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1.
Expert Opin Drug Saf ; 20(9): 1061-1074, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33896310

RESUMO

INTRODUCTION: Invasive fungal infections continue to be important causes of morbidity and mortality in severely ill and immunocompromised patient populations. The past three decades have seen a considerable expansion in antifungal drug research, resulting in the clinical development of different classes of antifungal agents with different pharmacologic properties. Among drug-specific characteristics of antifungal agents, renal disposition and nephrotoxicity are important clinical considerations as many patients requiring antifungal therapy have compromised organ functions or are receiving other potentially nephrotoxic medications. AREAS COVERED: The present article reviews incidence, severity and mechanisms of nephrotoxicity associated with antifungal agents used for prevention and treatment of invasive fungal diseases by discussing distribution, metabolism, elimination and drug-related adverse events in the context of safety data from phase II and III clinical studies. EXPERT OPINION: Based on the available data amphotericin B deoxycholate has the highest relative potential for nephrotoxicity, followed by the lipid formulations of amphotericin B, and, to a much lesser extent and by indirect mechanisms, the antifungal triazoles.


Assuntos
Antifúngicos/administração & dosagem , Infecções Fúngicas Invasivas/tratamento farmacológico , Insuficiência Renal/induzido quimicamente , Animais , Antifúngicos/efeitos adversos , Antifúngicos/farmacocinética , Desenvolvimento de Medicamentos , Interações Medicamentosas , Humanos , Hospedeiro Imunocomprometido , Incidência , Rim/efeitos dos fármacos , Rim/metabolismo , Rim/fisiopatologia , Insuficiência Renal/epidemiologia , Insuficiência Renal/fisiopatologia , Índice de Gravidade de Doença
2.
Am J Obstet Gynecol ; 225(2): 185.e1-185.e9, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33744176

RESUMO

BACKGROUND: Dynamic cerebral autoregulation and cerebral perfusion pressure are altered in pregnancies complicated by preeclampsia compared with normotensive pregnancies, but the connections of dynamic cerebral autoregulation, cerebral perfusion pressure, and cerebral complications in preeclampsia remain unclear. OBJECTIVE: This study aimed to assess dynamic cerebral autoregulation and cerebral perfusion pressure after delivery in women with eclampsia, in women with preeclampsia both with and without severe features, and in normotensive women. STUDY DESIGN: This was a prospective case control study at a large referral hospital in Cape Town, South Africa. The recruitment of participants was done at diagnosis (cases) or at admission for delivery (controls). Transcranial Doppler examinations with continuous noninvasive blood pressure measurements and end-tidal CO2 monitoring were conducted for cases and controls after delivery. Cerebral perfusion pressure and dynamic cerebral autoregulation index were calculated, and values were compared among groups. RESULTS: We included 16 women with eclampsia, 18 women with preeclampsia with severe features, 32 women with preeclampsia without severe features, and 21 normotensive women with uncomplicated pregnancies. Dynamic cerebral autoregulation was depressed in pregnant women with eclampsia; (autoregulation index, 3.9; interquartile range, 3.1-5.2) compared with all other groups (those with preeclampsia with severe features, autoregulation index, 5.6 [interquartile range, 4.4-6.8]; those with preeclampsia without severe features, autoregulation index, 6.8 [interquartile range, 5.1-7.4]; and normotensive controls, autoregulation index, 7.1 [interquartile range, 6.1-7.9]). Pregnant women with eclampsia had increased cerebral perfusion pressure (109.5 mm Hg; interquartile range, 91.2-130.9) compared with those with preeclampsia without severe features and those with normal blood pressure (84 mm Hg [interquartile range, 73.0-122.0] and 80.0 mm Hg [interquartile range, 67.5-92.0], respectively); furthermore, there was no difference in cerebral perfusion pressure between pregnant women with eclampsia and pregnant women with preeclampsia with severe features (109.5 mm Hg [interquartile range, 91.2-130.9] vs 96.5 mm Hg [interquartile range, 75.8-110.5]). CONCLUSION: Cerebral perfusion pressure and dynamic cerebral autoregulation are altered in eclampsia and may be important in the pathophysiological pathway and constitute a therapeutic target in the prevention of cerebral complications in preeclampsia.


Assuntos
Encéfalo/irrigação sanguínea , Circulação Cerebrovascular , Eclampsia/fisiopatologia , Homeostase , Artéria Cerebral Média/diagnóstico por imagem , Pré-Eclâmpsia/fisiopatologia , Adolescente , Adulto , Pressão Arterial , Dióxido de Carbono , Estudos de Casos e Controles , Feminino , Análise de Fourier , Síndrome HELLP/etiologia , Síndrome HELLP/fisiopatologia , Hemodinâmica , Humanos , Gravidez , Estudos Prospectivos , Edema Pulmonar/etiologia , Edema Pulmonar/fisiopatologia , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Índice de Gravidade de Doença , Ultrassonografia Doppler Transcraniana , Adulto Jovem
3.
J Vasc Interv Radiol ; 32(3): 459-465, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33386206

