Behdad Besharatian

Heme-pigment nephropathy after transurethral resection of prostate cancer

Introduction: Transurethral resection of the prostate is one of the most common surgical procedures performed in men to relieve bladder outlet obstruction, most often due to benign prostatic hyperplasia. However, transurethral resection of the prostate may also be used in patients with metastatic prostate cancer who have bladder outlet obstruction. Acute kidney injury after transurethral resection of the prostate has been described and attributed to a variety of mechanisms, including acute tubular necrosis, rhabdomyolysis, and hemolysis with heme-pigment nephropathy. However, to our knowledge, no case of kidney biopsy-proven heme-pigment nephropathy due to hemolysis from a transurethral resection of the prostate procedure has been published to date. Case description: We describe a case of an 82-year-old man with metastatic prostate cancer who presented with severe oliguric renal failure 2 weeks after transurethral resection of the prostate for bladder outlet obstruction. Laboratory studies showed evidence of hemolysis, and a kidney biopsy showed heme-pigment cast nephropathy. Conclusions: We hypothesize that the patient’s kidney injury was induced by hemolysis resulting from rapid absorption of hypotonic fluid administered during the transurethral resection of the prostate procedure. Patients with prostate cancer undergoing transurethral resection of the prostate for bladder outlet obstruction may experience severe complications related to rapid absorption of hypotonic fluid. Our case illustrates the importance of nephrology evaluation and kidney biopsy in patients with benign and malignant prostate conditions who experience post-transurethral resection of the prostate syndrome and acute kidney injury in order to better characterize these complications, and to develop preventative strategies for future cases.

The association of discharge decisions after deceased donor kidney transplantation with the risk of early readmission: Results from the deceased donor study

Kidney transplant (KT) recipients experience high rates of early (≤30 days) hospital readmission (EHR) after KT, and existing studies provide limited data on modifiable discharge factors that may mitigate EHR risk.

A case report curriculum to promote scholarship

Engaging in scholarly activity during residency can facilitate the acquisition of important skills; however, residents may encounter barriers such as unclear expectations as to what constitutes scholarship, a paucity of dedicated time and a lack of mentorship.

More May be Less; Yet Another Way which More Intense Renal Replacement Therapy May Not be Better

Comparison of Urine Output Among Patients Treated With More Intensive Versus Less Intensive RRT: Results From The Acute Renal Failure Trial Network Study. Mc Causland FR, Asafu-Adjei J, Betensky RA, Palevsky PM, Waikar SS. Clin J Am Soc Nephrol 11(8):1335–42, 2016 The question of when to initiate acute hemodialysis or continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) has been the subject of recent prospective clinical trials. Unfortunately, very different study designs, patient populations, and criteria for dialysis initiation led to conflicting findings, so the “when?” question remains unanswered. Once a decision is made to initiate RRT, the next question is often “how much” dialysis should be prescribed. While some studies suggested that more intensive RRT is associated with better outcomes (1–3), others found otherwise (4,5). Subsequently, two large multicenter randomized controlled trials evaluated the potential benefit of more intensive RRT (6,7). The ATN Study randomized 1124 critically ill patients in US hospitals initiating RRT to more intensive RRT [intermittent hemodialysis (iHD) or sustained low-efficiency dialysis (SLED) six times per week or continuous venovenous hemodiafiltration (CVVHDF) at 35 ml/ kg per hour] or less intensive RRT (iHD or SLED three times per week or CVVHDF at 20 ml/kg per hour). The RENAL Study was a multicenter trial conducted in Australia and New Zealand that randomized 1508 critically ill patients with AKI to receive RRT with CVVHDF that was intensive (40 ml/kg per hour) or less intensive (25 ml/kg per hour). Just as randomized controlled trials for the most part have not shown a significant benefit of CRRT compared to iHD for AKI (8–11), neither of these two studies showed a benefit of more intensive RRT on mortality, renal recovery, or other important outcomes. It has been postulated that in addition to greater removal of “uremic toxins” and other “evil humors” with more intensive renal replacement therapies, greater removal of beneficial substances, including antibiotics and undefined “good humors” with CRRT compared to iHD/SLED and more intensive CRRT compared to less intensive CRRT, may account for these findings. An additional possibility is now more squarely in the spotlight. Just as residual renal function has been associated with lower mortality in patients with ESRD (12–15), studies have suggested an association between higher urine volume and improved renal prognosis and mortality among patients with AKI (16–19). McCausland et al.(20), the subject of this commentary, hypothesized that more intensive RRT in the ATN study cohort would be associated with decreased urine output and that any such association might partially account for the lack of benefit of more intensive RRT for AKI. Their post hoc analysis of the ATN Study assessed the relationship between RRT intensity and changes in urine volume. The primary outcome of interest was the change in daily urine output among survivors through day 7 from the time of randomization (n = 871). Additional analyses examined the association between RRT intensity and need for continued RRT at days 28 and 60. The secondary outcome was time to ≥50% decline in daily urine output in the complete cohort from randomization through day 28 (n = 1103). Baseline characteristics of the two study groups were similar as were the average cardiovascular sequential organ failure assessment (CV-SOFA) scores, urine volumes (median = 264 ml/day in the less intensive group and 274 ml/day in the more intensive group), and ultrafiltration volumes achieved by RRT during the first 7 days of the study. In unadjusted analysis of the primary outcome, mean urine output averaged 32 ml/day higher in the less versus the more intensive groups (P = 0.01). Similar trends were seen with adjustments for baseline covariates including sex, age, race, oliguria, weight, height, heart disease, peripheral vascular disease, hypertension, Address correspondence to: Jeffrey S. Berns, MD, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 1 Founders Pavilion, Philadelphia, PA 19104, or e-mail: jeffrey.berns@uphs.upenn.edu Seminars in Dialysis—Vol 29, No 6 (November–December) 2016 pp. 515–517 DOI: 10.1111/sdi.12556