AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.

With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.

BackgroundPatients on anti-tuberculosis treatment may develop acute kidney injury (AKI), but little is known about the renal outcome and prognostic factors, especially in an aging population. This study aimed to calculate the incidence of AKI due to anti-TB drugs and analyze the outcomes and predictors of renal recovery.MethodsFrom 2006 to 2010, patients on anti-TB treatment were identified and their medical records reviewed. Acute kidney injury was defined according to the criteria established by the AKI Network, while renal recovery was defined as a return of serum creatinine to baseline. Predictors of renal recovery were identified by Cox regression analysis.ResultsNinety-nine out of 1394 (7.1%) patients on anti-TB treatment had AKI. Their median age was 68 years and there was male predominance. Sixty (61%) developed AKI within two months of anti-TB treatment, including 11 (11%) with a prior history of rifampin exposure. Thirty (30%) had co-morbid chronic kidney disease or end-stage renal disease. The median time of renal recovery was 39.6 days (range, 1–180 days). Factors predicting renal recovery were the presence of fever, rash, and gastro-intestinal disturbance at the onset of AKI. Sixty-two of the 71 (87%) patients who recovered from AKI had successful re-introduction or continuation of rifampin.ConclusionsRenal function impairment is not a rare complication during anti-TB treatment in an elderly population. The presence of fever and rash may be associated with renal recovery. Rifampin can still be used in most patients who recover from AKI.

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Background: Kidney dysfunction is a strong determinant of prognosis in many settings. Methods: A systematic review and meta-analysis was undertaken to explore the relationship between estimated glomerular filtration rate (eGFR) and adverse outcomes after surgery. Cohort studies reporting the relationship between eGFR and major outcomes, including all-cause mortality, major adverse cardiovascular events, and acute kidney injury after cardiac or noncardiac surgery, were included. Results: Forty-six studies were included, of which 44 focused exclusively on cardiac and vascular surgery. Within 30 days of surgery, eGFR less than 60 ml·min·1.73 m −2 was This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. ABSTRACTThe use of ultrasound guidance has provided an opportunity to perform many peripheral nerve blocks that would have been difficult to perform in children based on pure landmark techniques due to the potential for injection into contiguous sensitive vascular areas. This review article provides the readers with techniques on ultrasoundguided peripheral nerve blocks of the extremities and trunk with currently available literature to substantiate the available evidence for the use of these techniques. Ultrasound images of the blocks with corresponding line diagrams to demonstrate the placement of the ultrasound probe have been provided for all the relevant nerve blocks in children. The authors hope that this review will stimulate further research into ultrasound-guided regional anesthesia in infants, children, and adolescents and stimulate more randomized controlled trials to provide a greater understanding of the anatomy and physiology of regional anesthesia in pediatrics.

The viral spike (S) coat protein of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) engages the human angiotensin-converting enzyme2 (ACE2) cell surface receptor to infect the host cells. Thus, concerns arose regarding theoretically higher risk for Coronavirus -19 (COVID-19) in patients taking angiotensin-converting enzyme inhibitors (ACEI)/ angiotensin II type 1 receptor antagonists (ARBs). We systematically assessed case-population and cohort studies from MEDLINE (Ovid), Cochrane Database of Systematic Reviews PubMed, Embase, medRXIV, the World Health Organization data-base of COVID-19 publications and ClinicalTrials.gov through Jun 1, 2020, with planned ongoing surveillance. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. After pooling the adjusted odds ratios (aOR) from the included studies, no significant increase was noted in the risk of SARS-CoV-2 infection by the use of ACEi (aOR, 0.95; 95% CI, 0.86-1.05) or ARBs (aOR, 1.05; 95% CI, 0.97-1.14). However, the random-effects meta-regression revealed that age may modify the SARS-CoV-2 infection risk in subjects with the use of ARBs (coefficient, -0.006; 95% CI, -0.016 to 0.004)-i.e.: the use of ARBs, as opposed to ACEi, specifically augmented the risk of SARS-CoV-2 infection in younger subjects (< 60 years-old). The use of ACEi might not increase the susceptibility of SARS-CoV-2 infection, severity of disease and mortality in case-population and cohort studies. Additionally, we found for the first time that the use of ARBs, as opposed to ACEi, specifically augmented the risk of SARS-CoV-2 infection in younger subjects; without obvious effects on COVID-19 outcomes.

The clinical characteristics and outcomes in patients with clinical aldosterone-producing adenomas harboring KCNJ5 mutations with or without subclinical hypercortisolism remain unclear. This prospective study is aimed at determining factors associated with subclinical hypercortisolism in patients with clinical aldosterone-producing adenomas. Totally, 82 patients were recruited from November 2016 to March 2018 and underwent unilateral laparoscopic adrenalectomy with at least a 12-month follow-up postoperatively. Standard subclinical hypercortisolism (defined as cortisol >1.8 μg/dL after 1 mg dexamethasone suppression test [DST]) was detected in 22 (26.8%) of the 82 patients. Intriguingly, a generalized additive model identified the clinical aldosterone-producing adenoma patients with 1 mg DST>1.5 μg/dL had significantly larger tumors ( P =0.02) than those with 1 mg DST<1.5 μg/dL. Multivariable logistic regression showed that the presence of KCNJ5 mutations (odds ratio, 0.22, P =0.010) and body mass index (odds ratio, 0.87, P =0.046) were negatively associated with 1 mg DST>1.5 μg/dL, whereas tumor size was positively associated with it (odds ratio, 2.85, P =0.014). Immunohistochemistry revealed a higher degree of immunoreactivity for CYP11B1 in adenomas with wild-type KCNJ5 ( P =0.018), whereas CYP11B2 was more commonly detected in adenomas with KCNJ5 mutation ( P =0.007). Patients with wild-type KCNJ5 and 1 mg DST>1.5 μg/dL exhibited the lowest complete clinical success rate (36.8%) after adrenalectomy. In conclusion, subclinical hypercortisolism is common in clinical aldosterone-producing adenoma patients without KCNJ5 mutation or with a relatively larger adrenal tumor. The presence of serum cortisol levels >1.5 μg/dL after 1 mg DST may be linked to a lower clinical complete success rate.

Epigenetic regulation plays a major role in uremic toxin-induced chronic kidney disease (CKD) progression. The KLOTHO protein is a key modulator of homeostasis in renal function. Uremic toxin accumulation can induce DNA methyltransferase (DNMT) protein expression, which is involved in the silencing of KLOTHO through hypermethylation. Treatment with DNMT inhibitors can induce a hypermethylated status of KLOTHO and suppress mRNA and protein expression. Epigenetic targeting of specific genes may become an effective strategy to prevent progression of uremia-related CKD.