Longitudinal changes in nutritional parameters and resting energy expenditure in end-stage renal disease / Alterações longitudinais nos parâmetros nutricionais e gasto energético de repouso na doença renal em estágio terminal

Abstract Aims: To evaluate the nutritional status, resting energy expenditure, caloric and protein intake, and evolution of biochemical parameters in three stages of chronic kidney disease: pre-dialytic, at the beginning of the dialysis treatment, and 30 days after starting treatment. Methods: The chi-square and Student's t tests were used to compare the variables, and analysis of repeated measurements was used to compare the data obtained in the three moments evaluated. The results were discussed at the 5% level of significance. Results: We evaluated 35 patients, 60% female and 60% with diabetes mellitus. There was a decrease in midarm circumference and serum albumin. Inflammatory state and caloric and protein intake increased. There was no significant difference in resting energy expenditure in the three moments. The serum urea and serum albumin, handgrip strength, and protein consumption after 30 days from the start of dialysis were greater in the peritoneal dialysis patients, when compared to the hemodialysis population. Conclusion: there was a decrease in midarm circumference and serum albumin and an increase in protein intake after dialysis. The peritoneal dialysis patients had higher muscle strength, even with lower protein intake. Resting energy expenditure was not different between dialysis methods and the moments evaluated.

Resumo Objetivos: Avaliar o estado nutricional, o gasto energético em repouso, o gasto calórico e proteico e a evolução dos parâmetros bioquímicos em três estágios da doença renal crônica: pré-dialítico, no início do tratamento dialítico e 30 dias após o início do tratamento. Métodos: O teste do qui-quadrado e o teste t de Student foram utilizados para comparar as variáveis, e a análise das medidas repetidas foi utilizada para comparar os dados obtidos nos três momentos avaliados. Os resultados foram discutidos ao nível de significância de 5%. Resultados: Foram avaliados 35 pacientes, 60% mulheres e 60% com diabetes mellitus. Houve uma diminuição na circunferência do terço médio do braço (CMB) e na albumina sérica. O estado inflamatório e a ingestão calórica e protéica aumentaram. Não houve diferença significativa no gasto energético em repouso nos três momentos. A ureia sérica e a albumina sérica, a força de preensão manual e o consumo de proteínas após 30 dias do início da diálise foram maiores nos pacientes em diálise peritoneal, quando comparados com a população em hemodiálise. Conclusão: houve diminuição da circunferência do terço médio do braço e na albumina sérica, e aumento da ingestão protéica após a diálise. Os pacientes em diálise peritoneal apresentaram maior força muscular, mesmo com menor consumo proteico. O gasto energético em repouso não foi diferente entre os métodos de diálise e os momentos avaliados.

Fatores de risco relacionados à mortalidade em pacientes internados por Doença Arterial Periférica / Risk Factors related to patients hospitalized for Peripheral Arterial Disease

Introdução: Pacientes portadores de vasculopatia periférica internam recorrentemente para procedimentos cirúrgicos ou tratamento clínico devido a complicações da doença de base. O real impacto da desnutrição nesses pacientes durante a internação ainda é pouco compreendido. Objetivo: Investigar os fatores de risco associados à mortalidade em pacientes internados com doença vascular periférica devido a complicação da doença vascular. Métodos: Estudo observacional retrospectivo avaliou cento e dezessete pacientes acima de 18 anos admitidos no serviço de cirurgia vascular de hospital terciário no período de junho de 2013 a agosto de 2014 por complicação da doença vascular. Avaliados parâmetros clínicos, comorbidades, dados demográficos, complicações durante a internação e estado nutricional. Dados coletados por meio de entrevista, aplicação do questionário Avaliação Global Subjetiva (AGS), exame físico e laboratoriais e dados de prontuário. Resultados: Cento e dezessete pacientes com doença vascular periférica avaliados em relação a complicações vasculares durante internação. Mortalidade geral de 7,7% e pacientes desnutridos ou com suspeita de desnutrição eram 39% da amostra Através da análise multivariada, tanto a classificação AGS (OR 6,15 CI 1,092-34,74 P = 0,039) quanto a presença de doença cardíaca (OR 8,51 CI 1,56-47,44 P = 0,015) foram fatores preditores independentes para mortalidade. Pacientes com doença vascular classificados em suspeita de estarem desnutridos ou desnutridos apresentaram chance de ir a óbito durante a internação aumentada em 6,15 vezes, enquanto a cardiopatia elevou essa chance 8,51 vezes. Conclusão: Pacientes internados por complicação de doença vascular periférica apresentam como fatores de risco para mortalidade a desnutrição e a presença de doença cardíaca.(AU)

Patients with peripheral vasculopathy are routinely hospitalized for surgical procedures or clinical treatment due to complications of the underlying disease. The real impact of malnutrition in these patients during hospitalization is still poorly understood. Aim: This study aimed to assess mortality predictors in patients with peripheral vascular disease during hospitalization. Methods: This retrospective observational study evaluate one hundred and seventeen patients over 18 years admitted to the vascular surgery service of a tertiary hospital in the period of June 2013 and August 2014 due to complications of vascular disease. They were assessed for clinical parameters, comorbidities, demographics, complications during hospitalization and nutritional status. Data were collected through interviews, the questionnaire Subjective Global Nutritional Assessment (SGA), laboratory exam and physical examination. Results: One hundred and seventeen patients with peripheral vascular disease were followed during admission due to vascular complications. Overall mortality was 7.7%, and malnourished patients or patients at nutritional risk were 39,0% of the sampled population By multivariate analysis both rating by SGA (OR 6.15, CI 1.092 to 34.74, P = 0.039), the presence of heart disease (OR 8.51 CI 1,56 to 47.44 P = 0.015) were independent predictors of mortality. When the patient was classified as malnourished or suspected of being malnourished by SGA it increased 6.15 times the odds of death during hospitalization, while the presence of heart disease increased by 8.51 times. Conclusion: Patients hospitalized for complications of peripheral vascular disease present as risk factors for mortality: malnutrition and the presence of heart disease. (AU)

