Ritesh Raichoudhury

RATIONALE & OBJECTIVE: Acute kidney injury treated with kidney replacement therapy (AKI-KRT) occurs frequently in critically ill patients with coronavirus disease 2019 (COVID-19). We examined the clinical factors that determine kidney recovery in this population. STUDY DESIGN: Multicenter cohort study. SETTING & PARTICIPANTS: 4,221 adults not receiving KRT who were admitted to intensive care units at 68 US hospitals with COVID-19 from March 1 to June 22, 2020 (the "ICU cohort"). Among these, 876 developed AKI-KRT after admission to the ICU (the "AKI-KRT subcohort"). EXPOSURE: The ICU cohort was analyzed using AKI severity as the exposure. For the AKI-KRT subcohort, exposures included demographics, comorbidities, initial mode of KRT, and markers of illness severity at the time of KRT initiation. OUTCOME: The outcome for the ICU cohort was estimated glomerular filtration rate (eGFR) at hospital discharge. A 3-level outcome (death, kidney nonrecovery, and kidney recovery at discharge) was analyzed for the AKI-KRT subcohort. ANALYTICAL APPROACH: The ICU cohort was characterized using descriptive analyses. The AKI-KRT subcohort was characterized with both descriptive analyses and multinomial logistic regression to assess factors associated with kidney nonrecovery while accounting for death. RESULTS: . Oliguria at the time of KRT initiation was also associated with nonrecovery (ORs of 2.10 [95% CI, 1.14-3.88] and 4.02 [95% CI, 1.72-9.39] for patients with 50-499 and <50 mL/d of urine, respectively, compared to ≥500 mL/d of urine). LIMITATIONS: Later recovery events may not have been captured due to lack of postdischarge follow-up. CONCLUSIONS: Lower baseline eGFR and reduced urine output at the time of KRT initiation are each strongly and independently associated with kidney nonrecovery among critically ill patients with COVID-19.

The unprecedented surge of nephrology inpatients needing kidney replacement therapy placed hospital systems under extreme stress during the COVID-19 pandemic. In this article, we describe the formation of a cross campus "New-York Presbyterian COVID-19 Kidney Replacement Therapy Task Force" with intercampus physician, nursing, and supply chain representation. We describe several strategies including the development of novel dashboards to track supply/demand of resources, urgent start peritoneal dialysis, in-house preparation of kidney replacement fluid, the use of unconventional personnel resources to ensure the safe and continued provision of kidney replacement therapy in the face of the unanticipated surge. These approaches facilitated equitable sharing of resources across a complex healthcare-system and allowed for the rapid implementation of standardized protocols at each hospital.

Background: Use of ketamine has been associated with urinary tract pathology, including contraction of urinary bladder and lower urinary tract obstruction, leading to secondary renal injury. Clinical presentation and image findings include contracted bladder, ureteral stricture, and hydronephrosis. Ketamine is excreted in bile and urine. It has been proposed that tissue damage is related to the duration of exposure and contact with ketamine metabolites in the urinary system, and that bladder wall is usually the first organ to present with lower urinary tract symptoms followed by the lower third of the ureter and renal pelvis .We present a series with history of ketamine abuse resulting in obstructive uropathy and chronic kidney disease. Methods: Chart review of deidentified patient records with history of ketamine abuse who presented to New York Presbyterian Queens Hospital The following features were extracted: baseline demographic data, serum creatinine , BUN, estimated glomerular filtration rate, and renal imaging. Results: Seven patients presented to the hospital with abnormal renal function and history of ketamine abuse, all with hydronephrosis on imaging. Six were Asian and one African American. They were predominantly female (5:1). The median age of presentation was 32 (range, 31-56) years. Three patients had hypertension. Serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate were 2.2 mg/dL(range 1.03 to 3.07), 36.2 mg/dL (range 21.4 to 64.3), 34 cc/min (25 to 45), respectively. All had the following abnormalities: elevated liver enzymes (median alanine aminotransferase of 47.5 U/L ,aspartate aminotransferase of 65 U/L , and alkaline phosphatase of 1060 U/L ; bile duct dilation; bladder wall thickening with moderate to severe hydronephrosis. All required urological intervention (six patients had bilateral ureter stents and one patient had bilateral percutaneous nephrostomy). One patient required transient hemodialysis and one died. Conclusion: Our experience of Ketamine abuse is consistent with findings in the literature. Image findings of obstructive uropathy are typical and when present, is associated with chronic kidney disease. It is associated with high morbidities and requires frequent hospitalizations and procedures. Cases are likely underreported as most patients may not have symptoms.