S100B level and cognitive dysfunction after robotic-assisted laparoscopic radical prostatectomy procedures: a prospective observational study / Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

Abstract Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively, and at 7 days and 3 months postoperatively. Results: Twenty four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both). Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD. Trial Registry Number: Clinicaltrials.gov (N° NCT03018522).

Resumo Introdução: O presente estudo investigou a associação entre Disfunção Cognitiva Pós-Operatória (DCPO) e aumento do nível sérico de S100B após Prostatectomia Radical Laparoscópica Assistida por Robô (PRLAR). Métodos: O estudo incluiu 82 pacientes consecutivos submetidos à PRLAR. Os níveis séricos de S100B foram determinados: no pré-operatório, após indução anestésica, e aos 30 minutos e 24 horas do pós-operatório. A função cognitiva foi avaliada com testes neuropsicológicos no pré-operatório, no 7° dia pós-operatório (7 DPO) e aos 3 meses após a cirurgia (3 MPO). Resultados: Observamos 24 pacientes (29%) com DCPO no 7 DPO e 9 pacientes com DCPO (11%) após 3 meses da cirurgia. Quando comparados com os pacientes sem DCPO, os níveis séricos de S100B estavam significantemente aumentados aos 30 minutos e às 24 horas do pós-operatório nos pacientes que apresentaram DCPO no 7 DPO (p= 0,0001 para os dois momentos) e 3 meses após a cirurgia (p= 0,001 para os dois momentos) A duração anestésica também foi significantemente maior em pacientes com DCPO no 7 DPO e 3 MPO em comparação com pacientes sem DCPO (p= 0,012, p= 0,001, respectivamente), assim como a duração da posição de Trendelenburg (p= 0,025, p= 0,002, respectivamente). O escore Z composto nos testes realizados no 7 DPO foi significantemente correlacionado com a duração da posição de Trendelenburg e a duração da anestesia (p= 0,0001 para ambos). Conclusão: S100B aumenta após PRLAR e o aumento está associado ao desenvolvimento de DCPO. A duração anestésica e o tempo decorrido em posição de Trendelenburg contribuem para o desenvolvimento de DCPO. Número de registro do estudo: Clinicaltrials.gov (n° NCT03018522)

Evaluation of perioperative high-sensitive cardiac troponin i as a predictive biomarker of major adverse cardiovascular events after noncardiac surgery

ABSTRACT Background: Various studies suggest that perioperative concentrations of high-sensitivity troponins are incremental and predictive factors of a major adverse cardiac event (MACE) and all-cause mortality. Objective: The objective of the study was to evaluate the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in the development of MACE and all-cause mortality, within 30-days and 1-year follow-up after noncardiac surgery. Methods: In this prospective cohort study, we included men ≥ 45 years and women ≥ 55 years with ≥ 2 cardiovascular risk factors and undergoing intermediate or high-risk noncardiac surgery. Demographic and clinical information was collected from clinical charts. We measured baseline hs-cTnI 24 h before surgery, and its post-operative concentration 24 h after surgery. Results: In the entire sample, 8 patients (8.6%) developed MACE at 30-days follow-up (4 deaths), 12 (12.9%) within the 1st year (7 deaths), and 17 (18.2%) after complete post-surgical follow-up (10 deaths). We observed higher baseline and post-operative concentrations in patients who presented MACE (12 pg/ml vs. 3.5 pg/ml; p = 0.001 and 18.3 pg/ml vs. 5.45 pg/ml; p = 0.009, respectively). The hazard ratios (HRs) calculated by Cox regression analysis between the hs-cTnI baseline concentration and the post-operative development of MACE at 30-days and 1-year were 5.70 (95% confidence interval [CI], 1.10-29.40) with hs-cTnI > 6.2 pg/ml and 12.86 (95% CI, 1.42-116.34) with hs-cTnI > 3.3 pg/ml, respectively. The estimated post-operative HR death risk at 1-year was 14.43 (95% CI, 1.37-151.61) with hs-cTnI > 4.5 pg/ml. Conclusions: Pre-operative hs-cTnI was an independent predictive risk factor for MACE at 30-days and 1-year after noncardiac surgery and for all-cause mortality at 1-year after noncardiac surgery.

Recuperação clínica e laboratorial dos pacientes submetidos à cirurgia combinada de lipoaspiração corporal e lipoabdominoplastia / Clinical and laboratory recovery of patients undergoing body liposuction associated with lipoabdominoplasty

Introdução: A lipoaspiração corporal e abdominoplastia são cirurgias muitas vezes realizadas em conjunto para obter melhores resultados na modelagem corporal. Cirurgias associadas sempre aumentam a espoliação, por isto conhecer o comportamento da hemoglobina (Hb) no pós-operatório e a recuperação do paciente submetido a estas cirurgias combinadas é importante para sua segurança. O objetivo deste trabalho foi estudar a queda da Hb e a recuperação clínica e laboratorial dos pacientes submetidos à cirurgia combinada de lipoaspiração corporal e lipoabdominoplastia. Métodos: Realizou-se um estudo prospectivo em pacientes submetidos à lipoaspiração corporal e lipoabdominoplastia, coletando-se hemogramas antes da indução anestésica, ao final da cirurgia, antes da alta hospitalar, após a 1ª, 2ª e 4ª semanas de pós-operatórios e também acompanhando suas evoluções clínicas. Resultados: A média da Hb ao final da cirurgia e na alta hospitalar foi de 10,4g/dl (desvio padrão (DP) 0,76) e 8,92g/dl (DP 0,86), respectivamente. A recuperação em média da Hb após 1ª, 2ª e 4ª semanas foi de 2,4% (DP 18,07), 41,6% (DP 18,4) e 74% (DP 15,2), respectivamente, em relação a redução que ocorreu entre a Hb inicial e a da alta hospitalar. Queixas de fraqueza e lipotimia foram frequentes até o segundo dia. Conclusão: A melhora clínica ocorreu até o segundo dia de pós-operatório (DPO) e a hemoglobina levou aproximadamente 1 mês para normalizar na maioria dos pacientes tratados apenas com reposição oral de ferro, sem necessidade de hemotransfusão.