Estado nutricional de portadores de doença renal crônica em hemodiálise no Sistema Único de Saúde / Nutritional status of individuals with chronic renal failure in hemodialysis in the Unified Health System

Resumo A desnutrição é um fator relevante na evolução dos pacientes com doença renal crônica (DRC) em hemodiálise (HD), estando associada a maior frequência e duração de internações hospitalares. Objetivou-se avaliar o estado nutricional de pacientes com DRC em HD em unidades públicas ou privadas vinculadas ao SUS no Distrito Federal. Dados sociodemográficos, bioquímicos e antropométricos foram obtidos de 96 participantes, sendo 35,5% provenientes de hospitais públicos. Os critérios utilizados para avaliação de desnutrição na DRC foram Índice de Massa Corpórea (IMC) < 23 kg/m2, circunferência muscular do braço (CMB) reduzida e albumina sérica < 3,8 g/dl. Do total de avaliados, 14,6% apresentou desnutrição (60 ± 12 anos; 57% masculino; 69% clínicas privadas); 33,3% apresentou estado nutricional adequado (55 ± 14 anos; 53% masculino; 57% clínicas privadas); 52,1% tinha ao menos uma variável relacionada à desnutrição, onde o IMC abaixo do recomendado foi o mais prevalente (42,7%), seguido da CMB reduzida (41,7%) e da albumina sérica (33,3%). Com base nos resultados conclui-se que ao menos uma variável relacionada ao estado nutricional esteve alterada em metade da amostra estudada, o que reforça a importância da avaliação nutricional no contexto do tratamento da DRC.

Abstract Malnutrition is a major factor in the evolution of patients with chronic kidney disease (CKD) on hemodialysis (HD). It is associated with increased frequency and the duration of hospitalizations. The scope of this study was to evaluate the nutritional status of patients with CKD on HD in public or private clinics of the Unified Health System in the Federal District. Sociodemographic, biochemical and anthropometric data were obtained from 96 participants, 35.5% of which were from public clinics. Parameters for evaluation of malnutrition in CKD included Body Mass Index (BMI) < 23 kg/m2, reduced arm muscle circumference (AMC) and serum albumin < 3.8 g/dL. From all participants, 14.6% were classified as malnourished (60 ± 12 years; 57% male; 69% private clinics); 33.3% presented adequate nutritional status (55 ± 14 years; 53% male; 57% private clinics); 52.1% had at least one parameter related to malnutrition. BMI below the recommended parameter was the most prevalent variable (42.7%), followed by reduced AMC (41.7%) and serum albumin (33.3%). Based on these results, it may be concluded that at least one positive variable was related to malnutrition in half of the sample, which reinforces the importance of nutritional assessment in the context of the treatment of CKD.

Malnutrition associated with inflammation in the chronic renal patient on hemodialysis

SUMMARY INTRODUCTION Malnutrition-Inflammation-Atherosclerosis Syndrome is very frequent in patients with chronic kidney disease on haemodialysis. In these patients, the inflammation associated with malnutrition is observed by the Malnutrition-Inflammation Score. OBJECTIVE To analyse the relationship between malnutrition-inflammation-atherosclerosis syndrome and anthropometric and biochemical parameters of patients on haemodialysis. METHODS A cross - sectional study was performed at the Haemodialysis Clinic of the Barão de Lucena Hospital, Recife, Brazil, between July and August 2016, with patients cared at the clinic for at least six months. Patients with amputees, hospitalized, visually impaired, HIV positive, with catheters in the neck, ascites and/or oedema, and those who were unable to provide information at the time of the interview were excluded. The patients were submitted to anthropometric evaluation for the classification of the nutritional status by waist circumference, neck circumference, body mass index, waist-to-hip ratio and waist-to-height ratio. Nutritional status related to inflammation was measured by the Malnutrition-Inflammation Score and nutritional status assessment using biochemical indicators that used urea, creatinine and albumin. RESULTS Twenty-seven individuals of both genders, adults and elderly, aged 51.3 ± 13.3 years old participated in the study. The anthropometric evaluation showed that most of the population presented cardiovascular risk. The biochemical evaluation reported low frequencies of malnutrition. Malnutrition-Inflammation-Atherosclerosis syndrome was evidenced in 3.7% of the patients. The Malnutrition-Inflammation Score had a moderate negative correlation with body mass index, waist circumference, neck circumference, waist-to-height ratio and creatinine. CONCLUSION The correlation seen among the parameters suggests that most of the parameters evaluated can be used as an indirect indicator of malnutrition-inflammation-atherosclerosis syndrome.

