Protocolos de Vigilancia Centinela de enfermedad renal crónica y manual de registro guatemalteco de diálisis y trasplante renal. No. 12 / Sentinel Surveillance Protocols of chronic kidney disease and manual of Guatemalan dialysis and renal transplantation. No. 12

Estos protocolos están dirigido a personal médico, paramédico y otros profesionales que realizan acciones gerenciales y operativas de vigilancia epidemiológica en los servicios de salud del país, y están divididos en varios tomos para dar a conocer y actualizar la identificación y medidas de control para diversos padecimientos a fin de continuar con el mejoramiento de las capacidades técnicas de los trabajadores de salud, que permita planificar la prestación de servicios con decisiones partiendo de un enfoque epidemiológico comprobado, para responder a los cambios de tendencias epidemiológicas y con ello contribuir al fortalecimiento de prácticas asertivas de la salud pública de nuestro país. Por otra parte, en el documento se afirma que "en el marco de la "Reunión de Alto Nivel sobre Enfermedad Renal Crónica de Causas no Tradicionales en Centroamérica" (ERCnT), celebrada en abril del 2013, los Estados Miembros de Centroamérica y la República Dominicana, que forman parte del Sistema de la Integración Centroamericana (SICA) y la Comisión de Ministros de Salud de Centroamérica y República Dominicana (COMISCA) a través de la "Declaración de San Salvador" reconocen que la enfermedad renal crónica es un problema de salud pública importante en Centroamérica y requiere de una acción urgente."

The effect of tadalafil therapy on kidney damage caused by sepsis in a polymicrobial septic model induced in rats: a biochemical and histopathological study

ABSTRACT Introduction Sepsis is an inflammatory reaction to bacteria involving the whole body and is a significant cause of mortality and economic costs. The purpose of this research was to determine whether tadalafil exhibits a preventive effect on sepsis in a septic model induced in rats with cecal ligation and puncture (CLP). Materials and Methods Rats were randomly separated into groups, 10 rats in each: (i) a sham (control) group, (ii) an untreated sepsis group, (iii) a sepsis group treated with 5mg/kg tadalafil and (iv) a sepsis group treated with 10mg/kg tadalafil. A polymicrobial sepsis model was induced in rats using CLP. Rats were sacrificed after 16h, and blood and kidney tissues were collected for biochemical and histopathological study. Results Levels of the inflammatory parameter IL-6 decreased significantly in the sepsis groups receiving tadalafil in comparison with the untreated sepsis group (p<0.05). In terms of histopathology, inflammation scores investigated in kidney tissues decreased significantly in the sepsis groups receiving tadalafil compared to the untreated sepsis group (p<0.05). In addition, levels of creatinine and cystatin C measured in septic rats receiving tadalafil were lower by a clear degree than in septic rats (p<0.05). Conclusion In this study, tadalafil exhibited a preventive effect for sepsis-related damage by suppressing inflammation in serum and kidney tissue of septic rats in a polymicrobial sepsis model induced with CLP.

Ibuprofen and indomethacin for the closure of the patent ductus arteriosus / Ibuprofen, indometacina e fechamento do canal arterial

The ductus arteriosus connects the pulmonary artery with the aorta and allows right ventricular blood to bypass the unexpanded lungs. In mature infants, the ductus arteriosus closes after birth. Patent ductus arteriosus occurs in 70% of preterm infants with a birth weight < 1,000 grams. Failure of the ductus arteriosus to close has been associated with intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, periventricular leukomalacia, renal failure, and persistent pulmonary hypertension. The drugs used to treat the patent ductus arteriosus are ibuprofen and indomethacin which are potent non-selective inhibitors of cyclo-oxygenase (COX) and therefore inhibit prostaglandin E2 synthesis. Prostaglandin E2 relaxes smooth muscle and tends to inhibit the closure of the patent ductus arteriosus. Intravenous ibuprofen and indomethacin inhibit prostaglandin E2 synthesis and thereby close the patent ductus arteriosus with similar efficacy. Indomethacin reduces the blood flow velocity in kidneys, intestine and brain. Ibuprofen has less effect on blood flow velocity in these organs. There is a significant increase in serum creatinine after indomethacin administration but not after ibuprofen and infants treated with ibuprofen have higher creatinine clearance. Oliguria (urine output < 1 ml/kg/h) occurs more frequently with indomethacin than with ibuprofen. Indomethacin requires furosemide for urine output more often than ibuprofen. Ibuprofen reduces the risk of necrotizing enterocolitis and transient renal insufficiency and it is the drug of choice for closing the patent ductus arteriosus. Ibuprofen and indomethacin may be administered orally. In conclusion, intravenous ibuprofen and indomethacin close the patent ductus arteriosus at the same rate, but indomethacin is more toxic than ibuprofen.