Introduction: Body liposuction and abdominoplasty are surgeries often performed together to obtain superior results in body modeling. Since associated surgeries often increase spoliation, being aware of the evolution of hemoglobin (Hb) in the postoperative period and during the recovery of the patients undergoing these associated surgeries is important for their safety. This study aimed to analyze the decrease in Hb and the clinical and laboratory results throughout the recovery of patients undergoing body liposuction associated with lipoabdominoplasty. Methods: A prospective study was conducted with patients undergoing body liposuction and lipoabdominoplasty. CBCs were collected before anesthetic induction, at the end of the surgery, before hospital discharge, after the 1st, 2nd, and 4th postoperative weeks, and during their clinical follow-up period. Results: The average Hb values at the end of surgery and hospital discharge were 10.4 g/dL (standard deviation (SD) 0.76) and 8.92 g/dL (SD 0.86), respectively. The average values during the recovery of Hb after the 1st, 2nd, and 4th weeks were 2.4% (SD 18.07), 41.6% (SD 18.4), and 74% (SD 15.2), respectively. This is in relation to the reduction between the initial Hb and at hospital discharge. Complaints of weakness and lipothymia were frequent until the second day. Conclusion: Clinical improvement was observed until the second postoperative day (PO day). Hemoglobin required approximately 1 month to normalize in most patients. These patients were treated only with oral iron replacement and did not require blood transfusions.

Is hypoalbuminemia a predictor for acute kidney injury after coronary bypass grafting in diabetes mellitus patients?

Abstract Objective: Acute kidney injury (AKI) is one of the most important complications after coronary artery bypass grafting (CABG) procedure. Serum albumin, which is an acute phase reactant, is suggested to be associated with AKI development subsequent to various surgical procedures. In this study, we research the relation between preoperative serum albumin levels and postoperative AKI development in diabetes mellitus (DM) patients undergoing isolated CABG. Methods: We included a total of 634 diabetic patients undergoing CABG (60.5±9.1 years, 65.1% male) into this study, which was performed between September 2009 and January 2014 in a single center. The relation between preoperative serum albumin levels and postoperative AKI development was observed. AKI was evaluated and diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. Results: AKI was diagnosed in 230 (36.3%) patients. Multiple logistic regression analysis was performed to determine the independent predictors of AKI development. Proteinuria (odds ratio [OR] and 95% confidence interval [CI], 1.066 [1.002-1.135]; P=0.043) and low preoperative serum albumin levels (OR and 95% CI, 0.453 [0.216-0.947]; P=0.035) were found to be independent predictors of AKI. According to the receiver operating characteristic curve analysis, albumin level <3mg/dL (area under the curve: 0.621 [0.572-0.669], P<0.001) had 83% sensitivity and 10% specificity on predicting the development of AKI. Conclusion: We observed that a preoperative low serum albumin level was associated with postoperative AKI development in patients with DM who underwent isolated CABG procedure. We emphasize that this adjustable albumin level should be considered before the operation since it is an easy and clinically implementable management for the prevention of AKI development.

Thrombocytopenia after transcatheter valve-in-valve implantation: prognostic marker or mere finding?

Abstract Objective: To analyze the behavior of platelets after transcatheter valve-in-valve implantation for the treatment of degenerated bioprosthesis and how they correlate with adverse events upon follow-up. Methods: Retrospective analysis of 28 patients who received a valve-in-valve implant, 5 in aortic, 18 in mitral and 5 in tricuspid positions. Data were compared with 74 patients submitted to conventional redo valvular replacements during the same period, and both groups' platelet curves were analyzed. Statistical analysis was conducted using the IBM SPSS Statistics(r) 20 for Windows. Results: All patients in the valve-in-valve group developed thrombocytopenia, 25% presenting mild (<150.000/µL), 54% moderate (<100.000/µL) and 21% severe (<50.000/µL) thrombocytopenia. The platelet nadir was on the 4th postoperative day for aortic ViV, 2nd for mitral and 3rd for tricuspid patients, with the majority of patients recovering regular platelet count. However, the aortic subgroup comparison between valve-in-valve and conventional surgery showed a statistically significant difference from the 7th day onwards, where valve-in-valve patients had more severe and longer lasting thrombocytopenia. This, however, did not translate into a higher postoperative risk. In our study population, postoperative thrombocytopenia did not correlate with greater occurrence of adverse outcomes and only normal preoperative platelet count could significantly predict a postoperative drop >50%. Conclusion: Although thrombocytopenia is an extremely common finding after valve-in-valve procedures, the degree of platelet count drop did not correlate with greater incidence of postoperative adverse outcomes in our study population.

