The Effect of Early Administration of Hypertonic Saline Solution In Acute Decompensated Heart Failure. / O Efeito da Administração Precoce de Solução Salina Hipertônica na Insuficiência Cardíaca Descompensada Aguda.

BACKGROUND: There was no scientific evidence about the initial treatment of hypertonic saline solution (HSS) in acutely decompensated heart failure (ADHF). OBJECTIVES: This study assessed the impact of using HSS along with a loop diuretic (LD) as the first diuretic treatment for ADHF, focusing on renal function, electrolyte levels, and clinical outcomes. METHODS: In this retrospective case-control study, 171 adult patients (93 females/78 males) with ADHF were included between January 1, 2022, and December 31, 2022. Patients were allocated into two groups: upfront combo HSS+LD and standardized LD. The primary endpoint was worsening renal function (WRF). Hospitalization for HF and all-cause mortality were evaluated during 6 months of follow-up. The significance level adopted in the statistical analysis was 5%. RESULTS: The groups exhibited similarities in baseline characteristics.A significantly higher diuresis on the 1st day (3975 [3000-5150] vs. 2583 [2000-3250], p=0.001) and natriuresis on the 2nd hour (116.00 [82.75-126.00] vs. 68.50 [54.00-89.75], p=0.001) in the initial upfront combo HSS+LD were found in comparison with the standardized LD.When compared to the standardized LD, the utilization of HSS led to an increase in serum Na+ (137.00 [131.75-140.00] vs. 140.00 [136.00-142.25], p=0.001 for upfront combo HSS, 139.00 [137.00-141.00] vs. 139.00 [136.00-140.00], p=.0470 for standardized LD), while chloride (99.00 [94.00-103.25] vs. 99.00[96.00-103.00], p=0.295), GFR (48.50 [29.75-72.50 vs. 50.00 [35.50-63.50, p=0.616), and creatinine (1.20 [0.90-1.70] vs. 1.20 [1.00-1.50], p=0.218) remained stable in the upfront combo HSS group when compared to standardized LD group (Cl-: 102.00 [99.00-106.00] vs. 98.00 [95.00-103.00], p=0.001, eGFR: 56.00 [41.00-71.00] vs. 55.00 [35.00-71.00], p=0.050, creatinine:1.10 [0.90-1.40] vs. 1.20 [0.90-1.70], p=0.009). Worsening renal function (16.1% vs 35.5%, p=0.007), and length of stay in the hospital (4 days [3-7] vs. 5 days [4-7], p=0.004) were lower in the upfront combo HSS+LD in comparison with the standardized LD. In-hospital mortality, hospitalization for HF, and all-cause mortality were similar between the two groups. CONCLUSION: HSS as an initial therapy, when combined with LD, may provide a safe and effective diuresis without impairing renal function in ADHF. Therefore, HSS may lead to a shorter length of stay in the hospital for these patients.

FUNDAMENTO: Não houve evidência científica sobre o tratamento inicial com solução salina hipertônica (SSH) na insuficiência cardíaca agudamente descompensada (ICAD). OBJETIVOS: Este estudo avaliou o impacto do uso de SSH junto com um diurético de alça (DA) como o primeiro tratamento diurético para ICAD, com foco na função renal, níveis de eletrólitos e resultados clínicos. MÉTODOS: Neste estudo retrospectivo de caso-controle, 171 pacientes adultos (93 mulheres/78 homens) com ICAD foram incluídos entre 1º de janeiro de 2022 e 31 de dezembro de 2022. Os pacientes foram alocados em dois grupos: combinação inicial de SSH+DA e DA padronizada. O desfecho primário foi piora da função renal (PFR). A hospitalização por IC e a mortalidade por todas as causas foram avaliadas durante 6 meses de acompanhamento. O nível de significância adotado na análise estatística foi de 5%. RESULTADOS: Os grupos exibiram semelhanças nas características basais. Diurese significativamente maior no 1º dia (3975 [3000-5150] vs. 2583 [2000-3250], p=0,001) e natriurese na 2ª hora (116,00 [82,75-126,00] vs. 131,75-140,00] vs. 94,00-103,25] vs. 99,00 [96,00-103,00], p=0,295), TFG (48,50 [29,75-72,50 vs. 50,00[35,50-63,50, p=0,616) e creatinina (1,20 [0,90-1,70] vs. 1,20 [1,00-1,50], p=0,218) permaneceu estável no grupo SSH combinado inicial quando comparado ao grupo DA padronizado (Cl-: 102,00[99,00-106,00] vs. 98,00[95,00-103,00], p=0,001, TFGe: 56,00 [41,00-71,00] vs. 55,00[35,00-71,00], p=0,050, creatinina: 1,10[0,90-1,40] vs. 1,20 [0,90-1,70], p=0,009). A piora da função renal (16,1% vs. 35,5%, p = 0,007) e o tempo de internação hospitalar (4 dias [3-7] vs. 5 dias [4-7], p = 0,004) foram menores na combinação inicial SSH+DA em comparação com o DA padronizado. A mortalidade hospitalar, a hospitalização por IC e a mortalidade por todas as causas foram semelhantes entre os dois grupos. CONCLUSÃO: SSH como terapia inicial, quando combinada com DA, pode proporcionar uma diurese segura e eficaz sem prejudicar a função renal na ICAD. Portanto, a SSH pode levar a um menor tempo de internação hospitalar para esses pacientes.

