Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

Polyomavirus-associated nephropathy (PVAN) is an emerging cause of kidney transplant failure affecting 1-10% of patients. As uncertainty exists regarding risk factors, diagnosis, and intervention, an independent panel of experts reviewed the currently available evidence and prepared this report. Most cases of PVAN are elicited by BK virus (BKV) in the context of intense immunosuppression. No specific immunosuppressive drug is exclusively associated with PVAN, but most cases reported to date arise while the patient is on triple immunosuppressive combinations, often comprising tacrolimus and/or mycophenolate mofetil plus corticosteroids. Immunologic control of polyomavirus replication can be achieved by reducing, switching, and/or discontinuing components of the immunosuppressive regimen, but the individual's risk of rejection should be considered. The success rate of this intervention is increased with earlier diagnosis. Therefore, it is recommended that all renal transplant recipients should be screened for BKV replication in the urine: 1) every three months during the first two years posttransplant; 2) when allograft dysfunction is noted; and 3) when allograft biopsy is performed. A positive screening result should be confirmed in <4 weeks and assessed by quantitative assays (e.g. BKV DNA or RNA load in plasma or urine). Definitive diagnosis of PVAN requires allograft biopsy. If PVAN and concurrent acute rejection is diagnosed, antirejection treatment should be considered, coupled with subsequently reducing immunosuppression. The antiviral cidofovir is not approved for PVAN, but investigational use at low doses (0.25-0.33 mg/kg intravenously biweekly) without probenicid should be considered for refractory cases. Retransplantation after renal allograft loss to PVAN remains a treatment option for patients clearing polyomavirus replication.

Polyomavirus-Associated Nephropathy in Renal Transplantation: Interdisciplinary Analyses and Recommendations

Hyponatraemia, defined as a serum sodium concentration !135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association – European Dialysis and Transplant Association (ERA–EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

/pdf/clinical-practice-guideline-on-diagnosis-and-treatment-of-509w3449ob.pdf

Clinical practice guideline on diagnosis and treatment of hyponatraemia

https://www.kidney-international.org/article/S0085-2538(15)52823-8/pdf

Association between obesity and kidney disease: a systematic review and meta-analysis.

This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.

Advanced heart failure : a position statement of the Heart Failure Association of the European Society of Cardiology

version from a CNI-based regimen, were included. The clinical and laboratory records were reviewed and monitoring trends of urinary protein excretion through qualitative (urine analysis) or quantitative measurements were explored before and after the initiation of mTORi. Out of 411 OHT patients who were included, 91 (22%) received an mTORi (72 sirolimus and 19 everolimus), which was started de novo in 32 out of 91 (35%) of patients. Prior to the initiation of mTORi, urine protein excretion had been assessed only in 56 out of 91 (62%) patients with either urinalysis (26/91 (29%)) or quantitatively (30/91 (33%)). After the initiation of mTORi therapy, only 60 out of 91 (66%) patients had at least onetime evaluation for proteinuria during follow-up by urine analysis (26/91; 29%) or quantitatively (34/91; 37%). The timing of the measurement of proteinuria was highly variable ranging from 4 weeks to 7 years after starting mTORi (median 15.7 months). Among patients who received mTORi, 31 (34%) patients had no assessment of proteinuria throughout their transplant follow-up. These results reveal that a significant subset of OHT recipients (i.e. more than a third) may not undergo any assessment of urinary protein excretion prior to Dear editor, Proteinuria is a well-recognized complication of the mammalian target of rapamycin inhibitors (mTORi) in renal transplant recipients and is associated with an adverse impact on the outcomes [1, 2] . These macrolide antibiotics with potent antiproliferative and antirejection properties are also used in the setting of orthotopic heart transplantation (OHT) in an attempt to avoid the nephrotoxicity of calcineurin inhibitors (CNIs) or to slow the progression of cardiac allograft vasculopathy. Although renal complications of mTORi are not as widely studied in OHT, emerging evidence suggests that these patients are at higher risk for the development of proteinuria and deterioration in renal function [3, 4] . It has been proposed that OHT patients receiving mTORi should be monitored for the development of proteinuria, as early detection and management of this complication could conceivably result in improved renal outcomes [3] . We studied the monitoring trends of OHT recipients in our institution with respect to the development of proteinuria in those who received an mTORi-based regimen. All patients who underwent OHT between January 2000 and December 2015 and received an mTORi, whether de novo or following conReceived: August 26, 2016 Accepted after revision: September 30, 2016 Published online: November 8, 2016

Need for Raising Awareness - Monitoring Urinary Protein Excretion in Cardiac Transplant Patients Receiving Mammalian Target of Rapamycin Inhibitors.