O canal arterial conecta a artéria pulmonar com a aorta e permite que o sangue oriundo do ventrículo direito evite passar pelos pulmões fetais não expandidos. Em recém-nascidos maduros, o canal arterial se fecha após o nascimento. A persistência do canal arterial ocorre em 70% dos recém-nascidos prematuros com peso de nascimento < 1.000 gramas. O não fechamento do canal arterial associa-se a hemorragia intraventricular, enterocolite necrosante, displasia bronco-pulmonar, leucomalacia periventricular, insuficiência renal e hipertensão pulmonar persistente. Os medicamentos utilizados para tratar a persistência do canal arterial são o ibuprofeno e a indometacina. Ambos são potentes inibidores não seletivos da ciclo-oxigenase e inibem a síntese de prostaglandina E2. Esta relaxa a musculature vascular lisa e tende a inibir o fechamento do canal arterial. O ibuprofeno e a indometacina inibem a síntese de prostaglandina E2 e favorecem o fechamento do canal arterial. A indometacina reduz a velocidade do fluxo sanguíneo renal, intestinal e cerebral. O Ibuprofeno tem efeito menor sobre a velocidade do fluxo de sangue nesses órgãos. Há um aumento significativo da creatinina sérica após a administração de indometacina, mas não após o ibuprofeno; por isso, recém-nascidos tratados com ibuprofeno têm maior depuração da creatinina. A oligúria ocorre mais frequentemente com a indometacina vs. ibuprofeno. A indometacina requer furosemida para a produção de urina mais frequentemente do que o ibuprofeno. O ibuprofeno reduz o risco de enterocolite necrotizante e de insuficiência renal transitória e é a droga de escolha para o fechamento do canal arterial patente. O ibuprofeno e a indometacina podem ser ministrados por via oral. Em conclusão, o ibuprofeno e a indometacina fecham o canal arterial patente com a mesma velocidade, mas a indometacina é mais tóxica.

Protective effect of hydrogen sulfide on renal injury in the experimental unilateral ureteral obstruction

Introduction/Objective: Ureteral obstruction is a common pathology and causes kidney fibrosis and dysfunction at late period. In this present study, we investigated the antifibrotic and antiinflammatory effects of hydrogen sulfide on kidney damage after unilateral ureteral obstruction (UUO) in rats. Materials and Methods: 24 rats were divided into four groups. Group 1 was control, group 2 was sham, group 3 included rats with UUO and group 4 rats with UUO which were given sodium hydrogen sulfide (NaHS)-exogenous donor of hydrogen sulfide (intraperitoneally 56μmoL/kg/day). After 14 days, rats were killed and their kidneys were taken and blood analysis was performed. Tubular necrosis, mononuclear cell infiltration and interstitial fibrosis were determined histopathologically in a part of the kidneys; nitric oxide (NO), malondialdehyde (MDA) and reduced glutathione (GSH) levels were determined in the other part of the kidneys. Urea-creatinine levels were investigated by blood analysis. Statistical analyses were made by the Chi-square test and one-way analysis of variance (ANOVA). Results: There was no significantly difference for urea-creatinine levels among groups. Pathologically, there was serious tubular necrosis and fibrosis in group 3 and there was significantly decreasing of tubular necrosis and fibrosis in group 4 (p<0.005). Also, there was significantly increase of NO and MDA levels and decrease of GSH levels in group 3 compared to other groups (p<0.005). Conclusions: hydrogen sulfide prevents kidney damage with antioxidant and antiinflammatory effect.

An analysis of tacrolimus-related complications in the first 30 days after liver transplantation

OBJECTIVES: Orthotopic liver transplantation has improved survival in patients with end-stage liver disease; however, therapeutic strategies that achieve ideal immunosuppression and avoid early complications are lacking. To correlate the dose and level of Tacrolimus with early complications, e.g., rejection, infection and renal impairment, after liver transplantation. From November 2011 to May 2013, 44 adult liver transplant recipients were studied in this retrospective comparative study. RESULTS: The most frequent indication for liver transplantation was hepatitis C cirrhosis (47.7%), with a higher prevalence observed in male patients (68.18%). The ages of the subjects ranged from 19-71 and the median age was 55.5 years. The mean length of the hospital stay was 16.1±9.32 days and the mean Model for End-stage Liver Disease score was 26.18±4.28. There were five cases of acute cellular rejection (11.37%) and 16 cases of infection (36.37%). The blood samples that were collected and analyzed over time showed a significant correlation between the Tacrolimus blood level and the deterioration of glomerular filtration rate and serum creatinine (p<0.05). Patients with infections had a higher serum level of Tacrolimus (p = 0.012). The dose and presence of rejection were significantly different (p = 0.048) and the mean glomerular filtration rate was impaired in patients who underwent rejection compared with patients who did not undergo rejection (p = 0.0084). CONCLUSION: Blood Tacrolimus levels greater than 10 ng/ml were correlated with impaired renal function. Doses greater than 0.15 mg/kg/day were associated with the prevention of acute cellular rejection but predisposed patients to infectious disease. .

