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Introdução: Histoplasma capsulatum é uma das principais causas de morte em pessoas vivendo com HIV/Aids (PVHA). A histoplasmose disseminada progressiva (HDP) é a forma mais grave da doença, oferecendo risco à vida quando não diagnosticada precocemente. A HDP persiste um desafio diagnóstico a despeito de novos métodos. A identificação de H. capsulatum por visualização direta ou cultura confirma o diagnóstico de HDP. O antígeno urinário para Histoplasma (AgU-Histo) reagente reforça o diagnóstico de HDP em PVHA proveniente de área endêmica com quadro clínico compatível. Objetivo: Analisar os métodos diagnósticos utilizados para HDP em pacientes PVHA. Método: Estudo retrospectivo que avaliou PVHA com HDP, diagnosticadas por métodos tradicionais, como visualização direta do fungo ou cultura positiva em creme leucocitário (CL), esfregaço de sangue periférico ou aspirado medular, ou através do AgU-Histo internados no Hospital São José de Doenças Infecciosas (HSJ), em Fortaleza/CE, no período entre abril de 2023 e abril de 2024. Este trabalho faz parte de uma coorte prospectiva de casos de HDP em PVHA aprovado pelo comitê de ética do HSJ (Certificado de Apresentação de Apreciação Ética: 60380022.0.0000.5044). Resultados: Foram identificados 43 PVHA com diagnósticos clínico e laboratorial de HDP. A média T CD4+ foi de 67,5 céls/mm³, com média de nadir de CD4 de 36,4 céls/mm³. A carga viral do HIV foi detectável em 40 pacientes (93%). Vinte (46,5%) tiveram diagnóstico recente de HIV, sem uso prévio de terapia antirretroviral (TARV), 23 (53,4%) já haviam sido expostos a TARV e dois (8,6 %) estavam em TARV. Todos os pacientes tinham algum método diagnóstico positivo, por: visualização direta 26 (60,4%); culturas em 20 (46,5%) pacientes; AgU-Histo (Histoplasma Urine Antigen LFA Test Kit®) em 22 (51,1%). Dos pacientes com AgU-Histo reagente, dez (45%) tinham pelo menos um outro método positivo e em 12 (28%) o diagnóstico laboratorial foi possível apenas com o AgU-Histo. A visualização direta em CL obteve positividade de 60,4%, cultura para fungos, 46,5%, e o AgU-Histo de 45%. CONCLUSÃO: Este estudo revela a diversidade dos métodos diagnósticos na atualidade, mantendo a importância dos métodos microbiológicos. Estes ainda são responsáveis pela maior parte dos diagnósticos de HPD, pela sua disponibilidade e seu custo. O AgU-Histo mostrou-se relevante, pois possibilitou diagnosticar rapidamente a HDP em PVHA, o que reforça a necessidade de ter este teste em áreas endêmicas de H. capsulatum.

Abstract Arboviruses are endemic in several countries and represent a worrying public health problem. The most important of these diseases is dengue fever, whose numbers continue to rise and have reached millions of annual cases in Brazil since the last decade. Other arboviruses of public health concern are chikungunya and Zika, both of which have caused recent epidemics, and yellow fever, which has also caused epidemic outbreaks in our country. Like most infectious diseases, arboviruses have the potential to affect the kidneys through several mechanisms. These include the direct action of the viruses, systemic inflammation, hemorrhagic phenomena and other complications, in addition to the toxicity of the drugs used in treatment. In this review article, the epidemiological aspects of the main arboviruses in Brazil and other countries where these diseases are endemic, clinical aspects and the main laboratory changes found, including changes in renal function, are addressed. It also describes how arboviruses behave in kidney transplant patients. The pathophysiological mechanisms of kidney injury associated with arboviruses are described and finally the recommended treatment for each disease and recommendations for kidney support in this context are given.

Introduction: Rhabdomyolysis (RML) is characterized by the destruction of muscle fibers and the release of intracellular constituents, with the potential to cause local and systemic complications, such as acute kidney injury (AKI). Methodology: Literature review in which articles were analyzed between 2011 and 2021, from the PubMed database. Results: RML can occur directly, indirectly, or secondary to trauma, metabolic disorders, medications and exogenous intoxication. Clinically, it may present asymptomatically, but a classic triad consisting of myalgia, generalized weakness and dark urine is common. AKI, despite being a late complication, is common. Laboratory markers used to diagnose RML are serum Creatine Kinase (CK) and serum and urinary Myoglobin, with CK being more sensitive. The approach can occur through classic strategies, such as hydration, diuretics, alkalinization and renal replacement therapy (RRT), but also through new strategies, such as iron chelators and antioxidants; anti-inflammatories and new extracorporeal blood filter. Discussion: Trauma was the most common etiology of AKI due to RML, with a minority of patients requiring RRT. Furthermore, it was found that COVID-19 infection did not result in major kidney complications. Strenuous exercise has been shown to be a rare etiology of AKI due to RML. Other less common causes were drug use/intoxication and metabolic diseases, the majority of which patients did not require RRT or had a favorable outcome. Conclusion: RML is a potentially serious condition, making it important to know its causes and management in order to reduce the chances of serious complications and to avoid patient death.

Introduction: To evaluate the function of vascular biomarkers to predict need for hemodialysis in critically-ill patients with COVID-19. Methods: This is a prospective study with 58 critically-ill patients due to COVID-19 infection. Laboratory tests in general and vascular biomarkers, such as VCAM-1, Syndecan-1, Angiopoietin-1 and Angiopoeitin-2 were quantified on intensive care unit (ICU) admission. Results: There was a 40% death rate. VCAM and Ang-2/Ang-1 ratio on ICU admission were associated with need for hemodialysis. Vascular biomarkers (VCAM-1, Syndecan-1, angiopoetin-2/ anogiopoetin-1 ratio) were predictors of death and their cut-off values were useful to stratify patients with a worse prognosis. In the multivariate cox regression analysis with adjusted models, VCAM-1 [O.R. 1.13 (C.I. 95%: 1.01 - 1.27); p= 0.034] and Ang-2/Ang-1 ratio [O.R. 4.87 (C.I.95%: 1.732 - 13.719); p= 0.003] were associated with need for dialysis. Conclusion: Vascular biomarkers, mostly VCAM-1 and Ang-2/Ang-1 ratio, showed better efficiency to predict need for hemodialysis in critically-ill COVID-19 patients.

