Hypercitratemia is a mortality predictor among patients on continuous venovenous hemodiafiltration and regional citrate anticoagulation.

The use of regional citrate anticoagulation (RCA) in liver failure (LF) patients can lead to citrate accumulation. We aimed to evaluate serum levels of citrate and correlate them with liver function markers and with the Cat/Cai in patients under intensive care and undergoing continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA). A prospective cohort study in an intensive care unit was conducted. We compared survival, clinical, laboratorial and dialysis data between patients with and without LF. Citrate was measured daily. We evaluated 200 patients, 62 (31%) with LF. Citrate was significantly higher in the LF group. Dialysis dose, filter lifespan, systemic ionized calcium and Cat/Cai were similar between groups. There were weak to moderate positive correlations between Citrate and indicators of liver function and Cat/Cai. The LF group had higher mortality (70.5% vs. 51.8%, p = 0.014). Citrate was an independent risk factor for death, OR 11.3 (95% CI 2.74-46.8). In conclusion, hypercitratemia was an independent risk factor for death in individuals undergoing CVVHDF-ARC. The increase in citrate was limited in the LF group, without clinical significance. The correlation between citrate and liver function indicators was weak to moderate.

Perfil clínico-epidemiológico dos pacientes em cuidados paliativos atendidos em um serviço de urgência geral / The clinical-epidemiological profile of patients in palliative care treated in an general emergency service

Os pacientes em cuidados paliativos procuram o pronto-socorro para alívio imediato da dor ou de outros sintomas físicos. Os profissionais que atuam em serviços de urgência são treinados para prestar cuidados focados no tratamento direcionado a doenças agudas, mas podem fornecer intervenções paliativas para gerenciar as exacerbações de doenças crônicas ou os cuidados próximos ao fim da vida. Conhecer o perfil dos pacientes em cuidados paliativos atendidos em serviço de urgência e emergência é imprescindível para implementação de medidas que melhorem a qualidade do atendimento deste grupo de pacientes e otimizem o serviço prestado. O objetivo do estudo é descrever o perfil clínico-epidemiológico dos pacientes em cuidados paliativos atendidos no pronto-socorro. Foi realizado um estudo transversal, observacional e retrospectivo, de pacientes adultos de ambos os sexos, em cuidados paliativos atendidos em uma unidade de pronto atendimento ­ UPA, num período de dez meses. O estudo teve aprovação do Comitê de Ética e Pesquisa. Foram analisados 83 pacientes com média de idade de 78,5 (±14,3) anos. Houve predominância do sexo feminino (61,4%). A maioria era procedente do domicílio (87,9%). Havia a presença de cuidador em 91.57% dos casos, predominando o cuidador familiar não-remunerado (76,3%). Sobre atendimento prévio, 44,58% haviam procurado o pronto-socorro no último mês. Quanto à doença de base, 31,3% era oncológica e 68,6% não-oncológica. O câncer de próstata representou a principal causa oncológica (30,7%), seguido de neoplasia hepática e das vias biliares (15,4%). Nos casos não-oncológicos, foi mais frequente a síndrome de fragilidade (42,10%) e sequela grave de acidente vascular cerebral (17,5%). O principal sintoma foi a dispneia em 38 pacientes (45,7%). A dor e a dispneia foram mais frequentes nos casos oncológicos (34,6% e 23,0%, respectivamente), seguidos de dispneia e delirium nos casos não-oncológicos (56,1% e 28,0%, respectivamente). No presente estudo, predominou a faixa etária idosa em cuidados paliativos com cuidador presente com maior frequência de doença de base não-oncológica, dispneia, dor e delirium (AU)