Predictive factors for renal failure and a control and treatment algorithm / Fatores preditivos da insuficiência renal e algoritmo de controle e tratamento / Factores de predicción de la insuficiencia renal y el algoritmo de control y tratamiento

OBJECTIVES: to evaluate the renal function of patients in an intensive care unit, to identify the predisposing factors for the development of renal failure, and to develop an algorithm to help in the control of the disease. METHOD: exploratory, descriptive, prospective study with a quantitative approach. RESULTS: a total of 30 patients (75.0%) were diagnosed with kidney failure and the main factors associated with this disease were: advanced age, systemic arterial hypertension, diabetes mellitus, lung diseases, and antibiotic use. Of these, 23 patients (76.6%) showed a reduction in creatinine clearance in the first 24 hours of hospitalization. CONCLUSION: a decline in renal function was observed in a significant number of subjects, therefore, an algorithm was developed with the aim of helping in the control of renal failure in a practical and functional way. .

OBJETIVOS: avaliar a função renal de pacientes em uma unidade de terapia intensiva, identificar os fatores predisponentes ao desenvolvimento da insuficiência renal e desenvolver um algoritmo para auxiliar no controle da doença. MÉTODO: estudo exploratório, descritivo, prospectivo, com abordagem quantitativa. RESULTADOS: trinta pacientes (75,0%) tiveram diagnóstico de insuficiência renal e os principais fatores associados a essa doença foram: a idade avançada, a hipertensão arterial sistêmica, o diabetes mellitus, as doenças pulmonares e o uso de antibióticos. Dos pacientes, 23 (76,6%) apresentaram redução do clearance de creatinina nas primeiras 24 horas de internação. CONCLUSÃO: houve redução da função renal de um expressivo número de sujeitos, portanto, foi desenvolvido um algoritmo com a finalidade de auxiliar o controle da insuficiencia renal de forma prática e funcional. .

OBJETIVOS: evaluar la función renal de pacientes en una unidad de terapia intensiva, identificar los factores predisponentes al desarrollo de la insuficiencia renal y desarrollar un algoritmo para auxiliar en el control de la enfermedad. MÉTODO: estudio exploratorio, descriptivo y prospectivo, con abordaje cuantitativo. RESULTADOS: 30 pacientes (75,0%) tuvieron diagnóstico de insuficiencia renal y los principales factores asociados a esa enfermedad fueron la edad avanzada, la hipertensión arterial sistémica, la diabetes mellitus, las enfermedades pulmonares y el uso de antibióticos. 23 pacientes (76,6%) presentaron reducción del clearance de creatinina en las primeras 24 horas de internación. CONCLUSIÓN: hubo reducción de la función renal de un expresivo número de sujetos, por tanto, fue elaborado un algoritmo con la finalidad de auxiliar en el control de la insuficiencia renal de forma práctica y funcional. .

Rabdomiolisis secundaria a intoxicación etílica: caso clínico / Rhabdomyolysis following alcohol intoxication: a case report

Introduction: rhabdomyolysis is a potentially lethal syndrome characterized by disintegration of striated muscle fibers. In children Rhabdomyolysis is caused mostly by trauma, nonketotic hyperosmolar coma, viral myositis, dystonia and malignant hyperthermia. Case report: a 14 year old male was brought into the emergency room because of a decreased level of consciousness following alcohol and cannabis. An initial assessment indicated the presence of hypothermia and a Glasgow Coma Scale of 9. A blood biochemical analysis showed a mixed acidosis and CPK levels of 12260 U/L (CK-MB 132 U/L). After diagnosing alcohol induced coma and rhabdomyolysis, intravenous fluids and urinary alkalinization are administered. The patient presented a rapid neurological improvement reaching normal within 12 hours. He remained normotensive, adequate diuresis, negative balances, normal blood gas values and urine test strips presented no pathological changes. A maximum level of serum CPK was observed 24 hours after ingestion (20820 U/L), with subsequent decline to 6261 U/L at day 5, once he was discharged. Discussion: alcohol poisoning is a rare cause of rhabdomyolysis in pediatrics. The main therapeutic goal is to prevent acute renal failure, aggressive fluid therapy and urine alkalinization then must be administered, monitoring possible electrolyte abnormalities and the presence of myoglobinuria. In conclusion, rhabdomyolysis is one of the possible complications after alcohol poisoning. Given its potential morbidity, it should always be considered.

