Síndrome nefrótico secundario a preeclampsia: presentación, manejo y evolución clínica observados en 5 años de experiencia / Nephrotic syndrome due to preeclampsia: Presentation, management and clinical evolution observed in 5 years experience

Introducción: El síndrome nefrótico (SN) es una entidad rara durante el embarazo. En esta etapa, la preeclampsia (PE) severa es la principal causa. Nuestro objetivo fue describir la presentación clínica, las características analíticas, el manejo médico y la evolución de mujeres con SN por PE. Materiales y métodos: Estudio descriptivo, retrospectivo, realizado entre el 1 de enero de 2017 y el 1 de enero de 2022 (5años). Incluyó mujeres con embarazo ≥20semanas de edad gestacional (EG), internadas por trastorno hipertensivo del embarazo (THE), sin evidencia de daño renal previo a la gestación. Resultados: Entre 652 THE se identificaron 452 PE y 21 SN. La edad materna fue de 25±5,7 años, y la EG al diagnóstico, de 33,1±5,1 semanas. Todas presentaron edema facial y periféricos: 5 derrame pleural, 3 derrame pericárdico y 2 anasarca. La P24 fue de 6,17±2,34g (3,10-10,8), la albúmina sérica de 2,5±0,27g/dl (2,10-2,90) y el colesterol sérico de 281,4±21,7mg/dl (251-316). Hubo 13 que desarrollaron complicaciones maternas: daño renal agudo, edema pulmonar, miocardiopatía dilatada, eclampsia y síndrome HELLP. Todas permanecieron hipertensas en el posparto, requiriendo combinación de dos a tres fármacos antihipertensivos. En el posparto todas recibieron estatinas e inhibidores de la enzima convertidora de angiotensina (IECA) para el manejo de la proteinuria; ninguna desarrolló hiperkalemia o elevaciones de creatinina. La estancia hospitalaria fue de 10,4±3,7 días. Todas revirtieron los parámetros proteinúricos de rango nefrótico antes del alta. No se registraron muertes. Conclusión: La presentación incluyó desde edemas periféricos hasta compromiso seroso. La severidad de la proteinuria fue variable. El uso de IECA no precipitó hiperkalemia ni fallo renal. Las complicaciones maternas fueron frecuentes, pero no se observaron óbitos. (AU)

Introduction: Nephrotic syndrome (NS) is rare during pregnancy. The main cause is severe pre-eclampsia (PR). Our aim was to describe the clinical presentation, analytical features, medical management, and progress of women with NS due to PE. Materials and methods: A descriptive, retrospective study, conducted from 01/01/2017 to 01/01/2022 (5years). Women with a gestational age (GA) ≥20weeks were included in the study, hospitalised due to hypertensive disorders in pregnancy (HDP), with no evidence of kidney damage prior to gestation. Results: Of the 652 HDP, 452 PE and 21 NS were identified. Maternal age was 25±5.7 years, GA at diagnosis was 33.1±5.1 weeks. All the women had facial and peripheral oedema: 5 pleural effusion, 3 pericardial effusion, and 2 anasarca. Their p24 was 6.17±2.34grams (3.10-10.8), serum albumin 2.5±0.27g/dL (2.10-2.90), and serum cholesterol 281.4±21.7mg/dL (251-316). Thirteen developed maternal complications: acute kidney damage, pulmonary oedema, dilated cardiomyopathy, eclampsia, and HELLP syndrome. They all remained hypertensive postpartum, and required a combination of two to three antihypertensive drugs. They all received statins postpartum, and angiotensin converting enzyme (ACE) inhibitors to manage proteinuria. None developed hyperkalaemia or creatinine elevation. Hospital stay was 10.4±3.7days. All nephrotic range proteinuria parameters reversed prior to discharge. No deaths were recorded. Conclusion: Presentation ranged from peripheral oedema to serous involvement. Severity of proteinuria varied. Use of ACE inhibitors did not precipitate hyperkalaemia or kidney failure. Maternal complications were frequent, but no deaths were recorded. (AU)

[Nephrotic syndrome due to preeclampsia: Presentation, management and clinical evolution observed in 5 years experience]. / Síndrome nefrótico secundario a preeclampsia: presentación, manejo y evolución clínica observados en 5 años de experiencia.

