Insulin and the kidneys: a contemporary view on the molecular basis.

Insulin is a hormone that is composed of 51 amino acids and structurally organized as a hexamer comprising three heterodimers. Insulin is the central hormone involved in the control of glucose and lipid metabolism, aiding in processes such as body homeostasis and cell growth. Insulin is synthesized as a large preprohormone and has a leader sequence or signal peptide that appears to be responsible for transport to the endoplasmic reticulum membranes. The interaction of insulin with the kidneys is a dynamic and multicenter process, as it acts in multiple sites throughout the nephron. Insulin acts on a range of tissues, from the glomerulus to the renal tubule, by modulating different functions such as glomerular filtration, gluconeogenesis, natriuresis, glucose uptake, regulation of ion transport, and the prevention of apoptosis. On the other hand, there is sufficient evidence showing the insulin receptor's involvement in renal functions and its responsibility for the regulation of glucose homeostasis, which enables us to understand its contribution to the insulin resistance phenomenon and its association with the progression of diabetic kidney disease.

Utilidad del citoquímico urinario en cuidados intensivos, una herramienta olvidada

El sedimento urinario es una herramienta utilizada hace tantos años para caracterizar manifestaciones renales de enfermedades primarias y secundarias, que es necesario realizar una estandarización y aprender a interpretar el mismo. En los pacientes ingresados a la unidad de cuidados intensivos, muchas veces no se realiza, o hay que tener en cuenta varios factores para su interpretación debido al estado hemodinámico del paciente a la filtración glomerular, la excreción tubular, la reabsorción de agua y los solutos además del equilibrio acido-base, los cuales pueden variar significativamente en pacientes en estado crítico con diferentes condiciones fisiopatológicas. Se presenta una revisión de las condiciones para la interpretación del urianálisis.

A urinary sediment is a tool used for years to characterize renal manifestations of primary and secondary diseases, which requires standardization and learning to interpret it. In patients admitted to the intensive care unit, it is often not performed, or several factors must be taken into account for its interpretation due to the patient's hemodynamic status, glomerular filtration, tubular excretion, water reabsorption, and solutes. In addition to the acid-base balance, which can vary significantly in critically ill patients with different pathophysiological conditions? A review of the conditions for the interpretation of urinalysis is presented.

Utilidad del citoquímico urinario en cuidados intensivos, una herramienta olvidada / The usefulness of urinary sediment in intensive care, a forgotten tool

El sedimento urinario es una herramienta utilizada hace tantos años para caracterizar manifestaciones renales de enfermedades primarias y secundarias, que es necesario realizar una estandarización y aprender a interpretar el mismo. En los pacientes ingresados a la unidad de cuidados intensivos, muchas veces no se realiza, o hay que tener en cuenta varios factores para su interpretación debido al estado hemodinámico del paciente a la filtración glomerular, la excreción tubular, la reabsorción de agua y los solutos además del equilibrio acido-base, los cuales pueden variar significativamente en pacientes en estado crítico con diferentes condiciones fisiopatológicas. Se presenta una revisión de las condiciones para la interpretación del urianálisis.

A urinary sediment is a tool used for years to characterize renal manifestations of primary and secondary diseases, which requires standardization and learning to interpret it. In patients admitted to the intensive care unit, it is often not performed, or several factors must be taken into account for its interpretation due to the patient's hemodynamic status, glomerular filtration, tubular excretion, water reabsorption, and solutes. In addition to the acid-base balance, which can vary significantly in critically ill patients with different pathophysiological conditions? A review of the conditions for the interpretation of urinalysis is presented.

Novel Biomarkers of Diabetic Kidney Disease.

