Incidence, predictors and prognosis of acute kidney injury in nonagenarians: an in-hospital cohort study.

BACKGROUND: Given the aging of the population, nephrologists are ever more frequently assisting nonagenarians with acute kidney injury (AKI). The management of these patients presents unique characteristics, including bioethical dilemmas, such as the utilization of renal replacement therapy (RRT) at this extreme age. METHODS: We conducted a retrospective cohort study at a tertiary hospital. Over a 10-year period, 832 nonagenarians were hospitalized for two or more days. A random sample of 461 patients was obtained; 25 subjects were excluded due to lack of essential data. AKI was defined and staged according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: We analyzed data from 436 patients, mean age 93.5 ± 3.3 years, 74.3% female; 76.4% required intensive care unit (ICU). The incidence of AKI was 45%. Length of hospital stay, ICU admission, vasopressors, and mechanical ventilation (MV) were independent predictors of AKI. Overall in-hospital mortality was 43.1%. Mortality was higher in the AKI compared to the no AKI group (66.8% vs. 23.8%, p < 0.001). Only 13 patients underwent RRT; all were critically ill, requiring vasopressors and 76.9% in MV. Mortality for this RRT group was 100% but not significantly higher than that observed in 26 non-RRT controls (96.1%, p = 1.0) obtained by proportional random sampling, matched by variables related to illness severity. In multivariable analysis, age, Charlson's score, vasopressors, MV, and AKI - but not RRT - were independent predictors of mortality. CONCLUSIONS: AKI is common in hospitalized nonagenarians and carries a grave prognosis, especially in those who are critically iil. The use of RRT was not able to change the fatal prognosis of this subgroup of patients. Our data may help guide informed decisions about the utility of RRT in this scenario.

Hormonal and Psychogenic Risk Factors for Erectile Dysfunction in Men with HTLV-1.

INTRODUCTION: Erectile dysfunction (ED) is associated with neurological damage due to human T-lymphotropic virus 1 (HTLV-1) infection, but hormonal and psychogenic factors also cause ED. AIM: To evaluate the association of psychogenic and hormonal factors with ED in men infected with HTLV-1. METHODS: In this cross-sectional study, we compared total testosterone, follicle stimulating hormone, luteinizing hormone, prolactin, anxiety symptoms, depressive symptoms, and neurologic manifestations in HTLV-1-infected men with or without ED. The International Index of Erectile Function was used to determine the degree of ED. Participants were grouped according to Osame's Motor Disability Scale and the Expanded Disability Status Scale: HTLV-1-associated myelopathy or tropical spastic paraparesis (HAM/TSP), probable HAM/TSP, or HTLV-1 carrier. Chi-square and Fisher's exact tests were used to compare the groups, and regression analyses were used to show predictors of ED. MAIN OUTCOME MEASURE: Sexual hormonal levels, psychogenic factors, and neurologic disabilities were found to be associated with ED. RESULTS: ED was associated with age older than 60 years (P < .001), degree of neurologic involvement (P < .001), depression (P = .009), and anxiety (P = .008). In the multivariate analyses, only age and degree of neurological injury remained as risk factors for ED. CLINICAL IMPLICATIONS: Neurological manifestations are a stronger predictor of ED than hormonal and psychogenic factors in HTLV-1-infected men. STRENGTHS & LIMITATIONS: The statistical power of the study was limited due to the low number of participants, but neurologic manifestations were clearly associated with ED. There was no strong association between hormonal and psychogenic factors and ED. CONCLUSION: Hormonal and psychogenic factors did not show a strong association with ED in individuals with HTLV-1, but neurological manifestations were strongly associated with ED in these individuals. de Oliveira CJV, Neto, JAC, Andrade RCP, et al. Hormonal and Psychogenic Risk Factors for Erectile Dysfunction in Men with HTLV-1. J Sex Med 2019; 16:1763-1768.

Risk Factors for Erectile Dysfunction in Men With HTLV-1.