Patients seek emergency rooms for immediate relief from pain or other physical symptoms. Professionals in emergency rooms are trained to render focused care in the targeted treatment of acute diseases and provide palliative interventions to manage exacerbations of chronic illnesses or end-of-life care to patients under palliative care. Knowing the patient's profile for palliative care in the emergency room can be helpful for implementing targeted measures to provide better patient care. This study aims to describe the clinical-epidemiological profile on patients in palliative care treated in an emergency room. A transversal, observational, and retrospective study was carried out of adult patients of both sexes in palliative care treated at Unidade de Pronto Atendimento -UPA over ten months. Data were collected about admission, type of caregiver, pathology, and outcomes. The study was approved by the Research and Ethics Committee. In total, 83 patients with a mean age of 78.5 (±14.3) were analyzed. There was a predominance of female patients (61.4%), and most came from a residence (87.9%). Further, 91.57% had caregivers, predominantly unpaid family caregivers (76.3%). Regarding previous care, 44.58% had sought palliative care less than one month ago. As the base disease, 68.6% were oncological and 31.3% non-oncological. Prostate cancer constituted the primary oncological cause (30.7%), followed by hepatic neoplasia and bile ducts (15.4%). Fragility syndrome (42.10%) and severe complications after a stroke (17.5%) were more frequent in non-oncological base cases. The main symptom was dyspnea noted in 38 patients (45.7%). Pain and dyspnea were more frequent in oncological cases (34.6% and 23.0%, respectively), followed by dyspnea and delirium in non-oncological cases (56.1% and 28.0%, respectively). In the present study, predominantly older patients with a caregiver demonstrated a more significant frequency of non-oncological base disease, dyspnea, pain, and delirium (AU)

Acute kidney injury in hospitalized patients who underwent percutaneous kidney biopsy for histological diagnosis of their renal disease.

BACKGROUND: Performing a kidney biopsy is necessary to accurately diagnose diseases such as glomerulonephritis and tubulointerstitial nephritis, among other such conditions. These conditions predispose patients to chronic kidney disease, as well as acute kidney injury (AKI). Notably, most epidemiological studies describing AKI have not investigated this patient population. METHODS: Included patients admitted to the nephrology ward of a tertiary hospital who underwent percutaneous kidney biopsy. AKI was diagnosed based on the Kidney Disease: Improving Global Outcomes criteria. RESULTS: Of the 223 patients investigated, 140 (62.8%) showed AKI. Of these, 91 (65%), 19 (13.6%), and 30 (21.4%) presented with AKI classified as stages 1, 2, and 3, respectively. The primary indication for performing biopsy was nephrotic syndrome or nephrotic proteinuria (73 [52.1%] in the AKI vs. 51 [61.4%] in the non-AKI group, p = 0.048). Focal segmental glomerulosclerosis was the most prevalent primary disease (24 [17.1%] in the AKI vs. 15 [18.0%] in the non-AKI group, p = 0.150). Multivariate analysis of risk factors associated with AKI showed hemoglobin levels (odds ratio [OR] 0.805, 95% confidence interval [CI] 0.681-0.951, p = 0.011), serum high-density lipoprotein cholesterol levels (HDL-c, OR 0.970, 95% CI 0.949-0.992, p = 0.008), and baseline serum creatinine levels (OR 2.703, 95% CI 1.471-4.968, p = 0.001) were significantly associated with AKI. CONCLUSIONS: We observed a high prevalence of AKI in hospitalized patients who underwent kidney biopsy to investigate their renal disease, particularly glomerulonephritis. Higher levels of hemoglobin and serum HDL-c were associated with a lower risk of AKI.

The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function.

BACKGROUND: Many controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI. METHODS: We conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge. RESULTS: In 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999-2003, 2004-2008, and 2009-2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p < 0.001), and in the use of continuous renal replacement therapy (CRRT) as initial dialysis modality choice (from 64.2 to 72.2%; p < 0.001). The mortality rate (53.9%) and dialysis dependence at hospital discharge (12.3%) remained unchanged over time. Individuals who recovered renal function (33.8%) showed that those who had initially undergone CRRT had a higher eGFR than those in the intermittent hemodialysis group (54.0 × 46.0 ml/min/1.73 m2, respectively; p = 0.014). In multivariate analysis, type of patient, sepsis-associated AKI and APACHE II score were associated to death. For each additional unit of the APACHE II score, the odds of death increased by 52%. The odds ratio of death for medical patients with sepsis-associated AKI was estimated to be 2.93 (1.81-4.75; p < 0.001). CONCLUSION: Our study showed that the incidence of D-AKI increased with illness severity, and the use of CRRT also increased over time. The improvement in renal outcomes observed in the CRRT group may be related to the better baseline kidney function, especially in the dialysis dependence patients at hospital discharge.

