In the current paper, we will focus on requirements to ensure big data can advance the outcomes of our patients suffering from kidney disease. The associated ethical question is whether and how we as a nephrology community can and should encourage the collection of big data of our patients. We identify some ethical reflections on the use of big data, and their importance and relevance. Furthermore, we balance advantages and pitfalls and discuss requirements to make legitimate and ethical use of big data possible.  The collection, organization, and curation of data come upfront in the pipeline before any analyses. Great care must therefore be taken to ensure quality of the data at this stage, to avoid the 'garbage in garbage out' problem and suboptimal patient care as a consequence of such analyses.  Access to the data should be organized so that correct and efficient use of data is possible. This means that data must be stored safely, so that only those entitled to do so can access them. At the same time, those who are entitled to access the data should be able to do so in an efficient way, so as not to hinder relevant research.  Analysis of observational data is itself prone to many errors and biases. Each of these biases can finally result in provision of low-quality medical care. Secure platforms should therefore also ensure correct methodology is used to interpret the available data. This requires close collaboration of a skilled workforce of experts in medical research and data scientists. Only then will our patients be able to benefit fully from the potential of AI and big data.

With the increasing frequency and severity of disasters and the increasing number of patients living with kidney disease, on dialysis and with transplants around the world, the need for kidney care in humanitarian settings is increasing. Almost all humanitarian emergencies pose a threat to kidney health because all treatments are highly susceptible to interruption, and interruption can be deadly. Providing support for people requiring dialysis in humanitarian settings can be complex and is associated with many trade-offs. The global kidney care community must become familiar with the ethics, principles and duties essential to meeting the overarching goals of ethical and effective disaster relief. Ethics principles and values must be considered on the individual, public health and global levels. The wellbeing of a single patient must be considered in the context of the competing needs of many others, and optimal treatment may not be possible due to resource constraints. Public health ethics principles, including considerations of triage and resource allocation, maximization of benefit and feasibility, often become directly relevant at the bedside. Individuals delivering humanitarian relief must be well trained, competent, respectful and professional, while involved organizations need to uphold the highest professional and ethical standards. There may be dissonance between ethical guidance and practical realities in humanitarian settings, which for inexperienced individuals may present significant challenges. Sustaining dialysis care in emergencies brings these issues starkly to the fore. Preparedness for dialysis in emergencies is an ethical imperative that mandates multisectoral stakeholder engagement and action, development of surge response plans, clinical and ethics guidance, and transparent priority setting. This manuscript outlines common ethics challenges and considerations that apply in all humanitarian actions, and illustrates their relevance to kidney care as a whole, using examples of how these may apply to dialysis and kidney disaster relief efforts in humanitarian settings.

Due to the shortage of deceased and genetically- or emotionally-related living donors, living unrelated paid donor (LURpD) kidney transplantation has been considered; however, this practice may result in medical, ethical and social dilemmas, induce organ trading (commodification), and even criminal activities. Commodification also risks undermining public trust in the transplant system and impeding the development of proper altruistic or deceased donor programs by ignoring altruism, volunteerism, and dignity. However, despite many objections by authoritative organizations, black market practices are involved in up to 10% of all transplants worldwide. The authors strongly discourage any payment or rewards for organ donation, and instead urge the governments of all countries to provide adequate and accessible kidney health care. However, it is an undeniable fact that paid-living donor transplantation is increasing despite all objections, disapprovals and regulations. We feel it as our responsibility not to ignore this uncertain and undesirable practice, but rather to underline the necessity for strict rules and prohibitions to minimize unacceptable medical, social and ethical risks as long as it exists. Furthermore, economic profit, be it direct or indirect, must not be the goal of those involved, and the employment of intermediaries must be avoided entirely. Additionally, the donor should be in a position where not donating has no detrimental effect on his/her future in any way (free agency). In our view, every country has the obligation and responsibility to provide adequate kidney health care and to make kidney transplantation accessible to those in need. This provision is key to stop transplant tourism and commercialization of kidney transplantation. The nephrology community has a duty to establish structures that optimize organ availability within strict ethical limits. The legal position of LURpD varies considerably worldwide. Strictly respecting each country's legislation and local values is mandatory to minimize medical and ethical risks and controversies.