RESUMO INTRODUÇÃO A síndrome Desnutrição-Inflamação-Aterosclerose é frequente nos pacientes com doença renal crônica em hemodiálise, acarretando perda de proteínas corporais e produção de citocinas pró-inflamatórias. OBJETIVO Verificar, entre os indicadores nutricionais estudados, aqueles que melhor se correlacionam com a síndrome Desnutrição-Inflamação-Aterosclerose em pacientes submetidos à hemodiálise. MÉTODOS O estudo foi transversal, realizado na Clínica de Hemodiálise do Hospital Barão de Lucena, no Recife (PE), entre julho e agosto de 2016, com pacientes atendidos há pelo menos seis meses. Foram excluídos pacientes amputados, internados, com deficiência visual, cateter no pescoço, HIV positivo, ascite e/ou edema e aqueles incapazes de prestar informações no momento da entrevista. Os pacientes foram submetidos à avaliação antropométrica para a classificação do estado nutricional pela circunferência da cintura, perímetro do pescoço, índice de massa corporal, relação cintura-quadril e relação cintura-estatura. O estado nutricional relacionado à inflamação foi mensurado pelo escore Desnutrição-Inflamação e a avaliação do estado nutricional pelos indicadores bioquímicos: ureia, creatinina e albumina. RESULTADOS Participaram do estudo 27 indivíduos de ambos os sexos, adultos e idosos, com idade de 51,3 ± 13,3 anos. A avaliação antropométrica mostrou que a maior parte da população apresentava risco cardiovascular. A avaliação bioquímica relatou baixas frequências de desnutrição. Foi evidenciada síndrome Desnutrição-Inflamação-Aterosclerose em 3,7% dos pacientes. O escore Desnutrição-Inflamação apresentou correlação moderada negativa com o índice de massa corporal, circunferência da cintura, perímetro do pescoço, relação cintura-estatura e creatinina. CONCLUSÃO A correlação observada entre os parâmetros sugere que a maioria dos parâmetros avaliados pode ser utilizada como indicador indireto da síndrome Desnutrição-Inflamação-Aterosclerose.

Fatores de risco pré-operatórios para lesão renal aguda após transplante hepático: resultados de um estudo transversal no Nordeste do Brasil / Preoperative risk factors for acute kidney injury after liver transplantation: results from a cross-sectional study in northeast of brazil

ABSTRACT BACKGROUND: Acute kidney injury (AKI) is a common complication in the immediate postoperative period of patients undergoing liver transplantation. OBJECTIVE: The aim of this study was to evaluate preoperative risk factors for AKI after liver transplantation. METHODS: A cross-sectional study was conducted with adults submitted to orthotopic liver transplantation at a reference hospital in Fortaleza, Northeast of Brazil, from January to December 2016. Preoperative risk factors were evaluated for AKI development in the immediate postoperative period. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. RESULTS: A total of 40 patients were included in the study. AKI was found in 85% of patients in the first 24 hours after transplantation, most of them (40%) classified in KDIGO stage 1. Preoperative data indicate that serum albumin levels were lower in the KDIGO stage 3 group compared to the non-AKI group, as well as the hematocrit levels. Direct bilirubin (DB) was higher in the KDIGO stage 3 group compared to the group without AKI, as well as alkaline phosphatase (AP) and gamma-glutamiltransferase (GGT). In a logistic regression analysis independent risk factors for AKI were increase levels of AP, GGT and DB and decrease level of serum albumin. CONCLUSION: Low levels of serum albumin, and elevated levels of DB, AP and GGT in the preoperative period are risk factors for AKI development after liver transplantation.

RESUMO CONTEXTO: Lesão renal aguda (LRA) é uma complicação comum no pós-operatório imediato do transplante hepático. OBJETIVO: O objetivo foi avaliar os fatores de risco pré-operatórios para LRA após o transplante hepático. MÉTODOS: Foi realizado estudo transversal com adultos submetidos a transplante hepático ortotópico em um hospital de referência em Fortaleza, Nordeste do Brasil, de janeiro a dezembro de 2016. Foram avaliados os fatores de risco pré-operatórios para o desenvolvimento de LRA no pós-operatório. LRA foi definida de acordo com os critérios do Kidney Disease: Improving Global Outcomes (KDIGO). RESULTADOS: Foram incluídos 40 pacientes no estudo. LRA foi encontrada em 85% dos casos nas primeiras 24 horas após o transplante, sendo a maioria deles (40%) classificados no estágio KDIGO 1. Os dados pré-operatórios indicaram que os níveis séricos de albumina eram menores nos pacientes no estágio KDIGO 3, em comparação com o grupo sem LRA, bem como os níveis de hematócrito. Os níveis de bilirrubina direta (BD) eram maiores nos pacientes no estágio KDIGO 3 em comparação ao grupo sem LRA, bem como os níveis de fosfatase alcalina (FA) e gama-glutamiltransferase (GGT). Em um modelo de regressão logística, os fatores de risco independentes para LRA foram: níveis elevados de FA, GGT e BD e níveis reduzidos de albumina. CONCLUSÃO: Níveis reduzidos de albumina sérica, e níveis elevados de BD, FA e GGT no período pré-operatório são fatores de risco para o desenvolvimento de LRA após o transplante hepático.

