Risk factors for mortality in coronavirus disease 2019 patients with silent hypoxemia.

OBJECTIVE: To describe the predictors of mortality in hospitalized patients with severe acute respiratory syndrome (SARS) due to COVID-19 presenting with silent hypoxemia. MATERIAL AND METHODS: Retrospective cohort study of hospitalized patients with SARS due to COVID-19 and silent hypoxemia at admission, in Brazil, from January to June 2021. The primary outcome of interest was in-hospital death. Multivariable logistic regression analysis was performed. RESULTS: Of 46,102 patients, the mean age was 59 ±â€¯16 years, and 41.6% were female. During hospitalization, 13,149 patients died. Compared to survivors, non-survivors were older (mean age, 66 vs. 56 years; P < 0.001), less frequently female (43.6% vs. 40.9%; P < 0.001), and more likely to have comorbidities (74.3% vs. 56.8%; P < 0.001). Non-survivors had higher needs for invasive mechanical ventilation (42.4% vs. 6.6%; P < 0.001) and intensive care unit admission (56.9% vs. 20%; P < 0.001) compared to survivors. In the multivariable regression analysis, advanced age (OR 1.04; 95%CI 1.037-1.04), presence of comorbidities (OR 1.54; 95%CI 1.47-1.62), cough (OR 0.74; 95%CI 0.71-0.79), respiratory distress (OR 1.32; 95%CI 1.26-1.38), and need for non-invasive respiratory support (OR 0.37; 95%CI 0.35-0.40) remained independently associated with death. CONCLUSIONS: Advanced age, presence of comorbidities, and respiratory distress were independent risk factors for mortality, while cough and requirement for non-invasive respiratory support were independent protective factors against mortality in hospitalized patients due to SARS due to COVID-19 with silent hypoxemia at presentation.

Development and validation of a simple machine learning tool to predict mortality in leptospirosis.

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 < 80 mmHg and hematocrit < 30%) and good predictive accuracy (AUC-ROC = 0.788). LeptoScore and QuickLepto had better accuracy to predict mortality in patients with leptospirosis when compared to SPIRO score (AUC-ROC = 0.500) and quick SOFA score (AUC-ROC = 0.782). The main result is a new scoring system, the QuickLepto, that is a simple and useful tool to predict death in leptospirosis patients at hospital admission.

[Controversy in estimating glomerular filtration rate through traditional equations in transgender people: discussion through a case report].

Introduction: Chronic kidney disease (CKD) and the number of transgender people is on the rise. Hormone replacement therapy may be associated with the development of adverse effects, including kidney disease. Objective: To report the case of a transgender patient using hormone therapy who developed CKD. Case Report: Male transgender patient, 28 years old, using testosterone cypionate every 15 days, without any comorbidity. Evolved with hypertensive peaks of 160-150/110 mmHg and loss of kidney function (Ur 102 mg/dl, Cr 3.5 mg/dl, estimated Glomerular Filtration Rate (eGFR) of 22 ml/min/1.73m2 considering male gender and 16.6 ml/min/1.73m2 considering female gender). Abdominal ultrasound showed chronic parenchymal nephropathy. Due to the significant reduction in eGFR, the patient was referred for kidney transplantation, but he was not included in the list because he had a creatinine clearance of 23 ml/min/1.73m2 for males and 21.5 ml/min/1.73m2 for females in the most recent tests. Conclusion: Hormone replacement may have contributed to the increase in the patient's blood pressure and, consequently, to the development of CKD. There is still no well-established consensus on the best way to estimate the GFR in transgender people, and it seems to be more appropriate to consider the gender to which the person self-identifies or to perform the calculation for both genders, obtaining an estimate of the range in which the patient's GFR lies.

Progressive disseminated histoplasmosis in HIV-positive patients.