RESUMO

PURPOSE: To analyze the effect of a patient's renal failure status on acute outcomes after lower extremity endovascular interventions for peripheral artery disease. MATERIALS AND METHODS: A retrospective analysis of the American College of Surgery National Surgical Quality Improvement Program database from 2014 to 2017 was conducted. Patients were included based on current procedural terminology codes. They were divided into renal failure cohorts. Six thousand seven hundred and sixty-five patients were included in the analysis, 11.0% of whom had renal failure. A univariate analysis was performed using chi-squared test or Fischer's exact test as appropriate. Multivariate logistic regression models were constructed, while controlling for relevant patient factors, to identify the effect of renal failure on several outcomes of interest after the intervention. A sensitivity analysis was performed with a propensity score-matched cohort. RESULTS: Patients with renal failure were more likely to have infrapopliteal interventions (38.0% vs 20.9%), critical limb ischemia with tissue loss (73.5% vs 38.9%), diabetes (70.9% vs 52.3%), preoperative wound infection (59.2% vs 30.7%), mortality (5.1% vs 1.3%), prolonged hospital stay (68.5% vs 46.5%), transfusion after the intervention (13.3% vs 9.1%), reoperation (18.3% vs 9.5%), and readmission (24.9% vs 12.6%), compared to patients without renal failure. The multivariate analysis found renal failure to be significant for mortality (odds ratio [OR] = 4.11, 95% confidence interval [CI] = 2.71-6.24), any complication (OR = 2.03, 95% CI = 1.72-2.39), extended length of stay (OR = 1.53, 95% CI = 1.28-1.83), sepsis (OR = 2.37, 95% CI = 1.60-3.51), readmission (OR = 1.89, 95% CI = 1.57-2.29), reoperation (OR = 1.84, 95% CI = 1.48-2.27), major adverse cardiovascular event (OR = 3.50, 95% CI = 2.54-4.84), and major adverse limb event (OR = 1.97, 95% CI = 1.55-2.51). P value was <.001 unless otherwise noted. CONCLUSIONS: Renal failure before the intervention places patients at a significantly elevated risk of morbidity and mortality following endovascular revascularization procedures for peripheral artery disease.


Assuntos
Procedimentos Endovasculares , Rim/fisiopatologia , Doença Arterial Periférica/terapia , Insuficiência Renal/fisiopatologia , Idoso , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Insuficiência Renal/diagnóstico , Insuficiência Renal/mortalidade , Retratamento , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
4.
Sci Rep ; 11(1): 1525, 2021 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-33452282

RESUMO

Lupus nephritis (LN) is a life-threatening complication of systemic lupus erythematosus. The 2003 pathological classification of LN was revised in 2016; it quantitatively evaluates the interstitium in addition to the glomeruli. We performed a retrospective multi-centre cohort study and investigated the utility of the 2016 classification-including the activity index (AI), chronicity index (CI), and each pathological component to predict complete remission or renal function decline, defined as 1.5-fold increase in serum creatinine levels-and compare with that of the 2003 classification. Ninety-one consecutive adult patients with first-onset class III/IV LN who were newly prescribed any immunosuppressants were enrolled and followed up for a median of 51 months from January 2004. Cox regression analysis demonstrated the subclasses based on the 2003 classification, which mainly evaluate glomerular lesions, were not associated with clinical outcomes. After adjustments for estimated glomerular filtration rate and urinary protein levels, higher CI and higher interstitial fibrosis and lower hyaline deposit scores were associated with renal functional decline. Similarly, higher CI and interstitial inflammation scores were associated with failure to achieve complete remission. Therefore, the 2016 classification can predict the clinical outcomes more precisely than the 2003 classification.


Assuntos
Nefrite Lúpica/classificação , Nefrite Lúpica/metabolismo , Insuficiência Renal/fisiopatologia , Adulto , Estudos de Coortes , Creatinina/análise , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Rim/patologia , Glomérulos Renais/patologia , Lúpus Eritematoso Sistêmico/complicações , Nefrite Lúpica/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Indução de Remissão , Remissão Espontânea , Estudos Retrospectivos , Índice de Gravidade de Doença
5.
Cancer Chemother Pharmacol ; 87(2): 241-250, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33388951

RESUMO

PURPOSE: Glasdegib is being developed for indications in myeloid malignancies. The effect of renal impairment on the pharmacokinetics (PK) of a single, oral, 100-mg glasdegib dose under fasted conditions was assessed. METHODS: Open-label, parallel-group study (NCT03596567). Participants of good general health were selected and categorized, based on their estimated glomerular filtration rate, into normal (≥ 90 mL/min), moderate (≥ 30 to < 60 mL/min), or severe (< 30 mL/min) renal impairment groups. Blood samples were collected up to 120 h post-dose. PK exposure parameters were calculated using non-compartmental analysis. RESULTS: All 18 participants completed the study. Respectively, ratios of adjusted geometric means (90% confidence interval) for glasdegib area under the curve from time 0 to infinity and peak plasma concentration versus normal participants were 205% (142-295%) and 137% (97-193%) in the moderate group, and 202% (146-281%) and 120% (77-188%) in the severe group. Glasdegib median time to peak plasma concentration was 2.0 h in both impairment groups and 1.5 h in the normal group. Mean oral clearance was decreased by approximately 50% in both renal impairment groups compared with the normal group. The plasma-free fraction of glasdegib was not altered by renal impairment. Five all-causality adverse events were reported in three participants; two were considered treatment-related. CONCLUSION: The similar changes in exposure observed for participants with renal impairment, coupled with the known safety data from clinical experience, suggest that a lower starting dose of glasdegib may not be required for moderate or severe renal impairment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03596567 (started May 17, 2018).


