Pulmonary Hypertension: Insights From the Reservoir-Wave Approach

We employed the reservoir-wave approach to analyze high-fidelity pulmonary arterial (PA) pressure and Doppler flow velocity in 11 patients with varying cardiac diseases. Our specific objectives were to (1) to characterize PA wave pattern and (2) evaluate right ventricular (RV) performance. Wave pressure was partitioned into its forward and backward components. Among patients with lower PA pressures, pressure-decreasing and flow-increasing reflected waves that assist RV ejection were detected. Among the more pulmonary hypertensive patients, pressure-increasing and flow-decreasing reflected waves that impede RV ejection were detected. The four patients with the highest PA pressures showed an early systolic deceleration in flow, which was found to coincide with reflected pressure-increasing, flow-decreasing waves. Wave work done by the RV increased with PA pressure, but expressed as a fraction of total RV work, did not change. The reservoir-wave approach may prove to be a valuable tool to characterize PA-RV interaction and evaluate RV performance

Ibuprofen-Induced Renal Tubular Acidosis: Case Report on a Not-So-Basic Clinical Conundrum

Rationale: Renal tubular acidosis (RTA) is a cause of non-anion gap metabolic acidosis (NAGMA) that is infrequently diagnosed and is due to various underlying etiologies that impair the kidney’s ability to retain bicarbonate or excrete acid. Ibuprofen is an over-the-counter non-steroidal anti-inflammatory medication that is used by patients widely for a variety of reasons. Although it is well known that ibuprofen and other non-steroidal anti-inflammatory drugs may have nephrotoxic effects, the role of ibuprofen as a cause of RTA and hypokalemia is not well recognized. Presenting Concerns: A 66-year-old man with chemotherapy-treated lymphoma in remission and ongoing heavy ibuprofen use for chronic pain presented to hospital with a 1-week history of increasing lethargy and otherwise unremarkable review of systems. Investigations showed acute kidney injury, hypokalemia, hyperchloremia, and NAGMA with elevated urinary pH and positive urine anion gap. Diagnoses: The final diagnosis of distal RTA secondary to ibuprofen was made after ruling out gastrointestinal bicarbonate loss and additional secondary causes of RTA, including other medications, autoimmune conditions, and obstructive uropathy. Interventions: The patient was admitted and treated with intravenous sodium bicarbonate for 24 hours with correction of hypokalemia via oral supplementation. His ibuprofen-containing medication was discontinued. Outcomes: His acute kidney injury and electrolyte abnormalities resolved within 48 hours of initiating treatment with concurrent resolution of his lethargy. He was discharged home and advised to stop taking ibuprofen. Lessons Learned: We report a case of patient with hypokalemia and NAGMA secondary to ibuprofen and highlight the importance of monitoring for this side effect in patients taking ibuprofen

Warm Autoimmune Hemolytic Anemia and Pure Red Cell Aplasia during a Severe COVID-19 B.1.1.7 Infection

Warm autoimmune hemolytic anemia (AIHA) is a rare complication of COVID-19 infection. We report a case of warm AIHA in a patient with COVID-19 pneumonia treated with methylprednisolone and several red blood cell transfusions. Despite treatment of the warm AIHA, the patient’s reticulocyte count remained low, and his biochemical markers were suggestive of pure red cell aplasia, which was later attributed to a concurrent parvovirus B19 infection. This case highlights an unusual situation of two separate hematological processes caused by two separate and simultaneous viral infections

Generalized Tetanus in a Canadian Farmer Following Orthopedic Surgery

Tetanus is extremely rare in developed countries. We report the first documented case of tetanus in the province of Alberta since 2016: a farmer that developed trismus, shoulder stiffness, and fevers eight days following orthopedic surgery. Tetanus immunoglobulin elicited rapid recovery. We highlight risk factors, pathogenesis, epidemiology, and diagnostic challenges

Global Variability of Vascular and Peritoneal Access for Chronic Dialysis

Aim: Vascular and peritoneal access are essential elements for sustainability of chronic dialysis programs. Data on availability, patterns of use, funding models, and workforce for vascular and peritoneal accesses for dialysis at a global scale is limited.Methods: An electronic survey of national leaders of nephrology societies, consumer representative organizations, and policymakers was conducted from July-September 2018. Questions focused on types of accesses used to initiate dialysis, funding for services, and availability of providers for access creation.Results: Data from 167 countries were available. In 31 countries (25% of surveyed countries), &gt;75% of patients initiated hemodialysis (HD) with a temporary catheter. Seven countries (5% of surveyed countries) had &gt;75% of patients initiating HD with arteriovenous fistulas or grafts. Seven countries (5% of surveyed countries) had &gt;75% of their patients starting HD with tunnelled dialysis catheters. 57% of low-income countries (LICs) had &gt;75% of their patients initiating HD with a temporary catheter compared to 5% of high-income countries (HICs). Shortages of surgeons to create vascular access were reported in 91% of LIC compared to 46% in HIC. Approximately 95% of participating countries in the LIC category reported shortages of surgeons for peritoneal dialysis (PD) access compared to 26% in HIC. Public funding was available for central venous catheters, fistula/graft creation, and PD catheter surgery in 57%, 54% and 54% of countries respectively. Conclusions: There is a substantial variation in the availability, funding, workforce, and utilization of vascular and peritoneal access for dialysis across countries regions, with major gaps in low-income countries.<br/

