The chapter provides an overview of the management of the poisoned patient and introduces extracorporeal therapies to aid in detoxification. Indications for the use of hemodialysis, hemofiltration, and hemoperfusion are reviewed, and the principles underlying drug removal with each modality are described. Additional consideration is given to addition of chelating agents to augment clearance of metals, such as aluminum and iron. Clinical presentation, diagnosis, and therapeutic approach including extracorporeal treatment are described in detail for specific intoxicants: lithium, methanol, ethylene glycol, and salicylates. Comprehensive tables are included, containing drugs and intoxicants removed with extracorporeal therapy.

Non-adherence to hemodialysis (HD) is associated with increased morbidity and mortality. In this cross-sectional study, we compared correlates and rates of non-adherence between the US and Japan to determine if differences in patient knowledge about HD might account for international variation in adherence.

Renal involvement in non-Hodgkin lymphoma, especially mantle cell lymphoma (MCL) is rare.A 77-year-old man presented with acute kidney injury (AKI), which rapidly progressed to dialysis dependence.Kidney biopsy revealed patchy B-cell lymphocytic aggregates in the interstitium, which were positive for cyclin D1, consistent with atypical CD5-negative MCL as confirmed by the detection of translocation t(11;14) by FISH.Crescents were noted in 3 of 26 glomeruli; while PR-3 antineutrophil cytoplasmic antibody (ANCA) positivity and negative immunofluorescence suggested an additional pauci-immune (rapidly progressive) glomerulonephritis pattern of injury.Patient received chemotherapy (cyclophosphamide, vincristine, and prednisone), which improved his renal function and allowed for discontinuation of hemodialysis.However, he died from pulmonary hemorrhage 8 months after initial presentation.This is the first reported case of a patient with coexistence of renal MCL infiltration and ANCApositive pauci-immune glomerulonephritis.

Background: Acute kidney injury (AKI) is a growing global concern and often reversible. Saliva urea nitrogen (SUN) measured by a dipstick may allow rapid diagnosis. We studied longitudinal agreement between SUN and blood urea nitrogen (BUN) and the diagnostic performance of both. Methods: Agreement between SUN and BUN and diagnostic performance to diagnose AKI severity in AKI patients in the United States and Brazil were studied. Bland-Altman analysis and linear mixed effects models were employed to test the agreement between SUN and BUN. Receiver operating characteristics statistics were used to test the diagnostic performance to diagnose AKI severity. Results: We found an underestimation of BUN by SUN, decreasing with increasing BUN levels in 37 studied patients, consistent on all observation days. The diagnostic performance of SUN (AUC 0.81, 95% CI 0.63-0.98) was comparable to BUN (AUC 0.85, 95% CI 0.71-0.98). Conclusion: SUN reflects BUN especially in severe AKI. It also allows monitoring treatment responses. Video Journal Club ‘Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=445041.

