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Background: Critically ill patients with COVID-19 may develop multiple organ dysfunction syndrome, including acute kidney injury (AKI). We report the incidence, risk factors, associations, and outcomes of AKI and renal replacement therapy (RRT) in critically ill COVID-19 patients. Methods: We performed a retrospective cohort study of adult patients with COVID-19 diagnosis admitted to the intensive care unit (ICU) between March 2020 and May 2020. Multivariable logistic regression analysis was applied to identify risk factors for the development of AKI and use of RRT. The primary outcome was 60-day mortality after ICU admission. Results: 101 (50.2%) patients developed AKI (72% on the first day of invasive mechanical ventilation [IMV]), and thirty-four (17%) required RRT. Risk factors for AKI included higher baseline Cr (OR 2.50 [1.33–4.69], p = 0.005), diuretic use (OR 4.14 [1.27–13.49], p = 0.019), and IMV (OR 7.60 [1.37–42.05], p = 0.020). A higher C-reactive protein level was an additional risk factor for RRT (OR 2.12 [1.16–4.33], p = 0.023). Overall 60-day mortality was 14.4% {23.8% (n = 24) in the AKI group versus 5% (n = 5) in the non-AKI group (HR 2.79 [1.04–7.49], p = 0.040); and 35.3% (n = 12) in the RRT group versus 10.2% (n = 17) in the non-RRT group, respectively (HR 2.21 [1.01–4.85], p = 0.047)}. Conclusions: AKI was common among critically ill COVID-19 patients and occurred early in association with IMV. One in 6 AKI patients received RRT and 1 in 3 patients treated with RRT died in hospital. These findings provide important prognostic information for clinicians caring for these patients.

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 p p 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.

Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p

Background/Aims:Continuous renal replacement therapies (CRRT) are initially employed in patients with acute kidney injury (AKI) in ICU setting. After the period of serious illness, hemodialysis is usually used as a mode of transition from CRRT. Intermittent hemodiafiltration (HDF) is not commonly applied in this scenario.Objectives:To evaluate the feasibility of using HDF as transition therapy after CVVHDF in critically patients with AKI.Methods:An observational and prospective pilot study was conducted in ICU patients with dialysis-requiring AKI. Patients were initially treated with CVVHDF and, after medical improvement, those who still needed renal replacement therapy were switched to HDF treatment.Results:Ten Patients underwent 53 HDF sessions (mean of 5.3 sessions/patient). The main cause of renal dysfunction was sepsis ( N = 7; 70%). The APACHE II mean score was 27.6 ± 6.9. During HDF treatment, the urea reduction ratio was 64.5 ± 7.5%, for β-2 microglobulin serum levels the percentage of decrease was 42.0 ± 7.8%, and for Cystatin C was 36.2 ± 6.9%. Five episodes of arterial hypotension occurred (9.4% of sessions). There were 20 episodes of electrolytic disturbance (37.7% of sessions), mainly hypophosphatemia. No pyrogenic or suggestive episode of bacteremia was observed.Conclusion:Hemodiafiltration was safe and efficient to treat critically ill patients with acute kidney injury during the transition phase from continuous to intermittent dialysis modality. Special attention should be paid regarding the occurrence of electrolytic disturbance, mainly hypophosphatemia.

Resumo O envelhecimento da população e o crescimento no número de pessoas expostas aos cuidados do sistema de saúde suplementar no Brasil aumentam a preocupação dos gestores públicos e privados com o crescimento dos custos da área de saúde. Neste trabalho foram analisados os custos por gênero, por tipo de gasto médico e por faixa etária de uma operadora de autogestão brasileira no período entre 2007 a 2013. Tal operadora é de grande interesse pois além de retratar uma condição única de restrição de crescimento de receita, também replica o perfil demográfico esperado para o Brasil no ano de 2050, quando aproximadamente um terço da sua população estará acima dos 60 anos. As análises corroboram a literatura vigente uma vez que demonstram um aumento na utilização do plano pelos mais idosos, e apontam para uma diferença nas taxas de internação entre os gêneros. O estudo também mostra um expressivo aumento no tempo médio de permanência nos hospitais e mostra crescimento dos gastos médicos muito acima da inflação, com destaque para materiais e medicamentos. No geral, esperamos que o presente estudo auxilie estudiosos e interessados em futuras comparações dos gastos médicos por idade e gênero e que colabore na sustentabilidade das operadoras de saúde no Brasil. Abstract Brazil’s aging population and the rising number of people reliant upon the country’s supplementary healthcare system have elicited the concern of public and private managers regarding the increase in healthcare costs. In this paper, the costs per gender, per type of medical expenses and per age group of a major Brazilian self-managed healthcare provider between 2007 and 2013 were analyzed. This healthcare provider is of interest because, besides portraying a single condition of revenue growth restricted to the existing contributors, it also replicates the demographic profile expected for Brazil in 2050, when approximately one-third of its population will be over 60 years of age. The analyses confirm the current literature as they show an increase in healthcare plan usage by the elderly and the difference between admission rates by gender. They also reveal an increase in average length of stay in hospital and the increase in medical costs far above inflation, especially for materials and medicines. It is hoped that this study will help scholars and others interested in comparisons of medical expense trends, especially by age and sex, and that it encourages further collaboration on the sustainability of health insurance providers in Brazil.