Abstract Predicting risk factors for death in leptospirosis is challenging, and identifying high-risk patients is crucial as it might expedite the start of life-saving supportive care. Admission data of 295 leptospirosis patients were enrolled, and a machine-learning approach was used to fit models in a derivation cohort. The comparison of accuracy metrics was performed with two previous models—SPIRO score and quick SOFA score. A Lasso regression analysis was the selected model, demonstrating the best accuracy to predict mortality in leptospirosis [area under the curve (AUC-ROC) = 0.776]. A score-based prediction was carried out with the coefficients of this model and named LeptoScore. Then, to simplify the predictive tool, a new score was built by attributing points to the predictors with importance values higher than 1. The simplified score, named QuickLepto, has five variables (age > 40 years; lethargy; pulmonary symptom; mean arterial pressure

ABSTRACT Introduction: Acute Kidney Injury (AKI), a frequent manifestation in COVID-19, can compromise kidney function in the long term. We evaluated renal function after hospital discharge of patients who developed AKI associated with COVID-19. Methods: This is an ambidirectional cohort. eGFR and microalbuminuria were reassessed after hospital discharge (T1) in patients who developed AKI due to COVID-19, comparing the values with hospitalization data (T0). P < 0.05 was considered statistically significant. Results: After an average of 16.3 ± 3.5 months, 20 patients were reassessed. There was a median reduction of 11.5 (IQR: –21; –2.1) mL/min/1.73m2 per year in eGFR. Forty-five percent of patients had CKD at T1, were older, and had been hospitalized longer; this correlated negatively with eGFR at T1. Microalbuminuria was positively correlated with CRP at T0 and with a drop in eGFR, as well as eGFR at admission with eGFR at T1. Conclusion: There was a significant reduction in eGFR after AKI due to COVID-19, being associated with age, length of hospital stay, CRP, and need for hemodialysis.

ABSTRACT Background: The long-term effects of schistosomiasis on the glomerulus may contribute to the development of chronic kidney disease. This study aimed to investigate baseline Schistosoma mansoni-Circulating Anodic Antigen (CAA) levels and their association with kidney biomarkers related to podocyte injury and inflammation in long-term follow-up after praziquantel (PZQ) treatment. Methods: Schistosoma infection was diagnosed by detecting CAA in urine using a quantitative assay based on lateral flow using luminescent up-converting phosphor reporter particles. A cutoff threshold of 0.1 pg/mL CAA was used to diagnose Schistosoma infection (baseline) in a low-prevalence area in Ceará, Northeast, Brazil. Two groups were included: CAA-positive and CAA-negative individuals, both of which received a single dose of PZQ at baseline. Urinary samples from 55 individuals were evaluated before (baseline) and at 1, 2, and 3 years after PZQ treatment. At all time points, kidney biomarkers were quantified in urine and adjusted for urinary creatinine levels. Results: CAA-positive patients had increased baseline albuminuria and proteinuria and showed greater associations between kidney biomarkers. CAA levels correlated only with Vascular Endothelial Growth Factor (VEGF) (podocyte injury) levels. Increasing trends were observed for malondialdehyde (oxidative stress), monocyte chemoattractant protein-1 (inflammation marker), and VEGF. In the follow-up analysis, no relevant differences were observed in kidney biomarkers between the groups and different periods. Conclusions: S. mansoni-infected individuals presented subclinical signs of glomerular damage that may reflect podocyte injury. However, no causal effect on long-term renal function was observed after PZQ treatment.

ABSTRACT Objective: To verify the relationship between the presence of proteinuria as a renal injury marker in elderly without history of systemic arterial hypertension and cardiovascular diseases. A cross-sectional study was developed from January 2014 to December 2019, through kidney disease prevention campaigns promoted by the Federal University of Ceará in the city of Fortaleza. Methods: The sample consisted of 417 elderlies. A questionnaire was used to characterize individuals and assess previous diseases, and urinalysis reagent strips were used to assess proteinuria. Results: Statistically significant differences (p < 0.05) and moderate effect sizes were found for blood pressure levels (CI 0.53-0.93), systolic blood pressure, and diastolic blood pressure (CI 0.21-0.61). Significant differences in capillary glycemia were also found between groups (p = 0.033), but with a low effect size (0.02–0.42). The group with comorbidities was 2.94 times more likely to have proteinuria than those without comorbidities (OR 2.94, CI 1.55-4.01; p < 0.05). In the group without cardiovascular disease/high blood pressure, a statistically significant association was found for previous diabetes and proteinuria (p = 0.037), presenting 2.68 times higher risk of proteinuria in those with diabetes mellitus (OR 2.68, CI 1.05-6.85). Significant association was also found between age groups, with the older group having 2.69 times higher risk of developing proteinuria (75 to 90 compared to 60 to 74 years) (CI 1.01-7.16; p = 0.045). Conclusion: Even without systemic arterial hypertension or cardiovascular disease, diabetes and older age can be considered high risk factors for proteinuria.

ABSTRACT Introduction: Supplementation with probiotics for patients with chronic kidney disease (CKD) may be associated with decreased systemic inflammation. Objective: To assess the impact of oral supplementation with probiotics for patients with CKD on hemodialysis. Method: This double-blind randomized clinical trial included 70 patients on hemodialysis; 32 were given oral supplementation with probiotics and 38 were in the placebo group. Blood samples were collected at the start of the study and patients were given oral supplementation with probiotics or placebo for three months. The probiotic supplement comprised four strains of encapsulated Gram-positive bacteria: Lactobacillus Plantarum A87, Lactobacillus rhamnosus, Bifidobacterium bifidum A218 and Bifidobacterium longum A101. Patients were given one capsule per day for 3 months. Blood samples were taken throughout the study to check for inflammatory biomarkers. Non-traditional biomarkers Syndecan-1, IFN-y, NGAL, and cystatin C were measured using an ELISA kit, along with biochemical parameters CRP, calcium, phosphorus, potassium, PTH, GPT, hematocrit, hemoglobin, glucose, and urea. Results: Patients given supplementation with probiotics had significant decreases in serum levels of syndecan-1 (239 ± 113 to 184 ± 106 ng/mL, p = 0.005); blood glucose levels also decreased significantly (162 ± 112 to 146 ± 74 mg/dL, p = 0.02). Conclusion: Administration of probiotics to patients with advanced CKD was associated with decreases in syndecan-1 and blood glucose levels, indicating potential improvements in metabolism and decreased systemic inflammation.

Abstract COVID-19 is a pandemic associated with systemic clinical manifestations. In this study, we aimed to present a narrative review on kidney involvement in COVID-19. Kidney involvement could be derived from direct cytopathic effects, immunological mechanisms, indirect effects on renal tissue through other mediators, and dysfunction or injury of other organs. The evolution of COVID-19 may be complicated with acute kidney injury (AKI) in a significant percentage of patients, and renal dysfunction seems to be associated with worse prognosis. Patients with chronic kidney disease (CKD) seem to be more susceptible to the severe forms of COVID-19. Patients with renal replacement therapy (RRT) are also a vulnerable population as consequence of their advanced age, underlying comorbidities, impaired immune response, and clustering in hemodialysis centers, with requirements for frequent contact with healthcare services. Kidney transplant patients may be at high-risk due to long-term immunosuppression and comorbidities, hence, managing immunosuppression is imperative. Lastly, renal replacement therapy may be required during COVID-19, and different modalities are discussed based on clinical findings and laboratorial aspects. Therefore, COVID-19 seems to affect kidney by different mechanisms, which contributes for AKI development and increases the severity of the disease. Also, patients with CKD and kidney transplant recipients are at higher risk for COVID-19 and mortality.