Diabetic kidney disease (DKD) is a highly prevalent condition worldwide. It represents one of the most common complications arising from diabetes mellitus (DM) and is the leading cause of end-stage kidney disease (ESKD). Its development involves three fundamental components: the hemodynamic, metabolic, and inflammatory axes. Clinically, persistent albuminuria in association with a progressive decline in glomerular filtration rate (GFR) defines this disease. However, as these alterations are not specific to DKD, there is a need to discuss novel biomarkers arising from its pathogenesis which may aid in the diagnosis, follow-up, therapeutic response, and prognosis of the disease.

Bloqueo del eje renina angiontensina aldosterona (RAAS) en la enfermedad renal diabética. Más allá del control de la hipertensión arterial / Renin angiotensin aldosterone system (RAAS) and its suppression in diabetic kidney disease. Control of arterial hypertension and beyond

La enfermedad renal diabética (ERD) es una comorbilidad con alta prevalencia a nivel mundial, siendo una de las complicaciones más frecuentes de la diabetes mellitus (DM). La ERD se relaciona con complicaciones cardiovasculares y progresión de la enfermedad renal crónica (ERC), por ello la identificación de factores modificables, como el control de la presión arterial, es uno de los pilares más importantes en el manejo integral. En esta revisión hacemos un recorrido sobre el papel de la hipertensión y el bloqueo del eje renina angiotensina aldosterona (RAAS) en el curso de la ERD y las estrategias terapéuticas orientadas a la reducción de la presión arterial (PA), el bloqueo RAAS y el impacto en resultados renales y cardiovasculares. El objetivo de este artículo es hacer una revisión de las intervenciones más importantes que actúan bloqueando el eje renina angiotensina aldosterona (RAAS) y determinar si estas medidas en los pacientes con ERD, solo tienen impacto en el control de la presión arterial o si también son estrategias de nefro y cardio-protección. Conclusión: La ERD es una de las complicaciones más frecuentes de la diabetes mellitus (DM). El control de la PA sigue siendo un pilar fundamental para lograr estos objetivos. Los bloqueadores del RAAS (iECAS y BRAs) son los antihipertensivos de elección con efecto terapéutico por el bloqueo RAAS y esto les permite tener además del control de la PA, efectos nefroprotectores y cardioprotectores importantes en pacientes con ERD, sobre todo cuando hay la presencia de albuminuria. Evaluamos que además de los inhibidores de la enzima convertidora de angiotensina (iECAs) y los bloqueadores del receptor de angiotensina (BRAs), vienen tomando importancia los antagonistas selectivos del receptor mineralocorticoide (ARM) como Finerenona.

Diabetic kidney disease (DKD) is a comorbidity with a high worldwide prevalence, and one of the most frequent complications of diabetes mellitus (DM). CKD is related to cardiovascular complications and the progression of chronic kidney disease (CKD), therefore the identification of modifiable factors, such as blood pressure control, is one of the most important pillars in comprehensive management. In this review, we will analyze the role of hypertension and the renin-angiotensin-aldosterone system (RAAS) and its suppression in the course of CKD, and therapeutic strategies aimed at reducing blood pressure (BP), RAAS blockade, and the impact on renal and cardiovascular outcomes. The objective of this article is to review the most important interventions that act by blocking the renin-angiotensin-aldosterone system (RAAS) and to determine if these measures in patients with CKD only have an impact on blood pressure control or if they are also nephron and cardio-protective strategies. Conclusion: DKD is one of the most frequent complications of diabetes mellitus (DM). BP control continues to be a fundamental pillar to achieve these objectives. RAAS blockers (iECAS and ARBs) are the first-line antihypertensive with a therapeutic effect due to RAAS blockade and this allows them to have, in addition to BP control, important nephroprotective and cardioprotective effects in patients with CKD, especially when there is albuminuria. We evaluated that in addition to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), selective mineralocorticoid receptor antagonists (MRA) such as Finerenone are gaining importance.

Critically Ill Patients with Renal Hyperfiltration: Optimizing Antibiotic Dose.

