Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 3.533
Filtrar
2.
Medicina (Kaunas) ; 57(2)2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33530544

RESUMO

Traditionally, the management of patients with pulmonary embolism has been accomplished with anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although the administration of heparins and oral vitamin K antagonists still plays a role in pulmonary embolism management, the use of these therapies are limited due to other options now available. This is due to their toxicity profile, clearance limitations, and many interactions with other medications and nutrients. The emergence of direct oral anticoagulation therapies has led to more options now being available to manage pulmonary embolism in inpatient and outpatient settings conveniently. These oral therapeutic options have opened up opportunities for safe and effective pulmonary embolism management, as more evidence and research is now available about reversal agents and monitoring parameters. The evolution of the pharmacological management of pulmonary embolism has provided us with better understanding regarding the selection of anticoagulants. There is also a better understanding and employment of anticoagulants in pulmonary embolism in special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19.


Assuntos
Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Administração Oral , Anticoagulantes/administração & dosagem , Fibrinolíticos/administração & dosagem , Humanos , Falência Hepática/complicações , Neoplasias/complicações , Insuficiência Renal/complicações , Fatores de Risco
4.
Int J Mol Sci ; 22(3)2021 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-33513824

RESUMO

Cisplatin is one of the most widely used chemotherapeutic agents in oncology, although its nephrotoxicity limits application and dosage. We present the results of a clinical study on prophylaxis of cisplatin-induced nephrotoxicity in patients with peritoneal carcinomatosis undergoing cytoreduction and hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC-cisplatin). Prophylaxis was with imipenem/cilastatin. Cilastatin is a selective inhibitor of renal dehydropeptidase I in the proximal renal tubule cells that can reduce the nephrotoxicity of cisplatin. Unfortunately, cilastatin is not currently marketed alone, and can only be administered in combination with imipenem. The study has a retrospective part that serves as a control (n = 99 patients receiving standard surgical prophylaxis) and a prospective part with imipenem/cilastatin prophylaxis corresponding to the study group (n = 85 patients). In both groups, we collected specific data on preoperative risk factors of renal damage, fluid management, hemodynamic control, and urine volume during surgery (including the hyperthermic chemotherapy perfusion), as well as data on hemodynamic and renal function during the first seven days after surgery. The main finding of the study is that cilastatin may exert a nephroprotective effect in patients with peritoneal carcinomatosis undergoing cytoreduction and hyperthermic intraperitoneal cisplatin perfusion. Creatinine values remained lower than in the control group (ANOVA test, p = 0.037). This translates into easier management of these patients in the postoperative period, with significantly shorter intensive care unit (ICU) and hospital stay.


Assuntos
Antineoplásicos/uso terapêutico , Cilastatina/farmacologia , Cisplatino/efeitos adversos , Terapia Combinada/métodos , Rim/efeitos dos fármacos , Neoplasias Peritoneais/tratamento farmacológico , Insuficiência Renal/prevenção & controle , Adulto , Idoso , Cilastatina/uso terapêutico , Creatinina/sangue , Feminino , Humanos , Imipenem/farmacologia , Imipenem/uso terapêutico , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/complicações , Neoplasias Peritoneais/mortalidade , Estudos Prospectivos , Insuficiência Renal/complicações , Insuficiência Renal/etiologia , Estudos Retrospectivos
5.
Clin Appl Thromb Hemost ; 27: 1076029620979592, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33464938