Outcomes from a cohort of patients with acute kidney injury subjected to continuous venovenous hemodiafiltration: The role of negative fluid balance.

BACKGROUND: Several factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT. RESULTS: This was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55-76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and SOFA score at ICU admission was 61 (50-74) and 10 (7-12), respectively. The dialysis dose delivered was 33.2 (28.9-38.7) ml/kg/h. The median time between ICU admission and CVVHDF initiation was 2 (1-4) days. The median cumulative fluid balance during the CVVHDF period was -1838 (-5735 +2993) ml. The mortality rate up to90 days was 58%. The independent mortality risk factors in propensity score model were: chronic obstructive pulmonary disease (OR = 3.44[1.14-10.4; p = 0.028]), hematologic malignancy (OR = 5.14[1.66-15.95; p = 0.005]), oliguria (OR = 2.36[1.15-4.9; p = 0.02]), positive daily fluid balance during CVVHDF (OR = 4.55[2.75-13.1; p<0.001]), and total SOFA score on first dialysis day (OR = 1.27[1.12-1.45; p<0.001]). CONCLUSIONS: Dialysis-related factors may influence the outcomes. In our cohort, positive daily fluid balance during CRRT was associated with lower survival. Multicenter, randomized studies are needed to assess fluid balance as a primary outcome to define the best strategy in this patient population.

Avaliação da peroxidação lipídica em pacientes com infarto agudo do miocárdio / Lipid peroxidation assessment in patients with acute myocardial infarction

JUSTIFICATIVA E OBJETIVOS: A lipoproteína de baixa densidade oxidada (LDL-ox) é gerada durante a peroxidação lipídica, resultando da reação entre radicais livres e lipídios séricos. Existem evidências do envolvimento da LDL-ox na formação e ruptura de placas ateroscleróticas, também sendo biomarcador nas síndromes coronarianas agudas. O objetivo deste estudo foi avaliar a peroxidação lipídica em pacientes com infarto agudo do miocárdio (IAM). MÉTODO: Estudo realizado na Emergência Cardiológica do Hospital Universitário Oswaldo Cruz e do Pronto-Socorro Cardiológico de Pernambuco (PROCAPE). As variáveis estudadas foram: idade e sexo; fatores de risco para doença arterial coronariana (DAC); alterações do segmento ST no eletrocardiograma; avaliação do perfil lipídico e peroxidação lipídica através dos níveis séricos de malondialdeído. RESULTADOS: A amostra foi composta de 93 pacientes, sendo 56 (60,2%) do sexo masculino, com média de 64 anos. A hipercolesterolemia isolada foi encontrada em 27 pacientes (29%), sendo maior em mulheres. Cinquenta e quatro pacientes (58%) tinham HDL menor do que a referênciapara cada sexo. Encontrou-se correlação positiva entre altos níveis de malondialdeído com idade > 60 anos e tabagismo, embora não significativo estatisticamente. CONCLUSÃO: Os níveis de peroxidação lipídica se apresentaram maiores em pacientes infartados tabagistas e com idade > 60 anos (sem significância estatística nesta casuística), sendo estes identificados como portadores de maior estresse oxidativo.

Proteína C-reativa de alta sensibilidade em pacientes com infarto agudo do miocárdio na emergência cardiológica / High sensitivity C-reactive protein in patients with acute myocardial infarction on cardiologic emergency