Background The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data. Aim The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil. Methods This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status. Results The mean standardized stroke mortality in São Paulo decreased from 66 to 46-7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo. Conclusions In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28-5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

Anemia is a common feature in critically ill patients. Serum soluble-Fas (sFas) levels are associated with anemia in chronic kidney disease. It is possible that sFas levels are also associated with anemia in acute kidney injury (AKI) patients. The study aims to investigate the relationship between serum levels of sFas, erythropoietin (Epo), inflammatory cytokines, and hemoglobin (Hb) concentration in critically ill patients with AKI. We studied 72 critically ill patients with AKI (AKI group; n = 53) or without AKI (non-AKI group; n = 19), and 18 healthy volunteers. Serum sFas, Epo, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-10, iron status, and Hb concentration were analyzed in all groups. We also investigated the correlation between these variables in the AKI group. Critically ill patients (AKI and non-AKI groups) had higher serum levels of Epo than healthy volunteers. Hb concentration was lower in the AKI group than in the other groups. Serum sFas, IL-6, TNF-α, and ferritin levels were higher in the AKI group. Hb concentration correlated negatively with serum IL-6 (r = -0.37, P = 0.008), sFas (r = -0.35, P = 0.01), and Epo (r = -0.27, P = 0.04), while serum sFas correlated positively with iron levels (r = 0.36, P = 0.008) and IL-6 (r = 0.28, P = 0.04) in the AKI group. In multivariate analysis, after adjusting for markers of inflammation and iron stores, only serum sFas levels (P = 0.03) correlated negatively with Hb concentration in the AKI group. Serum Epo and inflammatory cytokine levels are elevated in critically ill patients with or without AKI. Serum levels of sFas are elevated and independently associated with anemia in critically ill patients with AKI.

Purpose of the Study: Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy worldwide. Its incidence increases with age and about 40% of cases occur in patients over 70 years. Herein, we describe a case of a frail elderly patient with renal insufficiency and DLBCL treated with R-mini-CHOP. Case Report: A 77-year-old man on maintenance hemodialysis started experiencing persistent fatigue. He was diagnosed with a large mass on the left lobe of the lung. Biopsy demonstrated a DLBCL, CD20 positive. The patient was assigned clinical stage IIBX, with a high age-adjusted international prognosis index. A proper geriatric assessment revealed a frail patient. Thus, an adapted chemotherapy regimen was proposed which consisted of R-mini-CHOP every 21 days, with a reduction of 10% in the doses of doxorubicin and cyclophosphamide. During the treatment, the patient went through regular dialysis sessions, 3 times per week, with an extra session performed 12 h after each chemotherapy administration. The patient experienced no adverse events or grade 3/4 toxicities. After 6 cycles of R-mini-CHOP, the patient achieved unconfirmed complete remission, and consolidation radiotherapy was performed. At the last follow-up, he was still in unconfirmed complete remission, with a progression-free survival of 11.3 months. Conclusions: R-mini-CHOP represented a reasonable treatment option for this patient with renal failure. The oncogeriatric approach led to a successful management of this frail patient, highlighting that an adapted plan of care is a key issue to improve the outcomes of elderly cancer patients.

Background Several factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT. Results This was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55–76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and SOFA score at ICU admission was 61 (50–74) and 10 (7–12), respectively. The dialysis dose delivered was 33.2 (28.9–38.7) ml/kg/h. The median time between ICU admission and CVVHDF initiation was 2 (1–4) days. The median cumulative fluid balance during the CVVHDF period was -1838 (-5735 +2993) ml. The mortality rate up to90 days was 58%. The independent mortality risk factors in propensity score model were: chronic obstructive pulmonary disease (OR = 3.44[1.14–10.4; p = 0.028]), hematologic malignancy (OR = 5.14[1.66–15.95; p = 0.005]), oliguria (OR = 2.36[1.15–4.9; p = 0.02]), positive daily fluid balance during CVVHDF (OR = 4.55[2.75–13.1; p

Background Many controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI. Methods We conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge. Results In 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999–2003, 2004–2008, and 2009–2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p