Objective: To describe the prognostic and clinical profile of hospitalized patients with chikungunya virus (CHIKV) infection focusing on renal outcomes. Methods: This is a cross-sectional study including all patients with confirmed chikungunya fever (CHIKF) admitted to 3 different high-complexity hospitals in Fortaleza, Brazil between January 2016 and June 2017. Data analysis was carried out to evaluate correlation between clinical profile and outcomes. Results: Fifty-five patients were included, with a median age of 77 (IQR=21) years, and 23 (41.82%) were male. Twenty-five patients (45.45%, 25/55) developed acute kidney injury (AKI), and 15 (60.00%, 15/25) were classified as KDIGO 1, 1 (4.00%) as KDIGO 2, and 9 (36.00%) as KDIGO 3. The overall mortality was 34.54% whilst AKI-related mortality was 64.00% (16/25). Both AKI and encephalitis were associated with higher mortality. Patients who died were significantly older [82 (IQR=12) years vs. 70 (IQR= 28.75) years, P

Renal vein thrombosis (RVT) associated with nephrotic syndrome (NS) in patients with flank pain is rarely the earliest manifestation. Despite the absence of formal guidelines, treatment generally consists of prophylaxis against new thrombotic events and clot dissolution (thrombolysis) or clot removal (thrombectomy). We describe the case of a 25-year-old woman with lumbar pain, nausea and vomiting, who developed nephrotic proteinuria, macroscopic hematuria and loss of renal function requiring hemodialysis without improvement with methylprednisolone and cyclophosphamide. Considered diagnoses of systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS). Angiotomography showed subacute vena cava thrombosis with extension to the two renal veins. Alteplase thrombolysis was performed to recovery of renal function. Patient progressed with improvement of renal function and discontinuation of hemodialysis. In conclusion, late thrombolysis may be effective for subacute RVT in NS patients.

ABSTRACT A wide spectrum of renal complications can occur with acute and chronic use of cocaine. Most cases are related to rhabdomyolysis, but other mechanisms are malignant hypertension, renal ischemia, and rapidly progressive glomerulonephritis (RPGN) associated-ANCA vasculitis. In recent years, the use of cocaine adulterated with levamisole has been associated with ANCA vasculitis and pauci-immune RPGN. RPGN is clinically manifested as a nephritic syndrome with a rapid and progressive decline in renal function, and its histopathological finding is the presence of crescents in more than 50% of the glomeruli. We report a case of a 38-year-old man chronic user of cocaine, alcohol, and cigarettes who had red urine, oliguria, swollen legs and eyelids, as well as the uremic symptoms anorexia, emesis, and mental confusion. He was admitted with acute kidney injury and performed six hemodialysis sessions during the first 16 days of hospitalization and then was transferred to a tertiary hospital for diagnostic investigation. Tests of ANF (antinuclear factor), ANCA, anti-DNA, serology for hepatitis B, C, and HIV virus were negative. A renal percutaneous biopsy revealed crescentic glomerulonephritis with mild tubular atrophy. The patient underwent pulse therapy with methylprednisolone (for 3 days) and cyclophosphamide. Then he maintained daily prednisone and monthly intravenous cyclophosphamide and evolved with progressive improvement of renal function.

The excessive chase for beauty standards and the rise of muscle dysmorphia have ultimately led to an increase in androgenic–anabolic steroids (AAS) and intramuscular injections of vitamins A, D and E (ADE) abuse, which is associated with several adverse effects and has become a public health issue. This review of literature discusses kidney injury associated with the use of AAS and ADE, highlighting the mechanisms of acute and chronic renal lesion, such as direct renal toxicity, glomerular hyperfiltration and hypercalcemia. Future perspectives regarding evaluation and early diagnosis of kidney injury in these patients are also discussed. Resumen: La búsqueda excesiva de los estándares estéticos y el aumento de casos de dismorfia muscular han llevado a un aumento excesivo del consumo de esteroides anabólicos androgénicos (AAS, por sus siglas en inglés) e inyecciones intramusculares de vitaminas A, D y E (ADE), que se asocian con varios efectos adversos y se convierte en un problema de salud pública. Esta revisión de literatura analiza la lesión renal asociada con el uso de AAS y vitaminas ADE, destacando los mecanismos de la lesión renal aguda y crónica, como la toxicidad renal directa, la hiperfiltración glomerular y la hipercalcemia. También se discuten las perspectivas futuras con respecto a la evaluación y el diagnóstico temprano de lesión renal en estos pacientes. Keywords: Acute kidney injury, Androgenic–anabolic steroids, Chronic kidney disease, Hypercalcemia, Vitamin D, Vitamin supplements, Palabras clave: Lesión renal aguda, Esteroides androgénicos-anabólicos, Enfermedad renal crónica, Hipercalcemia, Vitamina D, Suplementos vitamínicos

Abstract Objectives This study aims at evaluating whether subjective donor deferral (SDD) has the potential for increasing blood transfusion safety. Background Appropriate donor selection via clinical and serologic screening is necessary to prevent transfusion‐transmissible infections (TTIs). One additional strategy adopted by some Brazilian blood transfusion centers (BTCs) is the rejection of a donation by the pre‐donation interviewer based on subjective factors. Methods/Materials We conducted a STROBE‐guided cross‐sectional study including 105 005 prospective donors who presented to our BTC between 1 January 2013, and 31 December 2015. Donors were evaluated for age, gender, education level, donation type and history, confidential unit exclusion, SDD, and results of serologic screening for TTIs. Results Even after controlling for potential confounding variables, subjectively deferred donors were more likely to have at least one reactive serology in the standard screening (OR: 2.80; 95% CI: 2.13‐3.69; P

Abstract Acute kidney injury (AKI) is a common finding in Neotatal Intensive Care Units (NICU). Sepsis is one the main causes of AKI in preterm newborns. AKI has been associated with significant death rates. Early detection of the condition is the first step to improving prevention, treatment, and outcomes, while decreasing length of hospitalization, care costs, and morbimortality. AKI may progress to chronic kidney disease (CKD), a condition linked with dialysis and greater risk of cardiovascular disease. This review article aims to discuss cases of AKI in preterm newborns with sepsis, the use of biomarkers in lab workup, and the use of non-conventional biomarkers for the early identification of AKI.