RESUMO

Low-molecular-weight heparins are approved for primary and secondary venous thromboembolism prevention. Tinzaparin is the low-molecular-weight heparin with the highest average molecular weight. The purpose of this systematic review is to provide an update regarding the safety profile of tinzaparin, prescribed either as a prophylactic or as a therapeutic regimen for venous thromboembolism in special populations, including cancer patients and patients with renal impairment. We identified prospective studies up to August 2020 reporting safety outcomes for cancer patients and patients with renal impairment on tinzaparin regimens. In patients with cancer major bleeding rates fluctuated between 0.8% and 7%. Patients on tinzaparin exhibited significantly lower rates of clinically relevant nonmajor bleeding events in comparison with those on vitamin K antagonists. Bioaccumulation of tinzaparin was not correlated with age, body weight or creatinine clearance. Periodic administration of either prophylactic or therapeutic doses of tinzaparin did not result in bioaccumulation, even in patients with severe renal impairment and creatinine clearance < 20 ml/min. Major bleeding rates for non-cancer patients with renal impairment on prophylactic tinzaparin regimens were 0%. Non-cancer patients with renal impairment on therapeutic tinzaparin regimens exhibited major bleeding in 0 to 3.4% of cases; major bleeding rates were higher for cancer patients with renal impairment on therapeutic tinzaparin regimens (4.3 to 10%). Tinzaparin can be used without dose adjustment in patients with severe renal impairment and creatinine clearance > 20 ml/min. Tinzaparin represents a safe choice for special populations at increased risk for thrombosis and bleeding.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias/complicações , Insuficiência Renal/complicações , Tinzaparina/uso terapêutico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/efeitos adversos , Anticoagulantes/farmacocinética , Feminino , Hemorragia/etiologia , Humanos , Masculino , Prevenção Primária , Estudos Prospectivos , Segurança , Prevenção Secundária , Tinzaparina/efeitos adversos , Tinzaparina/farmacocinética
6.
Ren Fail ; 43(1): 273-280, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33491531

RESUMO

The appropriate immunosuppressive regimen in kidney transplant recipients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19) infection remains unclear. The impact of direct virus injury complicated by dysregulated hyperimmune response with overwhelming release of various cytokines in COVID-19 infected subjects contributes to the complexity of management. The largest concern of the practicing clinicians at current time is how to tailor maintenance immune-modulating therapy during active viral infection and the efficacy of the soon-to-be upcoming immunization for COVID-19. This targeted review aims to cover most of the current evidence on the effect of key maintenance immunosuppressive agents in COVID-19 infection and proposes a line of management to specific scenarios on this very rapidly evolving subject.


Assuntos
/complicações , Imunossupressão , Imunossupressores/uso terapêutico , Transplante de Rim , Insuficiência Renal/complicações , Insuficiência Renal/cirurgia , Algoritmos , Humanos
7.
Nefrología (Madrid) ; 40(5): 543-551, sept.-oct. 2020. tab
Artigo em Inglês | IBECS | ID: ibc-199036

RESUMO

BACKGROUND/AIMS: The most common adverse effect of baclofen, used for managing hiccups and spasticity, is neurotoxicity. As baclofen is primarily excreted by the kidneys, neurotoxicity is more likely to occur in patients with chronic kidney disease (CKD). We evaluated the risk factor for baclofen neurotoxicity and the recommended dosage for patients with severe CKD. METHODS: In this single-center retrospective study, we classified 401 patients with CKD as stage 4 (n=174), non-dialysis stage 5 (n=97), and on-dialysis (n=130). RESULTS: The prevalence of baclofen-induced neurotoxicity in patients with severe CKD was 7.0% (28 of 401 patients). There was no significant difference in the presence of neurotoxicity when the patients were classified as CKD stage 4, stage 5, and dialysis patients. There were significant differences in serum albumin levels and the presence of diabetic nephropathy between the patients with neurotoxicity and those without. The results from a multiple logistic regression analysis showed that serum albumin was independently associated with baclofen neurotoxicity (p = 0.007). The minimum daily dose for baclofen neurotoxicity was 10mg, 10mg, and 5mg in patients with CKD stages 4 and 5, and dialysis, respectively. CONCLUSIONS: In this study, the prevalence of baclofen-induced neurotoxicity in patients with severe CKD was 7.0%. Serum albumin was identified as an independent risk factor for neurotoxicity. We recommend initially administering a daily dose of 7.5mg for patients with severe CKD stages 4 and 5, and a daily dose of 2.5mg for patients receiving dialysis