Effects of serum sodium and chloride levels in the outcome of critically ill pediatric patients in the post-operative period of liver transplantation.

BACKGROUND: Sodium and chloride disturbances have attracted increasing attention in recent years. Many pathophysiological effects are associated with hyperchloremia, including reduction in mean arterial pressure and acute renal disease. Pediatric patients undergoing liver transplantation are at risk of developing various electrolyte and biochemical abnormalities, with an impact on their postoperative outcomes. OBJECTIVE: To analyze the impacts of serum sodium and chloride levels on prognosis of Pediatric Liver Transplant receptors. METHODS: This was a retrospective analytical observational study performed in a single transplant reference center in Sao Paulo, Brazil. Included patients were pediatric patients who underwent liver transplantation between January 2015 and July 2019. Statistical regression analysis and General Estimating Equations analysis were performed to evaluate the impacts of sodium and chloride disturbances on the development of acute renal failure and mortality. RESULTS: A total of 143 patients were included in this study. The main diagnosis was Biliary Atresia (62.9%). Twenty-seven patients died (18.9%), and graft dysfunction was the main cause of death (29.6%). The only variable individually associated with 28-days mortality was PIM-3 score (HR 1.59, CI 95% 1.165-2.177, p = 0.004). Forty-one patients (28.6%) developed moderate or severe AKI. PIM-3 score (OR 3.052, 95% CI 1.56-5.97, p = 0.001), hypernatremia (OR 3.49, 95% CI 1.32-9.23, p = 0.012), and hyponatremia (OR 4.24, 95% CI 1.52-11.85, p = 0.006) were independently associated with the development of moderate/severe AKI. CONCLUSIONS: In pediatric patients after liver transplantation, PIM-3 score, and abnormal serum sodium levels were correlated with AKI development.

[Hyponatremia in children with liver cirrhosis: Treatment strategies]. / Hiponatremia en niños con cirrosis hepática: Estrategias de tratamiento.

Hyponatremia is a common hydroelectrolytic disorder in pediatric patients with advanced cirrhosis. This complication is related to the alteration in the renal capacity to eliminate free water with solutes such as sodium, which leads to disproportionate water retention, a condition known as dilutional hyponatremia. The main pathogenic factors are the non-osmotic secretion of antidiuretic hormone and the activation of the renin-angiotensin-aldosterone axis and the sympathetic nervous system. Given that hyponatremia in cirrhosis is associated with an increase in morbidity and mortality, the objective of this review is to propose a systematic approach, based on the level of serum sodium, assessment of hemodynamic status and diuresis, which allows precise modifications that minimize negative impacts on survival and neurological sequelae.

Central Administration of Angiotensin-(1-7) Improves Vasopressin Impairment and Hypotensive Response in Experimental Endotoxemia.

Angiotensin-(1-7) [Ang-(1-7)]/Mas receptor is a counter-regulatory axis that counteracts detrimental renin-angiotensin system (RAS) effects, especially regarding systemic inflammation, vasopressin (AVP) release, and hypothalamic-pituitary-adrenal (HPA) activation. However, it is not completely understood whether this system may control centrally or systemically the late phase of systemic inflammation. Thus, the aim of this study was to determine whether intracerebroventricular (i.c.v.) administration of Ang-(1-7) can modulate systemic inflammation through the activation of humoral pathways in late phase of endotoxemia. Endotoxemia was induced by systemic injection of lipopolysaccharide (LPS) (1.5 mg/kg, i.v.) in Wistar rats. Ang-(1-7) (0.3 nmol in 2 µL) promoted the release of AVP and attenuated interleukin-6 (IL-6) and nitric oxide (NO) levels but increased interleukin-10 (IL-10) in the serum of the endotoxemic rats. The central administration of Mas receptor antagonist A779 (3 nmol in 2 µL, i.c.v.) abolished these anti-inflammatory effects in endotoxemic rats. Furthermore, Ang-(1-7) applied centrally restored mean arterial blood pressure (MABP) without affecting heart rate (HR) and prevented vascular hyporesponsiveness to norepinephrine (NE) and AVP in animals that received LPS. Together, our results indicate that Ang-(1-7) applied centrally promotes a systemic anti-inflammatory effect through the central Mas receptor and activation of the humoral pathway mediated by AVP.

