Lesión renal aguda en Latinoamérica en la era del big data / Acute kidney injury in Latin America in ‘big data’ era

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Creatinine- vs. cystatin C-based equations compared with 99mTcDTPA scintigraphy to assess glomerular filtration rate in chronic kidney disease.

BACKGROUND: In chronic kidney disease (CKD), accurate estimation of the glomerular filtration rate (GFR) is mandatory. Gold standard methods for its estimation are expensive and time-consuming. We compared creatinine- versus cystatin C-based equations to measure GFR, employing (99m)Tc-DTPA scintigraphy as the gold standard. METHODS: This was a prospective cross-sectional observational study including 300 subjects. CKD was defined according to K/DOQI guidelines, and patients were separated into groups: stage 1 (G1), n=26; stage 2 (G2), n=52; stage 3 (G3), n=90; stage 4 (G4), n=37; stage 5 (G5), n=60; and control group, n=35. Creatinine-based estimates were from 24-hour creatinine clearance using the Walser formula, Cockcroft-Gault, MDRD-4 and CKD-EPI; cystatin C equations used were Larsson, Larsson modified equation, Grubb and Hoek. RESULTS: Age and body mass index were different among groups; proteinuria, hypertension, diabetes and primary glomerulopathies significantly increased as CKD worsened. In the global assessment, CKD-EPI and Hoek gave the highest correlations with (99m)Tc-DTPA: rho=0.826, p<0.001 and rho=0.704, p<0.001, respectively. Most significant linear regressions obtained: CKD-EPI vs. (99m)Tc-DTPA, Hoek vs. (99m)Tc-DTPA and CKD-EPI vs. Hoek. However, important differences emerged when each group was analyzed separately. Best significant correlations obtained with (99m)Tc-DTPA: control group, creatinine clearance rho=0.421, p=0.012; G1, Crockoft-Gault rho=0.588, p=0.003; G2, CKD-EPI rho=0.462, p<0.05; G3, CKD-EPI rho=0.508, p<0.001; G4, Hoek rho=0.618, p<0.001; G5, CKD-EPI rho=0.604, p<0.001. CONCLUSIONS: At GFR <60 ml/min, CKD-EPI and Hoek equations appeared to best correlate with (99m)TcDTPA. In controls and at early stages of CKD, creatinine-based equations correlated better with (99m)Tc-DTPA, with CKD-EPI being the one with the best degree of agreement.

In hemodialysis, adiponectin, and pro-brain natriuretic peptide levels may be subjected to variations in body mass index.

Adiponectin exerts cardiovascular protective actions, although some studies have shown the opposite. In hemodialysis, obese subjects display lower mortality rates despite hypoadiponectinemia, while higher adiponectin concentrations correlate with an elevated cardiovascular risk in nonobese subjects. The aim of the study is to suggest that adiponectin level variations are associated with differences in the body mass index (BMI). The interplay between adiponectin and pro-brain natriuretic peptide (Pro-BNP) levels may vary according to body fat mass. Fifty-two chronic hemodialysis patients were divided into three groups. Group A, BMI<25 (n=20); Group B, BMI 25 to 30 (n=21), and Group C, BMI>30 (n=11). Diabetics: Group A 10%; Group B 6 29%; Group C 55%, P=0.027. Determinations: Adiponectin, Pro-BNP, insulin, insulin resistance (HOMA), troponin T, nutritional status, ultrafiltration rates, C-reactive protein (CRP), vascular accesses, and echocardiography. Group A: adiponectinemia positively and significantly correlated with Pro-BNP, CRP, and troponin T. As BMI increased, adiponectin, Pro-BNP, and malnutrition significantly decreased, while insulin, HOMA, and ultrafiltration rates significantly increased. Cardiac restriction was significantly higher in obese patients. In all groups, Pro-BNP and troponin T displayed a strong positive correlation. In low-BMI subjects, high Pro-BNP and adiponectin, low myocardial restriction, and worse nutritional status were prevalent. In obesity, hypoadiponectinemia stimulates cardiac remodeling, cardiac hypertrophy, and decreased stretching, rendering Pro-BNP levels low despite high ultrafiltration rates. Thus, adiponectin correlates inversely with BMI, probably playing different cardiovascular roles as BMI changes.