Abstract Background The consequences of cocaine use are multisystemic, such as, for instance, renal failure, hepatotoxicity and pulmonary toxicity, with renal alterations being the focus of the present study. The use of substances that modify the base composition of cocaine (or adulterants) aiming to potentiate its effects also has an impact on these manifestations. The present study aims to report three cases with different diagnosis of acute kidney injury related to cocaine use. Case presentation Case 01 - A 30-year-old female patient, who regularly used cocaine, started to have lower-limb edema, which showed a progressive and ascending evolution, affecting the face a few days later, associated with an isolated febrile episode and oligoanuria. The presence of cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) was verified: reactive 1:80, with renal biopsy compatible with rapidly progressive glomerulonephritis (RPGN). Case 02 - A 34-year-old female patient, with difficult-to-control hypertension and a frequent user of cocaine, showed generalized sudden edema together with diffuse and progressive pruritus associated with oliguria, fever, nausea, and vomiting. Schistocyte screening was positive, with negative direct Coombs test, and negative serologies for hepatitis B, C and HIV, as well as negative anti-double-stranded DNA, Anti-SSA and Anti-SSB. The renal biopsy was compatible with thrombotic microangiopathy, associated with moderate interstitial fibrosis and acute tubular necrosis Case 03 - A 25-year-old male patient who had been a cocaine user for 5 years had a sudden onset of generalized disabling myalgia (especially in the lower limbs) associated with recent frontotemporal headache, palpitation, dizziness, and a non-measured febrile episode; the patient had used cocaine at the night before symptom onset. CPK was 1731 U/L.The final probable diagnosis was AKI secondary to cocaine-induced rhabdomyolysis. Conclusions In conclusion basically, 05 etiologies of acute kidney injury should always be remembered: rhabdomyolysis, thrombotic microangiopathy, vasculitis, acute interstitial nephritis and renal infarction. Emphasis should be given to rhabdomyolysis due to its higher prevalence. Considering the increasing rates of cocaine use, especially with the use of adulterating substances, these pathologies will likely be increasingly prevalent.

ABSTRACT Leprosy may present kidney and endothelial abnormalities, being a risk factor for complications. However, the involvement of renal and vascular endothelia has been poorly investigated. We aimed to investigate if the levels of systemic endothelial biomarkers are associated with kidney abnormalities and the clinical forms of leprosy. This is a cross-sectional study with leprosy patients enrolled in January 2017 to December 2018, before the initiation of the multidrug therapy. Leprosy-associated clinical and epidemiological data were collected. Two groups were investigated: Paucibacillary (PB) and Multibacillary (MB) infections, for the comparisons. Serum and urine samples were obtained for laboratory analysis. In serum samples, were evaluated the endothelial biomarkers VCAM-1 and ICAM-1. In total, 101 leprosy patients were included, the mean age was 48±١٥ years and 71 (70%) were male. The multibacillary form occurred in 81 cases (80%), among which 22 had the Virchowian form. Serum creatinine was more elevated in the MB group than in PB patients. In addition, VCAM-1 was elevated in the MB group and was correlated with the bacteriological index (rho = 0.372, p 15 mg/g of creatinine, VCAM-1 showed a significant correlation with increased albuminuria and improved the correlation with the number of skin lesions (rho= 0.563, p=0.010). In conclusion, higher systemic VCAM-1 levels were associated with the multibacillary clinical form of leprosy and with increased albuminuria. Prospective studies are necessary to establish a cause-effect and evaluate the preventive role of these biomarkers to improve the clinical care.

ABSTRACT HIV-infected patients are at high risk for developing critical diseases, including opportunistic infections (OI), with consequent admission in intensive care units (ICU). Renal disfunctions are risk factors for death in HIV/AIDS patients, and survival rates in patients undergoing hemodialysis are smaller than the ones observed in the general population. In this context, this study aimed to investigate death-related factors in HIV/AIDS patients in an intensive care setting. This is a retrospective cross-sectional study performed through the analysis of medical records from 271 HIV/AIDS-diagnosed patients hospitalized in an intensive care unit of an infectious disease hospital, in Fortaleza, Ceara State, Brazil. Patients were divided into two groups: those who underwent dialysis during hospitalization and those who did not. Clinical and demographic parameters that could be associated with death were evaluated. Results indicated a prevalence of death of 19.1% (CI 95%: 14.8-24.3). The median age of patients was 47 years, with a male predominance (71.3%). The main causes of admission were pulmonary tuberculosis (16.9%), followed by neurotoxoplasmosis (14.9%). In the bivariate analysis, for those that did not undergo dialysis, age, fever, dyspnea, oliguria, disorientation, kidney injury, use of lamivudine and efavirenz, length of hospitalization, CD4 count, WBC count, platelet count, urea, sodium and LDH levels were the associated variables. In those who needed dialysis, the use of stavudine, abacavir and ritonavir, and the length of hospitalization were associated factors. Renal toxicity by the antiretroviral agents and length of hospitalization increased the risk of death among HIV patients under dialysis.

ABSTRACT Bothrops erythromelas are serpents that belong to the Viperidae family, which are the main species responsible for human snakebites in Ceara State, Northeast Brazil. Thrombotic microangiopathy (TMA) is an uncommon group of disorders characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia and acute kidney injury (AKI), and occurrence after snakebites have been rarely reported. In this report, we described the case of a 57 year-old-man without comorbidities who was bitten by a Bothrops erythromelas on his right ankle. He presented with pain, edema and local bleeding. Symptomatology and laboratory tests were compatible with the diagnosis of TMA. He received specific antivenom and fluids replacement without any anaphylactic reaction. The conservative treatment was effective and there was no need for red blood cells transfusion or plasmapheresis. The aim of this report was to describe the first case of thrombotic microangiopathy following Bothrops erythromelas envenoming in the Northeast Brazil, providing insights about important mechanistic pathways of Bothrops snakebite-associated TMA and how to change the prognosis of the disease.

ABSTRACT Tropical diseases are mainly found in the tropical regions of Asia, Africa and Latin America. They are a major Public Health problem in these regions, most of them are considered neglected diseases and remain as important contributors to the development of AKI (Acute Kidney Injury), which is associated with increased patients’ morbidity and mortality. In most countries, kidney disease associated to tropical diseases is attended at health services with poor infrastructure and inadequate preventive measures. The long-term impacts of these infections on kidney tissue may be a main cause of future kidney disease in these patients. Therefore, the investigation of novel kidney injury biomarkers in these tropical diseases is of utmost importance to explain the mechanisms of kidney injury, to improve their diagnosis and prognosis, as well as the assessment to health systems by these patients. Since 2011, our group has been studying renal biomarkers in visceral and cutaneous leishmaniasis, schistosomiasis, leptospirosis and leprosy. This study has increased the knowledge on the pathophysiology of kidney disease in the presence of these infections and has contributed to the early diagnosis of kidney injury, pointing to glomerular, endothelial and inflammatory involvement as the main causes of the mechanisms leading to nephropathy and clinical complications. Future perspectives comprise establishing long-term cohort groups to assess the development of kidney disease and the patients’ survival, as well as the use of new biomarkers such as urinary exosomes to detect risk groups and to understand the progression of kidney injuries.