Predicting Operative Outcomes in Patients with Liver Disease: Albumin-Bilirubin Score vs Model for End-Stage Liver Disease-Sodium Score.

BACKGROUND: The albumin-bilirubin score (ALBI) has recently been shown to have increased accuracy in predicting post-hepatectomy liver failure and mortality compared with the Model for End-Stage Liver Disease (MELD). However, the use of ALBI as a predictor of postoperative mortality for other surgical procedures has not been analyzed. The aim of this study was to measure the predictive power of ALBI compared with MELD-sodium (MELD-Na) across a wide range of surgical procedures. STUDY DESIGN: Patients undergoing cardiac, pulmonary, esophageal, gastric, gallbladder, pancreatic, splenic, appendix, colorectal, adrenal, renal, hernia, and aortic operations were identified in the 2015-2018 American College of Surgeons NSQIP database. Patients with missing laboratory data were excluded. Univariable analysis and receiver operator characteristic curves were performed for 30-day mortality and morbidity. Areas under the curves were calculated to validate and compare the predictive abilities of ALBI and MELD-Na. RESULTS: Of 258,658 patients, the distribution of ALBI grades 1, 2, 3 were 51%, 42%, and 7%, respectively. Median MELD-Na was 7.50 (interquartile range 6.43 to 9.43). Overall 30-day mortality rate was 2.7% and overall morbidity was 28.6%. Increasing ALBI grade was significantly associated with mortality (ALBI grade 2: odds ratio [OR] 5.24; p < 0.001; ALBI grade 3: OR 25.6; p < 0.001) and morbidity (ALBI grade 2: OR 2.15; p < 0.001; ALBI grade 3: OR 6.12; p < 0.001). On receiver operator characteristic analysis, ALBI outperformed MELD-Na with increased accuracy in several operations. CONCLUSIONS: ALBI score predicts mortality and morbidity across a wide spectrum of surgical procedures. When compared with MELD-Na, ALBI more accurately predicts outcomes in patients undergoing pulmonary, elective colorectal, and adrenal operations.

Kawasaki Disease and Clinical Outcome Disparities Among Black Children.

OBJECTIVE: To determine whether Black children with Kawasaki disease exhibit disparities in prevalence, sequelae, and response to intravenous gamma globulin (IVIG) treatment. STUDY DESIGN: International Classification of Diseases codes were used to identify children with Kawasaki disease admitted to a tertiary center in the southeastern US. Subjects diagnosed and treated according to American Heart Association criteria were included. Demographic, laboratory, clinical, and echocardiographic data from the electronic medical record (2000-2015) were compared between Blacks and Whites. RESULTS: Data from 369 subjects (52% Whites and 48% Blacks) were included in our analysis. No significant differences related to timely admission, IVIG treatment, or coronary artery (CA) abnormalities during hospitalization were observed. Blacks showed lower IVIG response rates than Whites for patients administered IVIG within 10 days of fever onset (86.6% vs 95.6%; P = .007). Blacks received more ancillary drugs (9.6% vs 2.6%; P = .003), and endured longer hospitalizations (mean, 5 ± 3.9 days vs 3.4 ± 2.2 days; P = .001). Blacks presented with higher C-reactive protein level and erythrocyte sedimentation rate and lower hemoglobin, albumin, and sodium levels. Blacks had a higher proportion of persistent CA abnormalities than Whites at second follow-up echocardiogram (14.5% vs 6.3%; P = .03), and at third follow-up echocardiogram (21.2% vs 6.9%; P = .01). CONCLUSIONS: Compared with White children, Black children with Kawasaki disease had higher IVIG refractory prevalence, more severe inflammation, more ancillary treatments, and longer hospitalizations. Despite no racial differences in time to diagnosis or initial treatment, there was greater CA abnormality persistence among Black children at follow-up.

Clinical assessment of acid-base balance in Netherland Dwarf rabbit / Avaliação clínica do equilíbrio ácido-básico em coelhos Anã Holandês

Pet rabbits have increased their popularity in a lot of countries. However, most of the laboratory profiles in rabbit medicine come from the observations made in rabbit as biomodels or meat production. So that further researches are necessary to obtain reference values for hematology and biochemical profiles in pet rabbits and the different breeds, especially, in relation to acid-base balance. The aim of this report was to offer the mean values of the main parameters connected with acid-base profile in Netherland Dwarf breed. Thirty-five healthy rabbits (15 males and 20 females) were studied. Venous blood sample from lateral saphenous vein was analyzed to measure: haematocrit, haemoglobin, blood urea nitrogen, glucose, blood pH, partial pressure of CO2 (pCO2), total CO2, ions bicarbonate, chloride, sodium, potassium, base excess and anion Gap. Results showed a shorter range that those reported by different researchers. Moreover, differences between genders were showed in pCO2, its values were higher in males. It may be associated with a greater cellular metabolism. Values obtained in this research should be taken into account by veterinary clinicians for this breed in their clinical assessments. Besides, these values provide new results in parameters with few reference values.

