Incidence of contrast-associated acute kidney injury: a prospective cohort / Incidência de lesão renal aguda associada ao contraste: uma coorte prospectiva

ABSTRACT Introduction: Contrast-associated acute kidney injury (CA-AKI) is a deterioration of kidney function that occurs after the administration of a iodinated contrast medium (ICM). Most studies that defined this phenomenon used older ICMs that were more prone of causing CA-AKI. In the past decade, several articles questioned the true incidence of CA-AKI. However, there is still a paucity of a data about the safety of newer ICM. Objective: To assess the incidence of CA-AKI in hospitalized patients that were exposed to computed tomography (CT) with and without ICM. Methods: Prospective cohort study with 1003 patients who underwent CT in a tertiary hospital from December 2020 through March 2021. All inpatients aged > 18 years who had a CT scan during this period were screened for the study. CA-AKI was defined as a relative increase of serum creatinine of ≥ 50% from baseline or an absolute increase of ≥ 0.3 mg/dL within 18 to 48 hours after the CT. Chi-squared test, Kruskal-Wallis test, and linear regression model with restricted cubic splines were used for statistical analyses. Results: The incidence of CA-AKI was 10.1% in the ICM-exposed group and 12.4% in the control group when using the absolute increase criterion. The creatinine variation from baseline was not significantly different between groups. After adjusting for baseline factors, contrast use did not correlate with worse renal function. Conclusion: The rate of CA-AKI is very low, if present at all, with newer ICMs, and excessive caution regarding contrast use is probably unwarranted.

RESUMO Introdução: Lesão renal aguda associada ao contraste (LRA-AC) é uma deterioração da função renal que ocorre após a administração de meio de contraste iodado (MCI). A maioria dos estudos que definiram esse fenômeno utilizaram MCI mais antigos, mais propensos a causar LRA-AC. Na última década, diversos artigos questionaram a verdadeira incidência de LRA-AC. Entretanto, ainda há escassez de dados sobre a segurança dos MCI mais novos. Objetivo: Avaliar a incidência de LRA-AC em pacientes hospitalizados expostos à tomografia computadorizada (TC) com e sem MCI. Métodos: Estudo de coorte prospectivo com 1.003 pacientes submetidos a TC em hospital terciário, de dezembro/2020 a março/2021. Todos os pacientes internados com idade ≥ 18 anos que realizaram TC nesse período foram selecionados. A LRA-AC foi definida como aumento relativo de creatinina sérica de ≥ 50% em relação ao valor basal ou aumento absoluto de ≥ 0,3 mg/dL dentro de 18 a 48 horas após a TC. Utilizamos o teste qui-quadrado, teste de Kruskal-Wallis e modelo de regressão linear com splines cúbicos restritos para análises estatísticas. Resultados: A incidência de LRA-AC foi 10,1% no grupo exposto ao MCI e 12,4% no grupo controle ao usar o critério de aumento absoluto. A variação da creatinina em relação ao valor basal não foi significativamente diferente entre os grupos. Após ajuste para fatores basais, o uso de contraste não se correlacionou com pior função renal. Conclusão: A taxa de LRA-AC é muito baixa, caso exista, com MCIs mais novos, e a cautela excessiva quanto ao uso de contraste provavelmente não se justifica.

Incidence of contrast-associated acute kidney injury: a prospective cohort.

INTRODUCTION: Contrast-associated acute kidney injury (CA-AKI) is a deterioration of kidney function that occurs after the administration of a iodinated contrast medium (ICM). Most studies that defined this phenomenon used older ICMs that were more prone of causing CA-AKI. In the past decade, several articles questioned the true incidence of CA-AKI. However, there is still a paucity of a data about the safety of newer ICM. OBJECTIVE: To assess the incidence of CA-AKI in hospitalized patients that were exposed to computed tomography (CT) with and without ICM. METHODS: Prospective cohort study with 1003 patients who underwent CT in a tertiary hospital from December 2020 through March 2021. All inpatients aged > 18 years who had a CT scan during this period were screened for the study. CA-AKI was defined as a relative increase of serum creatinine of ≥ 50% from baseline or an absolute increase of ≥ 0.3 mg/dL within 18 to 48 hours after the CT. Chi-squared test, Kruskal-Wallis test, and linear regression model with restricted cubic splines were used for statistical analyses. RESULTS: The incidence of CA-AKI was 10.1% in the ICM-exposed group and 12.4% in the control group when using the absolute increase criterion. The creatinine variation from baseline was not significantly different between groups. After adjusting for baseline factors, contrast use did not correlate with worse renal function. CONCLUSION: The rate of CA-AKI is very low, if present at all, with newer ICMs, and excessive caution regarding contrast use is probably unwarranted.