Justificativa e objetivos: Vários estudos mostram o valor da proteína C-reativa (PCR) na avaliação de pacientes com doença cardiovascular prévia ou fatores de risco, porém, não há um consenso das sociedades científicas quanto à aplicação deste marcador para avaliação destes pacientes no evento agudo. O objetivo deste estudo foi avaliar os níveis de PCR e perfil lipídico em pacientes na fase aguda de infarto agudo do miocárdio (IAM). Método: Foram avaliados 36 pacientes atendidos em emergência cardiológica entre maio e junho de 2007. Foram dosadas PCR de alta sensibilidade (PCR-as) por método imunoturbidimétrico e perfil lipídico. Resultados: Amostra composta de 83,4% de pacientes do sexo masculino e idade média de 62 anos. Aproximadamente 75% dos pacientes eram portadores de hipertensão arterial sistêmica (HAS), 66,6% tabagistas, 33,3% com história prévia de doença coronariana (DAC) e 30,5% portadores de diabetes mellitus (DM). O IAM sem elevação do segmento ST (IAMSEST) representou 58,3% dos casos. Foram registrados 72,2% pacientes com valores de PCR-as > 3 mg/L. O IAMSEST esteve associado com maiores níveis de PCR-as em relação ao IAM com elevação do segmento ST. Tabagistas e pacientes com DAC prévia tiveram maiores médias de PCR-as, não sendo observada relação estatística entre HAS ou DM com este marcador inflamatório. Os níveis de PCR-as foram maiores nos grupos com colesterol total e LDL-colesterol aumentados. Conclusão: Estes resultados indicam que os pacientes apresentam altos valores da PCR-as na fase aguda do IAM. Observou-se que o IAMSEST, história de tabagismo ou DAC prévia, colesterol total e LDL-colesterol aumentados relacionam-se com valores maiores da PCR-as, tendo estes grupos maior status inflamatório.

Background and objectives: Many studies show the value of C-reactive protein (CRP) in assessment of patients with previous cardiovascular disease or risk factors, but, there is no agreement of scientific societies about the use of this marker to assess these patients on acute event. The objective of this study was assessing CRP levels and lipid profile in patients with acute myocardial infarction (AMI). Method: Have been appraised 36 patients attended on cardiologic emergency among May and June of 2007. We accessed clinical profile, dosages of high sensitivity CRP (hs- CRP) by imunoturbidimetric method and profile lipid. Results: Pattern was built up from 83.4% of patients of male gender and median-age about 62 years. Approximately 75% patients had arterial hypertension (SAH), 66.6% smokers, 33.3% with previous history of coronary disease (CAD) and 30.5% had diabetes mellitus (DM). Non-STsegment elevation AMI (NSTSEAMI) was 58.3% of the cases. Have been registered 72.2% patients with hs-CPR levels higher than 3mg/L. NSTSEAMI was associate with higher levels of hs-CPR when compared with AMI with ST-segment elevation. Smokers and previous CAD patients had higher median of hs-CPR levels, no being observed statistics relation between SAH and DM with this inflammatory marker. The hs-CRP levels were higher in groups of higher levels of total cholesterol and LDL-cholesterol. Conclusion: These results indicate that patient present elevated hs-CPR levels in AMI. Also, NSTSEAMI, smokers, previous CAD, high levels of total cholesterol and LDL-cholesterol are related to higher hs-CRP levels, being these groups under major inflammatory status.

Comportamento da mortalidade perinatal na cidade do Recife e reprodutibilidade das informaçoes das variáveis da declaração de óbito / Perinatal mortality profile and its components in Recife: Reproducibility of the parameter information of the death certificate im 2002

O objetivo deste estudo foi descrever o perfil da mortalidade perinatal por componentes, de 1998 a 2002, em Recife; descrever os óbitos perinatais, segundo variáveis demográficas, biológicas e de organização de seviço. Verificar a concordância entre declaração de óbito e prontuário e o grau de não preenchimento para algumas variáveis, relativas aos óbitos perinatais. A amostra foi aleatória, proporcional à distribuição dos óbitos nas unidades de saúde, utilizando o Sistema de Informação em Mortalidade, e constituiu-se dos óbitos perinatais de mães residentes no Recife (1998-2002). Os dados foram analisados através do EPI INFO62 DO CDC-OMS e TABWIN. No período 1998-2002. Houve queda dos coeficientes de mortalidade perinatal e seus componentes. Em 2002, ocorreu o menor Coeficiente de Mortalidade Perinatal (18,66). Houve maior queda entre 1998 e 1999. A razão de taxas entre os Coeficientes de Mortalidade Perinatal e seus componentes, para variáveis sexo masculino, baixo peso, mães adolescentes, pré-termos e hospitais conveniados ao SUS mostrou declínio entre 1998 e 2002. Na validação, as variáveis que obtiveram maior concordância foram tipo de parto e peso; maior discordância foram tipo de parto e peso; maior discordância, escolaridade, idade gestacional, e maior grau de dados incompletos e gênero