Objective: The aim of the present study was to obtain information about deaths due to sepsis in São Paulo from 2004 to 2009 and their relationship with geographical distribution. Methods: Causes of death, both main and secondary, were defined according to the codes of the International Classification of Disease version 10 (ICD-10) contained in the database. Sepsis, septic shock, multiple organ failure, pneumonia, urinary tract infection, peritonitis and other intraabdominal infections, skin and soft tissue infections (including surgical wound infection) and meningitis were considered as immediate cause of death or as the condition leading to the immediate cause of death related or associated to sepsis. Results: In the analyzed period, there was a 15.3% increase in the absolute number of deaths from sepsis in São Paulo. The mean number of deaths during this period was 28,472 ± 1566. Most deaths due to sepsis and sepsis-related diseases over the studied period occurred in a hospital or health care facility, showing that most of the patients received medical care during the event that led to death. We observed a significant concentration of deaths in the most populous regions, tending more toward the center of the city. Conclusions: Georeferencing data from death certificates or other sources can be a powerful tool to uncover regional epidemiological differences between populations. Our study revealed an even distribution of sepsis all over the inhabited areas of São Paulo. Keywords: Sepsis, Mortality, Infection, Georeferencing

Background and Purpose— Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. Methods— Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. Results— We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8–32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2–26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score ≤2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. Conclusions— The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.

Objective: Reuse of hemodialysis filters is a standard practice and the sterilizing chemical most often employed is peracetic acid. Before starting the dialysis session, filters and lines are checked for residual levels of peracetic acid by means of a non-quantitative colorimetric test that is visually interpreted. The objective of this study was to investigate a new quantitative spectrophotometric test for detection of peracetic acid residues. Methods: Peracetic acid solutions were prepared in concentrations ranging from 0.01 to 10 ppm. A reagent (potassium-titanium oxide + sulfuric acid) was added to each sample in proportions varying from 0.08 to 2.00 drops/mL of solution. Optical densities were determined in a spectrophotometer using a 405-nm filter and subjected to visual qualitative test by different observers. Results: A relation between peroxide concentrations and respective optical densities was observed and it was linear with R2 > 0.90 for all reagent/substrate proportions. The peak optical densities were obtained with the reagent/substrate ratio of 0.33 drops/mL, which was later standardized for all further experiments. Both qualitative and quantitative tests yielded a specificity of 100%. The quantitative test was more sensitive than the qualitative test and resulted in higher positive and negative predictive values. There was a difference between observers in the qualitative test and some samples with significant amounts of peroxide were not detected. Conclusion: A quantitative spectrophotometric test may improve detection of residues of peracetic acid when compared to the standard visual qualitative test. This innovation may contribute to the development of safer standards for reuse of hemodialysis filters. RESUMO Objetivo: A reutilização de filtros de hemodiálise é uma prática disseminada e a substância química esterilizante mais empregada é o ácido peracético. Antes de iniciar a sessão de diálise, os filtros e as linhas são verificados em relação a níveis residuais de ácido peracético por meio de teste colorimétrico não quantitativo, com interpretação visual. O objetivo deste trabalho foi investigar um novo teste espectrofotométrico quantitativo para detecção de resíduos de ácido peracético. Métodos: As soluções de ácido peracético foram preparadas em concentrações que variam de 0,01 a 10 ppm. O reagente (óxido de potássio-titânio + ácido sulfúrico) foi acrescentado a cada amostra em proporções que variaram de 0,08 a 2,00 gotas/mL de solução. As densidades ópticas foram determinadas em um espectrofotômetro com filtro de 405 nm e submetidas a um teste visual qualitativo por diferentes observadores. Resultados: Observou-se a relação linear entre as concentrações de peróxido e as respectivas densidades ópticas com R2 > 0,90 para todas as proporções de reagente/substrato. As maiores densidades ópticas foram obtidas com a proporção reagente/substrato de 0,33 gotas/mL, que foi padronizada para todos os experimentos posteriores. Os testes qualitativos e quantitativos apresentaram especificidade de 100%. O teste quantitativo foi mais sensível do que o qualitativo e apresentou maiores valores preditivos positivos e negativos. Houve uma diferença entre os observadores no teste qualitativo e algumas amostras com quantidade significativa de peróxido não foram detectadas. Conclusão: O teste espectrofotométrico quantitativo pode melhorar a detecção de resíduos de ácido peracético em comparação ao teste visual qualitativo padrão. Essa inovação pode contribuir para o desenvolvimento de padrões mais seguros na reutilização de filtros de hemodiálise.

Metabolic acid–base disorders, especially metabolic acidosis, are common in critically ill patients who require renal replacement therapy. Continuous veno-venous hemodiafiltration (CVVHDF) achieves profound changes in acid–base status, but metabolic acidosis can remain unchanged or even deteriorate in some patients. The objective of this study is to understand the changes of acid–base variables in critically ill patients with septic associated acute kidney injury (SA-AKI) during CVVHDF and to determine how they relate to clinical outcome. Observational study of 200 subjects with SA-AKI treated with CVVHDF for at least 72 hours. Arterial blood gases and electrolytes and other relevant acid–base variables were analyzed using quantitative acid–base chemistry. Survivors and nonsurvivors had similar demographic characteristics and acid–base variables on day one of CVVHDF. However, during the next 48 hours, the resolution of acidosis was significantly different between the 2 groups, with an area under the ROC curve for standard base excess (SBE) and mortality of 0.62 (0.54–0.70), this was better than APACHE II score prediction power. Quantitative physicochemical analysis revealed that the majority of the change in SBE was due to changes in Cl and Na concentrations. Survivors of SA-AKI treated with CVVHDF recover hyperchloremic metabolic acidosis more rapidly than nonsurvivors. Further study is needed to determine if survival can be improved by measures to correct acidosis more rapidly. Abbreviations: AG = anion gap, APACHE = Acute Physiology and Chronic Health Evaluation, CVVHDF = continuous venovenous hemodiafiltration, ROC = receiver operator characteristics, SA-AKI = sepsis associated acute kidney injury, SIDa, SIDe = strong ion difference, SIG = strong ion gap.