Extended-time of noninvasive positive pressure ventilation improves tissue perfusion after coronary artery bypass surgery: a randomized clinical trial

Abstract Objective: To compare the effects of extended- versus short-time noninvasive positive pressure ventilation on pulmonary function, tissue perfusion, and clinical outcomes in the early postoperative period following coronary artery bypass surgery in patients with preserved left ventricular function. Methods: Patients were randomized into two groups according to noninvasive positive pressure ventilation intensity: short-time noninvasive positive pressure ventilation n=20 (S-NPPV) and extended-time noninvasive positive pressure ventilation n=21 (E-NPPV). S-NPPV was applied for 60 minutes during immediate postoperative period and 10 minutes, twice daily, from postoperative days 1-5. E-NPPV was performed for at least six hours during immediate postoperative period and 60 minutes, twice daily, from postoperative days 1-5. As a primary outcome, tissue perfusion was determined by central venous oxygen saturation and blood lactate level measured after anesthetic induction, immediately after extubation and following noninvasive positive pressure ventilation protocols. As a secondary outcome, pulmonary function tests were performed preoperatively and in the postoperative days 1, 3, and 5; clinical outcomes were recorded. Results: Significant drop in blood lactate levels and an improvement in central venous oxygen saturation values in the E-NPPV group were observed when compared with S-NPPV group after study protocol (P<0.01). The E-NPPV group presented higher preservation of postoperative pulmonary function as well as lower incidence of respiratory events and shorter postoperative hospital stay (P<0.05). Conclusion: Prophylactic E-NPPV administered in the early postoperative period of coronary artery bypass surgery resulted in greater improvements in tissue perfusion, pulmonary function and clinical outcomes than S-NPPV, in patients with preserved left ventricular function. Trial Registration: Brazilian Registry of Clinical trial - RBR7sqj78 - http://www.ensaiosclinicos.gov.br

Effect of plasma level of vitamin d on postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting

Abstract Objective: Postoperative atrial fibrillation (PoAF) is a common complication after coronary artery bypass grafting (CABG). The aim of the present study was to evaluate the association between development of PoAF and vitamin D levels in patients undergoing isolated CABG. Methods: This prospective randomized clinical trial was conducted on the patients with isolated CABG. The study was terminated when 50 patients in both PoAF(+) group and PoAF(-) group were reached. Development of AF until discharge period was assessed. Vitamin D level was measured immediately after AF; it was measured on the discharge day for the patients without PoAF. Predictive values of the independent variables were measured for the development of PoAF. Results: The groups were separated as PoAF(-) group (66% male, mean age 58.18±10.98 years) and PoAF(+) group (74% male, mean age 61.94±10.88 years). 25(OH) vitamin D level (OR=0.855, 95% CI: 0.780-0.938, P=0.001) and > 65 years (OR=3.525, 95% CI: 1.310-9.483, P=0.013) were identified as an independent predictor of postoperative AF after CABG surgery in multivariate analysis. The cut-off level for 25(OH) vitamin D level in receiver-operating characteristic curve analysis was determined as 7.65 with sensitivity of 60% and specificity of 64% for predicting PoAF (area under the curve: 0.679, P=0.002). Conclusion: Vitamin D level is considered an independent predictor for development of PoAF. Lower vitamin D levels may be one of the reasons for PoAF.

Are pre and postoperative platelet to lymphocyte ratio and neutrophil to lymphocyte ratio associated with early postoperative aki following cabg?

Abstract Objective: In this study, we investigated the role of two of the recent biomarkers of inflammation on the development of acute kidney injury in the early postoperative period of isolated coronary artery bypass grafting. Methods: Three hundred and eleven patients, who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass by the same surgery team in our clinic between May 2010 and October 2014, who had a preoperative serum creatinine level lower than 1.5 mg/dl were included in the study. These patients' records were reviewed retrospectively. The diagnosis of acute kidney injury was performed according to the Kidney Disease Improving Global Outcomes 2012 Acute Kidney Injury Guideline criteria. Patients who developed acute kidney injury in the early postoperative period were classified as Group-1 (n=62) and the patients with normal postoperative renal functions were classified as Group-2 (n=249). The demographic data, body mass index, comorbidities, hematologic/biochemical profiles, preoperative ejection fraction, blood transfusion history, and operative data of the groups were compared. Univariate analyses were performed to determine significant clinical factors, and multiple logistic regression analyses were subsequently done to determine independent predictors of acute kidney injury. Results: Sixty-two (19.9%) patients developed acute kidney injury during the first 72 hours postoperatively. Multivariate logistic regression analyses revealed preoperative increased creatinine (P=0.0001), C-reactive protein (P=0.02), neutrophil-lymphocyte ratio (P=0.04) and platelet-lymphocyte ratio (P=0.002); increased postoperative first day leukocyte count (P=0.03), C-reactive protein levels (P=0.02), neutrophil-lymphocyte ratio (P=0.002), platelet-lymphocyte ratio (P=0.01) and increased intubation time (P=0.006) as independent predictors of early postoperative acute kidney injury in patients who underwent isolated coronary artery bypass grafting. Conclusion: The preoperative and postoperative increased levels of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio which can be calculated by simple methods from routine blood analysis showed us that these parameters are independent biomarkers directly related to development of acute kidney injury in the early postoperative period.

Quantitative detection of BK virus in kidney transplant recipients: a prospective validation study / Detecção quantitativa de vírus BK em receptores de transplante renal: um estudo prospectivo de validação

Abstract Introduction: BK virus (BKV) infection in renal transplant patients may cause kidney allograft dysfunction and graft loss. Accurate determination of BKV viral load is critical to prevent BKV-associated nephropathy (BKVAN) but the cut-off that best predicts BKVAN remains controversial. Objective: To evaluate the performance of a commercial and an in-house qPCR test for quantitative detection of BK virus in kidney transplant recipients. Methods: This was a prospective study with kidney transplant recipients from two large university hospitals in Brazil. Patients were screened for BKV infection every 3 months in the first year post-transplant with a commercial and an in-house real time polymerase chain reaction (qPCR) test. BKVAN was confirmed based on histopathology. The area under the curve for plasma qPCR was determined from receiver operating characteristic analysis. Results: A total of 200 patients were enrolled. Fifty-eight percent were male, 19.5% had diabetes mellitus, and 82% had the kidney transplanted from a deceased donor. BKV viremia was detected in 32.5% and BKVAN was diagnosed in 8 patients (4%). BKVAN was associated with viremia of 4.1 log copies/mL, using a commercial kit. The cut-off for the in-house assay was 6.1 log copies/mL. The linearity between the commercial kit and the in-house assay was R2=0.83. Conclusion: Our study shows that marked variability occurs in BKV viral load when different qPCR methodologies are used. The in-house qPCR assay proved clinically useful, a cheaper option in comparison to commercial qPCR kits. There is an urgent need to make BKV standards available to the international community.

