Occupational risks associated with chronic kidney disease of non-traditional origin (CKDnt) in Brazil: it is time to dig deeper into a neglected problem / Riscos ocupacionais associados à doença renal crônica de origem não tradicional (DRCnt) no Brasil: é hora de nos aprofundarmos em um problema negligenciado

Abstract In the past decades, an epidemic of chronic kidney disease (CKD) has been associated with environmental and occupational factors (heat stress from high workloads in hot temperatures and exposure to chemicals, such as pesticides and metals), which has been termed CKD of non-traditional origin (CKDnt). This descriptive review aims to present recent evidence about heat stress, pesticides, and metals as possible causes of CKDnt and provide an overview of the related Brazilian regulation, enforcement, and health surveillance strategies. Brazilian workers are commonly exposed to extreme heat conditions and other CKDnt risk factors, including increasing exposure to pesticides and metals. Furthermore, there is a lack of adequate regulation (and enforcement), public policies, and strategies to protect the kidney health of workers, considering the main risk factors. CKDnt is likely to be a significant cause of CKD in Brazil, since CKD's etiology is unknown in many patients and several conditions for its development are present in the country. Further epidemiological studies may be conducted to explore causal associations and estimate the impact of heat, pesticides, and metals on CKDnt in Brazil. Moreover, public policies should prioritize reducing workers´ exposure and promoting their health and safety.

Resumo Nas últimas décadas, uma epidemia de doença renal crônica (DRC) tem sido associada a fatores ambientais e ocupacionais (estresse térmico decorrente de cargas de trabalho elevadas em altas temperaturas e exposição a produtos químicos, como agrotóxicos e metais), denominada DRC de origem não tradicional (DRCnt). Esta revisão descritiva tem como objetivo apresentar evidências recentes sobre estresse térmico, agrotóxicos e metais como possíveis causas de DRCnt e fornecer uma visão geral das estratégias brasileiras de regulamentação, fiscalização e vigilância sanitária relacionadas. Os trabalhadores brasileiros são comumente expostos a condições extremas de calor e outros fatores de risco de DRCnt, incluindo o aumento da exposição a agrotóxicos e metais. Além disso, há uma falta de regulamentação e fiscalização, políticas públicas e estratégias adequadas para proteger a saúde renal dos trabalhadores em relação aos principais fatores de risco. É provável que a DRCnt seja uma causa significativa de DRC no Brasil, uma vez que a etiologia da doença é desconhecida em muitos pacientes e diversas condições para seu desenvolvimento estão presentes no país. Estudos epidemiológicos devem ser realizados para explorar associações causais e estimar o impacto do calor, dos agrotóxicos e dos metais na DRCnt no Brasil. Além disso, as políticas públicas devem priorizar a redução da exposição dos trabalhadores e a promoção de sua saúde e segurança.

Occupational risks associated with chronic kidney disease of non-traditional origin (CKDnt) in Brazil: it is time to dig deeper into a neglected problem.

In the past decades, an epidemic of chronic kidney disease (CKD) has been associated with environmental and occupational factors (heat stress from high workloads in hot temperatures and exposure to chemicals, such as pesticides and metals), which has been termed CKD of non-traditional origin (CKDnt). This descriptive review aims to present recent evidence about heat stress, pesticides, and metals as possible causes of CKDnt and provide an overview of the related Brazilian regulation, enforcement, and health surveillance strategies. Brazilian workers are commonly exposed to extreme heat conditions and other CKDnt risk factors, including increasing exposure to pesticides and metals. Furthermore, there is a lack of adequate regulation (and enforcement), public policies, and strategies to protect the kidney health of workers, considering the main risk factors. CKDnt is likely to be a significant cause of CKD in Brazil, since CKD's etiology is unknown in many patients and several conditions for its development are present in the country. Further epidemiological studies may be conducted to explore causal associations and estimate the impact of heat, pesticides, and metals on CKDnt in Brazil. Moreover, public policies should prioritize reducing workers´ exposure and promoting their health and safety.

Crosstalk of Inflammation and Coagulation in Bothrops Snakebite Envenoming: Endogenous Signaling Pathways and Pathophysiology.

Snakebite envenoming represents a major health problem in tropical and subtropical countries. Considering the elevated number of accidents and high morbidity and mortality rates, the World Health Organization reclassified this disease to category A of neglected diseases. In Latin America, Bothrops genus snakes are mainly responsible for snakebites in humans, whose pathophysiology is characterized by local and systemic inflammatory and degradative processes, triggering prothrombotic and hemorrhagic events, which lead to various complications, organ damage, tissue loss, amputations, and death. The activation of the multicellular blood system, hemostatic alterations, and activation of the inflammatory response are all well-documented in Bothrops envenomings. However, the interface between inflammation and coagulation is still a neglected issue in the toxinology field. Thromboinflammatory pathways can play a significant role in some of the major complications of snakebite envenoming, such as stroke, venous thromboembolism, and acute kidney injury. In addition to exacerbating inflammation and cell interactions that trigger vaso-occlusion, ischemia-reperfusion processes, and, eventually, organic damage and necrosis. In this review, we discuss the role of inflammatory pathways in modulating coagulation and inducing platelet and leukocyte activation, as well as the inflammatory production mediators and induction of innate immune responses, among other mechanisms that are altered by Bothrops venoms.

