Ludotecas virtuales en tiempos de COVID-19. Un espacio relacional inclusivo / Ludoteques virtuals en temps de COVID-19. Un espai relacional inclusiu / Virtual play centres during COVID-19 times. An inclusive relational space

Con una fuerte impronta inclusiva, se presenta la co-creación de ludotecas virtuales modelizadas de acuerdo con la edad de sus participantes, vulnerabilidad, lugar de pertenencia, posibilidades de conectividad y diversidad en la formación de sus coordinadores, con encuadres específicos. Sus dos ejes centrales fueron: propiciar encuentros cara a cara en tiempos simultáneos y promover el juego libre. El equipo de trabajo pone en relevancia aportes provenientes de la relación intra e intergeneracional.(AU)

With a strong inclusive approach, we present the co-creation of virtual play centres modelled according to the age of their participants, vulnerability, place of belonging, connectivity possibilities, and diversity in the training of their coordinators, with specific frameworks. Its two central axes were: fostering face-to-face meetings at simultaneous times and promoting free play. The work team highlights contributions coming from intra and intergenerational relationships.(AU)

Amb una forta empremta inclusiva, es presenta la cocreació de ludoteques virtuals modelitzades d'acord amb l'edat dels participants, vulnerabilitat, lloc de pertinença, possibilitats de connectivitat i diversitat en la formació dels seus coordinadors, amb enquadraments específics. Els seus dos eixos centrals van ser: propiciar trobades cara a cara en temps simultanis i promoure el joc lliure. L'equip de treball posa en relleu aportacions provinents de la relació intra i intergeneracional.(AU)

[Prognosis evaluation in the critically ill with acute renal failure]. / Indici prognostici nel paziente critico con insufficienza renale acuta.

Acute renal failure (ARF) is highly incident among hospitalized patients, especially in intensive care units. ARF carries an independent and significant risk for increased mortality, morbidity, and health resources usage, both in the short- and the long-term perspective. Many controversies exist concerning the epidemiological and prognostic aspects of ARF. Key problems are the lack of a widely accepted ARF definition, the poor knowledge of the pathophysiological mechanisms of complications peculiar to ARF, and the unavailability of prognostic tools able to adequately express the medical complexity of the syndrome. These aspects are fundamental with regard to ARF prevention, a strategic goal in the approach to the syndrome; therefore, they will analyzed in depth in this review.

[Sustained low-efficiency dialysis in acute renal failure]. / Terapie sostitutive renali intermittenti prolungate (SLED/EED) nell'insufficienza renale acuta in terapia intensiva.

Renal replacement therapies (RRT) are a key component of the therapeutic approach to acute renal failure (ARF) in the intensive care unit (ICU), and they are usually performed as classic Intermittent (intermittent hemodialysis) or continuous RRT (such as for example continuous venovenous hemofiltration, CVVH). No clear evidence exists on what the first-choice RRT option should be for ICU patients with ARF. Alternative strategies have been developed, under the form of intermittent prolonged RRT, with the aim of providing easy to perform, highly efficient, and less expensive RRT in the ICU. In this review we put forward the hypothesis that hybrid RRT, such as sustained low-efficiency dialysis ( sLED), could offer a valuable alternative to the currently available strategies in the critically ill with ARF.

[Artificial nutrition in acute renal failure]. / Nutrizione artificiale nell'insufficienza renale acuta.

Artificial nutrition in course of acute renal failure (ARF) is reviewed, on the basis of recent concepts on epidemiology and prognosis of the syndrome in critically ill patients. The relationships between nutritional status and ARF are evaluated, analyzing the possible role of nutritional status alterations as comorbidities and complications; pathogenetic mechanisms and consequences of hypercatabolism are described, with special regard to the peculiar metabolic derangements which are the hallmark of ARF. The effects of artificial nutrition on mortality and morbility in ARF are illustrated, along with quantitative and qualitative aspects of nutritional support (energy and protein needs, trace elements, vitamins etc). A rational approach to nutritional management of ARF patients is proposed, stressing the potential role of enteral nutrition, as well as the need for a full integration between nutritional support and renal replacement therapies.

[Antihaemostatic strategies or renal replacement therapies in acute renal failure]. / Trattamento anticoagulante per le terapie sostitutive della funzione renale (RRT) nell'insufficienza renale acuta.

Critically ill patients with acute renal failure, and especially those with sepsis, may have increased coagulation changes as well as a high incidence of hemorrhagic complications. Thus, in this clinical condition, the use of renal replacement therapies (RRT) can be frequently complicated both by high rates of extracorporeal circuit coagulation, resulting in a reduced treatment efficacy, and by increased incidence of bleeding. Heparin is the most commonly used RRT anticoagulant, even if several alternative options have been proposed, aiming at obtaining regional anticoagulation (i.e., limited to the extracorporeal circuit). This review analyses modern strategies for RRT anticoagulation and evaluates safety and efficacy parameters of each method. In this regard, no definite recommendations can be made based on the available evidence further randomised controlled trials are needed in this field, with a clear endpoint definition.