A popularidade de coelhos como animais de estimação aumentou em muitos países. No entanto, a maioria dos perfis de laboratório em medicina de coelhos advém das observações de biomodelos animais ou da produção de carne. Assim, são necessárias pesquisas adicionais para obter valores de referência para hematologia e perfis bioquímicos em coelhos de estimação, e das diferentes raças, especialmente, em relação ao equilíbrio ácido-base. O objetivo deste relatório foi oferecer os valores médios dos principais parâmetros ligados ao perfil ácido-base na raça Anã Holandês. Trinta e cinco coelhos saudáveis ​​(15 machos e 20 fêmeas) foram estudados. A amostra de sangue venoso da veia safena lateral foi analisada para mensuração: hematócrito, hemoglobina, nitrogênio ureico sanguíneo, glicose, pH sanguíneo, pressão parcial de CO2 (pCO2), CO2 total, íons bicarbonato, cloreto, sódio, potássio, excesso de base e ânion Gap. Os resultados apresentaram um intervalo menor do que aqueles relatados por diferentes pesquisadores. Além disso, as diferenças entre os gêneros foram mostradas na pCO2, seus valores foram maiores no sexo masculino. Pode estar associado a um maior metabolismo celular. Os valores obtidos nesta pesquisa devem ser levados em consideração pelos clínicos veterinários para esta raça em suas avaliações clínicas. Além disso, esses valores fornecem novos resultados em parâmetros com poucos valores de referencia.

The role of urea-induced osmotic diuresis and hypernatremia in a critically ill patient: case report and literature review / O papel da diurese osmótica induzida por ureia na geração de hipernatremia no paciente crítico: relato de caso e revisão da literatura

Abstract Hypernatremia is a common electrolyte problem at the intensive care setting, with a prevalence that can reach up to 25%. It is associated with a longer hospital stay and is an independent risk factor for mortality. We report a case of hypernatremia of multifactorial origin in the intensive care setting, emphasizing the role of osmotic diuresis due to excessive urea generation, an underdiagnosed and a not well-known cause of hypernatremia. This scenario may occur in patients using high doses of corticosteroids, with gastrointestinal bleeding, under diets and hyperprotein supplements, and with hypercatabolism, especially during the recovery phase of renal injury. Through the present teaching case, we discuss a clinical approach to the diagnosis of urea-induced osmotic diuresis and hypernatremia, highlighting the utility of the electrolyte-free water clearance concept in understanding the development of hypernatremia.

Resumo A hipernatremia é um distúrbio eletrolítico comum no ambiente de terapia intensiva, com uma prevalência que pode chegar a 25%. Está associada a maior tempo de internação hospitalar e é um fator de risco independente para a mortalidade. Este relato ilustra um caso de hipernatremia de origem multifatorial no ambiente de terapia intensiva. Destacaremos o papel da diurese osmótica por geração excessiva de ureia, uma causa de hipernatremia pouco conhecida e subdiagnosticada. Este cenário pode estar presente em pacientes em uso de elevadas doses de corticoides, com sangramento gastrointestinal, em uso de dietas e suplementos hiperproteicos e estado de hipercatabolismo, especialmente durante a fase de recuperação de injúria renal. A seguir, discutiremos uma abordagem clínica para o diagnóstico da hipernatremia secundária à diurese osmótica induzida por ureia, destacando a importância do conceito de clearance de água livre de eletrólitos nesse contexto.

HEALTH STATUS AND BASELINE HEMATOLOGY, BIOCHEMISTRY, AND BLOOD GAS VALUES OF GALAPAGOS SHEARWATERS (PUFFINUS SUBALARIS).

The Galápagos shearwater, Puffinus subalaris, is a seabird endemic to the Galápagos archipelago. Hematology, blood chemistry, and general health parameters have not been published for this species. Analyses were run on blood samples drawn from 20 clinically healthy Galápagos shearwaters captured by hand at their nests at Islote Pitt on San Cristóbal Island in July 2016. A portable blood analyzer (iSTAT) was used to obtain near immediate field results for pH, pO2, pCO2, TCO2, HCO3 -, hematocrit, hemoglobin, sodium, potassium, chloride, ionized calcium, creatinine, urea nitrogen, anion gap, and glucose. Blood lactate was measured using a portable Lactate Plus analyzer. The reported results provide baseline data that can be used for comparisons among populations and in detecting changes in health status among Galápagos shearwaters.