Brazil's aging population and the rising number of people reliant upon the country's supplementary healthcare system have elicited the concern of public and private managers regarding the increase in healthcare costs. In this paper, the costs per gender, per type of medical expenses and per age group of a major Brazilian self-managed healthcare provider between 2007 and 2013 were analyzed. This healthcare provider is of interest because, besides portraying a single condition of revenue growth restricted to the existing contributors, it also replicates the demographic profile expected for Brazil in 2050, when approximately one-third of its population will be over 60 years of age. The analyses confirm the current literature as they show an increase in healthcare plan usage by the elderly and the difference between admission rates by gender. They also reveal an increase in average length of stay in hospital and the increase in medical costs far above inflation, especially for materials and medicines. It is hoped that this study will help scholars and others interested in comparisons of medical expense trends, especially by age and sex, and that it encourages further collaboration on the sustainability of health insurance providers in Brazil.

Background: Several studies report that certain factors such as socioeconomic status, living alone or being alone at onset of symptoms play a role in late arrival at hospitals thereby decreasing the ultimate success of medical interventions for stroke patients. There is little research about the influence of educational level upon early arrival in patients with acute stroke. We hypothesized that higher educational level is associated with early arrivals in patients with acute stroke. Methods: We conducted a prospective cohort study to evaluate consecutive patients admitted with a new stroke in 19 hospitals in Fortaleza, Brazil, from April 2009 to April 2012. Educational attainment was categorized into 5 levels: no school attendance, less than secondary school graduation, secondary school graduation, bachelor's degree and master's or doctorate degree. Multiple logistic regressions were used to investigate the influence of epidemiologic and clinical data on the frequency of early arrival (defined as hospital arrival within 4.5 hours from symptoms onset). Results: We evaluated 4679 patients (48% males, mean age: 67.67± 14.48). Ischemic stroke was the most frequent subtype (74.9%) followed by intraparenchymal hemorrhage (14.5%), subarachnoid hemorrhage (5.1%), transient ischemic attack (2.8%), and undetermined stroke (2.7%). A total of 1128 (24.1%) patients arrived within 4.5 hours from symptoms onset. Higher educational level was a predictor of early hospital arrival (p= 0.01). Other univariate predictors of early hospital arrival included having a decreased level of consciousness at presentation OR 1.36 [1.17-1.58], p Conclusions: Educational level is associated with early hospital arrival in patients with acute stroke. The association between educational level and early hospital arrival seems to be mediated by activation of the EMS.

A few studies have performed to evaluate the temperature variation influences over on the stroke rates in Brazil. METHOD: 176 medical records of inpatients were analyzed after having had a stroke between 2004 and 2006 at Hospital Israelita Albert Einstein. The temperature preceding the occurrence of the symptoms was recorded, as well as the temperature 6, 12 and 24 hours before the symptoms in 6 different weather substations, closest to their houses in São Paulo. RESULTS: Strokes occurred more frequently after a variation of 3ºC between 6 and 24 hours before the symptoms. There were most hospitalizations between 23-24ºC. CONCLUSION: Incidence of stroke on these patients was increased after a variation of 3º Celsius within 24 hours before the ictus. The temperature variations could be an important factor in the occurrence of strokes in this population. Poucos trabalhos têm estudado a variação sazonal e de temperatura em acidente vascular cerebral (AVC) no Brasil. MÉTODO: Foram analisados 176 registros de pacientes com AVC no Hospital Israelita Albert Einstein entre 2004 e 2006. Foram anotadas as temperaturas ambientes do início dos sintomas, bem como as temperaturas de 6, 12 e 24 horas antes dos sintomas, em 6 diferentes subestações metereológicas mais próximas da casa do paciente em São Paulo. RESULTADOS: Houve aumento da incidência do AVC com a variação de 3ºC entre 6 e 24 horas antes do início dos sintomas. Houve um pico de internação entre 23-24ºC. CONCLUSÃO: A variação de temperatura de 3ºC nas 24 horas que antecederam o início dos sintomas pode ter sido um fator importante na ocorrência do AVC.