ANTECEDENTES/OBJETIVOS: La neurotoxicidad es el efecto adverso más frecuente del baclofeno, un fármaco que se utiliza para tratar los espasmos y la espasticidad. Dado que el baclofeno se excreta principalmente a través de los riñones, es más probable que la neurotoxicidad se presente en pacientes con enfermedad renal crónica (ERC). Hemos evaluado el factor de riesgo para la neurotoxicidad por baclofeno y la dosis recomendada para pacientes con ERC grave. MÉTODOS: En este estudio retrospectivo unicéntrico, se clasificó a 401 pacientes con ERC en estadio 4 (n=174), estadio 5 sin diálisis (n=97) y en diálisis (n=130). RESULTADOS: La prevalencia de la neurotoxicidad inducida por baclofeno en pacientes con ERC grave fue del 7,0% (28 de 401 pacientes). No se observaron diferencias significativas en la presencia de neurotoxicidad al clasificar a los pacientes en ERC en estadio 4, estadio 5 y pacientes en diálisis. Se observaron diferencias significativas en los niveles de albúmina sérica y en la presencia de nefropatía diabética entre los pacientes con y sin neurotoxicidad. Los resultados de un análisis de regresión logística múltiple mostraron que la albúmina sérica estaba asociada de manera independiente a la neurotoxicidad por baclofeno (p = 0,007). La dosis diaria mínima para la neurotoxicidad por baclofeno fue de 10, 10 y 5mg en pacientes con ERC en estadio 4, estadio 5 y en diálisis, respectivamente. CONCLUSIONES: En este estudio, la prevalencia de la neurotoxicidad inducida por baclofeno en pacientes con ERC grave fue del 7,0%. Se identificó la albúmina sérica como un factor de riesgo independiente de neurotoxicidad. Recomendamos una administración inicial a una dosis diaria de 7,5mg en pacientes con ERC grave en estadios 4 y 5, y una dosis diaria de 2,5mg en pacientes que reciben diálisis


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Síndromes Neurotóxicas/epidemiologia , Baclofeno/efeitos adversos , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/diagnóstico , Insuficiência Renal/complicações , Fatores de Risco , Estudos Retrospectivos , Albumina Sérica/análise , Baclofeno/administração & dosagem , Baclofeno/toxicidade , Hipoalbuminemia/complicações
8.
Intern Med ; 59(18): 2237-2244, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32938851

RESUMO

Objective The intrarenal renin-angiotensin system (RAS) is activated in chronic kidney disease (CKD) patients and is not suppressed at night in CKD patients showing nocturnal hypertension, contributing to renal damage. Furthermore, changes in RAS inhibitor administration from morning to evening, namely chronotherapy, ameliorates renal damage at night. We attempted to clarify whether or not chronotherapy ameliorates renal damage by suppressing the intrarenal RAS activity. Methods We recruited 34 CKD patients with RAS inhibitors in the morning. We conducted ambulatory blood pressure (BP) monitoring and urine collection and evaluated urinary albumin (Alb) and angiotensinogen (AGT), which are surrogate markers for intrarenal RAS activity during the day and at night, respectively. The same experiments were conducted after changing the administration time. The ratio of values associated with morning versus evening dosing was defined as the morning to evening (M/E) ratio. Results The M/E ratio of urinary Alb had a significant and positive relationship with that of urinary AGT during the day and at night in all CKD patients. However, no significant relationships were found between the M/E ratios of urinary Alb and AGT using multiple linear regression analyses. Conversely, there was a significant and positive relationship between the M/E ratios of urinary Alb and AGT at night but not during the day in CKD patients whose estimated glomerular filtration rate was <45 mL/min/1.73 m2 and whose night-to-day ratio of systolic BP was >0.90, even after adjustment. Conclusion This study indicated that chronotherapy with RAS inhibitors improved the renal damage via intrarenal RAS suppression, especially in CKD patients with an impaired renal function and nocturnal hypertension.


Assuntos
Cronoterapia Farmacológica , Rim/fisiopatologia , Insuficiência Renal Crônica/tratamento farmacológico , Insuficiência Renal Crônica/fisiopatologia , Sistema Renina-Angiotensina/efeitos dos fármacos , Adulto , Albuminúria , Angiotensinogênio/urina , Biomarcadores/sangue , Pressão Sanguínea , Monitorização Ambulatorial da Pressão Arterial , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Insuficiência Renal/complicações , Sistema Renina-Angiotensina/fisiologia
9.
Med J Aust ; 213(8): 374-379, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32959366