BACKGROUND: Erectile dysfunction (ED) occurs in more than 50% of patients with human T-cell lymphotropic virus type 1 (HTLV-1) infection. In the general population, atherosclerosis is the main risk factor related to ED. AIM: To compare the contribution of neurologic disorders from HTLV-1 with that of atherosclerosis as risk factors for ED in men with HTLV-1. METHODS: In this cross-sectional study, men 18 to 70 years old with HTLV-1 were classified into one of two groups according to the presence or absence of ED. They were compared for obesity, waist circumference, dyslipidemia, metabolic syndrome, diabetes mellitus, high blood pressure, and neurologic manifestations. Comparisons between proportions were performed using the χ2 or Fisher exact test. Logistic regression analysis was performed to identify predictors of ED. Subjects with HTLV-1 were classified into three groups based on Osame's Disability Motor Scale and the Expanded Disability Status Scale: (i) HTLV-1 carriers; (ii) probable HTLV-1-associated myelopathy or tropical spastic paraparesis; and (iii) definitive HTLV-1-associated myelopathy or tropical spastic paraparesis. The International Index of Erectile Function was used to determine the degree of ED. RESULTS: In univariate logistic regression, age older 60 years (P = .003), diabetes mellitus (P = .042), and neurologic disease (P < .001) were associated with ED. In the multivariate model, the odds of ED was highest in patients with neurologic disease (odds ratio = 22.1, 95% CI = 5.3-92.3), followed by high blood pressure (odds ratio = 6.3, 95% CI = 1.4-30.5) and age older than 60 years (odds ratio = 4.6, 95% CI = 1.3-17.3). CLINICAL IMPLICATIONS: In men infected with HTLV-1, neurologic dysfunction is a stronger predictor of ED than risk factors for atherosclerosis. STRENGTHS AND LIMITATIONS: The small number of patients limited the power of the statistical analysis, but clearly neurologic manifestations had a greater association with ED than risk factors for atherosclerosis, and there was no association between metabolic syndrome and severity of ED. CONCLUSION: Neurologic impairment is the major cause of ED in individuals infected with HTLV-1 and risk factors for atherosclerosis did not have a strong relation with ED in this population. de Oliveira CJV, Neto JAC, Andrade RCP, et al. Risk Factors for Erectile Dysfunction in Men With HTLV-1. J Sex Med 2017;14:1195-1200.

Prevalence and risk factors for Human T-Lymphotropic Virus Type 1 (HTLV-1) among maintenance hemodialysis patients.

BACKGROUND: Infection with the human T-cell lymphotropic virus type 1 (HTLV-1), although asymptomatic in most cases, can lead to potentially grave consequences, such as adult T-cell leukemia-lymphoma and HTLV-1-associated myelopathy / tropical spastic paraparesis. Its prevalence varies widely across different populations and geographic regions. A population-based study in the city of Salvador, located in the Northeast region of Brazil, showed an overall prevalence of HTLV-1 seropositivity of 1.7%. Blood borne virus infections are recognized as important hazards for patients and staff in maintenance hemodialysis (MHD) units but most studies focus on hepatitis B, hepatitis C and human immunodeficiency viruses. There are scarce data about HTLV-1 infection in the MHD population. We aimed to determine the prevalence and risk factors for HTLV-1 infection among MHD patients in the city of Salvador-Bahia, Brazil. METHODS: We conducted a multi-center, cross-sectional study nested in a prospective cohort of MHD patients enrolled from four outpatient clinics. HTLV-1 screening was performed with ELISA and positive cases were confirmed by Western Blot. Factors associated with HTLV-1 seropositivity were identified by multivariable logistic regression. RESULTS: 605 patients were included in the study. The overall prevalence of HTLV-1 infection was 2.48% (15/605), which was similar to that of hepatitis B [1.98% (12/605)] and C [3.14% (19/605)] viruses in our sample. HTLV-1 seropositivity was positively associated with age [prevalence odds ratio (POR) 1.04; 95% confidence interval (CI) 1.01-1.08], unmarried status (POR 3.65; 95% CI 1.13-11.65), and history of blood transfusion (POR 3.35; 95% CI 1.01-11.13). CONCLUSIONS: The overall prevalence of HTLV-1 infection in a sample of MHD patients was similar to that of other viral infections, such as hepatitis B and C. Our data revealed that MHD patients who are older, unmarried or who have received blood transfusions are at higher risk for HTLV-1 infection.

Incidence, Predictors, and Impact on Hospital Mortality of Amphotericin B Nephrotoxicity Defined Using Newer Acute Kidney Injury Diagnostic Criteria.

Studies on amphotericin B (AmB) nephrotoxicity use diverse definitions of acute kidney injury (AKI). Here, we used the new Kidney Disease Improving Global Outcome (KDIGO) system to describe the incidence, predictors, and impact of AmB-induced AKI on hospital mortality in 162 patients treated with AmB (120 with deoxycholate preparation and 42 with liposomal preparation). KDIGO stage 1 requires an absolute increase of ≥0.3 mg/dl or ≥1.5× over baseline serum creatinine (SCr), while stage 2 requires ≥2×, and stage 3 requires ≥3×. A binary KDIGO definition (KDIGObin) corresponds to stage ≥1. For comparison, we included two definitions of AKI traditionally utilized in nephrotoxicity studies: ≥0.5 mg/dl (NT0.5) and ≥2× (NT2×) increase in baseline SCr. The overall incidence of AmB-induced AKI by KDIGObin was 58.6% (stage 1, 30.9%; stage 2, 18.5%; stage 3, 9.3%). Predictors of AKI by KDIGObin were older age and use of furosemide and angiotensin-converting enzyme inhibitor (ACE-I). Traditional criteria detected lower incidences of AKI, at 45.1% (NT0.5) and 27.8% (NT2×). Predictors of AKI by traditional criteria were older age and use of vancomycin (NT0.5) and use of vancomycin and vasopressors (NT2×). KDIGObin detected AKI 2 days earlier than the most sensitive traditional criterion. However, only traditional criteria were associated with intensive care unit (ICU) admission, mechanical ventilation, and mortality. In conclusion, the increase in sensitivity of KDIGObin is accompanied by a loss of specificity and ability to predict outcomes. Prospective studies are required to weigh the potential gain from early AKI detection against the potential loss from undue changes in management in patients with subtle elevations in SCr.