A severe disadvantage of administration of recombinant human erythropoietin to hemodialysis patients has been reported. A significant correlation has been shown with hemoglobin values determined online by use of the blood volume monitor (BVM) and by laboratory measurement. Online hemoglobin and hematocrit were measured by use of the BVM during hemodialysis session. Data were analyzed by t test and statistical significance was defined as a P of0.05. Increases in the mean values of hemoglobin and hematocrit from 11.6 +/- 1.9 to 13.9 +/- 2.4 g/dL (17.4 +/- 7.1%, P = 0.02) and from 34.4 +/- 6.8 to 42 +/- 8.3% (20.6 +/- 8.8%, P = 0.022), respectively, were observed from the beginning to the end of dialysis. We hypothesize that a new strategy for adjusting erythropoietin dose may be based on hemoglobin and hematocrit values evaluated at the end of hemodialysis, when patients are no longer hypervolemic. Inadvertent high levels of hemoglobin could be one explanation why patients present higher rates of cardiovascular and access-related events, especially when monitored online by use of the BVM to achieve the dry weight.

In cystic fibrosis, the absence of functional CFTR results in thick mucous secretions in the lung and intestines, as well as pancreatic deficiency. Although expressed at high levels in the kidney, mutations in CFTR result in little or no apparent kidney dysfunction. In an effort to understand this phenomenon, we analyzed Delta F508 CFTR maturation and function in kidney cells under conditions that are common to the kidney, namely osmotic stress. Kidney cells were grown in culture and adapted to 250 mM NaCl and 250 mM urea. High performance liquid chromatography analysis of lysates from kidney cells adapted to these conditions identified an increase in the cellular osmolytes glycerophosphorylcholine, myo-inositol, sorbitol, and taurine. In contrast to isoosmotic conditions, hyperosmotic stress led to the proper folding and processing of Delta F508 CFTR. Furthermore, three of the cellular osmolytes, when added individually to cells, proved effective in promoting the proper folding and processing of the Delta F508 CFTR protein in both epithelial and fibroblast cells. Whole-cell patch clamping of osmolyte-treated cells showed that Delta F508 CFTR had trafficked to the plasma membrane and was activated by forskolin. Encouraged by these findings, we looked at other features common to the kidney that may impact Delta F508 maturation and function. Interestingly, a small molecule, S-nitrosoglutathione, which is a substrate for gamma glutamyltranspeptidase, an abundant enzyme in the kidney, likewise promoted Delta F508 CFTR maturation and function. S-Nitrosoglutathione-corrected Delta F508 CFTR exhibited a shorter half-life as compared with wild type CFTR. These results demonstrate the feasibility of a small molecule approach as a therapeutic treatment in promoting Delta F508 CFTR maturation and function and suggest that an additional treatment may be required to stabilize Delta F508 CFTR protein once present at the plasma membrane. Finally, our observations may help to explain why Delta F508 homozygous patients do not present with kidney dysfunction.

IntroductionCritically ill patients with acute kidney injury (AKI) present high mortality rates. The magnitude of inflammatory response could determine the prognosis of such patients. Continuous renal replacement therapy (CRRT) may play an important role in removing inflammatory mediators in patients with AKI.AimTo investigate whether the magnitude of inflammatory mediator’s removal is associated with mortality among critically ill patients on CVVHDF, a CRRT modality.MethodsThis study consisted of 64 critically ill patients requiring CVVHDF. Plasma levels of C3a, TNF-α, IL-10, IL-6, IL-1β, sTNFRI and sTNFRII were determined by enzyme-linked immunosorbent assay (ELISA) at the beginning of CVVHDF and after 24h (outlet). Clearance of cytokines during the first 24h of CVVHDF was calculated. Clinical and laboratory data were acquired from patient’s records data.ResultsMean age of patients requiring CVVHDF was 63years, 67.2% were men and 87.3% were Caucasian. Thirty-five (35) patients (54.7%) died. Comparing non-survivors with the group of survivors we observed higher incidence of sepsis (68.6 versus 37.9%, p2.93)) we found that those patients with higher TNF-α removal by RRT (ITR3) had a better survival. Multivariable analysis showed that lower clearance of TNF-α remained independently associated with high mortality after adjustment for sex, age, use of vasoactive drugs, APACHE II score sepsis, creatinine and lactate before CVVHDF (HR: 0.179, 95% IC: 0.049–0.661, p