Incidence, risk factors, and prognosis of gastrointestinal hemorrhage complicating acute renal failure.

BACKGROUND: Few prospective data are currently available on acute gastrointestinal hemorrhage (AGIH) as a complication of acute renal failure (ARF). The aim of the present study was to define incidence, sources, risk factors, and outcome of AGIH in patients with ARF. METHODS: We performed a prospective study on an inception cohort of 514 patients admitted for ARF to a nephrology intermediate care unit. Data on clinical risk factors for bleeding, frequency of occurrence of AGIH, length of hospital stay, and in-hospital mortality were collected. Independent predictors of AGIH were identified. The relative odds of death and the relative increase in length of hospital stay associated with AGIH were calculated after adjusting for baseline comorbidities. RESULTS: Sixty-nine patients out of 514 [13.4% (95% CI, 10.6 to 16.7)] had AGIH as a complication of ARF; 59 were upper AGIH. Forty patients had clinically important bleeding. Erosions and/or ulcers accounted for 71% of cases of upper AGIH. Independent baseline predictors of AGIH were represented by severity of illness [odds ratio 1.45 (95% CI, 1.05 to 2.01) for every 10 point increase in APACHE II score], low platelet count [<50,000 mm3; 3.71 (1.70 to 8.11)], noncirrhotic chronic hepatic disease [2.22 (1.09 to 4.55)], liver cirrhosis [3.38 (1.50 to 7.60)], de novo ARF [2.77 (1.30 to 5.90)], and severe ARF [2.07 (1.10 to 3.88)]. In-hospital mortality was 63.8% in patients with AGIH and 34.2% in the other patients; after adjusting for baseline confounders, AGIH remained significantly associated with an increase in both mortality [2.57 (1.30 to 5.09), P = 0.006] and length of hospital stay [37% (1 to 87%), P = 0.047]. CONCLUSIONS: AGIH and clinically important bleeding are frequent complications of ARF. In this clinical condition, AGIH is more often due to upper gastrointestinal bleeding and is associated with a significantly increased risk of death and length of hospital stay. Both renal and extrarenal risk factors are related to the occurrence of AGIH.

Predicting patient outcome from acute renal failure comparing three general severity of illness scoring systems.

BACKGROUND: A major problem of studies on acute renal failure (ARF) arises from a lack of prognostic tools able to express the medical complexity of the syndrome adequately and to predict patient outcome accurately. Our study was thus aimed at evaluating the predictive ability of three general prognostic models [version II of the Acute Physiology and Chronic Health Evaluation (APACHE II), version II of the Simplified Acute Physiology Score (SAPS II), and version II of the Mortality Probability Model at 24 hours (MPM24 II)] in a prospective, single-center cohort of patients with ARF in an intermediate nephrology care unit. METHODS: Four hundred twenty-five patients consecutively admitted for ARF to the Nephrology and Internal Medicine Department over a five-year period were studied (272 males and 153 females, median age 71 years, interquartile range 61 to 78, median APACHE II score 23, interquartile range 18 to 28). Acute tubular necrosis (ATN) accounted for 68.7% (292 out of 425) of patients. Renal replacement therapies (hemodialysis or continuous hemofiltration) were used in 64% (272 out of 425) of ARF patients. RESULTS: Observed mortality was 39.1% (166 out of 425). The mean predicted mortality was 36.2% with APACHE II (P = 0.571 vs. observed mortality), 39.3% with SAPS II (P = 0.232), and 45.1% with MPM24 II (P < 0.0001). Lemeshow-Hosmer goodness-of-fit C and H statistics were 15.67 (P = 0.047) and 12.05 (P = 0.15) with APACHE II, 32.53 (P = 0.0001), 39.8 (P = 0.0001) with SAPS II, 21.86 (P = 0.005), and 20. 24 (P = 0.009) with MPM24 II, respectively. Areas under the receiver operating characteristic (ROC) curve were 0.75, 0.77, and 0.85, respectively. CONCLUSIONS: The APACHE II model was a slightly better calibrated predictor of group outcome in ARF patients, as compared with the SAPS II and MPM24 II outcome prediction models. The MPM24 II model showed the best discrimination capacity, in comparison with both APACHE II and SAPS II models, but it constantly and significantly overestimated mean predicted mortality in ARF patients. None of the models provided sufficient confidence for the prediction of outcome in individual patients. A high degree of caution must be exerted in the application of existing general prognostic models for outcome prediction in ARF patients.

Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study.

Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources.