Laboratory prediction of the requirement for renal replacement in acute falciparum malaria

BACKGROUND: Acute renal failure is a common complication of severe malaria in adults, and without renal replacement therapy (RRT), it carries a poor prognosis. Even when RRT is available, delaying its initiation may increase mortality. Earlier identification of patients who will need RRT may improve outcomes. METHOD: Prospectively collected data from two intervention studies in adults with severe malaria were analysed focusing on laboratory features on presentation and their association with a later requirement for RRT. In particular, laboratory indices of acute tubular necrosis (ATN) and acute kidney injury (AKI) that are used in other settings were examined. RESULTS: Data from 163 patients were available for analysis. Whether or not the patients should have received RRT (a retrospective assessment determined by three independent reviewers) was used as the reference. Forty-three (26.4%) patients met criteria for dialysis, but only 19 (44.2%) were able to receive this intervention due to the limited availability of RRT. Patients with impaired renal function on admission (creatinine clearance < 60 ml/min) (n = 84) had their laboratory indices of ATN/AKI analysed. The plasma creatinine level had the greatest area under the ROC curve (AUC): 0.83 (95% confidence interval 0.74-0.92), significantly better than the AUCs for, urinary sodium level, the urea to creatinine ratio (UCR), the fractional excretion of urea (FeUN) and the urinary neutrophil gelatinase-associated lipocalcin (NGAL) level. The AUC for plasma creatinine was also greater than the AUC for blood urea nitrogen level, the fractional excretion of sodium (FeNa), the renal failure index (RFI), the urinary osmolality, the urine to plasma creatinine ratio (UPCR) and the creatinine clearance, although the difference for these variables did not reach statistical significance. CONCLUSIONS: In adult patients with severe malaria and impaired renal function on admission, none of the evaluated laboratory indices was superior to the plasma creatinine level when used to predict a later requirement for renal replacement therapy

Endovascular Stent Placement for Hemodialysis Arteriovenous Access Stenosis

This study aims to report the outcomes of nitinol and polytetrafluoroethylene covered stent placement to treat hemodialysis arteriovenous access stenosis at a single center over a five-year period. Clinical and radiological information was reviewed retrospectively. Poststent primary and secondary patency rates were determined using Kaplan-Meier analysis. Ten clinical variables were subjected to multivariate Cox regression analysis to determine predictors of patency after stent placement. During the study period 60 stents were deployed in 45 patients, with a mean follow-up of 24.5 months. The clinical and anatomical success rate was 98.3% (59/60). Poststent primary patency rates at 6, 12, and 24 months were 64%, 46%, and 35%, respectively. Poststent secondary patency rates at 6, 12, and 24 months were 95%, 89%, and 85%, respectively. Stent placement for upper arm lesions and in access less than 12 months of age was associated with reduced primary patency (adjusted hazards ratio [HR] 5.1, p=0.0084, and HR 3.5, p=0.0029, resp.). Resistant or recurrent stenosis can be successfully treated by endovascular stent placement with durable long-term patency, although multiple procedures are often required. Stent placement for upper arm lesions and in arteriovenous access less than 12 months of age was associated with increased risk of patency loss

Lupus nephritis in Indigenous Australians: a single‐centre study

Background The incidence, presentation and outcomes of lupus nephritis (LN) vary with geography, ethnicity, socioeconomic status and gender. There are relatively few data on LN in the non-Caucasian populations in Australia. Aims To describe the clinical presentation, histological features, natural history, and outcomes of a historical cohort of Aboriginal and Torres Strait Islanders people in Far North Queensland with biopsy-proven LN. Methods This is a retrospective observational study, and the study was conducted in Cairns and Hinterland Hospital and Health Service, Queensland, Australia. The study included Aboriginal and Torres Strait Islander patients with biopsy-proven LN treated between 1990 and 2013. The main outcome measures were renal replacement therapy and overall patient survival. Results Aboriginal and Torres Strait Islander people represented a substantial proportion (n = 16/40, 40%) of all patients diagnosed with LN during the observation period. The frequency of nephrotic range proteinuria (n = 11/14, 78.5%), estimated glomerular filtration rate <60 mL/min/1.73 m(2) (n = 6/14, 42.8%) and proliferative LN (n = 13/16, 81.25%) was high at the time of presentation. Despite use of multiple immunosuppressive agents, the overall rate of remission was poor (n = 4/14, 28.5%) and incidence of end-stage kidney disease (n = 4/14, 28.5%) and death (n = 5/16, 31.25%) was high. Conclusions The clinical presentation of LN in Aboriginal and Torres Strait Islanders in Far North Queensland is severe and the response to standard immunosuppressive therapy is unsatisfactory. Larger prospective multi-centre studies are required to better understand ethnic disparities in prognosis and response to immunosuppressive therapy in this specific population