BACKGROUND: Histoplasmosis is the most common endemic mycosis among people living with advanced HIV infection. PURPOSE: Describe general aspects and challenges of this disease and its association with HIV. RESEARCH DESIGN: Review of literature. STUDY SAMPLE: Articles found using different combinations of terms including "disseminated histoplasmosis" and AIDS/HIV or immunosuppression in PubMed, Scopus, WHO Global health library, and Scielo database. ANALYSIS: We look for information on epidemiology, pathogenesis, diagnosis, and treatment of histoplasmosis in AIDS patients. RESULTS: Histoplasmosis is caused by Histoplasma capsulatum, a dimorphic fungus encountered throughout the world, mainly in soil enriched with bat and bird excreta. Progressive disseminated histoplasmosis is the main presentation of this mycosis in people living with advanced HIV and is fatal if left untreated. Symptoms include a systemic disease characterized by fever, weight loss, night sweats, skin manifestations, hepatomegaly, splenomegaly, and septic shock. Diagnostic tests include culture, visualization of H. capsulatum by direct and histopathological examination, serology, antigen, molecular, and skin testing. Patients with disseminated disease require aggressive and prolonged treatment to eradicate the pathogen and include amphotericin B and itraconazole. In many low income countries of endemic regions, histoplasmosis in HIV-positive patients is often undiagnosed or misdiagnosed as another opportunistic infection, due to the similarity in clinical manifestations and to the paucity of better diagnostic tests. CONCLUSION: Histoplasmosis remains a neglected disease. Few studies about the disease and expensive treatments make it difficult to reduce the morbidity and mortality of this condition. Public health services and physicians must be aware of histoplasmosis' burden among the HIV-positive population.

Anabolic androgenic steroid-induced hypogonadism, a reversible condition in male individuals? A systematic review.

The anabolic-androgenic steroids (AAS) are clinically used as an androgen replacement, in hypogonadism treatment, to induce puberty, and also in the treatment of chronic degenerative diseases. The AAS use out of clinical context is becoming massively, being used merely for aesthetic reasons. AAS abuse may cause severe disarrangement on the HPG axis and generate a significant decrease in testosterone synthesis and secretion by the testes. This review aims to evaluate whether the hypogonadism induced by AAS abuse is reversible and under what circumstances the reversibility is possible. For this, PRISMA guidelines and several databases are used between July and September 2020. Altogether, this systematic review identified and analysed 179 cases of AAS users. Of these, 168 cases had the hypogonadism clearly diagnosed and proven to be linked exclusively to AAS abuse. However, between these 168 cases, only 38 cases presented fully known outcomes and among these, merely in 4, the hypogonadism was completely reversible (2 based on drug therapy) with HPG axis recovery. In conclusion, this review presents evidences that AAS-induced hypogonadism is a seriously underestimated problem, and in the majority of cases, full recovery is very difficult to succeed.

Novel renal biomarkers show that creatine supplementation is safe: a double-blind, placebo-controlled randomized clinical trial.

The aim of this study was to evaluate the impact of creatine supplementation (CS) on renal function in young, healthy, and active subjects. We used a randomized, double-blind, placebo-controlled clinical trial as the study design. Thirty-six healthy male university students were recruited and divided into three groups: group placebo, group G3 (3 g/day of CS), and group G5 (5 g/day of CS). To assess renal function, new kidney biomarkers, kidney injury molecule-1 (KIM-1) and monocyte chemoattractant protein-1 (MCP-1), were quantified. Serum albumin, serum creatinine, serum urea, estimated glomerular filtration rate (eGFR), proteinuria, and albuminuria were also measured. All groups were evaluated at two times: prior CS or placebo (pre) and after 35 days on CS or placebo (post). After 35 days of intervention, all characteristics were maintained without significant difference (P > 0.05) between the groups, including serum creatinine, eGFR, and more sensitive kidney biomarker concentrations (KIM-1 and MCP-1). The paired analysis showed that the supplemented groups (G3 and 5G) had increased serum creatinine and decreased eGFR levels (P < 0.05). However, the values were still within the normal reference range. In conclusion, the results of renal function evaluation did not show any difference between the evaluated groups. Increased serum creatinine and decreased eGFR levels in CS groups can be explained by increased creatine stores and metabolism, since creatinine is a by-product of creatine metabolism. These findings indicate that the use of CS at doses of 3 g and 5 g/day for a short period (35 days) is safe and did not impair the kidneys or renal function in young healthy subjects.

