Evaluation of the registry DIALYREG for the assessment of continuous renal replacement techniques in the critically ill patient.

Continuous renal replacement techniques (CRRT) can induce complications and monitoring is crucial to ensure patient safety. We designed a prospective multicenter observational and descriptive study using the DIALYREG registry, an online database located on a REDCap web-based platform that allows real-time data analysis. Our main objective was to identify CRRT-related complications in our intensive care units (ICUs) and implement security measures accordingly. From January 2019 to December 2020, we included 323 patients with admission diagnoses of medical illness (54%), sepsis (24%), postoperative care (20%), and trauma (2%). CRRT indications were homeostasis (42%), oliguria (26%), fluid overload (15%), and hemodynamic optimization (13%). The median initial therapy dose was 30 ml/kg/h (IQR 25-40), and dynamic adjustment was performed in 61% of the treatments. Sets were anticoagulated with heparin (40%), citrate (38%) or no anticoagulation (22%). Citrate anticoagulation had several advantages: more frequent dynamic CRRT dose adjustment (77% vs. 58% with heparin and 56% without anticoagulation, p < 0.05), longer duration of set (median of 55 h, IQR 24-72 vs. 23 h, IQR 12-48 with heparin and 12 h, IQR 12-31 without anticoagulation, p < 0.05), less clotting of the set (26% vs. 46.7% with heparin, p < 0.05), and lower incidence of hypophosphatemia (1% citrate vs. 6% with heparin and 5% without anticoagulation). It was also safe and effective in subgroup analysis of patients with liver disease or sepsis. The main global complications were hypothermia (16%), hypophosphatemia (13%) and metabolic acidosis (10%). Weaning of the therapy was achieved through early discontinuation (56%), nocturnal therapy transition (26%) and progressive SLED (18%). 52% of the patients were discharged from the hospital, while 43% died in the ICU and 5% died during hospitalization. We can conclude that the DIALYREG registry is a feasible tool for real-time control of CRRT in our ICU.

C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study / Proteína C reactiva al ingreso en UCI como marcador de disfunción temprana del injerto tras trasplante hepático. Estudio unicéntrico, prospectivo y de cohortes

OBJECTIVE: To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD). DESIGN: A prospective, single-center cohort study was carried out. SETTING: The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997. PATIENTS: The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality. RESULTS: The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3) mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4) mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7] mg/L) than the patients without EAD (0.5 [53.9-67.0]; p < 0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p < 0.01, AUC 0.79 [0.65-0.92]). CONCLUSIÓN: Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality

OBJETIVO: Explorar el comportamiento de la proteína C reactiva (PCR) en el postoperatorio inmediato de trasplante hepático y su utilidad como marcador de disfunción grave del injerto hepático. DISEÑO: Estudio de cohortes prospectivo, unicéntrico. ÁMBITO: Unidad de cuidados intensivos (UCI) de un hospital regional. PACIENTES: Ciento ochenta y tres pacientes ingresados en nuestra UCI inmediatamente después del trasplante hepático entre 2009-2015. VARIABLES DE INTERÉS: Niveles de PCR al ingreso en UCI, 24 y 48h, disfunción grave del injerto hepático, mortalidad intrahospitalaria. RESULTADOS: Los niveles de PCR en el postoperatorio inmediato de trasplante fueron: al ingreso en UCI 57,5 (51,6-63,3) mg/L, a las 24h 80,1 (72,9-87,3) mg/L y a las 48h 69,9 (62,5-77,4) mg/L. Los pacientes con disfunción grave del injerto (14,2%) tuvieron una mayor mortalidad (23,1 vs. 2,5; OR 11,48: 2,98-44,19) y PCR más baja al ingreso en UCI (39,3 [29,8-48,7]mg/L) que los pacientes sin disfunción grave (0,5 [53,9-67]; p < 0,05), siendo el mejor punto de corte para la PCR de 68mg/L (sensibilidad 92,3%; especificidad 40,1%; índice de Youden 0,33). La PCR baja al ingreso tuvo correlación directa con la mortalidad (24,5 [9,2-39,7] vs. 59,4 [53,4-65,4]; p < 0,01, AUC 0,79 [0,65-0,92]). CONCLUSIÓN: El trasplante hepático es un estímulo inflamatorio intenso que se acompaña de niveles elevados de PCR. Un ascenso truncado de la PCR, en el primer día del postoperatorio de trasplante hepático, puede ser un marcador de funcionamiento inadecuado del injerto hepático y está relacionado con la mortalidad intrahospitalaria

Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort / Disfunción temprana del injerto tras trasplante hepático: Comparación de varios criterios diagnósticos en un estudio unicéntrico, prospectivo y de cohorte

OBJECTIVE: Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN: Single-center, prospective, cohort study. SETTINGS: ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS: 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. Variables of interest: Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS: The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSIÓN: We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality

OBJETIVO: Comparar diferentes criterios diagnósticos de disfunción temprana del aloinjerto hepático y su capacidad para predecir mortalidad. DISEÑO: Estudio de cohortes prospectivo, unicéntrico. Ámbito: Unidad de Cuidados Intensivos de un Hospital Regional con programa de trasplante hepático desde 1997. PACIENTES: 253 pacientes consecutivos ingresados en nuestra UCI inmediatamente después del trasplante entre 2009-2015. Variables de interés: Incidencia de disfunción temprana del aloinjerto hepático según cada criterio diagnóstico, relación entre disfunción grave acorde a cada criterio y mortalidad en UCI, mortalidad hospitalaria y a los 2 años utilizando como comparador el criterio para fallo primario de la UNOS (United Network for Organ Sharing). RESULTADOS: La incidencia de disfunción temprana según UNOS fue 13.8%, Makowka 6.3%, Ardite 10.7%, Nanashima 20.6%, Dhillon 30.8% y MEAF 13.4%. El coeficiente kappa mostró una pobre correlación entre ellos. Todos los criterios, excepto el de Dhillon, mostraron relación con la mortalidad en la UCI, pero solo los criterios de UNOS, Makowka y MEAF se asociaron con la mortalidad a 2 años. Finalmente, la capacidad predictiva de la mortalidad hospitalaria fue baja para todos, excepto para MEAF. CONCLUSIÓN: Existe una pobre correlación entre diferentes criterios diagnósticos de disfunción temprana del injerto hepático. El MEAF muestra la mejor relación con el pronóstico a corto y largo plazo en nuestra población

C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study.

OBJECTIVE: To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD). DESIGN: A prospective, single-center cohort study was carried out. SETTING: The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997. PATIENTS: The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality. RESULTS: The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3)mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4)mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7]mg/L) than the patients without EAD (0.5 [53.9-67.0]; p<0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p<0.01, AUC 0.79 [0.65-0.92]). CONCLUSION: Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality.

Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort.

OBJECTIVE: Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN: Single-center, prospective, cohort study. SETTINGS: ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS: 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST: Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS: The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSION: We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality.

Anomalous position of femoral dialysis catheters / Posición anómala de los catéteres femorales para diálisis

No disponible

Acute kidney injury: Renal disease in the ICU / Lesión renal aguda: nefropatía en la UCI

Acute kidney injury (AKI) in the ICU frequently requires costly supportive therapies, has high morbidity, and its long-term prognosis is not as good as it has been presumed so far. Consequently, AKI generates a significant burden for the healthcare system. The problem is that AKI lacks an effective treatment and the best approach relies on early secondary prevention. Therefore, to facilitate early diagnosis, a broader definition of AKI should be established, and a marker with more sensitivity and early-detection capacity than serum creatinine - the most common marker of AKI - should be identified. Fortunately, new classification systems (RIFLE, AKIN or KDIGO) have been developed to solve these problems, and the discovery of new biomarkers for kidney injury will hopefully change the way we approach renal patients. As a first step, the concept of renal failure has changed from being a ‘static’ disease to being a ‘dynamic process’ that requires continuous evaluation of kidney function adapted to the reality of the ICU patient