Quality of life on hemodialysis and inflammation: a descriptive analysis

Chronic kidney disease (CKD) is highly prevalent worldwide. Patients with CKD on hemodialysis are more likely to present behavioral changes and worse quality of life as a result of their routine and complications. They also have higher levels of cytokines. The aim of this study is to assess the relationship between the inflammatory profile and quality of life measured by KDOQL-SF36 in hemodialysis outpatients. Patients older than 21 years of age and on routine hemodialysis for at least 6 months with treatment on a regular weekly basis were included and their anthropometric parameters and serum inflammatory markers were evaluated. Thirty patients consented to participate. Homocysteine (Hcy) levels were correlated with worse glomerular filtration rate (GFR; P=0.003) and creatinine (P=0.002). IL-6 was not correlated with worse nutritional status taking into account body mass index (BMI; kg/m2; P=0.83). On the other hand, TNF-alpha was positively correlated with albumin (P=0.008), nutritional status by BMI (P=0.04), and nutritional status by arm circumference area (P=0.04). IL-6 was correlated with activity limitation (P=0.02) and Hcy with work status (P=0.04). Hcy was correlated with nutritional status and inflammatory markers. In this population, the majority of the sections in KDOQL-SF36 were not correlated with cytokines levels.

The association between periodontal conditions, inflammation, nutritional status and calcium-phosphate metabolism disorders in hemodialysis patients

Abstract Objectives To analyze the association between periodontal conditions and inflammation, nutritional status and calcium-phosphate metabolism disorders in hemodialysis (HD) patients. Material and Methods We analyzed 128 HD patients divided into two groups: dentate (n = 103) and edentulous (n=25). The following items were assessed: baseline characteristics, age at the start and duration of HD, biochemical data: C-reactive protein (CRP), serum albumin, calcium, phosphorus, alkaline phosphatase, parathormone. A single dentist performed a complete dental/periodontal examination, including parameters of oral hygiene and gingival bleeding. Results One person had healthy periodontium, 62.14% of the patients had gingivitis, and 36.9% had moderate or severe periodontitis. The age at HD onset had a positive impact on periodontal status and negatively correlated with the number of teeth. A positive correlation between age and CRP level and negative correlations between age and serum albumin and phosphorus were found. Pocket depth (PD) was negatively correlated with serum albumin. The number of teeth was negatively correlated with serum CRP. Conclusions High prevalence and severity of periodontal disease are observed in hemodialysis patients. There is a high probability that periodontal disease may be present at the early stages of chronic kidney disease (CKD) before the hemodialysis onset.

Repercussões em longo prazo da derivação gástrica em Y de Roux em população de baixa renda: avaliação após dez anos de cirurgia / Long-term repercussions of Roux-en-Y gastric bypass in a low-income population: assessment ten years after surgery

RESUMO Objetivo: avaliar a evolução ponderal, nutricional e a qualidade de vida de pacientes de baixa renda, após dez anos de derivação gástrica em Y de Roux (DGYR). Métodos: estudo longitudinal, retrospectivo e descritivo, que avaliou a perda do excesso de peso, o reganho de peso, a evolução da hipertensão arterial, do diabetes mellitus tipo 2, da anemia e da hipoalbuminemia em 42 pacientes de classes sociais D e E submetidos à DGYR. A qualidade de vida foi avaliada através do Bariatric Analysis and Reporting Outcome System (BAROS). Resultados: dos 42 pacientes, 68,3% se definiram como não praticantes de atividade física regular, e somente 44,4% e 11,9% tinham acompanhamento médico e nutricional regulares, respectivamente. Foi encontrada média da perda do excesso de peso de 75,6%±12 (IC=71,9-79,4) e perda ponderal insuficiente apenas em um paciente. O reganho ponderal médio foi de 22,3%±16,2 (IC=17,2-27,3), com 64,04% da amostra apresentando reganho maior do que 15% do peso mínimo. 52,3% da amostra apresentou anemia após dez anos de cirurgia e 47,6% deficiência de ferro. Hipoalbuminemia foi encontrada em 16,6% da amostra. Houve remissão da HAS em 66% e do diabetes mellitus tipo 2 em 50%. O BAROS demonstrou melhora na qualidade de vida em 85,8% dos pacientes. Conclusão: pudemos observar, em uma população com diversas limitações socioeconômicas, que a DGYR manteve resultados satisfatórios quanto à perda peso, mas o seguimento ineficiente pode comprometer o resultado final, especialmente no que diz respeito às deficiências nutricionais.

ABSTRACT Objective: to evaluate the weight, nutritional and quality of life of low-income patients after ten years of Roux-en-Y gastric bypass (RYGB). Methods: we conducted a longitudinal, retrospective and descriptive study evaluating the excess weight loss, weight regain, arterial hypertension, type 2 diabetes mellitus, anemia and hypoalbuminemia in 42 patients of social classes D and E submitted to RYGB. We assessed quality of life through the Bariatric Analysis and Reporting Outcome System (BAROS). Results: of the 42 patients, 68.3% defined themselves as doing non-regular physical activity, and only 44.4% and 11.9% had regular medical and nutritional follow-up, respectively. We found a mean excess weight loss of 75.6%±12 (CI=71.9-79.4), and in only one patient there was insufficient weight loss. The mean weight loss was 22.3%±16.2 (CI=17.2-27.3) with 64.04% of the sample presenting regain greater than 15% of the minimum weight; 52.3% of the sample presented anemia after ten years of surgery and 47.6%, iron deficiency. We found hypoalbuminemia in 16.6% of the sample. There was remission of hypertension in 66%, and of type 2 diabetes mellitus, in 50%. BAROS showed an improvement in the quality of life of 85.8% of the patients. Conclusion: in a population with different socioeconomic limitations, RYGB maintained satisfactory results regarding weight loss, but inefficient follow-up may compromise the final result, especially with regard to nutritional deficiencies.

