Precisión diagnóstica de la nueva definición propuesta de lesión renal aguda (KDIGO más uNGAL) en pacientes críticamente enfermos / Diagnostic accuracy of the proposed new definition of acute kidney injury (KDIGO plus uNGAL) in critically ill patients / Precisão diagnóstica da nova definição proposta de lesão renal aguda (KDIGO mais uNGAL) em pacientes em estado crítico

Resumen: Introducción: lo que ahora conocemos como lesión renal aguda (LRA) en el siglo pasado tuvo al menos 25 conceptos y 35 definiciones diferentes; en este siglo se desarrollaron las definiciones y sistemas de clasificación por gravedad, risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease (RIFLE por sus siglas en inglés), AKIN, Kidney Disease: Improving Global Outcome (KDIGO) basadas en creatinina, gasto urinario y necesidad de terapia de reemplazo renal. En la última década se han estudiado biomarcadores de LRA. Se sugiere que se realice investigación sobre si una combinación de biomarcadores de daño y funcionales junto con información clínica en pacientes de alto riesgo podría ayudar a mejorar la precisión diagnóstica de nueva definición propuesta de LRA. Objetivo: estimar la precisión diagnóstica de la nueva definición propuesta de LRA en pacientes críticamente enfermos. Material y métodos: se realizó un estudio observacional, analítico, prospectivo y longitudinal en pacientes mayores de 18 años, ingresados a terapia intensiva del Hospital Central Sur de Alta Especialidad en el periodo comprendido del 01 de mayo de 2022 al 10 de julio de 2022. Resultados: en el grupo de estudio (41 pacientes) la media de la edad fue 62.5 ± 14.22 años; y 33 (80.5%) fueron hombres. La media del peso, talla e índice de masa corporal (IMC) fue de 78.5 ± 18.61, 1.65 ± 0.08 y 28.93 ± 6.72 kg/m2, respectivamente; 14 (34.1%) pacientes presentaron sobrepeso y 16 (39%) tuvieron obesidad; 29 (70.7%) tuvieron sepsis. En 24 (58.5%) pacientes, el foco de infección fue pulmonar, tres (7.3%) abdominal y dos (4.9%) vías urinarias. De los pacientes, 33 (80.5%) se clasificaron como 1S y 1B. El uNGAL al ingreso tuvo una media de 451.36 ± 688.11. La sensibilidad de KDIGO más uNGAL fue 67%, especificidad 16%. La sensibilidad de KDIGO más uNGAL fue 75%, especificidad 19%. La sensibilidad de KDIGO más uNGAL fue 88%, especificidad 25%. El porcentaje de mortalidad predicha por la escala SAPS 3 fue 56.26 ± 23.7% y de la escala MPM III 43.94 ± 23.59. La mortalidad observada fue de 24 (58.5%); y el índice estandarizado de mortalidad con SAPS 3 fue de 1.04, y con el MPM III fue de 1.33. Conclusiones: el rendimiento diagnóstico de la nueva definición de lesión renal aguda propuesta no fue bueno debido a múltiples factores, dentro de los dos más importantes, el manejo preventivo de la lesión renal aguda que actualmente se aporta a los pacientes y el tamaño de la muestra. Se requiere continuar el estudio para lograr la muestra representativa de la población y tener una conclusión certera sobre el rendimiento diagnóstico de la nueva definición propuesta de lesión renal aguda.

Abstract: Introduction: what we now know as acute kidney injury (AKI) in the last century had at least 25 concepts and 35 different definitions; In this century, the RIFLE, AKIN, and KDIGO definitions and classification systems for severity were developed, based on creatinine, urine output, and need for renal replacement therapy. In the last decade, biomarkers of AKI have been studied; It is suggested that research be carried out on whether a combination of damage and functional biomarkers together with clinical information, in high-risk patients, could help improve the diagnostic accuracy of the proposed new definition of AKI. Objective: to estimate the diagnostic accuracy of the proposed new definition of AKI in critically ill patients. Material and methods: an observational, analytical, prospective and longitudinal study was carried out in patients older than 18 years, admitted to intensive care at the Hospital Central Sur de Alta Especialidad in the period from May 1, 2022 to July 10 2022. Results: in the study group (41 patients), the mean age was 62.5 ± 14.22 years; and 33 (80.5%) were men. The mean weight, height and body mass index (BMI) were 78.5 ± 18.61, 1.65 ± 0.08 and 28.93 ± 6.72 kg/m2, respectively; 14 (34.1%) patients were overweight and 16 (39%) patients were obese; 29 (70.7%) had sepsis. In 24 (58.5%) patients, the source of infection was pulmonary, 3 (7.3%) abdominal, and 2 (4.9%) urinary tract. Of the patients, 33 (80.5%) are classified as 1S and 1B. The uNGAL at admission had a mean of 451.36 ± 688.11. The sensitivity of KDIGO plus uNGAL was 67%, specificity 16%. The sensitivity of KDIGO plus NGAL was 75%, specificity 19%. The sensitivity of KDIGO plus uNGAL was 88%, specificity 25%. The percentage of mortality predicted by the SAPS 3 scale was 56.26 ± 23.7% and by the MPM III scale 43.94 ± 23.59. the observed mortality was 24 (58.5%); and the standardized mortality rate with SAPS 3 was 1.04, and with MPM III 1.33. Conclusions: the diagnostic performance of the new definition of acute kidney injury proposed was not good due to multiple factors, among the 2 most important, the preventive management of acute kidney injury that is currently provided to patients and the size of the sample. It is necessary to continue the study to achieve a representative sample of the population and to have an accurate conclusion about the diagnostic performance of the new proposed definition of acute kidney injury.