Resumo Introdução: A infecção pelo vírus BK (BKV) em pacientes de transplante renal pode levar a disfunção do aloenxerto renal e perda do enxerto. A determinação precisa da carga viral do BKV é fundamental para prevenir a nefropatia associada ao BKV (BKVAN), mas o ponto de corte de melhor valor preditivo para BKVAN ainda é foco de debates. Objetivo: Avaliar o desempenho de um teste de qPCR comercial e outro desenvolvido internamente para detecção quantitativa de vírus BK em receptores de transplante renal. Métodos: O presente estudo prospectivo incluiu receptores de transplante renal de dois grandes hospitais universitários no Brasil. Os pacientes foram testados para infecção por BKV a cada três meses no primeiro ano pós-transplante com um teste comercial de reação em cadeia de polimerase quantitativa em tempo real (qPCR) e outro desenvolvido internamente. A presença de BKVAN foi confirmada com base na histopatologia. A área sob a curva para o qPCR plasmático foi determinada a partir da análise da característica de operação do receptor. Resultados: Um total de 200 pacientes foram incluídos. Cinquenta e oito por cento eram do sexo masculino, 19,5% tinham diabetes mellitus e 82% tiveram seus rins transplantados de doadores falecidos. Viremia de BKV foi detectada em 32,5% dos pacientes e oito (4%) foram diagnosticados com BKVAN. BKVAN foi associada a viremia de 4,1 log cópias/mL usando o kit comercial. O corte para o ensaio interno foi de 6,1 log cópias/mL. A linearidade entre o kit comercial e o ensaio interno foi R2 = 0,83. Conclusão: Nosso estudo demonstrou uma acentuada variabilidade na carga viral de BKV quando diferentes metodologias de qPCR foram utilizadas. O ensaio interno de qPCR mostrou-se clinicamente útil, além de ser uma opção menos onerosa em relação aos kits comerciais de qPCR. Há uma necessidade urgente de se definir padrões de BKV para a comunidade internacional.

Relationship between high red cell distribution width and systemic inflammatory response syndrome after extracorporeal circulation

Abstract Objective: Cardiac surgical operations involving extracorporeal circulation may develop severe inflammatory response. This severe inflammatory response syndrome (SIRS) is usually associated with poor outcome with no predictive marker. Red cell distribution width (RDW) is a routine hematological marker with a role in inflammation. We aim to determine the relationship between RDW and SIRS through our study. Methods: A total of 1250 patients who underwent cardiac surgery with extracorporeal circulation were retrospectively analyzed out of which 26 fell into the SIRS criteria and 26 consecutive control patients were taken. RDW, preoperative clinical data, operative time and postoperative data were compared between SIRS and control groups. Results: The demographic profile of the patients was similar. RDW was significantly higher in the SIRS versus control group (15.5±2.0 vs. 13.03±1.90), respectively with P value <0.0001. There was significant mortality in the SIRS group, 20 (76.92%) as compared to 2 (7.6%) in control group with a P value of <0.005. Multiple logistic regression analysis revealed that there was significant association with high RDW and development of SIRS after extracorporeal circulation (OR for RDW levels exceeding 13.5%; 95% CI 1.0-1.2; P<0.05). Conclusion: Increased RDW was significantly associated with increased risk of SIRS after extracorporeal circulation. Thus, RDW can act as a useful tool to predict SIRS in patients undergoing cardiac surgery with extracorporeal circulation. Hence, more aggressive measures can be taken in patients with high RDW to prevent postoperative morbidity and mortality.

The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio

Abstract Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120 mg dL-1 while in the "Liberal" group (GII), it ranged between 80-180 mg dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.

Resumo Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos à cirurgia coronariana eletiva. No grupo "controle rigoroso" (GI), a glicemia foi mantida entre 80-120 mg.dL-1; enquanto no grupo "liberal" (GII), variou entre 80-180 mg.dL-1. A bateria de testes neuropsicológicos foi feita três vezes: fase basal, antes da cirurgia e na primeira e 12ª semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente.

Alta prevalencia de deficiencia de vitamina D en niños con enfermedad renal crónica y trasplante renal / High prevalence of vitamin D deficiency among children with chronic kidney disease and kidney transplant

Introducción. la deficiencia de vitamina D (25OHD) es muy común en pacientes con enfermedad renal crónica (ERC). Los obj etivos de este trabajo fueron determinar la prevalencia del déficit de 25OHD en niños con ERC e identificar factores de riesgo. Se estableció la correlación entre 25OHD y paratohormona molécula intacta. Población y métodos. Estudio transversal realizado entre enero de 2013 y diciembre de 2015. Se incluyeron pacientes menores de 19 años con y sin ERC. Resultados. Se incluyeron 167 pacientes. Grupo 1 (controles sanos): 32 participantes; grupo 2 (ERC, estadios 2-4, filtrado glomerular entre 89 y 15 ml/min/1,73 m²): 34 pacientes; grupo 3 (estadio 5, en diálisis): 46 pacientes; y grupo 4 (trasplantados renales): 55 pacientes. Presentaron deficiencia de 25OHD 12,5% de los controles sanos y 32% de los pacientes con ERC (p= 0,025). El 23% de los pacientes del grupo 2, el 51% del grupo 3 y el 22% del grupo 4 presentaron deficiencia de 25OHD; el valor medio de 25OHD de los pacientes en diálisis fue significativamente menor que en el resto de los grupos. Los predictores de deficiencia de 25OHD fueron la hipoalbuminemia, ERC avanzada y la procedencia de la región Noroeste. La paratohormona molécula intacta fue significativamente más elevada en el grupo de pacientes con deficiencia y mostró una correlación inversa con los valores de 25OHD. Conclusión. El 32% de los pacientes con ERC presentó deficiencia de 25OHD; en el estadio 5 (diálisis), alcanzó el 51%. Los predictores de deficiencia fueron hipoalbuminemia, ERC avanzada y la procedencia del noroeste.

