RESUMO
ObjectiveTo analyze the characteristics of severe trauma patients with acute kidney injury (AKI) receiving renal replacement therapy (RRT), in order to look for the risk factors of AKI and the opportune time for the initiation of RRT on prognosis.Methods A retrospective cohort study involving consecutive patients with severe trauma in emergency intensive care unit (ICU) in the Second Affiliated Hospital of Zhejiang University School of Medicine, from August 2011 to December 2014, was conducted. Inclusion criteria included age≥18 years, injury severity score (ISS)> 16, AKI receiving RRT, and the duration of hospital stay> 24 hours. The general data, the risk factors of AKI, the prognostic indicators, and the information of RRT were recorded. All patients were divided into two groups according to the prognosis, the time of onset of AKI and the initiation time of RRT. The independent risk factors for prognosis were screened by binary logistic regression analysis.Results Seventy-three patients were eligible for enrollment, including 48 deaths (65.8%); 49 patients suffered from AKI≤48 hours after trauma (early stage group), and in 24 patients it was longer than 48 hours (late stage group). In 55 patients RRT was routinely started (routine RRT group), 18 patients underwent RRT ahead of routine criteria decided by the judgment of the attending doctor (earlier RRT group). The main risk factors of RRT in traumatic patients with AKI were shock and sepsis, each accounted for 90.4% and 53.4%. Compared with survival group, in death group, the proportion of male patients was lower (70.8% vs. 100.0%,χ2 = 7.238,P = 0.007), acute physiology and chronic health evaluationⅡ (APACHEⅡ) scores were higher (23.7±5.1 vs. 14.4±3.7,t = 8.031,P< 0.001), Glasgow coma score (GCS) was lower [5.0 (3.0, 15.0) vs. 15.0 (8.0, 15.0),U = 320.000,P = 0.001], incidence of shock and sepsis was higher (97.9% vs. 76.0%,χ2 =6.755,P = 0.009; 64.6% vs. 32.0%,χ2 = 7.014,P = 0.008), the rate of use of contrast medium was lower (27.1% vs. 56.0%,χ2 = 5.898,P = 0.015), the time for the diagnosis of AKI post trauma was delayed [days: 2 (1, 5) vs. 2 (1, 2), U = 762.000,P = 0.049], the time for the initiation of RRT post trauma was later [days: 6.0 (3.0, 12.0) vs. 3.0 (2.0, 4.5), U = 868.500,P = 0.002], the recovery rate of renal function at discharge was lower (10.4% vs. 100.0%,χ2 = 54.497, P< 0.001). Compared with late stage group, in early stage group, the mortality was lower (55.1% vs. 87.5%,χ2 =7.509,P = 0.006), and the incidence of sepsis before AKI was also lower (38.8% vs. 83.3%,χ2 = 12.854,P< 0.001). Compared with routine RRT group, the recovery of renal function at discharge was better with a lower mortality rate in the earlier RRT group, but the difference was considered to be insignificant (55.6% vs. 36.4%,χ2 = 2.064,P = 0.151;50.0% vs. 70.9%,χ2 = 2.633,P = 0.105). Logistic regression analysis showed GCS [odds ratio (OR) = 0.852, 95%confidence interval (95%CI) = 0.747-0.972,P = 0.017], shock before AKI (OR = 85.350, 95%CI = 5.682-1 282.073, P = 0.001), and sepsis before AKI (OR = 11.499, 95%CI = 2.127 - 62.161,P = 0.005) were independent risk factors for the judgment of prognosis.Conclusions Shock and sepsis are the major risk factors of RRT in trauma patients with AKI. Shock, sepsis and traumatic brain injury are the independent risk factors of death. Perhaps early initiation of routine RRT cannot improve the outcome of the patients with posttraumatic renal insuficiency.
RESUMO
El melanoma maligno cutáneo es una enfermedad mortal, que durante los últimos años se ha propagado a nivel mundial, es una entidad que afecta la piel y los órganos que se originan de la cresta neural durante el desarrollo embrionario. La historia del melanoma, se resume en el crecimiento e invasión local de la piel, y en el desarrollo de la misma, influyen factores tanto ambientales como genéticos. Esta patología es infrecuente en tipos de raza, como los afrodescendientes e indígenas, por tanto, debido a este particular suceso, el objetivo del presente artículo, es demostrar a través de un estudio analítico observacional, el caso clínico de una mujer indígena, natural de Alto Baudó, Chocó Colombia, a quien durante el tiempo de tratamiento, se le diagnostica melanoma maligno cutáneo. En la actualidad esta patología tiene muchas opciones de tratamiento estándar, pero aun así, los familiares del paciente objeto de estudio, rechazan todo procedimiento quirúrgico para contrarrestar la enfermedad, pues para ellos, es más importante las creencias de sus resguardos indígenas, desconociendo de antemano, que un dictamen prematuro con tratamientos apropiados, resultan fundamentales para neutralizar a tiempo la enfermedad; lamentablemente en estas culturas indígenas, prima más sus creencias, que el derecho del paciente a tener una vida digna. (MÉD.UIS. 2014;27(1):59-68).
Cutaneous malignant melanoma is a deadly disease, which in recent years has spread worldwide, is an entity that affects the skin and organs that origínate from the neural crest during embryonic development. The history of melanoma is summarized in the growth and local invasion of the skin, and the development of it, influence of both environmental and genetic factors. This condition is uncommon in breed types, such as African and indigenous descent, therefore because of this particular event, the aim of this paper is to demonstrate through an observational analytic study, a case of an indigenous, natural woman Alto Baudó, Choco Colombia, who during the time of treatment, is diagnosed with cutaneous malignant melanoma. Currently this disease has many standard treatment options, but still, the patient's family under study, reject any surgical procedure to counteract the disease, because for them it is more important beliefs of the indigenous reserves, knowing in advance, a premature opinion with appropriate treatment, are essential to neutralize the disease in time, unfortunately in these indigenous cultures, their beliefs more raw, the patient's right to a dignified life. (MÉD.UIS. 2014;27(1):59-68).