Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol.

BACKGROUND: Delirium is a clinical condition characterised by acute and fluctuating deterioration of the cognitive state, generally secondary to an acute pathology. Delirium is associated with negative outcomes in older adults, such as longer hospitalisations, higher mortality, and short and medium-term institutionalisation. Randomised clinical trials have shown that delirium is preventable through non-pharmacological prevention measures, decreasing its incidence by 30-50%. These interventions include promoting physical activity, facilitating the use of glasses and hearing aids, cognitive stimulation, and providing frequent reorientation of time and space, among others. These measures are currently seldom applied in hospitals in Chile and around the world for reasons including the heavy workload of clinical staff, the lack of trained personnel, and in general the absence of a systematic implementation processes. We developed a software called PREVEDEL, which includes non-pharmacological strategies such as cognitive stimulation, early mobilisation, orientation, and pain assessment. We propose a randomised clinical trial to evaluate whether cognitive stimulation guided by PREVEDEL software prevents delirium status (full/subsyndromal delirium) in hospitalised older adults. METHOD: A randomised controlled trial, with parallel, multicentre groups. We will recruite patients 65 years or older who have been hospitalised for less than 48 h in the general ward or the intermediate care units of four hospitals in Santiago, Chile. The participants in the intervention group will use a tablet with cognitive stimulation software for delirium prevention for five continuous days versus the control group who will use the tablet without the software. We will evaluate the incidence, duration, density of delirium, subsyndromal delirium with the Confusion Assessment Method, cognitive with the Montreal Cognitive Assessment, and functional status with the Functional Independence Measure at discharge. Moreover, we will evaluate the adherence to prevention measures, as well as demographic variables of interest. DISCUSSION: The use of cognitive PREVEDEL software could increase and improve the implementation of non-pharmacological prevention measures for delirium in hospitalised older adults, thus reducing its incidence and contributing to patients and health professionals. TRIAL REGISTRATION: NCT05108207 ClinicalTrials.gov. Registered 4 November 2021.

Impact of a Novel Social Work Program on Access to Tertiary Care.

Background: In the movement for global health equity, increased research and funding have not yet addressed a shortage of evidence on effectively implementing context-specific interventions; one unmet need is facilitating access to specialty care within the public health sector in Mexico. Compañeros en Salud has been piloting a novel program, called Right to Healthcare (RTHC), to increase access to specialty care for the rural poor in Chiapas, Mexico. The RTHC program incorporates social work, patient navigation, referrals, direct economic support, and accompaniment for patients. Objectives: This study evaluates the effectiveness of the RTHC program. Primary outcomes analyzed included acceptance of any referral and attendance of any appointment. Secondary outcomes included acceptance of the first referral and rate of appointment attendance for patients with an accepted referral. Methods: Using referral process data for the years 2014 to 2019 from a public tertiary care hospital in Chiapas, 91 RTHC patients were matched using 2:1 optimal pair matching with a control cohort balancing covariates of patient age, sex, specialty referred to, level of referring hospital, and municipality. Findings: RTHC patients were more likely to have had an accepted referral (OR 17.42, 95% CI 3.68 to 414.16) and to have attended an appointment (OR 5.49, 95% CI 2.93 to 11.60) compared to the matched control group. RTHC patients were also more likely to have had their first referral accepted (OR 2.78, 95% CI 1.29 to 6.73). Among patients with an accepted referral, RTHC patients were more likely to have attended an appointment (OR 3.86, 95% CI 1.90 to 8.57). Conclusions: The results demonstrate that the RTHC model is successful in increasing access to specialty care by both increasing referral acceptance and appointment attendance.