BACKGROUND:This study evaluated the risk factors for delayed graft function (DGF) in a country where its incidence is high, detailing donor maintenance-related (DMR) variables and using machine learning (ML) methods beyond the traditional regression-based models. METHODS:A total of 443 brain dead deceased donor kidney transplants (KT) from two Brazilian centers were retrospectively analyzed and the following DMR were evaluated using predictive modeling: arterial blood gas pH, serum sodium, blood glucose, urine output, mean arterial pressure, vasopressors use, and reversed cardiac arrest. RESULTS:Most patients (95.7%) received kidneys from standard criteria donors. The incidence of DGF was 53%. In multivariable logistic regression analysis, DMR variables did not impact on DGF occurrence. In post-hoc analysis including only KT with cold ischemia time

Leptospirosis is a bacterial disease disseminated through the centuries in the whole world which causes symptoms that go from self-limited diseases to hemorrhagic manifestations and organ failure, including acute kidney injury (AKI), composing the severe disease known as the Weil's syndrome. Mortality rates varies according to the clinical presentation and usually increases when kidney injury is present, and is even higher in the setting of pulmonary hemorrhage. There are recent advances in the search for novel biomarkers of renal involvement and early detection of AKI in leptospirosis, as well as in its pathophysiology. We review in this article the clinical aspects of leptospirosis-associated AKI and the perspectives for future research.

Background: This study was conducted to investigate changes in the clinical pattern of leptospirosis over time, analyzing its clinical and laboratory presentations in a metropolitan city of Brazil. Method: This was a retrospective study including all patients with leptospirosis admitted to tertiary care hospitals in Fortaleza in the northeast of Brazil, between 1985 and 2015. Patients were divided into three groups according to the year of hospital admission: group I for the years 1985–1995, group II for 1996–2005, and group III for 2006–2015. Demographic, clinical, and laboratory data were compared between the groups. Results: A total of 507 patients were included. Their mean age was 37.3 ± 15.9 years and 82.4% were male. The mean time between symptom onset and admission was 7 ± 4 days. There was a linear decrease in the levels of serum urea (190.1 ± 92.7, 135 ± 79.5, and 95.6 ± 73.3 mg/dl, respectively, p

Background: Despite well-documented risks, injectable supplements containing high doses of vitamins are commonly used. Objectives: To describe acute kidney injury (AKI) as a complication of vitamin intoxication. Methods: Our series consisted of 16 patients with kidney complications resulting from the use of veterinary intramuscular injection supplements of vitamin A, D and E. The patients were admitted to two referral hospitals in Fortaleza (Brazil) between January 2010 and January 2015. Results: Patients’ mean age was 28.3 ± 8.9 years (19–53 years), and 11 (68.7%) were male. Main signs and symptoms upon admission were nausea (68.7%), vomiting (62.5%), weight loss (43.7%), epigastric pain (31.2%) and headache (31.2%). At hospital admission the mean laboratory values were: hemoglobin 10 ± 2.0 g/dL (6.1–14.2), leukocytes 10,542 ± 4871/mm3 (4100–15,100), creatinine 3.9 ± 5.2 mg/dL (0.7–22) and urea 91 ± 88 mg/dL (22–306), respectively. Serum calcium was 12 ± 2.2 mg/dL (8.8–15.5), 24-h urine calcium was 575 ± 329 mg (10.7–1058), serum PTH was 55 ± 141 pg/mL (2–406), and serum vitamin D concentration was 135 ± 75 ng/mL (22–265). Using KDIGO criteria, AKI was diagnosed in 13 patients (81.2%), classified as stage 1 (n = 3), stage 2 (n = 3) or stage 3 (n = 7). No deaths occurred in the study period. Conclusions: Excessive use of veterinary vitamin supplements containing high doses of vitamin A, D and E was associated with AKI. Hypercalcaemia, which was a common finding, appears to be a contributing factor to the development of this type of AKI.

ABSTRACT Leptospirosis is a globally distributed zoonosis with a broad clinical spectrum. This disease mostly affects liver and kidney tissues. Other organs such as the pancreas, can be affected by leptospirosis-induced vasculitis. In addition, cardiac manifestations are common, and the presence of transient ECG abnormalities can be found in 70% of the patients. We report a male patient who presented with an atypical leptospirosis that progressed with severe acute pancreatitis, acute kidney injury and atrial fibrillation. Early diagnosis and adequate supportive therapy are crucial for the appropriated management of symptoms.

Techniques with high sensitivity and specificity are required for an accurate diagnosis in low-transmission settings, where the conventional parasitological methods are insensitive. We determined the accuracy of an up-converting phosphor-lateral flow circulating anodic antigen (UCP-LF CAA) assay in urine and serum for Schistosoma mansoni diagnosis in low-prevalence settings in Ceará, Brazil, before and after praziquantel treatment. Clinical samples of a total of 258 individuals were investigated by UCP-LF CAA, point-of-care—circulating cathodic antigen (POC-CCA), soluble worm antigen preparation (SWAP)-ELISA and Kato-Katz (KK); a selection of 128 stools by real-time PCR technique. Three and 6-weeks after treatment, samples were collected and evaluated by detection Schistosoma circulating antigens (CAA and CCA). The UCP-LF CAA assays detected 80 positives (31%) with urine and 82 positives (31.8%) with serum. The urine POC-CCA and serum SWAP-ELISA assays detected 30 (11.6%) and 107 (40.7%) positives, respectively. The Kato-Katz technique revealed only 4 positive stool samples (1.6%). Among the 128 individuals with complete data records, 19 cases were identified by PCR (14.8%); Sensitivities and specificities of the UCP-LF CAA assays, determined versus a combined reference standard based on CCA/KK/PCR positivity, ranged from 60–68% to 68–77%, respectively. In addition only for comparative purposes, sensitivities of the different assays were determined vs. a comparative reference based on CAA/KK/PCR positivity, showing the highest sensitivity for the urine CAA assay (80%), followed by the serum CAA (70.9%), SWAP-ELISA (43.6%), PCR (34.5%), POC-CCA (29.1%), whilst triplicate Kato-Katz thick smears had a very low sensitivity (3.6%). CAA concentrations were higher in serum than in urine and were significantly correlated. There was a significant decrease in urine and serum CAA levels 3 and 6-weeks after treatment. The UCP-LF CAA assays revealed 33 and 28 S. mansoni-infected patients at the 3- and 6-week post-treatment follow-up, respectively. The UCP-LF CAA assays show high sensitivity for the diagnosis of S. mansoni in low-endemicity settings. It detects a considerably higher number of infections than microscopy, POC-CCA or PCR. Also it shows to be very useful for evaluating cure rates after treatment. Hence, the UCP-LF CAA assay is a robust and promising diagnostic approach in low-transmission settings.

Abstract INTRODUCTION: Chikungunya infection presents with distinct clinical features depending on the patient age group. METHODS: Medical records of children with positive IgM for the chikungunya virus who were hospitalized in a pediatric ward in Fortaleza, Ceará, Brazil were analyzed. RESULTS: Fourteen children with a median age of 4 months (36 days to 15 years) were included. All patients presented with fever persisting for an average of 5 days. The joints were involved in 6 (42.8%) children, and 8 (57.1%) children presented with bullous rash. CONCLUSIONS: Systemic involvement and atypical clinical manifestations characterize severe forms of chikungunya infection in children.

ABSTRACT Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

Objective: To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV‐infected children using and not using highly active antiretroviral therapy (HAART) prior to admission. Methods: A retrospective study was conducted with HIV‐infected pediatric patients (

We report a case of a 20-year-old man presented to the emergency department with oliguria and renal failure requiring urgent dialysis. An ultrasound revealed enlarged kidneys, and a renal biopsy showed non-Hodgkin’s lymphoma, subtype diffuse large B-cell.