OBJETIVO: Investigar a relação entre a transfusão de hemácias e os níveis séricos de Fas solúvel, eritropoietina e citocinas inflamatórias em pacientes gravemente enfermos, com e sem insuficiência renal aguda. MÉTODOS: Os seguintes grupos foram estudados: pacientes gravemente enfermos com insuficiência renal aguda (n=30) e sem insuficiência renal aguda (n=13), pacientes portadores de doença renal crônica terminal em hemodiálise (n=25) e indivíduos saudáveis (n=21). Os níveis séricos de Fas solúvel, eritropoietina, interleucina 6, interleucina 10 e ferro, além da concentração de hemoglobina e de hematócrito, foram analisados em todos os grupos. A associação entre tais variáveis foram estudadas nos pacientes gravemente enfermos. RESULTADOS: Os níveis séricos de eritropoietina mostraram-se mais elevados nos pacientes gravemente enfermos do que nos dos demais grupos. Concentrações mais baixas de hemoglobina foram documentadas nos pacientes com insuficiência renal aguda em relação aos demais. Níveis séricos mais elevados de Fas solúvel foram observados nos pacientes com insuficiência renal aguda e doença renal crônica terminal. Pacientes gravemente enfermos transfundidos apresentaram níveis séricos mais elevados de Fas solúvel (5.906±2.047 e 1.920±1.060; p

Patients diagnosed with multiple myeloma are more susceptible to infections which are the major causes of morbidity and mortality associated to this disease. The main infectious agents involved are Gram-positive bacteria. However, after chemotherapy an increase in the incidence of Gram-negative strains is observed. These bacteria are also responsible for most cases of urinary tract infections. Here is reported a rare case in a 73-year-old man with multiple myeloma who developed endocarditis due to pseudomonas.

A incidência de lesão renal aguda (LRA) em Unidade de Terapia Intensiva (UTI) é de 5 a 25% e está associada a elevada mortalidade. A intensidade da resposta inflamatória reflete a magnitude do processo fisiopatológico da LRA e parece estar relacionada a um aumento na gravidade desses pacientes. Os objetivos desse estudo foram: a) avaliar o nível de mediadores inflamatórios em pacientes críticos com LRA; b) avaliar o perfil desses mediadores em conjunto com parâmetros clínicos e laboratoriais, comparando pacientes críticos com e sem LRA; c) avaliar o impacto desses mediadores na sobrevida dos pacientes. Foi realizado um estudo observacional, prospectivo, do tipo caso-controle, em quatro UTIs do HCFMUSP no período entre novembro de 2006 e março de 2008. LRA foi definida segundo a classificação de RIFLE. Foram realizadas dosagens séricas dos seguintes marcadores: fator de necrose tumoral- (TNF-), receptor solúvel do tipo 1 do TNF- (sTNFR1), interleucina (IL)-6, IL-8, IL-10, leptina e proteína C-reativa (PCR). Os mediadores foram dosados no dia do diagnóstico de LRA (D1), dois dias após o D1, denominado D3 e quatro dias após o D1, denominado D5. A população final de análise foi composta por 52 pacientes no grupo caso e 9 pacientes no grupo controle. No D1, os níveis séricos de IL-6 estavam significativamente mais elevados nos pacientes com LRA: 61,68 (14,30 389,11) pg/mL versus 13,21 (1,50 47,06) pg/mL (p=0,032). Da mesma forma, os níveis de TNF-: 3,22 (0,57 xvi 15,9) pg/mL nos pacientes com LRA versus 0,32 (0,32 0,34) pg/mL nos controles (p