Development and validation of the MMCD score to predict kidney replacement therapy in COVID-19 patients

BackgroundAcute kidney injury (AKI) is frequently associated with COVID-19 and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalized COVID-19 patients. MethodsThis study is part of the multicentre cohort, the Brazilian COVID-19 Registry. A total of 5,212 adult COVID-19 patients were included between March/2020 and September/2020. We evaluated four categories of predictor variables: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) the need for mechanical ventilation at any time during hospitalization. Variable selection was performed using generalized additive models (GAM) and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. The accuracy was assessed using the area under the receiver operating characteristic curve (AUC-ROC). Risk groups were proposed based on predicted probabilities: non-high (up to 14.9%), high (15.0 - 49.9%), and very high risk ([≥] 50.0%). ResultsThe median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalization. The validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. Thirty-two variables were tested and four important predictors of the need for KRT during hospitalization were identified using GAM: need for mechanical ventilation, male gender, higher creatinine at admission, and diabetes. The MMCD score had excellent discrimination in derivation (AUROC = 0.929; 95% CI 0.918-0.939) and validation (AUROC = 0.927; 95% CI 0.911-0.941) cohorts an good overall performance in both cohorts (Brier score: 0.057 and 0.056, respectively). The score is implemented in a freely available online risk calculator (https://www.mmcdscore.com/). ConclusionThe use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalized COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation.

Hypothyroidism does not lead to worse prognosis in COVID-19: findings from the Brazilian COVID-19 registry

BackgroundIt is not clear whether previous thyroid diseases influence the course and outcomes of COVID-19. The study aims to compare clinical characteristics and outcomes of COVID-19 patients with and without hypothyroidism. MethodsThe study is a part of a multicentric cohort of patients with confirmed COVID-19 diagnosis, including data collected from 37 hospitals. Matching for age, sex, number of comorbidities and hospital was performed to select the patients without hypothyroidism for the paired analysis. ResultsFrom 7,762 COVID-19 patients, 526 had previously diagnosed hypothyroidism (50%) and 526 were selected as matched controls. The median age was 70 (interquartile range 59.0-80.0) years-old and 68.3% were females. The prevalence of underlying comorbidities were similar between groups, except for coronary and chronic kidney diseases, that had a higher prevalence in the hypothyroidism group (9.7% vs. 5.7%, p=0.015 and 9.9% vs. 4.8%, p=0.001, respectively). At hospital presentation, patients with hypothyroidism had a lower frequency of respiratory rate > 24 breaths per minute (36.1% vs 42.0%; p=0.050) and need of mechanical ventilation (4.0% vs 7.4%; p=0.016). D-dimer levels were slightly lower in hypothyroid patients (2.3 times higher than the reference value vs 2.9 times higher; p=0.037). In-hospital management was similar between groups, but hospital length-of-stay (8 vs 9 days; p=0.029) and mechanical ventilation requirement (25.4% vs. 33.1%; p=0.006) were lower for patients with hypothyroidism. There was a trend of lower in-hospital mortality in patients with hypothyroidism (22.1% vs. 27.0%; p=0.062). ConclusionIn this large Brazilian COVID-19 Registry, patients with hypothyroidism had a lower requirement of mechanical ventilation, and showed a trend of lower in-hospital mortality. Therefore, hypothyroidism does not seem to be associated with a worse prognosis, and should not be considered among the comorbidities that indicate a risk factor for COVID-19 severity.

Effectiveness, Explainability and Reliability of Machine Meta-Learning Methods for Predicting Mortality in Patients with COVID-19: Results of the Brazilian COVID-19 Registry

ObjectiveTo provide a thorough comparative study among state-of-the-art machine learning methods and statistical methods for determining in-hospital mortality in COVID-19 patients using data upon hospital admission; to study the reliability of the predictions of the most effective methods by correlating the probability of the outcome and the accuracy of the methods; to investigate how explainable are the predictions produced by the most effective methods. Materials and MethodsDe-identified data were obtained from COVID-19 positive patients in 36 participating hospitals, from March 1 to September 30, 2020. Demographic, comorbidity, clinical presentation and laboratory data were used as training data to develop COVID-19 mortality prediction models. Multiple machine learning and traditional statistics models were trained on this prediction task using a folded cross-validation procedure, from which we assessed performance and interpretability metrics. ResultsThe Stacking of machine learning models improved over the previous state-of-the-art results by more than 26% in predicting the class of interest (death), achieving 87.1% of AUROC and macro F1 of 73.9%. We also show that some machine learning models can be very interpretable and reliable, yielding more accurate predictions while providing a good explanation for the why. ConclusionThe best results were obtained using the meta-learning ensemble model - Stacking. State-of the art explainability techniques such as SHAP-values can be used to draw useful insights into the patterns learned by machine-learning algorithms. Machine-learning models can be more explainable than traditional statistics models while also yielding highly reliable predictions.