Renal hyperfiltration (RHF) is a prevalent phenomenon in critically ill patients characterized by augmented renal clearance (ARC) and increased of elimination of renally eliminated medications. Multiple risk factors had been described and potential mechanisms may contribute to the occurrence of this condition. RHF and ARC are associated with the risk of suboptimal exposure to antibiotics increasing the risk of treatment failure and unfavorable patient outcomes. The current review discusses the available evidence related to the RHF phenomenon, including definition, epidemiology, risk factors, pathophysiology, pharmacokinetic variability, and considerations for optimizing the dosage of antibiotics in critically ill patients.

Lipoma cardiaco / Cardiac masses

Resumen Las masas cardiacas son entidades raras que cursan con un espectro muy variado de manifestaciones clínicas que van desde cuadros asintomáticos hasta compromiso hemodinámico severo. Entre las lesiones benignas, los lipomas cardiacos son los segundos en frecuencia. Corresponden principalmente a lesiones neoplásicas benignas; no obstante, se pueden presentar otras patologías como trombos, vegetaciones y variantes de la normalidad. Gracias a la disponibilidad de técnicas de imagen de alta definición, como la ecocardiografía, la TC y la RM, ha aumentado su detección y tratamiento temprano. En el ámbito terapéutico se ofrece manejo quirúrgico, pues las imágenes no permiten la caracterización y diferenciación fidedigna de la naturaleza de las masas cardiacas. Se describe el caso de una paciente sin antecedentes cardiovasculares, con historial de disnea crónica, en quien se identificó, a través de estudios imagenológicos, masa cardiaca adosada al ventrículo con deformación leve de cavidades derechas. Fue llevada a resección quirúrgica y por histopatología se confirmó lipoma. Este hallazgo es el más infrecuente de todos los tumores cardíacos benignos. Se resalta la importancia del conocimiento de esta enfermedad para dar tratamiento eficaz y oportuno en aras de evitar complicaciones que impacten en morbimortalidad.

Abstract Cardiac masses are rare entities that present with a very varied spectrum of clinical manifestations that go from asymptomatic to pictures with severe hemodynamic compromise, within these, cardiac lipomas are the second in frequency within benign lesions. They mainly correspond to benign neoplastic lesions, however, other pathologies such as thrombi, vegetations and variants of normality can occur. Thanks to the availability of high-definition imaging techniques, echocardiography, CT and MRI have increased early detection and treatment. In the therapeutic field, surgical management is offered, since the images do not allow the characterization and reliable differentiation of the nature of cardia masses. It is described the case of a patient with no cardiovascular history, with chronic dyspnea, in whom the presence of CM attached to the ventricle with slight deformation of the right cavities is identified by imaging studies. Was taken to surgical resection confirming the presence of lipoma by histopathology, being this finding the rarest of all benign cardiac tumors. We highlight the importance of knowing this pathology to provide effective and timely treatment to avoid complications that impact morbidity and mortality.

Enfermedad renal diabética: puesta al día / Update on diabetic kidney disease

Introducción: La Diabetes Mellitus (DM) es una enfermedad inflamatoria sistémica de alta prevalencia e incidencia a nivel mundial. Dentro de las complicaciones crónicas, la enfermedad renal diabética es una de las más frecuentes y que marca el pronóstico. Objetivos: El objetivo de este artículo es hacer una revisión actualizada de la enfermedad renal diabética, a la luz de los cambios en los paradigmas que se han generado en los últimos años con respecto a sus nuevas definiciones, el papel de la inflamación en su desarrollo, la gestión del riesgo cardiovascular y los nuevos tratamientos. La enfermedad renal diabética puede presentarse en aproximadamente el 30-50% de la población con diabetes mellitus tipo 1 o 2 alrededor del mundo. En la patogénesis y progresión de esta condición se distinguen tres ejes fundamentales el hemodinámico, metabólico e inflamatorio. Es importante siempre hacer gestión del riesgo cardiovascular. El diagnóstico se debe hacer con el cálculo de la tasa de filtrado glomerular y la relación albuminuria / creatinuria en muestra ocasional. Los objetivos en el tratamiento deben ser: el control metabólico, reducir o enlentecer la progresión de la enfermedad renal y disminuir los desenlaces cardiovasculares. Conclusión: El tratamiento de la ERD debe ser holístico, desde intervenciones no farmacológicas, como la modificación de los estilos de vida, hasta los nuevos medicamentos como el uso de inhibidores SGLT-2, Agonistas del receptor GLP-1 y el uso antagonistas selectivos del receptor mineralocorticoide como finerenona. El futuro es promisorio.