Objective: Methanol poisoning can induce death and disability. Treatment includes the administration of antidotes (ethanol or fomepizole and folic/folinic acid) and consideration of extracorporeal treatment for correction of acidemia and/or enhanced elimination. The Extracorporeal Treatments in Poisoning workgroup aimed to develop evidence-based consensus recommendations for extracorporeal treatment in methanol poisoning. Design and Methods: Utilizing predetermined methods, we conducted a systematic review of the literature. Two hundred seventy-two relevant publications were identified but publication and selection biases were noted. Data on clinical outcomes and dialyzability were collated and a two-round modified Delphi process was used to reach a consensus. Results: Recommended indications for extracorporeal treatment: Severe methanol poisoning including any of the following being attributed to methanol: coma, seizures, new vision deficits, metabolic acidosis with blood pH ≤7.15, persistent metabolic acidosis despite adequate supportive measures and antidotes, serum anion gap higher than 24 mmol/L; or, serum methanol concentration 1) greater than 700 mg/L (21.8 mmol/L) in the context of fomepizole therapy, 2) greater than 600 mg/L or 18.7 mmol/L in the context of ethanol treatment, 3) greater than 500 mg/L or 15.6 mmol/L in the absence of an alcohol dehydrogenase blocker; in the absence of a methanol concentration, the osmolal/osmolar gap may be informative; or, in the context of impaired kidney function. Intermittent hemodialysis is the modality of choice and continuous modalities are acceptable alternatives. Extracorporeal treatment can be terminated when the methanol concentration is <200 mg/L or 6.2 mmol/L and a clinical improvement is observed. Extracorporeal Treatments in Poisoning inhibitors and folic/folinic acid should be continued during extracorporeal treatment. General considerations: Antidotes and extracorporeal treatment should be initiated urgently in the context of severe poisoning. The duration of extracorporeal treatment extracorporeal treatment depends on the type of extracorporeal treatment used and the methanol exposure. Indications for extracorporeal treatment are based on risk factors for poor outcomes. The relative importance of individual indications for the triaging of patients for extracorporeal treatment, in the context of an epidemic when need exceeds resources, is unknown. In the absence of severe poisoning but if the methanol concentration is elevated and there is adequate alcohol dehydrogenase blockade, extracorporeal treatment is not immediately required. Systemic anticoagulation should be avoided during extracorporeal treatment because it may increase the development or severity of intracerebral hemorrhage. Conclusion: Extracorporeal treatment has a valuable role in the treatment of patients with methanol poisoning. A range of clinical indications for extracorporeal treatment is provided and duration of therapy can be guided through the careful monitoring of biomarkers of exposure and toxicity. In the absence of severe poisoning, the decision to use extracorporeal treatment is determined by balancing the cost and complications of extracorporeal treatment to that of fomepizole or ethanol. Given regional differences in cost and availability of fomepizole and extracorporeal treatment, these decisions must be made at a local level.

Background and objectives Patients with ESRD on dialysis live in a complex sociomedical situation and are dependent on technology and infrastructure, such as transportation, electricity, and water, to sustain their lives. Interruptions of this infrastructure by natural disasters can result in devastating outcomes.Design, setting, participants, & measurements Between November of 2013 and April of 2014, a cross-sectional survey was conducted of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy on October 29, 2012 in lower Manhattan, New York. The primary outcome was the number of missed dialysis sessions after the storm. Dialysis-specific and general disaster preparedness were assessed using checklists prepared by the National Kidney Foundation and US Homeland Security, respectively.Results In total, 598 patients were approached, and 357(59.7%) patients completed the survey. Participants were 60.2% men and 30.0% black, with a median age of 60 years old; 94 (26.3%) participants missed dialysis (median of two sessions [quartile 1 to quartile 3 = 1-3]), and 236 (66.1%) participants received dialysis at nonregular dialysis unit(s): 209 (58.5%) at affiliated dialysis unit(s) and 27 (7.6%) at emergency rooms. The percentages of participants who carried their insurance information and detailed medication list were 75.9% and 44.3%, respectively. Enhancement of the dialysis emergency packet after the hurricane was associated with a significantly higher cache of medical records at home at follow-up survey (P<0.001, Fisher's exact test). Multivariate Poisson regression analysis showed that dialysis-specific preparedness (incidence rate ratio, 0.91; 95% confidence interval, 0.87 to 0.98), other racial ethnicity (incidence rate ratio, 0.34; 95% confidence interval, 0.20 to 0.57), dialysis treatment in affiliated units (incidence rate ratio, 0.69; 95% confidence interval, 0.51 to 0.94), and older age (incidence rate ratio, 0.98; 95% confidence interval, 0.97 to 0.99) were associated with a significantly lower incidence rate ratio of missed dialysis.Conclusions There is still room to improve the preparedness for natural disasters of patients with ESRD. Provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.

