Preethi Yerram

Nephrogenic Systemic Fibrosis: A Mysterious Disease in Patients with Renal Failure—Role of Gadolinium-Based Contrast Media in Causation and the Beneficial Effect of Intravenous Sodium Thiosulfate

Nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis (NSF) is an emerging scleromyxedema-like cutaneous disorder of unknown cause that is seen in patients with renal failure, and the number of reported cases has grown significantly since its first recognition. Recent case reports associated the use of gadolinium (Gd3+)-based contrast agents with the development of NSF. Herein is reported an additional patient who had NSF and had multiple previous exposures to Gd3+-based magnetic resonance imaging studies and had marked improvement in pain and skin changes after a trial of intravenous sodium thiosulfate. Discussed are the possible association of Gd3+-based contrast media with the development of NSF and potential for the use of sodium thiosulfate in the treatment of NSF.

Fluid overload and acute kidney injury

Acute kidney injury is commonly encountered in critically ill patients, and is associated with worse outcomes. Fluid therapy is a key component in the management of these patients, often leading to fluid overload, especially in the setting of septic acute kidney injury. Emerging data overwhelmingly suggest that fluid overload in these patients may be associated with adverse outcomes. Management of such patients should include a strategy of early guided resuscitation, followed by careful assessment of fluid status, and early initiation of renal replacement therapy as soon as it is deemed safe, aiming for a neutral or negative fluid balance. This review will focus on the pathophysiological link between fluid overload and acute kidney injury, mechanisms of organ dysfunction in fluid overload, and strategies for management.

Chronic kidney disease and cardiovascular risk

Chronic kidney disease (CKD) is a global public health concern, and there is emerging a strong relationship between CKD and increased cardiovascular disease (CVD) risk. CKD in the presence of other co-morbidities such as type 2 diabetes mellitus (T2DM) and hypertension (HTN) can lead to early progression to end-stage renal disease (ESRD/stage V CKD) and confer a greater risk for CVD morbidity and mortality. CVD events are the leading cause of premature death in patients with CKD, even before their progression to ESRD, with the rate of CVD progression being twice as common compared with the general population. The higher mortality from CVD persists even after adjusting for most of the traditional risk factors, suggesting the possible contributions of uremia-related, nontraditional risk factors. This has led to the current understanding that the pathophysiology of CVD in CKD involves a complex interplay of both the traditional as well as nontraditional, uremia-related risk factors. This review will elaborate on the pathophysiology of CVD in CKD and will discuss the role of microalbuminuria (MAU)-proteinuria as a potential diagnostic and prognostic tool for CVD in CKD risk assessment.

Novel role for the incretins in blood pressure regulation.

Purpose of reviewIncretin-based therapies are currently being used in the treatment of type 2 diabetes mellitus (T2DM). Apart from glycemic control, these agents have been shown to have multiple extra-pancreatic effects, including their role in blood pressure (BP) regulation. This article will review the origins of incretins, the incretin axis, possible mechanisms of antihypertensive effect of these agents, as well as the recent evidence. Recent findingsPreclinical and clinical studies demonstrate the antihypertensive effects of glucagon-like peptide-1 (GLP-1) and its analogs in patients with T2DM and hypertension. This effect seems to be mediated through vasodilatation as well as modulation of renal sodium handling causing natriuresis, although the exact mechanisms are not fully known. SummaryIncretin-based therapies are emerging as a novel class of hypoglycemic agents that display antihypertensive properties. Given the small decreases in BP, it is unlikely that these agents will be used as stand-alone antihypertensive agents, but they may be an attractive option in patients with T2DM and hypertension.