Introduction: Diabetes mellitus (DM) is a systemic inflammatory disease of high prevalence and incidence worldwide. Among the chronic complications, diabetic kidney disease is one of the most frequent and determines the prognosis. Objectives: The objective of this article is to make an updated review of diabetic kidney disease, in light of the changes in the paradigms that have been generated in recent years concerning to the new definitions, the role of inflammation-causing disease, cardiovascular risk management, and the new treatments. Diabetic kidney disease can present in approximately 30-50% of the population with diabetes mellitus type 1 or 2 around the world. In the pathogenesis and progression of this condition, three fundamental axes are distinguished: the hemodynamic, the metabolic, and the inflammatory. It is important to manage cardiovascular risk. The diagnosis must be made by calculating the glomerular filtration rate and the albuminuria/creatinuria ratio in a random urine sample. The objectives of the treatment should be: metabolic control, reduce or slow the progression of kidney disease and improve cardiovascular outcomes. Conclusion: The treatment of diabetic kidney disease should be holistic, from non-pharmacological interventions, such as lifestyle changes, to new medications such as the use of SGLT-2 inhibitors, GLP-1 receptor agonists, and the use of selective mineralocorticoid receptor antagonists such as finerenone. The future is promising.

Hypercapnia from Physiology to Practice.

Acute hypercapnic ventilatory failure is becoming more frequent in critically ill patients. Hypercapnia is the elevation in the partial pressure of carbon dioxide (PaCO2) above 45 mmHg in the bloodstream. The pathophysiological mechanisms of hypercapnia include the decrease in minute volume, an increase in dead space, or an increase in carbon dioxide (CO2) production per sec. They generate a compromise at the cardiovascular, cerebral, metabolic, and respiratory levels with a high burden of morbidity and mortality. It is essential to know the triggers to provide therapy directed at the primary cause and avoid possible complications.

Neuromuscular blocking agents in the intensive care unit.

Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.

A Rare Case of Meningitis Caused by Alcaligenes faecalis in an Immunocompetent Patient.

Alcaligenes faecalis (A. faecalis) is a Gram-negative rod rarely isolated as an infective bacterium worldwide. The first cases of infections caused by this microorganism, such as pneumonia, soft tissue infections, urinary tract infections, bacteremia, and meningitis, date back more than 40 years and are almost entirely in newborns and immunosuppressed hosts. Optimal antibiotic therapy for A. faecalis has not been well established in the literature. We report a case of an immunocompetent patient in Colombia who had meningitis due to A. faecalis after a dental procedure. It is important to know about this microorganism that nowadays could be considered a potentially emerging pathogen in immunocompetent adults.

When to Use Antibiotics in COVID-19: A Proposal Based on Questions.

The COVID-19 pandemic has affected millions of people, including hundreds of deaths. The search for adequate treatments and interventions that influence poor prognostic factors and reduce mortality has led to excessive use of antibiotics based on the possible existence of bacterial co-infection. However, there is no evidence to justify the systematic use of antimicrobials in COVID-19. The recommendations seek to provide knowledge regarding treatment; standardizing a management algorithm requires validation in clinical trials and studies of greater methodological rigor.

Prevalence of Chronic Infection by Hepatitis C Virus in Asymptomatic Population With Risk Factors in Cartagena, Colombia.