Role of urine neutrophil gelatinase-associated lipocalin in the early diagnosis of amphotericin B-induced acute kidney injury.

Determination of the neutrophil gelatinase-associated lipocalin (NGAL) level can be used to detect acute kidney injury (AKI) earlier than determination of the serum creatinine (SCr) level in settings such as cardiac surgery, contrast nephropathy, and intensive care units. We hypothesized that urine NGAL (UrNGAL) would be an early biomarker of drug nephrotoxicity. To test this, we studied hemodynamically stable patients treated with amphotericin B (AmB). We measured the SCr and UrNGAL levels at the baseline and daily after initiation of AmB up to day 14 or development of AKI by the use of the SCr criterion. AKI was defined according to a Kidney Disease: Improving Global Outcomes (KDIGO) criterion (an increase in the SCr level by ≥0.3 mg/dl within 48 h or an SCr level ≥1.5 times the baseline level within 7 days). We studied 24 patients with a mean age of 48.4 ± 16.4 years. Most patients were male, and the patients received AmB (12 received AmB deoxycholate and 12 received liposomal AmB) for the treatment of leishmaniasis (91.7%). Overall, 17/24 patients fulfilled a KDIGO criterion for AKI. Peak UrNGAL levels were higher in patients with AKI than in patients without AKI and in recipients of AmB deoxycholate than in recipients of liposomal AmB. The diagnostic performance of the UrNGAL level on day 5 for the detection of AKI was moderate, with the area under the curve (AUC) being 0.68 (95% confidence interval [CI], 0.41 to 0.95). In the subgroup receiving AmB deoxycholate, however, the AUC rose to 0.89 (95% CI, 0.67 to 1.00). In a patient-level analysis, we found that AKI could be detected 3.2 days earlier by the use of the UrNGAL criterion than by the use of the SCr criterion (times to AKI by the UrNGAL and SCr criteria, 3.7 ± 2.5 versus 6.9 ± 3.3 days, respectively; P = 0.001). Future studies should evaluate if a treatment strategy oriented toward evaluation of UrNGAL levels will improve outcomes. These findings for AmB-induced AKI in leishmaniasis patients could serve as a basis for the investigation of urine biomarkers in the early detection of drug nephrotoxicity in other clinical settings.

Opinions of students from a Brazilian medical school regarding online professionalism.

INTRODUCTION: Unprofessional online behavior by medical students or physicians may damage individual careers, and the reputation of institutions and the medical profession. What is considered unprofessional online behavior, however, is not clearly defined and may vary in different cultures. OBJECTIVES: To determine the frequency with which students from a Brazilian Medical School come across ten given examples of unprofessional online behavior by medical students or physicians, and gather the opinions of participants regarding the appropriateness of these behaviors. METHODS: A cross-sectional survey of 350 students from the Medical School of Bahia, Brazil. Only those who had a profile in social media were included in the final analyses. RESULTS: 336/350 (96.0%) medical students kept a profile in social media. Only 13.5% reported having discussions about online professionalism during ethics classes. They reported witnessing the investigated examples of unprofessional online behavior with varying frequencies, ranging from 13.7% for "violation of patient's privacy" to 85.4% for "photos depicting consumption of alcoholic beverages". Most participants felt neutral about posting "pictures in bathing suits", whereas the vast majority rated "violation of patient's privacy" as totally inappropriate. When presented with a case vignette illustrating violation of patients' privacy (publication of pictures of hospitalized children or neonates in social media), however, most participants felt neutral about it. Participants considered all investigated examples of unprofessional online behavior more inappropriate if carried out by doctors rather than by students. CONCLUSIONS: Medical students are witnessing a high frequency of unprofessional online behavior by their peers and physicians. Most investigated behaviors were considered inappropriate, especially if carried out by physicians. Participants were not able to recognize the publication of pictures of hospitalized children or neonates in social media as cases of violation of patients' privacy. Further studies are needed to determine if an academic curriculum that fosters online professionalism will change this scenario.

Osmotic demyelination as a complication of hyponatremia correction: a systematic review.