INTRODUCTION: Nephrotic syndrome (NS) is rare during pregnancy. The main cause is severe pre-eclampsia (PR). Our aim was to describe the clinical presentation, analytical features, medical management, and progress of women with NS due to PE. MATERIALS AND METHODS: A descriptive, retrospective study, conducted from 01/01/2017 to 01/01/2022 (5years). Women with a gestational age (GA) ≥20weeks were included in the study, hospitalised due to hypertensive disorders in pregnancy (HDP), with no evidence of kidney damage prior to gestation. RESULTS: Of the 652 HDP, 452 PE and 21 NS were identified. Maternal age was 25±5.7 years, GA at diagnosis was 33.1±5.1 weeks. All the women had facial and peripheral oedema: 5 pleural effusion, 3 pericardial effusion, and 2 anasarca. Their p24 was 6.17±2.34grams (3.10-10.8), serum albumin 2.5±0.27g/dL (2.10-2.90), and serum cholesterol 281.4±21.7mg/dL (251-316). Thirteen developed maternal complications: acute kidney damage, pulmonary oedema, dilated cardiomyopathy, eclampsia, and HELLP syndrome. They all remained hypertensive postpartum, and required a combination of two to three antihypertensive drugs. They all received statins postpartum, and angiotensin converting enzyme (ACE) inhibitors to manage proteinuria. None developed hyperkalaemia or creatinine elevation. Hospital stay was 10.4±3.7days. All nephrotic range proteinuria parameters reversed prior to discharge. No deaths were recorded. CONCLUSION: Presentation ranged from peripheral oedema to serous involvement. Severity of proteinuria varied. Use of ACE inhibitors did not precipitate hyperkalaemia or kidney failure. Maternal complications were frequent, but no deaths were recorded.

Niveles plasmáticos de troponina T y de la fracción aminoterminal del propéptido natriurético cerebral y su relación con mortalidad en COVID-19 / Troponin-T and n-terminal pro-brain type natriuretic peptide plasma levels and its relationship with mortality in COVID-19

Introducción: El compromiso cardiovascular en la enfermedad por coronavirus 2019 (COVID-19) no necesariamente se presenta con los síntomas clásicos descriptos en la miocarditis. Es creciente la evidencia que demuestra compromiso cardiovascular subclínico en contexto de la intensa inflamación desatada, la tormenta de citocinas involucradas, el estado protrombótico basal y la disfunción endotelial consecuente. Nos propusimos analizar si la troponina T (TT) y la fracción amino-terminal del propéptido natriurético cerebral (NT-proBNP) determinada al momento de ingreso hospitalario se relacionan con la mortalidad durante la internación de estos pacientes. Material y métodos: Estudio analítico, observacional, de cohortes retrospectivas y corte transversal. Incluyó sujetos con COVID-19 internados por enfermedad moderada-severa, del 20 de marzo de 2020 al 15 de noviembre de 2020. Se analizaron las determinaciones de TT y NT-proBNP obtenidas en las primeras 24 horas de ingreso. Se consideró TT alterada si ≥ 0,014 ng/dL y NT-proBNP alterado si ≥ 300 pg/mL. Resultados: Se incluyeron 108 sujetos, 63,2% hombres, edad 51,5 años (59-43). El 28% ingreso a Unidad de Cuidados Intensivos (UCI) y el 25% falleció. El grupo de pacientes con TT elevada presentó mayor mortalidad (OR = 3,1; IC 95% = 1,10-8,85; p = 0,028) al igual que el grupo con NT-proBNP elevado (OR = 3,47; IC 95% = 1,21-9,97; p = 0,017). Al análisis multivariado sólo NT-proBNP ≥300 pg/mL se mantuvo como factor de riesgo independiente. Conclusiones: Niveles de NT-proBNP ≥ 300 pg/mL al ingreso en pacientes con COVID-19 moderada-severa se relacionaron con una mayor mortalidad.(AU)