Clinical and nutritional factors associated with dialysis initiation and mortality in chronic kidney disease

BACKGROUND: Chronic kidney disease is worldwide recognized as a public health problem due to high rates of morbidity and mortality. At the end stage of the disease, which the glomerular filtration rate is equal or less than15 ml/min/1.73 m2, dialysis initiation is usually indicated. In the absence of a consensus on the best time of beginning, the aim of this study was to identify clinical and nutritional factors associated with clinical outcomes with the start of dialysis and death. METHODS: In a prospective cohort of 82 patients, clinical (underlying renal disease, renal survival time, systolic and diastolic blood pressure, estimated glomerular filtration rate) and nutritional data (protein intake, anthropometry, bioelectrical impedance test, and strength handgrip) were collected. We used mean and standard deviation ormedian and association of the variables with the outcome entry into dialysis or death, and a Cox regression model was applied. Statistical significance wasp< 0.05.RESULTS: Fifty-eight patients were included in group 1­G1 (without dialysis)­and 24 patients in group 2­G2(dialysis). The groups were different in blood urea nitrogen (p= <0.001), serum creatinine (p= 0.003), estimated glomerular filtration rate (p= 0.002), and serum phosphorus (p= 0.002). After multivariate analysis, only serumalbumin (HR 0.342,p= 0.004) and glomerular filtration rate (HR 0.001,p= 0.001) were associated with entry into dialysis and death. CONCLUSIONS: We concluded that lower levels of serum albumin and glomerular filtration rate values are associated with entry into dialysis or death.

Glycated albumin: a potential biomarker in diabetes

ABSTRACT Diabetes mellitus (DM) is a chronic and metabolic disease that presents a high global incidence. Glycated hemoglobin (A1C) is the reference test for long-term glucose monitoring, and it exhibits an association with diabetic chronic complications. However, A1C is not recommended in clinical situations which may interfere with the metabolism of hemoglobin, such as in hemolytic, secondary or iron deficiency anemia, hemoglobinopathies, pregnancy, and uremia. The glycated albumin (GA) is a test that reflects short-term glycemia and is not influenced by situations that falsely alter A1C levels. GA is the higher glycated portion of fructosamine. It is measured by a standardized enzymatic methodology, easy and fast to perform. These laboratory characteristics have ensured the highlight of GA in studies from the last decade, as a marker of monitoring and screening for DM, as well as a predictor of long-term outcomes of the disease. The aim of this review was to discuss the physiological and biochemistry characteristics of the GA, as well as its clinical utility in DM.

Therapy of tacrolimus combined with corticosteroids in idiopathic membranous nephropathy

We evaluated the efficacy and safety of tacrolimus (TAC) combined with corticosteroids in treating patients with idiopathic membranous nephropathy (IMN). One hundred seventy-seven biopsy-proven IMN patients were recruited in this retrospective clinical study. Sixty patients received TAC (target blood concentration of 4–8 ng/mL) and 117 patients received daily cyclophosphamide (CYC, 100 mg) combined with prednisone. Remission rates at the end of the first, second and third month in the TAC group were significantly higher than that in the CYC group (1st: 35.0 vs 19.7%, P<0.05; 2nd: 56.7 vs 38.5%, P<0.05; 3rd: 76.7 vs 59.0%, P<0.05). In the first 3 months, daily urinary protein and serum albumin in the TAC group obtained a better improvement than that in the CYC group (P<0.05). At the end of the sixth and the twelfth month, the remission rates, daily urinary protein and serum albumin were all comparable between the two groups (P>0.05). No significant difference of relapse rate between the groups was found (16.3 vs 12.0%, P>0.05). Patients were more likely to develop glucose intolerance in the TAC group. The TAC regimen obtained more benefits in treating IMN patients, especially in the first 3 months, than the CYC regimen.

Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression / Parâmetros indicativos de persistência de patologia valvular no diagnóstico inicial de cardite reumática aguda: o papel da albumina e da expressão de CD19

Abstract Objective: The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC). Methods: Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement. Results: During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6 ± 0.48 g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1. Conclusion: The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.

Resumo Objetivo: Definir os preditores da cardite crônica em pacientes com cardite reumática aguda (CRA). Métodos: Os pacientes diagnosticados com CRA entre maio de 2010 e maio de 2011 foram incluídos no estudo. Foram feitos os testes de ecocardiografia, eletrocardiograma, uma análise do subgrupo de linfócitos, provas de fase aguda, níveis de albumina plasmática, antiestreptolisina-O (ASO) na manifestação inicial. As avaliações ecocardiográficas foram repetidas no 6º mês de acompanhamento. Os pacientes foram divididos em dois grupos de acordo com a persistência da patologia valvular no 6º mês como Grupo 1 e Grupo 2 e todos os parâmetros clínicos e laboratoriais na internação foram comparados entre dois grupos de comprometimento valvular. Resultados: Durante o período do estudo de um ano, 22 pacientes apresentaram doença valvular; 17 (77,2%) apresentaram regressão da patologia valvular. Houve desaparecimento de regurgitação moderada inicial em oito pacientes (36,3%). Entre sete (31,8%) pacientes com regurgitação moderada inicialmente, a regurgitação desapareceu em três e quatro apresentaram melhoria para regurgitação leve. Dois pacientes com regurgitação grave inicialmente apresentaram melhoria para regurgitação moderada (9,1%). Em cinco (22,8%) pacientes o grau de regurgitação (regurgitação moderada em um [4,6%] e regurgitação grave em quatro [18,2]) continuou inalterado. O nível de albumina foi significativamente menor no diagnóstico no Grupo 2 (2,6 ± 0,48 gr/dL). A análise do subgrupo de linfócitos mostrou uma redução significativa no percentual de CD8 e um aumento significativo no percentual de CD19 no Grupo 2 em comparação com o Grupo 1. Conclusão: O nível de albumina no sangue e o percentual de linfócitos CD8 e CD19 (+) no diagnóstico podem ajudar a prever risco de doença valvular crônica em pacientes com cardite reumática aguda.