ABSTRACT Mass disasters are characterized by a disparity between healthcare demand and supply, which hampers complex therapies like kidney transplantation. Considering the scarcity of publications on previous disasters, we reviewed transplantation practice during the recent coronavirus disease 2019 (COVID-19) pandemic, and dwelled upon this experience to guide transplantation strategies in the future pandemic and non-pandemic catastrophes. We strongly suggest continuing transplantation programs during mass disasters, if medical and logistic operational circumstances are appropriate. Postponing transplantations from living donors and referral of urgent cases to safe regions or hospitals are justified. Specific preventative measures in anticipated disasters (such as vaccination programs during pandemics or evacuation in case of hurricanes or wars) may be useful to minimize risks. Immunosuppressive therapies should consider stratifying risk status and avoiding heavy immune suppression in patients with a low probability of therapeutic success. Discharging patients at the earliest convenience is justified during pandemics, whereas delaying discharge is reasonable in other disasters, if infrastructural damage results in unhygienic living environments for the patients. In the outpatient setting, telemedicine is a useful approach to reduce the patient load to hospitals, to minimize the risk of nosocomial transmission in pandemics and the need for transport in destructive disasters. If it comes down to saving as many lives as possible, some ethical principles may vary in function of disaster circumstances, but elementary ethical rules are non-negotiable. Patient education is essential to minimize disaster-related complications and to allow for an efficient use of healthcare resources.

Die akute Nierenschädigung stellt ein bedeutsames Problem kritisch kranker Patienten auf der Intensivstation dar und sollte als Systemerkrankung mit Konsequenzen für alle Organsysteme verstanden werden. Maßnahmen zur Prävention müssen daher frühzeitig eingeleitet werden. Wird trotzdem eine extrakorporale Nierenersatztherapie notwendig, ist eine individuelle Therapieform unter der Berücksichtigung der jeweiligen klinischen Situation für den einzelnen Patienten festzulegen.

Zusammenfassung Eine akute Nierenschädigung (AKI) tritt heute bei 50 % aller kritisch kranken Patienten auf und etwa 15 % müssen mit einer Nierenersatztherapie (NET) behandelt werden. Obwohl eine NET ein häufiges und essenzielles Organersatzverfahren in der deutschen Intensivmedizin darstellt, ist es ist nicht bekannt, in welchem Umfang Nierenersatzverfahren zur Verfügung stehen, wer mit welcher Qualifikation eine NET durchführt, welche Formen der Antikoagulation verwendet werden und wie die Dosis der NET verschrieben wird. Die Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI) hat deshalb Ende 2019 unter ihren Mitgliedern eine Umfrage zu den strukturellen Gegebenheiten der NET in ihrem Arbeitsumfeld durchgeführt. Es konnten 897 Datensätze erfasst werden (31,1 % der Befragten), anhand derer die aktuellen strukturellen und prozeduralen Gegebenheiten bei der Durchführung der NET auf deutschen Intensivstationen beschrieben werden können. Es waren Krankenhäuser aller Versorgungsstufen vertreten, allerdings waren Krankenhäuser mit einer Bettenzahl von > 400 Betten (69,1 %) und Krankenhäuser der Schwerpunkt- und Maximalversorgung und Unikliniken (74,5 %) verstärkt vertreten. Kontinuierliche Nierenersatzverfahren stehen auf 93,3 % und intermittierende Verfahren auf 75,8 % der Intensivstationen in Deutschland zur Verfügung. Die Indikation zur NET wird in 91,9 % durch eine/n Facharzt/Fachärztin oder einen Facharzt/Fachärztin mit Zusatzweiterbildung Intensivmedizin und/oder Nephrologie gestellt. In Fragen der Therapiedurchführung sind jedoch Aspekte der Dialysedosis besser zu implementieren und dokumentieren.

Zusammenfassung Die Nierenersatztherapie ist neben der Beatmung eines der wichtigsten und am häufigsten angewendeten Organersatzverfahren in der täglichen Praxis in der Intensivmedizin. Im Gegensatz zur Beatmungstherapie sind Qualitätsstandards für die Nierenersatztherapie weniger gut definiert und bekannt. In diesem Positionspapier der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) beschreiben wir Qualitätsstandards zur Nierenersatztherapie mit dem Ziel die Behandlungsqualität der Patienten mit einem schweren akuten Nierenversagen zu verbessern.

Renal replacement therapy is after mechanical ventilation one of the most important and frequently used organ replacement therapies in daily routine intensive care practice. In contrast to mechanical ventilation, quality standards for renal replacement therapy are less well known and defined. In this position paper of the German Interdisciplinary Association for Intensive Care and Emergency Medicine, we describe quality standards of renal replacement procedures in order to improve therapy of patients with severe acute kidney injury.