BACKGROUND: Rapid correction of hyponatremia, especially when severe and chronic, can result in osmotic demyelination. The latest guideline for diagnosis and treatment of hyponatremia (2014) recommends a correction limit of 10 mEq/L/day. Our aim was to summarize published cases of osmotic demyelination to assess the adequacy of this recommendation. METHOD: Systematic review of case reports of osmotic demyelination. We included cases confirmed by imaging or pathology exam, in people over 18 years of age, published between 1997 and 2019, in English or Portuguese. RESULTS: We evaluated 96 cases of osmotic demyelination, 58.3% female, with a mean age of 48.2 ± 12.9 years. Median admission serum sodium was 105 mEq/L and > 90% of patients had severe hyponatremia (<120 mEq/L). Reports of gastrointestinal tract disorders (38.5%), alcoholism (31.3%) and use of diuretics (27%) were common. Correction of hyponatremia was performed mainly with isotonic (46.9%) or hypertonic (33.7%) saline solution. Correction of associated hypokalemia occurred in 18.8%. In 66.6% of cases there was correction of natremia above 10 mEq/L on the first day of hospitalization; the rate was not reported in 22.9% and in only 10.4% was it less than 10 mEq/L/day. CONCLUSION: The development of osmotic demyelination was predominant in women under 50 years of age, with severe hyponatremia and rapid correction. In 10.4% of cases, there was demyelination even with correction <10 mEq/L/day. These data reinforce the need for conservative targets for high-risk patients, such as 4-6 mEq/L/day, not exceeding the limit of 8 mEq/L/day.

Case fatality rate among COVID-19 patients treated with acute kidney replacement therapy.

INTRODUCTION: Acute kidney injury (AKI) is a frequent complication of severe COVID-19 and is associated with high case fatality rate (CFR). However, there is scarcity of data referring to the CFR of AKI patients that underwent kidney replacement therapy (KRT) in Brazil. The main objective of this study was to describe the CFR of critically ill COVID-19 patients treated with acute kidney replacement therapy (AKRT). METHODS: Retrospective descriptive cohort study. We included all patients treated with AKRT at an intensive care unit in a single tertiary hospital over a 15-month period. We excluded patients under the age of 18 years, patients with chronic kidney disease on maintenance dialysis, and cases in which AKI preceded COVID-19 infection. RESULTS: A total of 100 out of 1479 (6.7%) hospitalized COVID-19 patients were enrolled in this study. The median age was 74.5 years (IQR 64 - 82) and 59% were male. Hypertension (76%) and diabetes mellitus (56%) were common. At the first KRT prescription, 85% of the patients were on invasive mechanical ventilation and 71% were using vasoactive drugs. Continuous veno-venous hemodiafiltration (CVVHDF) was the preferred KRT modality (82%). CFR was 93% and 81 out of 93 deaths (87%) occurred within the first 10 days of KRT onset. CONCLUSION: AKRT in hospitalized COVID-19 patients resulted in a CFR of 93%. Patients treated with AKRT were typically older, critically ill, and most died within 10 days of diagnosis. Better strategies to address this issue are urgently needed.

Hemodiafiltration versus Hemodialysis in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis.

Rationale & Objective: The use of hemodiafiltration (HDF) as a kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD) has sparked a debate regarding its advantages over conventional hemodialysis (HD). The present study aims to shed light on this controversy by comparing mortality rates and cause-specific deaths between ESKD patients receiving HDF and those undergoing HD. Study Design: Systematic review and meta-analysis of randomized controlled trials (RCTs). The search was conducted using PubMed, EMBASE, and Cochrane Central on July 1, 2023. Setting & Participants: Adult patients with ESKD on regular KRT. Exposure: Studies with participants undergoing HDF. Outcomes: Primary outcomes were all-cause mortality, cardiovascular (CV) mortality, deaths related to infections, and kidney transplant. We also evaluated the endpoints for deaths related to malignancy, myocardial infarction, stroke, arrhythmias, and sudden death. Analytical Approach: We included RCTs evaluating HDF versus HD. Crossover trials and studies with overlapping populations were excluded. Two authors independently extracted the data following predefined search criteria and quality assessment. The risk of bias was assessed with Cochrane's RoB2 tool. Results: We included 5 RCTs with 4,143 patients, of which 2,078 (50.1%) underwent HDF, whereas 2,065 (49.8%) were receiving HD. Overall, HDF was associated with a lower risk of all-cause mortality (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.73-0.91; P < 0.001; I2 = 7%) and a lower risk of CV-related deaths (RR, 0.75; 95% CI, 0.61-0.92; P = 0.007; I2 = 0%). The incidence of infection-related deaths was also significantly different between therapies (RR, 0.69; 95% CI, 0.50-0.95; P = 0.02; I2 = 26%). Limitations: In individual studies, the HDF groups achieved varying levels of convection volume. Conclusions: Compared with those undergoing HD, patients receiving HDF experienced a reduction in all-cause mortality, CV mortality, and infection-related mortality. These results provide compelling evidence supporting the use of HDF as a beneficial intervention in ESKD patients undergoing KRT. Registration: Registered at PROSPERO: CRD42023438362.