Assuntos
Antineoplásicos/farmacocinética , Benzimidazóis/farmacocinética , Compostos de Fenilureia/farmacocinética , Insuficiência Renal/fisiopatologia , Administração Oral , Idoso , Antineoplásicos/efeitos adversos , Área Sob a Curva , Benzimidazóis/efeitos adversos , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Compostos de Fenilureia/efeitos adversos , Índice de Gravidade de Doença
6.
Nutrients ; 13(1)2021 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-33430501

RESUMO

To investigate associations between dietary patterns and the risk of impaired kidney function, we analyzed data from 14,732 participants (40-89 years) who completed the baseline diet questionnaire of The Fukushima Health Management Survey in 2011. The incidence of chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 or proteinuria (≥1+ by dipstick test)) and annual changes in eGFR were assessed from 2012 to 2015. Three major dietary patterns were identified. The adjusted cumulative incidence ratio of the highest vs. lowest tertile of a vegetable diet scores was 0.90 (95% confidence interval (CI): 0.82, 1.00) for eGFR < 60 mL/min/1.73 m2, 0.68 (95% CI: 0.52, 0.90) for proteinuria, and 0.88 (95% CI: 0.80, 0.97) for CKD (P for trend = 0.031, 0.007, and 0.005, respectively). The incident risk of CKD in the highest tertile of juice diet scores was 18% higher than the lowest tertile. The odds ratio of the highest vs. lowest tertile of vegetable diet scores was 0.85 (95% CI: 0.75, 0.98) in the rapidly decreasing eGFR group (P for trend = 0.009). We did not observe significant associations for the meat dietary pattern. A Japanese vegetable diet could reduce the risk of developing impaired kidney function and CKD.


Assuntos
Dieta , Progressão da Doença , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Taxa de Filtração Glomerular , Inquéritos Epidemiológicos , Humanos , Incidência , Japão/epidemiologia , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Proteinúria , Insuficiência Renal/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Fatores de Risco , Inquéritos e Questionários , Verduras
7.
BMJ Case Rep ; 14(1)2021 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-33462030

RESUMO

This case represents a rare fulminant course of fried-rice associated food poisoning in an immunocompetent person due to pre-formed exotoxin produced by Bacillus cereus, with severe manifestations of sepsis, including multi-organ (hepatic, renal, cardiac, respiratory and neurological) failure, shock, metabolic acidosis, rhabdomyolysis and coagulopathy. Despite maximal supportive measures (continuous renal replacement therapy, plasmapheresis, N-acetylcysteine infusion and blood products, and broad-spectrum antimicrobials) and input from a multidisciplinary team (consisting of infectious diseases, intensive care, gastroenterology, surgery, toxicology, immunology and haematology), mortality resulted. This case is the first to use whole genome sequencing techniques to confirm the toxigenic potential of B. cereus It has important implications for food preparation and storage, particularly given its occurrence in home isolation during the COVID-19 pandemic.


Assuntos
Bacillus cereus/genética , Exotoxinas/genética , Doenças Transmitidas por Alimentos/diagnóstico , Acetilcisteína/uso terapêutico , Acidose/fisiopatologia , Acidose/terapia , Adulto , Antiarrítmicos/uso terapêutico , Antibacterianos/uso terapêutico , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Bacillus cereus/isolamento & purificação , Transtornos da Coagulação Sanguínea/fisiopatologia , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue , Encefalopatias , Terapia de Substituição Renal Contínua , Evolução Fatal , Feminino , Doenças Transmitidas por Alimentos/microbiologia , Doenças Transmitidas por Alimentos/fisiopatologia , Doenças Transmitidas por Alimentos/terapia , Sequestradores de Radicais Livres/uso terapêutico , Humanos , Imunocompetência , Falência Hepática/fisiopatologia , Falência Hepática/terapia , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Plasmaferese , Insuficiência Renal/fisiopatologia , Insuficiência Renal/terapia , Rabdomiólise/fisiopatologia , Rabdomiólise/terapia , Sepse/fisiopatologia , Sepse/terapia , Choque/fisiopatologia , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Sequenciamento Completo do Genoma
8.
Am J Kidney Dis ; 77(1): 35-43, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32828983

RESUMO

RATIONALE & OBJECTIVE: Studies showing an association between lower bicarbonate levels and worse kidney disease prognosis have not accounted for the influence of pH. It remains unknown whether this association is consistent across a wide range of blood pH values. This study sought to assess how pH modifies the relationship between hypobicarbonatemia and incident kidney failure requiring kidney replacement therapy (KFRT). STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,058 Japanese patients with estimated glomerular filtration rates<60mL/min/1.73m2. EXPOSURE: Baseline venous bicarbonate levels and venous pH. OUTCOME: KFRT defined as initiation of kidney replacement therapy (hemodialysis, peritoneal dialysis, and kidney transplantation). ANALYTICAL APPROACH: Cox proportional hazards model assessing the interaction between baseline bicarbonate levels and venous pH on incident KFRT. RESULTS: In the lowest bicarbonate quartile (≤21.5 mEq/L), 59% of patients had acidemia (pH<7.32), whereas 38% had venous pH within the normal range and 3% had alkalemia (pH>7.42). During a median follow-up of 3.0 years, 374 patients developed KFRT. Venous pH modified the association between bicarbonate level and rate of KFRT (P for interaction=0.04). After adjustment for potential confounders, including capacity for respiratory compensation, the lowest (vs the highest) bicarbonate quartile was associated with a 2.29-fold (95% CI, 1.10-4.77; P=0.03) higher rate of KFRT among patients with acidemia (pH<7.32). In contrast, among patients without acidemia (pH≥7.32), no significant association was found between bicarbonate level and KFRT. In an exploratory analysis, patients with higher respiratory compensation capacity had a lower rate of KFRT (HR per 0.1 increase in respiratory compensation capacity, 0.90; 95% CI, 0.87-0.94; P<0.001). LIMITATIONS: Observational study design; blood gas measurements were performed in a select patient population. CONCLUSIONS: Venous pH modified the association of hypobicarbonatemia with progression of chronic kidney disease to KFRT. Measurement of venous pH may be valuable for identifying patients with chronic kidney disease and hypobicarbonatemia and may inform treatment.