Lupus nephritis in Indigenous Australians: a single-centre study

Background The incidence, presentation and outcomes of lupus nephritis (LN) vary with geography, ethnicity, socioeconomic status and gender. There are relatively few data on LN in the non-Caucasian populations in Australia. Aims To describe the clinical presentation, histological features, natural history, and outcomes of a historical cohort of Aboriginal and Torres Strait Islanders people in Far North Queensland with biopsy-proven LN. Methods This is a retrospective observational study, and the study was conducted in Cairns and Hinterland Hospital and Health Service, Queensland, Australia. The study included Aboriginal and Torres Strait Islander patients with biopsy-proven LN treated between 1990 and 2013. The main outcome measures were renal replacement therapy and overall patient survival. Results Aboriginal and Torres Strait Islander people represented a substantial proportion (n = 16/40, 40%) of all patients diagnosed with LN during the observation period. The frequency of nephrotic range proteinuria (n = 11/14, 78.5%), estimated glomerular filtration rate <60 mL/min/1.73 m(2) (n = 6/14, 42.8%) and proliferative LN (n = 13/16, 81.25%) was high at the time of presentation. Despite use of multiple immunosuppressive agents, the overall rate of remission was poor (n = 4/14, 28.5%) and incidence of end-stage kidney disease (n = 4/14, 28.5%) and death (n = 5/16, 31.25%) was high. Conclusions The clinical presentation of LN in Aboriginal and Torres Strait Islanders in Far North Queensland is severe and the response to standard immunosuppressive therapy is unsatisfactory. Larger prospective multi-centre studies are required to better understand ethnic disparities in prognosis and response to immunosuppressive therapy in this specific population

Neutrophil–lymphocyte ratio predicts cardiovascular and all-cause mortality in hemodialysis patients

Neutrophil–lymphocyte ratio (NLR) is a marker of systemic inflammation that has been shown to predict mortality in patients with malignancies, ischemic heart disease and peripheral vascular disease. Its prognostic value in hemodialysis patients is unclear. The aims of this study were to: (i) explore the relationship between NLR and other biochemical parameters and (ii) to examine the value of NLR as a predictor of cardiovascular and all-cause mortality in hemodialysis patients. The study included all the incident hemodialysis patients from a single center between 2007 and 2012. NLR was calculated using samples obtained 3 months after commencing hemodialysis. One hundred seventy hemodialysis patients were included with a median follow-up of 37 months. There were 54 deaths (32%). NLR was positively correlated with C-reactive protein (r=0.24, p=0.0023) and negatively correlated with hemoglobin (r=-0.27, p=0.00048), albumin (r=-0.23, p¼0.0034) and total cholesterol (r=-0.17, p=-0.049) levels. In multivariate Cox regression, NLR was independently associated with both all-cause mortality (adjusted hazard ratio [HR] 1.4; 95% confidence interval [CI], 1.2–1.6; p<=0.0001) and cardiovascular death (HR 1.3, 95% CI 1.1–1.6, p=0.0032). Other predictors of all-cause mortality were age (HR 1.6 per decade; 95% CI, 1.2–2.1; p=0.0017), body mass index (HR 0.93; 95% CI, 0.88–0.98; p=0.0047), albumin (HR 0.91; 95% CI, 0.86–0.97; p=0.0035) and peripheral vascular disease (HR 2.7; 95% CI, 1.4–5.1; p=0.0023). NLR is a practical, cost-efficient and easy to use predictor of cardiovascular and all-cause mortality in incident hemodialysis patients

Predictors of patency after balloon angioplasty in hemodialysis fistulas: a systematic review

Percutaneous transluminal angioplasty (PTA) is an established treatment for dysfunctional hemodialysis fistulas. This article systematically reviews evidence for predictors of patency after PTA. Outcomes assessed were primary, assisted primary, and secondary patency after intervention, and findings were summarized descriptively. This review included 11 nonrandomized observational studies of 965 fistulas in 939 patients. Follow-up ranged from 0 days to 10 years. Study quality was overall suboptimal. Newer fistulas and longer lesion length may be associated with primary patency loss after PTA. Further studies are needed to confirm these findings, to identify potentially modifiable factors, and to guide the testing of new endovascular devices

Factors associated with patency following angioplasty of hemodialysis fistulae

Purpose: Patency after percutaneous transluminal angioplasty of native hemodialysis arteriovenous fistulae (AVFs) is highly variable. This study aimed to identify predictors of patency following angioplasty in native AVFs.\ud \ud Materials and Methods: All endovascular procedures performed in native AVFs between 2005 and 2013 at two institutions were retrospectively reviewed. Clinical, anatomic, biochemical, and medication variables were subjected to univariate and multivariate Cox regression analysis to identify predictors of post intervention primary and secondary patency.\ud \ud Results: During the study period, 207 patients underwent first angioplasty of their AVF. Follow-up ranged from 14 days to 8 years, during which another 247 endovascular interventions were performed to maintain patency. Post intervention primary patency rates at 6, 12, and 24 months were 66%, 49%, and 29%, respectively. Post intervention secondary patency rates at 6, 12, and 24 months were 94%, 84%, and 79%, respectively. On multivariate adjusted Cox regression analysis, upper-arm AVFs (P = .00072), AVFs less than 6 months of age (P = .0014), presence of multiple stenoses (P = .019), and degree of initial stenosis (P = .016) were significantly associated with shorter post intervention primary patency. A previously failed AVF was the only significant predictor of post intervention secondary patency loss (P = .0053).\ud \ud Conclusions: Anatomic factors related to the AVF location, AVF age, and the extent of the lesion are important predictors of restenosis after balloon angioplasty. Traditional cardiovascular risk factors, metabolic and inflammatory markers, and medications were not associated with post intervention patency