ABSTRACT Visceral leishmaniasis (VL) is an endemic parasitic disease frequently found in Northeast Brazil and may cause acute kidney injury (AKI) and glomerulonephritis. After appropriate treatment, renal function recovery may occur. We describe the rare case of a patient with VL, who developed severe AKI requiring dialysis and was subsequently diagnosed with Chagas disease coinfection. After specific treatment for VL, there was partial recovery of the renal function, followed by the onset of Chagas disease cardiomyopathy.

Objetivo: Esse estudo objetivou avaliar as características demográficas, clínicas e os desfechos da infecção por tuberculose (TB) após o transplante renal (TxR). Métodos: Estudo de coorte retrospectiva, incluindo receptores de TxR de um único centro de transplantes localizado no Nordeste do País. Foram considerados para análise os pacientes com diagnósticos realizados no período de 2004 a 2018 (n=33). Resultados: Os pacientes da coorte eram predominantemente homens (54,5%), adultos jovens (39,8+12,3 anos), com mediana de 29,8 meses de transplante. Nove fizeram tratamento para TB latente (LTBI). O regime imunossupressor principal foi indução com Thymoglobuline (48,4%) em associação com tacrolimo e ácido micofenólico (MPA) (72,7%). O sintoma inicial mais frequente foi febre (63,6%), seguido da perda ponderal (21,2%) e tosse (21,2%). Vinte e quatro pacientes tiveram TB localizada, cinco tiveram formas disseminadas e quatro pacientes receberam tratamento empírico sem definição de sítio. Todos foram submetidos ao tratamento com rifampicina, isoniazida e pirazinamida, com ou sem etambutol. O tempo médio de tratamento foi de 8,4+3,8 meses. Sete pacientes apresentaram hepatotoxicidade e dois apresentaram neuropatia periferica. A concentração de tacrolimo reduziu de 5,4 +1,9 ng/mL pré-tratamento para 1,6+0,6 ng/mL pós-tratamento (menor concentração), sendo a dose aumentada em 75,5% durante o tratamento. Doze pacientes apresentaram suspensão parcial ou completa da imunossupressão durante o tratamento. 79% dos pacientes evoluíram com lesão renal aguda (LRA), sendo, de acordo com o estadiamento KDIGO, 15 pacientes eram KDIGO 1, 8 eram KDIGO 2 e 3 eram KDIGO 3, e a principal causa foi LRA pré-renal. Três pacientes morreram no curso da doença ou do tratamento. Conclusões: A TB aconteceu tardiamente no curso do transplante e febre foi o principal sintoma inicial. Houve um elevado percentual de formas extrapulmonares. Como reportado em estudos prévios, o tratamento empírico é uma realidade no contexto do transplante. O tratamento associou-se à redução da concentração do inibidor de calcineurina por provável interação com a rifampicina. Foi elevado o percentual de disfunção aguda do enxerto renal.

Abstract Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used medications associated with nephrotoxicity, especially when used chronically. Factors such as advanced age and comorbidities, which in themselves already lead to a decrease in glomerular filtration rate, increase the risk of NSAID-related nephrotoxicity. The main mechanism of NSAID action is cyclooxygenase (COX) enzyme inhibition, interfering on arachidonic acid conversion into E2 prostaglandins E2, prostacyclins and thromboxanes. Within the kidneys, prostaglandins act as vasodilators, increasing renal perfusion. This vasodilatation is a counter regulation of mechanisms, such as the renin-angiotensin-aldosterone system works and that of the sympathetic nervous system, culminating with compensation to ensure adequate flow to the organ. NSAIDs inhibit this mechanism and can lead to acute kidney injury (AKI). High doses of NSAIDs have been implicated as causes of AKI, especially in the elderly. The main form of AKI by NSAIDs is hemodynamically mediated. The second form of NSAID-induced AKI is acute interstitial nephritis, which may manifest as nephrotic proteinuria. Long-term NSAID use can lead to chronic kidney disease (CKD). In patients without renal diseases, young and without comorbidities, NSAIDs are not greatly harmful. However, because of its dose-dependent effect, caution should be exercised in chronic use, since it increases the risk of developing nephrotoxicity.

ABSTRACT Rapidly progressive glomerulonephritis (RPGN) is a renal disease with an extensive differential diagnosis. This paper reports the case of a 55-year-old female patient diagnosed with Hansen's disease with acute progressive renal impairment after developing lower limb pyoderma. The association between Hansen's and kidney disease has been well documented, with glomerulonephritis (GN) ranked as the most common form of renal involvement. Post-infectious glomerulonephritis (PIGN) in adults has been associated with a number of pathogens occurring in diverse sites. The patient described in this case report had RPGN and biopsy findings suggestive of PIGN with C3 and IgA detected on immunofluorescence and kidney injury secondary to recent infection by Staphylococcus, a well-documented manifestation of renal impairment in patients with Hansen's disease.

ABSTRACT Despite the high number of accidents due to scorpion stings in Brazil, severe cases in adults are seldomly reported. In the Northeast region of Brazil, Tityus stigmurus is the most prevalent species. A 69 year-old woman who was stung by a scorpion attended the emergency room 5 hours after envenomation. She got worse due to abdominal pain. Clinical findings were concordant with class III scorpion envenomation (major systemic manifestations), complicated by acute kidney injury and acute pancreatitis. Intensive supportive therapy was adopted. In the follow-up, 3 months later, she was completely recovered. This report is being brought to recommend the thorough management of victims of scorpion accidents, enabling early diagnosis of severe complications, which could lead to death if aggressive supportive measures are not early and adequately taken.

A acidose tubular renal distal (tipo I) consiste em uma doença de curso crônico na qual ocorre secreção inadequada de prótons no túbulo distal. A depleção de potássio resultante dessa patologia, se não tratada precocemente, pode acarretar paralisia hipocalêmica em raros casos, podendo inclusive levar ao óbito do paciente por complicações decorrentes dessa condição. O presente artigo visa relatar o caso de uma paciente acompanhada no Serviço de Nefrologia do Hospital Universitário Walter Cantídio. Essa jovem possui acidose tubular renal distal, tendo evoluído com paralisia hipocalêmica. Ao longo de dez anos de acompanhamento no nosso serviço, a paciente apresentou vários episódios de paralisia hipocalêmica, alguns dos quais associados a extrassístoles ventriculares, devido à dificuldade de aderência ao tratamento. Foi evidenciada, ainda, nefrocalcinose, nefrolitíase, acidose metabólica hiperclorêmica e pH urinário inadequadamente alto.

Leprosy is a chronic disease caused by Mycobacterium leprae, highly incapacitating, and with systemic involvement in some cases. Renal involvement has been reported in all forms of the disease, and it is more frequent in multibacillary forms. The clinical presentation is variable and is determined by the host immunologic system reaction to the bacilli. During the course of the disease there are the so called reactional states, in which the immune system reacts against the bacilli, exacerbating the clinical manifestations. Different renal lesions have been described in leprosy, including acute and chronic glomerulonephritis, interstitial nephritis, secondary amyloidosis and pyelonephritis. The exact mechanism that leads to glomerulonephritis in leprosy is not completely understood. Leprosy treatment includes rifampicin, dapsone and clofazimine. Prednisone and non-steroidal anti-inflammatory drugs may be used to control acute immunological episodes.