Introdução: Pacientes com câncer frequentemente apresentam distúrbios de coagulação, que podem se manifestar clinicamente na forma de trombose ou simples alterações nos exames de hemostasia. A injúria renal aguda (IRA) é comum em pacientes oncológicos e pode ocorrer como consequência do próprio câncer; do tratamento; ou sepse secundária à imunossupressão causada pela quimioterapia. A IRA é encontrada em até 67% dos pacientes em UTI e está associada à alta mortalidade, além de resultar em maior custo e tempo na internação hospitalar. O sangramento causado pela uremia é uma complicação que pode ocorrer em pacientes com falência renal. O efeito da interação da IRA na coagulação dos pacientes com câncer ainda não está elucidado. Objetivo: Estudar o perfil de coagulação dos pacientes oncológicos com sepse grave ou choque séptico e avaliar o efeito da IRA na coagulação destes pacientes. Critérios de inclusão: pacientes maiores de 18 anos, portadores de tumores sólidos ou hematológicos, admitidos na UTI do ICESP com diagnóstico de sepse grave ou choque séptico. Critérios de exclusão: pacientes com insuficiência renal crônica em programa regular de diálise e pacientes com coagulopatia prévia ou história familiar de coagulopatia. Métodos: Foram estudados pacientes admitidos no período de agosto de 2012 a janeiro de 2014. A coleta de exames de sangue foi realizada no momento da admissão na UTI e ao apresentar IRA, pelo critério AKIN. O perfil de coagulação estudado compreendeu: TP, TTPa, D-dímero, fibrinogênio, fator VIII, avaliação de adesão e agregação plaquetária com Impact-R®, tromboelastografia e avaliação da geração de trombina. Dados clínicos e epidemiológicos foram obtidos a partir dos prontuários. Resultados: foram incluídos 144 pacientes na análise final. As características foram semelhantes nos grupos em relação à idade, IMC, sexo, e comorbidades tais como, hipertensão arterial e diabetes mellitus. Os testes convencionais de coagulação (TP, TT, TTPa) estavam alterados no grupo com IRA. Entretanto, a análise da coagulação pela tromboelastografia não demonstrou diferença entre os grupos com IRA comparados com o grupo que não apresentou IRA. A análise da função plaquetária pelo Impact-R® revelou que a uremia não piorou a adesão e agregação plaquetária. Observou-se que houve menor geração de trombina e nível de Ddímero mais elevado no grupo com IRA AKIN3. Regressão logística multivariada demonstrou que a necessidade de ventilação mecânica, nível de proteína C reativa mais elevada, e IRA estavam associados à maior mortalidade. Maior geração de trombina estava associada à menor mortalidade. Conclusão: a IRA em pacientes críticos oncológicos com sepse ou choque séptico está associada ao alargamento dos testes de coagulação convencionais (TP, TT, TTPa), devido à deficiência de alguns fatores de coagulação. Entretanto, a tromboelastografia, que analisa a hemostasia global do paciente, apresentou resultado normal devido à hiperativação da função plaquetária. O acúmulo de toxinas urêmicas, devido à injúria renal aguda, não levou à piora da função plaquetária. Pelo contrário, houve até um aumento na agregação e adesão plaquetária nos pacientes oncológicos. Introduction: Patients with cancer often have coagulation disorders, which may manifest clinically as thrombosis or simple changes in hemostasis tests. Acute kidney injury (AKI) is frequent in cancer patients and may occur as a consequence of the cancer itself or due to the treatment or sepsis secondary to immunosuppression caused by chemotherapy. AKI is found in up to 67% of ICU (Intensive Care Unit) patients, associated with high mortality, and resulting in increased cost and stay in the hospital. Bleeding caused by uremia is a complication that can occur in patients with renal failure. The effect of the interaction between AKI and coagulation in cancer patients has not been yet elucidated. Objectives: To analyse the coagulation profile in cancer patients with severe sepsis or septic shock and evaluate the effect of AKI in the coagulation profile. Inclusion criteria: patients older than 18 years old with solid or hematological tumors admitted to the ICU, diagnosed with severe sepsis or septic shock. Exclusion criteria: patients with chronic renal failure undergoing regular dialysis program and patients with previous coagulopathy or family history of coagulopathy. Methods: We studied patients admitted to the ICU between August 2012 and January 2014. The collection of blood samples was performed at the time of ICU admission and at the time of AKI, according to the AKIN criteria. The coagulation profile included: PT, aPTT, D-dimer, fibrinogen, factor VIII, platelet adhesion and aggregation, thromboelastography and evaluation of thrombin generation. Clinical and epidemiological data were obtained from medical records. Results: A total of 144 patients was included in the final analysis. The following characteristics were similar between groups: age, BMI, gender, and comorbidities such as hypertension and diabetes mellitus. Conventional coagulation tests results (PT, TT, aPTT) were altered in the group with AKI. However, analysis of coagulation by thromboelastography showed no difference between groups with AKI compared with the group without AKI. Platelet function analysis by Impact-R® revealed that uremia has not worsened platelet adhesion and aggregation. It was observed that there was less thrombin generation and higher D-dimer level in the AKIN3 group. Multivariate logistic regression showed that the need for mechanical ventilation, higher level of C-reactive protein, and AKI were associated with higher mortality. Higher thrombin generation was associated with lower mortality. Conclusions: AKI in critically ill cancer patients with sepsis or septic shock is associated with abnormalities of conventional coagulation tests (PT, TT, aPTT) due to some coagulation factors deficiency. However, thromboelastography which analyzes the global hemostasis presented a normal result, probably due to platelet function hyperactivation. Furthermore, the accumulation of uremic toxins due to acute kidney injury did not worsen platelet function in cancer patients

