Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation.

BACKGROUND: Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain. METHODS: This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. RESULTS: Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01). CONCLUSION: Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Lipid profile and statin use in critical care setting: implications for kidney outcome.

OBJECTIVE: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. METHODS: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. RESULTS: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. CONCLUSION: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.

Lipid profile and statin use in critical care setting: implications for kidney outcome / Perfil lipídico e uso de estatina em terapia intensiva: implicações no desfecho renal

ABSTRACT Objective: To determine whether pre-hospital statin use is associated with lower renal replacement therapy requirement and/or death during intensive care unit stay. Methods: Prospective cohort analysis. We analyzed 670 patients consecutively admitted to the intensive care unit of an academic tertiary-care hospital. Patients with ages ranging from 18 to 80 years admitted to the intensive care unit within the last 48 hours were included in the study. Results: Mean age was 66±16.1 years old, mean body mass index 26.6±4/9kg/m2 and mean abdominal circumference was of 97±22cm. The statin group comprised 18.2% of patients and had lower renal replacement therapy requirement and/or mortality (OR: 0.41; 95%CI: 0.18-0.93; p=0.03). The statin group also had lower risk of developing sepsis during intensive care unit stay (OR: 0.42; 95%CI: 0.22-0.77; p=0.006) and had a reduction in hospital length-of-stay (14.7±17.5 days versus 22.3±48 days; p=0.006). Statin therapy was associated with a protective role in critical care setting independently of confounding variables, such as gender, age, C-reactive protein, need of mechanical ventilation, use of pressor agents and presence of diabetes and/or coronary disease. Conclusion: Statin therapy prior to hospital admission was associated with lower mortality, lower renal replacement therapy requirement and sepsis rates.

RESUMO Objetivo: Determinar se o uso pré-admissão hospitalar de estatina está associado com menor necessidade de diálise e/ou óbito durante internação em unidade de terapia intensiva. Métodos: Análise de coorte prospectiva. Foram incluídos consecutivamente 670 pacientes admitidos na unidade de terapia intensiva de um hospital acadêmico de cuidados terciários. Os pacientes incluídos deveriam ter entre 18 e 80 anos e ter sido admitidos na unidade de terapia intensiva nas últimas 48 horas. Resultados: A média da idade dos pacientes foi de 66±16,1 anos. O índice de massa corporal foi de 26,6±4/9kg/m2 e a circunferência abdominal média foi de 97±22cm. O grupo que fez uso de estatina pré-admissão hospitalar (18,2% dos pacientes) necessitou menos de terapia de substituição renal e/ou evoluiu para óbito (OR: 0,41; IC95%: 0,18-0,93; p=0,03). O grupo que fez uso de estatina também apresentou menor risco de evoluir com sepse durante a internação na unidade de terapia intensiva (OR: 0,42; IC95%: 0,22-0,77; p=0,006) e teve menor duração da hospitalização (14,7±17,5 dias versus 22,3±48 dias; p=0,006). A terapia pré-admissão hospitalar com estatina foi associada a papel protetor no cenário da terapia intensiva independentemente de variáveis confundidoras, como sexo, idade, proteína C-reativa, necessidade de ventilação mecânica, uso de vasopressores e diagnóstico de diabetes e/ou coronariopatia. Conclusão: A terapia com estatina antes da admissão hospitalar foi associada a menor mortalidade, menor necessidade de terapia de substituição renal e taxa de ocorrência de sepse.

Compensatory effect of fibrinogen in a patient with bone marrow aplasia, septic shock, and severe thrombocytopenia guided by thromboelastometry: a case report. / Efeito compensatório do fibrinogênio em paciente com aplasia de medula óssea, choque séptico e trombocitopenia grave guiado por tromboelastometria: relato de caso.

Platelet transfusion is a common practice to prevent spontaneous bleeding or bleeding due to invasive procedures. Transfusion of allogeneic blood components is associated with increased mortality and a worse clinical outcome. The clot strength is assessed by thromboelastometry and determined by the interaction between platelets and fibrinogen. The compensatory effect of high levels of fibrinogen on clot strength in patients with thrombocytopenia has been demonstrated in different clinical settings including sepsis. We report the case of a patient with severe thrombocytopenia whose thromboelastometry showed clot strength that was compensated for by the increase in plasma fibrinogen levels as an acute phase reactant of septic patients. Here, we report a case of a 62-year-old female diagnosed with bone marrow aplasia admitted in the intensive care unit with septic shock and severe thrombocytopenia. During the first 24 hours in the intensive care unit, she presented acute respiratory insufficiency and circulatory shock. The use of invasive mechanical ventilation and norepinephrine was required. Her chest X-ray showed bilateral lung injury. Thus, bronchoscopy with bronchoalveolar lavage was requested. Thromboelastometry was performed and resulted in a normal coagulable profile. Despite severe thrombocytopenia (1,000/mm3), fibrinogen levels were increased (1,050mg/dL) due to septic shock. Bronchoscopy was performed without any active or further bleeding. Here, we report the use of thromboelastometry in the diagnosis of coagulation disorders, preventing unnecessary prophylactic platelet transfusion.