Introduction. Vitamin D (25(OH)D) deficiency is common among patients with chronic kidney disease (CKD). Our objective was to establish the prevalence of 25(OH)D deficiency among children with CKD and identify risk factors. A correlation was observed between 25(OH)D and parathormone intact molecule. Population and methods. Cross-sectional study conducted between January 2013 and December 2015. Patients younger than 19 years old with and without CKD were included. Results. One hundred and sixty-seven patients were included. Group 1 (healthy controls): 32 participants; group 2 (stage 2-4 CKD, glomerular filtration rate between 89 and 15 mL/min/1.73 m²): 34 patients; group 3 (stage 5 CKD, dialysis): 46 patients; and group 4 (kidney transplant recipients): 55 patients. Deficiency of 25(OH)D was detected in 12.5% of healthy controls and 32% of CKD patients (p= 0.025). Also, 23% of patients in group 2, 51% in group 3, and 22% in group 4 had 25(OH)D deficiency; the mean 25(OH)D level of dialysis patients was significantly lower than that of the rest of the groups. Predictors of 25(OH)D deficiency included hypoalbuminemia, advanced CKD, and place of origin from the Northwest region of Argentina. The parathormone intact molecule was significantly higher in the group of patients with deficiency and was inversely correlated with 25(OH)D levels. Conclusion. Among CKD patients, 32% had 25(OH)D deficiency, which reached 51% among those with stage 5 CKD (dialysis). Predictors of deficiency included hypoalbuminemia, advanced CKD, and place of origin from the Northwest region of Argentina.

Hemoglobin A1c Levels Predicts Acute Kidney Injury after Coronary Artery Bypass Surgery in Non-Diabetic Patients

Abstract INTRODUCTION: Elevated hemoglobin A1c levels in patients with diabetes mellitus have been known as a risk factor for acute kidney injury after coronary artery bypass grafting. However, the relationship between hemoglobin A1c levels in non-diabetics and acute kidney injury is under debate. We aimed to investigate the association of preoperative hemoglobin A1c levels with acute kidney injury in non-diabetic patients undergoing isolated coronary artery bypass grafting. METHODS: 202 non-diabetic patients with normal renal function (serum creatinine <1.4 mg/dl) who underwent isolated coronary bypass were analyzed. Hemoglobin A1c level was measured at the baseline examination. Patients were separated into two groups according to preoperative Hemoglobin A1c level. Group 1 consisted of patients with preoperative HbA1c levels of < 5.6% and Group 2 consisted of patients with preoperative HbA1c levels of ≥ 5.6%. Acute kidney injury diagnosis was made by comparing baseline and postoperative serum creatinine to determine the presence of predefined significant change based on the Kidney Disease Improving Global Outcomes (KDIGO) definition. RESULTS: Acute kidney injury occurred in 19 (10.5%) patients after surgery. The incidence of acute kidney injury was 3.6% in Group 1 and 16.7% in Group 2. Elevated baseline hemoglobin A1c level was found to be associated with acute kidney injury (P=0.0001). None of the patients became hemodialysis dependent. The cut off value for acute kidney injury in our group of patients was 5.75%. CONCLUSION: Our findings suggest that, in non-diabetics, elevated preoperative hemoglobin A1c level may be associated with acute kidney injury in patients undergoing coronary artery bypass grafting. Prospective randomized studies in larger groups are needed to confirm these results.

Evaluation of diagnostic tests for cytomegalovirus active infection in renal transplant recipients / Avaliação de métodos diagnósticos para infecção ativa por citomegalovírus em receptores de transplante renal

Abstract Introduction: Cytomegalovirus (CMV) infection is a main viral infection after kidney transplantation. The diagnostic methods currently employed are pp65 antigenemia and nucleic acid amplification by polymerase chain reaction (PCR) and aim at detecting viral replication. Objective: The goal of this study was to evaluate and compare by both methods the incidence of CMV active infection in kidney transplant patients and to establishthe best clinical-laboratory correlation. Methods: Thirty sequential kidney transplant recipients were enrolled in a single center prospective cohort study. Peripheral blood samples were drawn from day 15 until the 6th month after transplantation and tested for CMV replication by pp65 antigenemia and quantitative PCR assays (qPCR). Results: Two hundred forty samples were analyzed and the incidence of active infection was similar by both methods. Time elapsed to the first positive test was almost identical but more samples tested positive by qPCR than by antigenemia in a behavior that was almost evenly distributed overtime. Agreement between tests was observed in 217 samples (90.4%; kappa = 0.529; p < 0.001) and in 25 patients the tests were concordant (83.3%; kappa = 0.667; p < 0.001). The evaluation of the diagnostic parameters for CMV replication revealed higher sensitivity for the qPCR test (82.1%) against antigenemia (59.0%). Quantitative PCR was also slightly more accurate than antigenemia. Conclusion: Our data demonstrate that both methods are suitable and have almost equivalent accuracy for the detection of post-transplant cytomegalovirus replication. The choice for either test must take in consideration the demand, execution capability and cost-effectiveness at each institution.