RESUMO

OBJECTIVE: Gut microbiota-produced trimethylamine N-oxide (TMAO) is a risk factor for cardiovascular events. However, conflicting findings regarding the link between plasma TMAO level and prognosis for patients with heart failure have been reported. We examined the association of plasma TMAO concentration with risk of major adverse cardiac events (MACEs) and all-cause mortality in patients with heart failure. STUDY DESIGN: Meta-analysis of prospective clinical studies. DATA SOURCES: We searched electronic databases (PubMed, EMBASE) for published prospective studies examining associations between plasma TMAO level and MACEs and all-cause mortality in adults with heart failure. DATA SYNTHESIS: Hazard ratios (HRs) with 95% confidence intervals for associations between TMAO level and outcomes were estimated in random effects models. In seven eligible studies including a total of 6879 patients (median follow-up, 5.0 years) and adjusted for multiple risk factors, higher plasma TMAO level was associated with greater risks of MACEs (TMAO tertile 3 v tertile 1: HR, 1.68; 95% CI, 1.44-1.96; per SD increment: HR, 1.26; 95% CI, 1.18-1.36) and of all-cause mortality (TMAO tertile 3 v tertile 1: HR, 1.67; 95% CI, 1.17-2.38; per SD increment: HR, 1.26; 95% CI, 1.07-1.48). Higher TMAO level was also associated with greater risk of MACEs after adjusting for estimated glomerular filtration rate (eGFR; six studies included); however, the heterogeneity of studies in which risk was adjusted for eGFR was significant (I2  = 76%). CONCLUSIONS: Elevated plasma TMAO level in patients with heart failure is associated with poorer prognoses. This association is only partially mediated by renal dysfunction.


Assuntos
Insuficiência Cardíaca/sangue , Transplante de Coração/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Metilaminas/sangue , Mortalidade , Causas de Morte , Microbioma Gastrointestinal , Insuficiência Cardíaca/complicações , Humanos , Prognóstico , Modelos de Riscos Proporcionais , Insuficiência Renal/sangue , Insuficiência Renal/complicações
10.
Pediatr Cardiol ; 41(7): 1301-1318, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32915293

RESUMO

Alterations in blood pressure are common during the perioperative period in infants and children. Perioperative hypertension may be the result of renal failure, volume overload, or activation of the sympathetic nervous system. Concerns regarding end-organ effects or postoperative bleeding may mandate regulation of blood pressure. During the perioperative period, various pharmacologic agents have been used for blood pressure control including sodium nitroprusside, nitroglycerin, ß-adrenergic antagonists, fenoldopam, and calcium channel antagonists. The following manuscript outlines the commonly used pharmacologic agents for perioperative BP including dosing regimens and adverse effect profiles. Previously published clinical trials are discussed and efficacy in the perioperative period reviewed.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Adolescente , Antagonistas Adrenérgicos beta/efeitos adversos , Antagonistas Adrenérgicos beta/farmacologia , Antagonistas Adrenérgicos beta/uso terapêutico , Anti-Hipertensivos/efeitos adversos , Anti-Hipertensivos/farmacologia , Bloqueadores dos Canais de Cálcio/efeitos adversos , Bloqueadores dos Canais de Cálcio/farmacologia , Bloqueadores dos Canais de Cálcio/uso terapêutico , Criança , Pré-Escolar , Fenoldopam/efeitos adversos , Fenoldopam/farmacologia , Fenoldopam/uso terapêutico , Humanos , Hipertensão/etiologia , Lactente , Masculino , Nitroprussiato/efeitos adversos , Nitroprussiato/farmacologia , Nitroprussiato/uso terapêutico , Período Perioperatório , Insuficiência Renal/complicações , Resultado do Tratamento
11.
Medicine (Baltimore) ; 99(30): e21312, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32791719

