Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study

ABSTRACT BACKGROUND: Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. OBJECTIVES: To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. DESIGN AND SETTING: Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. METHODS: PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. RESULTS: One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CONCLUSIONS: CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.

Estomatitis Urémica como Complicación Oral de Insuficiencia Renal Crónica: Reporte de Caso y Revisión de la Literatura / Uremic Stomatitis as an Oral Complication of Chronic Renal Failure: Case Report and Literature Review

RESUMEN: La Estomatitis Urémica es una lesión oral poco frecuente que se presenta generalmente en pacientes con insuficiencia renal crónica avanzada o no tratada. A continuación, se reporta un caso clínico de un paciente masculino de 22 años de edad que acude a un servicio de urgencia con la presencia de placas blanquecinas indoloras en piso de boca, cara interna de mejilla, y lengua. Las probables causas, presentaciones clínicas, y manejo odontológico son discutidos.

ABSTRACT: Uremic stomatitis is a rare oral lesion that usually occurs in patients with advanced or untreated chronic renal failure. Here we report a case of a 22-year-old male patient who comes to an emergency department with the presence of painless whitish plaques on the floor of the mouth, internal cheek face, and tongue. Probable causes, clinical presentations, and dental management are discussed.

Characterization of an experimental model of progressive renal disease in rats

ABSTRACT PURPOSE: To characterize an experimental model of progressive renal disease induced by different degrees of nephrectomy in rats. METHODS: Eighty male Wistar rats were divided into four experimental groups (n=20/group): sham surgery (control group), progressive degrees of nephrectomy leading to mild uremia (group 1), moderate uremia (group 2) and severe uremia (group 3). Ten animals of each group were followed for two or four weeks. At the end, blood and 24-hour urine samples were collected to determine renal function parameters. Urine output and water and food intake were daily monitored. RESULTS: In rats of group 1, serum levels of creatinine and urea and microalbuminuria were increased, while reduced creatinine clearance (p<0.05, compared with control group), without changing blood pressure. Animals of group 2 had more accentuated alterations: increases in urinary output, blood pressure, serum concentrations of urea, creatinine, sodium, potassium, and in microalbuminuria, and reduction of creatinine clearance (p<0.05). Group 3 exhibited even more increased serum concentrations of urea, creatinine, sodium and potassium, blood pressure and microalbuminuria, and decreased creatinine clearance (p<0.05) in comparison with control group and unilateral nephrectomy. CONCLUSION: Progressive nephrectomy in rats seems to be useful to study the physiopathology of chronic kidney disease and its mechanisms of progression.

Unintended Cannulation of the Subclavian Artery in a 65-Year-Old-Female for Temporary Hemodialysis Vascular Access: Management and Prevention

Ultrasound-guided cannulation of a large-bore catheter into the internal jugular vein was performed to provide temporary hemodialysis vascular access for uremia in a 65-yr-old woman with acute renal failure and sepsis superimposed on chronic renal failure. Despite the absence of any clinical evidence such as bleeding or hematoma during the procedure, a chest x-ray and computed tomographic angiogram of the neck showed that the catheter had inadvertently been inserted into the subclavian artery. Without immediately removing the catheter and applying manual external compression, the arterial misplacement of the hemodialysis catheter was successfully managed by open surgical repair. The present case suggests that attention needs to be paid to preventing iatrogenic arterial cannulation during central vein catheterization with a large-bore catheter and to the management of its potentially devastating complications, since central vein catheterization is frequently performed by nephrologists as a common clinical procedure to provide temporary hemodialysis vascular access.

Influência da escolaridade na hipertrofia miocárdica de pacientes em hemodiálise / Influence of educational level on myocardial hypertrophy of hemodialysis patients

Introdução: A doença renal crônica apresenta elevado risco cardiovascular. dados da população geral associam as doenças cardiovasculares a baixo nível de escolaridade, porém nehum trabalho avaliou essa associação entre pacientes em hemodiálise. objetivo: Avaliar a associação entre Botucatu (UNESP). dados clínicos, laboratoriais e ecocardiográficos foram extraídos dos prontuários. os pacientes foram divididos em dois grupos de acordo com a mediana da escolaridade: o grupo I foi constituído por pacientes com escolaridade <- três anos, e grupo II por pacientes com escolaridade superior a três anos. resultados: pressão arterial, ganho de peso interdialítico e variáveis com diferença estatística entre os dois grupos ao nível de p< 0,2 foram selecionadas para análise múltipla. Na análise múltipla, associações independentes foram consideradas ao nível de p< 0,05. A média de idade dos pacientes foi 57+- 12.8 anos, 46 pacientes eram homens (57%) e 53 eram brancos (67%). As variáveis selecionadas para análise múltipla foram: idade (p= 0,004), anos de escolaridade (p, 0,0001), índice de massa corpórea (p= 0,124), diâmetro do ventrículo esquerdo (p= 0,048) e índice de massa ventricular (p= 0,006). As drogas anti-hipertensivas empregadas foram similares em ambos os grupos. A pressão sistólica (p=0,006) e a escolaridade (p=0,047) apresentaram correlação significativa e independente com índice de massa ventricular. Conclusão: Em pacientes em hemodiálise, houve correlação da massa do ventrículo esquerdo não apenas com a pressão arterial, mas também com o nível educacional.