Resumo: Introdução: o que hoje conhecemos como lesão renal aguda (LRA) teve no século passado pelo menos 25 conceitos e 35 definições diferentes; neste século, foram desenvolvidas as definições e sistemas de classificação de gravidade RIFLE, AKIN, KDIGO, baseados na creatinina, débito urinário e necessidade de terapia renal substitutiva. Na última década, foram estudadosos biomarcadores LRA; sugere-se que sejam realizadas pesquisas sobre se uma combinação de biomarcadores DE danos e funcionais juntamente com informação clínica, em pacientes de alto risco, poderia ajudar a melhorar a precisão diagnóstica da nova definição proposta de LRA. Objetivo: estimar a precisão diagnóstica da nova definição proposta de LRA em pacientes críticos. Material e métodos: foi realizado um estudo observacional, analítico, prospectivo e longitudinal em pacientes maiores de 18 anos internados na terapia intensiva do Hospital Central Sur de Alta Especialidad no período de 1o de maio de 2022 a 10 de julho de 2022. Resultados: no grupo de estudo (41 pacientes), a média de idade foi de 62.5 ± 14.22 anos; e 33 (80.5%) eram homens. As médias de peso, estatura e índice de massa corporal (IMC) foram 78.5 ± 18.61, 1.65 ± 0.08 e 28.93 ± 6.72 kg/m2, respectivamente; 14 (34.1%) pacientes apresentavam sobrepeso e 16 (39%) pacientes eram obesos; 29 (70.7%) tiveram sepse. Em 24 (58.5%) pacientes, o foco de infecção foi pulmonar, 3 (7.3%) abdominal e 2 (4.9%) trato urinário. Dos pacientes, 33 (80.5%) foram classificados como 1S e 1B. O uNGAL na admissão teve média de 451.36 ± 688.11. A sensibilidade de KDIGO mais uNGAL foi de 67%, especificidade de 16%. A sensibilidade de KDIGO mais NGAL foi de 75%, especificidade de 19%. A sensibilidade de KDIGO mais uNGAL foi de 88%, especificidade de 25%. O percentual de mortalidade previsto pela escala SAPS 3 foi de 56.26 ± 23.7% e pela escala MPM III 43.94 ± 23.59. a mortalidade observada foi de 24 (58.5%); e a taxa de mortalidade padronizada com SAPS 3 foi de 1.04 e com MPM III de 1.33. Conclusões: o desempenho diagnóstico da nova definição de lesão renal aguda proposta não foi bom devido a múltiplos fatores, entre os 2 mais importantes sendo o manejo preventivo da lesão renal aguda atualmente fornecido aos pacientes e o tamanho da amostra. É necessário continuar o estudo para obter uma amostra representativa da população e ter uma conclusão precisa sobre o desempenho diagnóstico da nova definição proposta de lesão renal aguda.

Association between acute kidney injury and mortality after successful cardiopulmonary resuscitation: a retrospective observational study.

BACKGROUND AND OBJECTIVES: Acute Kidney Injury (AKI) affect mortality and morbidity in critically ill patients. There have been few studies examining the prevalence of AKI and mortality after successful cardiopulmonary resuscitation. In the present study, we investigated the association between AKI and mortality in post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). METHODS: Our retrospective analysis included 109 patients, admitted to the ICU following successful cardiopulmonary resuscitation between 2014 and 2016. We compared two scoring systems to estimate mortality. RESULTS AND DISCUSSION: AKI were diagnosed in 46.7% (n = 51) of the patients based on the RIFLE criteria and 66.1% (n = 72) using the KDIGO. Mortality rate was significantly higher among patients with AKI diagnosed according to the RIFLE criteria (p = 0.012) and those with AKI diagnosed using KDIGO criteria (p = 0.003). Receiver Operating Characteristic (ROC) analysis showed that both scoring systems were able to successfully detect mortality (Area under the ROC curve = 0.693 for RIFLE and 0.731 for KDIGO). CONCLUSION: AKI increases mortality and morbidity rates after cardiac arrest. Although more renal injury and mortality were detected with KDIGO, the sensitivity and specificity of both scoring systems were similar in predicting mortality in patients with Return of Spontaneous Circulation (ROSC).

A new species of Macrelmis Motschulsky, 1859 (Coleoptera: Elmidae) and new records of Elmidae from Roraima State, northern Brazil.