RESUMO

Bleeding complications of acute coronary syndromes (ACS) after percutaneous coronary intervention (PCI) are strongly associated with adverse patient outcomes, and gastrointestinal bleeding (GIB) is the most common major bleeding event, especially in the early post-PCI period. Current guidelines recommend routinely conducting bleeding risk assessments. The existing tools are mainly used to evaluate the overall bleeding risk and guide the adjustment of antithrombotic strategies after 1 year. However, there are no specific tools for GIB risk assessment.Between January 2015 and June 2015, 4943 ACS patients underwent PCI were consecutively enrolled in the derivation cohort. GIB, cardiovascular, and cerebrovascular events were recorded within 1 year of follow-up. A validation cohort including 1000 patients who met the same inclusion and exclusion criteria was also established by propensity-score matching baseline characteristics. Multivariable cox proportional-hazards regression model was used to derive a risk-scoring system, and predictive variables were selected. A risk score nomogram based on the risk prediction model was created to estimate the 1-year risk of GIB.In this study, we found that the usage of clopidogrel (hazard ratio, HR: 2.52, 95% confidence intervals, CI: 1.573-4.021) and glycoprotein IIb/IIIa receptor inhibitors (HR: 1.863, 95% CI: 1.226-2.829), history of peptic ulcers (HR: 3.601, 95% CI: 1.226-2.829) or tumor (HR: 4.884, 95% CI: 1.226-2.829), and cardiac insufficiency (HR: 11.513, 95% CI: 7.282-18.202), renal insufficiency (HR: 2.010, 95% CI: 1.350-2.993), and prolonged activated partial thromboplastin time (HR: 4.639, 95% CI: 2.146-10.032) were independent risk factors for GIB 1 year after PCI. Based on these 7 factors, a nomogram and scoring system was established. The area under curve of risk score was 0.824 in the deviation cohort and 0.810 in the verification cohort. In both cohorts, the GIB score was significantly better than that of 3 classical bleeding scores (all P < .05).This score could well predict the risk of GIB within 1 year after PCI and could be used to guide antithrombotic strategies.


Assuntos
Síndrome Coronariana Aguda/complicações , Hemorragia Gastrointestinal/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Síndrome Coronariana Aguda/terapia , Idoso , Regras de Decisão Clínica , Clopidogrel/efeitos adversos , Clopidogrel/uso terapêutico , Estudos de Coortes , Feminino , Hemorragia Gastrointestinal/diagnóstico , Insuficiência Cardíaca/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Úlcera Péptica/complicações , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Insuficiência Renal/complicações , Projetos de Pesquisa/normas , Medição de Risco
12.
Khirurgiia (Mosk) ; (7): 68-75, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32736466

RESUMO

The paper is a narrative review of the literature on the use of direct oral anticoagulants (DOACs) for the VTE treatment in challenging patients: senile age (≥75 years), impaired renal function (estimated glomerular filtration rate ≤50 ml/min), fragility (one of the previous characteristics and/or bodyweight ≤50 kg). The paper discusses the studies of EINSTEIN DVT and PE (rivaroxaban), AMPLIFY (apixaban), HOKUSAI-VTE (edoxaban), RE-COVER I and II (dabigatran) in the focus of the secondary analysis in the pre-specified patient's subgroups, as well as their pooled analyzes and meta-analyzes. Based on the results of this review, it was concluded that in a subgroup of senile age patients, dabigatran increases the risk of major bleeding by 4.8 times and has no advantages over vitamin K antagonists (VKA); rivaroxaban and apixaban retain superiority over VKA on the safety outcomes and reduce the risk of major bleeding by 73% and 77%. In the subgroup of patients with impaired renal function, the use of apixaban and dabigatran is associated with an increase in the risk of major bleeding by 6.5 and 7.3 times, and these DOACs do not have advantages over VKA; rivaroxaban retains its superiority over VKA and reduces the risk of major bleeding by 78%. For fragile patients, a secondary analysis is available only for rivaroxaban, which remains superior to VKA on safety endpoints and reduces the risk of major bleeding by 73%. In the absence of direct comparisons between the available DOACs, the presented data can be used as a rational approach for the choice of appropriate treatment for VTE in challenging patients.


Assuntos
Dabigatrana/efeitos adversos , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Insuficiência Renal/complicações , Rivaroxabana/efeitos adversos , Tromboembolia Venosa/tratamento farmacológico , Administração Oral , Fatores Etários , Idoso , Antitrombinas , Dabigatrana/administração & dosagem , Idoso Fragilizado , Humanos , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Rivaroxabana/administração & dosagem , Tromboembolia Venosa/complicações
13.
Cardiol Young ; 30(8): 1196-1198, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32522306

RESUMO

Little is know about COVID-19 outcome in specific populations such as Adult congenital heart disease (ACHD) patients. We report three cases of adult patients with similar underlying disease with completely different clinical severity at the time of COVID-19 infection. The patient with the most severe clinical course was obese and diabetic, suggesting that COVID-19 mortality and morbidity in Adult congenital heart disease patients might be independent of anatomic complexity.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Cardiopatias Congênitas/complicações , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Adulto , Infecções por Coronavirus/terapia , Complicações do Diabetes/complicações , Cardiopatias Congênitas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Pandemias , Pneumonia Viral/terapia , Insuficiência Renal/complicações , Fatores de Risco
14.
Medicine (Baltimore) ; 99(25): e19732, 2020 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-32569153