Introduction: Chronic kidney disease has a high cardiovascular risk. data from the general population associated cardiovascular disease to low levels of schooling, but match any study evaluated the association between hemodialysis patients. Objective: To evaluate the association between Botucatu (UNESP). clinical, laboratory and echocardiographic findings were extracted from medical records. Patients were divided into two groups according to the median education level: group I comprised patients with educational <- three years, and group II patients with higher education for three years. results: blood pressure, interdialytic weight gain and variable with a statistical difference between the two groups at p <0.2 were selected for multivariate analysis. On multivariate analysis, independent associations were considered at p <0.05. The average patient age was 57 + - 12.8 years, 46 patients were men (57%) and 53 were white (67%). Variables selected for multivariate analysis were age (p = 0.004), years of schooling (p, 0.0001), body mass index (p = 0.124), left ventricular diameter (p = 0.048) and left ventricular mass indeThe antihypertensive drugs used were similar in both groups. Systolic pressure (p = 0.006) and education (p = 0.047) correlated significantly and independently with left ventricular mass index. Conclusion: In hemodialysis patients, there was a correlation between left ventricular mass with not only blood pressure but also to the educational level.x (p = 0.006).

[Comparison of hepatitis C virus genotypes in hemodialysis and nonuremic patients]

Hepatitis C viruses [HCVs], which is an enveloped RNA cense positive, are classified into six major genotypes and multiple subtypes. Infection with this virus has been found to be a major cause of liver disease. Also, HCV infection is quite high among chronic hemodialysis patients. The purpose of the present study was to compare the genotypes of HCV and associated risk factors in hemodialysis patients with positive HCV non uremic patients. Sera sample were taken from population consisted of 113 non uremic patients and uremic ones with HCV who referred to Imam Khomeini nephrology clinic and Sari and Ghaemshahr Dialysis Centers: Case group was consisted of 55 patients with positive HCV hemodialysis disease. The control group consisted of 58 patients suffering from non-uremic positive HCV. Samples were tested with improved Real-Time PCR technique using the appropriate kit. In this study, the mean age of case group was 44.88 +/- 14.6 and for the control group was 46.73 +/- 11.9. Considering the sex of participants, 23 [41.8%] were female patients and 32 [58.2%] were in the case group while 13 female [22.4%] and 45 male [77.6%] were in the control group. The most common genotype of HCV in case group was 1a-b [72.7%] and in control group was 3a [50%]. Significant differences [p<0.05] were seen in HCV genotypes between two case and control groups. BUN and Cratinin in hemodialysis patients showed observable differences in comparison to control group [p<0.05], while PTT, AST, ACT in control group were higher in compare with hemodialysis patients [P < 0.05]. This study showed that the hepatitis C virus genotype and its associated risk factors in hemodialysis patients and non uremic patients is different

Tratamientos sustitutivos en enfermedad renal: diálisis peritoneal, hemodiálisis y trasplante renal / Substitute treatment and replacement in chronic kidney disease: peritoneal dialysis, hemodialysis and transplant

Los tratamientos sustitutivos de diálisis crónica o trasplante renal se inician cuando la filtración glomerular del paciente medida por la depuración de creatinina endógena en la orina de 24 horas es inferior a 15 o 10 ml/mm y cuando se presentan complicaciones. A los enfermos con indicaciones de trasplante se les debe buscar un donador vivo seleccionado o inscribirlos en la lista de espera nacional de donación cadavérica si no existen contraindicaciones. Aun cuando no hay un registro nacional mexicano de pacientes en diálisis crónica, solo datos indirectos de la Fundación Mexicana del Riñón y de la industria de diálisis, se estima que de 40 mil a 50 mil son sujetos a este tratamiento y que anualmente la cifra se incrementa 11 %. En términos generales se considera que por cada enfermo en diálisis crónica hay otro que fallece sin acceso al tratamiento. Las unidades de hemodiálisis deben cumplir con la norma oficialmexicana de hemodiálisis y la cédula de evaluación de la calidad de las unidades de hemodiálisis del Consejo de Salubridad General. Es aconsejable que los pacientes sean incorporados a diálisis crónica después de ser presentados al comité de diálisis, y que el tratamiento se aplique con la aceptación del enfermo o sus familiares y se registre en el censo nominal.