Extracorporeal membrane oxygenation in COVID-19 patients and in-hospital mortality: results from the Brazilian Registry using a propensity score matched analysis

Around 5% of coronavirus disease 2019 (COVID-19) patients develop critical disease, with severe pneumonia and acute respiratory distress syndrome (ARDS). In these cases, extracorporeal membrane oxygenation (ECMO) may be considered when conventional therapy fails. This study aimed to assess the clinical characteristics and in-hospital outcomes of COVID-19 patients with ARDS refractory to standard lung-protective ventilation and pronation treated with ECMO support and to compare them to patients who did not receive ECMO. Patients were selected from the Brazilian COVID-19 Registry. At the moment of the analysis, 7,646 patients were introduced in the registry, eight of those received ECMO support (0.1%). The convenience sample of patients submitted to ECMO was compared to control patients selected by genetic matching for gender, age, comorbidities, pronation, ARDS and hospital, in a 5:1 ratio. From the 48 patients included in the study, eight received ECMO and 40 were matched controls. There were no significant differences in demographic, clinical and laboratory characteristics. Mortality was higher in the ECMO group (n = 7; 87.5%) when compared with controls (n = 17; 42.5%), (p=0.048). In conclusion, COVID 19 patients with ARDS refractory to conventional therapy who received ECMO support had worse outcomes to patients who did not receive ECMO. Our findings are not different from previous studies including a small number of patients, however there is a huge difference from Extracorporeal Life Support Organization results, which encourages us to keep looking for our best excellence.

ABC2-SPH risk score for in-hospital mortality in COVID-19 patients: development, external validation and comparison with other available scores

ObjectiveTo develop and validate a rapid scoring system at hospital admission for predicting in-hospital mortality in patients hospitalized with coronavirus disease 19 (COVID-19), and to compare this score with other existing ones. DesignCohort study SettingThe Brazilian COVID-19 Registry has been conducted in 36 Brazilian hospitals in 17 cities. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients that were admitted between March-July, 2020. The model was then validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients. ParticipantsConsecutive symptomatic patients ([≥]18 years old) with laboratory confirmed COVID-19 admitted to participating hospitals. Patients who were transferred between hospitals and in whom admission data from the first hospital or the last hospital were not available were excluded, as well those who were admitted for other reasons and developed COVID-19 symptoms during their stay. Main outcome measuresIn-hospital mortality ResultsMedian (25th-75th percentile) age of the model-derivation cohort was 60 (48-72) years, 53.8% were men, in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. From 20 potential predictors, seven significant variables were included in the in-hospital mortality risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO2/FiO2 ratio, platelet count and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829 to 0.859), which was confirmed in the Brazilian (0.859) and Spanish (0.899) validation cohorts. Our ABC2-SPH score showed good calibration in both Brazilian cohorts, but, in the Spanish cohort, mortality was somewhat underestimated in patients with very high (>25%) risk. The ABC2-SPH score is implemented in a freely available online risk calculator (https://abc2sph.com/). ConclusionsWe designed and validated an easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation, for early stratification for in-hospital mortality risk of patients with COVID-19. Summary boxesWhat is already known on this topic? O_LIRapid scoring systems may be very useful for fast and effective assessment of COVID-19 patients in the emergency department. C_LIO_LIThe majority of available scores have high risk of bias and lack benefit to clinical decision making. C_LIO_LIDerivation and validation studies in low- and middle-income countries, including Latin America, are scarce. C_LI What this study adds O_LIABC2-SPH employs seven well defined variables, routinely assessed upon hospital presentation: age, number of comorbidities, blood urea nitrogen, C reactive protein, Spo2/FiO2 ratio, platelets and heart rate. C_LIO_LIThis easy-to-use risk score identified four categories at increasing risk of death with a high level of accuracy, and displayed better discrimination ability than other existing scores. C_LIO_LIA free web-based calculator is available and may help healthcare practitioners to estimate the expected risk of mortality for patients at hospital presentation. C_LI

Dynamic reciprocity of sodium and potassium channel expression in a macromolecular complex controls cardiac excitability and arrhythmia.

