Risk factors for acute kidney injury after liver transplantation in intensive care unit: a retrospective cohort study

ABSTRACT BACKGROUND: Acute kidney injury (AKI) is a frequent complication during the postoperative period following liver transplantation. Occurrence of AKI in intensive care unit (ICU) patients is associated with increased mortality and higher costs. OBJECTIVE: To evaluate occurrences of moderate or severe AKI among patients admitted to the ICU after liver transplantation and investigate characteristics associated with this complication. DESIGN AND SETTING: Single-center retrospective cohort study in a public hospital, Belo Horizonte, Brazil. METHODS: Forty-nine patients admitted to the ICU between January 2015 and April 2017 were included. AKI was defined from a modified Kidney Disease Improving Global Outcomes (KDIGO) score (i.e. based exclusively on serum creatinine levels). RESULTS: Eighteen patients (36.7%) developed AKI KDIGO 2 or 3; mostly KDIGO 3 (16 out of the 18 patients). Lactate level within the first six hours after ICU admission (odds ratio, OR: 1.3; 95% confidence interval, CI: 1.021-1.717; P = 0.034) and blood transfusion requirement within the first week following transplantation (OR: 8.4; 95% CI: 1.687-41.824; P = 0.009) were independently associated with development of AKI. Patients with AKI KDIGO 2 or 3 underwent more renal replacement therapy (72.2% versus 3.2%; P < 0.01), had longer hospital stay (20 days versus 15 days; P = 0.001), higher in-hospital mortality (44.4% versus 6.5%; P < 0.01) and higher mortality rate after one year (44.4% versus 9.7%; P = 0.01). CONCLUSION: Need for blood transfusion during ICU stay and hyperlactatemia within the first six postoperative hours after liver transplantation are independently associated with moderate or severe AKI. Developing AKI is apparently associated with poor outcomes.

Perfil dos pacientes de pós-operatório oncológico em centro de terapia intensiva / Profile of post oncologic surgery patients in an intensive care center

Objetivo: descrever as características epidemiológicas e clínicas dos pacientes em pós-operatório de cirurgia oncológica e sua relação com o desfecho óbito. MÉTODO: estudo retrospectivo de caráter descritivo baseado na coleta de dados de pacientes internados no Centro de Tratamento Intensivo (CTI) do Hospital Alberto Cavalcanti (Fundação Hospitalar do Estado de Minas Gerais), no período de maio de 2008 a maio de 2009 com base em seu Banco de Dados. Resultado: foram analisados 44 pacientes em pós-operatório de cirurgia oncológica. A idade média foi de 62 anos (DP= + 14,3). O sexo masculino foi o predominante (62%). O Apache II dos pacientes que evoluíram para óbito foi significativamente maior (p<0,001*). A insuficiência renal foi observada em 20%, determinando aumento de risco de evolução para óbito (p<0,001*), RR 4,5, IC95% 1,326 ?15,277). O uso de ventilação mecânica observou-se em 54% dos pacientes e relacionou-se significativamente com o óbito (p=0,011, RR 1,412, IC 1,092 ? 1,825). As aminas foram utilizadas por 27% dos pacientes, determinando, também, relação estatisticamente significativa com o desfecho (p<0,001*, RR 2,4, IC 1,229 ? 4,688). Os antimicrobianos, a nutrição parenteral total e a laparostomia com bolsa de Bogotá foram usados em 41, 14 e 9% dos pacientes. Discussão: o aumento dos casos de câncer levando a maior demanda por internação em CTI torna necessário mais conhecimento das características clínicas e epidemiológicas desses pacientes, em especial de sua evolução em decorrência da instabilidade de órgãos e sistemas principais e de sua recuperação para a manutenção de vida autônoma e de qualidade. Conclussões: a evolução dos pacientes para o óbito associou-se`a sua classificalção em Apache II, uso de ventilação mecânica, de aminas vasoativas e desenvolvimento de insuficiência renal aguda.