Chronic dialysis replacement treatments or renal transplants are instituted when the patient's glomerular filtration rate, measured by 24-h urine endogenous creatinine clearance, is <10-15 ml/mm and, as the The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI), European and Canadian guidelines point out, when one or two of the following complications occur: "uremic toxicity" symptoms, significant fluid retention that does not respond to loop diuretics, hyperkalemia, chronic anemia (hemoglobin <8 g), metabolic acidosis or acute pulmonary edema. In all patients for whom transplant is indicated, a selected live donor must be sought or, in the absence of contraindications, the patient should be registered with the national cadaver donation waiting list. While waiting for the transplant, patients will be on a chronic dialysis program. There is no national registry of patients undergoing chronic dialysis; only indirect data from the Mexican Kidney Foundation and the dialysis industry are available. However, it is estimated that 40,000-50,000 people are under this treatment and the numbers grow by 11% every year. Overall, it is thought that for every patient receiving chronic dialysis, there is one more patient who dies without access to therapy. Hemodialysis units must comply with the Official Hemodialysis Standard and the General Health Council Hemodialysis Unit Quality Assessment Form.

Acute renal failure in neonatal sepsis.

OBJECTIVE: To evaluate the occurrence of acute renal failure (ARF) and the factors associated with it in cases of neonatal sepsis. METHODS: The case control study was conducted in the referral neonatal intensive care unit of a tertiary teaching hospital. 200 out born neonates with sepsis admitted to the nursery from January to July 2003 were evaluated for presence of ARF (cases) or not (controls). Sepsis was diagnosed on the basis of either a positive sepsis screen (immature: total (I:T) neutrophil ratio > 0.2, micro-ESR > age in days + 2 mm or> 15 mm, CRP> 6 mg/dl, TLC< 5000 cells/mm3; 2 or more positive) or a positive blood culture in symptomatic neonates. ARF was defined as blood urea nitrogen (BUN)> 20mg/dl on two separate occasions at least 24 hours apart. Oliguria was defined as urine output < 1 ml/Kg/hr. RESULTS: 52 out of 200 (26%) neonates with sepsis had ARF; only 15% of ARF was oliguric. The mean gestation of neonates with ARF was similar to those without ARF (36.1+/-4.1 wks vs. 36.6+/-3.5 wk; p = 0.41). A significantly higher number of babies with ARF weighed less than 2500 gm as compared to those without ARF (86.5% vs 67.6%; p = 0.008). The association of meningitis, disseminated intravascular coagulation (DIC) and shock was also significantly higher in neonates with ARF (46.8% vs 26.2%, p = 0.01; 65.4% vs 20.3%, p < 0.001; 71.2% vs 27.0%, p < 0.001 respectively). Mortality in neonates who developed ARF was significantly higher (70.2% vs 25%, p < 0.001). Factors including gestational age, weight, onset of sepsis, culture positivity, associated meningitis, asphyxia, shock, prior administration of nephrotoxic drugs were subjected to univariate analysis for prediction of fatality in neonates with sepsis and ARF; only shock was found to be a significant predictor of fatality (p< 0.001). ARF had recovered in 22 out of 49 neonates in whom data was available; three patients had left against medical advice. The mean duration of recovery in these 22 neonates was 5.5 days (range 1-14 days). Presence of co-existing morbidities (perinatal asphyxia/congestive heart failure (CHF)/ necrotising enterocolitis (NEC)) or nephrotoxic drugs did not alter the frequency of recovery of ARF in septic neonates (45.5% vs 44.4%,p = 0.944; 41% vs 52%, p = 0.308 respectively). CONCLUSION: Renal failure occurred in 26% neonates with sepsis. Although ARF in neonates has been reported to be predominantly oliguric, it was observed that ARF secondary to neonatal sepsis was predominantly non oliguric. Low birth weight was an important risk factor for the development of ARF. The mortality being three times higher in neonates with ARF demands a greater awareness of this entity among practitioners and better management of this condition.

Gene expression in uremic left ventricular hypertrophy: effects of hypertension andanemia

Hypertension and anemia may be causes of left ventricular hypertrophy (LVH) in uremia but the molecular mechanism is not known. Uremia was induced in male Spraugue Dawley rats by 5/6 nephrectomy. The following groups of rats were studied for 6 weeks; uremic rats (U) fed ad. lib., control rats (C) pair-fed with U, U rats given hydralazine (100 mg/kg/day) (UH), U rats given erythropoietin (48U/kg/week, i.p.) (UE). Both diastolic and mean arterial pressures are higher (P<0.01) in U and UE compared with C whereas both pressures in UH were normalized. Hemoglobin in U was lower than in C, and was normalized in UE. U, UH and UE had higher heart weight/body weight ratios (HW/BW) as well as left ventricular weight/body weight ratios (LV/BW) compared with C (P<0.01). Compared with U, UH has lower HW/BW and LV/BW (P <0.05) and UE has normal HW/BW but lower LV/BW than U (P<0.05). To see if the gene expression in uremic LVH is similar to that described in pressure overload LVH in which mRNA levels of angiotensin converting enzyme (ACE), transforming growth factor-beta1 (TGF-beta1), atrial natriuretic factors (ANF) and skeletal alpha-actin were increased, we measured these mRNA levels by Northern analysis. TGF-beta, ACE and alpha-actin mRNA levels were not changed in all 4 groups. ANF mRNA in U and UE was increased 3 fold over C, and normalized in UH. Treatment of anemia with erythropoietin improved uremic LVH but did not change ANF mRNA; whereas treatment of hypertension with hydralazine normalized ANF mRNA but did not completely correct uremic LVH. Thus, gene expression in uremic LVH is distinct from that in pressure- overload LVH, suggesting that other unidentified factor(s) might be involved in uremic LVH.

Evolving trends in the etiopathogenesis of acute renal failure.

Research during the last few years has uncovered the mechanisms responsible for acute renal failure. During the initiation phase of acute tubular necrosis sublethal injury, apoptosis or necrosis of the tubular epithelium, hemodynamic alterations, tubule obstruction and back leakage occur. Hypofiltration persists due to imbalance between endothelins and endothelium derived nitric oxide, medullary congestion and tubuloglomerular feedback. Recovery is characterised by tubular epithelium regeneration. A greater understanding of the pathogenesis of acute renal failure will allow better management of such cases.

Prurido urêmico / Uremic pruritus

A insuficiência renal crônica produz várias manifestaçöes dermatológicas, como a hiperceratose folicular, xerose, unhas ®half-and-half¼, hiperpigmentaçäo e prurido. Dessas, a que mais pode comprometer a qualidade de vida do paciente urêmico é, sem dúvida, o prurido. De etiologia näo completamente compreendida, o prurido urêmico acomete grande parte dos pacientes renais e seu tratamento envolve vários aspectos do gerenciamento da síndrome urêmica como diálise, controle do hiperparatireoidismo e correçäo da anemia. Esta revisäo discorre sobre os principais aspectos da fisiopatologia e tratamento desta freqüente manifestaçäo da uremia.

Effects of propranolol and verapamil on glycerol-induced acute renal failure in mice

1. Several mechanisms have been suggested for the renal damage induced by intramuscular injection of glycerol. 2. We investigated the role of beta recetor desensitization by propranolol, and blocking calcium channels by verapamil in providing protection to the renal tissue from glycerol-induced acute renal failure. 3. Propranolol but not verapamil provided a significant protection reflected by lowering blood urea and serum creatinine and attenuating histopathological changes. 4. We conclude that acute renal failure induced by glycerol may be partly mediated by stimulation of renal beta receptor

Reduced humoral immunity in uremic mice genetically selected for high antibody response

Biozzi's Selection IV-A mice, genetically selected for 25 generations for high and low antibody response to sheep red blood cells (SRBC), 2-3 months old, were made uremic by subtotal nephrectomy and characterized for antibody production against the selection antigen. T cell activity was evaluated in vitro by lymphocyte proliferation and interleukin 2 (IL 2) production in response to the superantigen staphylococcal enterotoxin B (SEB). Total and IgM antibody titers (log2) were similar in uremic and non-uremic low responder mice (total antobody: 4.0 +/- 0.6 vs 3.6 +/- 0.6; IgG: 3.0 +/- 0.7 vs 2.4 +/- 0,4), while uremic high responders presented a blunted humoral immune response to SRBC when compared with non-uremic animals (total antibody: 10.8 +/- 1.6 vs 13.0 +/- 0.2; IgG: 10.3 +/- 1.5 vs 11.7 +/- 0.3). T cell proliferation and IL 2 production were similar in uremic and ...