Associação entre o escore de desnutrição- inflamação e indicadores do estado nutricional em pacientes submetidos à hemodiálise / Association between the malnutrition-inflammation score and parameters of nutritional status in hemodialyzed patients

Introdução: O conhecimento e caracterização do estado nutricional de pacientes com doença renal crônica (DRC) em hemodiálise (HD) são fundamentais para a prevenção da desnutrição e para propiciar a intervenção nos pacientes em risco nutricional ou desnutridos. Objetivo: Verificar a associação entre o Malnutrition-Inflammation Score (MIS) e os indicadores: albumina sérica, índice de massa corporal, circunferência muscular do braço, força do aperto da mão, Avaliação Subjetiva Global (ASG) e Nutritional Risk Screening 2002 (NRS 2002). Método: Estudo transversal analítico, realizado na Unidade de Terapia Dialítica do Hospital Universitário da Universidade Federal de Santa Catarina, de junho a agosto de 2013. Realizada avaliação nutricional após sessão de hemodiálise. Foram utilizados os testes qui quadrado, t de Student ou Mann Whitney. Resultados: A amostra foi constituída de 25 pacientes e a prevalência de desnutrição variou de 21,7 a 96%, conforme o indicador nutricional utilizado. Conclusões: O MIS foi o indicador nutricional composto que identificou maior prevalência de desnutrição e foi associado com a ASG e o NRS 2002.(AU)

Introduction: The knowledge and characterization of the nutritional status of patients with chronic kidney disease (CKD) on hemodialysis (HD) are essential for the prevention of malnutrition and to provide intervention in patients at nutritional risk or malnourished. Objective: To investigate the association between Malnutrition-Inflammation Score (MIS) and indicators: serum albumin, body mass index, arm muscle circumference, hand grip strength, Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002). Methods: A cross-sectional study conducted in Dialytic Care Unit of the University Hospital of the Federal University of Santa Catarina, from June to August 2013. Nutritional assessment was held after hemodialysis session. Chi-square test, Student's t test or Mann-Whitney test were used. Results: The sample consisted of 25 patients and the prevalence of malnutrition varied from 21.7 to 96% as the nutritional indicator used. Conclusions: The MIS was the nutritional indicator compound identified higher prevalence of malnutrition and was associated with SGA and NRS 2002.(AU)

Procalcitonin determined at emergency department as an early indicator of progression to septic shock in patient with sepsis associated with ureteral calculi

ABSTRACT Introduction: To investigate the role of initial procalcitonin (PCT) level as an early predictor of septic shock for the patient with sepsis induced by acute pyelonephritis (APN) secondary to ureteral calculi. Materials and Methods: The data from 49 consecutive patients who met criteria of sepsis due to APN following ureteral stone were collected and divided into two groups: with (n=15) or without (n=34) septic shock. The clinical variables including PCT level for this outcome were retrospectively compared by univariate analysis, followed by multivariable logistic regression model. Results: All subjects had hydronephrosis, and were hospitalized with the mean of 11.8 days (3–42 days). The mean size of the ureteral stones was 7.5mm (3–30mm), and 57% were located in upper ureter. At univariate analysis, patients with septic shock were significantly older, a higher proportion had hypertension, lower platelet count and serum albumin level, higher CRP and PCT level, and higher positive blood culture rate. Multivariate models indicated that lower platelet count and higher PCT level are independent risk factors (p=0.043 and 0.046, respectively). In ROC curve, the AUC was significantly wider in PCT (0.929), compared with the platelet count (0.822, p=0.004). At the cut-off of 0.52ng/mL, the sensitivity and specificity were 86.7% and 85.3%. Conclusion: Our study demonstrated elevated initial PCT levels as an early independent predictor to progress into septic shock in patients with sepsis associated with ureteral calculi.

A hipoalbuminemia parece estar associada a uma maior taxa de hospitalização nos pacientes em hemodiálise / Hypoalbuminemia seems to be associated with a higher rate of hospitalization in hemodialysis patients

