Metabolic and volume status evaluation of hemodialysis patients with and without residual renal function in the long interdialytic interval / Avaliação metabólica e volêmica no maior intervalo interdialítico de pacientes em hemodiálise com e sem função renal residual

Abstract Introduction: It is unclear whether residual renal function (RRF) in dialysis patients can attenuate the metabolic impact of the long 68-hour interdialytic interval, in which water, acid, and electrolyte accumulation occurs. Objective: to evaluate serum electrolyte levels, water balance, and acid-base status in dialytic patients with and without RRF over the long interdialytic interval (LII). Methodology: this was a single-center, cross-sectional, and analytical study that compared patients with and without RRF, defined by diuresis above 200 mL in 24 hours. Patients were weighed and serum samples were collected for biochemical and gasometric analysis at the beginning and at the end of the LII. Results: 27 and 24 patients with and without RRF were evaluated, respectively. Patients without RRF had a higher increase in serum potassium during the LII (2.67 x 1.14 mEq/L, p < 0.001), reaching higher values at the end of the study (6.8 x 5.72 mEq/L, p < 0.001) and lower pH value at the beginning of the interval (7.40 x 7.43, p = 0.018). More patients with serum bicarbonate < 18 mEq/L (50 x 14.8%, p = 0.007) and mixed acid-base disorder (57.7 x 29.2%, p = 0.042), as well as greater interdialytic weight gain (14.67 x 8.87 mL/kg/h, p < 0.001) and lower natremia (137 x 139 mEq/L, p = 0.02) at the end of the interval. Calcemia and phosphatemia were not different between the groups. Conclusion: Patients with RRF had better control of serum potassium, sodium, acid-base status, and volemia throughout the LII.

Resumo Introdução: Não se sabe ao certo se a função renal residual (FRR) de pacientes dialíticos pode atenuar o impacto metabólico do maior intervalo interdialítico (MII) de 68 horas, no qual ocorre acúmulo de volume, ácidos e eletrólitos. Objetivo: Avaliar os níveis séricos de eletrólitos, balanço hídrico e status ácido-básico de pacientes dialíticos com e sem FRR ao longo do MII. Metodologia: Tratou-se de estudo unicêntrico, transversal e analítico, que comparou pacientes com e sem FRR, definida como diurese acima de 200 mL em 24 horas. Para tal, os pacientes foram pesados e submetidos à coleta de amostras séricas para análise bioquímica e gasométrica no início e fim do MII. Resultados: Foram avaliados 27 e 24 pacientes com e sem FRR, respectivamente. Pacientes sem FRR apresentaram maior aumento de potássio sérico durante o MII (2,67 x 1,14 mEq/L, p < 0,001) atingindo valores mais elevados no fim (6,8 x 5,72 mEq/L, p < 0,001); menor valor de pH no início do intervalo (7,40 x 7,43, p = 0,018), maior proporção de pacientes com bicarbonato sérico < 18 mEq/L (50 x 14,8 %, p = 0,007) e distúrbio ácido-básico misto (70,8 x 42,3 %, p = 0,042), além de maior ganho de peso interdialítico (14,67 x 8,87 mL/kg/h, p < 0,001) e menor natremia (137 x 139 mEq/L, p = 0,02) no fim do intervalo. A calcemia e fosfatemia não foram diferentes entre os grupos. Conclusão: Pacientes com FRR apresentaram melhor controle dos níveis séricos de potássio, sódio, status ácido-básico e da volemia ao longo do MII.

Effect of preoperative creatinine levels on mortality after coronary artery bypass grafting surgery: an observational study

Abstract Introduction: Renal function is an independent risk factor for mortality among on-pump coronary bypass grafting (ONCABG) patients. This association is well known in the international literature, but there is a lack of knowledge of how admission creatinine (AC) levels modulate each cardiovascular risk factor. Objective: The aim of this paper was to assess the effect of different AC levels on mortality among ONCABG patients. Methods: 1,599 patients who underwent ONCABG between December 1999 and February 2006 at Hospital de Base in São José do Rio Preto/SP-Brazil were included. They were divided into quartiles according to their AC levels (QI: 0.2 ≤AC < 1.0 mg/dL; QII: 1.0 ≤ AC < 1.2 mg/dL; QIII: 1.2 ≤ AC < 1.4 mg/dL; and QIV: 1.4 ≤ AC ≤ 2.6 mg/dL). Seven risk factors were then evaluated in each stratum. Results: Mortality was higher in the QIV group than QI or QII groups. Factors such as age (≥ 65 years) and cardiopulmonary bypass (CPB) time (≥ 115 minutes) in QIV, as well preoperative hospital stay (≥ 5 days) in QIII, were associated with higher mortality rates. Creatinine variation greater than or equal to 0.4 mg/dL increased mortality rates in all groups. The use of intra-aortic balloon pump and dialysis increased mortality rates in all groups except for QII. Type I neurological dysfunction increased the mortality rate in the QII and III groups. Conclusion: Creatinine levels play an important role in ONCABG mortality. The combination of selected risk factors and higher AC values leads to a worse prognosis. On the other hand, lower AC values were associated with a protective effect, even among elderly patients and those with a high CPB time.

Serum regucalcin is a useful indicator of liver injury severity in patients with hepatitis B virus-related liver diseases

Regucalcin is a soluble protein that is principally expressed in hepatocytes. Studies of regucalcin have mainly been conducted in animals due to a lack of commercially available kits. We aimed to develop an enzyme-linked immunosorbent assay (ELISA) to quantify serum regucalcin in patients with hepatitis B virus (HBV)-related disease. High-titer monoclonal antibodies and a polyclonal antibody to regucalcin were produced, a double-antibody sandwich ELISA method was established, and serum regucalcin was determined in 47 chronic hepatitis B (CHB) patients, 91 HBV-related acute-on-chronic liver failure (HBV-ACLF) patients, and 33 healthy controls. The ELISA demonstrated an appropriate linear range, and high levels of reproducibility, sensitivity, specificity, accuracy, and stability. The median serum regucalcin concentrations in HBV-ACLF and CHB patients were 5.46 and 3.76 ng/mL, respectively (P<0.01), which were much higher than in healthy controls (1.72 ng/mL, both P<0.01). For the differentiation of CHB patients and healthy controls, the area under curve (AUC) was 0.86 with a cut-off of 2.42 ng/mL, 85.7% sensitivity, and 78.8% specificity. In contrast, the AUC of alanine aminotransferase (ALT) was lower (AUC=0.80, P=0.01). To differentiate ACLF from CHB, the AUC was 0.72 with a cut-off of 4.26 ng/mL, 77.0% sensitivity, and 61.2% specificity while the AUC of ALT was 0.41 (P=0.07). Thus, we have developed an ELISA that is suitable for measuring serum regucalcin and have shown that serum regucalcin increased with the severity of liver injury due to HBV-related diseases, such that it appears to be more useful than ALT as a marker of liver injury.

Do We Need to Personalize Renal Function Assessment in the Stratification of Patients Undergoing Cardiac Surgery? / É Necessário Personalizar a Avaliação da Função Renal na Estratificação de Pacientes Submetidos à Cirurgia Cardíaca?

Abstract Background: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. Objective: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. Methods: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. Results: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. Conclusion: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Resumo Fundamentos: Disfunção renal é preditor independente de morbimortalidade após cirurgia cardíaca. Para uma melhor avaliação da função renal, o cálculo do clearance de creatinina (CC) pode ser necessário. Objetivo: Avaliar objetivamente se o CC é melhor que a creatinina sérica (CS) para predizer risco nos pacientes submetidos à cirurgia cardíaca. Métodos: Análise em 3285 pacientes do Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) incluídos de forma prospectiva, consecutiva e mandatória entre novembro de 2013 e janeiro de 2015. Foram obtidos valores de CS, CC (Cockcroft-Gault) e do EuroSCORE II. Análise de associações da CS e do CC com morbimortalidade foi realizada mediante testes de calibração e discriminação. Por regressão logística múltipla, foram criados modelos multivariados independentes com CS e com CC para predição de risco de morbimortalidade após cirurgia cardíaca. Resultados: Apesar da associação entre a CS e morbimortalidade, essa não calibrou adequadamente os grupos de risco. Houve associação entre o CC e morbimortalidade com boa calibração dos grupos de risco. Na predição do risco de mortalidade, a CS ficou descalibrada com valores >1,35 mg/dL (p < 0,001). A curva ROC revelou que o CC é superior à CS na predição de risco de morbimortalidade. No modelo multivariado sem CC, a CS foi a única preditora de morbidade, enquanto que no modelo sem a CS, o CC foi preditor de mortalidade e o único preditor de morbidade. Conclusão: Para avaliação da função renal, o CC é superior que a CS na estratificação de risco dos pacientes submetidos a cirurgia cardíaca.

Función renal y nivel plasmático de dabigatrán en el valle, medido por un ensayo de trombina diluida / Renal function and plasma dabigatran level measured at trough by diluted thrombin time assay

El dabigatrán etexilato (inhibidor directo de trombina) es eficaz en la prevención tromboembólica en pacientes con fibrilación auricular. No requiere control rutinario de laboratorio, pero dada su eliminación renal, sería importante medirlo ante el deterioro de la función renal. Los objetivos del trabajo fueron verificar la calidad analítica del ensayo tiempo de trombina diluido para medición de la concentración plasmática (cc) de dabigatrán, correlacionar las cc con las pruebas básicas de coagulación tiempo de protrombina (TP) y tiempo de tromboplastina parcial activada (APTT) y evaluarlas de acuerdo al clearance de creatinina (CLCr). Se utilizaron muestras de plasma de 40 pacientes que recibían dabigatrán 150 (n = 19) o 110 (n = 21) mg/12 horas, colectadas 10-14 horas después de la última toma. Los ensayos de trombina diluida HemosIL DTI para la medición de dabigatrán, TP y APTT (IL), fueron realizados en coagulómetros fotoópticos ACL TOP 300 y 500 (IL). El DTI presentó coeficiente de variación intraensayo < 5.4% e interensayo < 6.0%, rango de linealidad 0-493 ng/ml; cc medidas en pacientes: mediana 83 (4-945) ng/ml. Individuos con CLCr en tercil inferior (< 46.1 ml/min) presentaron cc significativamente más elevadas, 308 (49-945), que los de tercilos medio, 72 (12-190), y superior, 60 (4-118) ng/ml. Las correlaciones cc vs. APTT o TP fueron moderadas, r2 = 0.59, -0.66, p < 0.0001, respectivamente. La prueba ensayada permitió cuantificar el nivel de dabigatrán plasmático tanto en pacientes con función renal normal como deteriorada, representando una herramienta útil en situaciones clínicas como deterioro de la función renal, pre cirugía o emergencias.

Dabigatran etexilate (direct thrombin inhibitor) is effective in preventing embolic stroke in patients with atrial fibrillation. It does not require laboratory control, but given the high renal elimination, its measurement in plasma is important in renal failure. The objectives of the study were to verify the analytical quality of the diluted thrombin time assay for measurement of dabigatran plasma concentration (cc), correlate cc with classic coagulation assays, prothrombin time (PT) and activated partial thromboplastin time (APTT), and evaluate them according to the creatinine clearance (CLCr). Forty plasma samples of patients (34 consecutive and 6 suspected of drug accumulation) receiving dabigatran at 150 (n = 19) or 110 (n = 21) mg/12 hours were collected. Blood samples were drawn at 10-14 hours of the last intake. Dabigatran concentration was determined by diluted thrombin time (HemosIl DTI, Instrumentation Laboratory (IL). PT and APTT (IL) were performed on two fotooptical coagulometers, ACL TOP 300 and 500 (IL). DTI presented intra-assay coefficient of variation < 5.4% and inter-assay < 6%, linearity range 0-493 ng/ml. Patients´ cc: median 83 (4-945) ng/ml. Individuals with CLCr in the lowest tertile (22.6-46.1 ml/min) showed significantly higher median cc: 308 (49-945), compared to the average 72 (12-190) and highest tertile, 60 (4-118) ng/ml. Correlation between cc and APTT or PT were moderate, r2 = 0.59 and -0.66, p < 0.0001, respectively. DTI test allowed us to quantify plasma dabigatran levels, both in patients with normal or altered renal function, representing a useful tool in clinical situations such as renal failure, pre surgery or emergencies.

Influence of fresh frozen plasma as a trigger factor for kidney dysfunction in cardiovascular surgery / Plasma fresco congelado como fator de risco para a disfunção renal no pós-operatório de cirurgia cardiovascular

OBJECTIVE: Kidney dysfunction is a major complication in the postoperative cardiac surgery setting. Operative risk factors for its development are cardiopulmonary bypass, anemia, antifibrinolytic drugs and blood transfusion. The objective of this study was to identify the risk factors for developing kidney dysfunction in patients undergoing cardiac surgery. METHODS: Ninety-seven patients were studied and 84 were analyzed. The sample was stratified into two groups. A serum creatinine higher than 30% compared to the preoperative period was considered for the kidney dysfunction group (n=9; 10.71%). There also was a control group when the increase in serum creatinine remained lower than 30% (n=75; 89.28%). RESULTS: It was observed that intraoperative transfusion of fresh frozen plasma in the control group was 2.05 ± 0.78 units and 3.80 ± 2.16 units in the kidney dysfunction group with P= 0.032. CONCLUSION: It was possible to associate that fresh frozen plasma transfusion is a risk factor for postoperative kidney dysfunction after cardiovascular surgery.

OBJETIVO: A disfunção renal é uma complicação importante no cenário de pós-operatório de cirurgia cardiovascular. Como fatores de risco conhecidos no intraoperatório para o seu desenvolvimento destacam-se a circulação extracorpórea, a hemodiluição, drogas antifibrinolíticos e a transfusão sanguínea. O objetivo deste estudo é identificar os fatores de risco na transfusão de sangue e derivados para o desenvolvimento de disfunção renal em pacientes submetidos à cirurgia cardiovascular. MÉTODOS: Noventa e sete pacientes foram estudados e 84 foram analisados. A amostra foi estratificada em dois grupos, sendo que o incremento de 30% na creatinina sérica no pós-operatório foi considerado para o grupo com disfunção renal (n = 9; 10,71%). O grupo não disfunção renal foi caracterizado pela creatinina sérica, que permaneceu inferior a aumento de 30% no pós-operatório (n = 75; 89,28%). RESULTADOS: Foi observado que a transfusão de plasma fresco congelado no grupo não disfunção renal foi de 2,05 ± 0,78 unidades e 3,80 ± 2,16 unidades no grupo disfunção renal com P= 0,032. CONCLUSÃO: Foi possível associar, nesta série de pacientes, que a transfusão de plasma fresco congelado foi um fator de risco para disfunção renal pós-operatório de cirurgia cardiovascular.

Relation of CuZnSOD activity with renal insufficiency in hypertensive diabetic patients.

Diabetes and renal insufficiency are interrelated metabolic disorders closely associated with redox homeostasis disturbances. The aim of this study was to compare the activity of copper zinc superoxide dismutase (CuZnSOD) in the erythrocytes of hypertensive diabetic patients with or without renal insufficiency with normal healthy control subjects. In both groups of diabetic patients, blood glucose level and the content of glycosylated hemoglobin (HbA1c) were higher than in the control group. However, CuZnSOD activity was significantly higher than control only in hypertensive diabetic patients with renal insufficiency. Our results suggest that disturbances in superoxide homeostasis do correlate with long-term complication in diabetes, i.e. diabetic renal insufficiency and hypertension.

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.

Disfunção renal moderada não está associada a Troponina T elevada em síndromes coronarianas agudas / Moderate renal dysfunction is not associated with elevated Troponin T in acute coronary syndromes / Disfunción renal moderada no está asociada a Troponina T elevada en síndromes coronarias agudas

FUNDAMENTO: A interpretação dos resultados de troponina em pacientes com síndromes coronarianas agudas (SCA) e doença renal é dificultada pelo fato de que a disfunção renal aumenta os níveis de troponina, independente da necrose miocárdica. Embora tenha sido demonstrado que a doença renal em estágio terminal está associada com níveis elevados de troponina T cardíaca (TnT), ainda não é conhecido se esse biomarcador é alterado por níveis menos graves de disfunção renal. OBJETIVO: Avaliar se disfunção renal moderada está associada com elevação dos níveis de TnT em pacientes com SCA. MÉTODOS: Um total de 145 indivíduos com SCA e clearance de creatinina > 30 ml/min foram estudados. O clearance de creatinina foi estimado através da fórmula de Cockcroft-Gault e a TnT foi medida na admissão hospitalar. Disfunção renal moderada foi definida como clearance de creatinina de 30-59 ml/min e TnT positiva como níveis > 0,01 ug/l. RESULTADOS: Nenhuma correlação foi observada entre o clearance de creatinina e TnT (r = - 0,06, P=0,45). Os níveis de TnT foram similares entre indivíduos no primeiro (mediana=0,05 ug/l), segundo (mediana=0 ug/l), terceiro (mediana=0,07 ug/l) e quarto quartis (mediana=0 ug/l) de clearance de creatinina - P=0,63. De forma similar, não houve diferença nos valores de troponina entre indivíduos com disfunção renal moderada (mediana=0,02 ug/l) e indivíduos com função renal normal/quase normal (mediana=0,03 ug/l) - P=0.63. A prevalência de TnT positiva foi similar entre indivíduos com disfunção renal moderada e função renal normal/quase normal (55 por cento vs 52 por cento, P=0,65). CONCLUSÃO: Disfunção renal moderada não está associada com elevação dos níveis de TnT em pacientes com SCA. (Arq Bras Cardiol 2010; 95(5): 600-605).

BACKGROUND: Interpretation of troponin results in patients with acute coronary syndromes (ACS) and renal disease is confused by the fact that renal dysfunction increases troponin levels, regardless of myocardial necrosis. Although it has been demonstrated that end-stage renal disease is associated with elevated cardiac troponin T (cTnT) levels, it is not known whether this biomarker is altered by less than severe degrees of renal impairment. OBJECTIVE: To evaluate whether moderate renal dysfunction is associated with cTnT elevation in patients with ACS. METHODS: One hundred, forty-five individuals with ACS and creatinine clearance > 30 ml/min were studied. Creatinine clearance was estimated by the Cockcroft-Gault formula and cTnT was measured at hospital admission. Moderate renal dysfunction was defined as a creatinine clearance of 30-59 ml/min and positive cTnT as levels > 0.01 ug/l. RESULTS: No correlation was observed between creatinine clearance and cTnT (r = - 0.06, P=0.45). The levels of cTnT were similar among individuals in the first (median=0.05 ug/l), second (median=0 ug/l), third (median=0.07 ug/l) and fourth quartiles (median=0 ug/l) of creatinine clearance - P=0.63. Similarly, there was no difference in troponin values between individuals with moderate renal dysfunction (median=0.02 ug/l) and individuals with normal/near normal function (median=0.03 ug/l) - P=0.63. The prevalence of positive cTnT was similar between individuals with moderate renal dysfunction and normal/near normal renal function (55 percent vs 52 percent, P=0.65). CONCLUSION: Moderate renal dysfunction is not associated with cTnT elevation in patients with ACS. (Arq Bras Cardiol 2010; 95(5): 600-605).

FUNDAMENTO: La interpretación de los resultados de troponina en pacientes con síndromes coronarias agudas (SCA) y enfermedad renal es dificultada debido al hecho de que la disfunción renal aumenta los niveles de troponina, independientemente de la necrosis miocárdica. Aunque se haya sido evidenciada la enfermedad renal en fase terminal está asociada con niveles elevados de troponina T cardíaca (TnT), aún no se conoce si este biomarcador es alterado por niveles menos severos de disfunción renal. OBJETIVOS: Evaluar si la disfunción renal moderada está asociada con la elevación de los niveles de TnT en pacientes con SCA. MÉTODOS: Un total de 145 individuos con SCA y clearance de creatinina > 30 ml/min fueron estudiados. El clearance de creatinina se estimó a través de la fórmula de Cockcroft-Gault y la TnT se midió en la admisión hospitalaria. Disfunción renal moderada se definió como clearance de creatinina de 30-59 ml/min y TnT positiva como niveles > 0,01 ug/L. RESULTADOS: No se observó alguna correlación entre el clearance de creatinina y TnT (r = - 0,06, P=0,45). Los niveles de TnT fueron similares entre individuos en el primero (mediana=0,05 ug/L), segundo (mediana=0 ug/L), tercero (mediana=0,07 ug/L) y cuarto cuartiles (mediana=0 ug/L) de clearance de creatinina - P=0,63. De forma similar, no hubo diferencia en los valores de troponina entre individuos con disfunción renal moderada (mediana=0,02 ug/L) y individuos con función renal normal/casi normal (mediana=0,03 ug/L) - P=0.63. La prevalencia de TnT positiva fue similar entre individuos con disfunción renal moderada y función renal normal/casi normal (55 por ciento vs 52 por ciento, P=0,65). CONCLUSIÓN: Disfunción renal moderada no está asociada con la elevación de los niveles de TnT en pacientes con SCA. (Arq Bras Cardiol 2010;95(5):600-605).

Insuficiencia renal en pacientes con cirrosis y ascitis: incidencia, etiología y factores predictivos / Renal failure in patients with cirrhosis and ascites: incidence, etiology and predictive factors

BACKGROUND: renal insufficiency (RI) is a frequent complication in patients with cirrhosis and ascites. OBJECTIVE: to assess the incidence, causes, predictive factors and prognosis of RI in cirrhotic patients with ascites. PATIENT AND METHODS: descriptive study of cases and controls. Clinical histories of 162 admissions in 103 patients during 3 years were reviewed. It was considered RI when there was an increase of creatininemia > 1.5 mg/dl. The predictive factors, clinical features, and mortality of the patients with and without RI were compared. RESULTS: a diagnosis of RI was made in 35 cases (21.6%). Hospital mortality rate was 18.5%: with RI 57.1%, controls 7.8% (p<0.01). Etiology: reversible prerrenal failure (54.3%), SHR 1 (14.2%) and 2 (5.7%), septic shock by spontaneous bacterial peritonitis (SBP) (11.4%), NTA (8.5%). The patients with and without RI had a Child-Pügh score average (+/-DS): 12.8 (1.8) and 11.4 (1.9) (p=0.0002) respectively. The patients with RI had higher values of total bilirubin, AST, ALT, white blood cells, time prothrombin, and minors values of serum sodium, Hto, Hb, protein, albumin and cholinesterase that controls (p<0.05). The clinical variables associated with RI included infections (OR 1.4), SBP (OR 4) and hepatic encephalopathy (OR 2.4). In the multivariate analysis, the independent predictive factors for RI were hyponatremia, bilirubinemia greater to 10 mg/dl and SPB. CONCLUSION: in cirrhotic patients RI have high mortality. The most frequent cause was reversible prerrenal failure. The risk of RI was increased significantly in patients with hyponatremia, marked hyperbilirubinemia and SPB.

Background: renal insufficiency (RI) is a frequent complication in patients with cirrhosis and ascites. Objective: to assess the incidence, causes, predictive factors and prognosis of RI in cirrhotic patients with ascites. Patient and methods: descriptive study of cases andcontrols. Clinical histories of 162 admissions in 103 patients during 3 years were reviewed. It was consideredRI when there was an increase of creatininemia > 1,5 mg/dl. The predictive factors, clinical features, andmortality of the patients with and without RI were compared. Results: a diagnosis of RI was made in 35 cases (21.6%). Hospital mortality rate was 18.5%: with RI 57.1%, controls 7.8% (p< 0.01). Etiology: reversible prerrenal failure (54.3%), SHR 1 (14.2%) and 2 (5.7%), septic shock by spontaneous bacterial peritonitis (SBP) (11.4%), NTA (8.5%). The patientswith and without RI had a Child-Pügh score average (± DS): 12.8 (1.8) and 11,4 (1.9) (p=0.0002) respectively.The patients with RI had higher values of total bilirubin, AST, ALT, white blood cells, time prothrombin, and minors values of serum sodium, Hto, Hb, protein,albumin and cholinesterase that controls (p<0.05). The clinical variables associated with RI included infections (OR 1.4), SBP (OR 4) and hepatic encephalopathy (OR 2.4). In the multivariate analysis, the independent predictive factors for RI were hyponatremia, bilirubinemia greater to 10 mg/dl and SPB. Conclusion: in cirrhotic patients RI have high mortality.The most frequent cause was reversible prerrenal failure. The risk of RI was increased significantly in patients with hyponatremia, marked yperbilirubinemiaand SPB.