Leishmaniasis is an infectious disease caused by protozoa of the genus Leishmania transmitted by insects of the genus Lutzomyia sp. or Phlebotomus sp. The main syndromes are cutaneous leishmaniasis, mucocutaneous leishmaniasis, visceral leishmaniasis (kala-azar) and post-kala-azar dermal leishmaniasis. This article reviews kidney involvement in cutaneous and visceral leishmaniasis, highlighting the aspects of their pathophysiology, clinical manifestations, histopathological findings, outcome and treatment. Keywords: Visceral leishmaniasis, American cutaneous leishmaniasis, Kala-azar, Kidney disease

Acute kidney injury (AKI) following snakebite is common in developing countries and Bothrops genus is the main group of snakes in Latin America. To evaluate the pathogenic mechanisms associated with Bothrops venom nephrotoxicity, we assessed urinary and blood samples of patients after hospital admission resulting from Bothrops snakebite in a prospective cohort study in Northeast Brazil. Urinary and blood samples were evaluated during hospital stay in 63 consenting patients, divided into AKI and No-AKI groups according to the KDIGO criteria. The AKI group showed higher levels of urinary MCP-1 (Urinary monocyte chemotactic protein-1) (median 547.5 vs. 274.1 pg/mgCr; p = 0.02) and urinary NGAL (Neutrophil gelatinase-associated lipocalin) (median 21.28 vs. 12.73 ng/mgCr; p = 0.03). Risk factors for AKI included lower serum sodium and hemoglobin levels, proteinuria and aPTT (Activated Partial Thromboplastin Time) on admission and disclosed lower serum sodium (p = 0.01, OR = 0.73, 95% CI: 0.57–0.94) and aPTT (p = 0.031, OR = 26.27, 95% CI: 1.34–512.11) levels as independent factors associated with AKI. Proteinuria showed a positive correlation with uMCP-1 (r = 0.70, p < 0.0001) and uNGAL (r = 0.47, p = 0.001). FENa (Fractional Excretion of sodium) correlated with uMCP-1 (r = 0.47, P = 0.001) and uNGAL (r = 0.56, p < 0.0001). sCr (serum Creatinine) showed a better performance to predict AKI (AUC = 0.85) in comparison with new biomarkers. FEK showed fair accuracy in predicting AKI (AUC = 0.92). Coagulation abnormality was strongly associated with Bothrops venom-related AKI. Urinary NGAL and MCP-1 were good biomarkers in predicting AKI; however, sCr remained the best biomarker. FEK (Fractional Excretion of potassium) emerged as another diagnostic tool to predict early AKI. Positive correlations between uNGAL and uMCP-1 with proteinuria and FENa may signal glomerular and tubular injury. Defects in urinary concentrations highlighted asymptomatic abnormalities, which deserve further study.

SUMMARY Introduction: We present a fatal case of disseminated cryptococcosis in a young man whose diagnosis of HIV infection was made at the time of admission to the emergency room. Case report: The patient was a twenty-three-year-old man, with a history of daily fever during one month associated with diarrhea, weight loss, headache, vomiting and generalized seizures. He also had a history of diabetes mellitus, alcoholism and drug addiction. Upon physical examination the patient was pale, disoriented and had periods of agitation. White blood cells count was 3,440/mm3 (5% lymphocytes), hemoglobin was 10g/dL, platelets were 83,000/ mm3. Creatinine was 0.7 mg/dL; urea 19 mg/dL; Na, K, and liver enzymes were within normal limits. Lactic dehydrogenase was 494 IU/L. Cerebrospinal fluid (CSF) analysis revealed 10 white blood cells/mm3 (58% neutrophils, 31% lymphocytes, 11% monocytes) and 2 red blood cells/mm3. India ink test revealed six Cryptococcus yeasts/mm3. CSF glucose was 122 mg/dL and protein was 36 mg/ dL. VDRL test was negative and anti-HIV test was positive. Intravenous hydration, insulin, phenytoin, fluconazole, pyrimethamine, sulfadiazine, folinic acid, and amphotericin B were started. The patient did not improve and became obtunded and hypotensive. He was intubated and put on mechanical respiration. He received vasoactive drugs and died less than 24 hours after admission. A postmortem examination was performed and revealed disseminated cryptococcosis, with severe involvement of the kidneys. Conclusion: Cryptococcosis, as a rule, is a systemic disease that affects mostly immunocompromised individuals, especially patients with AIDS. When diagnosed late in its course it has a very high mortality.

Introduction This study aimed to describe the clinical spectrum of dengue in children and adolescents from a hyperendemic region who were admitted for hospitalization. Methods A retrospective study was conducted on patients diagnosed with dengue infection upon admission to a reference center in Fortaleza, Brazil. Results Of the 84 patients included, 42 underwent confirmatory testing. The main symptoms were fever, abdominal pain and vomiting. The median level of serum aspartate aminotransferase was 143.5±128mg/dL. Conclusions A peculiar clinical profile was evident among children and adolescents with dengue infection in a reference center in northeast Brazil, including gastrointestinal symptoms and liver involvement.

OBJETIVO: Investigar os fatores associados à lesão renal aguda e o prognóstico em pacientes com doença pulmonar. MÉTODOS: Foi realizado estudo prospectivo com cem pacientes consecutivos admitidos em uma unidade de terapia intensiva respiratória em Fortaleza (CE). Foram investigados fatores de risco para lesão renal aguda e mortalidade em um grupo de pacientes com doenças pulmonares. RESULTADOS: A média de idade foi de 57 anos, sendo 50% do gênero masculino. A incidência de lesão renal aguda foi maior nos pacientes com PaO2/FiO2

SUMMARY Background: The aim of this study is to describe clinical characteristics, outcomes and risk factors for death among patients with HIV-related acute kidney injury (AKI) admitted to an intensive care unit (ICU). Methods: A retrospective study was conducted with HIV-infected AKI patients admitted to the ICU of an infectious diseases hospital in Fortaleza, Brazil. All the patients with confirmed diagnosis of HIV and AKI admitted from January 2004 to December 2011 were included. A comparison between survivors and non-survivors was performed. Risk factors for death were investigated. Results: Among 256 AKI patients admitted to the ICU in the study period, 73 were identified as HIV-infected, with a predominance of male patients (83.6%), and the mean age was 41.2 ± 10.4 years. Non-survivor patients presented higher APACHE II scores (61.4 ± 19 vs. 38.6 ± 18, p = 0.004), used more vasoconstrictors (70.9 vs. 37.5%, p = 0.02) and needed more mechanical ventilation - MV (81.1 vs. 35.3%, p = 0.001). There were 55 deaths (75.3%), most of them (53.4%) due to septic shock. Independent risk factors for mortality were septic shock (OR = 14.2, 95% CI = 2.0-96.9, p = 0.007) and respiratory insufficiency with need of MV (OR = 27.6, 95% CI = 5.0-153.0, p < 0.001). Conclusion: Non-survivor HIV-infected patients with AKI admitted to the ICU presented higher severity APACHE II scores, more respiratory damage and hemodynamic impairment than survivors. Septic shock and respiratory insufficiency were independently associated to death.

