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Abstract Hyperparathyroidism-induced hypercalcemic crisis (HIHC) is an unusual state of marked progressive pri mary hyperparathyroidism (PHPT). Patients have severe hypercalcemia and may have severe symptoms such as kidney failure, acute pancreatitis, and mental changes. PHPT is due to the presence of a single gland adenoma/ disease in 80 to 85%; parathyroid carcinoma is reported in <1%. Among patients with adenoma, atypical parathy roid tumor can be found infrequently. Parathyroidectomy is the only curative approach for PHPT. In this report we present three cases of HIHC due to giant parathyroid adenomas (GPAs), one of them with histopathological characteristics of an atypical parathyroid tumor, with satisfactory evolution after parathyroidectomy.
Resumen La crisis hipercalcémica inducida por hiperparatiroi dismo (HIHC) es un estado inusual de hiperparatiroidis mo primario progresivo y marcado (HPTP). Los pacientes tienen hipercalcemia grave y pueden tener síntomas graves como insuficiencia renal, pancreatitis aguda y cambios mentales. El HPTP se debe a la presencia de un adenoma/enfermedad de una sola glándula en 80 a 85%; el carcinoma de paratiroides se informa en <1%. Entre los pacientes con adenoma, el tumor paratiroideo atípico se puede encontrar con baja frecuencia. La paratiroidec tomía es el único abordaje curativo del HPTP. En este reporte presentamos tres casos de HIHC por adenomas paratiroideos gigantes (APGs), uno de ellos con características histopatológicas de tumor paratiroideo atípico, con evolución satisfactoria luego de paratiroidectomía.
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Objective:To explore the role of thioredoxin interaction protein (TXNIP)/NOD-like receptor protein 3 (NLRP3) pathway in renal interstitial fibrosis induced by renal ischemia-reperfusion injury (IRI) in mice.Methods:Adult male C57BL/6J mice aged 6 to 8 weeks and TXNIP knockout mice with the same genetic background were selected. The wild type mice were divided into the sham operation (Sham) group and renal IRI group. The TXNIP knockout mice were divided into the sham+TXNIP KO group and IRI+TXNIP KO group, with 12 mice in each group. The model of renal ischemia-reperfusion injury was established by clamping bilateral renal pedicles for 45 min and then restoring perfusion. The sham operation model was only dissociated bilateral renal arteries without other treatment. Blood creatinine, urea nitrogen, kidney injury molecule-1 (Kim-1) and neutrophil gelatinase-associated lipocalin (NGAL), blood transforming growth factor-β (TGF-β) and interleukin 6 (IL-6) were measured on the 1st, 7th and 28th days after reperfusion. The renal cortex was taken on the 1st and 28th days for Masson staining, in which the renal tubule-interstitial injury score was obtained. TGF-β and IL-6 mRNA expression were detected by qPCR, TXNIP, NLRP3, Pro-IL-1β, IL-1β and α-SMA protein expression were detected by Western blot, and MDA and SOD levels were detected by ELISA. Homogeneity test of variance was performed before the statistics of normal distribution measurement data, one-way ANOVA was used for the comparison between multiple groups, and LSD- t test was used for the comparison between the two groups. Results:On the 1st, 7th and 28th days after IRI, compared with the sham group, the Scr, BUN, Kim-1, NGAL, TGF-β and IL-6 were increased continuously in the IRI group ( P<0.05). On the 28th day after IRI, large areas of collagen fibers and inflammatory cell infiltration were observed in the renal interstitium of the IRI group. In the IRI group, the scores of renal tubular injury and renal interstitial fibrosis on the 28th day were significantly higher than those on the 1st day (all P<0.05). On the 1st, 7th and 28th days after IRI, compared with the IRI group, the levels of Scr, BUN, Kim-1, NGAL, TGF-β and IL-6 were significantly decreased in the IRI+TXNIP KO group (all P<0.05). On the 1st and 28th days after IRI, compared to the IRI group, the areas of collagen fibers and inflammatory cell infiltration in the renal interstitium of the IRI+TXNIP KO group were decreased. The renal tubule injury score [Day 1, (192.2 ± 62.4) vs. (103.2 ± 49.1); Day 28, (154.3 ± 93.6) vs. (64.3 ± 24.8), both P<0.05] and interstitial fibrosis score [Day 1, (7.3 ± 3.2) vs. (4.8 ± 1.7); Day 28, (12.8 ± 3.9) vs. (2.3 ± 0.8), both P<0.05] were all decreased. The expression of TGF-β, IL-6 mRNA, TXNIP, NLRP3, Pro-IL-1 β, IL-1 β and α-SMA protein in renal cortex were significantly decreased (both P<0.05). In renal cortex, MDA level was decreased and SOD level was increased (all P<0.05). Conclusions:TXNIP/NLRP3 pathway is involved in the development of renal interstitial inflammation and fibrosis after renal ischemia and reperfusion. Knockout or inhibition of TXNIP can inhibit the progression of acute renal injury to chronic renal disease.
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Abstract The Department of Acute Kidney Injury (IRA) of the Brazilian Society of Nephrology prepared this document for the purpose of standardizing AKI terminology and dialysis modalities in the Portuguese language for Brazil. Several terms with similar meanings have been used in AKI and its dialysis modalities, causing confusion and disparities among patients, nephrologists, health institutions, private care companies, insurance companies and government entities. These disparities can impact medical care, hospital organization and care, as well as the funding and reimbursement of AKI-related procedures. Thus, consensual nomenclature and definitions were developed, including the definitions of AKI, acute kidney disease (AKD) and chronic kidney disease (CKD). Additionally, we addressed all dialysis modalities and extracorporeal procedures related to AKI, currently approved and available in the country. The Brazilian Society of Nephrology hopes that this Consensus can standardize the terminology and provide technical support to all involved in AKI care in Brazil.
Resumo O Departamento de Injúria Renal Aguda (IRA) da Sociedade Brasileira de Nefrologia elaborou o presente documento para fins de padronização da terminologia em IRA e modalidades dialíticas na língua portuguesa para o Brasil. Diversos termos com significados semelhantes têm sido empregados em IRA e suas modalidades dialíticas, causando confusão e disparidades entre pacientes, nefrologistas, instituições de saúde, empresas privadas de assistência, seguradoras e entidades governamentais. Essas disparidades podem impactar a assistência médica, a organização e o atendimento hospitalares, assim como o financiamento e reembolso dos procedimentos relacionados com a IRA. Assim, nomenclatura e definições consensuais foram elaboradas, incluindo-se as definições de IRA, doença renal aguda (DRA) e doença renal crônica (DRC). Adicionalmente, todas as modalidades dialíticas e os procedimentos extracorpóreos relacionados a IRA, atualmente aprovados e disponíveis no país, foram abordados. A Sociedade Brasileira de Nefrologia espera que este Consenso possa padronizar a nomenclatura e prover suporte técnico para todos os atores envolvidos na assistência à IRA no Brasil.
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Objective: Most cases of severe metabolic alkalosis have many causes that may result in renal failure and death. Therefore, these should be treated promptly for successful recovery.Patient: A 61-year-old man was hospitalized due to an acute kidney injury (creatinine level of 4.36 mg/dL) after a 3-month history of anorexia and recurrent vomiting. He had been treated for tuberculosis in the past.Results: Blood gas analysis revealed severe metabolic alkalosis with pH=7.66, HCO3=94 mmol/L, and pCO2=82.0 mmHg. Routine biochemical examination revealed severe hypokalemia (K 2.9 mEq/L) that was associated with prolonged QTc interval (0.52 seconds) on the electrocardiogram. Gastrofiberscopic examination also revealed severe stenosis and ulcerated scarring of the gastric pylorus and severe esophagitis. Intravenous hydration and correction of hypokalemia improved renal function and resolved metabolic alkalosis. An investigation that was repeated after 6 days revealed a creatinine level of 1.58 mg/dL, pH=7.47, HCO3=23.4 mmol/L, K=3.6 mEq/L, and QTc of 0.45 seconds. The patient underwent gastrectomy and adenocarcinoma was observed.Conclusion: We described a resolved case of severe metabolic alkalosis and acute kidney injury in a rural medical setting following conservative management.