ZUSAMMENFASSUNG Das akute Nierenversagen (ANV) stellt ein häufiges Problem bei der Versorgung intensivmedizinischer Patienten dar. Daten aus den USA belegen zudem eine Zunahme der Inzidenz des ANV von 10 % pro Jahr über die letzten 10 Jahre. Die Mortalität des ANV ist dabei unverändert hoch und liegt abhängig vom Stadium und Begleiterkrankungen zwischen 20 und 80 %. Die Indikation für die Einleitung einer akuten Nierenersatztherapie wird auf den Intensivstationen überwiegend von Anästhesisten gestellt. Auf Intensivstationen kleiner Krankenhäuser werden i. d. R. von Anästhesisten kontinuierliche Verfahren eingesetzt, während Internisten mit ambulanter nephrologischer Begleitung häufig intermittierende Hämodialyseverfahren einsetzen. Während es klare Empfehlungen zum Beginn einer Nierenersatztherapie für therapierefraktäre, vital bedrohliche Zustände gibt, ist die Datenlage für andere Situation unsicher. Seit der Publikation von 2 großen Studien ist die Frage der Dosis der Nierenersatztherapie allgemein konsentiert. Es konnte weder ein Überlebensvorteil noch eine Verbesserung der Organfunktion bei einer Steigerung der Dosis von 20–25 ml/kg KG/h beobachtet werden. Die KDIGO-Leitlinien empfehlen den Einsatz der regionalen Zitratantikoagulation, neuere Daten unterstützen auch den Einsatz bei Leberversagen oder Schock. Sollte dieses Verfahren nicht zur Verfügung stehen, sind SOPs für Patienten mit Blutungsrisiko zu entwickeln.

Objectives The International Society of Nephrology (ISN) has called for zero deaths by 2025. This survey aimed to determine the preparedness of Southern African Development Community (SADC) countries and Nigeria to heed this call. Setting A questionnaire was emailed to facilities, where renal replacement therapy is available; to determine type of services available; quality of care and identify clinicians involved. Participants Clinicians and administrators involved in the care of patients with acute kidney injury (AKI) completed the questionnaire. Results Completed questionnaires were received from 12 of the 15 SADC countries and Nigeria, covering 48 service providers. The government provided partial funding for dialysis in 41.7% of services. There was no funding for acute dialysis in two countries. Interdisciplinary teams in 72.9% of hospitals covered the intensive care units (ICUs), which included at least one nephrologist in 75%. Only 77% were able to provide dialysis in ICU. Intermittent haemodialysis was the most common modality available (91.7% of facilities), sustained low-efficiency dialysis in 50%, continuous therapies in 35% and peritoneal dialysis in 33.3%. Almost half (47.9%) of the sites were limited to one mode of dialysis and unable to care for severely ill patients. The clinical status was used to initiate and monitor dialysis, with very few sites having clear written standard operating procedures. Conclusion In the 16 countries surveyed, the majority had limited ability to provide comprehensive dialysis programmes for patients with AKI due to lack of facilities and government funding. Additionally, nephrologists are scarce; modes of dialysis are limited; as is the care for severely ill patients and lack of standard operating procedures. Resources, training and funding need to be made available to create universal coverage of dialysis for AKI. The ISN goal of providing renal replacement therapy to all by 2025 is unlikely to be achieved in SADC and Nigeria.

AIM:To study the demographics and outcome of acute kidney injury (AKI) at Groote Schuur Hospital, Cape Town, South Africa.METHODS AND FINDINGS:A prospective observational study of AKI fulfilling the Kidney Disease: Improving Global Outcomes definition, from 8 July 2012 to 8 July 2013. Ethics approval was granted by the University of Cape Town Human Research Ethics Committee. Consent was waived because patient data was de-identified and patient management was not adversely affected by the study. A clerking sheet was used for data collection. Patients were reassessed after 3 months. Main outcomes were renal recovery and 3 month mortality. Descriptive statistics and multivariate logistic regression were carried out for risk factors. Over this period there were 10,750 hospital admissions and 366 patients with AKI giving an incidence of 3.4%. Median age was 44 years (IQR 14-82) and 214 (58.5%) were male, with 152 (41.5%) female. Most, 265 (72.4%), had community acquired AKI. Common underlying comorbidities were hypertension (n = 152, 41.5%), diabetes mellitus (n = 65, 17.8%) Human immunodeficiency virus (HIV) (n = 75, 20.6%), heart disease (n = 58, 16.1%), and chronic kidney disease (n = 37, 10.1%). Renal biopsies were performed in 36 (9.8%) patients. In total, 202 (55.2%) patients were in the intensive care unit, and of the whole study population 204 (55.7%) were dialysed. Those admitted to ICU who required dialysis amounted to 145 (39.6%). The overall 3 month mortality was 38.8%. Among the 145 patients dialysed in ICU, there were 71 deaths (49%) at 3 month follow up. Of the 119 patients with follow up serum creatinine, 95 (79.8%) had full renal recovery, and 4 (3.4%) had end-stage renal disease. On multivariate analysis, mechanical ventilation was associated with 3 month mortality (OR 2.46, p-value 0.019, 95% CI 1.41-4.03). Sepsis had a borderline significant association (OR 1.83, P-value 0.066, 95%CI 1.02-3.27), as did prolonged time to dialysis (OR 1.93, p-value 0.08, 095% CI 0.93-4.03). HIV status did not affect outcome. The main study limitations were the large numbers of patients with AKI stage 3, reflecting the fact that the institution is a tertiary referral centre and that patients with earlier stages of AKI tended not to be referred. Another study limitation was the low number of patients who were available for follow up for 3 month serum creatinine.CONCLUSIONS:The incidence of AKI in the population studied is 3.4% of hospital admissions and carries a high mortality risk, most significant in mechanically ventilated patients. Sepsis and late dialysis initiation may carry a risk of mortality, but HIV infection did not affect outcome. Follow up of patients at least 3 months after an episode of AKI is essential to detect and appropriately manage those with incomplete renal recovery. In this study 36 patients underwent a kidney biopsy, and in many of these the results guided patient management. This study demonstrates finally that it remains imperative that clinicians actively pursue underlying causes of acute decline in renal function, including urine analysis, renal ultrasonography and if indicated and safe, a renal biopsy.