Introduction and Aims: Acute kidney injury (AKI) is an important public health problem.AKI is a risk factor for progression of kidney disease, incidence of chronic kidney disease (CKD) and mortality.The aim of the study was to assess characteristics, renal survival and mortality of patients who developed AKI stage 3, according to KDIGO guidelines, and needed renal replacement therapy (RRT), not in intensive care unit.Methods: All patients who required RRT due to AKI stage 3 along two years were included, excluding patients in intensive care unit.Demographic and personal history data, previous renal function, cause of AKI, renal function, renal survival, and mortality at one, three, six and twelve months after AKI were recorded.Results: A total of 107 patients were enrolled (incidence 134 patients/106 population/ year).Mean age 72.2±13.9(range 25-92), 57.9% men.Patient's characteristics: 77.6% were hypertensive, 40.2% were diabetics, 45.8% were dyslipemics, 41.1% were obese, 27.1% were smokers, and 61.2% with chronic renal failure (eFG<60mil/min) of which 54% stage 3, 36.5% stage 4, and 9.5% stage 5. Cause of AKI: renal disease 63.6%, prerrenal 28.9% and obstructive causes 7.5%.Renal function: Serum creatinine before AKI 1.78±1.12mg/dL; maximum serum creatinine during AKI hospitalization 7.39 ±4.43mg/dL; at discharge, 2.64±1.62mg/dL;one month later, 2.07±1.36mg/dL;three months later, 2.35±1.60mg/dL;six months later, 2.25±1.85mg/dLand one year later, 1.95±1.14mg/dL.During hospitalization, 24.3% died, 16.8% kept on RRT at discharge, and 58.9% recovered partial or completely renal function.One month after AKI, 31.7% had died, 15.8% kept on RRT, and 52.5% preserved renal function, 5.6% was missing.Three months later, 45.7% died, 10.9% kept on RRT, and 43.5% preserved renal function, 14% was missing.Six months later, 48.3% had die, 10% kept on RRT, and 33.3% preserved renal function, 8.3% were missing.Finally, one year after AKI, 71.8% of patients had died, 9.9% needed RRT, 18.3% recovered partial or completely renal function and 33.6% missing.AKI in diabetic or dyslipemic patients has an increased mortality ( p=0.03 and p=0.06 respectively).CKD before AKI is not associated with increased mortality.Renal function according to KDOQI classification of patients who had AKI stage 3 was: at discharge: stage 1 1.6%, 2 16.1%, 3 24.2%, 4 37.1% and 5 21.0%; three months after AKI : stage 1 2.5%, 2 15%, 3 30%, 4 32.5% and 5 17.5%; six months after AKI: 1 6.5%, 2 12.9%, 3 38.7%, 4 19.4% and 5 19.4% and one year after AKI, renal function was: 2 25%, 3 41.7%, 4 25% and 5 8.3%.Conclusions: In our health area AKI stage 3 requiring RRT have a incidence similar to other studies.Mortality in AKI patients exceeds 70% one year after AKI episode and renal survival decreases in this period.Nephrology follow-up must be established in patients who survive AKI.The develop of tools to identify high-risk patients and to promote renal recovery is important to reduce burden of CKD and mortality.

Calcific uremic arteriolopathy (CUA) is a rare and potentially fatal disorder of calcification involving subcutaneous small vessels and fat in patients with renal insufficiency. We describe the successful use of intravenous sodium thiosulfate (STS) for the treatment of CUA in two patients. The first case was complicated by the development of a severe anion gap metabolic acidosis, which was accompanied by a seizure. Both patients had complete wound healing within five months. Although STS should be considered in the treatment of CUA, little is known about pharmacokinetics and additional studies are required to determine dosing strategies to minimize severe potential side effects.

Artificial OrgansVolume 37, Issue 6 p. 497-498 In Memoriam George E. Schreiner, MD: A Man for All Seasons James F. Winchester MD, FRCP (Glas), FACP, James F. Winchester MD, FRCP (Glas), FACP Professor of Clinical Medicine, Chief, Vice Chair JWinches@chpnet.org Albert Einstein College of Medicine, Beth Israel Medical Center, New York, NY, 10003 USA Division of Nephrology & Hypertension, Beth Israel Medical Center, New York, NY, 10003 USA Department of Medicine, Beth Israel Medical Center, New York, NY, 10003 USASearch for more papers by this author James F. Winchester MD, FRCP (Glas), FACP, James F. Winchester MD, FRCP (Glas), FACP Professor of Clinical Medicine, Chief, Vice Chair JWinches@chpnet.org Albert Einstein College of Medicine, Beth Israel Medical Center, New York, NY, 10003 USA Division of Nephrology & Hypertension, Beth Israel Medical Center, New York, NY, 10003 USA Department of Medicine, Beth Israel Medical Center, New York, NY, 10003 USASearch for more papers by this author First published: 11 June 2013 https://doi.org/10.1111/aor.12101Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume37, Issue6June 2013Pages 497-498 RelatedInformation