Assuntos
Bicarbonatos/sangue , Concentração de Íons de Hidrogênio , Falência Renal Crônica , Insuficiência Renal , Terapia de Substituição Renal , Desequilíbrio Ácido-Base/sangue , Desequilíbrio Ácido-Base/etiologia , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Japão/epidemiologia , Falência Renal Crônica/sangue , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Prognóstico , Insuficiência Renal/epidemiologia , Insuficiência Renal/metabolismo , Insuficiência Renal/fisiopatologia , Terapia de Substituição Renal/métodos , Terapia de Substituição Renal/estatística & dados numéricos , Desequilíbrio Hidroeletrolítico/sangue , Desequilíbrio Hidroeletrolítico/etiologia
9.
Heart Vessels ; 36(1): 76-84, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32720094

RESUMO

This study aimed to clarify the effects of worsening renal function (WRF) during hospitalization on activities of daily living (ADL) at discharge of elderly heart failure (HF) patients. We included 323 consecutive patients hospitalized for HF who were prescribed phase I cardiac rehabilitation (CR) from November 2017 to April 2019. WRF was defined as a relative increase from baseline in serum creatinine of 25% or that in serum creatinine ≥ 0.3 mg/dL during hospitalization. The indices of ADL and physical function were the functional independence measure (FIM), short physical performance battery (SPPB) and 10-m comfortable gait speed as assessed at discharge. We compared background factors, clinical parameters, walking level before hospitalization, physical function, and FIM in two groups. Multiple regression analysis was performed with FIM at discharge as the dependent variable and items with P < 0.05 in bivariate correlation as independent variables. Ultimately, 160 patients were included and divided into the WRF group (n = 72) and non-WRF group (n = 88). FIM, SPPB, and 10-m comfortable walking speed were significantly lower in the WRF group. Moreover, even after adjustment for confounding factors (age, Hb, eGFR, CKD, GNRI, start day of standing), eGFR on admission (ß = 0.12), WRF (ß = - 6.42) and walking level before hospitalization (ß = - 10.00) were independent factors of ADL decline at discharge (adjusted R2 = 0.46). WRF during hospitalization of elderly HF patients was a factor affecting ADL decline at discharge along with walking level before hospitalization and renal function at admission.


Assuntos
Atividades Cotidianas , Taxa de Filtração Glomerular/fisiologia , Insuficiência Cardíaca/complicações , Hospitalização , Insuficiência Renal/etiologia , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Creatinina/sangue , Progressão da Doença , Feminino , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Prognóstico , Insuficiência Renal/sangue , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco
10.
Ann Vasc Surg ; 70: 568.e13-568.e17, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32890641

RESUMO

BACKGROUND: Renal dysfunction, requiring renal replacement therapy (RRT) is commonly encountered in patients with left ventricular assist devices (LVADs). Continuous flow LVAD (CFLVAD) is the most widely used device. Nonpulsatile blood flow begets special hemodynamic changes. This poses a unique challenge in choosing a long-term dialysis access for patients with CFLVAD where life expectancy is limited. METHODS: A 61-year-old man with an implanted CFLVAD and renal dysfunction receiving intermittent RRT through a nontunneled dialysis catheter had progressed to dialysis-dependent renal failure. He was referred to us for a permanent hemodialysis access. RESULTS: The patient underwent a right brachio-brachial arterio-venous graft (AVG) placement. The graft was successfully cannulated for hemodialysis on postoperative day 15. On regular follow-up at 18 months, the graft was still functional. CONCLUSIONS: Dialysis access for patients on LVAD is an exceptional management problem owing to both altered physiology and guarded overall prognosis. We recommend the use of AVG as a convenient and durable option-facilitating early cannulation and expediting freedom from indwelling catheters that may lead to catastrophic consequences. This should limit the need for secondary interventions, hospitalization, and cost, thus improving quality of life.


Assuntos
Braço/irrigação sanguínea , Derivação Arteriovenosa Cirúrgica , Artéria Braquial/cirurgia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Diálise Renal , Insuficiência Renal/terapia , Veias/cirurgia , Função Ventricular Esquerda , Artéria Braquial/diagnóstico por imagem , Artéria Braquial/fisiopatologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/complicações , Insuficiência Renal/diagnóstico , Insuficiência Renal/fisiopatologia , Resultado do Tratamento , Grau de Desobstrução Vascular , Veias/diagnóstico por imagem , Veias/fisiopatologia
11.
Vascular ; 29(3): 415-423, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32957848

RESUMO

OBJECTIVES: The objective of this study was to evaluate the efficacy and safety in patients with acute lower extremity deep venous thrombosis who underwent pharmacomechanical thrombectomy (PMT, AngioJet mechanical thrombus aspiration). METHODS: In this retrospective, 424 consecutive patients with acute lower extremity deep venous thrombosis from three institutions were enrolled in the study from January 2015 to December 2018. Of these, patients were divided into two groups, AngioJet group (n = 186) and catheter-directed thrombolysis (CDT) group (n = 238). Evaluation indexes including limb circumference difference, length of stay (LOS), urokinase dosage, periprocedural complications, follow-up imaging findings and villalta scores were analyzed from the medical records. RESULTS: A total of 424 patients diagnosed with acute lower extremity deep venous thrombosis were collected in this study. These patients were categorized into AngioJet group and CDT group. Significant differences were observed between the two groups with respect to the thigh circumference difference (5.32 ± 1.85 cm vs. 4.69 ± 2.15 cm; p = 0.04), calf circumference difference (2.79 ± 1.54 cm vs. 2.35 ± 1.25 cm; p = 0.01), thigh detumescence rate (72.19 ± 19.55% vs. 65.35 ± 17.26%; p = 0.00) and calf detumescence rate (62.79 ± 18.56% vs. 55.75 ± 17.27%; p = 0.00). The mean dose of urokinase in AngioJet group was 95.16 ± 45.89 million IU significantly less than that in the CDT group 293.76 ± 42.71 million IU (p = 0.00). The overall bleeding complication rate was 9.91% (19 patients in AngioJet group and 23 patients in CDT group), which included three major (0.71%, 3/424) and 39 minor (9.2%,39/424) events. In the AngioJet group, serum creatinine (sCr) concentration and urine erythrocyte from the hemolysis caused by the mechanical process were higher than baseline data at admission (p = 0.00, p = 0.00). The postoperative red blood cell and hemoglobin in two groups were lower than baseline data (p = 0.00, p = 0.00). Compared with CDT, AngioJet thrombectomy has significantly lower estimated incidence of PTS in the follow-up. CONCLUSION: AngioJet thrombectomy has stronger clearance ability for acute lower extremity deep venous thrombosis leading to significant reduction in the consumption of hospital resources, total dose of thrombolytic agents, and infusion time, thereby preventing adverse bleeding events, but patients with renal insufficiency should be careful. Ideal short-term and medium-term efficacy and safety are certain.


Assuntos
Fibrinolíticos/administração & dosagem , Extremidade Inferior/irrigação sanguínea , Trombectomia/instrumentação , Terapia Trombolítica , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Trombose Venosa/terapia , Adulto , Idoso , Desenho de Equipamento , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/etiologia , Insuficiência Renal/complicações , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Ativador de Plasminogênio Tipo Uroquinase/efeitos adversos , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologia , Adulto Jovem
12.
Surg Today ; 51(1): 165-171, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32862341

RESUMO

PURPOSE: Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy. METHODS: The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55 ml/min per 1.73 m2. RESULTS: There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups. CONCLUSION: Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.


Assuntos
Doenças Assintomáticas , Esofagectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Insuficiência Renal/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Insuficiência Renal/epidemiologia , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Risco , Fatores de Risco
13.
Leukemia ; 35(2): 562-572, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32444867

RESUMO

The randomized, phase 3 ICARIA-MM study investigated isatuximab (Isa) with pomalidomide and dexamethasone (Pd) versus Pd in patients with relapsed/refractory multiple myeloma and ≥2 prior lines. This prespecified subgroup analysis examined efficacy in patients with renal impairment (RI; estimated glomerular filtration rate <60 mL/min/1.73 m²). Isa 10 mg/kg was given intravenously once weekly in cycle 1, and every 2 weeks in subsequent 28-day cycles. Patients received standard doses of Pd. Median progression-free survival (PFS) for patients with RI was 9.5 months with Isa-Pd (n = 55) and 3.7 months with Pd (n = 49; hazard ratio [HR] 0.50; 95% confidence interval [CI], 0.30-0.85). Without RI, median PFS was 12.7 months with Isa-Pd (n = 87) and 7.9 months with Pd (n = 96; HR 0.58; 95% CI, 0.38-0.88). The overall response rate (ORR) with and without RI was higher with Isa-Pd (56 and 68%) than Pd (25 and 43%). Complete renal response rates were 71.9% (23/32) with Isa-Pd and 38.1% (8/21) with Pd; these lasted ≥60 days in 31.3% (10/32) and 19.0% (4/21) of patients, respectively. Isa pharmacokinetics were comparable between the subgroups, suggesting no need for dose adjustment in patients with RI. In summary, the addition of Isa to Pd improved PFS, ORR and renal response rates.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Resistencia a Medicamentos Antineoplásicos , Mieloma Múltiplo/tratamento farmacológico , Recidiva Local de Neoplasia/tratamento farmacológico , Insuficiência Renal/fisiopatologia , Terapia de Salvação , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/administração & dosagem , Dexametasona/administração & dosagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/complicações , Mieloma Múltiplo/patologia , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida , Talidomida/administração & dosagem , Talidomida/análogos & derivados
14.
J Vasc Surg ; 73(1): 92-98, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32416308

RESUMO

BACKGROUND: Conflicting evidence exists regarding the comparative effects of endovascular aneurysm repair (EVAR) with and without suprarenal fixation. We compare outcomes in patients treated by EVAR with baseline normal kidney function and moderate and severe chronic kidney disease. METHODS: Patients with normal kidney function (glomerular filtration rate [GFR] ≥60 mL/min/1.73 m2) or moderate (GFR = 30-59 mL/min/1.73 m2) or severe (GFR <30 mL/min/1.73 m2) kidney disease who underwent EVAR (N = 5534) were identified from the American College of Surgeons National Surgical Quality Improvement Program targeted database (2011-2015). Groups were determined by the presence (Cook Zenith [Cook Medical, Bloomington, Ind] or Medtronic Endurant [Medtronic, Minneapolis, Minn]) or absence (Gore Excluder [W. L. Gore & Associates, Flagstaff, Ariz]) of a suprarenal fixation system. Postoperative renal complications, defined as rise in creatinine concentration of >2 mg/dL without dialysis or new dialysis requirements, were analyzed within the first 30 days with results stratified by degree of kidney disease. RESULTS: A total of 5534 patients underwent EVAR, with 3225 (58.3%) receiving a device using a suprarenal fixation system. Suprarenal fixation systems were less commonly used for symptomatic patients (11.0% vs 13.7%; P = .002) and patients with ruptured abdominal aortic aneurysm (4.5% vs 6.3%; P = .01). There was no difference in baseline kidney function between groups. EVAR with suprarenal fixation was associated with more renal complications (1.40% vs 0.65%; P = .008). In subgroup analysis, patients with moderate kidney dysfunction (n = 1780) had more renal complications (2.2% vs 0.8%; P = .02) with suprarenal fixation systems. No differences were seen in patients with normal kidney function (0.4% vs 0.2%; P = .32; n = 3597) or severe kidney dysfunction (14.3% vs 10.2%; P = .45; n = 157). This difference was driven mostly by postoperative elevation of creatinine concentration (0.6% vs 0.2%; P = .03) without requirements for new dialysis (0.8% vs 0.4%; P = .08). After adjustments with multivariate logistic regression models, EVAR with suprarenal fixation was associated with more renal complications (odds ratio, 2.65; 95% confidence interval, 1.32-5.34). CONCLUSIONS: In our study, EVAR with suprarenal fixation devices was associated with more perioperative renal complications in patients with moderate kidney dysfunction. Long-term evaluation of these patients undergoing EVAR should be considered.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Procedimentos Endovasculares/métodos , Taxa de Filtração Glomerular/fisiologia , Rim/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Insuficiência Renal/fisiopatologia , Idoso , Feminino , Humanos , Masculino , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
15.
J Surg Res ; 259: 14-23, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33278793

RESUMO

BACKGROUND: This study explores the use of induction therapy in orthotopic heart transplantation as it relates to preoperative renal function and evaluates the impact of its utilization on post-transplant outcomes. METHODS: We conducted a retrospective analysis using the United Network for Organ Sharing database from 2000 to 2018 evaluating the initiation of de novo dialysis after transplantation. We examined the relationship between induction immunosuppression and pre-transplant estimated glomerular filtration rate with post-transplant outcomes, accounting for inter-center variability through a mixed-effects logistic regression model. RESULTS: In total, 16,201 patients were included with a median age of 57 y (interquartile range 47, 63); 26% were women (n = 4222) and 28% (n = 4552) had a history of diabetes mellitus. The median estimated glomerular filtration rate (eGFR) was 67.5 mL/min (interquartile range 53.1, 86.7); 51.2% (n = 3068) of the recipients with eGFR < 60 received induction therapy compared to 42.5% (n = 4336) within the eGFR ≥ 60 group (P < 0.001). Adjusted multivariable analysis found that induction therapy was associated with de novo dialysis (odds ratio 1.25, 95% confidence interval 1.10-1.43, P < 0.001), with the most significant effect on patients with eGFR ≥ 60. Although significant, there was a weak correlation between center-level induction utilization and mean eGFR (r = -0.2, P < 0.001). CONCLUSION: In this analysis, the use of induction immunosuppression in orthotopic heart transplantation varied widely between centers and did not correlate strongly with pre-transplant eGFR. In addition, its utilization did not mitigate the risk of renal replacement therapy after transplantation and in fact was associated with increased risk even after adjusting for confounders most notably in patients with eGFR ≥ 60.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração/efeitos adversos , Imunossupressão/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Insuficiência Renal/epidemiologia , Adulto , Idoso , Fatores de Confusão Epidemiológicos , Feminino , Taxa de Filtração Glomerular/fisiologia , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Humanos , Imunossupressão/métodos , Imunossupressão/normas , Imunossupressão/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Período Pré-Operatório , Diálise Renal/estatística & dados numéricos , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Insuficiência Renal/terapia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
16.
Artigo em Inglês | MEDLINE | ID: mdl-33229428

RESUMO

Per prescribing guidance, remdesivir is not recommended for SARS-CoV-2 in patients with renal disease given the absence of safety data in this patient population. This study was a multicenter, retrospective chart review of hospitalized patients with SARS-CoV-2 who received remdesivir. Safety outcomes were compared between patients with an estimated creatinine clearance (eCrCl) of <30 ml/min and an eCrCl of ≥30 ml/min. The primary endpoint was acute kidney injury (AKI) at the end of treatment (EOT). Of 359 patients who received remdesivir, 347 met inclusion criteria. Patients with an eCrCl of <30 ml/min were older {median, 80 years (interquartile range [IQR], 63.8 to 89) versus 62 (IQR, 54 to 74); P < 0.001}, were more likely to be on vasopressors on the day of remdesivir administration (30% versus 12.7%; P = 0.003), and were more likely to be mechanically ventilated during remdesivir therapy (27.5% versus 12.4%; P = 0.01) than those with an eCrCl of ≥30 ml/min. Despite these confounders, there was no significant difference in the frequency of EOT AKI (5% versus 2.3%; P = 0.283) or early discontinuation due to abnormal liver function tests (LFTs) (0% versus 3.9%; P = 0.374). Of the 5% of patients who developed EOT AKI on remdesivir with an eCrCl <30 ml/min, no cases were attributable to remdesivir administration per the treating physician. Comparable safety outcomes were observed when 1:1 nearest neighbor matching was applied to account for baseline confounders. In conclusion, remdesivir administration was not significantly associated with increased EOT AKI in patients with an eCrCl of <30 ml/min compared to patients with an eCrCl of ≥30 ml/min.


Assuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/administração & dosagem , COVID-19/tratamento farmacológico , Insuficiência Renal/tratamento farmacológico , SARS-CoV-2/efeitos dos fármacos , Monofosfato de Adenosina/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Alanina/administração & dosagem , COVID-19/fisiopatologia , COVID-19/virologia , Estudos de Coortes , Creatinina/metabolismo , Humanos , Rim/fisiopatologia , Testes de Função Renal , Pessoa de Meia-Idade , Insuficiência Renal/fisiopatologia , Insuficiência Renal/virologia , Estudos Retrospectivos
17.
Am J Kidney Dis ; 77(2): 255-263, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32771648

RESUMO

The omission of outcomes that are of relevance to patients, clinicians, and regulators across trials in autosomal dominant polycystic kidney disease (ADPKD) limits shared decision making. The Standardized Outcomes in Nephrology-Polycystic Kidney Disease (SONG-PKD) Initiative convened an international consensus workshop on October 25, 2018, to discuss the identification and implementation of a potential core outcome set for all ADPKD trials. This article summarizes the discussion from the workshops and the SONG-PKD core outcome set. Key stakeholders including 11 patients/caregivers and 47 health professionals (nephrologists, policy makers, industry, and researchers) attended the workshop. Four themes emerged: "Relevance of trajectory and impact of kidney function" included concerns about a patient's prognosis and uncertainty of when they may need to commence kidney replacement therapy and the lack of an early prognostic marker to inform long-term decisions; "Discerning and defining pain specific to ADPKD" highlighted the challenges in determining the origin of pain, adapting to the chronicity and repeated episodes of pain, the need to place emphasis on pain management, and to have a validated measure for pain; "Highlighting ADPKD consequences" encompassed cyst-related complications and reflected patient's knowledge because of family history and the hereditary nature of ADPKD; and "Risk for life-threatening but rare consequences" such as cerebral aneurysm meant considering both frequency and severity of the outcome. Kidney function, mortality, cardiovascular disease, and pain were established as the core outcomes for ADPKD.


Assuntos
Doenças Cardiovasculares/fisiopatologia , Mortalidade , Dor/fisiopatologia , Rim Policístico Autossômico Dominante/fisiopatologia , Insuficiência Renal/fisiopatologia , Atividades Cotidianas , Pessoal Administrativo , Doenças Cardiovasculares/etiologia , Cuidadores , Técnica Delfos , Progressão da Doença , Humanos , Nefrologistas , Avaliação de Resultados em Cuidados de Saúde , Dor/etiologia , Rim Policístico Autossômico Dominante/complicações , Rim Policístico Autossômico Dominante/terapia , Insuficiência Renal/etiologia , Participação dos Interessados
18.
Food Chem ; 339: 128092, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33152880

RESUMO

The production of low potassium vegetables arose out of the dietary needs of patients with renal dysfunction. Attempts have been made to reduce potassium content in vegetables and fruits; however, induced potassium deficiency has often resulted in decreased yields. Here, we investigated a new method of producing low potassium kale and present the characteristics of the resulting produce. By substituting potassium nitrate with calcium nitrate in the nutrient solution 2 weeks before harvesting, the potassium content of kale was reduced by 70% without a deterioration in yield and semblance qualities. Despite no relationships being detected between potassium deficiency and anti-oxidative properties, the total glucosinolate content, an indicator of the anti-cancer effect of cruciferous vegetables, was significantly increased by potassium deficiency in kale. This study demonstrates a novel method of producing low potassium kale for patients with renal failure, without a reduction in yield but with beneficial increase in glucosinolates.


Assuntos
Agricultura/métodos , Brassica/metabolismo , Dieta , Glucosinolatos/metabolismo , Potássio/metabolismo , Insuficiência Renal/dietoterapia , Insuficiência Renal/fisiopatologia , Brassica/efeitos dos fármacos , Glucosinolatos/farmacologia , Humanos
19.
Rev. clín. esp. (Ed. impr.) ; 220(9): 537-547, dic. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-200548