Resumo Introdução: Citomegalovírus (CMV) é uma importante causa de infecção viral após o transplante renal. Os métodos diagnósticos presentemente utilizados são a antigenemia pp-65 e os métodos que utilizam a amplificação de ácidos nucléicos pela reação em cadeia da polimerase (PCR) e visam à detecção da replicação viral. Objetivo: O objetivo deste estudo foi avaliar e comparar a incidência de infecção ativa por CMV em pacientes transplantados renais pelos dois métodos e estabelecer a melhor correlação clínico-laboratorial. Métodos: Trinta pacientes transplantados renais seqüenciais em um único centro foram incluídos em um estudo de coorte prospectiva. Amostras de sangue periférico foram coletadas a partir do 15º dia até o 6º mês pós-transplante e avaliadas para replicação de CMV por Antigenemia pp-65 e PCR quantitativo (qPCR). Resultados: Foram analisadas 240 amostras e a incidência de infecção ativa foi similar pelos dois métodos. O tempo médio transcorrido desde o transplante até o primeiro teste com resultado positivo foi quase idêntico entretanto mais amostras tiveram resultado positivo por qPCR do que antigenemia, um comportamento que se manteve quase uniforme ao longo do tempo. Concordância entre os testes foi observada em 217 amostras (90,4%; kappa = 0,529; p < 0,001) e em 25 pacientes (83,3%; kappa = 0,667; p < 0,001). A avaliação dos parâmetros diagnósticos para replicação de CMV revelaram maior sensibilidade para qPCR (82,1%) contra antigenemia (59,0%). PCR quantitativo também foi levemente mais preciso do que antigenemia. Conclusão: Nossos dados demonstram que ambos os métodos são adequados e tem precisão quase equivalente para a detecção da replicação do CMV após o transplante renal. A escolha entre um ou outro deve levar em consideração a demanda, capacidade de execução e custo-efetividade em cada instituição.

Diagnostic and prognostic value of procalcitonin for early intracranial infection after craniotomy

Intracranial infection is a common clinical complication after craniotomy. We aimed to explore the diagnostic and prognostic value of dynamic changing procalcitonin (PCT) in early intracranial infection after craniotomy. A prospective study was performed on 93 patients suspected of intracranial infection after craniotomy. Routine peripheral venous blood was collected on the day of admission, and C reactive protein (CRP) and PCT levels were measured. Cerebrospinal fluid (CSF) was collected for routine biochemical, PCT and culture assessment. Serum and CSF analysis continued on days 1, 2, 3, 5, 7, 9, and 11. The patients were divided into intracranial infection group and non-intracranial infection group; intracranial infection group was further divided into infection controlled group and infection uncontrolled group. Thirty-five patients were confirmed with intracranial infection after craniotomy according to the diagnostic criteria. The serum and cerebrospinal fluid PCT levels in the infected group were significantly higher than the non-infected group on day 1 (P<0.05, P<0.01). The area under curve of receiver operating characteristics was 0.803 for CSF PCT in diagnosing intracranial infection. The diagnostic sensitivity and specificity of CSF PCT was superior to other indicators. The serum and CSF PCT levels have potential value in the early diagnosis of intracranial infection after craniotomy. Since CSF PCT levels have higher sensitivity and specificity, dynamic changes in this parameter could be used for early detection of intracranial infection after craniotomy, combined with other biochemical indicators.

LDL oxidada: Como um fator de risco para doença cardiovascular no transplante renal / Oxidized LDL: As a risk factor for cardiovascular disease in renal transplantation

RESUMO Objetivos: A taxa de mortalidade de pacientes com doença renal crônica (DRC), que tenham sido submetidos à terapia de substituição renal, é muito elevada devido a doenças cardiovasculares (DCV). Alguns estudos indicaram que a ciclosporina A (CsA), um medicamento utilizado para prevenir a rejeição de transplante, está associada à perda óssea após o transplante. Além disso, ela tem um efeito oxidante sobre os lipídeos circulantes. Seu efeito pró-oxidante nas membranas celulares provoca a liberação de cálcio. Este estudo teve como objetivo analisar se o transplante renal pode ou não resultar em melhora no estresse oxidativo (EO); e avaliar a associação entre a LDL oxidada (LDL-ox) e algumas variáveis na predição do risco de DCV em pacientes transplantados renais (TR), comparados com o grupo controle. Materiais e Métodos: Um total de 30 pacientes com DRC foram recrutados para avaliação das alterações dependentes do tempo no biomarcador de EO antes e após TR. Foram avaliados: LDL-ox, parâmetros do metabolismo dos lipídeos, a CsA, creatinina, cálcio e fosfato tanto antes do TR, 10 dias e 6 meses após o TR, em comparação com o grupo controle (n = 30). Resultados: após 6 meses, a concentração de LDL-ox mudou de 79,7 ± 9,7-72 ± 7 mU/ml (p < 0,009). O nível de fosfato de cálcio foi positivamente correlacionado com a concentração de LDL-ox (R = 0,467, p = 0,011) e ciclosporina (r = 0,419, p = 0,024) 6 meses após o transplante. Conclusão: Os resultados indicaram que a restauração da função renal pelo transplante, melhora o estresse oxidativo induzido pela uremia. O produto de fosfato de cálcio, como um fator de risco independente para DCV, correlaciona-se com o LDL-ox antes do TR e 6 meses após o TR. O produto de fosfato de cálcio também se correlaciona com a ciclosporina no grupo TR.