El tratamiento de lesiones renales agudas (LRA) en la UCI requiere habitualmente procedimientos complementarios costosos, se asocia a una elevada morbilidad y su pronóstico a largo plazo no es tan bueno como se creía hasta ahora. En consecuencia, las LRA ocasionan una importante carga para el sistema sanitario. El problema es que no existe un tratamiento eficaz para las LRA y el mejor enfoque se basa en la prevención secundaria precoz. Por consiguiente, para facilitar el diagnóstico precoz, es necesario establecer una definición más amplia de la LRA así como identificar un marcador con mayor sensibilidad y capacidad de diagnóstico precoz que la creatinina sérica (el marcador más habitual de LRA en la actualidad). Afortunadamente, se han desarrollado nuevos sistemas de clasificación (RIFLE, AKIN o KDIGO) para solucionar este problema y se espera que el descubrimiento de nuevos biomarcadores de lesión renal cambie la forma en que abordamos el tratamiento de los pacientes con nefropatía. Como primer paso, el concepto de insuficiencia renal ha pasado de considerarse una enfermedad «estática» a un «proceso dinámico» que requiere una evaluación continua de la función renal adaptada a la realidad del paciente en la UCI

Acute kidney injury: Renal disease in the ICU.

Acute kidney injury (AKI) in the ICU frequently requires costly supportive therapies, has high morbidity, and its long-term prognosis is not as good as it has been presumed so far. Consequently, AKI generates a significant burden for the healthcare system. The problem is that AKI lacks an effective treatment and the best approach relies on early secondary prevention. Therefore, to facilitate early diagnosis, a broader definition of AKI should be established, and a marker with more sensitivity and early-detection capacity than serum creatinine - the most common marker of AKI - should be identified. Fortunately, new classification systems (RIFLE, AKIN or KDIGO) have been developed to solve these problems, and the discovery of new biomarkers for kidney injury will hopefully change the way we approach renal patients. As a first step, the concept of renal failure has changed from being a "static" disease to being a "dynamic process" that requires continuous evaluation of kidney function adapted to the reality of the ICU patient.

Dialysis Efficiency of AN69, a Semisynthetic Membrane Not Well Suited for Diffusion.

AN69 membrane is not suited for diffusion, with an suggested limit at 25 mL/min dialysate flow rate. When prescribing continuous hemodialysis this threshold must be surpassed to achieve. We designed a study aimed to check if a higher dose of dialysis could be delivered efficiently with this membrane. Ten ICU patients under continuous hemodiafiltration with 1.4 m(2) AN69 membrane were included and once a day we set the monitor to exclusively 50 mL/min dialysate flow rate and 250 mL/min blood flow rate and after 15 minutes measured dialysate saturation for urea, creatinine, and ß 2-microglobulin. We detected that urea saturation of dialysate was nearly complete (1.1 ± 0.09) for at least 40 hours, while creatinine saturation showed a large dispersion (0.86 ± 0.22) and did not detect any relation for these variables with time, blood flow, or anticoagulation regime. Saturation of ß 2-microglobulin was low (0.34 ± 0.1) and decreased discretely with time (r (2) = 0.15, P < 0.05) and significantly with TMP increases (r (2) = 0.31, P < 0.01). In our experience AN69 membrane shows a better diffusive capability than previously acknowledged, covering efficiently the range of standard dosage for continuous therapies. Creatinine is not a good marker of the membrane diffusive capability.

Thiolated DAB dendrimer/ZnSe nanoparticles for C-reactive protein recognition in human serum.

A nanocomposite obtained by a thiol DAB-dendrimer (generation 5), coated with fluorescent ZnSe quantum dots, was successfully synthesized for the selective recognition of C-reactive protein. The procedure presented was carried out by a novel, cheap and non-toxic bottom up synthesis. The nanocomposite showed an excitation at 180 nm, with two emission bands at 411 and 465 nm, with a full-width at half-maximum of 336 nm. The Stokes shift was influenced by the presence of coating molecules and the intensity was dependent on pH due to the presence of a charge transfer process. The transmission electron microscopy images demonstrated that the spherical nanoparticles obtained displayed a regular shape of 30 nm size. The fluorescence intensity was markedly quenched by the presence of C-reactive protein, with a dynamic Stern-Volmer constant of 0.036 M(-1). The quenching profile shows that about 51% of the ZnSe QDs are located in the external layer of the thiol dendrimer accessible to the quencher. The precision of the method obtained as relative standard deviation was 3.76% (4 mg L(-1), n=3). This water soluble fluorescent nanocomposite showed a set of favorable properties to be used as a sensor for the C-reactive protein in serum samples, at concentrations of risk levels.