["Malnutrition-inflammation complex syndrome" in chronic hemodialysis]. / "Sindrome complejo de malnutricion e inflamacion" en la hemodialisis cronica.

Protein-energy wasting (PEW) and inflammation are usually common and concurrent conditions in maintenance dialysis patients and associated with poor prognosis. Low appetite and hypercatabolic states are common features. In dialysis patients, the former has been suggested to be secondary to inflammation; however, the evidence is not conclusive. Hence, the term malnutrition-inflammation complex syndrome (MICS) was coined to include this clinical entity, regardless the original causes. Possible causes of MICS include comorbid illnesses, oxidative stress, nutrient loss through dialysis, hyporexia, uremic toxins, decreased clearance of inflammatory cytokines, volume overload, increased blood phosphate and dialysis-related factors. MICS is believed to be the main cause of erythropoietin hypo-responsiveness, cardiovascular atherosclerotic disease, decreased quality of life, hospitalization and increased mortality in dialysis patients. Because MICS leads to a low body mass index, hypocholesterolemia, decrease in muscle mass, hypocreatininemia and hypohomocysteinemia, a "reverse epidemiology" phenomenon of cardiovascular risk factors can occur in dialysis patients. Therefore, obesity, hypercholesterolemia, and increased blood levels of creatinine and homocysteine, within certain limits, appear to be protective and paradoxically associated with a better outcome. There is no consensus about how to determine the degree of severity of MICS or how to manage it. Several diagnostic tools and treatment modalities are discussed in this paper. The correct management of MICS may diminish the cardiovascular disease, main cause of death in this population.

"Síndrome complejo de malnutrición e inflamación" en la hemodiálisis crónica / "Malnutrition-inflammation complex syndrome" in chronic hemodialysis

La malnutrición calórico-proteica y la inflamación suelen ser condiciones comunes y concurrentes en pacientes con hemodiálisis crónica, asociándose ambas a mal pronóstico. La hiporexia y el hipercatabolismo son características comunes y frecuentes. Se ha sugerido que la primera es secundaria a la inflamación. Si bien la evidencia no es concluyente, se ha acuñado el término síndrome complejo de malnutrición e inflamación para englobar esta situación clínica, independientemente de la causa originaria. Posibles causas de este síndrome incluyen diferentes comorbilidades, estrés oxidativo, pérdida de nutrientes a través de la diálisis, hiporexia, toxinas urémicas, elevación de citoquinas inflamatorias, sobrecarga de volumen, hiperfosfatemia, subdiálisis, entre otros. Se cree que en este síndrome la resistencia a la eritropoyetina, promueve la enfermedad aterosclerótica, disminuyendo la calidad de vida e incrementando el tiempo de internación y la mortalidad. Este síndrome origina un bajo índice de masa corporal, hipocolesterolemia, sarcopenia e hipocreatininemia, e hipohomocisteinemia, paradójicamente incrementando el riesgo cardiovascular. A este fenómeno se lo ha denominado "epidemiología reversa". Por lo tanto, y dentro de ciertos límites, la obesidad, la hipercolesterolemia, el incremento de la creatinina y de la homocisteína jugarían un rol protector, asociándose a mejor pronóstico. No existe consenso sobre cómo determinar la gravedad del síndrome complejo de malnutrición e inflamación, su abordaje y su tratamiento. En este trabajo se discuten varias herramientas diagnósticas y modalidades de tratamiento. El correcto manejo de este cuadro podría disminuir en última instancia la enfermedad cardiovascular, principal causa de óbito en esta población.

Protein-energy wasting (PEW) and inflammation are usually common and concurrent conditions in maintenance dialysis patients and associated with poor prognosis. Low appetite and hypercatabolic states are common features. In dialysis patients, the former has been suggested to be secondary to inflammation; however, the evidence is not conclusive. Hence, the term malnutrition-inflammation complex syndrome (MICS) was coined to include this clinical entity, regardless the original causes. Possible causes of MICS include comorbid illnesses, oxidative stress, nutrient loss through dialysis, hyporexia, uremic toxins, decreased clearance of inflammatory cytokines, volume overload, increased blood phosphate and dialysis-related factors. MICS is believed to be the main cause of erythropoietin hypo-responsiveness, cardiovascular atherosclerotic disease, decreased quality of life, hospitalization and increased mortality in dialysis patients. Because MICS leads to a low body mass index, hypocholesterolemia, decrease in muscle mass, hypocreatininemia and hypohomocysteinemia, a "reverse epidemiology" phenomenon of cardiovascular risk factors can occur in dialysis patients. Therefore, obesity, hypercholesterolemia, and increased blood levels of creatinine and homocysteine, within certain limits, appear to be protective and paradoxically associated with a better outcome. There is no consensus about how to determine the degree of severity of MICS or how to manage it. Several diagnostic tools and treatment modalities are discussed in this paper. The correct management of MICS may diminish the cardiovascular disease, main cause of death in this population.

Elevated pro-brain natriuretic peptide, troponin T and malnutrition inflammatory score in chronic hemodialysis patients with overt cardiovascular disease.

BACKGROUND: We assessed the relationship between pro-brain natriuretic peptide (pro-BNP), troponin T (TropT) and nutritional status. METHODS: A total of 48 chronic hemodialysis patients were grouped according to the presence [group A (GA); n = 24] or not [group B (GB)] of cardiovascular disease. RESULTS: Compared to GB subjects, GA subjects were older, had been on hemodialysis for a longer period and had higher prevalences of vascular grafts, hypertension and elevated C-reactive protein (CRP) [GA vs. GB: 1.1 (range 0.1-32.9) vs. 0.4 (0-28.1) mg/dl; p = 0.028], malnutrition inflammatory score (MIS) (GA vs. GB: 7.50 vs. 4.00; p = 0.001), pro-BNP [GA vs. GB: 6,760 (601-103,200) vs. 686 (75-83,700) pg/ml; p < 0.001] and TropT [GA vs. GB: 0.3650 (0.011-0.199) vs. 0.010 (0.0-0.290) ng/ml; p = 0.002]. Pro-BNP correlated with TropT (rho 0.539; p < 0.001), MIS (rho 0.502; p < 0.0001), homocysteine (rho 0.321; p = 0.13) and CRP (rho 0.511; p < 0.0001). Pro-BNP levels were lower in GB patients as the body mass index increased; the opposite occurred in GA. CONCLUSIONS: Patients with cardiovascular disease had elevated pro-BNP and TropT levels. In patients without cardiovascular disease, malnutrition and inflammation were associated with vascular prostheses, while pro-BNP was lower in obese patients.

H1N1 infection and the kidney in critically ill patients.

BACKGROUND: Acute renal failure due to viral infections is rare. We assessed the development of acute kidney injury (AKI) in critically compromised patients due to the H1N1 influenza virus. METHODS: All patients with a PCR -confirmed diagnosis of H1N1 influenza infection admitted to the intensive care unit between May and July 2009 were retrospectively studied. Thereafter, the risk factors associated with the development of acute renal injury, the requirements of acute hemodialysis (HD) and death were analyzed. RESULTS: Twenty-two patients with H1N1 pneumonia were included: age: 52.91 ± 18.89 years; gender: males 11 (50%); chronic airway disease: 9 (41%); oncohematological disease: 8 (36.7%); cardiovascular disease 5 (22.7%); chronic renal insufficiency: 4 (18.2%); obesity 3 (13.6%); concomitant pregnancy: 2 (9.1%); diabetes mellitus: 2 (9.1%); previous influenza A vaccination: 9 (41%). All patients received oseltamivir within 48 hours of presumed diagnosis. Seventeen patients (77.3%) developed fever initially. Six patients (27.3%) required noninvasive ventilation assistance and 15 patients (68.2%) received invasive ventilatory support. Mean days on mechanical respiratory assistance: 11 ± 10.35. Arterial partial pressure of oxygen/fraction of inspired oxygen ratio: 140.11 ± 83.03 mmHg. Inotropic drugs were administered to 15 patients (68.2%). Fourteen patients (63.6%) developed AKI. Mean highest creatinine levels: 2.74 ± 2.83 mg/dl. Four patients (18.2%) needed renal replacement therapy with a mean duration of 15 ± 12 days. Six patients (42.9%) recovered renal function. AKI was associated with pregnancy, immunosuppression, high APAC HE, SOFA and MURRA Y scores, and less time on mechanical ventilation assistance, hemodynamical instability and thrombocytopenia. HD requirements were associated with elevated SOFA scores (12.25 ± 1.75 vs. 6.22 ± 0.8, p<0.05), elevated creatine phosphokinase (933 ± 436.6 vs. 189.9 ± 79.3 U/L, p<0.05) and alanine transferase levels (843.3 ± 778.8 vs. 85.33 ± 17.4 U/L, p<0.05). Twelve patients died (54.6%), 10 of whom had acute renal failure (83.3%) and 3 had been on acute HD (25%). Mortality was associated with higher APACHE, SOFA and Murray scores, a higher oseltamivir dose (253.1 ± 25.8 vs. 183.8 ± 27.6 mg, p<0.05), lower oxygen inspired fraction/alveolar pressure ratio (99.3 ± 12.2 vs. 196.3 ± 33.9 mmHg, p<0.01), thrombocytopenia (88966 ± 22977 vs. 141200 ± 17282 mm3, p<0.05), hypoalbuminemia (1.82 ± 0.1 vs. 2.61 ± 0.2 g/dl, p<0.01), acute renal failure (10 vs. 4, p<0.05), oligoanuria (5 vs. 0, p<0.05) and lack of recovery of renal function (2 vs. 4, p<0.01). Three out of 4 (75%) of the hemodialyzed patients died. CONCLUSIONS: In the critically ill due to H1N1 pneumonia, renal insufficiency was a frequent complication, demanding renal replacement therapy in 18% of cases. The need for HD was associated with an elevated risk of death. Mortality was mainly associated with multiple organ failure, oligoanuria, acute renal injury and a lack of recovery of renal function.

[Acute kidney injury in severe sepsis]. / Injuria renal aguda en la sepsis grave.

Sepsis affects 40% of critically ill patients, with a reported mortality of approximately 30% in severe sepsis, raising to 75% when acute kidney injury ensues, which occurs in about 20-51% of cases. The present study consists on a one-year prospective, observational, longitudinal trial undergone in 80 severe septic patients to determine the risk of development of acute kidney injury and its relationship with mortality; the association of the clinical course and blood parameter variations with mortality; the severe sepsis mortality rate; an eventual correlation between death and septic focus, and to assess mortality predictibility based on initial creatinine levels and final variations. Two groups were defined: Dead (n=25) and Not-dead (n=55). According to creatinine on admission, 39 subjects presented with normal creatinine levels (10 deaths) and 41 presented elevated creatinine measurements (15 deaths); regarding final creatinine levels, 48 presented normal levels and 7 patients died, while 32 developed acute kidney injury, with 18 deaths. Of the total of 25 deaths, 72% presented renal injury. Seven alive patients and 2 deceased patients required hemodialysis. The most frequent primary septic focus was the airway (26.4%). The development of kidney injury is a high predictor of mortality in sepsis, independent of initial serum creatinine levels. Older patients, hypertension, a higher APACHE score, a more severe degree of anemia, hypoalbuminemia, hyperphosphatemia and hyperkalemia were associated with a higher mortality rate. The global mortality was: 31.3%. The failure to identify the primary septic focus was associated with higher mortality. The respiratory focus was related with a higher risk to require hemodialysis.