Prospective evaluation of immune haemolysis in liver transplantation.

BACKGROUND: Immune haemolysis in liver transplant (LT) can occur due to autoantibodies and alloantibodies. The aim of this study was to evaluate the prevalence and risk factors for immune haemolysis in LT. METHODS: A total of 175 consecutive patients were included. Multiorgan recipients were excluded. Samples, from before LT, seven consecutive days and weekly for 4 weeks, were evaluated for haemolysis and immunohaematological tests. SPSS 24 was used for statistical analysis. RESULTS: Nine patients (5·1%) presented positive antibody screen (AS) before LT, (2·3% clinically significant), more frequent in RhD-negative (P = 0·017). Positive DAT occurred in 53 (30·3%) and was related to high MELD score (P = 0·048), HCV (P = 0·005) and furosemide use (P = 0·001). Positive AS after LT occurred in 22 patients (12·5%), with nine (5·7%) clinically significant antibodies. Positive AS occurred more frequently in RhD negative (P = 0·021) and in those transfused (P = 0·022). Post-transplant positive DAT was associated with piperacillin-tazobactam use (P = 0·021) and minor ABO incompatibility (P = 0·0038). Five patients presented passenger lymphocyte syndrome (PLS), all received liver-graft O, four presented haemolysis, and three were transfused due to PLS. CONCLUSION: Auto- and alloantibodies against red blood cell antigens are frequent in LT, but the frequency of immune haemolysis was only 2·8%. The only risk factor for PLS was minor ABO mismatch.

Visceral leishmaniasis-associated nephropathy in hospitalised Brazilian patients: new insights based on kidney injury biomarkers.

OBJECTIVE: To evaluate the usefulness of early acute kidney injury (AKI) biomarkers in clinical management of visceral leishmaniasis. METHODS: Prospective study with 50 hospitalised VL patients. AKI biomarkers, that is, serum and urinary neutrophil gelatinase-associated lipocalin (sNGAL, uNGAL, respectively), urinary kidney injury molecule-1 (uKIM-1) and urinary monocyte chemotactic protein-1 (uMCP-1), were quantified by immunoassay (ELISA). Also, interferon-gamma (INF-y) and C-reactive protein (CRP) were evaluated as inflammatory biomarkers possibly related to VL severity. RESULTS: VL patients had hyponatremia, hypoalbuminemia, hypergammaglobulinemia, haematologic and hepatic disorders. AKI was found in 46%, and one death (2%) occurred. The AKI group had significant longer hospital stay, lower levels of IFN-y and higher levels of CRP, more clinical renal abnormalities and higher levels of sNGAL, uNGAL, uKIM-1 and uMCP-1. Overall, sNGAL, uKIM-1 and uMCP-1 showed correlations with important clinical renal abnormalities, such as proteinuria, albuminuria, serum creatinine and glomerular filtration rate using adjusted correlations with CRP and IFN-y. Only sNGAL showed an early association with AKI development (OR = 2.78, 95% CI = 1.429-5.428, per each increase of 50 ng/ml), even after adjusting for clinical signals of VL severity and for immune biomarkers. Moreover, sNGAL showed a better performance in predicting AKI development (AUC-ROC = 0.81, 95% CI = 0.69-0.93; cut-off = 154 ng/ml, sensitivity = 82.6%, specificity = 74.1%, P < 0.001). CONCLUSIONS: Visceral leishmaniasis-associated nephropathy showed important proximal tubular injury and glomerular inflammation. Serum NGAL showed an early association with VL-associated nephropathy and may be used to improve clinical management strategies and decrease morbimortality in VL patients.

Changing patterns in leptospirosis: a three-decade study in Brazil.