Understanding essential hypertension from the perspective of the cardiometabolic syndrome

Hypertension (HTN) is an important modifiable risk factor for major health problems such as coronary heart disease, stroke, congestive heart failure, end-stage renal disease, and peripheral vascular disease. Because of the associated morbidity and mortality, and the cost to society, HTN is an important public health challenge. HTN is frequently associated with other cardiovascular disease risk factors constituting the cardiometabolic syndrome, which individually and synergistically influence the pathophysiology of HTN, and the resultant increased redox stress contributes to the remodeling changes in key organs such as the heart and kidney. Remodeling at the subcellular level, and extracellular matrix in the heart and kidney of the hypertensive Ren2 transgenic rat model of tissue angiotensin II overexpression (TG(mREN-2)27), compared with the Sprague Dawley control rat model, has been observed by light and electron microscopy and are discussed. A better understanding of the pathophysiology of HTN may provide clinician and researcher, tools to effectively investigate and manage this complicated disease process.

Obesity and chronic kidney disease: therapeutic implications

Obesity has now reached epidemic proportions, with far-reaching healthcare and economic implications. Obesity has been associated with end-organ damage in several tissues including the kidney and is one of the most important modifiable and preventable causes of death. Insulin resistance and the compensatory hyperinsulinemia, oxidative stress and adipocytokines, among others, have been implicated in the causation of obesity-related kidney damage. Obesity-related focal glomerulosclerosis is now a well recognized distinct histopathological entity and its pathophysiology has been related to the ‘hyperfiltration’ mechanism associated with increased renal plasma flow and glomerular filtration rate. This review will discuss the epidemiology and pathophysiology of obesity-related kidney damage with special focus on the central role of insulin resistance/hyperinsulinemia, adipocytokines and oxidative stress, as well as summarize the current evidence and recommendations in the management of this condition.

Technical and Clinical Complications of Intermittent Hemodialysis in the Intensive Care Unit

Abstract Acute kidney injury (AKI) requiring renal replacement therapy (RRT) in the intensive care unit (ICU) is a serious condition with high mortality. Although intermittent hemodialysis (IHD) and sustained low-efficiency dialysis (SLED) are viable alternatives to continuous renal replacement therapy (CRRT) in the management of AKI, these therapeutic modalities engender their own complications. Such complications can be classified generally into two broad categories, technical and clinical. The technical complications relate to vascular access problems, air embolism, hemolysis, and electrolyte and acid-base disorders. For example, a poorly functioning vascular access is a major cause of treatment “down time” in the acute setting. The clinical complications consist of bleeding, thrombosis, hypotension, hypoxemia, bio-incompatibility and allergic reactions, arrhythmias, febrile reactions, and dialysis dysequilibrium syndrome. Other important issues related to dialysis in an acute care setting consist of recovery of renal function, nutrition, and dose of dialysis in AKI. These complications and issues require prompt recognition and management. Although local expertise with the use of IHD/SLED in the management of AKI remains the key factor in determining outcome, prompt recognition and awareness of the above issues enhance such expertise.

A case of hypothermia on CRRT

A 64‐year‐old Asian man, with past medical history of hypertension, hypothyroidism, and hyperlipidemia, presented with 3 days history of fever associated with cough and worsening shortness of breath. Subsequent clinical course was complicated by acute lung injury leading to acute respiratory distress syndrome requiring positive pressure ventilation, septic shock requiring inotropic support, and acute kidney injury requiring continuous renal replacement therapy (CRRT). On day 3 of CRRT, the patient developed significant hypothermia (temporal temperature 27.5°C), which was successfully managed. Continuous renal replacement therapy was subsequently discontinued as renal function recovered and the patient was discharged home after a prolonged hospital stay. He currently remains off dialysis and is being followed as an outpatient for chronic kidney disease. In this article, we examine various aspects of pathophysiology and management of hypothermia on CRRT and review relevant literature in this field.

Unplanned Start of Hemodialysis and Transition to Community

Advances in medicine have helped fight disease allowing people to live longer, albeit with a myriad of chronic medical conditions. There is no universally accepted definition of “elderly, old, or older” person, but the generally accepted age range for this cohort is over 65 years. Those over the age of 80 years are considered “very-elderly.”