Injuria renal aguda en la sepsis grave / Acute kidney injury in severe sepsis

La sepsis afecta al 40% de los pacientes críticos, siendo su mortalidad de aproximadamente un 30% en el caso de la sepsis grave, y de 75% con injuria renal aguda, la cual sucede en el 20-51% de los casos. Se realizó un estudio prospectivo, observacional, longitudinal, en 80 pacientes sépticos graves en el lapso de 1 año para determinar el desarrollo de injuria renal aguda y su relación con la mortalidad; correlacionar antecedentes clínicos y variaciones del laboratorio con la mortalidad; determinar la tasa de mortalidad de la sepsis grave; relacionar óbito y foco séptico primario; evaluar la predictibilidad de mortalidad según niveles de creatinina de ingreso y sus variaciones finales. Se definieron dos grupos: Obito (n = 25) y No-óbito (n = 55). Analizados según la creatinina de ingreso, 39 tenían valores normales de creatinina (10 óbitos) y 41 la presentaban elevada (15 óbitos); según la creatinina de egreso, 48 presentaron creatinina normal y fallecieron 7, mientras que 32 tenían daño renal agudo, de los cuales 18 fallecieron. De los 25 pacientes fallecidos, el 72% presentaron daño renal. De éstos, 7 pacientes vivos y 2 fallecidos requirieron hemodiálisis. El foco primario más frecuente fue el respiratorio (26.4%). El desarrollo de daño renal es un alto predictor de mortalidad en la sepsis, independientemente de los valores iniciales de creatinina. Edad más avanzada, hipertensión arterial, score APACHE más elevado, anemia más grave, hipoalbuminemia, hiperfosfatemia e hiperkalemia se asociaron a mayor mortalidad. La mortalidad global fue 31.3%. La imposibilidad de identificar el foco séptico primario se asoció a mayor mortalidad. El foco respiratorio se relacionó a mayor riesgo de requerir hemodiálisis.

Sepsis affects 40% of critically ill patients, with a reported mortality of approximately 30% in severe sepsis, raising to 75% when acute kidney injury ensues, which occurs in about 20-51% of cases. The present study consists on a one-year prospective, observational, longitudinal trial undergone in 80 severe septic patients to determine the risk of development of acute kidney injury and its relationship with mortality; the association of the clinical course and blood parameter variations with mortality; the severe sepsis mortality rate; an eventual correlation between death and septic focus, and to assess mortality predictibility based on initial creatinine levels and final variations. Two groups were defined: Dead (n=25) and Not-dead (n=55). According to creatinine on admission, 39 subjects presented with normal creatinine levels (10 deaths) and 41 presented elevated creatinine measurements (15 deaths); regarding final creatinine levels, 48 presented normal levels and 7 patients died, while 32 developed acute kidney injury, with 18 deaths. Of the total of 25 deaths, 72% presented renal injury. Seven alive patients and 2 deceased patients required hemodialysis. The most frequent primary septic focus was the airway (26.4%). The development of kidney injury is a high predictor of mortality in sepsis, independent of initial serum creatinine levels. Older patients, hypertension, a higher APACHE score, a more severe degree of anemia, hypoalbuminemia, hyperphosphatemia and hyperkalemia were associated with a higher mortality rate. The global mortality was: 31.3%. The failure to identify the primary septic focus was associated with higher mortality. The respiratory focus was related with a higher risk to require hemodialysis.