A new species of Macrelmis Motschulsky, 1859 (Macrelmis rodrigoi sp. nov.) is described and illustrated based on specimens found in mountainous areas of the northern Roraima State, Brazil. Pagelmis amazonica Spangler, 1981, Potamophilops bostrychophallus Maier, 2013 and Stegoelmis geayi Spangler, 1990 are recorded in Brazil for the first time and new records for Gyrelmis obesa Hinton, 1940, Macrelmis thorpei Hinton, 1945 and Neolimnius palpalis Hinton, 1939 are presented.

Incidencia acumulada de insuficiencia renal aguda en el posoperatorio de cirugía cardíaca / Accumulated incidence of acute renal failure in the postoperative period of cardiac surgery

Resumen: Introducción: la insuficiencia renal aguda (IRA) constituye una causa frecuente de morbimortalidad en el posoperatorio de cirugía cardíaca, con incidencia variable según la definición utilizada y los factores derivados del paciente y del procedimiento quirúrgico. Objetivo: los objetivos de este artículo fueron determinar la incidencia de IRA en un centro de cirugía cardíaca, la presencia de predictores y su asociación con mortalidad quirúrgica. Métodos: estudio prospectivo y observacional con elementos analíticos. Se incluyeron todos los pacientes con función renal normal y sin antecedentes de enfermedad renal sometidos a cirugía cardíaca en el período julio 2014 - julio 2015. Se determinó la creatininemia basal y a las 24 y 48 horas de la cirugía. La IRA fue definida utilizando el criterio RIFLE. Se valoró mortalidad quirúrgica y se analizaron variables pre e intraoperatorias como predictoras de desarrollo de IRA utilizando análisis uni y multivariado. Resultados: cumplieron los criterios de inclusión 400 pacientes. La incidencia de IRA por criterio RIFLE fue 10,3% (IC95% 8,7-11,8); la mortalidad quirúrgica en este grupo alcanzó 19,5%, mientras que en los controles fue 1,9%. Las variables asociadas al desarrollo de IRA fueron EuroSCORE más elevado, cirugía combinada, uso de circulación extracorpórea (CEC) y clampeo aórtico. La cirugía de revascularización miocárdica (CRM) presentó una asociación inversa con la aparición de IRA y constituyó predictor independiente en el análisis multivariado. La presencia de IRA fue un predictor independiente de mortalidad quirúrgica. Conclusiones: la incidencia de IRA es frecuente en el posoperatorio de cirugía cardíaca y se encuentra dentro de los valores internacionales. Su presencia implica mayor mortalidad quirúrgica.

Summary: Introduction: acute renal failure (ARF) is a frequent cause of morbidity and mortality in the postoperative period of cardiac surgery, with variable incidence depending on the definition used, factors derived from the patient and the surgical procedure. Objective: determine the incidence of ARF in a cardiac surgery center, the presence of predictors and its association with surgical mortality. Methods: this is a prospective and observational study with analytical elements. All patients with normal renal function and no history of kidney disease undergoing cardiac surgery were included in the period from July 2014 to July 2015. Baseline creatininemia was determined, and 24 and 48 hours later, after surgery. Acute renal failure was defined using the RIFLE criterion. Surgical mortality, pre and intra-operative variables were assessed using univariate and multivariate analysis. Results: four hundred patients met the inclusion criteria. The incidence of acute renal failure by RIFLE criterion was 10,3% (95% CI 8,7-11,8), surgical mortality in this group reached 19,5% while in controls it was 1,9%. The variables associated with the presence of ARF were the higher EuroSCORE, combined surgery, use of extracorporeal circulation and aortic clamping. The CRM presented an inverse association and was an independent predictor in the multivariate analysis. The presence of ARF was an independent predictor of surgical death. Conclusions: the incidence of ARF is frequent in the postoperative period of cardiac surgery and is within the international values. Its presence implies greater surgical mortality.

A 2-year-old boy with circulatory failure owing to streptococcal toxic shock syndrome: case report.