RESUMO

ANTECEDENTES Y OBJETIVO: La insuficiencia cardíaca (IC) es una enfermedad frecuente que deteriora la calidad de vida de los pacientes que la padecen y condiciona una elevada morbimortalidad. En los últimos años, se están desarrollando gran cantidad de trabajos para determinar qué factores influyen en el pronóstico de la IC. Sin embargo, son escasos los que evalúan el pronóstico de los pacientes hospitalizados por su primer episodio de IC. El objetivo de nuestro estudio es analizar el impacto pronóstico de la función renal en pacientes hospitalizados por un primer episodio de IC. MATERIALES Y MÉTODOS: Se recogió a 600 pacientes hospitalizados por un primer episodio de IC en 3hospitales españoles de tercer nivel. Se analizó el riesgo de mortalidad durante el primer año de seguimiento en función del grado de función renal en el momento del ingreso. RESULTADOS: Los pacientes con mayor grado de insuficiencia renal en el momento del ingreso presentaban edad más avanzada (p < 0,001) eran más frecuentemente mujeres (p = 0,01), presentaban un mayor grado de dependencia (p < 0,05) y mayor prevalencia de hipertensión arterial (p < 0,001), insuficiencia renal crónica (p < 0,001) y anemia (p < 0,001). En el análisis multivariante, el grado de insuficiencia renal al ingreso se mantuvo como predictor independiente de mayor riesgo de mortalidad durante el primer año de seguimiento. CONCLUSIONES: La presencia de insuficiencia renal en el momento del ingreso es un marcador de mal pronóstico en nuestra cohorte de pacientes hospitalizados por un primer episodio de IC


BACKGROUND AND OBJECTIVE: Heart failure (HF) is a frequent condition that deteriorates quality of life and results in high morbidity and mortality. A considerable number of studies have been implemented in recent years to determine the factors that affect the prognosis of HF; however, few studies have assessed the prognosis of patients hospitalised for their first episode of HF. The aim of our study was to analyse the prognostic impact of renal function on patients hospitalised for a first episode of HF. MATERIAL AND METHODS: We recruited 600 patients hospitalised for a first episode of HF in 3 tertiary Spanish hospitals. We analysed the mortality risk during the first year of follow-up according to renal function at the time of admission. RESULTS: The patients with the highest degree of kidney failure at admission were older (P<.001), were more often women (p=.01) and presented a higher degree of dependence (P<.05), as well as a higher prevalence of arterial hypertension (P<.001), chronic renal failure (P<.001) and anaemia (P<.001). In the multivariate analysis, the degree of kidney failure at admission remained an independent predictor of increased mortality risk during the first year of follow-up. CONCLUSIONS: The presence of kidney failure at admission was a marker of poor prognosis in our cohort of patients hospitalised for a first episode of HF


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Insuficiência Cardíaca/complicações , Insuficiência Renal/etiologia , Índice de Gravidade de Doença , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Taxa de Filtração Glomerular , Insuficiência Renal/fisiopatologia , Seguimentos , Prognóstico
20.
J Am Coll Cardiol ; 76(25): 2968-2976, 2020 12 22.
Artigo em Inglês | MEDLINE | ID: mdl-33334426

RESUMO

BACKGROUND: Hepatorenal dysfunction is a risk factor for mortality in patients with chronic tricuspid regurgitation due to acquired heart disease. Ebstein anomaly is the most common cause of primary tricuspid regurgitation in adults with congenital heart disease, but the prevalence and prognostic implications of hepatorenal dysfunction are unknown in this population. OBJECTIVES: The purpose of this study was to determine the risk factors and prognostic implications of hepatorenal dysfunction, as measured primarily by the use of model for end-stage liver disease excluding international normalized ratio (MELD-XI score), as well as looking at other associated factors. METHODS: This was a retrospective study of adults with Ebstein anomaly who received care at Mayo Clinic from 2003 to 2018. RESULTS: Of 692 patients, the median MELD-XI score was 10.2 (interquartile range: 9.4 to 13.3); 53 (8%) died and 3 (0.4%) underwent heart transplant. MELD-XI was an independent predictor of death/transplant (hazard ratio: 1.32; 95% confidence interval: 1.11 to 2.06; p < 0.001). In the subset of patients with serial MELD-XI scores (n = 416), temporal change in MELD-XI score (ΔMELD-XI) was also a predictor of death/transplant. In the subset of patients who underwent tricuspid valve surgery (n = 344), a post-operative improvement in MELD-XI score (ΔMELD-XI) was associated with improved long-term survival. Impaired right atrial (RA) reservoir strain and elevated estimated RA pressure were associated with worse baseline MELD-XI and ΔMELD-XI scores. CONCLUSIONS: Hepatorenal dysfunction is a predictor of mortality in Ebstein anomaly, and RA dysfunction and hypertension are hemodynamic biomarkers that can identify patients at risk for deterioration in hepatorenal function and mortality. These data highlight the prognostic importance of noncardiac organ-system dysfunction, and provide complementary clinical risk stratification metrics for management of these patients.


Assuntos
Anomalia de Ebstein , Transplante de Coração , Insuficiência Hepática , Testes de Função Renal/métodos , Testes de Função Hepática/métodos , Insuficiência Renal , Insuficiência da Valva Tricúspide , Adulto , Anomalia de Ebstein/complicações , Anomalia de Ebstein/mortalidade , Anomalia de Ebstein/fisiopatologia , Anomalia de Ebstein/cirurgia , Feminino , Transplante de Coração/métodos , Transplante de Coração/estatística & dados numéricos , Insuficiência Hepática/diagnóstico , Insuficiência Hepática/etiologia , Insuficiência Hepática/fisiopatologia , Humanos , Coeficiente Internacional Normatizado , Masculino , Prognóstico , Modelos de Riscos Proporcionais , Insuficiência Renal/diagnóstico , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Fatores de Risco , Índice de Gravidade de Doença , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/epidemiologia , Insuficiência da Valva Tricúspide/etiologia , Estados Unidos/epidemiologia
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