Marcadores de generacion de trombina en insuficiencia renal de niños con sindrome uremico hemolitico epidemico / Markers of thrombin generation in kidney failure of children with epidemic hemolytic uremic syndrome

Se presentan aquí los niveles de los marcadores tempranos de activación de la coagulación y del TNF-alpha en 12 niños con la forma epidémica del síndrome urémico hemolítico, de 16 meses de edad, (12-18) (mediana y rango) Todos los pacientes se recuperaron de las enfermedad dentro de las 2 a 4 semanas de evolución. Se tomaron cuatro muestras de sangre: al ingreso al hospital, luego en la primera y segunda semana y en la remisión. Las determinaciones del F1+2 TAT y TNF-alpha se realizaron por técnicas de ELISA comerciales, mientras que el factor von Willebrand se determinó por el método de Laurell. Los valores de F1+2 y del TAT al ingreso fueron 7.8 nM (3.7-12.3) y 22.7 ng/ml (8-76) respectivamente. Además, se encontró correlación significativa entre los niveles de F1+2 vs creatinina sérica, r:0.47 p < 0.001; F1+2 vs úrea sérica, r:0.66 p < 0.001; TAT vs creatinina sérica, r:0.77 p < 0.001; TAT vs urea , r:0.59 p <0.001. La mediana del FvW al ingreso en 11/12 niños fue de 260 por ciento (170-420). Los niveles del FvW se correlacionaron con los del F1+2; r:0.77 p < 0.001 y con los del TAT, r:0.41 p < 0.01. Los valores de estos marcadores séricos tendieron a normalizarse con la mejoría de la enfermedad. Se encontró una correlación negativa entre el recuento plaquetario y los niveles del F1+2, r:-0.64 p<0.001. Los niveles de TNF-alpha estuvieron aumentados en 5 niños, 22.2 pg/ml (17.2-53.7). Los resultados sugieren que estas anormalidades pueden ser atribuidas a un estímulo común sobre células endoteliales.

Effect of hemodialysis on protein C and antithrombin III

The effect of hemodialysis on natural coagulation inhibitors including protein C [PC] and antithrombin III [AT III] had been studied. Plasma PC and AT III levels measured in 20 uremic patients on maintenance hemodialysis immediately before and after dialysis treatment. These values were compared with those obtained from 20 matched healthy controls. Functional activities of PC was determined by coagulometric method and functional activities of AT III was determined by amidolytic method. Both the functional activities of PC and AT III in uremic patients were significantly lower than those of controls. No significant change in the level of AT III was observed with dialysis, but a progressive increase of functional activity of PC was documented with hemodialysis. On the luisis of this study, the risk of thrombosis may increase due the decrease in AT III levels. However, this effect may be compensated by the increase in PC activity, possibly due to the removal of an inhibitory substance on PC activity

Elevated serum aluminium and lead in renal haemodialysis patients

Serum aluminium [Al] and lead [Pb] have been measured in dialysis patients with advanced renal failure [characterised by hyperkalaemia, hyperphosphataemia and hypocalcaemia] and in healthy subjects with normal kidney function for comparison. In those under dialysis, pre and post-dialysis levels of Al and Pb were evaluated. The results revealed increased serum Al [P

Hepatitis C virus [HCV] antibodies in patients with chronic renal failure and treated with regular hemodialysis and those treated with renal transplantation