Interleukin-10 limits the initial steps of the cardiorenal damage induced by ethanol consumption.

AIMS: Reactive oxygen species (ROS) and pro-inflammatory cytokines play a critical role in organ damage induced by ethanol consumption. Interleukin (IL)-10 maintain tissue homeostasis through restriction of excessive inflammatory responses and inhibition of ROS generation. These responses limit unnecessary tissue damage in the cardiorenal system. We hypothesized that IL-10 would limit the deleterious effects induced by ethanol consumption in the cardiorenal system. MATERIALS AND METHODS: Male C57BL/6J wild-type (WT) or IL10-deficient mice (IL-10-/-) were treated with ethanol (20% v/v) for 6 weeks. KEY FINDINGS: IL-10 deficiency was associated with an increased mortality rate. Ethanol consumption decreased plasma levels of IL-10 in WT mice. Increased levels of IL-6 were detected in the aorta from IL-10-deficient mice, but not WT mice. No alterations in the levels of urea, creatinine, sodium, potassium or creatine kinase (CK)-MB were found after treatment with ethanol. Augmented concentration of thiobarbituric acid reactive substances (TBARS) was found in the left ventricle (LV) of IL-10-deficient mice, but not WT mice. Increased levels of superoxide anion (O2-) were found in the renal cortex of both WT and IL-10-deficient mice. Renal cortex from WT mice chronically treated with ethanol showed decreased levels of H2O2. No changes in the expression of Nox1, Nox4 or catalase were found in the renal cortex from ethanol-treated mice. SIGNIFICANCE: IL-10 limited the production of ROS and the synthesis of pro-inflammatory cytokines induced by ethanol in the cardiorenal system. These findings provided novel evidence that IL-10 counteracted the initial mechanisms whereby ethanol induces its cardiorenal damages.

The Short-Term Effects of Roux-en-Y Gastric Bypass on Renal Excretion of Sodium and Its Association with Blood Pressure.

INTRODUCTION: Bariatric surgery has been shown to be effective in reducing weight and has benefits, such as lowering blood pressure. An increase in urinary sodium excretion has been suggested as a possible mechanism. This study explored changes in sodium excretion and their correlation with blood pressure after Roux-en-Y gastric bypass. MATERIALS AND METHODS: This study was conducted on 28 obese participants with body mass index (BMI) of 44.54 ± 7.81 kg/m2 who underwent gastric bypass. Before surgery and at the third and sixth months after gastric bypass, blood pressure, urinary sodium concentration, 24-hour (24-h) urinary sodium excretion, and fractional excretion of sodium were evaluated. In addition, serum sodium and potassium levels were determined. Nonparametric tests were used to analyze the data. RESULTS: Blood pressure decreased after surgery and remained at low levels over the 3- and 6-month periods. The urinary sodium concentration increased at 3 months after surgery; however, the 24-h urinary sodium excretion and urine volume decreased. Interestingly, although some associations between variables were observed, significant correlations between the 24-h urinary sodium excretion and the systolic, diastolic, and mean blood pressures were found. In addition, the urine volume was higher in the sixth month than in the third month following surgery. CONCLUSIONS: In the months immediately following surgery, a low-salt and low-volume diet favors decreases in urine volume and 24-h urinary sodium excretion. In addition, in the sixth month after surgery, an association between blood pressure and 24-h urinary sodium excretion was observed.

The role of urea-induced osmotic diuresis and hypernatremia in a critically ill patient: case report and literature review.

Hypernatremia is a common electrolyte problem at the intensive care setting, with a prevalence that can reach up to 25%. It is associated with a longer hospital stay and is an independent risk factor for mortality. We report a case of hypernatremia of multifactorial origin in the intensive care setting, emphasizing the role of osmotic diuresis due to excessive urea generation, an underdiagnosed and a not well-known cause of hypernatremia. This scenario may occur in patients using high doses of corticosteroids, with gastrointestinal bleeding, under diets and hyperprotein supplements, and with hypercatabolism, especially during the recovery phase of renal injury. Through the present teaching case, we discuss a clinical approach to the diagnosis of urea-induced osmotic diuresis and hypernatremia, highlighting the utility of the electrolyte-free water clearance concept in understanding the development of hypernatremia.

Metabolic and Hemodynamic Results and Early Complications in Simultaneous Bilateral versus Unilateral Hip Arthroscopy.