The cardiac electrical impulse depends on an orchestrated interplay of transmembrane ionic currents in myocardial cells. Two critical ionic current mechanisms are the inwardly rectifying potassium current (I(K1)), which is important for maintenance of the cell resting membrane potential, and the sodium current (I(Na)), which provides a rapid depolarizing current during the upstroke of the action potential. By controlling the resting membrane potential, I(K1) modifies sodium channel availability and therefore, cell excitability, action potential duration, and velocity of impulse propagation. Additionally, I(K1)-I(Na) interactions are key determinants of electrical rotor frequency responsible for abnormal, often lethal, cardiac reentrant activity. Here, we have used a multidisciplinary approach based on molecular and biochemical techniques, acute gene transfer or silencing, and electrophysiology to show that I(K1)-I(Na) interactions involve a reciprocal modulation of expression of their respective channel proteins (Kir2.1 and Na(V)1.5) within a macromolecular complex. Thus, an increase in functional expression of one channel reciprocally modulates the other to enhance cardiac excitability. The modulation is model-independent; it is demonstrable in myocytes isolated from mouse and rat hearts and with transgenic and adenoviral-mediated overexpression/silencing. We also show that the post synaptic density, discs large, and zonula occludens-1 (PDZ) domain protein SAP97 is a component of this macromolecular complex. We show that the interplay between Na(v)1.5 and Kir2.1 has electrophysiological consequences on the myocardium and that SAP97 may affect the integrity of this complex or the nature of Na(v)1.5-Kir2.1 interactions. The reciprocal modulation between Na(v)1.5 and Kir2.1 and the respective ionic currents should be important in the ability of the heart to undergo self-sustaining cardiac rhythm disturbances.

When is dialysis indicated in acute kidney injury?

The indications for dialysis in patients with acute kidney injury (AKI), as well as the dose and timing of initiation, remain uncertain. Recent data have suggested that early initiation of renal replacement therapy (RRT) may be associated with decreased mortality but not with the recovery of kidney function. A blood urea nitrogen (BUN) level of 75 mg/dL is a useful indicator for dialysis in asymptomatic patients, but one that is based on studies with limitations. Different parameters, including absolute and relative indicators, are needed. Currently, nephrologists should consider the trajectory of disease, and the clinical condition and prognosis of the patient are more important than numerical values in the decision to initiate dialysis.

Continuous peritoneal dialysis compared with daily hemodialysis in patients with acute kidney injury.