Introducción: la rabdomiolisis es un síndrome potencialmente letal caracterizado por la destrucción de fibras musculares estríadas. En niños es producido fundamentalmente por traumatismos, coma hiperosmolar no cetósico, miositis vírica, distonía o hipertermia maligna. Caso clínico: varón de 14 años que es traído al servicio de Urgencias por disminución del nivel de conciencia secundaria a consumo de alcohol y cannabis. En la valoración inicial en nuestro centro se constatan hipotermia y una puntuación según la escala de Glasgow de 9. En el análisis bioquímico sanguíneo destacan una acidosis mixta y niveles de CPK de 12.260 U/L (CK-MB 132 U/L). Con los diagnósticos de coma etílico y rabdomiolisis se inicia administración de fluidoterapia intravenosa y alcalinización urinaria. Presentó una rápida mejoría neurológica con normalización en las primeras 12 h. Se mantuvo normotenso, con adecuada diuresis, balances negativos, normalización de los valores gasométricos y tiras reactivas de orina seriadas sin hallazgos patológicos. Se objetivó un nivel máximo de CPK sérica 24 h tras la ingesta (20.820 U/L), con descenso posterior hasta 6.261U/L a los 5 días, cuando se dio de alta. Discusión: la intoxicación etílica constituye una causa infrecuente de rabdomiolisis en pediatría. El principal objetivo terapéutico es evitar el fracaso renal agudo, por lo que se deben iniciar fluidoterapia agresiva y eventual alcalinización de la orina, manteniendo monitorizados las posibles alteraciones electrolíticas así como la presencia de mioglobinuria. En conclusión, la rabdomiolisis es una de las posibles complicaciones de la intoxicación etílica. Dada su potencial morbimortalidad, siempre debe ser tenida en cuenta.

Evolução hospitalar de pacientes com choque cardiogênico por infarto agudo do miocárdio com supradesnivelamento do segmento ST / In-hospital outcomes of patients with cardiogenic shock due to ST-elevation myocardial infarction

INTRODUÇÃO: O choque cardiogênico é uma condição clínica de inadequada perfusão tecidual devido à disfunção cardíaca. A etiologia mais comum é o infarto agudo do miocárdio com elevação do segmento ST (IMCSST) levando à insuficiência ventricular esquerda, mas também pode ser causado por complicações mecânicas, como insuficiência mitral aguda, ruptura do septo interventricular ou da parede livre do ventrículo esquerdo. Apesar dos avanços terapêuticos, a mortalidade continua elevada. MÉTODOS: Estudo retrospectivo, observacional, unicêntrico, incluindo pacientes consecutivos internados com o diagnóstico de IMCSST e choque cardiogênico, tratados por intervenção coronária percutânea (ICP), em hospital terciário especializado em cardiologia. O objetivo primário foi avaliar os desfechos clínicos hospitalares. RESULTADOS: Foram incluídos 78 pacientes, a maioria do sexo masculino (67,9%), com idade de 67,5 ± 13,4 anos e 41,0% diabéticos. ICP primária foi realizada em 46,2% dos pacientes, ICP de resgate em 25,6% e ICP eletiva em 28,2% dos casos. As artérias mais frequentemente acometidas foram a descendente anterior e a coronária direita, com 44,9% cada uma. O balão intra-aórtico foi utilizado em 32,1% e os inibidores da glicoproteína IIb/IIIa em 30,8% dos casos. A incidência de insuficiência renal aguda foi de 61,5%. A necessidade de reintervenção ocorreu em 9,0%, e a taxa de trombose aguda/subaguda foi de 3,8%. Óbito, no choque cardiogênico, ocorreu em 46,2%. CONCLUSÕES: O choque cardiogênico permanece uma entidade frequente e grave, com quase 50% de mortalidade hospitalar, apesar da evolução na terapêutica instituída atualmente.

BACKGROUND: Cardiogenic shock is a clinical condition of inadequate tissue perfusion due to cardiac dysfunction. The most common etiology is ST-segment elevation myocardial infarction (STEMI) leading to left ventricular failure, but it may also be caused by mechanical complications such as acute mitral regurgitation, ventricular septal rupture or rupture of the left ventricular free wall. Despite therapeutic advances, mortality rates remain high. METHODS: Retrospective, observational, single-center study, including consecutive patients admitted with a diagnosis of STEMI and cardiogenic shock treated by percutaneous coronary intervention (PCI) at a tertiary hospital specialized in cardiology. The primary objective was to evaluate in-hospital clinical outcomes. RESULTS: A total of 78 patients were included, most of them were male (67.9%), mean age was 67.5 ± 13,4 years and 41.0% were diabetic. Primary PCI was performed in 46.2% of the patients, rescue PCI in 25.6% and elective PCI in 28.2% of the cases. The most frequently involved arteries were the left anterior descending artery and the right coronary artery, with 44.9% each. Intra-aortic balloon pump was used in 32.1% of cases and glycoprotein IIb/IIIa inhibitors in 30.8% of the cases. The incidence of acute renal failure was 61.5%. The need for reintervention was observed in 9.0% and the rate of acute/subacute thrombosis was 3.8%. Death due to cardiogenic shock was observed in 46.2%. Conclusions: Cardiogenic shock remains a frequent and serious condition with almost 50% of in-hospital mortality despite the therapeutic advances.