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±15.9years 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±73.3mg/dl, respectively, p <0.0001) and creatinine (5.8±2.9, 3.8±2.6, and 3.0±2.5mg/dl, respectively, p <0.0001) in each decade, while levels of hemoglobin (10.31±1.9, 10.8±2.0, and 11.5±2.1g/dl, respectively, p <0.0001) and platelets (57.900±52.650, 80.130±68.836, and 107.101±99.699×109/l, respectively, p<0.0001) increased. There was a tendency towards a linear decrease in mortality (22%, 14%, and 11.6%, respectively, p=0.060). CONCLUSIONS: Leptospirosis showed significant changes over time in this region. The main changes point to a decrease in disease severity and complications, such as acute kidney injury. Mortality has decreased, being close to 11%.

Endothelial Glycocalyx Damage and Renal Dysfunction in HIV Patients Receiving Combined Antiretroviral Therapy.

Widespread use of combined antiretroviral therapy (cART) increased HIV patients' life expectancy, however, favored the development of kidney and cardiovascular diseases. The aim of this study was to investigate endothelial glycocalyx (eGC) damage and its association with renal function in HIV patients receiving cART. This is a cross-sectional study with HIV-infected patients with no renal and cardiovascular disease, recruited in public health centers in Brazil. Clinical and laboratory parameters of HIV patients were compared according to cART use and with a healthy control group. Blood ICAM-1 and syndecan-1 levels were quantified by ELISA kit. Estimated glomerular filtration rate (eGFR) was evaluated. A total of 69 HIV patients were included, with mean age of 33.4 ± 8.9 years, and 77.3% were male. Serum urea, creatinine, and eGFR were similar in all groups. No HIV patient had decreased GFR <60 ml/min. All HIV patients had higher systemic syndecan-1 compared with healthy controls (71.8 ± 25.4 ng/ml vs. 36.5 ± 14.3 ng/ml, p < .001). Syndecan-1 showed a significant positive correlation with serum creatinine (r = 0.437, p = .001), serum urea levels (r = 0.352, p = .006), and a negative correlation with eGFR (r = -0.315, p = .015) in HIV patients. Syndecan-1 remained independently associated with serum creatinine and reduced GFR even after we forced variables related with HIV infection status, tenofovir use, treatment time, dyslipidemia, and others in a multivariate analysis. HIV patients using cART with no clinical renal and cardiovascular disease presented eGC damage and it is associated with clinical markers of kidney dysfunction. Syndecan-1 may be a useful early biomarker to monitoring renal dysfunction in HIV patients in chronic use of cART. Further research is needed to evaluate this applicability.

Sleep Quality Among Psychiatry Residents.

OBJECTIVE: Medical residency programs are traditionally known for long working hours, which can be associated with a poor quality of sleep and daytime sleepiness. However, few studies have focused on this theme. Our objective was to investigate sleep quality, daytime sleepiness, and their relation with anxiety, social phobia, and depressive symptoms. METHODS: This cross-sectional observational study involved 59 psychiatry residents. The Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) were used to measure the quality of sleep and excessive daytime sleepiness ([EDS] and ESS > 10), respectively. RESULTS: Among the 59 psychiatry residents, 59.3% had poor sleep quality (PSQI > 5) and 28.8% had EDS. Poor sleep quality was associated with higher EDS (P = 0.03) and the year of residency program (P = 0.03). Only 20% of residents with poor sleep had consulted at least once for sleep problems; 54.2% had used medications for sleep; and 16.9% were using medications at the time of interview. Only 30% obtained medication during medical consultations. Poor sleep was associated with irregular sleep hours (P = 0.001) and long periods lying down without sleep (P = 0.03). Poor sleep quality was also associated with high scores of anxiety symptoms (P < 0.001) and social phobia symptoms (P = 0.02). CONCLUSION: Psychiatry residents frequently have poor sleep quality and EDS. Considering that sleep disorders can affect quality of life, predispose to metabolic syndrome, and be associated with worse performance at work, attention to this clinical problem is needed.

Health of Psychiatry Residents: Nutritional Status, Physical Activity, and Mental Health.