Assessment of Immune and Clinical Response in Patients with Mucosal Leishmaniasis Treated with Pentavalent Antimony and Pentoxifylline.

Mucosal leishmaniasis (ML) is a severe form of tegumentary leishmaniasis associated with a persistent inflammatory response. High levels of TNF, IFN-γ, CXCL9 and CXCL10 are found in ML patients, and the association of pentoxifylline with antimony is more effective in decreasing the healing time in ML patients when compared to antimony alone. The present study aimed to investigate the existence of a correlation between cytokine and chemokine production and ML severity and evaluate the potential value of cytokine and chemokine production as marker of therapeutic response in ML patients. This prospective study included 86 subjects in an area of endemic Leishmania braziliensis transmission. Patients diagnosed with ML were classified into clinical stages ranging from I to V according to disease severity. TNF, IFN-γ, CXCL9 and CXCL10 levels were quantified in the supernatant of the mononuclear cell cultures by ELISA before and after treatment with antimony alone or antimony plus pentoxifylline. The median TNF level in the group with mild disease (Stages I-II) was 1064 pg/mL (142-3738 pg/mL), while, in the group with moderate or severe disease (Stages III-V), it was 1941 pg/mL (529-5294 pg/mL) (p = 0.008). A direct correlation was observed between ML clinical severity and levels of TNF production (r = 0.44, p = 0.007). Patients who were treated with antimony and pentoxifylline healed significantly faster than those treated with antimony alone (52 vs. 77 days, hazard ratio = 0.60; 95% confidence interval = 0.38-0.95, p = 0.013). Therapeutic failure was higher in the group that received antimony alone (25% vs. 7%; p = 0.041). There was a significant decrease in CXCL9 after therapy of ML in both groups (p = 0.013; p = 0.043). TNF levels are associated with the severity of mucosal diseases, and pentoxifylline associated with antimony should be the recommended therapy for ML in countries where liposomal amphotericin B is not available.

Bladder dysfunction in human T cell lymphotropic virus infection: A prospective cohort study.

BACKGROUND: While bladder dysfunction is observed in the majority of patients with human T cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy (HAM), it is also observed in patients who do not fulfill all diagnostic criteria for HAM. These patients are classified as having possible or probable HAM/TSP. However, it remains unclear whether the severity and progression of bladder dysfunction occurs similarly between these two groups. OBJECTIVE: Compare the severity and evolution of bladder dysfunction in HTLV-1-infected patients with possible and definite HAM/TSP. METHODS: The present prospective cohort study followed 90 HTLV-1 patients with possible HAM/TSP and 84 with definite HAM/TSP between April 2011 and February 2019. Bladder dysfunction was evaluated by bladder diary, overactive bladder symptoms scores (OABSS) and urodynamic studies. Bladder dysfunction progression was defined as the need for clean self-intermittent catheterization (CIC). RESULTS: At baseline, nocturia, urgency and OABSS scores were worse in definite compared to possible HAM/TSP patients. The main urodynamic finding was detrusor overactivity, present in 77.8% of the patients with definite HAM/TSP versus 58.7% of those with possible HAM/TSP (P = 0.05). Upon study conclusion, the cumulative frequency of patients requiring CIC increased in both groups, from 2 to 6 in possible HAM/TSP and from 28 to 44 in definite HAM/TSP patients. The estimated time to need for CIC was 6.7 years (95%CI 6.5-7.0) in the possible HAM/TSP group compared to 5.5 years (95%CI 4.8-6.1) in the definite HAM/TSP group. CONCLUSIONS: Although both groups showed similarities in bladder dysfunction and tended to progress to requiring CIC over time, patients with possible HAM/TSP presented less severe manifestations at baseline and progressed more slowly than those with definite HAM/TSP.

Schistosomal glomerulopathy and changes in the distribution of histological patterns of glomerular diseases in Bahia, Brazil.

Distinct patterns of glomerular lesions, including membranoproliferative glomerulonephritis and focal segmental glomerulosclerosis, are associated with infection by Schistosoma mansoni or Schistosoma japonicum. Evidence suggests that immune complex deposition is the main mechanism underlying the different forms of schistosomal glomerulonephritis and that immune complex deposition may be intensified by portal hypertension. The relationship between focal segmental glomerulosclerosis and schistosomiasis remains poorly understood. A clinicopathologic classification of schistosomal glomerulopathies was proposed in 1992 by the African Association of Nephrology. In Brazil, mass treatment with oral medications has led to a decrease in the occurrence of schistosomal glomerulopathy. In a survey of renal biopsies performed in Salvador, Brazil, from 2003-2009, only 24 (4%) patients were identified as positive for S. mansoni infection. Among these patients, only one had the hepatosplenic form of the disease. Focal segmental glomerulosclerosis was found in seven patients and membranoproliferative glomerulonephritis was found in four patients. Although retrospective studies on the prevalence of renal diseases based on kidney biopsies may be influenced by many patient selection biases, a change in the distribution of glomerulopathies associated with nephrotic syndrome was observed along with a decline in the occurrence of severe forms of schistosomiasis.