Prevention of renal damage by treating hyperuricemia

Nephrolithiasis, obstructive renal failure, essential hypertension, and chronic tubulointerstitial nephritis have been considered as the renal complications of hyperuricemia. Massive proteinuria has been rarely reported as the primary manifestation of increased serum uric acid. This is the report of a child presented with proteinuira, hypertension, and glomerular scelrosis secondary to hypouricosuric hyperuricemia, who was treated by uric acid lowering management.

Disfunción renal en el paciente cirrótico: prevención y tratamiento / Renal failure in the cirrhotic patient: prevention and treatment

Prerenal injury and hepatorenal syndrome (HRS) are the main causes of acute renal injury (ARI) in liver cirrhosis. Both can produce a reduction to the blood flow and lead to acute tubular necrosis. Cirrhotic patients may also present with chronic renal diseases, for example, diabetic nephropathy or chronic glomerulonephritis; however these are less frequent in cirrhosis as a cause of renal failure. The causes of acute renal failure that can be excluded before HRS diagnosis are: hypovolemia, shock, parenchymal renal disease and use of nephrotoxic drugs. Parenchymal renal disease must be suspected when there is significant proteinuria and microhematuria, or if renal ultrasound shows abnormal renal size. Renal biopsy might help in the diagnosis. ARI treatment is correction of hypovolemia with plasma expanders in the first place, and then, in case of Type 1 HRS, the use of a vasoconstrictor drug such as terlipressin plus intravenous albumin; both have shown benefit as a bridge to a liver transplant, and the latter is the definitive treatment for HRS. Transjugular intrahepatic portosystemic shunt (TIPS) has shown to reduce portal hypertension, reducing ascites and improving renal function in patients with Type 2 HRS. Intermittent or continuous hemodialysis can be used in Type 1 HRS patients as a bridge to a liver transplant, because without the transplant a minority will survive, even with renal replacement therapy.

La insuficiencia renal pre-renal y el síndrome hepato-renal (SHR) son las principales causas de insuficiencia renal aguda (IRA) en cirrosis hepática. Ambas pueden producir una disminución del flujo sanguíneo renal y conducir a una necrosis tubular aguda. Los pacientes con cirrosis también pueden tener enfermedades renales crónicas, por ejemplo una nefropatía diabética o una glomerulonefritis crónica, pero son menos frecuentes en cirrosis como causa de insuficiencia renal. Las causas de falla renal aguda que pueden ser excluidas antes de llegar al diagnóstico de SHR son: hipovolemia, shock, enfermedad renal parenquimatosa y uso de drogas nefrotóxicas. La enfermedad renal parenquimatosa debe ser sospechada cuando hay proteinuria significativa y microhematuria o si la ecografía renal muestra anormalidades en el tamaño renal. La biopsia renal podría realizarse para ayudar al diagnóstico. El tratamiento de la insuficiencia renal aguda pasa primero por la corrección de la hipovolemia con expansores plasmáticos y luego en el caso del SHR tipo 1, la utilización de un vasoconstrictor como la terlipresina asociado a la albúmina endovenosa, que han demostrado beneficio como puente para el trasplante hepático, siendo este último el tratamiento definitivo del SHR. El shunt transyugular porto sistémico o TIPS ha demostrado beneficio en disminuir la hipertensión portal, reducción de la ascitis y mejoría de la función renal en pacientes con SHR tipo 2. La hemodiálisis intermitente o continua puede usarse en los pacientes con SHR tipo1 como puente para el trasplante, ya que la minoría sobrevivirán incluso con reemplazo renal si no son trasplantados.

Imnunosupresión tras el trasplante hepático: más nefrones, menos hepatocarcinoma / Immunosupression after liver transplant: more nephrons, less hepatocellular carcinoma

Following liver transplantation, immunosuppressive drugs are responsible for a significant proportion of the morbidity and mortality. Thus, renal failure and hepatocellular carcinoma recurrence are critically related to the use of immunosuppressive drugs. In this article, the immunosuppressive strategies that allow preservation of the renal function and minimization of the recurrence rate of hepatocellular carcinoma are detailed.

Tras el trasplante hepático, la inmunosupresión es responsable de buena parte de la morbi-mortalidad asociada. El deterioro de la función renal y la recurrencia del hepatocarcinoma son ámbitos donde la inmunosupresión tiene un impacto significativo. En el presente artículo se abordan las estrategias inmunosupresoras que permiten preservar la función renal y minimizar la recurrencia del hepatocarcinoma tras el trasplante hepático.

Current strategies for preventing renal dysfunction in patients with heart failure: a heart failure stage approach

Renal dysfunction is common during episodes of acute decompensated heart failure, and historical data indicate that the mean creatinine level at admission has risen in recent decades. Different mechanisms underlying this change over time have been proposed, such as demographic changes, hemodynamic and neurohumoral derangements and medical interventions. In this setting, various strategies have been proposed for the prevention of renal dysfunction with heterogeneous results. In the present article, we review and discuss the main aspects of renal dysfunction prevention according to the different stages of heart failure.