Objective: To describe the epidemiologic and clinic characteristics of post oncologic surgery patients and their relation with cases of death. Method: This descriptive, retrospective study builds on data collected from the Hospital Alberto Cavalcanti database regarding patients treated in the intensive care center from May 2008 through May 2009. Results: Data analysis addressed 44 post oncologic surgery patients. Mean age was 62 years (SD = +14,3). Male patients outnumbered female patients (62 %). Apache II was significantly higher among those patients that eventually died (p<0.001*). Kidney failure was reported among 20% of patients, increasing death risk (p<0.001*, RR 4.5, CI 95 %, 1.326-15.277). Use of mechanical ventilation was reported in 54 % of patients and significantly related to death (p=0.011, RR 1.412, CI 1.092-1.825). Use of amines was reported in 27 % pulof patients and was also significantly related to death (p<0.001*, RR 2.4, CI 1.229-4.688). Use of antimicrobial drugs, total parenteral nutrition and laparotomy with Bogota bag were reported in 41, 14 and 9 % of patients respectively. Discussion: Given the increased number of cancer cases and the subsequent demand of intensive care treatment, it is necessary to gain understanding of both clinic and epidemiologic characteristics of such patients, especially of their progress in response to instability of major organs and systems as well as of their recovery and maintenance of well-being and autonomous life. Conclusions: Patients? progression to death was related to Apache II classification, use of mechanical ventilation, vasoactive amines, and acute kidney failure.

Estudo de pacientes reanimados pós-parada cardiorrespiratória intra e extra-hospitalar submetidos à hipotermia terapêutica / Study of resuscitated in- and out-hospital cardiorespiratory arrest patients undergoing therapeutic hypothermia

OBJETIVO: Conhecer as características dos pacientes submetidos a um protocolo operacional padrão institucional de atendimento a pacientes reanimados após episódio de parada cardiorrespiratória incluindo a aplicação de hipotermia terapêutica. MÉTODOS: Foram analisados retrospectivamente 26 pacientes consecutivos após episódio de parada cardiorrespiratória de janeiro de 2007 a novembro de 2008. RESULTADOS: Todos os casos foram submetidos a hipotermia terapêutica. Idade média de 63 anos, predominantemente do sexo masculino. O local da parada cardiorrespiratória foi extra-hospitalar em 8 casos, pronto socorro em 3, durante internação fora da unidade de terapia intensiva em 13 casos e o bloco cirúrgico em 2 casos. O ritmo de parada foi fibrilação ventricular em sete pacientes, assistolia em 11, atividade elétrica sem pulso em 5 casos e não foi determinado em 3 pacientes. O intervalo entre a parada e o retorno à circulação espontânea foi de 12 ± 5 minutos. O tempo requerido para alcançar a temperatura alvo foi de 5 ± 4 horas, o tempo de hipotermia foi de 22 ± 6 horas e para o reaquecimento usaram-se 9 ± 5,9 horas. Catorze pacientes evoluíram a óbito na unidade de terapia intensiva, representando uma mortalidade de 54 por cento, e três pacientes tiveram o mesmo desfecho durante a internação, determinando uma mortalidade intra-hospitalar de 66 por cento. Houve redução estatisticamente significativa dos valores de hemoglobina (p <0,001), leucócitos (p=0,001), plaquetas (p<0,001), lactato (p<0,001) e potássio (p=0,009), e aumento de proteína C reativa (p=0,001) e RNI (p=0,004) após aplicação de hipotermia. CONCLUSÕES: A elaboração de protocolo operacional padrão de hipotermia terapêutica para o tratamento de pacientes com parada cardiorrespiratória, utilizando-se das rotinas adaptadas de estudos randomizados, resultou em elevada aderência e seus resultados assemelham-se aos dados publicados na literatura.