ABSTRACT Objectives: The mortality rate of chronic kidney disease (CKD) patients that have undergone renal replacement therapy is very high due to cardiovascular diseases (CVD). Some studies have indicated that cyclosporine A, a drug used to prevent transplant rejection, is associated with bone loss following transplantation. Furthermore, it has an oxidative effect on circulating lipids. Its prooxidant effect on cell membranes causes calcium release. This study aimed to examine whether or not renal transplantation result in improvement in oxidative stress and to assess the association between oxidized LDL (ox-LDL) and some variables in the prediction of CVD risk in Renal Transplantation (RT) patients that were compared with the control group. Material and Methods: A total number of 30 CKD patients were recruited to evaluate time dependent changes in biomarker of OS before and after RT. The ox-LDL, lipid metabolism parameters, CsA, creatinine, calcium and phosphate were assessed both before RT, 10 days and 6 months after RT in comparison with the control group (n = 30). Results: Over 6 months, ox-LDL concentration changed from 79.7 ± 9.7 to 72 ± 7 mU/mL (p < 0.009). calcium phosphate level was positively correlated with the concentration of ox-LDL (R = 0.467, p = 0.011) and cyclosporine (R = 0.419, p = 0.024) 6 months after transplantation. Conclusion: The findings indicated that restoring renal function by transplantation, improves uremia induced oxidative stress. calcium phosphate product, as an independent risk factor for CVD, correlates with ox-LDL before RT and 6 months after RT. Calcium phosphate product correlates with cyclosporine in the RT group, too.

Impact of deficient nutrition in bone mass after bariatric surgery / Impacto da deficiência nutricional na massa óssea após cirurgia bariátrica

Background : Essential nutrients are considered for the prevention of the bone loss that occurs after bariatric surgery. Aim : Evaluate nutrients involved in bone metabolism, and relate to serum concentrations of calcium, vitamin D, and parathyroid hormone, and the use of supplements and sun exposure on the bone mass of patients who had undergone gastric bypass surgery. Methods : An observational study, with patients who had undergone the surgery 12 or more months previously, operated group (OG), compared to a control group (CG). Results : Were included 56 in OG and 27 in the CG. The mean age was 36.4±8.5 years. The individuals in the OG, compared to CG, consumed inadequate amounts of protein and daily calcium. The OG had a higher prevalence of low sun exposure, lower levels of 25OH Vitamin D (21.3±10.9 vs. 32.1±11.8 ng/dl), and increased serum levels of parathyroid hormone (68.1±32.9 vs. 39.9±11.9 pg/ml, p<0.001). Secondary hyperparathyroidism was present only in the OG (41.7%). The mean lumbar spine bone mineral density was lower in the OG. Four individuals from the OG had low bone mineral density for chronological age, and no one from the CG. Conclusion : The dietary components that affect bone mass in patients undergoing bariatric surgery were inadequate. The supplementation was insufficient and the sun exposure was low. These changes were accompanied by secondary hyperparathyroidism and a high prevalence of low bone mass in lumbar spine in these subjects.

Racional : Alguns nutrientes são essenciais para a prevenção da perda de massa óssea que ocorre após a cirurgia bariátrica. Objetivo : Avaliar nos pacientes que foram submetidos à cirurgia bariárica pela técnica de bypass gástrico os nutrientes envolvidos no metabolismo ósseo e sua relação com: a concentração sérica de cálcio; a vitamina D e paratormônio; o uso de suplementos alimentares e a exposição solar. Métodos : Estudo observacional com pacientes que foram previamente submetidos à cirurgia, 12 meses ou mais que compuseram o grupo operado (OG), em comparação a um grupo controle (GC). Resultados : Foram avaliados 56 pacientes no OG e 27 no GC. A média de idade foi de 36,4±8,5 anos. Os indivíduos do OG, em comparação com o CG, consumiram diariamente quantidades insuficientes de proteína e cálcio. O OG apresentou maior prevalência de baixa exposição solar, níveis mais baixos de 25OH vitamina D (21,3±10,9 vs 32,1±11,8 ng/ dL) e aumento dos níveis séricos de paratormônio (68,1±32,9 vs 39,9±11,9 pg/ml, p<0,001). Hiperparatiroidismo secundário foi presente apenas no OG (41,7%). A densidade mineral óssea da coluna lombar foi significativamente menor no OG. Quatro indivíduos do OG tiveram baixa densidade mineral óssea comparado com a idade cronológica, e nenhum do CG. Conclusão : Os componentes da dieta que afetam a massa óssea em pacientes submetidos à cirurgia bariátrica estavam inadequados. A suplementação alimentar foi insuficiente e a exposição solar baixa. Estas alterações foram acompanhadas de hiperparatireoidismo secundário e alta prevalência de baixa massa óssea em coluna lombar nestes pacientes.

Colesterol HDL y troponina T ultrasensible como biomarcadores predictivos de fibrilación auricular postoperatoria / HDL cholesterol and high-sensitive troponin T as predictives biomarkers of atrial fibrillation after heart surgery

Introducción: La fibrilación auricular (FA), con una incidencia aproximada del 30%, es la arritmia más frecuente tras cirugía cardiaca. Se han asociado a la FA factores como la inflamación, la presencia de fibrosis cardiaca, el estrés y la apoptosis de cardiomiocitos. Objetivos: Consideramos que el remodelado auricular es un proceso preexistente en los pacientes con FA posquirúrgica. Analizamos los factores relacionados con la incidencia de FA en el postoperatorio de cirugía cardiaca. Métodos: Incluimos a pacientes consecutivos, estables hemodinámicamente y en ritmo sinusal, sometidos a cirugía cardiaca programada con circulación extracorpórea. Se valora la caída en FA posquirúrgica. Resultados: Se incluyeron un total de 100 pacientes sometidos a cirugía de revascularización coronaria (59) o sustitución valvular aórtica (41) por estenosis aórtica grave. La FA postoperatoria se produjo en 29 pacientes con predominio de la cirugía valvular respecto a la cirugía coronaria. Los factores predictivos de la aparición de FA postoperatoria en el análisis multivariable fueron el sexo masculino, la ausencia de terapia crónica con betabloqueadores, la perfusión de fibrinógeno intraoperatorio, valores bajos de colesterol HDL y valores elevados de troponina T ultrasensible en el preoperatorio. Conclusiones: El colesterol HDL y la troponina T ultrasensible pueden ser biomarcadores útiles para predecir la aparición de FA postoperatoria. La identificación precoz de estos pacientes nos permite adoptar medidas preventivas para minimizar sus efectos negativos.