Terapia com inibidor da ECA com dosagens relativamente altas e risco de agravamento renal na insuficiência cardíaca crônica / ACE-inhibitor therapy at relatively high doses and risk of renal worsening in chronic heart failure

FUNDAMENTO: O efeito renoprotetor dos inibidores da ECA vem sendo questionado no caso de diminuição do volume circulante efetivo, como na insuficiência cardíaca crônica direita ou biventricular. Objetivo: Detectar os preditores clínicos de agravamento renal na população de pacientes com ICC, caracterizado por dois tipos de regime de dosagem de inibidores da ECA. MÉTODOS: De acordo com um desenho de coorte retrospectiva, seguimos dois grupos de pacientes com ICC - tanto direita quanto biventricular -, todos na classe III da NYHA, tratados com inibidores da ECA (enalapril ou lisinopril), e com fração de ejeção do ventrículo esquerdo (FEVE) < 50 por cento, por meio de distinção em sua dosagem de inibidor da ECA: média-baixa (< 10 mg por dia) ou dosagem "alta" (> 10 mg por dia) de enalapril ou lisinopril. A disfunção renal agravada (ARD) foi definida pelo aumento de Cr > 30 por cento com relação ao segmento basal. O modelo de risco proporcional de Cox foi utilizado para identificar os preditores da ARD entre as seguintes variáveis: os inibidores da ECA com "alta" dosagem, idade, FEVE basal, histórico de repetidas terapias intensivas com diuréticos de alça por via intravenosa (diurético intravenoso), diabete, Cr basal, histórico de hipertensão, pressão arterial sistólica < 100 mmHg. RESULTADOS: Cinquenta e sete pacientes foram recrutados, dos quais 15 foram tratados com inibidor da ECA com dosagem "alta". Durante um seguimento médio de 718 dias, a ARD ocorreu em 17 pacientes (29,8 por cento). Apenas o inibidor da ECA com "alta" dosagem (RR: 12,4681 IC: 2,1614 - 71,9239 p = 0,0050) e Cr basal (RR:1,2344 IC: 1,0414 - 1,4632 p = 0,0157) foi demonstrado ser preditor da ARD. Além disso, demonstrou-se que o inibidor da ECA com dosagens "altas" não previu ARD em ICC sem diurético intravenoso e ICC com diabete. CONCLUSÃO: Na ICC de classe III da NYHA, o inibidor da ECA com "altas" dosagens e um maior Cr basal foi preditor da ARD. A nefrotoxicidade relacionada com inibidores da ECA em "altas" dosagens foi aumentada com o diurético intravenoso, ao passo que, em pacientes com ICC com diabete, aquela não foi detectada.

BACKGROUND: Renoprotective effect of ACE-inhibitors has been questioned in case of decreased effective circulating volume, like in right or biventricular chronic heart failure. OBJECTIVE: To detect clinical predictors of renal worsening in CHF patient population characterized by two types of ACE-inhibitor dosing regimens. METHODS: According to a retrospective cohort design, we followed 2 groups of patients with CHF - whether right or biventricular -, all in III NYHA class treated with ACE-inhibitors (enalapril or lisinopril), and with left ventricular ejection fraction (LVEF) < 50 percent, by distinguishing them by ACE-inhibitor dosing: average-low (<10 mg per day) or "high" dose (>10 mg per day) of enalapril or lisinopril. Worsened renal failure (ARD) was defined by Cr increase >30 percent from baseline. Cox proportional hazards model was used to identify the predictors of ARD among the following variables: ACE-inhibitors "high" dose, age, basal LVEF, history of repeated intensive intravenous loop diuretic therapies (IV diur), diabetes, basal Cr, history of hypertension, systolic blood pressure < 100 mm Hg. RESULTS: 57 patients were recruited, of whom 15 were treated with ACE-inhibitor "high" dose. During a mean follow-up of 718 days, ARD occurred in 17 (29.8 percent) patients. Only ACE-inhibitor "high" dose (HR: 12.4681 C.I.: 2.1614-71.9239 p=0.0050) and basal Cr (HR: 1.2344 C.I.: 1.0414-1.4632 p=0.0157) were shown to predict ARD. Moreover, ACE-inhibitor "high" doses were shown to fail to predict ARD in both CHF without IV diur and CHF with diabetes. CONCLUSION: In III NYHA class CHF, ACE-inhibitor "high" doses and a higher basal Cr predicted ARD. Nephrotoxicity related to ACE-inhibitor "high" doses was increased by IV diur, whereas it was not detected in CHF patients with diabetes.