BACKGROUNDAcute interstitial nephritis (AIN) is a common cause of acute kidney injury that has not been adequately characterized in Sub-Saharan Africa (SSA) despite an increasing use of potentially inciting agents for the treatment of human immunodeficiency virus (HIV) and tuberculosis in the region.METHODSA retrospective audit of records of patients with biopsy-proven AIN diagnosed at Groote Schuur Hospital, Cape Town from the 1st of January, 2006, to the 31st of December, 2015.RESULTS54 patients with biopsy-proven AIN were reviewed. The majority were of black African origin (59.2%), with HIV (42.8%) and HIV-tuberculosis coinfection (30.5%) as the most common comorbidities. Drug-related AIN was seen in 38 (67.9%) patients, with rifampicin as the most often implicated medication. Probable drug-related AIN was seen in 3 (5.4%) patients, infection-related AIN in 8 (14.3%), and unspecified causes in 4 (7.4%). AIN was suspected in 44.6% of patients before biopsy. 18 patients (34%) received hemodialysis, while 19 (35.2%) were treated with corticosteroids. Complete renal recovery at 30 and 90 days was seen in 23 (42.6%) patients and 24 (45.3%) patients, respectively, with the majority seen among those with drug-induced AIN. Six (11.1%) patients died; 4 (10.5%) of the patients were in the drug-related group. There was no correlation between degree of interstitial inflammation and severity of renal failure (p = 0.10). On multivariate logistic regression, drug-related causes of AIN were predictive of complete recovery at day 30 (OR 16.63; 95% CI: 1.71 - 161.6, p = 0.02), and presence of interstitial fibrosis reduced likelihood of recovery (OR 0.03; 95% CI 0.002 - 0.46, p = 0.012). Steroid use did not influence partial recovery (OR 0.59, 95% CI 0.17 - 1.77; p = 0.32) or complete recovery (OR 3.38, 95% CI 0.38 - 30.39, p = 0.28).CONCLUSIONSAIN is common in patients with HIV or those on treatment for tuberculosis. Drug-related AIN is often associated with improved outcomes. This is particularly reassuring in the SSA region where the use of potentially-inciting medications is rife from a high burden of HIV and tuberculosis.
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BACKGROUND:Mortality of critically-ill patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT) in an intensive-care setting continues to remain high. There is still uncertainty as to which factors should guide clinical judgement.METHODS:A cohort of 155 patients admitted to an intensive-care unit and necessitating RRT due to AKI were retrospectively analyzed. Demographic and clinical parameters at the time of RRT initiation were retrieved. Multi- and univariate analyses were performed to determine the impact of different risk factors on mortality.RESULTS:The most common causes of AKI were sepsis (39.3%) and cardiac events (32%). The majority of patients were treated by continuous (67.3%), the others by intermittent RRT. After 30 days, 51.0% of patients survived. Nonsurvivors were older (73 vs. 69 years), had a higher APACHEE II score (30.1 ± 5.6 vs. 26.5 ± 7.1), and were more likely to be vasopressor dependent, mechanically ventilated, or treated by continuous RRT. Multivariate analysis revealed that higher age, higher APACHEE II score, and lower serum creatinine at baseline were independent predictors for mortality, whereas histories of diabetes mellitus, arterial hypertension, coronary heart disease, or stroke were not.CONCLUSION:Critically-ill patients with AKI requiring RRT continue to have a high mortality. Age and APACHE II score showed an impact on mortality whereas traditional cardiovascular risk factors did not. Higher BUN and creatinine levels do not have a negative impact on mortality. Our findings support the current practice that RRT initiation should primarily be guided by clinical decision.
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BACKGROUNDAlthough citrate dialysate (CiDi) is regarded to be safe, dialysis modalities using higher dialysate volumes, like haemodiafiltration (HDF), may expose patients to higher citrate load and thus increase the risk of complications. We investigated the residual risk of CiDi compared with standard dialysate (StDi) in patients on different dialysis modalities and its effect on dialysis dose.METHODSIn a multicentre randomized crossover study, 92 dialysis patients (HDF post-dilution: n = 44, HDF pre-dilution: n = 26, haemodialysis: n = 25) were treated for 4 weeks with each dialysate (StDi and CiDi). Hypocalcaemia (ionized calcium ≤0.9 mmol/L), alkalosis (pH ≥7.55), post-treatment bicarbonate ≥32 mmol/L, pre-treatment bicarbonate ≥27 mmol/L, intra-dialytic events (IEs) and adverse events (AEs) between dialysis sessions were investigated as primary end points. The secondary objective was dialysis efficacy, i.e. dose and removal ratios of urea, creatinine, phosphate and β-2-microglobulin.RESULTSPost-dialysis overcorrection of bicarbonate (>32 mmol/L) was less frequent with CiDi (P = 0.008). Other predefined calcium and acid-base disturbances did not vary. There was no significant difference in IE. However, more patients developed AEs such as fatigue, muscle spasms or pain using CiDi (StDi: 41 versus CiDi: 55 patients, P = 0.02), particularly in the first 2 weeks of exposure. Dialysis efficacy was comparable with both dialysates.CONCLUSIONSIt can be confirmed that CiDi is not associated with the development of severe calcium and acid-base disorders, even when dialysis modalities with higher citrate loads are used. However, a refinement of the CiDi composition to minimize AEs is necessary.