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Objective@#To investigate the risk factors of clinically diagnosed acute kidney injury (AKI) patients progressing to acute kidney disease (AKD).@*Methods@#The clinical data of AKI patients admitted to the First Affiliated Hospital of Zhengzhou University from January 1, 2018 to December 31, 2018 were retrospectively analyzed. According to the outcome of the patients, AKI patients were divided into non-acute kidney disease (NAKD) group and AKD group. Clinical characteristics and laboratory data of two groups were compared. The risk factors of AKD in patients with AKI were analyzed by logistic regression, and then the receiver operating characteristic curve (ROC) was drawn to evaluate the predictive value of these risk factors.@*Results@#A total of 254 patients with AKI were enrolled, and 186 patients developed AKD with an incidence of 73.2%. The incidences of AKD in stage 1, stage 2 and stage 3 of AKI were 20.0%, 46.7% and 83.5% respectively. Multivariate logistic regression analysis showed increased peak serum creatinine (within 7 days after AKI diagnosis) (OR=2.561, 95% CI 1.584-4.140, P<0.001), proteinuria (OR=2.952, 95% CI 1.162-7.500, P=0.023) and increased intact parathyroid hormone (OR=1.757, 95%CI 1.104-2.797, P=0.017) were independent risk factors for progression to AKD in patients with AKI. The ROC showed that increased peak serum creatinine (within 7 days after AKI diagnosis) was an important predictor of AKD in patients with AKI (AUC=0.798, P<0.001).@*Conclusion@#Increased peak serum creatinine (within 7 days after AKI diagnosis), proteinuria and increased intact parathyroid hormone are independent risk factors for progression to AKD in patients with AKI, providing new evidences and ideas for clinical preventions and treatments of AKD.
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Objective To investigate the risk factors of clinically diagnosed acute kidney injury (AKI) patients progressing to acute kidney disease (AKD). Methods The clinical data of AKI patients admitted to the First Affiliated Hospital of Zhengzhou University from January 1, 2018 to December 31, 2018 were retrospectively analyzed. According to the outcome of the patients, AKI patients were divided into non - acute kidney disease (NAKD) group and AKD group. Clinical characteristics and laboratory data of two groups were compared. The risk factors of AKD in patients with AKI were analyzed by logistic regression, and then the receiver operating characteristic curve (ROC) was drawn to evaluate the predictive value of these risk factors. Results A total of 254 patients with AKI were enrolled, and 186 patients developed AKD with an incidence of 73.2％. Theincidences of AKD in stage 1, stage 2 and stage 3 of AKI were 20.0％, 46.7％and 83.5％respectively. Multivariate logistic regression analysis showed increased peak serum creatinine (within 7 days after AKI diagnosis) (OR=2.561, 95％ CI 1.584-4.140, P<0.001), proteinuria (OR=2.952, 95％ CI 1.162-7.500, P=0.023) and increased intact parathyroid hormone (OR=1.757, 95％CI 1.104-2.797, P=0.017) were independent risk factors for progression to AKD in patients with AKI. The ROC showed that increased peak serum creatinine (within 7 days after AKI diagnosis) was an important predictor of AKD in patients with AKI (AUC=0.798, P<0.001). Conclusion Increased peak serum creatinine (within 7 days after AKI diagnosis), proteinuria and increased intact parathyroid hormone are independent risk factors for progression to AKD in patients with AKI, providing new evidences and ideas for clinical preventions and treatments of AKD.
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Resumen ANTECEDENTES: la insuficiencia renal aguda es una de las complicaciones más severas de la cirrosis y conlleva un pronóstico ominoso. Los estudios que han utilizado definiciones más actuales de daño renal agudo, como AKIN (Acute Kidney Injury Network) o RIFLE (The Risk, Injury, Failure, Loss and End-stage kidney disease criteria) se enfocan en pacientes admitidos en unidades de cuidados intensivos y no pueden generalizarse a otros pacientes hospitalizados. El Club Internacional de Ascitis (ICA por sus siglas en inglés) recientemente adoptó una definición dinámica de insuficiencia renal crónica en pacientes con cirrosis, definiéndola como el incremento de la creatinina sérica mayor o igual de 0.3 mg/dL en las últimas 48 horas o un incremento de más de 50% de la creatinina basal conocida ocurrida en los últimos siete días, estadificándose de acuerdo con los incrementos de la creatinina. OBJETIVO: evaluar la repercusión de la severidad de la insuficiencia renal aguda de acuerdo con la clasificación del Club Internacional de Ascitis en la mortalidad de los pacientes con cirrosis hepática hospitalizados, así como conocer los principales desencadenantes de insuficiencia renal aguda en pacientes con cirrosis hepática hospitalizados, los patrones de recuperación o progresión de la misma. PACIENTES Y MÉTODO: estudio transversal, observacional, no