Introduction: Point of care ultrasonography (POCUS) is being increasingly recognized as an adjunct to physical examination in the field of nephrology. However, paucity of trained faculty and standardized curricula remain key barriers to widespread adoption of this skill as well as development of reliable quality assessment programs at the institutional level. Herein, we sought to explore the utility of Twitter polls to gain insights into knowledge deficits of the learners for making curricular improvements while simultaneously disseminating POCUS pearls and pitfalls. Methods: A series of 57 single-question polls were tweeted over a 12-month period, each containing an ultrasound image or a video asking for correct interpretation. These were sent out from the Twitter handle of NephroPOCUS.com (@NephroP), an online POCUS education tool. The answer and a brief explanation were shared in a subsequent tweet at the end of the voting period. Information on the percentage of correct answers, Tweet impressions, and engagements was collected and analyzed by the pre-determined difficulty level (I-III) and the organ/learning objective being tested. Results: The number of responses per poll was 228 ± 94.6 (mean ± SD), and the percentage of correct responses was 57.9 ± 17.5 (mean ± SD). 16 (of 57) polls received less than 50% correct responses, of which 8 belonged to level III difficulty. The learning objectives that received the least number of correct responses in the kidney, cardiac, lung, vascular, and other categories were identification of end-stage kidney (16.2% correct answers), right pleural effusion on the parasternal short axis view of the heart (29%), right pleural effusion from the subxiphoid window (39%), grading of systemic venous congestion (27.3%), and identification of ascites on the right lateral chest window (15%), respectively. The overall engagement rate was 6.96%, which was above the median for health and higher education-related tweets on Twitter. Targeted didactic material was developed based on these results, published on various open-access nephrology education platforms. Conclusions: Twitter polls aid in identifying the knowledge gaps among POCUS learners. Information obtained from the polls can be used to improve POCUS-related curricula and develop targeted educational material to facilitate remote learning.

Point of Care Ultrasound Training in Nephrology: Twitter Poll as a Modern Tool for Development of an Effective Curriculum

Could the pattern of water consumption alter its potential medicinal effects

INTRODUCTION
Fluid overload has been associated with untoward outcomes in a variety of clinical settings. Isolated extracorporeal ultrafiltration (UF) allows for mechanical extraction of excess fluid and optimization of volume status without the established risks associated with use of high dose diuretics. Conventional machines for renal replacement therapy can be used to perform isolated UF. However, they typically need high blood flow rates with high circuit volumes and the therapy has to be performed by trained nurses. Herein, we describe a novel device, the Artificial Diuresis-1, or AD 1 (Medica S.p.A., Medolla, Italy), which is a portable technology designed to perform extracorporeal UF at bedside.


MATERIALS AND METHODS
The AD 1 uses a polysulfone mini-filter to generate ultrafiltrate with the help of two forces: blood flow (Qb) and gravity (based on the height at which the ultrafiltrate collection bag is placed). In vitro experiments were performed using human blood to evaluate vascular access pressures and ultrafiltrate volumes using various central venous catheters (12 Fr bilume, 10 Fr with 2 separate lumens, pediatric catheter 7 Fr). A variety of combinations were tested with Qb of 20, 35, 50 mL/min and collection bag height at 20, 40, 60 cm, measuring the UF rate per minute each while monitoring the pressures in the venous and arterial lines and filtration fraction.


RESULTS
The device's performance was as expected. Regarding the pediatric CVC, it was possible to perform measurements only with a Qb of 20 mL/min due to increased venous pressure. Ultrafiltration rates when lines were directly connected to the blood container as well as for CVC Tesio ranged from 3.7 to 11 mL/min, for the CVC Niagara™ from 4.5 to 12.5 mL/min and for the CVC 7 Fr from 8.5 to 10 mL/min. The pressures of the vascular accesses were kept within a range of -5/-40 mmHg for the artery and +10/+70 mmHg for the vein. The highest venous pressure values were found with the CVC 7 Fr (+80/+100 mmHg).


CONCLUSIONS
This novel device allows to treat patients with fluid overload in a variety of settings, from low-intensity department such as long-term care facilities to the intensive care unit. The device is small and portable, has a simple design, and is user-friendly. Future studies will be needed to evaluate whether gentle ultrafiltration and treatment of volume overload will translate into improvement in clinical outcomes such as a reduction in congestion-related hospital admission.

https://www.karger.com/Article/Pdf/529613

The Science of Extracorporeal Ultrafiltration: Introducing a Novel Miniaturized Device.

We read with great interest the article of Chiva-Blanch et al recently published in your journal.1 This randomized controlled trial evaluates the impact of dealcoholized red wine (DRW) on blood pressure (BP) in patients with high cardiovascular risk and concludes on its ability to lower BP. Although excited about the interesting results of this trial, we think several concerns exist that, if addressed in future studies, might lead to a better understanding of the findings and a wider acceptance of the conclusions.

First, office measurement has been used to evaluate the impact of various interventions on BP. Although not specified in the article, the patients were likely to have the interventions (ie, beverage intake) during evening hours. As such, there has been an interval of several hours between the intervention and the measurement of BP, which took place during the office visit the next day. It has been shown that repeated alcohol intake has a biphasic impact on BP (ie, initially decreasing, …

Amir Kazory

Papers

Need for Raising Awareness - Monitoring Urinary Protein Excretion in Cardiac Transplant Patients Receiving Mammalian Target of Rapamycin Inhibitors.

Point of Care Ultrasound Training in Nephrology: Twitter Poll as a Modern Tool for Development of an Effective Curriculum

Could the pattern of water consumption alter its potential medicinal effects

The Science of Extracorporeal Ultrafiltration: Introducing a Novel Miniaturized Device.

The Impact of Red Wine on Blood Pressure Dizziness Continues