CdSe and ZnSe quantum dots capped with PEA for screening C-reactive protein in human serum.

A fluorescence chemical sensor for C-reactive protein (CRP) was developed based on the selective interaction with CdSe and ZnSe quantum dots (QDs) coated with O-phosphorylethanolamine (PEA). Synthesis procedure and analytical parameters such as pH and ionic strength were studied. The decrease in the fluorescence emission intensity was explained due to the specific interaction of the QDs-PEA with CRP, and a correlation was observed between the quenching of the fluorescence and the concentration of CRP. The accuracy of the proposed method was 0.37% as RSD. The proposed method was applied to screen serum samples, and showed to be sensible at the C-reactive protein concentrations of risks levels.

[Variability in renal dysfunction defining criteria and detection methods in intensive care units: are the international consensus criteria used for diagnosing renal dysfunction?]. / Variabilidad en los criterios de definición y métodos de detección de la disfunción renal en las unidades de cuidados intensivos ¿se aplican los consensos internacionales para el diagnóstico de la disfunción renal?

OBJECTIVE: To evaluate variability in the detection and prevention of acute kidney injury (AKI) in the intensive care unit (ICU), and application of the international recommendations in this field (Acute Dialysis Quality Initiative [ADQI] and Acute Kidney Injury Network [AKIN]). DESIGN: A prospective, observational, multicenter study. SETTING: A total of 42 ICUs in 32 hospitals (78% in third level hospitals and 70.7% general units) recruited for a study on the prevalence of AKI (COFRADE). INTERVENTIONS: Survey. VARIABLES: Aspects related to AKI detection and prevention and renal replacement therapy protocols. RESULTS: The method used for estimating glomerular filtration rate was serum creatinine in 36.6%, creatinine clearance in 41.5% and equations in 22%; none reported using cystatin-C. Only 39.1% ICUs acknowledged the use of stratification systems (13 RIFLE and 3 AKIN). A total of 48.8% ICUs had no written protocols for AKI prevention, 31.7% reported using them only for contrast nephropathy, 7.3% for nephrotoxic drugs and 12.2% for both. In contrast, 63.4% participants had written protocols for renal replacement therapy, 70.7% had implemented a training program, and 53.7% had some method for adjusting doses of drugs when on renal replacement therapy. CONCLUSIONS: We observed important variability regarding diagnostic criteria and prevention of AKI in Spanish ICUs, the application of ADQI or AKIN recommendations still being low in our units. Renal replacement therapy seems to generate more concern among our intensivists than AKI management.

Desarrollo de un modelo experimental de shock séptico orientado a la formación. Aplicación en el entrenamiento de técnicas de depuración en el manejo de la sepsis grave / Development of a septic shock experimental model oriented at training. Application in the training of depuration techniques in the management of severe sepsis

ObjetivoDefinir un modelo experimental de shock séptico que pueda aplicarse al entrenamiento en el manejo inicial del shock séptico, de forma concreta mediante el uso de técnicas de depuración extrarrenal (TDE).DiseñoEstudio experimental de casos-control.ÁmbitoHospital veterinario universitario.SujetosDiez perros Beagle (peso 12-15kg).IntervencionesSe provocó shock infundiendo 1mg/kg de lipopolisacárido de Escherichia coli (LPS) en 20ml salino en 10min, con un seguimiento posterior de 6h. Cinco animales no recibieron intervención para definir el curso del shock y 5 fueron tratados con hemofiltración de alto volumen (HVHF, 100ml/kg/h) para valorar la rapidez de respuesta.Variables de interésSe monitorizaron presiones (arterial y pulmonar), parámetros hemodinámicos, tonometría gástrica y función respiratoria.ResultadosA los 2min el efecto de la infusión de LPS era apreciable y al final de la infusión los 10 animales mostraban shock severo. A las 2h se apreciaban diferencias en gasto cardíaco, variabilidad de volumen sistólico y CO2 mucoso entre tratados y no tratados. En 4h la diferencia era evidente también en presión arterial media. Ningún control y todos los tratados sobrevivieron las 6h del experimento. Posteriormente, hemos desarrollado un taller docente basado en este protocolo que se ha aplicado en cinco cursos de formación (www.ccmijesususon.com; www.crrtcordoba.com.es/), obteniendo los resultados previstos.ConclusionesEste modelo de shock muestra una respuesta predecible en el tiempo, una latencia muy corta y una mejoría en animales tratados suficientemente rápida como para aplicarlo en talleres de formación. Es útil para el entrenamiento en HVHF y, asimismo, podría aplicarse en otros escenarios de manejo precoz del shock séptico (AU)