Positive fluid balance as an early biomarker for acute kidney injury: a prospective study in critically ill adult patients.

OBJECTIVES: Positive fluid balance is frequent in critically ill patients and has been considered a potential biomarker for acute kidney injury (AKI). This study aimed to evaluate positive fluid balance as a biomarker for the early detection of AKI in critically ill patients. METHODS: This was a prospective cohort study. The sample was composed of patients ≥18 years old who stayed ≥3 days in an intensive care unit. Fluid balance, urinary output and serum creatinine were assessed daily. AKI was diagnosed by the Kidney Disease Improving Global Outcome criteria. RESULTS: The final cohort was composed of 233 patients. AKI occurred in 92 patients (40%) after a median of 3 (2-6) days following ICU admission. When fluid balance was assessed as a continuous variable, a 100-ml increase in fluid balance was independently associated with a 4% increase in the odds of AKI (OR 1.04; 95% CI 1.01-1.08). Positive fluid balance categorized using different thresholds was always significantly associated with subsequent detection of AKI. The mixed effects model showed that increased fluid balance preceded AKI by 4 to 6 days. CONCLUSION: These results suggest that a positive fluid balance might be an early biomarker for AKI development in critically ill patients.

Challenges in clinical-pathologic correlations: acute tubular necrosis in a patient with collapsing focal and segmental glomerulosclerosis mimicking rapidly progressive glomerulonephritis.

Herein, we report a case of acute kidney injury (AKI) due to diarrhea-induced acute tubular necrosis (ATN) in a patient with nephrotic syndrome secondary to biopsy-proven collapsing focal and segmental glomerulosclerosis (FSGS). The clinical picture mimicked rapidly progressive glomerulonephritis (RPGN) and motivated pulse therapy with methylprednisolone and cyclophosphamide. The case presentation is followed by a brief overview of the epidemiology of AKI in nephrotic syndrome as well as a discussion of its risk factors and potential mechanisms involved.

Osmotic demyelination as a complication of hyponatremia correction: a systematic review / Desmielinização osmótica como complicação da correção de hiponatremia: uma revisão sistemática

ABSTRACT Background: Rapid correction of hyponatremia, especially when severe and chronic, can result in osmotic demyelination. The latest guideline for diagnosis and treatment of hyponatremia (2014) recommends a correction limit of 10 mEq/L/day. Our aim was to summarize published cases of osmotic demyelination to assess the adequacy of this recommendation. Method: Systematic review of case reports of osmotic demyelination. We included cases confirmed by imaging or pathology exam, in people over 18 years of age, published between 1997 and 2019, in English or Portuguese. Results: We evaluated 96 cases of osmotic demyelination, 58.3% female, with a mean age of 48.2 ± 12.9 years. Median admission serum sodium was 105 mEq/L and > 90% of patients had severe hyponatremia (<120 mEq/L). Reports of gastrointestinal tract disorders (38.5%), alcoholism (31.3%) and use of diuretics (27%) were common. Correction of hyponatremia was performed mainly with isotonic (46.9%) or hypertonic (33.7%) saline solution. Correction of associated hypokalemia occurred in 18.8%. In 66.6% of cases there was correction of natremia above 10 mEq/L on the first day of hospitalization; the rate was not reported in 22.9% and in only 10.4% was it less than 10 mEq/L/day. Conclusion: The development of osmotic demyelination was predominant in women under 50 years of age, with severe hyponatremia and rapid correction. In 10.4% of cases, there was demyelination even with correction <10 mEq/L/day. These data reinforce the need for conservative targets for high-risk patients, such as 4-6 mEq/L/day, not exceeding the limit of 8 mEq/L/day.

RESUMO Antecedentes: A correção rápida da hiponatremia, principalmente quando grave e crônica, pode resultar em desmielinização osmótica. A última diretriz para diagnóstico e tratamento da hiponatremia (2014) recomenda um limite de correção de 10 mEq/L/dia. Nosso objetivo foi sumarizar os casos publicados de desmielinização osmótica para avaliar a adequação dessa recomendação. Método: Revisão sistemática de relatos de caso de desmielinização osmótica. Incluímos casos confirmados por imagem ou anatomia patológica, em maiores de 18 anos, publicados entre 1997 e 2019, nas línguas inglesa ou portuguesa. Resultados: Avaliamos 96 casos de desmielinização osmótica, sendo 58,3% do sexo feminino e com média de idade de 48,2 ± 12,9 anos. A mediana de sódio sérico admissional foi 105 mEq/L e > 90% dos pacientes apresentavam hiponatremia grave (<120 mEq/L). Foram comuns os relatos de distúrbios do trato gastrointestinal (38,5%), etilismo (31,3%) e uso de diuréticos (27%). A correção da hiponatremia foi feita principalmente com solução salina isotônica (46,9%) ou hipertônica (33,7%). Correção de hipocalemia associada ocorreu em 18,8%. Em 66,6% dos casos houve correção da natremia acima de 10 mEq/L no primeiro dia de internamento; a velocidade não foi relatada em 22,9% e em apenas 10,4% foi menor que 10 mEq/L/dia. Conclusão: O desenvolvimento da desmielinização osmótica foi predominante em mulheres, abaixo de 50 anos, com hiponatremia grave e correção rápida. Em 10,4% dos casos, houve desmielinização mesmo com correção <10 mEq/L/dia. Esses dados reforçam a necessidade de alvos conservadores para pacientes de alto risco, como 4-6 mEq/L/dia, não ultrapassando o limite de 8 mEq/L/dia.

Case fatality rate among COVID-19 patients treated with acute kidney replacement therapy / Letalidade entre pacientes com injúria renal aguda por COVID-19 tratados com suporte renal artificial

Abstract Introduction: Acute kidney injury (AKI) is a frequent complication of severe COVID-19 and is associated with high case fatality rate (CFR). However, there is scarcity of data referring to the CFR of AKI patients that underwent kidney replacement therapy (KRT) in Brazil. The main objective of this study was to describe the CFR of critically ill COVID-19 patients treated with acute kidney replacement therapy (AKRT). Methods: Retrospective descriptive cohort study. We included all patients treated with AKRT at an intensive care unit in a single tertiary hospital over a 15-month period. We excluded patients under the age of 18 years, patients with chronic kidney disease on maintenance dialysis, and cases in which AKI preceded COVID-19 infection. Results: A total of 100 out of 1479 (6.7%) hospitalized COVID-19 patients were enrolled in this study. The median age was 74.5 years (IQR 64 - 82) and 59% were male. Hypertension (76%) and diabetes mellitus (56%) were common. At the first KRT prescription, 85% of the patients were on invasive mechanical ventilation and 71% were using vasoactive drugs. Continuous veno-venous hemodiafiltration (CVVHDF) was the preferred KRT modality (82%). CFR was 93% and 81 out of 93 deaths (87%) occurred within the first 10 days of KRT onset. Conclusion: AKRT in hospitalized COVID-19 patients resulted in a CFR of 93%. Patients treated with AKRT were typically older, critically ill, and most died within 10 days of diagnosis. Better strategies to address this issue are urgently needed.

Resumo Introdução: Injúria renal aguda (IRA) é uma complicação frequente da COVID-19 grave e está associada a alta taxa de letalidade (TL). Entretanto, há escassez de dados referentes à TL de pacientes com IRA submetidos a suporte renal artificial (SRA) no Brasil. O objetivo principal deste estudo foi descrever a TL de pacientes graves com IRA por COVID-19 tratados com SRA. Métodos: Estudo de coorte descritivo retrospectivo. Incluímos todos os pacientes tratados com SRA em unidade de terapia intensiva de um único hospital terciário por 15 meses. Excluímos pacientes menores de 18 anos, pacientes com doença renal crônica em diálise de manutenção e casos nos quais a IRA precedeu a infeção por COVID-19. Resultados: Incluímos neste estudo um total de 100 dos 1479 (6,7%) pacientes hospitalizados com COVID-19. A mediana de idade foi 74,5 anos (IIQ 64 - 82) e 59% eram homens. Hipertensão (76%) e diabetes mellitus (56%) foram comuns. Na primeira prescrição de SRA, 85% dos pacientes estavam em ventilação mecânica invasiva e 71% em uso de drogas vasoativas. A hemodiafiltração contínua foi a modalidade de SRA preferida (82%). A TL foi de 93% e 81 dos 93 óbitos (87%) ocorreram nos primeiros 10 dias do início da SRA. Conclusão: O SRA em pacientes hospi­talizados com IRA por COVID-19 resultou em TL de 93%. Os pacientes tratados com SRA eram geralmente idosos, gravemente enfermos e a maioria foi a óbito em até 10 dias após o diagnóstico. Estratégias melhores para abordar esse problema são urgentemente necessárias.

Prevalence of Bowel Symptoms in Patients Infected with Human T-Lymphotropic type 1 Virus.