This work was carried out to study the prevalence of hepatitis C Virus [HCV] infection, its associated risk factors and possible routes of transmission in chronic renal failure patients treated with either regular hemodialysis or renal transplantation. Seventy patients and 20 normal controls were included in this study. Patients were classified into 2 groups: Group I: 50 hemodialysis patients [HD group] and Group II: 20 renal transplant recipients [RTR group]. Each individual was subjected to full clinical examination, estimation of serum alanine aminotransferase [ALT], testing for antibodies to hepatitis C virus [anti-HCV] by ELISA 2nd generation, screening for hepatitis B surface antigen [HBsAg], antibodies to hepatitis B surface antigen [anti-HBs] and core antigen [anti HBc] by modified ELISA technique. Anti-HCV was found in 72% of hemodialysis patients and 65% of renal transplant patients and in 15% of the control group. There was a significant correlation between the presence of anti-HCV and the duration on dialysis in HD and RTR groups [P < 0.05 in both], while no significant correlation was detected between HCV positive cases and the number of units of transfused blood in HD and RTR groups [P > 0.05 in both]. Serum ALT was elevated in patients with HCV infection, but there was no significant correlation between the presence of anti-HCV and elevated ALT level among the examined groups of patients [P > O.OS in both]. The prevalence of HCV infection was not correlated with the duration of renal transplantation [P>0.05] and the type of immunosuppressive therapy [P > 0.05]. Coinfection with HBV and HCV could occur, as previous infection with HBV was demonstrated. Anti-HBc was found in 33.3% and 30.8% of anti-HCV positive patients in both HD and RTR groups respectively. Anti-HBs was detected in 25% and 15.4% of anti HCV positive in HD and RTR groups. HBsAg was found in 5.6% of anti-HCV positive hemodialysis patients. From this study we concluded that there are high prevalence of antibodies to HCV in serum of these patients with CRF whether treated with regular hemodialysis or with renal transplantation. This may mean high prevalence of HCV infection in these patients. Also it is found that the duration of hemodialysis rather than the number of units of blood transfusion is the main risk factor and that the transmission in hemodialysis units is the most important rather than by blood transfusion although its importance. Also we may recommend [1] All the hygienic measures to prevent spread of hepatitis C virus infection in these patients and treatment of cases. [2] Separate dialysis machines should be used for anti-HCV positive patients as we do for HBsAg positive patients. [3] Routine application of PCR technique in these patients may be useful for accurate diagnosis of the HCV infection. [4] Retrospective study on large number of transplanted patients for all risk factors of HCV infection, in addition to study the causes of this relatively high prevalence of infection inbetween them

Infarto renal con hipertensión arterial: informe de un caso pediátrico / Renal infarction with arterial hypertension: report of a pediatric case

El infarto renal puede definirse como la muerte de tejido renal debido a interferencia con su circulación sanguínea. Se presenta el caso de un paciente masculino, de nueve años de edad, con cefalea universal, vómitos de contenido gástrico y una tensión arterial (TA) de 140/100 mmHg. Su renina plasmática periférica fue de 7.4 ng/mL/h (normal hasta 2.5 ng/mL/h). La arteriografía renal indicó infarto parenquimatoso en polo superior de riñón derecho. Actualmente, está controlado con una tensión arterial de 110/70 mmHg, para lo cual recibe 1 mg/kg/día de captopril complementado con dieta hiposódica.

Serum transcobalamin II levels in patients with malaria infection.

Serum transcobalamin II (TCII) levels were determined in 56 patients with P. falciparum malaria infection. They were divided into 3 groups: severe (malarial parasite > 5% or patients with cerebral malaria or renal insufficiency), moderate (1-5% infection without complications) and mild (1% infection). Elevated serum TCII values were found only in patients with severe malaria infection. These values correlated directly with parasitemia, blood urea nitrogen and creatinine, but were not correlated with alkaline phosphatase. As 17 patients with azotemia had elevated serum TCII levels while other 3 patients with normal BUN and creatinine concentrations had serum TCII levels within the normal limits. These findings indicated that malarial patients with renal insufficiency had increased serum TCII. A possible mechanism is the reduced TCII-B12 that filtered through the glomeruli due to the reduced renal blood flow with the decreased its uptake by proximal tubular cells resulting in the decreased degradation of TCII by the tubular lysosomal enzymes. Determination of serum TCII level may be used as an indicator of renal function in malarial patients with renal insufficiency.