Introdução: Pacientes portadores de câncer estão sobrevivendo mais devido aos avanços no diagnóstico precoce e tratamento dos tumores. A diminuição da mortalidade relacionada ao câncer e o envelhecimento da população acarretaram um número crescente de pacientes oncológicos internados em UTI. Objetivos: Identificar a prevalência e os fatores de risco para IRA nos pacientes oncológicos críticos. Métodos: Foram avaliados, prospectivamente, 371 pacientes oncológicos internados nas UTIs do Instituto do Câncer do Estado de São Paulo e do Hospital AC Camargo, entre novembro de 2011 a março de 2013. Os pacientes foram avaliados na admissão, 24h e 48h da internação na UTI. Foram coletados os parâmetros demográficos, clínicos e laboratoriais os quais foram analisados para os desfechos IRA, conforme o critério AKIN (Cr > 0,3 mg/dl ou aumento de 50% sobre a Cr basal em 48h) e óbito na UTI. Os dados foram submetidos à análise bivariada e multivariada. Resultados: A incidência de IRA nos pacientes oncológicos foi de 45,1%, sendo que apenas 5,2% necessitaram de tratamento dialítico. Os pacientes com IRA apresentaram mais frequentemente admissão cirúrgica (49% IRA vs 34% sem IRA; p=0,022). Na admissão à UTI, os fatores associados ao desenvolvimento de IRA (IRA vs sem IRA) foram: ventilação mecânica (26,6% vs 16,0%; p=0,031), frequência cardíaca (88 bpm vs 82 bpm; p=0,029), balanço hídrico (575 ml vs 275 ml; p = 0,0002), lactato (19 mg/dL vs 17 mg/dL; p= 0,046) e fósforo (3,9 mg/dL vs 3,4 mg/dL; p < 0,0001). A taxa de óbito hospitalar foi de 37,3% sendo que 25,3% ocorreu na UTI. A mortalidade foi mais prevalente em pacientes com câncer hematológico (8,6% sobreviventes vs 19,5% óbitos; p = 0,008), procedentes do pronto atendimento (23,5% sobreviventes vs 34,1% óbitos; p = 0,002), admissão clínica (50,4% sobreviventes vs 84,1% óbitos; p < 0,0001) e internação não planejada (59,9% vs 86,6% óbitos; p < 0,0001). Outros fatores relacionados ao óbito foram: sinais de congestão, uso de drogas vasoativas, choque séptico e infecção respiratória (p < 0,0001). Os dias de internação prévios à admissão na UTI também se relacionaram ao óbito (6 dias óbitos vs 2 dias sobreviventes; p < 0,0001). Os exames laboratoriais que se relacionaram ao óbito foram (sobreviventes vs óbitos): hipoalbuminemia (2,7 g/dL vs 2,4 g/dL; p= 0,003), aumento do INR (1,3 vs 1,5; p < 0,0001); aumento do lactato (17 mg/dL vs 20,5 mg/dL; p = 0,037), PCR (41,8 mg/dL vs 148,4 mg/dL; p < 0,0001) e TP (69% vs 59,5%; p = 0,001). Conclusão: A IRA é frequente em pacientes oncológicos admitidos na UTI e apresenta alta mortalidade. As ocorrências de IRA e óbito encontram-se mais relacionados com a gravidade das disfunções orgânicas no momento da admissão à UTI, do que às características da neoplasia de base Introduction: Cancer patients are currently presenting longer survival due to advances in diagnosis and treatment. Mortality reduction related to cancer and aging of population had led to an increased admission of cancer patients in the ICU. Objectives: Evaluation of the prevalence and risk factors for AKI in critically ill cancer patients. Methods: It was prospectively evaluated 371 cancer patients admitted to the ICU in Instituto do Câncer do Estado de São Paulo and Hospital AC Camargo, from November 2011 until March 2013. Patients were evaluated at admission, 24h and 48h in the ICU. Demographic, clinical and laboratory parameters were collected which were correlated with the outcome AKI (AKIN I - Cr > 0.3 mg/dL or 50% increase over baseline in 48h) and mortality in the ICU. Statistical analysis was performed using bivariate and multivariate analysis. Results: The incidence of AKI in cancer patients was 45.1% but only 5.2% were dialysed. AKI patients were more frequently admitted due to surgical admission (AKI 53% vs. 49% non-AKI, p=0.022). At ICU admission, factors associated with AKI development (AKI vs. non-AKI) were: mechanical ventilation (26.6% vs. 16%, p =0.031), heart beats (88 bpm vs. 82 bpm, p=0.029), fluid balance (575 ml vs. 275 ml, p=0.0002), lactate (19 mg/dLvs. 17 mg/dL, p=0.046) and phosphorus (3.9 mg/dL vs. 3.4 mg/dL, p < 0.0001). Hospital mortality rate was 37.3% whereas ICU mortality was 25.3%. Mortality was more prevalent in patients with hematological cancer (8.6% survivors vs. 19.5% non-survivors, p = 0.008), patients from emergency room (23.5% survivors vs. 34.1% non-survivors, p = 0.002), patients with clinical admission (50.4% survivors vs. 84.1% non-survivors, p < 0.0001) and non-elective admission (59.9% vs. 86.6% non-survivors, p < 0.0001). Other factors related to mortality were: volume overload, vasoactive drugs use, septic shock and pulmonary infection (p < 0.0001). Hospitalization period before ICU admission also correlated with mortality (6 days survivors vs. 2 days non-survivors, p 0.0001). The laboratory parameters that correlated to mortality were (survivors vs. non-survivors): hypoalbuminemia (2.7 g/dL vs. 2.4 g/dL, p=0.003), increased INR (1.3 vs. 1.5, p < 0.0001), increased lactate (17 mg/dL vs. 20.5 mg/dL, p=0.037), PCR (41.8 mg/dL vs 148.4 mg/dL, p < 0.0001) e PT (69% vs. 59.5%, p = 0.001). Conclusions: AKI is a frequent complication in cancer patients admitted to ICU, presenting high mortality rate. AKI and mortality outcomes are more related to the severity of organs dysfunction at ICU admission than the patient´s cancer disease