BACKGROUND: In some parts of the world, peritoneal dialysis is widely used for renal replacement therapy (RRT) in acute kidney injury (AKI), despite concerns about its inadequacy. It has been replaced in recent years by hemodialysis and, most recently, by continuous venovenous therapies. We performed a prospective study to determine the effect of continuous peritoneal dialysis (CPD), as compared with daily hemodialysis (dHD), on survival among patients with AKI. METHODS: A total of 120 patients with acute tubular necrosis (ATN) were assigned to receive CPD or dHD in a tertiary-care university hospital. The primary endpoint was hospital survival rate; renal function recovery and metabolic, acid-base, and fluid controls were secondary endpoints. RESULTS: Of the 120 patients, 60 were treated with CPD (G1) and 60 with dHD (G2). The two groups were similar at the start of RRT with respect to age (64.2 +/- 19.8 years vs 62.5 +/- 21.2 years), sex (men: 72% vs 66%), sepsis (42% vs 47%), shock (61% vs 63%), severity of AKI [Acute Tubular Necrosis Individual Severity Score (ATNISS): 0.68 +/- 0.2 vs 0.66 +/- 0.22; Acute Physiology and Chronic Health Evaluation (APACHE) II: 26.9 +/- 8.9 vs 24.1 +/- 8.2], pre-dialysis blood urea nitrogen [BUN (116.4 +/- 33.6 mg/dL vs 112.6 +/- 36.8 mg/dL)], and creatinine (5.85 +/- 1.9 mg/dL vs 5.95 +/- 1.4 mg/dL). In G1, weekly delivered Kt/V was 3.59 +/- 0.61, and in G2, it was 4.76 +/- 0.65 (p < 0.01). The two groups were similar in metabolic and acid-base control (after 4 sessions, BUN < 55 mg/dL: 46 +/- 18.7 mg/dL vs 52 +/- 18.2 mg/dL; pH: 7.41 vs 7.38; bicarbonate: 22.8 +/- 8.9 mEq/L vs 22.2 +/- 7.1 mEq/L). Duration of therapy was longer in G2 (5.5 days vs 7.5 days; p = 0.02). Despite the delivery of different dialysis methods and doses, the survival rate did not differ between the groups (58% in G1 vs 52% in G2), and recovery of renal function was similar (28% vs 26%). CONCLUSION: High doses of CPD provided appropriate metabolic and pH control, with a rate of survival and recovery of renal function similar to that seen with dHD. Therefore, CPD can be considered an alternative to other forms of RRT in AKI.

Influência do treinamento na evolução da diálise peritoneal / Influence of training on the progression of peritoneal dialysis

Objetivo: Conhecer a influência do cuidador no treinamento da diálise peritoneal (DP) e no tempo livre de peritonite. Método: Estudo retrospectivo com 38 pacientes prevalentes, atendidos na Diálise Ambulatorial do Hospital das Clínicas/Botucatu, que receberam treinamento para DP pela mesma enfermeira. Avaliaram-se: 1) o responsável pela técnica de diálise (paciente ou cuidador); 2) o treinamento (tempo dispensado e desempenho atingido); 3) o tempo livre de peritonite. Foram realizadas regressão logística e análise de sobrevivência por Kaplan-Meyer. Resultado: A DP foi realizada por umcuidador em 71% (N=27) dos pacientes. Dos diabéticos, 89% (N=16) necessitavam de cuidador e 11% (N=2) realizaram o próprio tratamento (p<0,05); quanto à idade, 26% (N=10) apresentavam mais de 65 anos e, destes, 90% (N=9) tinham o cuidador para DP (p=0,05); dos pacientes provenientes de outras localidades (N=23), 74% (N=17) necessitavam do cuidador (p=0,07). O treinamento foi concluído no tempo médio por 71% (N=27), e 79% (N=30) obtiveram desempenho bom, sem diferenças quanto ao responsável pela técnica. A probabilidade de permanecer livre de peritonite no primeiro ano detratamento foi maior quando o cuidador realizava a DP, sendo 54% para o paciente e 78% para o cuidador (p<0,05). Conclusão: Pacientes com mais de 65 anos e diabéticos necessitaram de cuidador na diálise. No treinamento, tempo dispensado e desempenho atingido não diferiram quanto ao responsável pela técnica. O tempo livre de peritonite foi maior para os pacientes em que a diálise foi realizada por cuidador. O responsável pela diálise (paciente ou cuidador) pode influenciar na evolução da DP.

Objective: To evaluate the influence of the caretaker on the training time of peritoneal dialysis (PD) and peritonitis-free time. Method: Retrospective medical record review of 38 patients receiving PD training from the same nurse at the Dialysis Unit of Botucatu Medical School Hospital. Assessment included: 1) home PD provider (patient or caretaker); 2) training (length and performance achieved); 3) peritonitis-free time. Result: In 71% (N=27) of the cases, PD was performed by a caretaker. Among diabetic patients, 89% (N=16) were supported by a caretaker, and 11 % (N=2) performed their own dialysis (p=0.03); 26% (N=10) were over 65 years of age, with 90% (N=10) of them having a PD caretaker (p=0.05). Among patients from other areas (N=23), 74% (N=17) were supported by a PD caretaker (p=0.07). Training was concluded after the mean time by 71% (N=27) and a good performance level was achieved in 79% (N=30) of the cases with no difference between provider type. The probability of the patient remaining peritonitis-free over the first year was higher when PD was performed by a caretaker (patient= 54%; caretaker = 78%; p<0.05). Conclusion: The presence of caretakers was more frequent among the patients who were over 65 years of age or diabetic. With respect to training, length of time and performance did not differ according to the person responsible for technique. Peritonitis-free time was longer among patients supported by caretakers. The PD provider (patient or caretaker) may influence PD results.