Resumo Introdução: Anemia, inflamação e hipoalbuminemia são complicações frequentemente observadas em pacientes submetidos à hemodiálise crônica. Existem poucos dados nacionais que avaliam a associação dessas condições à morbidade e mortalidade especialmente considerando a região nordeste do país onde a ocorrência de anemia e desnutrição é elevada. Objetivo: O objetivo desse estudo foi avaliar o impacto da presença da anemia, inflamação e hipoalbuminemia sobre os desfechos clínicos (óbito e hospitalização) de pacientes sob hemodiálise. Método: Trata-se de um estudo de coorte prospectivo observacional com pacientes pre avaliados 221 pacientes adultos, considerando-se os valores de hemoglobina, proteína C reativa (PCR), albumina sérica no início do estudo. A ocorrência de hospitalização e óbito foi computada em um seguimento aproximado de 13 meses. Resultados: A ocorrência de hospitalização e óbito não diferiu entre os grupos com e sem anemia (Hb ≤ 10g/dL) ou inflamação (PCR ≥ 0,5mg/dL). Houve um maior número de hospitalização entre os pacientes com hipoalbuminemia. A albumina não apresentou correlação com os níveis séricos de PCR. Observou-se um menor tempo livre de hospitalização entre os pacientes com hipoalbuminemia (p = 0,008), houve uma tendência de menor tempo livre de hospitalização entre os pacientes com PCR aumentado (p = 0,08), e a anemia não se relacionou com o tempo livre de hospitalização. Não houve diferença na sobrevida em relação à presença de anemia, inflamação e hipoalbuminemia. A análise de regressão de Cox apontou a hipoalbuminemia como fator independente relacionado à hospitalização, mesmo após ajustes para idade, presença de diabetes, PCR e hemoglobina. Conclusão: A hipoalbuminemia, e não anemia ou inflamação, mostrou-se um marcador independente de hospitalização em pacientes submetidos à hemodiálise.

Abstract Introduction: Anemia, inflammation and hypoalbuminemia are frequent disorders among patients underwent hemodialysis. There are few national data, particularly from Northeast region where anemia and malnourished were common findings, analyzing the association between these conditions and clinical outcomes. Objective: The aim of this study was to evaluate the impact of the presence of anemia, inflammation and hypoalbuminemia on clinical outcomes (death and hospitalization) of hemodialysis patients. Methods: In this prospective observational study 221 adult patients were evaluated, considering the presence of anemia (hemoglobin ≤ 10 g/dL), inflammation (C-reactive protein (CRP) ≥ 0,5 mg/dL) and hypoalbuminemia (albumin < 3,8 g/ dL) at baseline. Clinical outcomes were recorded over 13 months. Results: The occurrence of hospitalization and death did not differ between the groups with and without anemia or inflammation. Patients with hypoalbuminemia had more hospitalizations, and the presence of hypoalbuminemia was associated with shorter hospitalization event-free time (p = 0.008). There was a trend of shorter hospitalization event-free time among patients with increased PCR (p = 0.08). There was no correlation between albumin and CRP levels. The presence of anemia, inflammation and hypoalbuminemia were not associated with lower survival. Adjusting for confounders, hypoalbuminemia was a predictor of hospitalization in hemodialyzed patients. Conclusion: The presence of hypoalbuminemia, but not anemia or inflammation, was able to predict hospitalization in hemodialysis patients.

Shenhua Tablet inhibits mesangial cell proliferation in rats with chronic anti-Thy-1 nephritis

BACKGROUND: In China, mesangial proliferative glomerulonephritis (MsPGN) is one of the most common kidney diseases. In this study, we treated a rat model of chronic anti-Thy-1 MsPGN with Shenhua Tablet and evaluated whether the tablet was able to protect the kidney function. Thirty-six Wistar rats were randomly divided into six groups: (1) Sham surgery (Sham); (2) anti-Thy-1 nephritis model (Thy-1); (3) anti-Thy-1 nephritis model + irbesartan-treated (Irb); (4) anti-Thy-1 nephritis model + low-dose of Shenhua Tablet (SHL); (5) anti-Thy-1 nephritis model + medium-dose of Shenhua Tablet (SHM); (6) anti-Thy-1 nephritis model + high-dose of Shenhua Tablet (SHH). RESULTS: Thirteen weeks after drug treatment, urinary proteins were quantified and renal pathological changes were thoroughly examined at the time point of 24 h. Meanwhile, the expression levels of p-Erk1/2, cyclin D1 and p21 at the renal cortex were also tested. The levels of urinary proteins and total cholesterol in the blood were significantly reduced in rats treated with any drug tested in this study. The level of triglyceride was significantly reduced in all three Shenhua Tablet-treated groups. Renal pathomorphological scores were significantly improved in groups of Irb, SHM and SHH. Mesangial cell proliferation was significantly inhibited in any drug-treated group. p-Erk1/2 and cyclin D1 were downregulated whereas p21 was upregulated in the renal cortex. CONCLUSIONS: Our study indicated that Shenhua Tablet is able to inhibit the abnormal proliferation of mesangial cells and to prevent kidney damage, which is likely associated with downregulation of p-Erk1/2 and reduced activity of its downstream target-cyclin D1.

Risk factors for postoperative complications following oral surgery

AbstractObjective The objective of this study was to clarify significant risk factors for postoperative complications in the oral cavity in patients who underwent oral surgery, excluding those with oral cancer.Material and Methods This study reviewed the records of 324 patients who underwent mildly to moderately invasive oral surgery (e.g., impacted tooth extraction, cyst excision, fixation of mandibular and maxillary fractures, osteotomy, resection of a benign tumor, sinus lifting, bone grafting, removal of a sialolith, among others) under general anesthesia or intravenous sedation from 2012 to 2014 at the Department of Oral and Maxillofacial Reconstructive Surgery, Hiroshima University Hospital.Results Univariate analysis showed a statistical relationship between postoperative complications (i.e., surgical site infection, anastomotic leak) and diabetes (p=0.033), preoperative serum albumin level (p=0.009), and operation duration (p=0.0093). Furthermore, preoperative serum albumin level (<4.0 g/dL) and operation time (≥120 minutes) were found to be independent factors affecting postoperative complications in multiple logistic regression analysis results (odds ratio 3.82, p=0.0074; odds ratio 2.83, p=0.0086, respectively).Conclusion Our results indicate that a low level of albumin in serum and prolonged operation duration are important risk factors for postoperative complications occurring in the oral cavity following oral surgery.