OBJECTIVE: This study aims to analyze mental health, nutritional status, and physical activity in psychiatry residents. METHODS: Sixty-two residents were invited and 59 participated (95.2% response). Depressive, anxious, and social phobic symptoms; alcohol use; and nicotine dependence were measured. Body mass index and lifestyle were also evaluated. RESULTS: Almost half of psychiatry residents were overweight or obese, and 61% reported a sedentary lifestyle. Furthermore, 33.9% of residents had high scores for anxiety; 30.5% for social phobia; and 19% for depression. In addition, 81.4% reported alcohol use, and 22% had harmful alcohol use. High scores for anxiety were associated with lower attention and worse relationship with preceptors, and high scores of depressive symptoms were related to a worse relationship with patients and preceptors. Anxiety was associated with depressive symptoms (p < 0.001) and social phobia (p = 0.006). CONCLUSION: The findings of this study highlight high rates of overweight/obesity, physical inactivity, and depressive and anxiety symptoms in psychiatric residents.

Dengue Fever Among Renal Transplant Recipients: A Series of 10 Cases in a Tropical Country.

This is a case series of 10 consecutive renal allograft recipients, followed at a tertiary hospital in northeast Brazil, with a confirmed diagnosis of dengue. Five of the patients needed hospitalization. Half of them were males and age ranged from 19 to 60 years with a median of 38.2 years. They had been transplanted for a mean of 5 days to 166 months. Four patients developed dengue hemorrhagic fever (DHF). All patients had myalgia and headache. All of them, except one, had fever. Positive dengue serology (IgM) was found in all patients. No patient died. Dengue is an important infectious disease that can affect renal transplant recipients, mainly in endemic areas. Its presentation seems to be similar to that seen in immunocompetent patients.

Acute kidney injury in schistosomiasis: a retrospective cohort of 60 patients in Brazil.

The aim of this study is to investigate renal involvement in schistosomiasis. This is a retrospective cohort of 60 consecutive patients with schistosomiasis admitted to a university hospital in Maceió, Brazil. The patients were divided into 2 groups: patients with and without acute kidney injury (AKI) according to the RIFLE criteria. We compared the groups for differences in clinical manifestations and laboratory tests. Patients' mean age was 58 ± 16 yr, and 56.7% were female. The average length of hospital stay was 16.4 ± 12.1 days. Patients with hypertension and diabetes were 35% and 21.7% respectively. The main clinical symptoms and signs presented were ascites (86.7%), splenomegaly (80%), and hepatomegaly (63.3%). Current or previous history of upper gastrointestinal bleeding was found in 45% of patients, esophageal varices on endoscopy were present in 92%, and periportal fibrosis on ultrasound examination in 81% of patients. AKI incidence was 43.3% during hospital stay. Mean age and length of hospitalization were higher in the AKI group. Diuretic use, such as furosemide and spironolactone, ascites, and AST levels were also associated with AKI. Death occurred in 5 cases (8.5%), 4 of them in the AKI group. The classifications Child-Pugh score (CHILD) and Model for End-Stage Liver Disease (MELD), used to assess the severity and prognosis of chronic liver disease, presented higher scores among patients with AKI (CHILD: 9.5 ± 1.5 vs. 8.4 ± 1.7, P = 0.02; MELD: 19 ± 5.8 vs. 13 ± 3.9, P < 0.001). Renal dysfunction is an important feature of schistosomiasis, which is associated with significant morbidity and possible increased mortality. Further studies are necessary to establish the mechanisms through which schistosomiasis can lead to renal dysfunction.

Rabdomiólisis y fallo renal agudo asociado con el consumo de cocaína y ejercicio vigoroso / Rhabdomyolysis and acute kidney failure associated with the use of cocaine and vigorous exercice