Introduction: Cardiovascular compromise in coronavirus disease 2019 (COVID-19) does not necessarily present with the classic symptoms described in myocarditis. There is growing evidence demonstrating subclinical cardiovascular compromise in the context of the intense inflammation unleashed, the cytokine storm involved, the baseline prothrombotic state, and the consequent endothelial dysfunction. We set out to analyse whether Troponin-T (TT) and the amino-terminal fraction of pro-brain natriuretic peptide (NT-proBNP) determined at hospital admission, are related to mortality during the hospitalization of these patients. Material and methods: Analytical, observational, retrospective cohort and cross-sectional study. It included subjects with COVID-19 hospitalized for moderate-severe illness, from 20/03/20 to 15/11/20. The TT and NT-proBNP obtained in the first 24 hours from admission were analysed. Altered TT was considered if ≥.014 ng/dl and altered NT-proBNP if ≥300 pg/ml. Results: One hundred and eight subjects were included, 63.2% men, age 51.5 years (59-43), 28% were admitted to the Critical Unit and 25% died. The group with elevated TT presented higher mortality (OR = 3.1; 95%CI = 1.10-8.85; p = .02). The group with elevated NT-proBNP also show higher mortality (OR = 3.47; 95%CI = 1.21-9.97; p = .01). On multivariate analysis, only NT-proBNP ≥300 pg/ml remained an independent risk factor. Conclusions: NT-proBNP levels ≥300 pg/ml at admission in patients with moderate-severe COVID-19 were associated with higher mortality.(AU)

[Troponin-T and n-terminal pro-brain type natriuretic peptide plasma levels and its relationship with mortality in COVID-19]. / Niveles plasmáticos de troponina T y de la fracción aminoterminal del propéptido natriurético cerebral y su relación con mortalidad en COVID-19.

INTRODUCTION: Cardiovascular compromise in coronavirus disease 2019 (COVID-19) does not necessarily present with the classic symptoms described in myocarditis. There is growing evidence demonstrating subclinical cardiovascular compromise in the context of the intense inflammation unleashed, the cytokine storm involved, the baseline prothrombotic state, and the consequent endothelial dysfunction. We set out to analyse whether Troponin-T (TT) and the amino-terminal fraction of pro-brain natriuretic peptide (NT-proBNP) determined at hospital admission, are related to mortality during the hospitalization of these patients. MATERIAL AND METHODS: Analytical, observational, retrospective cohort and cross-sectional study. It included subjects with COVID-19 hospitalized for moderate-severe illness, from 20/03/20 to 15/11/20. The TT and NT-proBNP obtained in the first 24 hours from admission were analysed. Altered TT was considered if ≥.014 ng/dl and altered NT-proBNP if ≥300 pg/ml. RESULTS: One hundred and eight subjects were included, 63.2% men, age 51.5 years (59-43), 28% were admitted to the Critical Unit and 25% died. The group with elevated TT presented higher mortality (OR = 3.1; 95%CI = 1.10-8.85; p = .02). The group with elevated NT-proBNP also show higher mortality (OR = 3.47; 95%CI = 1.21-9.97; p = .01). On multivariate analysis, only NT-proBNP ≥300 pg/ml remained an independent risk factor. CONCLUSIONS: NT-proBNP levels ≥300 pg/ml at admission in patients with moderate-severe COVID-19 were associated with higher mortality.

Tratamiento farmacológico de la hipertensión arterial no severa durante el embarazo, el posparto y la lactancia / Pharmacological treatment of non-severe hypertension during pregnancy, postpartum and breastfeeding

La hipertensión arterial (HTA) en el embarazo se define como una presión arterial sistólica ≥ 140 y/o diastólica ≥ 90 mmHg. Con base en las cifras, se clasifica en no severa (< 160/110 mmHg) y severa (≥ 160/110 mmHg). Previamente a iniciar tratamiento en HTA no severa, se debe descartar HTA de bata blanca. Si es posible el manejo ambulatorio, se sugiere el inicio farmacológico ante valores sostenidamente elevados, evitando cifras < 120/80 mmHg. Los fármacos seguros durante la gestación son metildopa, labetalol y nifedipino-RETARD, pudiendo contemplarse el uso de nifedipino-OROS o amlodipino con menor nivel de evidencia. La utilización de diuréticos, atenolol y otros betabloqueadores con fines antihipertensivos no está recomendada en esta etapa. Los inhibidores del sistema renina-angiotensina-aldosterona están terminantemente contraindicados. En posparto y lactancia, puede mantenerse el mismo esquema terapéutico empleado durante el embarazo, intentando retirar la metildopa precozmente. Durante el puerperio, amlodipino y enalapril resultan seguros, con ínfima excreción por leche materna. (AU)