AbstractObjective: To define a septic shock experimental model that can be used in for training in theearly management of septic shock, specifically by extracorporeal depuration (ECD).Design: A case-control experimental study.Setting: Veterinary university hospital.Subjects: Ten Beagle dogs (weight 12-15 kg).Interventions: Shock was induced using 1 mg/kg Escherichia coli lipopolysaccharide (LPS) dilutedin 20mL saline infused in 10 minutes, with a subsequent follow-up at 6 hours. There was nointervention in 5 animals in order to define the natural course of the shock and 5 underwenthigh volume hemofiltration (HVHF, 100 mL/kg/h) to define delay in response to treatment.Variables: Pressures (arterial and pulmonary), hemodynamic parameters, gastric tonometryand respiratory function were recorded.Results: The LPS effect was evidenced at 2 minutes of the infusion and the 10 animals showedsevere shock at the end of the infusion. At 2-hours, changes between treated and non-treatedanimals were seen in cardiac output, systolic volume variability and mucous CO2. Mean arterialpressure was significantly different at four hours. All non-treated subjects died duringthe 6-hour follow-up and all the treated animals survived for this period. Based on theseresults, we developed a workshop that has been used in five courses (www.ccmijesususon.com— www.crrtcordoba.com.es/), obtaining the previous results.Conclusions: Our shock model shows a predictable behavior, very short latency and a sufficientlyrapid improvement in the treated animals for it to be applied in training workshops. It is usefulfor training in the high-volume hemofilitration (HVHF) and can be used for training in the earlymanagement of septic shock (AU)

[Development of a septic shock experimental model oriented at training. Application in the training of depuration techniques in the management of severe sepsis]. / Desarrollo de un modelo experimental de shock séptico orientado a la formación. Aplicación en el entrenamiento de técnicas de depuración en el manejo de la sepsis grave.

OBJECTIVE: To define a septic shock experimental model that can be used in for training in the early management of septic shock, specifically by extracorporeal depuration (ECD). DESIGN: A case-control experimental study. SETTING: Veterinary university hospital. SUBJECTS: Ten Beagle dogs (weight 12-15kg). INTERVENTIONS: Shock was induced using 1mg/kg Escherichia coli lipopolysaccharide (LPS) diluted in 20 mL saline infused in 10 minutes, with a subsequent follow-up at 6 hours. There was no intervention in 5 animals in order to define the natural course of the shock and 5 underwent high volume hemofiltration (HVHF, 100mL/kg/h) to define delay in response to treatment. VARIABLES: Pressures (arterial and pulmonary), hemodynamic parameters, gastric tonometry and respiratory function were recorded. RESULTS: The LPS effect was evidenced at 2 minutes of the infusion and the 10 animals showed severe shock at the end of the infusion. At 2-hours, changes between treated and non-treated animals were seen in cardiac output, systolic volume variability and mucous CO(2). Mean arterial pressure was significantly different at four hours. All non-treated subjects died during the 6-hour follow-up and all the treated animals survived for this period. Based on these results, we developed a workshop that has been used in five courses (www.ccmijesususon.com - www.crrtcordoba.com.es/), obtaining the previous results. CONCLUSIONS: Our shock model shows a predictable behavior, very short latency and a sufficiently rapid improvement in the treated animals for it to be applied in training workshops. It is useful for training in the high-volume hemofiltration (HVHF) and can be used for training in the early management of septic shock.