Early changes in serum albumin: impact on 2-year mortality in incident hemodialysis patients / Alterações precoces da albumina sérica: impacto sobre a mortalidade aos 2 anos em pacientes incidentes em hemodiálise

Abstract Introduction/objective: We evaluated the predictability of early changes in serum albumin (sAlb) on the two-year mortality of incident hemodialysis patients. Methods: Observational, longitudinal retrospective study using the database of Fresenius Medical Care of Latin America. Adult patients starting dialysis from January/2000 to June/2004, from 25 centers were included. Changes in sAlb during the first 3 months on hemodialysis were used as the main predictor. The outcome was death from any cause. Results: 1,679 incident patients were included. They were 52 ± 15 years old, 58.7% male and 21.5% diabetic, with a median sAlb of 38 g/L (bromocresol green). 923 patients had sAlb < 38 g/L (Low sAlb Group) and 756 ones had sAlb > 38.0 g/L (Adequate sAlb Group). The mortality was significantly higher in Low sAlb Group (17% vs. 11%, p < 0.001). Early changes in sAlb significantly affected two-year mortality. Factoring the Kaplan Meier curve of Low sAlb Group by the presence of an increase in sAlb uncovered of a statistically significant difference in mortality favoring the ones whose sAlb went up (19% vs. 15%, p = 0.043). Differently, patients from Adequate sAlb Group with a decrease in their sAlb had a statistically higher mortality rate (13% vs. 8%, p = 0.029). Conclusions: Early sAlb changes showed a significant predictive power on mortality at 2 years in incident hemodialysis patients. Those with low initial sAlb may have a better prognosis if their sAlb rises. In contrast, patients with satisfactory initial levels can have a worsening of their prognosis in the case of an early reduction in sAlb. .

Resumo Introdução/objetivo: Avaliou-se o impacto das alterações precoces na albumina sérica (sAlb) na mortalidade em 2 anos de hemodialisados incidentes. Métodos: Estudo longitudinal retrospectivo usando o banco de dados da Fresenius Medical Care da América Latina. Adultos iniciando diálise de janeiro de 2000 a junho de 2004, originados de 25 centros de diálise foram incluídos. Mudanças na sAlb durante os primeiros 3 meses em hemodiálise foram usadas como a variável de principal interesse. O desfecho foi morte por qualquer causa. Resultados: Um total de 1.679 pacientes incidentes foi incluído. Eles tinham 52 ± 15 anos, 58,7% eram do sexo masculino e 21,5%, diabéticos, com sAlb mediana de 38,0 g/L (bromocresol verde). Novecentos e vinte e três pacientes tiveram sAlb ≤ 38,0 g/L (Grupo sAlb baixa) e 756, sAlb > 38,0 g/L (Grupo sAlb adequada). A mortalidade foi significativamente maior no Grupo sAlb baixa (17% vs. 11%, p < 0,001). Alterações precoces na sAlb afetaram significativamente a mortalidade em dois anos. Fatoração da curva de Kaplan-Meier do Grupo sAlb baixa pela presença de um aumento na sAlb revelou uma diferença na mortalidade favorecendo aqueles cuja sAlb subiu (19% vs. 15%, p = 0,043). Em contraste, pacientes do Grupo sAlb adequada que mostraram diminuição na sAlb tiveram maior taxa de mortalidade (13% vs. 8%, p = 0,029). Conclusão: Alterações precoces na sAlb mostraram um poder previsor significativo sobre a mortalidade em 2 anos em hemodialisados incidentes. Casos com sAlb inicial baixa melhoraram seu prognóstico quando houve elevação na sAlb, enquanto que aqueles com níveis iniciais satisfatórios tiveram um agravamento de seu prognóstico quando houve redução na sAlb. .

Preoperative serum albumin as a prognostic factor in patients with upper urinary tract urothelial carcinoma

Purpose The study evaluated whether preoperative measures of the C-reactive protein-based systemic inflammatory response may predict cancer survival independent of tumor stage in patients with upper urinary tract urothelial carcinoma (UTUC). Materials and Methods Between September 1999 and October 2010, 181 patients submitted to radical nephroureterectomy were available for evaluation. Multivariate survival analyses were performed using Cox’s proportional hazards model and the coefficient for each factor was divided by the highest coefficient, multiplied by 4, and rounded to the nearest integer. Results Multivariate analyses showed that tumor location, pathologic T stage, lymphovascular invasion, margin status, and albumin level were independent contributors. The bootstrap-corrected C statistics of the model were 0.813 for disease-specific survival and 0.755 for overall survival, respectively. For time to disease-specific and overall mortality for patients, integrated area under the curve values were 0.792 and 0.739, respectively. When patients were clustered into three groups according to their model-predicted survival, the 5-year disease-specific survival in the low-, intermediate- and high-risk group was 95.4%, 76.2%, and 36.9%, respectively (p<0.001), and were 87.8%, 54.4%, and 31.8%, respectively, for overall survival (p<0.001). Decision curve analysis revealed that the use of model was associated with net benefit gains relative to the treat-all strategy. Conclusions   Pretreatment albumin is a simple biomarker based on routinely available well-standardized measures, and is not an expensive and time-consuming process. Hypoalbuminemia is an independent marker of poor prognosis in patients with upper urinary tract urothelial carcinoma. .