BACKGROUND: To compare the hemodynamic parameters-electrolyte concentration, D-dimer level, creatine phosphokinase level-and the incidence of early complications of simultaneous bilateral versus unilateral hip arthroscopy. METHODS: A prospective study was conducted on patients (> 18 years of age) undergoing unilateral or bilateral hip arthroscopy under the same anesthetic between 2013 and 2015. Patients were followed up for 30 days after surgery. In all cases, data were collected before, during, and after the surgical procedure. RESULTS: One hundred cases of hip arthroscopy (51 unilateral and 49 bilateral) were included in this study. There was a greater variation in systolic blood pressure and heart rate in the unilateral group. The sodium levels were higher in the bilateral group with an adjusted mean difference of 5.31 mmol/L (p < 0.001). During the first 24 hours after the procedure, the proportion of patients with an altered D-dimer of > 500 ng/mL was 85.7% in the bilateral group and 56.9% in the unilateral group. There was no significant difference in the incidence of complications between the groups (bilateral, 8.2%; unilateral, 9.8%; crude odds ratio, 0.83; 95% confidence interval, 0.24 to 2.92; p = 0.526). CONCLUSIONS: The variations of hemodynamic parameters in patients undergoing hip arthroscopy remained within normal ranges. The findings of this study suggest that bilateral hip arthroscopy be selected according to the patient's condition, considering that the risk of complications and metabolic alterations in bilateral hip arthroplasty are similar to those in unilateral arthroscopy.

IMPACT OF MELD SODIUM ON LIVER TRANSPLANTATION WAITING LIST.

BACKGROUND: Serum sodium was incorporated to MELD score for the allocation of liver transplantation In the USA in 2016. Hyponatremia significantly increased the efficacy of the score to predict mortality on the waiting list. Such modification was not adopted in Brazil. AIM: To carry out a simulation using MELD-Na as waiting list ordering criteria in the state of Paraná and to compare to the list ordered according to MELD score. METHODS: The study used data of 122 patients waiting for hepatic transplantation and listed at Parana´s Transplantation Central. Two classificatory lists were set up, one with MELD, the current qualifying criteria, and another with MELD-Na. We analyzed the changes on classification comparing these two lists. RESULTS: Among all patients, 95.1% of the participants changed position, 30.3% showed improvement, 64.8% presented worsening and 4.9% maintained their position. There were 19 patients with hyponatremia, of whom 94.7% presented a change of position, and in all of them there was an improvement of position. One hundred and one patients presented sodium within the normal range and 95% of them presented a change of position: Improved placement was observed in 18.8%, and worsened placement in 76.2%. Two patients presented hypernatremia and changed their position, both worsening the placement. There was a significant different behavior on waiting list according to sodium serum level when MELD-Na was applied. CONCLUSION: The inclusion of serum sodium caused a great impact in the classification, bringing benefit to patients with hyponatremia.

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.

Possible association between dysnatremias and mortality during hospitalization in patients undergoing acute hemodialysis: analysis from a Peruvian retrospective cohort / Possível associação entre distúrbios do sódio e mortalidade hospitalar em pacientes submetidos a hemodiálise aguda: análise de uma coorte retrospectiva peruana

Abstract Objective: To evaluate the association between dysnatremias or dyschloremias and mortality during hospitalization in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) undergoing acute hemodialysis. Methods: We carried out a retrospective cohort study on adult patients undergoing acute hemodialysis with AKI or CKD diagnosis at a public hospital in Lima, Peru. Dysnatremias were categorized as hyponatremia (Na < 135mmol/L) or hypernatremia (Na > 145mmol/L), and dyschloremias were defined as hypochloremia (Cl < 98 mmol/L) or hyperchloremia (Cl > 109mmol/L). The outcome of interest was mortality during hospitalization. We performed generalized lineal Poisson family models with bias-corrected and accelerated non-parametric bootstrap to estimate the risk ratios at crude (RR) and adjusted analysis (aRR) by gender, age, HCO3 (for all patients) and Liaño score (only for AKI) with CI95%. Results: We included 263 patients (mean age: 54.3 years, females: 43%): 191 with CKD and 72 with AKI. Mortality was higher in patients with AKI (59.7%) than in patients with CKD (14.1%). In overall, patients with hypernatremia had a higher mortality during hospitalization compared to those who had normal sodium values (aRR: 1.82, 95% CI: 1.17-2.83); patients with hyponatremia did not have different mortality (aRR: 0.19, 95% CI: 0.69-2.04). We also found that hyperchloremia (aRR: 1.35, 95% CI: 0.83-2.18) or hypochloremia (aRR: 0.66, 95% CI: 0.30-14.78) did not increase mortality in comparison to normal chloride values. No association between dysnatremias or dyschloremias and mortality during hospitalization was found in CKD and AKI subgroups. Conclusions: In our exploratory analysis, only hypernatremia was associated with mortality during hospitalization among patients with AKI or CKD undergoing acute hemodialysis.