Vitamin E ameliorates renal damage in streptozotocin induced diabetes in albino rats

This study was designed to find out the role of Vitamin E on serum glucose and Creatinine concentrations of male albino rats made diabetic by streptozotocin. Prospective study. This study was conducted at the Department of Physiology; Basic Medical Sciences Institutes [BMSI], Jinnah post Graduate Medical Center [JPMC], Karachi from Feb. 2010 to March 2010. In a 4 weeks study, 45 male albino rats were divided into 3 groups containing 15 animals each. Group A was treated as control, Group B and Group C received 45 mg/kg STZ once at the start of the experiment whereas Group C additionally received 600 mg/kg Vitamin E Intramuscularly 3 times weekly. Serum glucose and Creatinine concentrations were measured at the beginning of the experiment and once weekly. Serum glucose and Creatinine levels were significantly elevated in Group B as compared to control. In Group C, blood glucose was elevated but the levels of serum Creatinine were significantly reduced, when compared to group B. our findings conclude that Vitamin E supplementation may have protective effects against deterioration of renal function brought about by free radical toxicity in diabetes mellitus

Reduction of kidney damage by supplementation of vitamins C and E in rats with deoxycorticosterone-salt-induced hypertension

We assessed whether cosupplementation of vitamins C and E has additive beneficial effects on reducing the kidney damage and attenuation of the arterial pressure elevation compared to administration of either vitamin C or vitamin E alone in deoxycorticosterone acetate-salt-induced hypertension. Forty rats were divided into 4 study groups and 1 sham-operated group. Unilateral nephrectomy was carried out in the study groups and hypertension was induced by deoxycorticosterone injection and 1% sodium chloride and 0.2% potassium chloride added to the drinking water. Vitamins C and E [200 mg/kg/day] or combination of them were administered with DOCA-salt for 4 weeks in 3 study groups. The effects of DOCA and salt and treatment with vitamins were compared in terms of blood pressure, urinary protein excretion, antioxidant activity of the kidneys, and renal histological changes. Four weeks of supplementations of vitamins C, vitamin E, and both in the DOCA-salt-treated rats had comparable significant effects in decreasing systolic blood pressure. Urinary protein excretion and histological damage did not significantly change with the combination therapy of vitamins C and E compared to the vitamin C or E alone. The renal levels of glutathione and ferric reducing/antioxidant power in combination therapy group were similar to the two other treatment groups and were significantly higher than non-treated group. Co-administration of vitamin C and E does not have an additive beneficial effect on reducing the kidney damage and hypertension compared to either vitamin C or E alone in DOCA-salt-induced hypertension

Theophylline for prevention of kidney dysfunction in neonates with severe asphyxia

Recent studies have suggested theophylline for prevention of kidney dysfunction in asphyxia. This study was designed to determine whether theophylline could prevent or ameliorate kidney dysfunction in term neonates with perinatal asphyxia. We assigned 36 severely asphyxiated term infants [Apgar score

Renal impairment after valvular heart surgery in adult

Cardiac surgery can either induce acute renal failure or improve GFR by improving the cardiac performance. Acute renal shutdown [urine output <0.5ml/kg/hr.] is an uncommon but fatal complication which occurs in cases of insufficient cardiac function and may be accompanied with multi-organ failure. Acute renal failure [ARF] after open heart valve surgery occurs in about 8% of adult cardiac surgical patients with some preoperative renal impairment and in about 3-4% of patients with normal preoperative renal function test. This study was done to determine the frequency of acute renal shutdown after valvular open heart surgery and to detect any suggestive risk factors. 90 patients undergoing valve replacement [mitral and/ or aortic] were prospectively evaluated in three time periods: before, 24 hours after surgery and 48 hours after surgery. The association between preoperative, intra-operative and postoperative variables and the development of ARF was assessed thoroughly. Of the 90 consecutive patients 3 [3.49%] patients developed acute renal failure [serum creatinine>2.5 mg/dl] and 16 [18.6%] patients developed acute renal dysfunction [serum creatinine 1.6-2.4 mg/dl]. The risk factors that were noted in the development of ARF were age, raised preoperative blood urea and creatinine, low cardiac output state, diabetes mellitus, oligurea, total cross clamp time total CPB time, and significant hypotension during the procedure or during intensive care unit [ICU] stay. Mortality rate for established ARF was extremely poor [50%]. Avoidance of this dangerous outcome looks better than trying to treat once it is fully established

Efecto de la n-acetilcisteína, valsartan y lisinopril en la prevención de la disfunción renal precoz secundaria a neumoperitoneo: modelo en ratas / Effect of n-acetylcysteine, valsartan and lisinopril in preventing renal insufficiency secondary to pneumoperitoneum in a rat model