High volume peritoneal dialysis for acute renal failure.

BACKGROUND: Peritoneal dialysis (PD) is still widely used for acute renal failure (ARF) in developing countries despite concerns about its inadequacy. Continuous PD has been evaluated in ARF by analyzing the resolution of metabolic abnormality and normalization of plasma pH, bicarbonate, and potassium. METHODOLOGY: A prospective study was performed on 30 ARF patients who were assigned to high-dose continuous PD (Kt/V = 0.65 per session) via a flexible catheter (Tenckhoff) and automated PD with a cycler. Fluid removal, pH and metabolic control, protein loss, and patient outcome were evaluated. RESULTS: Patients received 236 continuous PD sessions; 76% were admitted to ICUs. APACHE II score was 32.2+/-8.65. BUN concentrations stabilized after 3 sessions, creatinine after 4, and bicarbonate and pH after 2. Fluid removal was 2.1+/-0.62 L/day. Creatinine and urea clearances were 15.8+/-4.16 and 17.3+/-5.01 mL/minute respectively. Normalized creatinine clearance and urea Kt/V values were 110.6+/-22.5 L/week/1.73 m(2) body surface area and 3.8+/-0.6 respectively. Solute reduction index was 41%+/-6.5% per session. Serum albumin values remained stable in spite of considerable protein losses (median 21.7 g/day, interquartile range 9.1-29.8 g/day). Regarding ARF outcome, 23% of patients presented renal function recovery, 13% remained on dialysis after 30 days of follow-up, and 57% died. CONCLUSION: High-dose continuous PD by flexible catheter and cycler was an effective treatment for ARF. It provided high solute removal, allowing appropriate metabolic and pH control, and adequate dialysis dose and fluid removal. Continuous PD can therefore be considered an alternative to other forms of renal replacement therapy in ARF.

Utilization of peritoneal dialysis in the acute setting.

Peritoneal dialysis (PD), although classically described and utilized in the treatment of patients with end-stage renal disease, can also be utilized in the acute setting in different clinical situations. Recent studies showed that, in patients with acute renal failure, it is possible to obtain reasonable dialysis doses with adequate metabolic and electrolytic control and low incidence of complications by utilizing continuous PD through a cycler at high volume. In patients with congestive heart failure without end-stage renal disease, PD is capable of promoting clinical improvement with slow removal of liquids, becoming an attractive alternative for situations of rapidly or slowly worsening cardiac function. In patients submitted to chronic hemodialysis but who have vascular access difficulties, PD can also be utilized as a "bridge," thereby avoiding the use of central venous catheters, which can be associated with infectious complications such as bacterial endocarditis. New studies must be realized showing other indications for PD.

Peritoneal dialysis in acute renal failure.

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF. Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred. There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.

Mortalidade e prognóstico específico em pacientes com insuficiência renal aguda / Assessment of mortality and specific index in acute renal failure