Acute renal failure in cases at perinatal asphyxia

Acute renal failure in the neonates usually occurs following complicated delivery with perinatal hypoxia and shock. In our study, 41 neonates who suffered perinatal asphyxia and needed admission to the Neonatal Intensive Care Unit of Cairo University, were investigated for the detection of occurrence of acute renal failure. 15 normal infants were included as controls. Out of the 41 cases, 11 asphyxiated babies developed renal impairment suggestive of acute renal failure [26.8%]. Mean serum urea was significantly higher both in preterm [47.65 +/- 23.7 mg/dl] and term infants [61.47 +/- 55.6 mg/dl] than in control cases [24.5 +/- 7.69 mg/dl]. It was also significantly higher in cases who developed acute renal failure [111.9 +/- 45.7 mg/dl] than those cases without failure [33.7 +/- 12.5 mg/dl]. Mean serum creatinine was also significantly higher in asphyxiated babies [0.96 +/- .35 mg/dl in preterms and 1.005 +/- 0.432mg/dI in full terms] than in control eases 0.813 +/- 0.178] mean serum sodium was significantly lower in preterm and full term cases [129.2 +/- 12.02 mEq/I and 130.5 +/- 12.23 mEq/l]. This hyponatremia is explained by the inappropriate secretion of antidiuretic hormone secondary to hypoxIa insult to the central nervous system. Hyperkalemia occurred in 75% of asphyxiated babies [7.49 +/- 2.815 in preterm and 7.55 +/- 2.59 mEq/l in term cases]. Urinary casts [hyaline and granular] with many epithelial cells were found in 60% of cases. Convulsions were reported more frequently in the asphyxiated infants with renal failure. Hypoxia, uremia and hyponatremia were the contributary factors of the occurrence of convulsions. Abnormal ultrasound findings in the form of enlarged kidney size and increased pyramid echogenicity were reported. Prevention of perinatal asphyxia and prompt postnatal ressuscitation should be the cornerstone in avoiding and minimizing renal damage. Non invasive investigation tooIs as simplc urine analysis and abdominal utlrasonography are greatly valuable for the early diagnosis of acute renal damage in these asphyxiated neonates

Study of some acute phase reactants in chronic renal failure before and after hemodialysis

Thirty subjects were available for this study, they were divided into three equal groups: group I: ten patients with chronic renal failure [CRF] on regular hemodialysis, group II: ten patients with C.R.F., on conservative therapy, group III: ten healthy subjects served as control. Serum C-reactive protein [C.R.P], haptoglobin [HPT] and alpha-1-acid glycoprotein [AAG] as acute phase reactants were estimated for all subjects and for the hemodialysis group before and after hemodialysis. The estimation was done by Turbi-Timer method. Unlike CRP, the AAG has a significant value in hemodialysis patients, while HPT, like CRP, cannot be recommended as an acute phase reactant in these patients because of the unacceptable high false positive rate. In the uremic [non dialysed] patients, the CRP maintains its diagnostic value then comes the AAG whose level is correlated with the degree of renal impairment. On the contrary, HPT cannot be recommended because of high false positive rate

Pericarditis Uremica: estudio retrospectivo en 233 casos de insuficiencia renal crónica severa en el Hospital Cayetano Heredia entre 1980-1990 / Uremic Pericarditis: retrospective study about severe renal chronic insufficiency in 233 coles at the Hospital Nacional Cayetano Heredia betwen 1980 to 1990

El presente es un estudio retrospectivo que incluyó 233 casos de IRC severa atendidos en el HNCH durante los años 1980-1990. Se identificaron 52 pacientes con sospecha clínica de pericarditis urémica (22.26 por ciento). Dos terceras partes de los pacientes afectos tenían diagnóstico de IRC por menos de 10 meses (p igual 0.001). No hallamos diferencias en las etiologías de IRC con reportes previos. Los pacientes menores de 50 años fueron los más afectados (p igual 0.03). Dispnea, edemas y dolor torácico fueron los sintomas más usuales. Se confirmaron ecocardiográficamente 15 efusiones leves y 8 moderadas. La ecocardiografía fue el método diagnóstico de mayor utilidad. Sólo el 48 por ciento de pacientes con hemodiálisis mostraron mejoría clínica. El 78 por ciento de ellos recibió tratamiento hemodiálitico insuficiente. La diálisis peritoneal exclusiva constituyó el mejor tratamiento alternativo. Se registró taponamiento cardiáco en 10 por ciento de casos y la letalidad fue de 11 por ciento por causas directamente atribuíbles a la pericarditis y la IRC