A 2-year-old boy presented with severe hypotension and acute kidney injury after a prodrome of non-bloody diarrhoea and fever in the preceding 3 days. He had a mild Ebstein cardiac anomaly but otherwise a normal past history and growth. On examination, he looked ill, his temperature was 37.5 °C, circulation was poor, and there were several purpuric lesions on the face, hands and scrotum. Haemoglobin was 7.8 g/dL (11-14), total white cell count 27 × 109/L, platelets 62 × 109/L, blood urea nitrogen 20.7 mmol/L (4.2-17.1), serum creatinine 95.4 µmol/L (21.2-36.2), CRP 154 mg/L (<5), AST 296 U/L (11-50), ALT 909 U/L (7-40) and C3 component of complement 0.8 g/L (0.9-1.8). Activated partial thromboplastin time (APTT) and prothrombin time (PT) were prolonged and fibrinogen level was 1.0 g/L (2-4). He received immediate fluid resuscitation (IV 0.9% saline solution, 2 × 10 ml/kg boluses, followed by glucose 5/0.45% sodium chloride solution, 2 × 10 ml/kg) and antibiotics (ciprofloxacin and amikacin) but circulation continued to deteriorate with development of decreased consciousness. He was placed on mechanical ventilation and vasopressor agents were added. Despite improved circulation over the next 2 days, he developed oliguria, progressive fluid overload, generalised oedema and a right-sided pleural effusion. Dialysis was commenced on day 3 of admission. Differential diagnosis included sepsis, atypical haemolytic uraemic syndrome and lupus nephritis. Blood and urine cultures remained negative but an anti-streptolysin O titre of 1318 (<200) IU/mL led to the diagnosis of streptococcal toxic shock syndrome which is rare in early childhood and associated with high mortality. Haemodialysis was commenced and continued for 10 days with successful treatment of fluid overload and subsequent extubation. Renal function was completely restored over the following 6 weeks and he was discharged in good clinical condition about 2 months after intial admission. The clinical course and outcome are discussed, and the importance of timely initiation of dialysis when there is fluid overload is emphasised.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases. .

Insuficiencia renal aguda en el pos-trasplante hepático / Acute kidney injury following liver transplantation

Objetivo: Estudiar la incidencia de Insuficiencia renal aguda (IRA) en el postrasplante hepático, sus factores de riesgo y evaluar mortalidad en la internación y al año postrasplante. Material y métodos: Se realizó un análisis retrospectivo de 157 pacientes trasplantados hepáticos mayores de 18 años en el período comprendido entre diciembre de 2001 a mayo 2011. Fue analizada la función renal dentro de las 48 hs. previas al trasplante y postrasplante durante la internación. Se definió IRA al aumento de creatinina sérica en 1.5 veces el valor basal. Resultados: la incidencia de IRA postrasplante hepático fue del 33% (n=53). En el análisis multivariado la edad y la diabetes mostraron una asociación significativa con la presencia de IRA postrasplante hepático. La estadía hospitalaria entre los pacientes del grupo IRA promedió los 20 días (15-31) versus 14 días (11-23) del grupo no IRA (p=0,009). La mortalidad hospitalaria del grupo IRA fue de 16.9% (n=9) versus 3.8%(n=4) del grupo no IRA (p=0.005). La mortalidad al año postrasplante del grupo IRA fue de 26.4%(n=14) versus 7.6%(n=8) del grupo no IRA (p=0.001). Conclusión: la IRA en el postrasplante hepático es una complicación frecuente que está asociada a un aumento de la estadía hospitalaria, mortalidad a corto plazo y menor sobrevida al año postrasplante. La edad y la diabetes fueron factores independientes asociados a la presencia de IRA postrasplante hepático.

Objectives: Assessing: a).- The incidence of Acute Kidney Injury (AKI) in post-liver transplantation and its risk factors; b).- Mortality during hospitalization and one year after the transplantation. Materials and Methods: A retrospective analysis in 157 liver transplantation patients over 18 years of age was conducted from December of 2001 to May of 2011. Kidney function was assessed within 48 hours prior to the transplantation and during hospitalization after the transplantation. AKI was defined as a 1.5-fold serum creatinine increase from baseline. Results: AKI incidence following liver transplantation was 33% (n=53). In the multivariate analysis, age and diabetes showed significant association with the presence of AKI following liver transplantation. Average length of stay in hospital among patients in the AKI group was 20 days (15-31) versus 14 days (11- 23) in the non-AKI group (p=0.009). Hospital mortality in the AKI group was 16.9% (n=9) versus 3.8% (n=4) in the non-AKI group (p=0.005). Mortality one year following transplantation in the AKI group was 26.4% (n=14) versus 7.6%(n=8) in the non-AKI group (p=0.001).Conclusion: AKI following liver transplantation is a common complication which is associated withan increased stay in hospital, short-term mortality, and lower survival one year after transplantation. Age and diabetes were independent factors associated with the presence of AKI following liver transplantation.

Insuficiencia renal aguda en el pos-trasplante hepático / Acute kidney injury following liver transplantation

Objetivo: Estudiar la incidencia de Insuficiencia renal aguda (IRA) en el postrasplante hepático, sus factores de riesgo y evaluar mortalidad en la internación y al año postrasplante. Material y métodos: Se realizó un análisis retrospectivo de 157 pacientes trasplantados hepáticos mayores de 18 años en el período comprendido entre diciembre de 2001 a mayo 2011. Fue analizada la función renal dentro de las 48 hs. previas al trasplante y postrasplante durante la internación. Se definió IRA al aumento de creatinina sérica en 1.5 veces el valor basal. Resultados: la incidencia de IRA postrasplante hepático fue del 33% (n=53). En el análisis multivariado la edad y la diabetes mostraron una asociación significativa con la presencia de IRA postrasplante hepático. La estadía hospitalaria entre los pacientes del grupo IRA promedió los 20 días (15-31) versus 14 días (11-23) del grupo no IRA (p=0,009). La mortalidad hospitalaria del grupo IRA fue de 16.9% (n=9) versus 3.8%(n=4) del grupo no IRA (p=0.005). La mortalidad al año postrasplante del grupo IRA fue de 26.4%(n=14) versus 7.6%(n=8) del grupo no IRA (p=0.001). Conclusión: la IRA en el postrasplante hepático es una complicación frecuente que está asociada a un aumento de la estadía hospitalaria, mortalidad a corto plazo y menor sobrevida al año postrasplante. La edad y la diabetes fueron factores independientes asociados a la presencia de IRA postrasplante hepático.(AU)