A transfusão de concentrado de plaquetas é prática comum para prevenção de sangramento espontâneo ou decorrente de procedimentos invasivos; sabe-se que a transfusão de componentes alogênicos do sangue se associa a aumento da mortalidade e piora do desfecho clínico. A força do coágulo é avaliada por meio da tromboelastometria rotacional e determinada pela interação entre plaquetas e fibrinogênio. O efeito compensatório do incremento na concentração sérica de fibrinogênio na força do coágulo, em pacientes com trombocitopenia, tem sido demonstrado em diferentes contextos clínicos, incluindo sepse. Relatamos o caso de uma paciente com trombocitopenia grave, cujo resultado da tromboelastometria rotacional demonstrou efeito compensatório na força do coágulo determinada pelos níveis plasmáticos aumentados de fibrinogênio como reagente de fase aguda em pacientes sépticos. Relatamos o caso de uma paciente de 62 anos com diagnóstico de aplasia de medula óssea admitida a uma unidade de terapia intensiva com choque séptico e trombocitopenia grave. Nas primeiras 24 horas na unidade de terapia intensiva, ela apresentou quadro clínico de insuficiência respiratória aguda e choque. Foi necessário utilizar ventilação mecânica invasiva e fármaco vasoativo. A radiografia de tórax mostrou padrão de lesão pulmonar bilateral. Desta forma, foi solicitada broncoscopia com lavagem broncoalveolar para investigação diagnóstica. Conduziu-se uma tromboelastometria rotacional, e seu resultado mostrou perfil de coagulação normal. Apesar da trombocitopenia grave (1.000/mm3), os níveis de fibrinogênio aumentaram (1.050mg/dL) devido ao choque séptico. A broncoscopia foi realizada sem que subsequentemente ocorresse sangramento ativo. Este caso relata o uso da tromboelastometria como ferramenta diagnóstica em distúrbios da coagulação de pacientes graves, permitindo prevenir o uso desnecessário de transfusões profiláticas de concentrado de plaquetas.

Efeito compensatório do fibrinogênio em paciente com aplasia de medula óssea, choque séptico e trombocitopenia grave guiado por tromboelastometria: relato de caso / Compensatory effect of fibrinogen in a patient with bone marrow aplasia, septic shock, and severe thrombocytopenia guided by thromboelastometry: a case report

RESUMO A transfusão de concentrado de plaquetas é prática comum para prevenção de sangramento espontâneo ou decorrente de procedimentos invasivos; sabe-se que a transfusão de componentes alogênicos do sangue se associa a aumento da mortalidade e piora do desfecho clínico. A força do coágulo é avaliada por meio da tromboelastometria rotacional e determinada pela interação entre plaquetas e fibrinogênio. O efeito compensatório do incremento na concentração sérica de fibrinogênio na força do coágulo, em pacientes com trombocitopenia, tem sido demonstrado em diferentes contextos clínicos, incluindo sepse. Relatamos o caso de uma paciente com trombocitopenia grave, cujo resultado da tromboelastometria rotacional demonstrou efeito compensatório na força do coágulo determinada pelos níveis plasmáticos aumentados de fibrinogênio como reagente de fase aguda em pacientes sépticos. Relatamos o caso de uma paciente de 62 anos com diagnóstico de aplasia de medula óssea admitida a uma unidade de terapia intensiva com choque séptico e trombocitopenia grave. Nas primeiras 24 horas na unidade de terapia intensiva, ela apresentou quadro clínico de insuficiência respiratória aguda e choque. Foi necessário utilizar ventilação mecânica invasiva e fármaco vasoativo. A radiografia de tórax mostrou padrão de lesão pulmonar bilateral. Desta forma, foi solicitada broncoscopia com lavagem broncoalveolar para investigação diagnóstica. Conduziu-se uma tromboelastometria rotacional, e seu resultado mostrou perfil de coagulação normal. Apesar da trombocitopenia grave (1.000/mm3), os níveis de fibrinogênio aumentaram (1.050mg/dL) devido ao choque séptico. A broncoscopia foi realizada sem que subsequentemente ocorresse sangramento ativo. Este caso relata o uso da tromboelastometria como ferramenta diagnóstica em distúrbios da coagulação de pacientes graves, permitindo prevenir o uso desnecessário de transfusões profiláticas de concentrado de plaquetas.

