with reduced intensive care unit length of stay, hospital length of stay, and use of KRT in cases of physician-perceived treatment futility., Clinical Trial Registry Name and Registration Number: Acute Kidney Injury Standardized Clinical Assessment and Management Plan for Renal Replacement Initiation, NCT03368183., Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022&#95;02&#95;07&#95;CJN02060221.mp3., (Copyright © 2022 by the American Society of Nephrology.)

Purpose: We investigated the effect of potentially modifiable continuous renal replacement therapy (CRRT)-related treatment factors on the risk of severe hypotension., Materials and Methods: We carried out a secondary statistical analysis of the Acute Renal Failure Trial Network (ATN) trial. The primary exposures of interest were CRRT treatment dose, ultrafiltration rate, blood flow rate, ionized calcium level and type of anti-coagulation used. The primary outcome was severe hypotension, defined as vasopressor-inotropic score > 18 and calculated based on treatment doses of vasopressor and inotropic agents., Results: Of 1124 individuals enrolled in the ATN Trial, 786 were managed with CRRT. 265/786 (33.7%) patients experienced severe hypotension during the trial. A serum ionized calcium <1.02 mmol/l was associated with a higher risk of severe hypotension compared to a serum calcium >1.02 mmol/l (hazard ratio 2.9; 95% CI 1.5-5.7). There was no significant difference in the risk of hypotension associated with other CRRT treatment factors., Conclusions: Of the CRRT treatment factors studied, hypocalcemia with a serum ionized calcium <1.02 mmol/l was associated with a significantly increased risk of treatment-associated hypotension. Further studies will be required to assess whether treatment targets for serum calcium improve the risk of hypotension during CRRT., Competing Interests: Declaration of Competing Interest None of the authors have any financial or other conflict of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear., Methods: We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months; n =159) along with an email to the provider (intervention II; 3 months; n =105), compared with a control (baseline; 6 months; n =176). A comment was generated if a patient's creatinine increased by >0.5 mg/dl (previous creatinine ≤2.0 mg/dl) or by 50% (previous creatinine >2.0 mg/dl) within 180 days. Process measures included documentation of AKI and clinical actions. Clinical outcomes were defined as recovery from AKI within 7 days, prolonged AKI from 8 to 89 days, and progression to CKD with in 120 days., Results: Providers were more likely to document AKI in interventions I ( P =0.004; OR, 2.80; 95% CI, 1.38 to 5.67) and II ( P =0.01; OR, 2.66; 95% CI, 1.21 to 5.81). Providers were also more likely to discontinue nephrotoxins in intervention II ( P <0.001; OR, 4.88; 95% CI, 2.27 to 10.50). The median time to follow-up creatinine trended shorter among patients with AKI documented (21 versus 42 days; P =0.11). There were no significant differences in clinical outcomes., Conclusions: An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. Translation of these findings into improved outcomes may require corresponding standardization of clinical practice protocols for managing AKI., Competing Interests: M.L. Mendu reports having consultancy agreements with Bayer AG. N.V. Tol an reports receiving research funding from Abbott Diabetes Care and Biomerieux; and reports being a scientific advisor or member of the American Association for Clinical Chemistry, College of American Pathologists, and the Journal of Applied Laboratory Medicine. S. Ahmed reports having an ownership interest in The Kidney Health and Preventive Medicine Institute. All remaining authors have nothing to disclose., (Copyright © 2021 by the American Society of Nephrology.)