Objectives: Assessing: a).- The incidence of Acute Kidney Injury (AKI) in post-liver transplantation and its risk factors; b).- Mortality during hospitalization and one year after the transplantation. Materials and Methods: A retrospective analysis in 157 liver transplantation patients over 18 years of age was conducted from December of 2001 to May of 2011. Kidney function was assessed within 48 hours prior to the transplantation and during hospitalization after the transplantation. AKI was defined as a 1.5-fold serum creatinine increase from baseline. Results: AKI incidence following liver transplantation was 33% (n=53). In the multivariate analysis, age and diabetes showed significant association with the presence of AKI following liver transplantation. Average length of stay in hospital among patients in the AKI group was 20 days (15-31) versus 14 days (11- 23) in the non-AKI group (p=0.009). Hospital mortality in the AKI group was 16.9% (n=9) versus 3.8% (n=4) in the non-AKI group (p=0.005). Mortality one year following transplantation in the AKI group was 26.4% (n=14) versus 7.6%(n=8) in the non-AKI group (p=0.001).Conclusion: AKI following liver transplantation is a common complication which is associated withan increased stay in hospital, short-term mortality, and lower survival one year after transplantation. Age and diabetes were independent factors associated with the presence of AKI following liver transplantation.(AU)

High lactate levels are predictors of major complications after cardiac surgery.

OBJECTIVE: Although hyperlactatemia after cardiac surgery is common, the implications of raised levels remain controversial. The aim of this study was to evaluate whether high lactate levels after cardiac surgery are predictors of major complications including mortality. PATIENTS AND METHODS: This was a substudy of TRACS (Transfusion Requirements After Cardiac Surgery), which was designed as a prospective, randomized, controlled trial evaluating the effects of a transfusion strategy on morbidity and mortality. RESULTS: Of the 502 patients enrolled, 52 (10%) had at least 1 major complication. Patients with complications were older, had a higher EuroSCORE, lower left ventricular ejection fraction, lower preoperative hemoglobin, a higher prevalence of renal disease, and received more blood transfusions than the group without complications. Lactate levels were higher in the group with complications at the end of surgery (3.6 mmol/L [2.8-5.1] vs 3.3 mmol/L [2.2-4.8]; P = .018), immediately after intensive care unit (ICU) admission (0 hour) (4.4 mmol/L [3.1-8.4] vs 4 mmol/L [2.6-6.4]; P = .048); 6 hours (4 mmol/L [2.7-5.8] vs 2.6 mmol/L [2-3.6], P < .001), and 12 hours after admission (2.3 mmol/L [1.8-3.2] vs 1.7 mmol/L [1.3-2]; P < .001). In a multivariate model, higher age (odds ratio [OR], 1.048, 95% confidence interval [CI], 1.011-1.086; P = .010), left ventricular ejection fraction (LVEF) lower than 40% (OR, 3.03; 95% CI, 1.200-7.510; P = .019 compared with LVEF of 40%-59%; OR, 3.571; 95% CI, 1.503-8.196; P = .004 compared with LVEF higher than 60%), higher EuroSCORE (OR, 1.138; 95% CI; 1.007-1.285; P = .038), red blood cell transfusion (OR, 1.230; 95% CI, 1.086-1.393; P = .001), and lactate levels 6 hours after ICU admission (OR, 3.28, 95% CI; 1.61-6.69; P = .001) are predictors of major complications. CONCLUSIONS: Hyperlactatemia 6 hours after ICU admission is an independent risk factor for worse outcomes in adult patients after cardiac surgery.

Impact of cystatin C and RIFLE on renal function assessment after cardiac surgery.

The lack of a consensus classification system and of a specific, sensitive, and early-stage biomarker for kidney injury frequently results in late diagnosis of acute kidney injury (AKI). The aim of the present study was to characterize the discriminatory power of cystatin C and the RIFLE and Acute Kidney Injury Network (AKIN) criteria for the assessment of renal dysfunction after cardiac surgery. A longitudinal, quantitative study was conducted in intensive care units of the Heart Institute (São Paulo, Brazil) in which 121 patients were followed for the first 72 hr after cardiac surgery. Most of the patients were male (61.2%), and the mean age was 50 years. The most frequent surgeries were valve replacement (48.8%) and myocardial revascularization (43.8%). AKI was defined as an increase of at least 50%, 0.3 mg/dl or 0.5 mg/dl in baseline serum creatinine. The percentage of participants meeting each of these criteria was 13.2%, 28.1%, and 11.6%, respectively. A progressive increase in cystatin C levels was associated with a worsening of renal function, as classified by RIFLE and AKIN (p < .05). Analysis of the receiver operating characteristic (ROC) curves showed the RIFLE and AKIN classification to have good discriminatory power for the assessment of renal function, with the performance of cystatin C being poorer (area under the curve: 0.804 and 0.794 vs. 0.719). However, combining cystatin C and RIFLE resulted in greater discriminatory power for detecting kidney injury in postoperative patients than any marker in isolation.