Acute kidney injury after snakebite accident treated in a Brazilian tertiary care centre.

AIM: Acute kidney injury (AKI) is one of the main causes of morbidity and mortality in cases of envenomation by venomous snakes. The present study was carried out to investigate the clinical and laboratory manifestations in accidents with venomous snakes and the risk factors associated with AKI in these accidents. METHODS: A retrospective study was carried out with patients victims of snakebite admitted to a reference centre. AKI was defined according to the RIFLE and AKIN criteria. RESULTS: A total of 276 patients were included, of which 230 (83.7%) were males. AKI was observed in 42 cases (15.2%). The mean genus involved in the accidents was Bothrops (82.2%). Mean age of patients with AKI was higher than in patients without AKI (43 ± 20 vs. 34 ± 21 years, P = 0.015). The time elapsed between the accident and medical care was higher in the AKI group (25 ± 28 vs. 14 ± 16h, P = 0.034), as well as the time elapsed between the accident and the administration of antivenom (30.7 ± 27 vs. 15 ± 16 h, P = 0.01). Haemodialysis was required in 30% of cases and complete renal function recovery was observed in 54.8% of cases at hospital discharge. There were four deaths, none of which had AKI. Factors associated with AKI were haemorrhagic abnormalities (P = 0.036, OR = 6.718, 95% CI: 1.067-25.661) and longer length of hospital stay (P = 0.004, OR = 1.69, 95% CI 1.165-2.088). CONCLUSION: Acute kidney injury is an important complication of snakebite accidents, showing low mortality, but high morbidity, which can lead to partial renal function recovery.

Acute kidney injury caused by Crotalus and Bothrops snake venom: a review of epidemiology, clinical manifestations and treatment.

Ophidic accidents are an important public health problem due to their incidence, morbidity and mortality. An increasing number of cases have been registered in Brazil in the last few years. Several studies point to the importance of knowing the clinical complications and adequate approach in these accidents. However, knowledge about the risk factors is not enough and there are an increasing number of deaths due to these accidents in Brazil. In this context, acute kidney injury (AKI) appears as one of the main causes of death and consequences for these victims, which are mainly young males working in rural areas. Snakes of the Bothrops and Crotalus genera are the main responsible for renal involvement in ophidic accidents in South America. The present study is a literature review of AKI caused by Bothrops and Crotalus snake venom regarding diverse characteristics, emphasizing the most appropriate therapeutic approach for these cases. Recent studies have been carried out searching for complementary therapies for the treatment of ophidic accidents, including the use of lipoic acid, simvastatin and allopurinol. Some plants, such as Apocynaceae, Lamiaceae and Rubiaceae seem to have a beneficial role in the treatment of this type of envenomation. Future studies will certainly find new therapeutic measures for ophidic accidents.

Epidemiological profile of snakebite accidents in a metropolitan area of northeast Brazil.

The aim of this study was to describe the epidemiological profile of snakebite accidents reported by the toxicological assistance center in Fortaleza, Ceará, Brazil. Database information on snakebite accidents was analyzed regarding the period from January 2003 to December 2011. A total of 1063 cases were found. The accidents occurred during the rainy months (March, April and May), in urban areas (52.3%), affecting individuals younger than 50 years and predominantly among males (70.7%). The lower limbs were the most frequently affected body area (33.7%). Most accidents involved non-venomous snakes (76.1%). The genus Bothrops was the main one involved in venomous accidents (83%). It is expected that this study can be used as the substrate to improve healthcare surveillance and implementing better measures for the treatment of this population.

ACUTE KIDNEY INJURY CAUSED BY Crotalus AND Bothrops SNAKE VENOM: A REVIEW OF EPIDEMIOLOGY, CLINICAL MANIFESTATIONS AND TREATMENT / Lesão renal aguda causada pelo veneno das cobras Crotalus e Bothrops: revisão da epidemiologia, das manifestações clínicas e do tratamento

SUMMARY Ophidic accidents are an important public health problem due to their incidence, morbidity and mortality. An increasing number of cases have been registered in Brazil in the last few years. Several studies point to the importance of knowing the clinical complications and adequate approach in these accidents. However, knowledge about the risk factors is not enough and there are an increasing number of deaths due to these accidents in Brazil. In this context, acute kidney injury (AKI) appears as one of the main causes of death and consequences for these victims, which are mainly young males working in rural areas. Snakes of the Bothrops and Crotalus genera are the main responsible for renal involvement in ophidic accidents in South America. The present study is a literature review of AKI caused by Bothrops and Crotalus snake venom regarding diverse characteristics, emphasizing the most appropriate therapeutic approach for these cases. Recent studies have been carried out searching for complementary therapies for the treatment of ophidic accidents, including the use of lipoic acid, simvastatin and allopurinol. Some plants, such as Apocynaceae, Lamiaceae and Rubiaceae seem to have a beneficial role in the treatment of this type of envenomation. Future studies will certainly find new therapeutic measures for ophidic accidents. .