Generalized Tetanus in a Canadian Farmer Following Orthopedic Surgery

Tetanus is extremely rare in developed countries. We report the first documented case of tetanus in the province of Alberta since 2016: a farmer that developed trismus, shoulder stiffness, and fevers eight days following orthopedic surgery. Tetanus immunoglobulin elicited rapid recovery. We highlight risk factors, pathogenesis, epidemiology, and diagnostic challenges

Organization and structures for detection and monitoring of CKD across world countries and regions:Observational data from a global survey

Rationale &amp; Objective: Established therapeutic interventions effectively mitigate the risk and progression of chronic kidney disease (CKD). Countries and regions have a compelling need for organizational structures that enable early identification of people with CKD who can benefit from these proven interventions. We aimed to report the current global status of CKD detection programs. Study Design: A multinational cross-sectional survey. Setting &amp; Participants:Stakeholders, including nephrologist leaders, policymakers, and patient advocates from 167 countries, participating in the International Society of Nephrology (ISN) survey from June to September 2022.Outcomes:Structures for the detection and monitoring of CKD, including CKD surveillance systems in the form of registries, community-based detection programs, case-finding practices, and availability of measurement tools for risk identification.Analytical Approach:Descriptive statistics.Results: Of all participating countries, 19% (n=31) reported CKD registries and 25% (n=40) reported implementing CKD detection programs as part of their national policies. There were variations in CKD detection program, with 50% (n=20) using a reactive approach (managing cases as identified) and 50% (n=20) actively pursuing case-finding in at-risk populations. Routine case-finding for CKD in high-risk populations was widespread, particularly for diabetes (n=152; 91%) and hypertension (n=148; 89%). Access to diagnostic tools, estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR), was limited, especially in low-income (LICs) and lower-middle-income (LMICs) countries, at primary (eGFR: LICs 22%, LMICs 39%, UACR: LICs 28%, LMICs 39%) and secondary/tertiary healthcare levels (eGFR: LICs 39%, LMICs 73%, UACR: LICs 44%, LMICs 70%), potentially hindering CKD detection. Limitations:A lack of detailed data prevented an in-depth analysis.Conclusion:This comprehensive survey highlights a global heterogeneity in the organization and structures (surveillance systems, detection programs and tools) for early identification of CKD. Ongoing efforts should be geared toward bridging such disparities to optimally prevent the onset and progression of CKD and its complications.<br/

Global variations in funding and use of hemodialysis accesses:An international report using the ISN Global Kidney Health Atlas

AbstractBackground: There is a lack of contemporary data describing global variations in vascular access for hemodialysis (HD). We used the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to highlight differences in funding and availability of hemodialysis accesses used for initiating HD across world regions. Methods: Survey questions were directed at understanding the funding modules for obtaining vascular access and types of accesses used to initiate dialysis. An electronic survey was sent to national and regional key stakeholders affiliated with the ISN between June and September 2022. Countries that participated in the survey were categorized based on World Bank Income Classification (low-, lower-middle, upper-middle, and high-income) and by their regional affiliation with the ISN. Results: Data on types of vascular access were available from 160 countries. Respondents from 35 countries (22% of surveyed countries) reported that &gt; 50% of patients started HD with an arteriovenous fistula or graft (AVF or AVG). These rates were higher in Western Europe (n=14; 64%), North &amp; East Asia (n=4; 67%), and among high-income countries (n=24; 38%). The rates of &gt; 50% of patients starting HD with a tunneled dialysis catheter were highest in North America &amp; Caribbean region (n=7; 58%) and lowest in South Asia and Newly Independent States and Russia (n= 0 in both regions). Respondents from 50% (n=9) of low-income countries reported that &gt; 75% of patients started HD using a temporary catheter, with the highest rates in Africa (n=30; 75%) and Latin America (n=14; 67%). Funding for the creation of vascular access was often through public funding and free at the point of delivery in high-income countries (n=42; 67% for AVF/AVG, n=44; 70% for central venous catheters). In low-income countries, private and out of pocket funding was reported as being more common (n=8; 40% for AVF/AVG, n=5; 25% for central venous catheters). Conclusions: High income countries exhibit variation in the use of AVF/AVG and tunneled catheters. In low-income countries, there is a higher use of temporary dialysis catheters and private funding models for access creation.<br/