Hypertension (HTN) in pregnancy is defined as systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg. Based on the values, it is classified as non-severe (< 160/110 mmHg) and severe (≥ 160/110 mmHg). Before starting treatment in non-severe HTN, white- coat HTN should be ruled out. If outpatient management is possible, pharmacological initiation is suggested with sustained high values, avoiding < 120/80 mmHg. Safe drugs during pregnancy are methyldopa, labetalol, and nifedipine-retard. The use of nifedipine-XL or amlodipine can be considered with a lower level of evidence of safety. Diuretics, atenolol, and other beta-blockers for antihypertensive purposes is not recommended in this period. Renin-angiotensin-aldosterone system inhibitors are strictly contraindicated. In postpartum and breastfeeding, the same therapeutic regimen used during pregnancy can be maintained, trying early withdrawal of methyldopa. During puerperium, amlodipine and enalapril are safe, with minimal excretion in breast milk. (AU)

[Pharmacological treatment of non-severe hypertension during pregnancy, postpartum and breastfeeding]. / Tratamiento farmacológico de la hipertensión arterial no severa durante el embarazo, el posparto y la lactancia.

Hypertension (HTN) in pregnancy is defined as systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg. Based on the values, it is classified as non-severe (< 160/110 mmHg) and severe (≥ 160/110 mmHg). Before starting treatment in non-severe HTN, white- coat HTN should be ruled out. If outpatient management is possible, pharmacological initiation is suggested with sustained high values, avoiding < 120/80 mmHg. Safe drugs during pregnancy are methyldopa, labetalol, and nifedipine-retard. The use of nifedipine-XL or amlodipine can be considered with a lower level of evidence of safety. Diuretics, atenolol, and other beta-blockers for antihypertensive purposes is not recommended in this period. Renin-angiotensin-aldosterone system inhibitors are strictly contraindicated. In postpartum and breastfeeding, the same therapeutic regimen used during pregnancy can be maintained, trying early withdrawal of methyldopa. During puerperium, amlodipine and enalapril are safe, with minimal excretion in breast milk.

[HELLP Syndrome: clinical-analytical characteristics and evolution observed in two years of experience]. / Síndrome HELLP: características clínicas, analíticas y evolutivas observadas en dos años de experiencia.

INTRODUCTION: HELLP syndrome (H: hemolysis, EL: elevated liver enzymes and LP: low platelets) is a form of severe preeclampsia (PE). The syndrome can be: complete or incomplete (with three analytical criteria, or only one or two); Class i, ii or iii (according platelets < 50,000; 50,000-100,000 or > 100,000/mm3); postpartum or antepartum; with early or late installation (before or after the 34nd week of gestation). We describe and analyze characteristics and evolution observed in hypertensive pregnant patients who developed HELLP. MATERIAL AND METHODS: Retrospective cohort with observation period of two years. It included pregnant hypertensive women who developed HELLP, during the course of their hospitalization in the maternity hospital of our tertiary care hospital. RESULTS: It included 318 hypertensive pregnant women. We observed 28 HELLP. Maternal age was 25.8 ±7.2 years and gestational age at diagnosis 31 ± 1 week. Hypertension was chronic in 4 and gestational in 24; eight had presented PE in the previous pregnancy. There were 10 complete and 18 incomplete syndromes; according to platelet disease there were 3 Class i, 16 Class ii and 9 Class iii. HELLP was postpartum in 3 and antepartum in 25: 18 early and 7 late. There were 17 patients who required intensive care and 10 developed complications linked to HELLP. No maternal deaths were recorded. CONCLUSION: Presentation was variable, exhibiting mostly in gestational hypertension, antepartum and early. Incomplete form and class II thrombocytopenia were more frequent. Maternal complications were frequent but no deaths were observed.

[Cystatin C: Biomarker of cardiovascular risk in HIV]. / Cistatina C: Biomarcador de riesgo cardiovascular en VIH.