INTRODUCTION: Bowel dysfunction is frequent in patients with spinal cord diseases, but little is known about the prevalence of bowel symptoms in human T-lymphotropic virus-(HTLV-1) infected individuals. The purpose of this study is to determine the frequency of bowel symptoms in HTLV-1 infected individuals and their correlation with the degree of neurologic disease. METHODS: This is a cross-sectional study comparing the frequency of bowel symptoms in HTLV-1-infected individuals* and seronegative donors (controls). Patients answered a questionnaire, the Rome III Criteria was applied, and stool consistency was evaluated by the Bristol Stool Form Scale. The individuals were classified as HTLV-1 carriers, probable HTLV-1 myelopathy and definitive HTLV-1 associated myelopathy or tropical spastic paraparesis (definitive HAM / TSP)**. RESULTS: We studied 72 HTLV-1 infected individuals and 72 controls with equal age and gender distribution. Constipation was the most frequent complaint, occurring in 38 % of HTLV-1 individuals and in 15 % of the controls. In comparison to the seronegative controls, the probability of constipation occurrence was approximately 18 times higher in definitive HAM / TSP patients. Straining, lumpy or hard stools, sensation of anorectal obstruction/blockage, fewer than 3 defecations per week, flatulence, soiling, evacuation pain, and bleeding were also more frequent in the HTLV-1 patients than in the controls. Moreover, bowel symptoms were more frequent in patients with definitive or probable HAM / TSP than in carriers. CONCLUSIONS: Bowel symptoms were more frequent in HTLV-1-infected patients than in seronegative controls and the frequency of bowel symptoms correlated with the severity of neurologic disease.

Venous Thromboembolism After Adult Lung Transplantation: A Frequent Event Associated With Lower Survival.

BACKGROUND: The incidence of venous thromboembolism (VTE) after lung transplantation (LTX) varies significantly across studies. Two studies have suggested that these thrombotic events are associated with a lower posttransplant survival. Herein, we sought to determine the incidence, predictors, and impact of VTE on survival after LTX at a quaternary referral center. METHODS: This was a large cohort study of LTX recipients. Key outcome parameters were time to VTE after transplant and survival. Deep vein thrombosis (DVT) diagnosis required a positive ultrasound. Pulmonary embolism diagnosis required either a positive chest computed tomography angiogram or a high-probability ventilation/perfusion scan. RESULTS: The overall incidence of VTE among 701 LTX recipients was 43.8%, of which 97.7% were DVT episodes, of which 71.3% were in the upper extremities. Predictors of VTE were prior history of DVT (hazard ratio [HR], 2.82; 95% confidence interval [CI], 1.49-5.37), days in intensive care (HR, 1.01; 95% CI, 1.01-1.02), and the use of extracorporeal membrane oxygenation (HR, 2.22; 95% CI, 1.43-3.45). Importantly, VTE predicted a lower posttransplant survival (HR, 1.70; 95% CI, 1.28-2.26), when occurring within or after the first 30 days. The location of the DVT, either upper extremity or below the knee, also predicted a poor survival. CONCLUSIONS: VTE was frequent in LTX recipients and predicted a poor survival even when located in the upper extremities or below the knee. These data suggest that aggressive VTE screening/treatment protocols be implemented in post-LTX population.

Relationship between vitamin D status, glycemic control and cardiovascular risk factors in Brazilians with type 2 diabetes mellitus.

OBJECTIVES: Determine the prevalence and identify predictors of hypovitaminosis D in patients with type 2 diabetes mellitus (T2DM); 2) correlate vitamin D levels with variables indicative of glycemic control and cardiovascular risk. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study with consecutive patients treated at a University Hospital's Endocrinology outpatient clinic located at 12°58'S latitude, between October 2012 and November 2013. Hypovitaminosis D was defined as 25-hydroxyvitamin D < 30 ng/mL (chemiluminescence). RESULTS: We evaluated 108 patients with mean duration of T2DM of 14.34 ± 8.05 years and HbA1c of 9.2 ± 2.1%. Mean age was 58.29 ± 10.34 years. Most were women (72.2%), non-white (89.8%) and had hypertension (75.9%) and dyslipidemia (76.8%). Mean BMI was 28.01 ± 4.64 kg/m2; 75.9% were overweight. The prevalence of hypovitaminosis D was 62%. In multiple logistic regression, independent predictors of hypovitaminosis D were female gender (OR 3.10, p = 0.02), dyslipidemia (OR 6.50, p < 0.01) and obesity (OR 2.55, p = 0.07). In multiple linear regression, only total cholesterol (ß = -0.36, p < 0.01) and BMI (ß = -0.21, p = 0.04) remained associated with levels of 25-hydroxyvitamin D. CONCLUSIONS: Using currently recommended cutoffs, the prevalence of hypovitaminosis D in Brazilians with T2DM was as high as that of non-tropical regions. Female gender, dyslipidemia and obesity were predictors of hypovitaminosis D. Low levels of 25-hydroxyvitamin D were correlated with high cholesterol and BMI values. Future studies are needed to evaluate whether vitamin D replacement would improve these parameters and reduce hard cardiovascular outcomes.