La rabdamiolisis es una condición clínica en la que ocurre daño al músculo esquelético, lo que lleva a la liberación de componentes celulares a la circulación, siendo una de sus complicaciones el fallo renal agudo. Describimos el caso de un paciente de 46 años, usuario de drogas por mas de 20 años, que había hecho uso de grandes cantidades de cocaína y luego realizó actividades extenuantes. Después del episodio, presentó dolor abdominal de moderada intensidad, asociado con el oscurecimiento de la orina y oliguria, refiriéndose nauseas, vómitos y fiebre. Fue admitido con cuadro de insuficiencia respiratoria, fallo renal agudo y acidosis metabólica. Los niveles de creatinokinasa estaban significativamente elevados (4791 UI/L). Se realizó hemodiálisis de emergencia. El paciente mejoró en los diez días siguientes, con recuperación de la función renal. Presentó un sindrome de abstinencia que fue controlada con benzodiazepínicos. Este caso ilustra la ocurrencia de rabdomiólisis y fallo renal agudo causados por el uso de cocaína. Se debe tener en cuenta la posible ocurrencia de estas complicaciones en todo paciente drogadicto, para realizar un diagnóstico y tratamiento adecuado.

Rabdomiólisis y fallo renal agudo asociado con el consumo de cocaína y ejercicio vigoroso / Rhabdomyolysis and acute kidney failure associated with the use of cocaine and vigorous exercice

La rabdamiolisis es una condición clínica en la que ocurre daño al músculo esquelético, lo que lleva a la liberación de componentes celulares a la circulación, siendo una de sus complicaciones el fallo renal agudo. Describimos el caso de un paciente de 46 años, usuario de drogas por mas de 20 años, que había hecho uso de grandes cantidades de cocaína y luego realizó actividades extenuantes. Después del episodio, presentó dolor abdominal de moderada intensidad, asociado con el oscurecimiento de la orina y oliguria, refiriéndose nauseas, vómitos y fiebre. Fue admitido con cuadro de insuficiencia respiratoria, fallo renal agudo y acidosis metabólica. Los niveles de creatinokinasa estaban significativamente elevados (4791 UI/L). Se realizó hemodiálisis de emergencia. El paciente mejoró en los diez días siguientes, con recuperación de la función renal. Presentó un sindrome de abstinencia que fue controlada con benzodiazepínicos. Este caso ilustra la ocurrencia de rabdomiólisis y fallo renal agudo causados por el uso de cocaína. Se debe tener en cuenta la posible ocurrencia de estas complicaciones en todo paciente drogadicto, para realizar un diagnóstico y tratamiento adecuado.

C.E.R.A. maintains stable hemoglobin in Latin American patients on dialysis.

BACKGROUND: C.E.R.A. is a continuous erythropoietin receptor activator with characteristics that permit a once-monthly schedule of administration for the maintenance treatment for chronic kidney disease (CKD) patients. The main objective of this study was to assess the maintenance of Hb concentration with once-monthly intravenous and/or subcutaneous C.E.R.A. therapy in Latin American dialysis patients with chronic renal anemia previously treated with epoetin alfa s.c or i.v 1-3 times per week. METHODS: This was a single-arm, open-label, multicenter, 32-week study of anemic patients with CKD previously treated with epoetin alfa sc or iv 1-3 times per week. After a 4-week screening period, during which mean Hb levels were maintained between 10.5 and 12.5 g/dL on their previous erythropoiesis stimulating agent, eligible patients entered a 16-week C.E.R.A. dose titration period followed by a 4-week efficacy evaluation period (EEP) and a 28-week safety follow-up. The starting dose of C.E.R.A. was based on the previous dose of epoetin alfa. Doses of C.E.R.A. were then adjusted to maintain Hb levels within ±1.0 g/dL of the reference concentration and between 10.5 and 12.5 g/dL. The Hb reference concentration was defined as the mean of all Hb levels during screening. The primary end point was the proportion of patients maintaining a mean Hb concentration (g/dL) within ±1 g/dL of their reference Hb and between 10.5 and 12.5 g/dL during the EEP. RESULTS: A total of 163 patients from 27 centers in Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Peru, Uruguay, and Venezuela entered the treatment period and 102 completed the prescribed course of C.E.R.A. Forty-five patients (43.7 %) maintained a mean Hb concentration within ±1 g/dL of their reference Hb value and between 10.5 and 12.5 g/dL during the EEP. The median monthly dose remained constant at 120 µg during the titration period and during the EEP. On the average, there were only 2.3 dose changes per patient in 28 weeks of treatment, covering 7 C.E.R.A. scheduled administrations. 53 % of all dose changes were dose decreases, 47 % increases. A total of 10 AEs and 4 SAEs were considered to be related to the study treatment. CONCLUSIONS: Once-monthly C.E.R.A. treatment effectively maintains stable Hb concentrations in patients with chronic renal anemia undergoing dialysis with a good safety and tolerability profile.