The osteoarticular involvement in sickle cell disease has been poorly studied and it is mainly characterized by osteonecrosis, osteomyelitis and arthritis. The most frequent complications and those that require hospital care in sickle cell disease patients are painful vaso-occlusive crises and osteomyelitis. The deoxygenation and polymerization of hemoglobin S, which results in sickling and vascular occlusion, occur more often in tissues with low blood flow, such as in the bones. Bone microcirculation is a common place for erythrocyte sickling, which leads to thrombosis, infarct and necrosis. The pathogenesis of microvascular occlusion, the key event in painful crises, is complex and involves activation of leukocytes, platelets and endothelial cells, as well as hemoglobin S-containing red blood cells. Osteonecrosis is a frequent complication in sickle cell disease, with a painful and debilitating pattern. It is generally insidious and progressive, affecting mainly the hips (femur head) and shoulders (humeral head). Dactylitis, also known as hand-foot syndrome, is an acute vaso-occlusive complication characterized by pain and edema in both hands and feet, frequently with increased local temperature and erythema. Osteomyelitis is the most common form of joint infection in sickle cell disease. The occurrence of connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus, has rarely been reported in patients with sickle cell disease. The treatment of these complications is mainly symptomatic, and more detailed studies are required to understand the pathophysiological mechanisms involved in the complications and propose more adequate and specific therapies.

OBJETIVO: Determinar os dados demográficos, clínicos e laboratoriais de pacientes com litíase urinária em Fortaleza (CE). PACIENTES E MÉTODOS: Trata-se de estudo documental baseado em dados secundários de 197 pacientes litiásicos de Fortaleza, entre 1996-2006. Foram realizadas avaliação clínica e metabólica na urina de 24 horas, para medida de volume urinário e dosagens de creatinina, cálcio, fósforo, ácido úrico, sódio, potássio e magnésio. O pH e a densidade foram determinados na primeira urina da manhã. A cistinúria foi definida por meio da análise de cristais e/ou cálculos. RESULTADOS: A relação homem:mulher foi de 1:1,7. A média de idade na primeira sintomatologia foi de 35,8 ± 13,3 anos, não havendo diferença entre os gêneros. A faixa etária mais acometida foi entre 20 e 39 anos (56,3%); 72,4% apresentaram cólica nefrética, 69,5% procuraram a emergência médica, 46,7% apresentaram um episódio de litíase e 53,3% eram recorrentes. O rim direito foi o mais afetado (44,4%) nas mulheres, enquanto que nos homens o acometimento foi bilateral (39,7%). As principais alterações metabólicas encontradas foram hipernatriúria (80,7%), seguida de hipercalciúria (48,7%), hiperuricosúria (17,3%) e cistinúria em 5 (2,5%). A média do pH urinário foi de 5,74 ± 0,59 e da densidade urinária, de 1015,6 ± 7,1. O volume urinário foi baixo em 43% dos casos. CONCLUSÃO: Em nosso meio, a litíase acomete adultos jovens entre 20-39 anos, com predominância do gênero feminino, e os distúrbios mais frequentes, em ordem decrescente, foram hipernatriúria, hipercalciúria e hiperuricosúria, associadas à baixa ingestão de líquidos.

A leptospirose é a zoonose mais importante do mundo. Os pacientes são tipicamente homens jovens. Vários fatores estão envolvidos na insuficiência renal aguda (IRA) na leptospirose, incluindo ação nefrotóxica direta da leptospira, hiperbilirrubinemia, rabdomiólise e hipovolemia. Os principais achados histológicos são nefrite intersticial aguda e necrose tubular aguda. A IRA na leptospirose é geralmente não oligúrica e hipocalêmica. Alterações da função tubular precedem a queda na taxa de filtração glomerular, o que poderia explicar a alta frequência de hipocalemia. O tratamento antibiótico é eficaz nas fases precoces e tardias e/ou graves. Para pacientes críticos com IRA na leptospirose, as seguintes condutas são recomendadas: hemodiálise precoce e diária; baixa infusão de volume (devido ao risco de hemorragia pulmonar), e estratégias de proteção pulmonar. A mortalidade na IRA associada à leptospirose está em torno de 22%.

PURPOSE: To compare chemical to morphological kidney stone composition analysis based on a sample of 50 stones retrieved from patients at a nephrology service. METHODS: The chemical analysis was performed with a Bioclin® kit, while a 10-mm magnifying glass (10x; Prolabo, Paris, France) was employed in the morphological analysis. Findings obtained with the two methods were compared and classified as concordant (100% agreement), partly concordant (concordant for major components, discordant for minor components) or discordant (discordant for major components). RESULTS: In the chemical analysis, the most commonly observed major component was calcium (70%), followed by oxalate (66%), ammonium (56%), urate (28%) and carbonate (24%). In the morphological analysis, the most commonly observed major components were calcium phosphate and magnesium (32% each), followed by calcium oxalate monohydrate (24%), uric acid and urates (20% each), calcium oxalate dihydrate (18%) and cystine (6%). Infectious kidney stones were identified in 34% and 24% of cases by morphological and chemical analysis, respectively. Thirty-eight percent of the samples were classified as concordant, 52% were partly concordant and 10% were discordant. CONCLUSION: We suggest kidney stones be routinely submitted to both types of analysis for a better understanding of the mechanisms involved in lithogenesis.OBJETIVO: Comparar a análise química com a análise morfológica de 50 cálculos urinários provenientes de pacientes em um serviço de nefrologia. MÉTODOS: A análise química foi realizada utilizando o kit da Bioclin®, enquanto que a morfológica foi realizada com auxílio de uma lupa de 10mm (Prolabo, Paris, France). A comparação entre as técnicas foi classificada em concordante (100% de concordância), parcialmente concordante (componentes majoritários concordantes e minoritários discordantes) e discordante (discordância nos componentes majoritários). RESULTADOS: Na análise química os principais componentes majoritários foram cálcio (70%), oxalato (66%), amônio (56%), urato (28%) e carbonato (24%). Na análise morfológica os principais componentes majoritários foram fosfato cálcico (PCa) e magnesiano-PCa (32%), oxalato de cálcio monohidratado (24%), ácido úrico e uratos (20%), oxalato de cálcio dihidratado (18%) e cistina (6%). Cálculos de infecção foram identificados em 34% e 24% casos pela análise morfológica e química, respectivamente. Concordância total foi observada em 38%, concordância parcial em 52% e discordância em 10%. CONCLUSÃO: Sugere-se a utilização simultânea das duas técnicas para melhor compreensão dos mecanismos litogênicos.