Resumo Objetivo: Avaliar a associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar de pacientes com insuficiência renal aguda (IRA) ou doença renal crônica (DRC) submetidos a hemodiálise aguda. Métodos: O presente estudo de coorte retrospectiva incluiu pacientes adultos submetidos a hemodiálise aguda com diagnóstico de IRA ou DRC em um hospital público de Lima, Peru. Os distúrbios do sódio foram classificados como hiponatremia (Na < 135mmol/L) ou hipernatremia (Na > 145mmol/L), enquanto os distúrbios do cloro foram classificados como hipocloremia (Cl < 98 mmol/L) ou hipercloremia (Cl > 109mmol/L). O desfecho de interesse foi mortalidade hospitalar. Utilizamos modelos de Poisson da família de modelos lineares generalizados com bootstrap não-paramétrico e correção de viés acelerado para estimar os riscos relativos na análise bruta (RR) e ajustada (RRa) para sexo, idade, HCO3 (para todos os pacientes) e escore de Liaño (apenas para IRA) com IC 95%. Resultados: Foram incluídos 263 pacientes (idade média 54,3 anos; 43% do sexo feminino), 191 com DRC e 72 com IRA. A mortalidade foi mais elevada nos pacientes com IRA (59,7%) do que nos indivíduos com DRC (14,1%). No geral, os pacientes com hipernatremia tiveram mortalidade hospitalar mais elevada do que os indivíduos com valores normais de sódio (RRa: 1,82; IC 95%: 1,17-2,83). Os pacientes com hiponatremia não apresentaram mortalidade diferente (RRa: 0,19; IC 95%: 0,69-2,04). Também identificamos que hipercloremia (RRa: 1,35; IC 95%: 0,83-2,18) e hipocloremia (RRa: 0,66; IC 95%: 0,30-14,78) não elevaram a mortalidade em comparação a indivíduos com níveis normais de cloro. Não foi encontrada associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar nos subgrupos com DRC e IRA. Conclusões: Em nossa análise exploratória, apenas hipernatremia apresentou associação com mortalidade hospitalar em pacientes com IRA ou DRC submetidos a hemodiálise aguda.

Effects of cyclosporine on ischemia-reperfusion injuries in rat kidneys. An experimental model.

PURPOSE: To assess Cyclosporine A (CsA) therapy at an intraperitoneal dose of 15 mg.kg -1 in a rodent model of non-septic renal ischemia. METHODS: Twenty male Wistar rats were randomized to receive CsA therapy or none therapy before undergoing 30 minutes of renal ischemia followed by reperfusion. Additionally, 10 rats were randomized to undergo the same surgical procedure of the aforementioned animals with neither ischemia nor CsA therapy. Twelve hours after kidney ischemia, the left kidneys were evaluated for histological injury according to Park's criteria. Serum creatinine (Cr), urea nitrogen (Ur) and sodium levels were obtained at different times of the experimental protocol. RESULTS: Rodents in the CsA group showed negative results (p<0.05) in serum variables (Cr: 0.41±0.05mg/dL vs . 4.17±1.25mg/dL; Ur: 40.90±3.98mg/dL vs . 187.70±22.93mg/dL) even the non CsA or control group (Cr: 0.35±0.07mg/dL vs . 3.80±1.20mg/dL; Ur: 40.10±4.70mg/dL vs . 184.50±49.80mg/dL). The negative results were also verified in histological evaluation, CsA group had 50% in the very severe grade of lesion, 10% in the severe and 40% in the moderate to severe whereas the control group had 90% in the very severe grade. CONCLUSION: CsA was incapable of preventing the deleterious effects of ischemia-reperfusion injury in rat kidneys.

Possible association between dysnatremias and mortality during hospitalization in patients undergoing acute hemodialysis: analysis from a Peruvian retrospective cohort.

OBJECTIVE: To evaluate the association between dysnatremias or dyschloremias and mortality during hospitalization in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) undergoing acute hemodialysis. METHODS: We carried out a retrospective cohort study on adult patients undergoing acute hemodialysis with AKI or CKD diagnosis at a public hospital in Lima, Peru. Dysnatremias were categorized as hyponatremia (Na < 135mmol/L) or hypernatremia (Na > 145mmol/L), and dyschloremias were defined as hypochloremia (Cl < 98 mmol/L) or hyperchloremia (Cl > 109mmol/L). The outcome of interest was mortality during hospitalization. We performed generalized lineal Poisson family models with bias-corrected and accelerated non-parametric bootstrap to estimate the risk ratios at crude (RR) and adjusted analysis (aRR) by gender, age, HCO3 (for all patients) and Liaño score (only for AKI) with CI95%. RESULTS: We included 263 patients (mean age: 54.3 years, females: 43%): 191 with CKD and 72 with AKI. Mortality was higher in patients with AKI (59.7%) than in patients with CKD (14.1%). In overall, patients with hypernatremia had a higher mortality during hospitalization compared to those who had normal sodium values (aRR: 1.82, 95% CI: 1.17-2.83); patients with hyponatremia did not have different mortality (aRR: 0.19, 95% CI: 0.69-2.04). We also found that hyperchloremia (aRR: 1.35, 95% CI: 0.83-2.18) or hypochloremia (aRR: 0.66, 95% CI: 0.30-14.78) did not increase mortality in comparison to normal chloride values. No association between dysnatremias or dyschloremias and mortality during hospitalization was found in CKD and AKI subgroups. CONCLUSIONS: In our exploratory analysis, only hypernatremia was associated with mortality during hospitalization among patients with AKI or CKD undergoing acute hemodialysis.