Introduction: Infection by the hepatitis C virus (HCV) is an important cause of chronic liver disease, considered a public health problem worldwide with high morbidity and mortality due to limited access to diagnostic tests in developing countries. Only a small percentage know their infection status and receive timely treatment. It is critical to make diagnostic tests for HCV infection accessible and to provide timely treatment, which not only reduces the spread of infection but also stops the progression of HCV disease without symptoms. Objective: To determine the prevalence of chronic infection by HCV in patients with risk factors by using rapid tests in Cartagena, Colombia, and describe their epidemiological characteristics. Methodology: A cross-sectional descriptive observational study was carried out on asymptomatic adults with risk factors for HCV infection in the city of Cartagena between December 2017 and November 2019. A rapid immunochromatographic test was performed to detect antibodies, characterizing the population. Results: In total, 1,023 patients were identified who met the inclusion criteria, 58.5% women and 41.4% men, obtaining nine positive results, confirming chronic infection with viral load for HCV, finding seven cases of genotype 1b and two genotype 1a. Conclusion: In our study, a prevalence of hepatitis C infection of 0.9% was found in asymptomatic individuals with risk factors, which allows us to deduce that the active search for cases in risk groups constitutes a pillar for the identification of the disease, the initiation of antiviral therapy, and decreased morbidity and mortality.

[Encephalitis as neurological complication due dengue]. / Encefalitis como complicación neurológica por dengue.

We present the case of a 32-year-old male, previously healthy, with a 5-day history of fever, frontal-occipital headache, retro-ocular pain, rash, petechiae, myalgia, arthralgia, and abdominal pain. Blood tests with leukopenia, severe thrombocytopenia, transaminitis, long clotting times. Severe dengue with associated coagulopathy was diagnosed, indicating transfer to ICU. Presents torpid evolution, altered state of consciousness, psychomotor agitation, and aggressiveness. Structural, ischemic-hemorrhagic alterations, bacterial and fungal infections were ruled out. Finally diagnosing dengue encephalitis, confirmed by DENV PCR in CSF. Support measures are provided with favorable evolution. Encephalitis is the most serious neurological complication after dengue virus infection.

Multimodality cardiac imaging in the diagnostic approach to chronic dyspnea: a patient with pericardial lipoma.

Cardiac masses are rare entities that present with a very varied spectrum of manifestations ranging from asymptomatic to severe hemodynamic compromise. They mainly correspond to benign neoplastic lesions; however, other pathologies may occur. The availability of high-definition imaging techniques has increased early detection. Nevertheless, these techniques do not allow the characterization and reliable differentiation of the nature of the mass. We describe a patient with no cardiovascular history with a chronic dyspnea, in whom the presence of a cardiac mass attached to the ventricle with slight deformation of the right cavities was identified by imaging studies. The patient underwent surgical resection, which confirmed the presence of lipoma by histopathology. This finding is the rarest of all benign cardiac tumors.

Cardiac lipomas are rare benign tumors of the heart. They are usually asymptomatic, but when symptoms occur, they are usually nonspecific, so it is necessary to consult an internist, cardiologist or pulmonologist for proper study, identification and treatment. Multimodal images are very useful in these cases.

Intensive Care Unit Acquired Weakness Associated With Acute Severe Asthma.

Context: Neuromuscular complications in the intensive care unit (ICU) are frequent, multifactorial, and clinically difficult to recognize during their acute phase. The physical examination is the starting point for identification. Case Report: We present a patient with a history of poorly controlled asthma who was admitted to the ICU with status asthmaticus. After 4 days of being under ventilatory support, he developed muscle weakness. The diagnostic approach made it possible to establish myopathic and neurological compromise through electrophysiology studies. Conclusions: ICU-acquired weakness (ICUAW) can bring long-term consequences, early identification, and management, as well as preventive measures, are essential to minimize chronic disability and morbidity.