OBJECTIVE: To determine the characteristics of patients undergoing standard institutional protocol for management of resuscitated patients after a cardiac arrest episode, including therapeutic hypothermia. METHODS: This was a retrospective analysis of 26 consecutive patients admitted following cardiac arrest, between January 2007 and November 2008. RESULTS: All cases underwent therapeutic hypothermia. Average age was 63 years, and the patients were predominantly male. Cardiac arrest event was out-of-hospital in 8 cases, in the emergency room in 3 cases, in the wards in 13 cases and in the operation room in 2 cases. The cardiac arrest rhythm was ventricular fibrillation in seven patients, asystolia in 11, pulseless electrical activity in 5 cases, and was undetermined in 3 patients. The interval between the cardiac arrest and return of spontaneous circulation was 12 minutes (SD ± 5 min). The time to reach the target temperature was 5 ± 4 hours, the hypothermia time was 22 ± 6 hours and time to rewarming 9 ± 5.9 hours. Fourteen patients died in the intensive care unit, a 54 percent mortality, and three patients died during the in-hospital stay, a 66 percent in-hospital mortality. There was statistically significant reduction in hemoglobin (p<0.001), leukocytes (p=0.001), platelets (p<0.001), lactate (p<0.001) and potassium (p=0.009), values and increased C reactive protein (p=0.001) and INR (p=0.004) after hypothermia. CONCLUSIONS: The creation of a standard operative protocol for therapeutic hypothermia in post cardiac arrest patients management resulted in a high use of therapeutic hypothermia. The clinical results of this protocol adapted from randomized studies are similar to the literature.

Estudo das características epidemiológicas e clínicas de pacientes portadores do vírus da imunodeficiência humana em Pronto Atendimento do Hospital das Clínicas da Universidade Federal de Minas Gerais / Study on the clinical and epidemiological characteristics of patients with human immunodeficiency virus at the walk-in service of the teaching hospital of the Federal University of Minas Gerais

Este trabalho objetiva a análise prospectiva das características clínicas e epidemiológicas que levam os pacientes adultos com HIV/AIDS a procurarem atendimento clínico de urgência em Pronto Atendimento do Hospital das Clínicas da Universidade Federal de Minas Gerais. Noventa e nove pacientes perfizeram 118 internações. A idade foi em média 39,4 anos. A relação homem e mulher foi de 1,35:1. O tempo desde o diagnóstico até a admissão situou-se de forma mais freqüente entre 0-5 anos em 40,4 por cento dos casos. A terapêutica anti-retroviral era usada regularmente em 56,8 por cento das admissões. A contagem de linfócitos T CD4+ foi inferior a 200 células/mm³ em 45,7 por cento dos pacientes. As queixas mais freqüentes foram aumento da temperatura corpórea, diarréia, tosse e dispnéia. O aparelho respiratório foi o mais acometido. As doenças oportunistas mais freqüentes foram pneumocistose, pneumonia comunitária, síndrome diarréica, e candidiase oral. A demanda de internações de pacientes com HIV representou 2,8 por cento das admissões, com tempo médio de permanência hospitalar de 4,6 dias. Os pacientes possuíam, em sua maioria, contagem de linfócitos TCD4+ baixa, quase metade não usava a terapia anti-retroviral altamente eficaz. Houve tendência à feminização. As doenças relacionadas à AIDS continuam sendo as mais freqüentes no nosso meio.

This study had the aim of prospectively analyzing the clinical and epidemiological characteristics that lead adult patients with HIV/AIDS to seek urgent medical care in the walk-in service of the teaching hospital of the Federal University of Minas Gerais. Over a one-year period, all admissions of adult patients with HIV were evaluated. There were 118 admissions involving 99 patients. Their mean age was 39.4 years. The male-to-female ratio was 1.35:1. The length of time from diagnosis to admission was most frequently 0-5 years (40.4 percent of the cases). Antiretroviral therapy was being regularly used among 56.8 percent of the admissions. The T CD4+ lymphocyte count was less than 200 cells/mm³ in 45.7 percent of the patients. The most frequent complaints were increased body temperature, diarrhea, coughing and dyspnea. The respiratory tract was the region most affected. The most common opportunistic diseases were pneumocystosis, community-acquired pneumonia, diarrheal syndrome and oral candidiasis. The demand for admissions among HIV patients represented 2.8 percent of all admissions, with an average length of stay of 4.6 days. Most of the patients had low T CD4+ lymphocyte counts, and almost half of them were not taking highly active antiretroviral therapy. There was a tendency towards feminization. AIDS-related diseases continue to be the most frequent occurrences within our setting.