ABSTRACT Platelet transfusion is a common practice to prevent spontaneous bleeding or bleeding due to invasive procedures. Transfusion of allogeneic blood components is associated with increased mortality and a worse clinical outcome. The clot strength is assessed by thromboelastometry and determined by the interaction between platelets and fibrinogen. The compensatory effect of high levels of fibrinogen on clot strength in patients with thrombocytopenia has been demonstrated in different clinical settings including sepsis. We report the case of a patient with severe thrombocytopenia whose thromboelastometry showed clot strength that was compensated for by the increase in plasma fibrinogen levels as an acute phase reactant of septic patients. Here, we report a case of a 62-year-old female diagnosed with bone marrow aplasia admitted in the intensive care unit with septic shock and severe thrombocytopenia. During the first 24 hours in the intensive care unit, she presented acute respiratory insufficiency and circulatory shock. The use of invasive mechanical ventilation and norepinephrine was required. Her chest X-ray showed bilateral lung injury. Thus, bronchoscopy with bronchoalveolar lavage was requested. Thromboelastometry was performed and resulted in a normal coagulable profile. Despite severe thrombocytopenia (1,000/mm3), fibrinogen levels were increased (1,050mg/dL) due to septic shock. Bronchoscopy was performed without any active or further bleeding. Here, we report the use of thromboelastometry in the diagnosis of coagulation disorders, preventing unnecessary prophylactic platelet transfusion.

Frequency of TGF- ß and IFN- γ genotype as risk factors for acute kidney injury and death in intensive care unit patients.

Genetic variations in TGF-ß and IFN-γ may interfere with proinflammatory cytokine production and, consequently, may be involved with inflammatory diseases, as acute kidney injury (AKI). We considered that genetic polymorphisms of these cytokines may have a crucial role in the outcome of critically ill patients. To investigate whether the genetic polymorphisms of rs1800470 (codon 10 T/C), rs1800471 (codon 25 C/G) from the TGF-ß, and rs2430561 (+874 T/A) from IFN-γ may be a risk factor for ICU patients to the development of AKI and/or death. In a prospective nested case-control study, were included 139 ICU patients who developed AKI, 164 ICU patients without AKI, and 244 healthy individuals. We observed a higher frequency to T/A genotype for IFN-γ (intermediate producer phenotype) and higher frequency of TT GG and TC GG genotype (high producer) for TGF-ß polymorphism in overall population. However, these polymorphisms have not been shown as a predictor of risk for AKI and death. We found an increased prevalence of high and intermediate producer phenotypes from TGF-ß and IFN-γ, respectively, in patients in ICU setting. However, the studied genetic polymorphism of the TGF-ß and IFN-γ was not associated as a risk factor for AKI or death in our population.

Low estimated glomerular filtration rate and chronic kidney failure following liver transplant: a retrospective cohort study.

BACKGROUND: Patients undergoing orthotropic liver transplant (LTx) often present with chronic kidney disease (CKD). Identification of patients who will progress to end-stage renal disease (ESRD) might allow not only the implementation of kidney protective measures but also simultaneous kidney transplant. STUDY DESIGN: Retrospective cohort study in adults who underwent LTx at a single center. ESRD, death, and composite of ESRD or death were studied outcomes. RESULTS: 331 patients, who underwent LTx, were followed up for 2.6 ± 1.4 years; 31 (10%) developed ESRD, 6 (2%) underwent kidney transplant after LTx and 25 (8%) remained on chronic hemodialysis. Patients with preoperative eGFR lesser than 60 ml/min per 1.73 m2 had a 4-fold increased risk of developing ESRD after adjustment for sex, diabetes mellitus, APACHE II score, use of nephrotoxic drugs, and severe liver graft failure (HR = 3.95, 95% CI 1.73, 9.01; p = 0.001). Other independent risk factors for ESRD were preoperative diabetes mellitus and post-operative severe liver graft dysfunction. CONCLUSION: These findings emphasize low eGFR prior to LTx as a predictor for ESRD or death. The consideration for kidney after liver transplant as a treatment modality should be taken into account for those who develop chronic kidney failure after LTx.