Dynamics of dengue and SARS-COV-2 co-infection in an endemic area of Colombia.

Since the COVID-19 outbreak, millions of people have been infected with SARS-CoV-2 around the world. An area of epidemiological relevance is Latin America, tropical regions, due to the distribution of endemic diseases such as chikungunya, dengue (DENV), malaria, Zika virus, where febrile disease abounds. The early signs and symptoms of DENV and COVID-19 could be similar, making it a risk that patients may be wrongly diagnosed early during the disease. The problem increases since COVID-19 infection can lead to false positives in DENV screening tests. We present two cases of acute undifferentiated febrile syndrome that were diagnosed with SARS-CoV-2 and DENV co-infection, confirmed by ELISA and RT-PCR for both viral pathogens. The occurrence of simultaneous or overlapped infections can alter the usual clinical course, severity, or outcome of each infection. Therefore, epidemiological surveillance and intensified preparation for those scenarios must be considered, as well as further studies should be done to address cases of co-infection promptly to avoid major complications and fatal outcomes during the current pandemic. Other endemic tropical diseases should not be neglected.

Insuficiencia renal en cirrosis: revisión de la literatura

Contexto: en el curso de la enfermedad del paciente cirrótico, la insuficiencia renal es un evento de mal pronóstico. Objetivo: identificar en estos pacientes los factores de riesgo de IRA, tales como: presencia de procesos infecciosos, hipovolemia inducida por hemorragia, pérdidas gastrointestinales o renales y agentes nefrotóxicos, ya que conocer de su aparición es primordial para dar comienzo a las medidas terapéuticas y las acciones profilácticas. Metodología: se realizó una búsqueda bibliográfica en las bases de datos PubMed, EMBASE, Scopus y Google académico, usando los términos MeSH como insuficiencia renal aguda, creatinina, cirrosis hepática, síndrome hepatorenal. Se obtuvieron resultados entre artículos originales, metaanálisis, reportes de casos, series de casos y revisiones de la literatura, y se escogieron 16 documentos para la elaboración de esta revisión. Resultados: los nuevos criterios definidos por el Club Internacional de Ascitis (AKI-IAC), los cuales eliminan el gasto urinario, se determinan por un aumento de la creatinina sérica ≥ 0,3 mg/dL en menos de 48 horas y, mejoran el pronóstico, permitiendo realizar intervenciones oportunas. Conclusiones: la creatinina sigue siendo el biomarcador más utilizado en insuficiencia renal aguda (IRA), incluso en pacientes cirróticos, a pesar de sus múltiples limitaciones. Un criterio dinámico modificado a partir de los criterios de AKIN, se convierte en el patrón de oro para el diagnóstico de IRA en cirrosis.

Introduction: During the cirrhotic patient's disease, renal failure is a poor prognostic event. Purpose: Knowing the risk factors for AKI in these patients given by the presence of infectious processes, loss of fluids due to hemorrhage, gastrointestinal or kidney, and nephrotoxic agents are essential for initiating therapeutic measures and prophylactic actions. Methodology: A bibliographic search was carried out in the PubMed, EMBASE, Scopus and academic Google databases, using the terms MeSH acute renal failure, creatinine, liver cirrhosis, hepatorenal syndrome. Original articles, meta-analyzes, case reports, case series and literature reviews were obtained, choosing 16 documents for the preparation of this review. Results: The new criteria defined by the International Ascites Club (AKI-IAC), which eliminate urinary output, are determined by an increase in serum creatinine ≥ 0.3 mg / dL in less than 48 hours and improve the prognosis, allowing timely interventions. Conclusions: Creatinine continues to be the most widely used biomarker in AKI, even in cirrhotic patients, despite its multiple limitations. A dynamic criterion modified from the AKIN criteria becomes the gold standard for the diagnosis of AKI in cirrhosis.