Vários sistemas de estratificação de risco têm sido estudados com o objetivo de predizer a evolução de pacientes graves com insuficiência renal aguda (IRA). OBJETIVOS: Avaliar e comparar as taxas de mortalidade e o escore de severidade individual de necrose tubular aguda (ATN-ISS) em pacientes que desenvolveram IRA tratados em hospital universitário de atendimento predominantemente terciário. MÉTODOS: Foram estudados prospectivamente 103 pacientes com IRA por necrose tubular aguda (NTA), atendidos no Hospital das Clínicas da Faculdade de Medicina de Botucatu - UNESP, acompanhados até recuperação do quadro renal ou óbito. No momento da primeira avaliação do nefrologista foi aplicado o escore ATN-ISS. Os resultados foram apresentados em média ± desvio padrão ou mediana, com nível de significância de 5 por cento. RESULTADOS: Verificamos que 51,4 por cento eram do sexo masculino, com média de idade de 58 ± 36 anos. A mortalidade geral foi de 44,3 por cento, sendo estatisticamente maior nos pacientes provenientes de enfermarias cirúrgicas (52,7 por cento) quando comparados àqueles de enfermarias clínicas (35,3 por cento), e naqueles que realizaram diálise (63,8 por cento) quando comparados aos de tratamento conservador (23,5 por cento). O escore ATN-ISS apresentou boa confiabilidade, com elevado poder discriminatório (área sob a curva de 0,95) e boa calibração, principalmente a partir do quintil 3. CONCLUSÃO: Na população estudada, as taxas de mortalidade foram semelhantes àquelas encontradas na literatura. O escore ATN-ISS mostrou ser um índice prognóstico com grande confiabilidade, podendo ser aplicado na prática diária do nefrologista.

Sobrevida em hemodiálise no hospital das clínicas da faculdade de medicina de Botucatu Unesp: comparação entre a primeira e a segunda metades da década de 90 / Hemodialysis Survival at the Hospital das Clínicas da Faculdade de Medicina de Botucatu - Unesp: Comparison Between The First and Second Halves of the 1990Æs

Comparar a sobrevida em hemodiálise da primeira com a segunda metades da década de 90. Método: Foram avaliados 153 renais crônicos tratados exclusivamente por hemodiálise no Hospital das Clínicas da Faculdade de Medicina de Botucatu no período de março de 1990 a março de 2000, comparando a sobrevida entre a primeira (Grupo 1; n= 75) e a segunda (Grupo 2; n= 78) metades da década, sendo que a primeira metade estava claramente relacionada à menor utilização de recursos tecnológicos como diálises em máquinas de tanque, banho contendo acetato como tampão e tratamento de água feito por deionizador. Na segunda metade, a maioria das máquinas era de proporção com ultrafiltração controlada, dialisato contendo bicarbonato e tratamento da água por osmose reversa. Resultados: A sobrevida global foi de 77% em um ano e de 58% em 5 anos. Esses valores foram de 78% e 57% para o Grupo 1 e 79% e 61% para o Grupo 2. Não houve diferença estatisticamentesignificante quanto à sobrevida entre as duas metades da década, mesmo quando corrigida para os principais fatores de risco: idade e presença de diabetes. Conclusões: Não pudemos observar melhora na sobrevida apesar da incorporação de novas tecnologias, ocorrida principalmente na segunda metade da década, o que não exclui que a morbidade pudesse ter melhorado.(au)

[Assessment of mortality and specific index in acute renal failure]. / Mortalidade e prognóstico específico em pacientes com insuficiência renal aguda.

UNLABELLED: A variety of systems of risk factor stratification have been studied to predict the outcome in acute renal failure (ARF). OBJECTIVES: Assess and compare mortality and the Acute Tubular Necrosis Individual Severity Score (ATN-ISS) in patients with AFR treated in a university hospital. METHODS: A prospective analysis was made of 103 patients with a diagnosis of intrinsic ARF admitted to the Hospital das Clinicas da Faculdade de Medicina de Botucatu, UNESP. Patients were followed up until recovery of renal function or death. The Score ATN-ISS was recorded during the first hours of the assessment by a nephrologist. Results were reported as median or mean +/- SD, with statistical significance of p < 0.05. RESULTS: Fifty-one percent of patients were male with a mean age of 58 +/- 36 years. Forty-four percent died in the hospital. Mortality was higher in patients from the surgical wards (52.7%) and in patients who were treated with dialysis (63.8%). The score ATN-ISS showed a good confidence level, with high discriminatory power (area under the curve of 0.95) and good accuracy. CONCLUSIONS: Mortality in this study was comparable to that found in literature. The ATN-ISS was shown to be a prognostic index with a high confidence level that could be routinely applied by nephrologists to patients with AFR.