Osmoregulatory disturbance in Neotropical fish exposed to the crude extracts of the cyanobacterium, Radiocystis fernandoi.

Blooms of cyanobacteria, a common event in eutrophic environments, result in the release of potentially toxic substances into the water. The cyanobacterium Radiocystis fernandoi produces microcystin (MC) and other peptides that may disturb homeostasis. This study evaluated the effect of intraperitoneal injections containing the crude extract (CE) of R. fernandoi strain R28 on the gills and kidneys of neotropical fish, Piaractus mesopotamicus, 3, 6 and 24 h post-injection. CE contained MC-RR, MC-YR and minor other oligopeptides. Plasma ions and the activities of the enzymes PP1 and PP2A, Na+/K+-ATPase (NKA), H+-ATPase (HA) and carbonic anhydrase (CA) were determined and morphological changes in both the gills and kidneys were characterized. Compared to controls, the concentration of Na+ within the plasma of P. mesopotamicus decreased after treatment with CE 3 h post treatment and increased after 24 h; the concentration of K+ decreased after 6 h. The activity of the endogenous PP1 and PP2A was unchanged in the gills and was inhibited in the kidneys 6 h after i.p. injection. In the gills, NKA activity increased after 3 h and decreased 6 h post i.p. exposure. Further, NKA activity did not differ from the controls 24-h post injection. In the kidneys, NKA, HA and CA activities were unaffected by treatment. The mitochondria-rich cell (MRC) density in the gills decreased after 3 h in the filament and 3 and 6 h in the lamellae and was restored to the control levels 24 h post-exposure. Filament epithelial hyperplasia and hypertrophy, lamellar atrophy and rupture of the lamellar epithelium were the most common effects of treatment in the gills. No histopathological changes occurred in the kidneys. This study demonstrates that a single dose of toxic CE from R. fernandoi can cause a transitory ion imbalance in P. mesopotamicus which is related to the changes in MRC levels and NKA activity. Ionic balance was recovered 24 h post i.p. injection, however, morphological changes that occurred in the gills took a longer amount of time to return to normal. To conclude, the effects of components contained within the CE of R. fernandoi may be harmful to P. mesopotamicus. In particular, the recovery of ionic regulation depends on MRC responses and histopathological changes produced by CE may affect gas exchange and other gill functions.

Haematological and biochemical analysis of healthy neonatal puppies during the immediate foetal-to-neonatal transition.

For the neonatal patient, precocity of diagnosis is crucial for effectiveness of medical approach. However, the newborn has its own physiological peculiarities due to ongoing adaptive mechanism for extrauterine life and deserves special attention in order to underline a specific management or clinical approach. The objective of this work was to verify clinical adaptations and biochemical balance of neonates during immediate period, with special reference to haematological, renal and metabolic functions. Neonatal puppies (n = 51) were physically examined for vitality and rectal temperature at birth, 5 and 60 min post-birth. Blood was collected at birth and 60 min post-birth for analysis of glucose, sodium, potassium, chlorine, blood urea nitrogen (BUN), haematocrit and haemoglobin. Neonatal vitality was lower at birth compared with 5 min and 60 min post-birth. Progressive decline in rectal temperature (36.5 ± 0.3°C, 34.2 ± 0.2°C, 32.3 ± 0.5°C) was observed at birth, 5 min and 60 min post-birth, respectively. Puppies presented slight hyponatremia (140.7 ± 0.5 mmol/L) at birth and hypopotassemia (3.5 ± 0.1 mmol/L) and blood urea nitrogen (13.1 ± 0.7 mg/dl) during the first hour, and high haematocrit (45.1 ± 1.0%) and haemoglobin (15.3 ± 0.3 g/dl) concentration. In conclusion, puppies had rapid evolution of vitality. Marked decrease in rectal temperature occurred at 5 min post-birth. Haematological values of neonates immediately after birth reflected mainly the dam's blood status, not being useful for a blood panel at this time point. The peculiar pattern of BUN, sodium and potassium observed during transition period, suggested that specific reference range should be considered for neonatal puppies.