Introduction: Atrial fibrillation (AF) has an incidence rate of approximately 30% and is the most frequent arrhythmia following heart surgery. Factors such as inflammation, the presence of heart fibrosis, stress and cardiomyocyte apoptosis, have all been associated with AF. Objectives: We believe that atrial remodelling is a pre-existent process in patients with post-surgical AF. We have analyzed the factors related to the incidence of atrial fibrillation in the period after heart surgery. Methods: We included consecutive, hemodynamically stable patients with a sinusal rhythm who were subjected to programmed heart surgery with extracorporeal circulation. An assessment was made of the fall in atrial fibrillation after surgery using prolonged electrocardiographic monitoring. Results: A total of 100 patients were included in the study and were subjected to either coronary revascularisation surgery (59) or aortic valve substitution due to severe aortic stenosis (41). Postoperative AF occurred in 29 patients who received predominantly more valve surgery than coronary surgery. The following factors were predictive of postoperative AF in the multivariate analysis: Male sex; beta-blocker therapy for chronic disease; the use of intraoperative; fibrinogen perfusion; low HDL cholesterol values; and high sensitive troponin T values, in the preoperative period. Conclusions: HDL cholesterol and high sensitive troponin T can be useful biomarkers to predict the occurrence of AF after surgery. The early identification of these patients who develop of FA allows us to take preventive measures to minimize the negative effects.

Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery / Lesão renal aguda baseada nos critérios KDIGO (Kidney Disease: Improving Global Outcomes) em pacientes com creatinina sérica elevada submetidos à cirurgia cardíaca

Introduction: Preoperatively elevated serum creatinine (SCr) is considered an independent risk factor for morbidity and mortality after cardiac surgery. The aim of this study was to apply the Kidney Disease Improving Global Outcomes classification for acute kidney injury in a population of patients with preoperatively elevated serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to evaluate the acute worsening of renal function as a predictor of 30-day mortality. Methods: This was a single-center retrospective study that included patients from the Postoperative Cardiac Surgery Intensive Care Unit of the Hospital de Base, São José do Rio Preto Medical School. Demographics, type of surgery, laboratory data and pre, peri and postoperative data were obtained from a prospectively collected database. From January 2003 to June 2013, 2,878 patients underwent cardiac surgery, either coronary artery bypass grafting or cardiac valve surgery, at the Hospital de Base of São José do Rio Preto Medical School. Out of those, 918 showed elevated preoperative serum creatinine, with SCr > 1.30 mg/dL for men and > 1.00 mg/dL for women. Five hundred and forty nine patients (60%) undergoing coronary artery bypass grafting and 369 patients (40%) undergoing cardiac valve surgery. A Multivariate Cox Proportional Hazard Model (stepwise) was used to assess the relationship between AKI and mortality at 30 days. Results: Out of the 918 patients studied, 391 (43%) had postoperative AKI: 318 (35%) had Kidney Disease Improving Global Outcomes stage 1, 27 (2.9%) had Kidney Disease Improving Global Outcomes stage 2, and 46 (5.0%) had Kidney Disease Improving Global Outcomes stage 3. Patients in every stage of acute kidney injury showed progressive increase in EuroSCORE values, 30-day mortality ratescardiopulmonary bypass duration, and intensive care length of stay. Among patients classified ...

Introdução: Creatinina sérica (CSr) elevada no período pré-operatório é considerada um fator de risco independente para morbidade e mortalidade em cirurgia cardíaca. Avaliar o impacto da lesão renal aguda pelos critérios Kidney Disease Improving Global Outcomes como preditor de mortalidade em 30 dias em pacientes submetidos à revascularização miocárdica ou cirurgia valvar com creatinina sérica pré-operatória elevada. Métodos: Este foi um estudo retrospectivo de centro único que incluiu pacientes da Unidade de Cuidados Intensivos em Pós-operatório de Cirurgia Cardíaca do Hospital de Base, Faculdade de Medicina de São José do Rio Preto. Dados demográficos, tipos de cirurgia, dados laboratoriais e informações pré, peri e pós-operatórias foram obtidos a partir de uma coleta prospectiva de banco de dados. Foram considerados 2878 pacientes consecutivamente submetidos à revascularização miocárdica ou cirurgia valvar no período de janeiro de 2003 a junho de 2013. Destes, 918 indivíduos apresentavam creatinina sérica alterada no pré-operatório (CrS > 1.30 mg/dL para homens e > 1.00 mg/dL para mulheres), compreendendo 549 pacientes (60%) submetidos à revascularização miocárdica e 369 pacientes (40%) submetidos à cirurgia valvar. O modelo de riscos proporcionais de Cox foi utilizado para avaliar a relação entre lesão renal aguda e mortalidade em 30 dias. Resultados: Nesta casuística, 391 pacientes (43%) apresentaram lesão renal aguda no pós-operatório, sendo 318 (35%) Kidney Disease Improving Global Outcomes estágio 1, 27 (2,9%) Kidney Disease Improving Global Outcomes estágio 2 e 46 (5,0%) Kidney Disease Improving Global Outcomes estágio 3. EuroSCORE, mortalidade em 30 ...