Comparison of Incidence and Prognosis of Myocardial Injury in Patients with COVID-19-Related Respiratory Failure and Other Pulmonary Infections: A Contemporary Cohort Study.

Myocardial injury (MI) is frequent in critically ill patients with COVID-19, but its pathogenesis remains unclear. We hypothesized that MI is not solely due to viral infection by SARS-CoV-2 but rather due to the common pathophysiological mechanisms associated with severe pulmonary infections and respiratory failure. This contemporary cohort study was designed to compare the incidence of MI in patients with acute respiratory failure caused by COVID-19 to patients with other pulmonary infections. In addition, we aimed to investigate whether MI was a distinct risk factor for in-hospital mortality in patients with COVID-19 compared to those with non-COVID-19 infections. This study included 1444 patients with COVID-19 (55.5% men; age 58 (46;68) years) and 182 patients with other pulmonary infections (46.9% men; age 62 (44;73) years). The incidence of MI at ICU admission was lower in COVID-19 patients (36.4%) compared to non-COVID-19 patients (56%), and this difference persisted after adjusting for age, sex, coronary artery disease, heart failure, SOFA score, lactate, and C-reactive protein (RR 0.84 (95% CI, 0.71-0.99)). MI at ICU admission was associated with a 59% increase in mortality (RR 1.59 (1.36-1.86); p < 0.001), and there was no significant difference in the mortality between patients with COVID-19 and those with other pulmonary infections (p = 0.271). We concluded that MI is less frequent in patients with critical COVID-19 pneumonia and respiratory failure compared to those with other types of pneumonia. The occurrence of MI is a significant risk factor for in-hospital mortality, regardless of the etiology of the pulmonary infection.

Pulmonary embolism in patients with COVID-19 and D-dimer diagnostic value: A retrospective study.

BACKGROUND: D-dimer levels are significantly higher in COVID-19 patients with Pulmonary Thromboembolism (PTE) as compared to those without PTE, but its clinical utility is still uncertain. PURPOSE: To determine the D-dimer performance for ruling out PTE in patients with COVID-19. We also assessed clinical and laboratory factors associated with the presence of PTE on CT Pulmonary Angiogram (CTPA). METHODS: Retrospective study involving all patients who presented at a tertiary care hospital from March 2020 to May 2021 with severe acute respiratory syndrome from COVID-19, who underwent CTPA and had D-dimer collected within 48 hours from CTPA. The D-dimer ability to classify patients with or without PTE according to CTPA was evaluated. RESULTS: A total of 697 patients [382 (54.8%) men; mean (SD) age, 59 (20.5) years] were included, of which 71.5% required intensive care admission, 32.4% had PTE, and 35.6% died during hospitalization. PTE was independently associated with mortality [42.5% vs. 32.3%; p = 0.038]. D-dimer levels were higher in patients with PTE [9.1 (3.9; 20) vs. 2.3 (1.2; 5.1); p < 0.001]. Using the D-dimer cutoff of 0.5 µg/mL or above, sensitivity was 98.2% and specificity 5.7%. The 0.3 µg/mL threshold was associated with 100% of sensitivity for the presence of PTE, with which 99.1% of patients had increased values. ROC curve AUC was 0.77, demonstrating moderate discriminative power of D-dimers to detect PTE. CONCLUSIONS: D-dimer levels are higher among COVID-19 hospitalized patients with PTE as compared to those without PTE and have moderate discriminative power to detect PTE, but its use to exclude PTE in this population may have limited clinical utility.

Pulmonary embolism in patients with COVID-19 and D-dimer diagnostic value: A retrospective study

ABSTRACT Background: D-dimer levels are significantly higher in COVID-19 patients with Pulmonary Thromboembolism (PTE) as compared to those without PTE, but its clinical utility is still uncertain. Purpose: To determine the D-dimer performance for ruling out PTE in patients with COVID-19. We also assessed clinical and laboratory factors associated with the presence of PTE on CT Pulmonary Angiogram (CTPA). Methods: Retrospective study involving all patients who presented at a tertiary care hospital from March 2020 to May 2021 with severe acute respiratory syndrome from COVID-19, who underwent CTPA and had D-dimer collected within 48 hours from CTPA. The D-dimer ability to classify patients with or without PTE according to CTPA was evaluated. Results: A total of 697 patients [382 (54.8%) men; mean (SD) age, 59 (20.5) years] were included, of which 71.5% required intensive care admission, 32.4% had PTE, and 35.6% died during hospitalization. PTE was independently associated with mortality [42.5% vs. 32.3%; p = 0.038]. D-dimer levels were higher in patients with PTE [9.1 (3.9; 20) vs. 2.3 (1.2; 5.1); p < 0.001]. Using the D-dimer cutoff of 0.5 μg/mL or above, sensitivity was 98.2% and specificity 5.7%. The 0.3 μg/mL threshold was associated with 100% of sensitivity for the presence of PTE, with which 99.1% of patients had increased values. ROC curve AUC was 0.77, demonstrating moderate discriminative power of D-dimers to detect PTE. Conclusions: D-dimer levels are higher among COVID-19 hospitalized patients with PTE as compared to those without PTE and have moderate discriminative power to detect PTE, but its use to exclude PTE in this population may have limited clinical utility.

Preoperative Binge Eating and Weight Loss After Bariatric Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Several studies have investigated if bariatric surgery candidates with binge eating disorder (BED) are at risk for suboptimal postoperative weight loss. The aim of this systematic review with meta-analysis was to evaluate the association between binge eating diagnosed preoperatively and weight loss after bariatric surgery. METHODS: MEDLINE, EMBASE, CENTRAL, LILACS, and other specialized databases were searched on August 2020. Clinical trials and observational studies including individuals who had undergone any type of bariatric surgical treatment with preoperative evaluation of BED and at least one postoperative measure of weight were initially selected. Four reviewers independently screened for eligibility. The mean difference was calculated using the random-effects model. RESULTS: Nineteen studies, comprising 3223 participants (80.25% women; median age 41 years), met the inclusion criteria for meta-analysis. At 6 months postoperative, the percentage of total weight loss (%TWL) was not significantly different between BED and non-BED groups [6 studies, 914 participants: - 0.75% (95% CI, - 2.79 to 1.29; I2 = 0%)], even when analyzing only those three studies that included gold standard assessment tools. No significant differences were found at 12, 24, 36, or 60 months. CONCLUSIONS: Pre-bariatric BED seems to have little or no influence on weight loss after surgery. However, many questions remain unanswered because of the use of different measures across studies. The heterogeneity among studies emphasizes the importance of investigators using the same assessment measures.

Binge eating scores pre-bariatric surgery and subsequent weight loss: A prospective, 5 years follow-up study.

BACKGROUND & AIMS: To compare groups of bariatric patients with preoperative scores of Binge Eating Scale (BES) above and below the clinical cut off value on weight outcomes up to 60 months following surgery. METHODS: This is a prospective observational study involving 108 Brazilian patients (follow-up rate: 48.1%) operated by Roux-en-Y gastric bypass. In the preoperative period, they were clinically evaluated, and BES was applied. Based on the scores, patients were categorized as high or low according to established cut off 17 for binge eaters. Follow-up weight loss was obtained (3, 6, 12, 24, 36, 48, and 60 months) using data from medical records. The percentage of total weight loss (%TWL) was examined by generalized linear model. RESULTS: 41.7% of patients had BES scores higher than 17 at baseline. Weight loss was significant up to 12 months. The greatest weight loss was at 24 months of follow-up, ranging from 2.7 to 110.4 kg (mean 42.9 ± 17.8 kg). In the short postoperative period (3, 24, and 36 months), %TWL was significantly different between groups. At 24 months, patients with higher scores lost more %TWL than those with lower scores (35.1 ± 0.8% vs 31.6 ± 0.7%, p = 0.029). However, this difference was not fount at 60 months postoperatively (mean 28.9 ± 9.6%). In a multivariate analysis, the presence of depression, age, and BES score were not associated with %TWL at 24 and 60 months. CONCLUSIONS: The results suggest that preoperative BES scores point to a similar weight loss after bariatric surgery. Further studies with long-term follow-up are necessary to evaluate this finding.

Prevalence of Vitamin D Depletion, and Associated Factors, among Patients Undergoing Bariatric Surgery in Southern Brazil.

BACKGROUND: Hypovitaminosis D is common, before and after gastric bypass surgery. The prevalence of hypovitaminosis D in a large group of candidates for bariatric surgery in Brazil and South America has not been studied. OBJECTIVE: To evaluate the prevalence of hypovitaminosis D and associated factors in patients undergoing bariatric surgery in Southern Brazil. MATERIALS AND METHODS: Cross-sectional study involving all patients presenting for bariatric surgery at Hospital de Clínicas de Porto Alegre, from January 2013 to June 2018. Data were extracted from the patients' electronic medical records. Patients who were taking multivitamin supplements or vitamin D supplements, who had renal insufficiency, or had missing data for 25(OH) vitamin D [25(OH)D] levels were excluded. RESULTS: A total of 291 patients were included. Mean subjects' age was 44.9 (SD 10.7) years, and BMI 49.3 (SD 8.3) kg/m2; 76.6% of the study patients were women, and 87.3% were white. More than half the patients (55.3%) were vitamin D deficient (serum 25(OH)D ≤ 19.9 ng/ml), and 37.1% had insufficient levels (20-29.9 ng/mL). Mean vitamin D level was 19.2 ng/mL (SD 7.6). An inverse correlation was found between 25(OH)D levels and BMI. Vitamin D deficiency was more prevalent in patients with higher BMI [PR 1.02; CI 95% (1.00-1.03)], higher fasting glucose [PR 1.01; CI 95% (1.00-1.01)], in nonwhite patients [PR 1.58; CI 95% (1.30-1.92)] and during autumn/winter season [PR 1.41; CI 95% (1.14-1.75)]. CONCLUSIONS: Prevalence of vitamin D insufficiency and deficiency is very high among patients presenting for bariatric surgery in Southern Brazil, and the known associated factors are confirmed in this population.

Malignant otitis externa in a 21-year-old male patient with Prader-Willi syndrome.

Malignant otitis externa is an invasive infection of the external auditory canal and temporal bone with potentially life-threatening complications. Elderly patients with type 2 diabetes mellitus are the population most commonly affected by malignant otitis externa, but any type of immunosuppression predisposes to the disease. Prader-Willi syndrome is a genetic cause of obesity, often associated with insulin resistance and type 2 diabetes mellitus. This report describes a case of a 21-year-old male patient with Prader-Willi syndrome who had malignant otitis externa that progressed to sepsis during hospitalization. To the best of the authors' knowledge, this is the first description of malignant otitis externa in a young patient with Prader-Willi syndrome.

Polimorfismo Ala54Thr do gene fatty acid-binding protein-2 (FABP-2): uma revisão bibliográfica / The Ala54Thr polymorphism of the fatty acid-binding protein-2 (FABP-2) gene: a literature review

O polimorfismo p.Ala54Thr (rs1799883) do gene fatty acid-binding protein-2 (FABP2) tem associação com resistência insulínica, síndrome metabólica e obesidade. A hipótese é de que o alelo mutante aumente a absorção de ácidos graxos intestinais, a concentração lipídica plasmática e a oxidação de gordura. Assim, o objetivo deste trabalho foi revisar o papel do polimorfismo p.Ala54Thr do gene FABP-2 na obesidade. A busca da literatura foi realizada na base de dados MEDLINE, através do PubMed e no Portal de Periódicos de Aperfeiçoamento de Pessoal de Nível Superior (Capes) com termos relacionados com o polimorfismo e obesidade. Parece não haver uma associação significativa da presença do alelo Thr54 com obesidade, apesar de ser uma doença complexa e que possivelmente não tenha sido captada por estudos de associação; diferente do colesterol total e lipoproteína de baixa densidade (low density level cholesterol, LDL-c), maior nos portadores do alelo Thr54. Alterações de adipocitocinas devem estar associadas a estas diferenças de perfil lipídico.

The p.Ala54Thr polymorphism (rs1799883) of the fatty acid-binding Protein-2 (FABP-2) gene has been associated with insulin resistance, metabolic syndrome and obesity. The hypothesis that the mutant allele increases the absorption of fatty acid by the bowel, plasma lipid concentration, and fat oxidation. Thus, the aim of this study was to review the role of FABP-2 Ala54Thr polymorphism in obesity. A literature search was conducted in MEDLINE database, using PubMed and Capes Portal with terms related to polymorphism and obesity. It does not seem to be a significant association between Thr54 allele and obesity, although being a complex disease and that possibly has not been captured by association studies; unlike total cholesterol and low density level cholesterol (LDL-c), which were higher in Thr54 allele carriers. Adipocytokines changes should be associated with these differences in lipid profile.