Epidemiología de la injuria renal aguda en unidades de cuidados críticos de un hospital general de agudos / Epidemiology of acute renal injury in the critical care units of a general hospital for acute patients

Introducción: La Injuria Renal Aguda (IRA) se presenta en el 1 al 25% de los pacientes críticos con una mortalidad entre el 15 y el 60%. En el 2004, la ADQI publicó la definición del consenso RIFLE. Objetivos: Evaluar: 1- incidencia, evolución, y mortalidad asociada a la IRA en Unidades Criticas (UCC) del HIGA San Martín de La Plata. 2- características demográficas y clínicas. Métodos: Se estudiaron los pacientes mayores de 16 años admitidos en las UCC desde el 01-06-2010 al 31-05-2011 internados al menos 24 hrs. y que contaron con 2 determinaciones de laboratorio como mínimo, desde su ingreso hasta el día 30 de internación, alta de la UCC u óbito. Se registraron patologías preexistentes, tratamientos farmacológicos previos y durante la internación, estado hemodinámico, requerimiento de ARM y parámetros bioquímicos. La IRA fue definida según la clasificación RIFLE. Resultados: Se incluyeron 290 pacientes, edad x 49.6 años, 71% masculino, etiologías de ingreso: cardiovasculares 23.3%, neurológicas 22.6%. trauma 17.4% e infecciosas 15.3%. Se observó progresión a categorías de mayor severidad del sistema RIFLE (p 0.001). El desarrollo de IRA se asoció con mayor edad (p 0.001) y comorbilidades previas (p 0.002). El requerimiento de HD fue de 5.17% (15 ptes.). La mortalidad fue mayor con la progresión en la clasificación RIFLE (R 46.5%; 1 55.8%, F 69.2%) y con el requerimiento de HD (80%). Conclusiones: La IRA fue frecuente en las UCC, predominando en los grupos de más edad y con comorbilidades. El desarrollo y progresión del daño renal muestran correlación con mayor mortalidad.

Introduction: Acute kidney injury (AKI) occurs in 1 to 25% of critically ill patients with a morality rate between 15 and 60%. In 2004, the ADQI published the RIFLE consensus definition. Objectives: To evaluate; 1 - incidence, evolution and mortality associated with AKI in critical units of HIGA San Martín de La Plata. 2 – Demographic and clinical characteristics. Methods: We studied patients over 16 years admitted in the UCC from 06/01/2010 to 05/31/2011 hospitalized at least 24 hours and that included two laboratory determinations al least, from entry to day 30 of hospitalization, discharge from the UCC or death. Preexisting pathologies were registered, also previous drug treatments during hospitalization, hemodynamic status, requirement for ARM and biochemical parameters. The IRA was defined according to the RIFLE classification. Results: 290 patients were included, 49.6 x age years, 71% male, etiologies of income: 23.3% cardiovascular, neurological 22.6%, 17.4% trauma and infectious 15.3%. Progression to more severe categories of RIFLE system was observed (p 0.001). The development of AKI was associated with older age (p 0.001) and previous comorbidities (p 0.002). The requirement for HD was 5.17% (15 patients). Mortality was higher with progression in the RIFLE classification (R 46.5% 55.8% I, F 69.2%) and with the requirement of HD (80%). Conclusions: AKI was frequent in UCC, predominantly in older age groups and with comorbidities. The development and progression of renal damage show a correlation with an increased mortality.

Epidemiología de la injuria renal aguda en unidades de cuidados críticos de un hospital general de agudos / Epidemiology of acute renal injury in the critical care units of a general hospital for acute patients

Introducción: La Injuria Renal Aguda (IRA) se presenta en el 1 al 25% de los pacientes críticos con una mortalidad entre el 15 y el 60%. En el 2004, la ADQI publicó la definición del consenso RIFLE. Objetivos: Evaluar: 1- incidencia, evolución, y mortalidad asociada a la IRA en Unidades Criticas (UCC) del HIGA San Martín de La Plata. 2- características demográficas y clínicas. Métodos: Se estudiaron los pacientes mayores de 16 años admitidos en las UCC desde el 01-06-2010 al 31-05-2011 internados al menos 24 hrs. y que contaron con 2 determinaciones de laboratorio como mínimo, desde su ingreso hasta el día 30 de internación, alta de la UCC u óbito. Se registraron patologías preexistentes, tratamientos farmacológicos previos y durante la internación, estado hemodinámico, requerimiento de ARM y parámetros bioquímicos. La IRA fue definida según la clasificación RIFLE. Resultados: Se incluyeron 290 pacientes, edad x 49.6 años, 71% masculino, etiologías de ingreso: cardiovasculares 23.3%, neurológicas 22.6%. trauma 17.4% e infecciosas 15.3%. Se observó progresión a categorías de mayor severidad del sistema RIFLE (p 0.001). El desarrollo de IRA se asoció con mayor edad (p 0.001) y comorbilidades previas (p 0.002). El requerimiento de HD fue de 5.17% (15 ptes.). La mortalidad fue mayor con la progresión en la clasificación RIFLE (R 46.5%; 1 55.8%, F 69.2%) y con el requerimiento de HD (80%). Conclusiones: La IRA fue frecuente en las UCC, predominando en los grupos de más edad y con comorbilidades. El desarrollo y progresión del daño renal muestran correlación con mayor mortalidad.(AU)

Introduction: Acute kidney injury (AKI) occurs in 1 to 25% of critically ill patients with a morality rate between 15 and 60%. In 2004, the ADQI published the RIFLE consensus definition. Objectives: To evaluate; 1 - incidence, evolution and mortality associated with AKI in critical units of HIGA San Martín de La Plata. 2 û Demographic and clinical characteristics. Methods: We studied patients over 16 years admitted in the UCC from 06/01/2010 to 05/31/2011 hospitalized at least 24 hours and that included two laboratory determinations al least, from entry to day 30 of hospitalization, discharge from the UCC or death. Preexisting pathologies were registered, also previous drug treatments during hospitalization, hemodynamic status, requirement for ARM and biochemical parameters. The IRA was defined according to the RIFLE classification. Results: 290 patients were included, 49.6 x age years, 71% male, etiologies of income: 23.3% cardiovascular, neurological 22.6%, 17.4% trauma and infectious 15.3%. Progression to more severe categories of RIFLE system was observed (p 0.001). The development of AKI was associated with older age (p 0.001) and previous comorbidities (p 0.002). The requirement for HD was 5.17% (15 patients). Mortality was higher with progression in the RIFLE classification (R 46.5% 55.8% I, F 69.2%) and with the requirement of HD (80%). Conclusions: AKI was frequent in UCC, predominantly in older age groups and with comorbidities. The development and progression of renal damage show a correlation with an increased mortality.(AU)

Diferentes abordagens na detecção da disfunção renal aguda em pacientes graves / Different approaches in the detection of acute renal dysfunction in serious patients

JUSTIFICATIVA E OBJETIVOS: As diversas definições para disfunção renal aguda (DRA) têm dificultado intervenções precoces nestes quadros, recentemente a classificação Risk, Injury, Failure, Loss and End-stage Renal Desease (RIFLE) tem contribuído para reverter esse quadro. O objetivo deste estudo foi comparar o método tradicional com a classificação RIFLE/AKIN (AcuteKidney Injury Network) para o diagnóstico de DRA. MÉTODO: Estudo retrospectivo transversal por análise de prontuáriosdos pacientes internados no período de 15 meses, na unidadede terapia intensiva do Hospital Universitário de Alagoas.Os indivíduos, classificados em dois grupos (I - com lesão renal e II - sem lesão renal), foram avaliados quanto ao sexo, idade, motivo da admissão, necessidade de ventilação mecânica e fármacos vasoativos, sepse, escore de Sepsis Occurrence in Acutely ill Patients(SOFA) e mortalidade. A avaliação para DRA foi comparada com a registrada em prontuários pelo médico plantonista.RESULTADOS: A ocorrência de DRA foi de 21%, com maior gravidade e tempo de internação neste grupo. Em relação ao diagnóstico, osplantonistas levaram o dobro do tempo para detectar DRA, utilizandoos critérios tradicionais, quando comparado ao uso do RIFLE/AKIN (p = 0,0056). Pacientes classificados com lesão e falência pelo RIFLE foram os que apresentaram maior gravidade e pior evolução. CONCLUSÃO: A taxa de DRA encontrada foi compatível com a literatura. A escassa utilização da classificação RIFLE/AKIN pelos plantonistas dificulta ações preventivas e o tratamento da DRA, o que prejudica a evolução e o prognóstico dos pacientes,sendo necessária maior atenção destes médicos.

BACKGROUND AND OBJETIVES: The various definitions for acute kidney injury (AKI) have hampered early intervention in these clinical conditions, recently the Risk, Injury, Failure, Loss and End-stage Renal Disease (RIFLE) classification has helped to reverse this. Our study aimed to compare the traditional method with RIFLE/AKIN (Acute Kidney Injury Network) classification for the diagnosis of AKI. METHOD: Retrospective cross-section studies by medical records analysis of patients admitted within 15 months in the intensive care unit of University Hospital of Alagoas. Individuals were classified into two groups (I - with renal injury and II - without renal injury); they were evaluated for sex, age, admission reason, mechanical ventilation need and vasoactive drugs, sepsis, Sepsis Occurrence in Acutely ill Patients (SOFA) score and mortality. Our assessment for AKI was compared with that recorded in medical records by the doctor on duty.RESULTS: The occurrence of AKI was 21%, with greater severity and duration of hospitalization in this group. Regarding diagnosis, doctor on duty took twice as long to detect AKI using the traditional criteria, when compared to the use of RIFLE/AKIN (p = 0.0056). Patients classified with injury and failure, by RIFLE, were those with greater severity and worse outcome. CONCLUSION: The rate of AKI has been found compatible to the literature. The little use of the RIFLE/AKIN classification, by doctors, hampers preventive actions and treatment of AKI that affect the evolution and prognosis, requiring more attention these doctors.

Efectos de la introducción progresiva de los inhibidores de la calcineurina en la función renal de una cohorte de pacientes que recibieron trasplante de hígado / Effects of progressive introduction of calcineurin inhibitors on the renal function of a cohort of liver transplant recipients

Introducción: la enfermedad renal aguda (ERA) se presenta en el postrasplante de hígado con una incidencia que varía de 12-64%, con una mortalidad intrahospitalaria asociada de 40-67%. Este estudio utiliza los criterios RIFLE para analizar el efecto del esquema inmunosupresor con inhibidores de la calcineurina en la aparición de ERA en los primeros quince días postrasplante de hígado. También evalúa el protocolo de introducción tardía y progresiva de los medicamentos inhibidores de la calcineurina (CNi) como estrategia para disminuir la incidencia de ERA postrasplante. Métodos: estudio analítico de cohortes de 163 pacientes con trasplante de hígado. Resultados: ciento sesenta y tres pacientes cumplieron con los criterios de inclusión del estudio con un promedio de edad de 51 (46-56) años. De éstos, sólo 11 (6.74%) presentaron ERA postrasplante. Ciclosporina fue administrada a 126 (77.3%) de los pacientes trasplantados y tacrolimus a 21 (12.88%). Inmediatamente después del trasplante los pacientes fueron clasificados en dos grupos: pacientes con riesgo alto de desarrollar ERA y pacientes sin problemas renales. A los primeros se les inició el CNi a partir del tercer día postrasplante y a los últimos entre seis y 18 horas después del trasplante, a una dosis que se aumentó gradualmente Conclusiones: la introducción tardía y progresiva de los CNi podría ser una estrategia efectiva para disminuir la incidencia de ERA en el postrasplante de hígado (Acta Med Colomb 2011; 36: 130-134).

Background: acute renal disease (ARD) occurs in liver transplantation with an incidence ranging from 12 to 64%, with an associated hospital mortality of 40 to 67%.This study used the RIFLE criteria to analyze the effect of an immunosuppressive regime including calcineurin inhibitors (CNi) in the development of ARD in patients with liver transplantation. It also assesses the protocol and progressive late introduction of CNi as a strategy to reduce the incidence of posttransplant ARD Methods: cohort analytic study of 163 patients with liver transplantation Results: 163 patients met the study inclusion criteria with an average age of 51 (46-56) years. Of these patients, only 11 (6.74%) had ARD transplantation. Cyclosporine was administered to 126 (77.3%) of tacrolimus in transplant patients and 21 (12.88%). Immediately after the transplant, patients were classified into two groups: patients with high risk of developing ERA and patients without kidney problems. At first they were introduced to the CNi from the third day after transplantation and the last six to 18 hours after the transplant, a dose that was gradually increased Conclusions: late and gradual introduction of CNi could be an effective strategy to reduce the incidence of acute renal disease in liver transplantation (Acta Med Colomb 2011; 36: 130-134).

Acute kidney injury in AIDS: frequency, RIFLE classification and outcome

The objective of the present study was to evaluate the characteristics of acute kidney injury (AKI) in AIDS patients and the value of RIFLE classification for predicting outcome. The study was conducted on AIDS patients admitted to an infectious diseases hospital inBrazil. The patients with AKI were classified according to the RIFLE classification: R (risk), I (injury), F (failure), L (loss), and E (end-stage renal disease). Univariate and multivariate analyses were used to evaluate the factors associated with AKI. A total of 532 patients with a mean age of 35 ± 8.5 years were included in this study. AKI was observed in 37 percent of the cases. Patients were classified as "R" (18 percent), "I" (7.7 percent) and "F" (11 percent). Independent risk factors for AKI were thrombocytopenia (OR = 2.9, 95 percentCI = 1.5-5.6, P < 0.001) and elevation of aspartate aminotransferase (AST) (OR = 3.5, 95 percentCI = 1.8-6.6, P < 0.001). General mortality was 25.7 percent and was higher among patients with AKI (40.2 vs17 percent, P < 0.001). AKI was associated with death and mortality increased according to RIFLE classification - "R" (OR 2.4), "I" (OR 3.0) and "F" (OR 5.1), P < 0.001. AKI is a frequent complication in AIDS patients, which is associated with increased mortality. RIFLE classification is an important indicator of poor outcome for AIDS patients.