RESUMO

INTRODUCTION: Anesthesia management for high-risk elderly patients with hip fracture is challenging, it is significant to choose a more minimally invasive anesthesia technique for them than using conventional methods, like general anesthesia and neuraxial anesthesia. PATIENTS CONCERNS: Herein the patient suffered from the right intertrochanteric fracture, combined with heart failure, renal failure at the stage of uremia and pneumonia in her upper left lung DIAGNOSIS:: Because of right intertrochanteric fracture, internal fixation with proximal femoral intramedullary nail was scheduled for this patient INTERVENTIONS:: Ultrasound-guided "hourglass-pattern" fascia iliac block combined with sacral plexus and gluteal epithelial nerve block were performed to a high-risk elderly patient OUTCOMES:: The surgery in our report was successfully completed with our effective anesthesia technique and no perioperative complication occurred CONCLUSION:: Ultrasound-guided "hourglass-pattern" fascia iliac block combined with gluteal epithelial nerve block and sacral plexus block not only satisfied the anesthesia and provided effective postoperative analgesia of hip operation, but also has minimal invasion to high-risk elderly patients, and contributed to enhancing recovery after surgery.


Assuntos
Fraturas do Quadril/cirurgia , Bloqueio Nervoso/métodos , Insuficiência Renal/complicações , Idoso , Feminino , Fixação Intramedular de Fraturas , Fraturas do Quadril/complicações , Humanos , Plexo Lombossacral , Ultrassonografia de Intervenção
15.
Autops. Case Rep ; 10(2): e2020164, Apr.-June 2020. graf
Artigo em Inglês | LILACS | ID: biblio-1131820

RESUMO

Emphysematous gastritis (EG) is a rare and potentially lethal process caused by invasive, gas-producing bacteria leading to inflammation and gas dissection of the stomach. The most common etiologic agents are Clostridium infections, but other organisms, including enterobacteria, staphylococcus, and fungi have also been identified. We report the first case of EG due to Sarcina ventriculi in a solid organ transplant recipient, who presented with epigastric pain and vomiting. The patient had a history of type 1 diabetes mellitus (DM) with recurrent episodes of ketoacidosis and systemic diabetic complications, including severe gastroparesis. CT scan studies demonstrated EG with venous air, and endoscopy showed severe gastritis and ulcerations. In the gastric biopsies, abundant Sarcina ventriculi were noted in areas of mucosal/submucosal necrosis. Antibiotic treatment was instituted at admission, and subsequent endoscopy demonstrated the disappearance of Sarcina, with some improvement of the gastric inflammation; however, the patient developed septic shock with multiorgan failure and expired. This case highlights the need to consider other infectious etiologies in transplant patients, in addition to the well-known opportunistic infections.


Assuntos
Humanos , Adulto , Complicações do Diabetes , Transplantados , Infecções/etiologia , Autopsia , Infecções Oportunistas/etiologia , Colestase , Infecções por Clostridium , Falência Hepática , Evolução Fatal , Gastroparesia/complicações , Insuficiência Renal/complicações , Rejeição de Enxerto
17.
Chirurgia (Bucur) ; 115(2): 246-251, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32369729

RESUMO

Intraoperative monitoring of parathyroid hormone can confirm the complete excision of hyperfunctional parathyroid tissue, as the plasma half-life of PTH is approximately 5 minutes. The purpose of this study was to analyse the values of parathormon (PTH) and the intraoperative impact in patients with secondary hyperparathyroidism of renal cause (sHPT). A series of 86 patients who were hospitalised in our clinic between February 2015 to December 2018, were included in the study rom. All patients underwent surgery with PTH monitoring. PTH was determined preoperatively, intraoperatively 15 minutes after parathyroidectomy and postoperatively. Out of a total of 86 patients, 6 patients had non-functional renal transplant. 81 patients were operated on per primam and 5 patients were operated for disease recurrence. There were 77 total parathyroidectomies and 4 subtotal parathyroidectomies. One patient had 5 parathyroid glands. There were 4 patients with recurrent hyper-plastic tissue excision. Blood samples were collected intraoperatively through the puncture of the jugular vein. The PTH value was determined by the Elecsys PTH STATÃÂî test. The mean value of preoperative PTH was 1658 pg / mL and decreased to 46.5 pg / mL at the end of the operation. Subsequently, the level of PTH harvested at 3-6 months increased slightly to 59.8 pg / mL. 80 (93%) of patients had elevated preoperative calcium values. Recurrent hyperparathyroidism was found in 1 of the 4 patients who underwent subtotal parathyroidectomy. IPTH value is influenced by the intraoperative manipulation of the parathyroid glands, the individual variability of PTH half-life and the physiological state of the patient. The decrease of PTH measured intraoperatively at 15 minutes after harvest with at least 90% of the preoperative value indicates the success of a total parathyroidectomy, with normalisation of calcium and PTH.


