Clinical Characteristics and Outcomes of Drug-Induced Acute Kidney Injury Cases

Introduction Drug-induced acute kidney injury (DI-AKI) is a frequent adverse event. The identification of DI-AKI is challenged by competing etiologies, clinical heterogeneity among patients, and a lack of accurate diagnostic tools. Our research aims to describe the clinical characteristics and predictive variables of DI-AKI. Methods We analyzed data from the DIRECT study (NCT02159209), an international, multi-center, observational cohort study of enriched clinically adjudicated DI-AKI cases. Cases met the primary inclusion criteria if the patient was exposed to at least one nephrotoxic drug for a minimum of 24 hours prior to acute kidney injury (AKI) onset. Cases were clinically adjudicated and inter-rater reliability (IRR) was measured using Krippendorff's alpha. Variables associated with DI-AKI were identified using L1 regularized multivariable logistic regression. Model performance was assessed using the area under the receiver operating characteristic curve (ROC AUC). Results 314 AKI cases met the eligibility criteria for this analysis, and 271 (86%) cases were adjudicated as DI-AKI. The majority of the AKI cases were recruited from the United States (68%). The most frequent causal nephrotoxic drugs were vancomycin (48.7%), non-steroidal anti-inflammatory drugs (18.2%), and piperacillin/tazobactam (17.8%). The IRR for DI-AKI adjudication was 0.309. The multivariable model identified age, vascular capacity, hyperglycemia, infections, pyuria, serum creatinine trends, and contrast media as significant predictors of DI-AKI with good performance, ROC AUC 0.86. Conclusions The identification of DI-AKI is challenging even with comprehensive adjudication by experienced nephrologists. Our analysis identified key clinical characteristics and outcomes of DI-AKI compared to other AKI etiologies

Adjusting the Lens: Real World Outcomes in Nephrotic Syndrome.

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Outcomes of immunosuppression in IgA nephropathy based on the oxford classification

Numerous studies have addressed the predictive value of pathology findings from the Oxford Classification. Whether this influences treatment choice has not been determined. We evaluated patients with IgA nephropathy who were immunosuppressed and correlated our findings with both clinical and histological features as per the Oxford Classification. This was a retrospective observational study of 45 patients who had biopsy-proven IgA nephropathy with a mean follow-up of 2.6 years. Primary outcomes were time to end-stage renal disease (ESRD) or a 50% rise in serum creatinine. Immunosuppression was not associated with lower hazards for both ESRD and 50% rise in serum creatinine. From the Oxford Classification, only T0 was associated with significantly lower hazards for ESRD [hazard ratio (HR), 0.067; confidence interval (CI) 0.01–0.58]. Patients who had crescents and/or necrotizing lesions on biopsy were more likely to be immunosuppressed (odds ratio 9.99; 95% CI 1.99–50.06, P = 0.005) but demonstrated a statistically nonsignificant higher hazard for both renal end points (HR, 1.61; CI 0.19-13.89). Such lesions were also associated with a higher incidence of hypertension (149 vs. 135 mm Hg) and greater proteinuria (2.7 vs. 1.9 g/day) at presentation. The use of the Oxford Classification did not aid decision-making with regard to the use of immunosuppression. Crescents and/or necrosis identified on histology were associated with the use of immunosuppression. Hence, there is a need for these lesions to be evaluated further in large cohorts and incorporated into future disease classifications

Improving transition onto Haemodialysis: a novel trainee-led clinic

Background: Starting haemodialysis (HD) is a precarious time with high mortality and worse outcomes in unplanned starts. An audit of our unit demonstrated median time to first consultant clinic review after HD start was 51 days. Two patients died before review and there were 31 emergency admissions within 60 days of HD start. Running an HD unit is in the UK training curriculum. A 2018 survey of nephrology trainees revealed only 40% within 2 years of completion felt, “somewhat/very confident to run an HD unit”.Methods: A trainee led clinic with 1 hour slots 2-3 weeks following in or outpatient HD start was co-designed with patients and the renal MDT. Consultations focused on background, route onto HD, modality choice, vascular access, transplant prospect, medication review, HD adequacy and fluid status exam. Pre-specified data were collected from hospital records and compared with patients starting HD prior to the clinic start using Mann Whitney U tests.Results: Between Nov 2022 and May 2023 all patients commencing HD (n=47) were seen in the clinic. Patient characteristics (age, gender, ESKD aetiology), route onto HD (planned vs unplanned), modality prior to HD start and dialysis access in use at start were similar to the baseline audit. Time to first review reduced from 51 to 19 days (p=Conclusions: Earlier formal medical review of patients improved time to target weight review, earlier opportunities for referrals to the wider MDT and earlier tailoring of immunosuppression and stop of medications no longer indicated. Trainees gained experience of managing HD patients outside a pager-based, trouble-shooting setting. Future data collection is ongoing to explore reduction in hospital admissions and improvements in trainee confidence in managing HD patients.</p

Understanding the impact of academic difficulties among medical students: a scoping review

Background Many medical students may encounter a range of academic and personal challenges during their course of study, but very little is known about their experiences. Our aim was to review the literature to inform future scholarship and to inform policy change. Methods A scoping review was conducted searching PubMed, MEDLINE, EMBASE, PsycInfo, British Education Index, Web of Science and ERIC for English language primary research with no date limits. This retrieved 822 papers of which eight met the requirements for inclusion in the review. Data were independently reviewed by two researchers and underwent thematic analysis by the research team. Results Three major themes emerged. Theme 1: ‘Identity preservation’ addressed students' aim to preserve their sense of self in the face of academic difficulty and their tendency to seek support. This connected the apprehension many students expressed about their educational institutions to Theme 2: ‘The dual role of the medical school’—medical schools are required to support struggling students but are predominantly seen as a punitive structure acting as the gatekeeper to a successful career in medicine. Students' apprehension and attempts to protect their identities within this complex landscape often resulted in ‘maladaptive coping strategies’ (Theme 3). Conclusion Understanding and exploring the academic challenges faced by medical students through their own experiences highlight the need for the development of more individualised remediation strategies. Educators may need to do more to bridge the gap between students and institutions. There is a need to build trust and to work with students to enhance their sense of self and remediate approaches to engagement with learning, rather than focusing efforts on success in assessments and progression