Impact of acute kidney injury exposure period among liver transplantation patients.

BACKGROUND: Acute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival. METHODS: The study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study. RESULTS: A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001). CONCLUSIONS: Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.

Cystatin C at Admission in the Intensive Care Unit Predicts Mortality among Elderly Patients.

Introduction. Cystatin C has been used in the critical care setting to evaluate renal function. Nevertheless, it has also been found to correlate with mortality, but it is not clear whether this association is due to acute kidney injury (AKI) or to other mechanism. Objective. To evaluate whether serum cystatin C at intensive care unit (ICU) entry predicts AKI and mortality in elderly patients. Materials and Methods. It was a prospective study of ICU elderly patients without AKI at admission. We evaluated 400 patients based on normality for serum cystatin C at ICU entry, of whom 234 (58%) were selected and 45 (19%) developed AKI. Results. We observed that higher serum levels of cystatin C did not predict AKI (1.05 ± 0.48 versus 0.94 ± 0.36 mg/L; P = 0.1). However, it was an independent predictor of mortality, H.R. = 6.16 (95% CI 1.46-26.00; P = 0.01), in contrast with AKI, which was not associated with death. In the ROC curves, cystatin C also provided a moderate and significant area (0.67; P = 0.03) compared to AKI (0.47; P = 0.6) to detect death. Conclusion. We demonstrated that higher cystatin C levels are an independent predictor of mortality in ICU elderly patients and may be used as a marker of poor prognosis.

Esofagohiatopexia izquierda para el tratamiento de las hernias hiatales por deslizamiento

RESUMEN:El objetivo de este trabajo de tesis es presentar nuestra experiencia con un procedimiento de reparación quirúrgica de la hernia hiatal por deslizamiento, desarrollado en el servicio de la Cátedra de la Unidad Académica de Cirugía Nº 1, Hospital Nacional de Clínicas, Fac.de Med.Cba. Para ello se comenzó con el estudio crítico de las técnicas en uso, analizando sus ventajas y sus posibles incovenientes, lo que hizo necesario a nuestro juicio, el enfoque del desarrollo del método que a

Esofagohiatopexia izquierda para el tratamiento de las hernias hiatales por deslizamiento

RESUMEN:El objetivo de este trabajo de tesis es presentar nuestra experiencia con un procedimiento de reparación quirúrgica de la hernia hiatal por deslizamiento, desarrollado en el servicio de la Cátedra de la Unidad Académica de Cirugía Nº 1, Hospital Nacional de Clínicas, Fac.de Med.Cba. Para ello se comenzó con el estudio crítico de las técnicas en uso, analizando sus ventajas y sus posibles incovenientes, lo que hizo necesario a nuestro juicio, el enfoque del desarrollo del método que ahora preconizamos: La esófagohiatopexia izquierda. El primer capítulo está destinado, por consiguiente, a una revisión historica y a un análisis de lo hasta este momento realizado en el campo de la cirugía de la hernia hiatal. Como complemento indispensable para la facil comprensión de los hechos fundamentales que informan el procedimiento, en el segundo capítulo nos ocupamos de hacer un recuerdo de la anatomía, fisiología y fisiopatología quirúrgica, no perdiendo de vista en momento el objetivo esencial del trabajo, cual es la fundamentación de una técnica original, como la propuesta. Para poder entrar en lleno al tratamiento es necesario-y así se hace en capítulo tercero- establecer una clasificación de esta bastante frecuente patología, así como una revisión de los síntomas clínicos y los procedimientos auxiliares de diagnostico,que deben ser utilizados mpara poder establecer una correcta valoración del estadío de los pacientes, como guía hacia una completa y adecuada indicación terapéutica. Posteriormente, en el capítulo destinado a la pormenorización del procedimiento quirúrgico, se describen los tiempos de la operación con mención de los detalles técnicos que hacen a una ajustada ejecución de la misma y son indispensables para obtener los resultados deseados. Por último, en el capítulo quinto nos ocupamos del análisis casuístico, lo mas completo que nos fuera posible, de los 52 casos que integran el material de este trabajo, siguiendo criterios ya conocidos e introduciendo otros, que nos parecieron útiles para obtener parámetros válidos para la evaluación. En el final se establecen-mediante la discusión- las conclusiones, a las que nos ha llevado la elaboración de esta Tesis y que nos hacen que ejecutemos la esófagohiatopexia izquierda como técnica de elección en el tratamiento de la hernia hiatal por deslizamiento.