Prognostic factors in hemodialysis patients: experience of a Havana hospital.

INTRODUCTION: Knowledge of prognostic factors in end-stage renal disease patients has improved dialysis management and methods for reducing morbidity and mortality, underlining the importance of identification, prevention and control of these factors. OBJECTIVE: Identify factors affecting prognosis (survival or death) in hemodialysis patients at the Medical-Surgical Research Center in Havana over a ten-year period. METHODS: Descriptive, prospective study of 81 end-stage renal disease patients who received hemodialysis at the Medical-Surgical Research Center from 1995 to 2004. Prognostic factors were identified at initiation of and during dialysis treatment, using chi square, t test, McNemar test, Kaplan Meier analysis, log-rank test and Cox regression model, with significance threshold set at p <0.05. RESULTS: Hypertension and diabetes were the leading causes of end-stage renal disease. Six patients were referred late. Mean survival was 4.4 years; with survival of 86.6%, 54.7% and 26.6% at one, three and five years respectively. Factors predictive of decreased survival that were most frequent at initiation of hemodialysis were hypertension and chronic anemia (both present in 95.9% of cases); malnutrition, hypoalbuminemia, cardiovascular disease and chronic liver disease increased during treatment while hypertension decreased. In multivariate analysis, prognostic factors that significantly predicted decreased survival were hypertension, inadequate vascular access and diabetes. Patients aged ≥ 60 years and those with malnutrition, hypoalbuminemia, anemia, cardiovascular disease or liver disease had lower survival figures at the end of the study period. Leading causes of death were infections (45.2%) and cardiovascular disease (41.9%); the latter was present in 93.5% of deaths, independent of underlying cause of death. CONCLUSIONS: Survival of hemodialysis patients diminished at five years. Some negative predictive factors are present at initiation of hemodialysis, such as diabetes, hypertension and chronic anemia; others increased later, including malnutrition, hypoalbuminemia, cardiovascular disease and liver disease.

Continuous venovenous hemodiafiltration in patients with multiple organ dysfunction syndrome in an intensive care unit.

INTRODUCTION: Continuous venovenous hemodiafiltration, generally used in patients with acute renal failure, enables elimination of humoral mediators of systemic inflammatory response and sepsis from blood. This effect should improve treatment results in patients with multiple organ dysfunction, but evidence of improved survival is insufficient. OBJECTIVES: Describe the effect of continuous venovenous hemodiaflitration on patients with multiple organ dysfunction syndrome in terms of systemic and brain hemodynamics, oxygenation, metabolism and status on ICU separation. METHODS: An observational case series was done of 18 patients (11 men and 7 women) aged 24-78 years with multiple organ dysfunction syndrome treated with continuous venovenous hemodiafiltration in the Medical-Surgical Research Center's ICU in Havana. General, systemic and brain hemodynamic, oxygenation and metabolic variables were assessed immediately before and 12 hours after starting the procedure; vital status on separation from intensive care was recorded. For analysis, patients were grouped by whether cause of multiple organ dysfunction syndrome was septic or nonseptic. Variable means before and after treatment were compared using the Wilcoxon matched pairs test. Standardized mortality ratios were calculated for both groups, with survival efficacy defined by a ratio of <0.9. RESULTS: After 12 hours continuous venovenous hemodiafitration, the septic group showed clinical improvement, with statistically significant improvement in all variables except mean arterial pressure and brain hemodynamics. Survival to discharge from ICU was 64%, with a standardized mortality ratio of 0.66. In the nonseptic group, survival was 0% and ratio was 2.13; temperature was the only variable found to improve significantly. CONCLUSIONS: Continuous venovenous hemodiafltration improved clinical parameters and survival in patients with multiple organ dysfunction of septic origin. Further studies are needed with larger numbers of patients to corroborate these results.

Fatal 2009 pandemic influenza A (H1N1) in a bone marrow transplant recipient.

Conditions characterized by immunosuppression have been recently reported as risk factors for severe novel swine-origin influenza A (H1N1) virus (S-OIV) infection during the current 2009 pandemic.  We report clinical and virological findings, antiviral therapy, and post-mortem study of S-OIV in an adult bone marrow transplant recipient. The viral genome was amplified by real time reverse transcriptase polymerase chain reaction (RT-PCR) from a nasopharyngeal swab specimen. The patient developed acute respiratory distress syndrome, septic shock, and eventually succumbed with a severe pulmonary haemorrhage. To the best of our knowledge, the entire clinical/therapy management and pathological examination in a transplant recipient infected with the S-OIV has not been previously documented. The fatal ending in this bone marrow transplant recipient supports recommendations that call for education measures, S-OIV vaccination, early diagnosis and aggressive treatment in the transplant population.