INTRODUCTION: Patients infected with the human immunodeficiency virus (HIV) have a higher cardiovascular risk (CVR). The development of cardiovascular disease (CVD) in this population involves traditional CVR factors and factors related to the infection itself, such as chronic inflammatory status, immune dysfunction, as well as the antiretroviral therapy received. Cystatin C (CC) has shown to be useful in assessing the presence of CVR factors and CVD established in the general population, the elderly population, and patients with chronic kidney disease. An analysis was performed on this association in an HIV positive population (HIV+). MATERIAL AND METHODS: Analytical, observational, cross-sectional study was conducted, and included collecting information about CVR factors and CVD in HIV+, as well as measuring CC. The patients were divided into 2 groups: Group1=high CC (≥0.95mg/L) and Group2=normal CC (<0.95mg/L). RESULTS: A total of 95 patients were included. Group1=27 (28.4%) and Group2=68 (71.5%). A value of CC≥0.95mg/L was related to the presence of CVD (P=.01). It was also related with and an increase in waist circumference (P=.05), neck circumference (P=.04), systolic blood pressure (P=.04), diastolic blood pressure (P=.01), Framingham score (P=.03), and Framingham score adapted for HIV (P=.01). After performing multivariate analysis with incorporation of variables associated with CVD in the bivariate analysis, only CC≥0.95mg/L continued to be related to CVD. CONCLUSION: CC≥0.95mg/L was independently associated with CVD. This cut-off point was also linked to higher levels of blood pressure, and higher CVR at 10 years using the Framingham Score and Framingham Score adapted for HIV population.

[Low-risk community-acquired pneumonia: implications of its outcome due to the determining factors for admission not contemplated by the scores]. / Neumonía adquirida en la comunidad de bajo riesgo: Consecuencias evolutivas de los determinantes de internación no contemplados por los scores.

OBJECTIVES: The decision to admit patients with community-acquired pneumonia (CAP) to hospital are based on stratification scales. This classification into risk groups is not perfect. In low-risk community-acquired pneumonia (LR-CAP), physicians often depend on their subjective impressions to decide the need for hospitalisation, which suggests the existence of conditions not considered by the scores. The aim of this article was to describe the determining factors for admission in LR-CAP, and to analyse the relationship between these causes and clinical outcome. MATERIAL AND METHODS: A descriptive, observational, retrospective study, based on the review of medical records during a 2 year-period. It included patients over 18 years, who were hospitalised in a third level hospital in Argentina due to LR-CAP. RESULTS: A total of 80 cases were identified. The causes that led to hospitalisation were: comorbidities not included in the scores, development of pleural effusion and sepsis, lack of response to ambulatory antibiotic treatment, oral intolerance, and social causes. HIV infection was associated with an unfavourable clinical progress during hospital admission (p=.03), as well as the lack of response to outpatient treatment (p=.03) and the development of pleural effusion (p=.03). Social causes were associated with a need for longer intravenous treatment. CONCLUSIONS: HIV infection, social causes, and lack of response to ambulatory treatment were related to unfavourable clinical progress.

[Utility of the neutrophil/lymphocyte ratio and the polymorphonuclear/ monomorphonuclear ratio, in the prediction of preeclampsia]. / Utilidad del índice neutrófilo/linfocito y del índice polimorfonuclear/monomorfonuclear, en la predicción de preeclampsia.

INTRODUCTION: The appearance of preeclampsia (PE) would comprise the alteration of endothelial function and activation of the inflammatory response, leading to placental hypoperfusion. The neutrophil/lymphocyte ratio (NLR) and the polymorphonuclear/monomorphonuclear ratio (PMR) could measure the underlying inflammatory component and predict the onset of the disorder. MATERIAL AND METHODS: Observational, analytical, case and control study. We retrospectively analysed medical records of pregnant women, hospitalized for hypertension registers. The patients were divided into Group1=with PE development, and Group2=without PE development. RESULTS: 110 patients were included: Group1=58.2% and Group2=41.8%, observing differences between the NLR means (P=.01) and PMR means (P=.02). An NLR ≥4.5 (P=.002; OR=3.9; 95%CI=1.6-9.5) and a PMR ≥3 (P=.004; OR=3.5; 95%CI=1.4-8.4) was related with PE. CONCLUSION: The elevation of NLR and PMR in hypertensive pregnant patients, could be considered indicators for the development of PE.