Concordancia en pacientes críticos entre las ecuaciones diseñadas para la estimación del filtrado glomerular y el aclaramiento de creatinina en orina de 24h / Concordance in critical patients between the equations designed for the calculation of glomerular filtration rate and 24-hour creatinine clearance

Objetivo: Estudiar el comportamiento de las ecuaciones empleadas para estimar el filtrado glomerular cuando se aplican a pacientes críticos y comparar con el método actualmente más aceptado: el aclaramiento de creatinina (ClCr) en orina de 24h (ClCr-24h). Diseño: Estudio retrospectivo de una base de datos procedente de un estudio prospectivo observacional previo. Ámbito: Una unidad de cuidados intensivos polivalente en un hospital de tercer nivel. Participantes: Todos los pacientes adultos ingresados en nuestra unidad con sondaje vesical. Se excluyó a los pacientes en anuria. Intervenciones: A los pacientes seleccionados se les midió el ClCr-24h y aplicamos las ecuaciones Modified Diet in Renal Disease (MDRD), Jelliffe modificada (JF), Clínica Mayo (CM) y Cockroft-Gault (C-G) para estimar el filtrado glomerular. Variables de interés: Para valorar el grado de acuerdo, agrupamos a los pacientes según el ClCr-24h como normales (>70 ml/min/1,73m2), con disfunción moderada (69-50 ml/min/1,73m2) y con disfunción renal grave (<50ml/min/1,73m2). Resultados: Trescientos siete pacientes de 54±18 años, el 69,7% varones. El ClCr-24h fue de 109,2±78,2ml/min/1,73m2 y el estimado de 95,5±56,7 ml/min/1,73m2 para JF, de 87,4±53,4 ml/min/1,73m2 para C-G, de 86,9±55,9 ml/min/1,73m2 para MDRD y de 85,6±39,9 ml/min/1,73m2 para CM. La diferencia fue significativa (p<0,001) para todas las medidas, pero menor para JF (13,7±53,2 ml/min/1,73m2) que para C-G (21,9±58,3 ml/min/1,73m2), CM (23,6±59,6 ml/min/1,73m2) o MDRD (22,3±60,4 ml/min/1,73m2). El coeficiente de correlación fue 0,73 para JF; 0,67 para C-G y CM y 0,64 para MDRD. El grado de acuerdo fue discreto en todos los casos (estadístico κ de 0,55 para JF y MDRD; 0,51 para C-G, y 0,5 para CM). Conclusiones: La ecuación de JF muestra mayor concordancia con el ClCr que las de C-G, MDRD o CM cuando se aplica a pacientes de unidad de cuidados intensivos. Sin embargo, cuando se requiere una medición fiable, ninguna de ellas es adecuada y es necesario en estos casos calcular el ClCr (AU)

Objective: To study the behavior of the different equations used to estimate glomerular filtration rate (GFR) applied to critical care patients compared to the standard method: 24-hour creatinine clearance (24-CrCl). Design: Retrospective analysis of data base from a previous observational prospective study. Setting: Polyvalent ICU in a tertiary Hospital. Population: All adult patients admitted to our Unit during the study who had a bladder catheter inserted. Anuric patients were excluded. Interventions: We measured 24-CrCl and estimated GFR by MDRD, modified Jelliffe (JF), Mayo-Clinic (CM) and Cockroft-Gault (C-G) equations. Variables: To evaluate degree of agreement, we grouped patients regarding 24-CrCl as normal (>70), moderate dysfunction (69-50) or severe renal dysfunction (< 50mL/min/1.73m2). Results: 307 patients, aged 54±18, 69.7% males. Measured 24-CrCl was 109.2±78.2mL/min/1.73m2 and the estimate one 95.5±56.7 for JF, 87.4±53.4 for C-G, 86.9±55.9 for MDRD and 85.6±39.9 for CM. The difference was significant (p<0.001) for all estimates but lower for (13.7±53.2mL/min/1.73m2) than C-G (21.9±58.3), CM (23.6±59.6) or MDRD (22.3±60.4). Correlation coefficient was 0.73 for JF, 0.67 C-G or CM and 0.64 for MDRD. The degree of agreement was only fair for all measures (Kappa 0.55 for JF or MDRD, 0.51 for C-G and 0.5 for CM). Conclusions: Modified Jelliffe equation showed higher agreement with 24-CrCl than Cockroft-Gault, MDRD or Mayo-Clinic equations when used in critically ill patients. However, when exact measurement is needed, none of the equations can be considered adequate and in these cases, the CrCl should be calculated (AU)

[Concordance in critical patients between the equations designed for the calculation of glomerular filtration rate and 24-hour creatinine clearance]. / Concordancia en pacientes críticos entre las ecuaciones diseñadas para la estimación del filtrado glomerular y el aclaramiento de creatinina en orina de 24h.

OBJECTIVE: To study the behavior of the different equations used to estimate glomerular filtration rate (GFR) applied to critical care patients compared to the standard method: 24-hour creatinine clearance (24-CrCl). DESIGN: Retrospective analysis of data base from a previous observational prospective study. SETTING: Polyvalent ICU in a tertiary Hospital. POPULATION: All adult patients admitted to our Unit during the study who had a bladder catheter inserted. Anuric patients were excluded. INTERVENTIONS: We measured 24-CrCl and estimated GFR by MDRD, modified Jelliffe (JF), Mayo-Clinic (CM) and Cockroft-Gault (C-G) equations. VARIABLES: To evaluate degree of agreement, we grouped patients regarding 24-CrCl as normal (>70), moderate dysfunction (69-50) or severe renal dysfunction (< 50 mL/min/1.73 m(2)). RESULTS: 307 patients, aged 54+/-18, 69.7% males. Measured 24-CrCl was 109.2+/-78.2 mL/min/1.73 m(2) and the estimate one 95.5+/-56.7 for JF, 87.4+/-53.4 for C-G, 86.9+/-55.9 for MDRD and 85.6+/-39.9 for CM. The difference was significant (p<0.001) for all estimates but lower for (13.7+/-53.2 mL/min/1.73 m(2)) than C-G (21.9+/-58.3), CM (23.6+/-59.6) or MDRD (22.3+/-60.4). Correlation coefficient was 0.73 for JF, 0.67 C-G or CM and 0.64 for MDRD. The degree of agreement was only fair for all measures (Kappa 0.55 for JF or MDRD, 0.51 for C-G and 0.5 for CM). CONCLUSIONS: Modified Jelliffe equation showed higher agreement with 24-CrCl than Cockroft-Gault, MDRD or Mayo-Clinic equations when used in critically ill patients. However, when exact measurement is needed, none of the equations can be considered adequate and in these cases, the CrCl should be calculated.

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[Liver transplantation: influence of donor-related factors]. / Trasplante hepático: influencia de los factores dependientes del donante.

OBJECTIVE: To detect donor characteristics related to graft function after orthotopic liver transplantation (OLT). DESIGN: Retrospective cohort study. CONTEXT: Polyvalent intensive care unit. PATIENTS: 145 liver transplant recipients and their respective donors. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: In donors: age, hypernatremia, and infection. In recipients: reperfusion syndrome, coagulopathy, infection, ARDS, shock, kidney failure, primary graft dysfunction, and mortality. RESULTS: 71.7% of recipients were male. Mean recipient age was 54.5 +/- 9.9 years; 66.2% of patients were classified as Child B and and 19.3% as Child C. The mean model for end-stage liver disease (MELD) score was 14.6 +/- 4.8 and the mean APACHE II score was 17.3 +/- 4.9. A total of 64.1% of the donors were male. Mean donor age was 42.3 +/- 16.3 years, and mean APACHE II score was 22.3 +/- 5.8. Donor age > 65 years was associated to higher recipient aspartate aminotransferase (AST) levels but not to increased complications or mortality. No other donor factors (including age, sex, serum sodium, severity level, transfusions, hemodynamic alterations, renal dysfunction, or infection) were associated to evolution or prognosis. Infection was diagnosed in 18 recipients (12.4%) in the postoperative period; the incidence of infection in recipients that received an organ from infected donors was not different from those that received an organ from an uninfected donor (14.6% versus 11.5%; p > 0.05). CONCLUSIONS: We detected no donor characteristics related to graft function or the appearance of complications in recipients during the immediate postoperative period. Donor age > 65 years and documented but appropriately treated bacteremia posed no risk for the viability of the liver after transplantation.