Introducción: El trasplante renal es el tratamiento de elección para los pacientes en insuficiencia renal terminal. A pesar que la nefrectomía clásica del donante vivo ha resultado ser un procedimiento seguro y bien tolerado, existen factores que desincentivan este acto de donación. La nefrectomía laparoscópica del donante vivo ha dado una respuesta a este último punto. Sin embargo, varios investigadores han comunicado mayor disfunción renal precoz en riñones procurados laparoscópicamente en comparación con los procurados en forma clásica abierta. Existe información que la Nacetilcisteina y Valsartán tendrían un efecto protector frente al neumoperitoneo. Con respecto al Lisinopril (inhibidor ECA) existen datos disímiles. El objetivo de este trabajo es evaluar la utilidad dela N-acetilcisteína, Valsartán y Lisinopril en la prevención de la disfunción renal precoz de riñones sometidos a neumoperitoneo en un modelo en ratas. Material y métodos: Se utilizaron 40 ratas Sprague Dawley, macho, de 250 a 300 g, separadas en 4 grupos: Grupo 1: 10 ratas sometidas a hidratación subcutánea con solución salina (control), Grupo 2: 10 ratas sometidas a hidratación subcutánea con solución salina más N-acetilcisteina, Grupo 3: 10ratas sometidas a hidratación subcutánea con solución salina más Valsartán, y Grupo 4: 10 ratas sometidas a hidratación subcutánea con solución salina más Lisinopril. Las ratas fueron anestesiadas y colocadas en neumoperitoneo a 12 mmHg por 90 minutos. Luego las ratas se colocaron en jaula metabólica donde se midió diuresis, presión arterial, función renal, microalbuminuria y enzimas tubulares. Las ratas fueron sacrificadas al séptimo día realizándose estudio histológico. En el análisis estadístico se utilizaron modelos lineales generalizados, análisis de la varianza (Anova) y test exacto de Fisher y Chi-cuadrado...

Introduction: Renal transplant it the treatment of choice for patients with terminal renal insufficiency. Classic open live donor nephrectomy is a safe and well tolerated procedure, however there some factors that may inhibit patients from donating. Laparoscopic live donor nephrectomy has gained wide acceptance, nevertheless several authors have reported early renal insufficiency in these patients compared to those harvested through the classic approach. Apparently n-acetylcysteine and valsartan would have a protective effect against pneumoperitoneum, however there is contradicting data for Lisinopril. We evaluate n-acetylcysteine, valsartan and lisinopril for prevention of early renal insufficiencyin kidneys undergoing pneumoperitoneum in a rat model. Material and methods: A total of 40 male rats (Sprague Dawley) of 250 and 300 grams were divided in4 groups. Group 1 (control): 10 rats with subcutaneous hydration with saline. Group 2: 10 rats with subcutaneous hydration with saline and n-acetylcysteine. Group 3: 10 rats with subcutaneous hydration with saline and Valsartan and Group 4: 10 rats with subcutaneous hydration with saline and Valsartan. All rats underwent general anesthesia with pneumoperitoneum at 12 mmHg for 90 minutes. Rats were placed in a metabolic cage where urine output, blood pressure, renal function, microalbuminuria and tubular enzymes were measured. At postoperative day seven, all animals were put to sleep and histological analysis was performed. Statistics was done using lineal generalized models, Anova, Fisher and Chi-square models were also used. Results: Pneumoperitoneum did not produce early renal insufficiency. Rats with lisinopril presented a decrease in creatinine clearance (0,92 ml/min) p=0,056; higher microalbuminuria (27073,9 mg/dl/creatininuria) p < 0,001 and more histological lesions p=0,017. Urine output, blood pressure, tubular...

Avaliação da função renal: creatinina e outros biomarcadores / Evaluation of renal function: creatinine and other biomarkers

JUSTIFICATIVA E OBJETIVOS: Os biomarcadores são ferramentas diagnósticas discriminatórias entre o estado de saúde e doença. O objetivo deste estudo foi reconhecer a aplicação clínica dos biomarcadores de função renal na prática clínica, com a finalidade de disponibilizar conhecimento do avanço diagnóstico da lesão renal aguda (LRA). MÉTODO: Estudo descritivo de levantamento bibliográfico de periódicos indexados de 1975 a outubro de 2006, por meio das bases de dados LILACS e PubMed. RESULTADOS: Foram disponibilizados 505 artigos nas bases de dados PubMed e 6 nas do LILACS. Foram selecionados 106 artigos e, após leitura na íntegra, apenas 69 traduziam a abordagem temática pretendida. CONCLUSÕES: Nesse levantamento foi verificado que apesar do progresso na compreensão dos mecanismos celular e molecular envolvendo a LRA, ainda existe um hiato entre a compreensão e a aplicação de tratamentos efetivos e específicos na prevenção e controle dessa síndrome.

BACKGROUND AND OBJECTIVES: Biomarkers are diagnostic tools which discriminate between the good health and the illness. This study had as objective to recognize the clinical application of the renal function biomarkers in the clinical practice, in order to inform the diagnostic advances of the acute kidney injury (AKI). METHODS: Descriptive study of bibliographical survey of indexed periodicals from 1975 to October, 2006, by means of the LILACS and PubMed databases. RESULTS: Were available 505 articles from the bibliographical survey in the PubMed database and 6 in the Lilacs database. 106 articles were selected and, after full reading, only 69 referred to the intended thematic approach. CONCLUSIONS: In this survey, it was verified that despite the progresses in the molecular and cellular mechanisms understanding related to AKI, there is still a gap between the comprehension and the application of effective and specific therapeutics in the prevention and control of this syndrome.