aleatorizado y multicéntrico, en el que se utilizó la definición de insuficiencia renal aguda propuesta por el Club Internacional de Ascitis. Los pacientes se captaron en un lapso de cuatro meses, del 1 de abril al 31 de julio de 2015, en el Hospital General Ticomán y en el Hospital General de Ecatepec; se solicitó consentimiento informado de los pacientes o en caso pertinente, del familiar responsable del mismo. Se excluyeron los pacientes menores de 18 años, sujetos con insuficiencia hepática aguda y los pacientes con enfermedad renal crónica. RESULTADOS: se incluyeron 45 pacientes con cirrosis hepática, de los que 36 eran hombres, con edad promedio de 46.2 años. La causa de la cirrosis hepática fue por alcohol en 40 pacientes (89%), viral en 3 (7%) y mixta en 2 (4%); la estadificación de insuficiencia renal aguda inicial fue: estadio 1: 36 (80%), estadio 2: 8 (18%) y estadio 3: 1 (2%). Ocurrieron siete defunciones (15.5%); de éstas, todos los pacientes estaban en la categoría C de la clasificación Child-Pugh, con insuficiencia renal aguda en estadio inicial 1; en 6 (13%) pacientes con progresión a estadio 3 y en estadio inicial 2; en 1 (2%) paciente con progresión a estadio 3. La severidad de la cirrosis en la escala MELD (Model for End-Stage Liver Disease) fue de 31.07±8.44 puntos en los pacientes que fallecieron versus 22.98±9.64 puntos (p=1.21) en los supervivientes. El puntaje de Child-Pugh en el grupo de pacientes fallecidos fue de 14.29±0.9 vs 0.29±2.31 en los supervivientes (p=0.001). CONCLUSIONES: la mortalidad en pacientes con cirrosis hepática e insuficiencia renal aguda fue más frecuente en pacientes con progresión al estadio de insuficiencia renal aguda y en sujetos con mayor severidad de la cirrosis hepática, valorada por Child-Pugh o por la escala MELD. Se requieren estudios de cohorte en nuestra población para validar la reciente clasificación del Club Internacional de Ascitis de la insuficiencia renal aguda en cirrosis y para determinar los factores asociados con incremento en la mortalidad en este grupo de pacientes.
Abstract BACKGROUND: Acute renal failure is one of the most severe complications of cirrhosis and entails a bad prognosis. The studies that had used most current definitions of acute kidney injury such as AKIN (Acute Kidney Injury Network) or RIFLE (The Risk, Injury, Failure, Loss and End-stage kidney disease criteria) has focused in patients admitted to the critical care units, and thus they can not be generalized to other hospitalized patients. Recently, the International Club of Ascites (ICA) adopted a dynamic definition of acute kidney failure in patient with cirrhosis, defined like increase of the creatinine level ≥0.3 mg/dL in the last 48 h; or a increase ≥50% from the basal creatinine in the last seven days, staged according the increase of creatinine. OBJECTIVES: To evaluate the impact of acute kidney injury severity according to the classification of the International Club of Ascites in the mortality of hospitalized patients with liver cirrhosis. To know the main triggers of acute kidney failure in hospitalized patients with liver cirrhosis, and to know the patterns of recovery and progression of renal failure. PATIENTS AND METHOD: A transversal, observational, no-randomized multicentric study designed. We used the definition of acute kidney failure proposed for the ICA. Patients were included from the General Hospital Ticoman and the General Hospital of Ecatepec in Mexico, in a four-month-period, from 1st April to 31st July of 2015; informed consent was obtained from the patients or in the pertinent case from the responsible familiar. Patients with less than 18 years old, with acute liver failure or chronic renal failure were excluded. RESULTS: They were included 45 patients with liver cirrhosis, 36 men, with a mean age of 46.2 years old. The etiology of the liver cirrhosis was alcohol in 40 patients (89%), viral in 3 (7%) and mixed in 2 (4%). The stage of acute liver failure was stage 1: 36 (80%), stage 2: 8 (18%) and stage 3: 1 (2%). Seven deaths occurred (15.5%), from there all the patients were classified in the C stage of the Child-Pugh Classification; death occurred with acute renal failure in initial stage 1; in 6 (13%) with progression to the stage 3 and in initial stage 2 in 1 (2%) with progression to stage 3. The severity of cirrhosis accord to the MELD classification was 31.07±8.44 points in the mortality cases, compared with 22.9±9.64 points (p=1.21) in the survivals. Child-Pugh score in the cases of death was 14.29±.9 vs 0.29±2.31 in survivals (p=0.001). CONCLUSION: Mortality in patients with liver cirrhosis and acute kidney failure was more frequent in patients with progression of the acute kidney failure, and in those with a more severe liver damage in the MELD or Child-Pugh scores. There are necessary cohort studies for the validation of the recent classification of the International Club of Ascites for Acute kidney failure in cirrhosis, and to determine the factors associated to the increase of mortality in this group of patients.