Composition of kidney stone fragments obtained after extracorporeal shock wave lithotripsy.

BACKGROUND: The objective of this study was to determine the composition of kidney stone fragments obtained after extracorporeal shock wave lithotripsy (ESWL). METHODS: Kidney stone fragments from 25 patients with urolithiasis treated with ESWL were submitted for morphological analysis. The composition was determined for all the recovered fragments. RESULTS: Thirteen patients (52%) had pure stones. The most common type of pure stone was calcium oxalate (61.6%), of which half was the monohydrate type (COM) and half was the dihydrate type (COD). The other pure stones consisted of either uric acid (30.8%) or struvite (7.6%). For mixed stones, the most frequently observed component was COM or COD (50%), followed by a mixture of COD and carbapatite (25.1%). CONCLUSIONS: Our findings indicate that the composition of kidney stone fragments recovered after ESWL can be determined. Knowledge of stone composition is fundamental to understand the etiology of lithogenesis.

Leptospiral nephropathy.

Leptospirosis is recognized as a globally re-emerging zoonosis. Interstitial nephritis is the principal feature of the disease. Leptospirosis-induced acute kidney injury typically is nonoliguric and includes hypokalemia. Tubular function alterations precede a decrease in the glomerular filtration rate, which could explain the high frequency of hypokalemia. Studies in human beings and animals have shown increased urinary fractional excretion of potassium and sodium, as well as an increased potassium/sodium ratio, suggesting increased distal potassium secretion caused by increased distal sodium delivery consequent to functional impairment of proximal sodium reabsorption. Confirming these findings, Western blot studies have shown lower renal expression of the sodium/hydrogen exchanger isoform 3 and of aquaporin 2, together with higher renal expression of the Na-K-2Cl cotransporter NKCC2, in infected animals. The severe form (Weil's disease) manifests as diffuse alveolar hemorrhage, pulmonary edema, acute respiratory distress syndrome, or a combination of these features, accompanied by acute kidney injury and can be highly lethal. Antibiotic treatment is efficient in the early and late/severe phases. For critically ill leptospirosis patients, the following are recommended: daily hemodialysis, low daily net fluid intake (because of the risk for pulmonary hemorrhage), and lung-protective strategies (low tidal volumes and high positive end-expiratory pressures after recruitment maneuvers).

Risk factors for death in acquired immunodeficiency syndrome-associated disseminated histoplasmosis.

We performed a retrospective study of 164 human immunodeficiency virus (HIV)-infected patients with disseminated histoplasmosis to identify the risk factors for death. Death occurred in 32% of the cases. Univariate analysis identified the following risk factors: diarrhea (odds ratio [OR] = 3.9, P = 0.001), neurologic manifestations (OR = 5.8, ; P = 0.001), hemoglobin level < 8.0g/dL (OR = 2.7, P = 0.004), urea level 2 times the normal upper limit (OR = 5.0, P < 0.001), creatinine level > 1.5 mg/dL (OR = 2.9, P = 0.005), aspartate aminotransferase (AST) level > 2.5 times the normal upper limit (OR = 3.1, P = 0.01), respiratory insufficiency (OR = 9.7, P < 0.001), sepsis (OR = 20.2, P < 0.001), and acute renal failure (OR = 2.5, P = 0.011). A hemoglobin level < 8.0 g/dL (OR = 3.8, P = 0.008), an AST level >or= 2.5 times the normal limit (OR = 1.0, P = 0.007), acute renal failure (OR = 2.96, P = 0.015), and respiratory insufficiency (OR = 12.2, P = 0.01) were independent risk factors for death.