Introduction and Aims: Vascular endothelial growth factor (VEGF) promotes endothelial cell proliferation and differentiation and mediates endothelium dependent vasodilatation. Increased serum levels of VEGF have been reported in patients with acute coronary syndromes and gene transfer therapies habe been attemted in patients with coronary artery disease (CAD). We evaluated the impact of VEGF levels on the development of CAD in patients with end-stage renal disease. Methods:We studied n=105 patients on chronic dialysis with angiographically confirmed (n=45) or excluded (n=60) CAD, followed up for 3.5 ± 3.1 years after initiation of dialysis. VEGF serum levels at the time of coronany angiography were determined by ELISA. Results: A large variation in VEGF levels was noted among the dialysis patients (mean 440.1 ± 314 pg/dl, median 362.9 pg/dl, range 78.5-1672.0 pg/dl). A weak negativ association of VEGF levels with the time elapsed since the inatiation of dialysis was observed (r=-0.194, p=0.062). VEGF levels were not associated with the sex or the age of the patients, the presence of diabetes mellitus, secondary hyperthyroidism, smoking, treatment with statins, or CRP levels. VEGF levels did not differ significantly between patients with angiographically confirmed (428,4 ± 300) or excluded CAD (449,9 ± 327 pg/dl, ns). There was also no correlation between VEGF levels and the number of affected coronary artery vesels (one vesel CAD: 408,8 ± 259, two vesel CAD: 361,8 ± 291, three vesel CAD: 525,2 ± 379 pg/dl, ns). Furthermore, VEGF levels were similar among patients who expierenced myocardial infarction or underwend revascularization during follow up (447,5 ± 313) and the rest of the cohort (437,9 ± 317 pg/dl, ns). Conclusions: According to our results, VEGF levels are not associated with the demelopment of coronary artery disease in chronic dialysis patients.

Acute kidney injury (AKI) can be treated either by continuous forms of extracorporeal treatment (CRRT) or by intermittent hemodialysis (IHD). Treatment should be started early to avoid organ damage. In critically ill patients treated with CRRT a dosage of 25 ml/kg/h should be achieved to avoid further damage and to improve outcome. With intermittent hemodialysis fluid balancing often requires 4 to 5 treatments per week. Regional citrate anticoagulation (RCA) prevents bleeding complications. To optimize patient’s outcome individualized treatment strategies are required rather than prescribing by the traditional ‘one-size-fits-all’ approach.