RESUMO Os acidentes ofídicos são importante problema de saúde pública devido à incidência, morbidade e mortalidade. Aumento do número de casos tem sido registrado no Brasil nos últimos anos. Vários estudos apontam para a importância do conhecimento das complicações clínicas e do tratamento adequado desses acidentes. Entretanto o conhecimento dos fatores de risco não é suficiente, e existe número crescente de óbitos devido a esses acidentes no Brasil. Neste contexto, a injúria renal aguda (IRA) aparece como uma das principais causas de óbito e sequela nestas vítimas, que são principalmente homens trabalhadores de zonas rurais. Os gêneros Bothrops e Crotalus são os principais responsáveis pelo envolvimento renal nos acidentes ofídicos na América do Sul. O presente estudo faz uma revisão da literatura sobre a IRA causada pela picada das serpentes dos gêneros Bothrops e Crotalus em suas diversas características, enfatizando a abordagem terapêutica mais adequada para estes casos. Estudos recentes tem sido realizados para a busca de terapias complementares para o tratamento dos acidentes ofídicos, incluindo o uso de ácido lipóico, sinvastatina e alopurinol. Algumas plantas, como a Apocynaceae, Lamiaceae e Rubiaceae parecem ter papel benéfico no tratamento destes envenenamentos. Estudos futuros irão certamente encontrar novas estratégias terapêuticas para os acidentes ofídicos. .

Epidemiologicalpprofile of snakebite accidents in a metropolitan area of northeast Brazil / Perfil epidemiologico dos acidentes por picada de cobra em regiao metropolitana do nordeste do Brasil

SUMMARY The aim of this study was to describe the epidemiological profile of snakebite accidents reported by the toxicological assistance center in Fortaleza, Ceará, Brazil. Database information on snakebite accidents was analyzed regarding the period from January 2003 to December 2011. A total of 1063 cases were found. The accidents occurred during the rainy months (March, April and May), in urban areas (52.3%), affecting individuals younger than 50 years and predominantly among males (70.7%). The lower limbs were the most frequently affected body area (33.7%). Most accidents involved non-venomous snakes (76.1%). The genus Bothrops was the main one involved in venomous accidents (83%). It is expected that this study can be used as the substrate to improve healthcare surveillance and implementing better measures for the treatment of this population. .

RESUMO O objetivo deste estudo é descrever o perfil epidemiológico dos acidentes ofídicos atendidos e notificados ao Centro de Assistência Toxicológica (CEATOX), em Fortaleza, Ceará, Brasil. Foram analisadas informações sobre os acidentes ofídicos relativos ao período compreendido entre janeiro de 2003 a dezembro de 2011, por meio de banco de dados. Os resultados demonstraram 1063 casos notificados ao CEATOX, Ceará. Os acidentes ocorreram principalmente em meses chuvosos (março, abril e maio), em áreas urbanas (52,3%), em uma faixa etária menor de 50 anos, acometendo predominantemente o sexo masculino (70,7%). Os membros inferiores foram os locais mais afetados (33,7%). A maior parte dos acidentes envolveu serpentes não peçonhentas (76,1%). O gênero Bothrops foi o maior responsável pelos acidentes com serpentes peçonhentas (83%). Espera-se que os dados da casuística obtida sirvam de ferramenta para o planejamento de medidas de saúde voltadas para prevenção e atendimento mais adequado da população em estudo. .

Dengue and aplastic anemia--a rare association.

Aplastic anemia is a medullary insufficiency secondary to the complete or partial disappearance of hematopoietic tissue without abnormal cellular proliferation. This is a rare complication of infections, such as dengue hemorrhagic fever. A 15-year-old girl was admitted with anemia, bleeding from the gums, petechiae and fever. Laboratory tests at the time of admission showed: Hemoglobin 4.8 g/dl; Hematocrit 13.4%; white blood count 2240/microl and platelets 11,500/microl. Dengue virus IgM antibodies were found. A bone marrow aspirate and biopsy showed severe aplastic anemia. Treatment with intravenous immunoglobulin and methylprednisolone was started. The patient had a favorable outcome. She was then given long-term treatment with cyclosporin. She is now in remission, without any symptoms. Dengue can induce aplastic anemia through direct bone marrow invasion. This is a rare complication which must be identified early. Immunosuppressive therapy can induce complete remission.