Assuntos
Hiperparatireoidismo Secundário/sangue , Hiperparatireoidismo Secundário/cirurgia , Hormônio Paratireóideo/sangue , Paratireoidectomia , Insuficiência Renal/sangue , Humanos , Hiperparatireoidismo Secundário/etiologia , Monitorização Intraoperatória/métodos , Paratireoidectomia/métodos , Insuficiência Renal/complicações
18.
Clin Drug Investig ; 40(6): 567-573, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32314297

RESUMO

BACKGROUND: Factor-Xa inhibitors (FXaIs) are widely used for the treatment of non-valvular atrial fibrillation (NVAF). Although we have previously reported the distribution of the anti-factor Xa activity (AXA) values of three different FXaIs in NVAF patients, the differences in the distribution of AXA values among the different FXaIs in patients with renal impairment (RI) have not been fully elucidated. METHODS: Trough and peak AXA values were measured in 94 patients taking rivaroxaban, 124 patients taking apixaban, and 66 patients taking edoxaban. Of them, we identified 26 patients with moderate RI [creatinine clearance (CrCl) 30-49 mL/min] and 17 patients with severe RI (CrCl 15-29 mL/min) in the rivaroxaban cohort, 37 patients with moderate RI and 17 patients with severe RI in the apixaban cohort, and 21 patients with moderate RI and 9 patients with severe RI in the edoxaban cohort. AXA values were measured using chromogenic AXA assays. Both trough and peak AXA values were compared between patients with moderate RI and those with severe RI in each cohort, and differences in the peak-to-trough ratio among the different drugs were assessed. RESULTS: In the rivaroxaban cohort, the peak AXA value was significantly higher in patients with severe RI than in those with moderate RI. In the apixaban cohort, neither the trough nor peak AXA values significantly differed between patients with moderate RI and those with severe RI. In the edoxaban cohort, the trough AXA value was significantly higher in patients with severe RI than in those with moderate RI, and peak AXA tended to be higher in patients with severe RI. The peak-to-trough ratio of AXA values was significantly lower in patients taking apixaban than in those taking rivaroxaban and edoxaban. CONCLUSION: Among Japanese NVAF patients with RI, the peak or trough AXA values were higher in patients with severe RI than in those with moderate RI when taking rivaroxaban and edoxaban, whereas both the peak and trough AXA values were similar between patients with severe RI and those with moderate RI when taking apixaban. The peak-to-trough ratio of AXA values was the lowest in patients taking apixaban.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Pirazóis/uso terapêutico , Piridinas/uso terapêutico , Piridonas/uso terapêutico , Insuficiência Renal/complicações , Rivaroxabana/uso terapêutico , Tiazóis/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
19.
Am J Kidney Dis ; 76(3): 350-360, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32336487

RESUMO

RATIONALE & OBJECTIVE: The use of kidney histopathology for predicting kidney failure is not established. We hypothesized that the use of histopathologic features of kidney biopsy specimens would improve prediction of clinical outcomes made using demographic and clinical variables alone. STUDY DESIGN: Retrospective cohort study and development of a clinical prediction model. SETTING & PARTICIPANTS: All 2,720 individuals from the Biopsy Biobank Cohort of Indiana who underwent kidney biopsy between 2002 and 2015 and had at least 2 years of follow-up. NEW PREDICTORS & ESTABLISHED PREDICTORS: Demographic variables, comorbid conditions, baseline clinical characteristics, and histopathologic features. OUTCOMES: Time to kidney failure, defined as sustained estimated glomerular filtration rate ≤ 10mL/min/1.73m2. ANALYTICAL APPROACH: Multivariable Cox regression model with internal validation by bootstrapping. Models including clinical and demographic variables were fit with the addition of histopathologic features. To assess the impact of adding a histopathology variable, the amount of variance explained (r2) and the C index were calculated. The impact on prediction was assessed by calculating the net reclassification index for each histopathologic variable and for all combined. RESULTS: Median follow-up was 3.1 years. Within 5 years of biopsy, 411 (15.1%) patients developed kidney failure. Multivariable analyses including demographic and clinical variables revealed that severe glomerular obsolescence (adjusted HR, 2.03; 95% CI, 1.51-2.03), severe interstitial fibrosis and tubular atrophy (adjusted HR, 1.99; 95% CI, 1.52-2.59), and severe arteriolar hyalinosis (adjusted HR, 1.53; 95% CI, 1.14-2.05) were independently associated with the primary outcome. The addition of all histopathologic variables to the clinical model yielded a net reclassification index for kidney failure of 5.1% (P < 0.001) with a full model C statistic of 0.915. Analyses addressing the competing risk for death, optimism, or shrinkage did not significantly change the results. LIMITATIONS: Selection bias from the use of clinically indicated biopsies and exclusion of patients with less than 2 years of follow-up, as well as reliance on surrogate indicators of kidney failure onset. CONCLUSIONS: A model incorporating histopathologic features from kidney biopsy specimens improved prediction of kidney failure and may be valuable clinically. Future studies will be needed to understand whether even more detailed characterization of kidney tissue may further improve prognostication about the future trajectory of estimated glomerular filtration rate.


Assuntos
Rim/patologia , Insuficiência Renal/patologia , Adolescente , Adulto , Biópsia , Comorbidade , Nefropatias Diabéticas/epidemiologia , Nefropatias Diabéticas/patologia , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Proteinúria/epidemiologia , Proteinúria/etiologia , Insuficiência Renal/complicações , Insuficiência Renal/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Resultado do Tratamento , Adulto Jovem
20.
Intern Med ; 59(7): 909-916, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32238661

RESUMO

Objective A positive correlation is observed between the progression of renal impairment and the increasing risk of cardiovascular disease. Our aim was to examine the relationship between the renal resistive index (RRI) assessed by duplex sonography and the extent of atherosclerosis in patients without renal impairment undergoing vascular imaging studies. Methods The RRI was evaluated pre-procedurally among 106 outpatients with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 undergoing clinically-driven coronary computed tomography angiography (CCTA). In those subjects, a carotid artery ultrasound scan was also performed to evaluate carotid artery disease. We investigated the association between the RRI and the atherosclerotic extent, defined by the presence of coronary artery calcium (CAC) >0 and carotid intima-media thickness (cIMT) ≥1.0 mm. Results Multi-site atherosclerosis (CAC>0 and cIMT≥1.0 mm) was found in 31 patients. The RRI was significantly increased with an increasing number of atherosclerotic vessels (absence of atherosclerosis: 0.65±0.04 vs. single-site atherosclerosis: 0.67±0.06 vs. multi-site atherosclerosis: 0.71±0.05, p<0.001). A multivariate logistic regression analysis showed that RRI>0.70 [odds ratio (OR): 4.05, 95% confidence interval (CI), 1.37-12.0, p=0.01], cardio ankle vascular index (CAVI) ≥9.0 (OR: 8.18, 95% CI: 2.47-27.1, p<0.01), diabetes (OR: 4.34, 95% CI: 1.37-13.7, p=0.01) and an eGFR>90 mL/min/1.73 m2 (OR: 5.89, 95% CI: 1.39-25.1, p=0.01) were associated with multi-site atherosclerosis. Conclusion The RRI, a sub-clinical renal parameter is an atherosclerotic marker in patients without renal impairment.


Assuntos
Aterosclerose/fisiopatologia , Circulação Renal/fisiologia , Insuficiência Renal/complicações , Resistência Vascular , Idoso , Aterosclerose/complicações , Velocidade do Fluxo Sanguíneo , Doenças das Artérias Carótidas/diagnóstico por imagem , Espessura Intima-Media Carotídea , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/diagnóstico por imagem , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/fisiopatologia , Ultrassonografia Doppler
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...