Ana Patrícia Freitas Vieira

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

INTRODUCTION Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. METHODS This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. RESULTS A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. CONCLUSIONS AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Evaluation of renal function in sickle cell disease patients in Brazil

The objective of this study was to investigate renal function in a cohort of 98 patients with sickle cell disease (SCD) followed up at a tertiary hospital in Brazil. Clinical and laboratory characteristics at the time of the most recent medical examination were analyzed. Renal function was evaluated by the estimation of glomerular filtration rate (GFR) by the criteria of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). We compared patients with normal GFR to patients with decreased GFR (<60 mL·min−1·(1.73 m2)−1) and hyperfiltration (>120 mL·min−1·(1.73 m2)−1). Comparison between patients according to the use of hydroxyurea and comparison of clinical and laboratory parameters according to GFR were also carried out. Average patient age was 33.8 ± 13.3 years (range 19-67 years), and 57 (58.1%) patients were females. The comparison of patients according to GFR showed that patients with decreased GFR (<60 mL·min−1·(1.73 m2)−1) were older, had lower levels of hematocrit, hemoglobin and platelets and higher levels of urea and creatinine. Independent risk factors for decreased GFR were advanced age (OR = 21.6, P < 0.0001) and anemia (OR = 39.6, P < 0.0001). Patients with glomerular hyperfiltration tended to be younger, had higher levels of hematocrit, hemoglobin and platelets and lower levels of urea and creatinine, with less frequent urinary abnormalities. Hydroxyurea, at the dosage of 500-1000 mg/day, was being administered to 28.5% of the patients, and there was no significant difference regarding renal function between the two groups. Further studies are required to establish the best therapeutic approach to renal abnormalities in SCD.

Factors associated with thrombocytopenia in severe leptospirosis (Weil's disease)

OBJECTIVE: This study was conducted to investigate factors associated with thrombocytopenia in a large cohort of patients with leptospirosis in an endemic area. METHODS: This retrospective study included 374 consecutive patients with leptospirosis who were admitted to tertiary hospitals in Fortaleza, Brazil. All patients had a diagnosis of severe leptospirosis (Weils disease). Acute kidney injury was defined according to the RIFLE criteria. Thrombocytopenia was defined as a platelet count <100,000/mm3. RESULTS: A total of 374 patients were included, with a mean age of 36.1±15.5 years, and 83.4% were male. Thrombocytopenia was present at the time of hospital admission in 200 cases (53.5%), and it developed during the hospital stay in 150 cases (40.3%). The patients with thrombocytopenia had higher frequencies of dehydration (53% vs. 35.3%, p = 0.001), epistaxis (5.7% vs. 0.8%, p = 0.033), hematemesis (13% vs. 4.6%, p = 0.006), myalgia (91.5% vs. 84.5%, p = 0.038), hematuria (54.8% vs. 37.6%, p = 0.011), metabolic acidosis (18% vs. 9.2%, p = 0.016) and hypoalbuminemia (17.8% vs. 7.5%, p = 0.005). The independent risk factors associated with thrombocytopenia during the hospital stay were lengthy disease (OR: 1.2, p = 0.001) and acute kidney injury (OR: 6.6, p = 0.004). Mortality was not associated with thrombocytopenia at admission (12.5% vs. 12.6%, p = 1.000) or during the hospital stay (12.6% vs. 11.3%, p = 0.748). CONCLUSIONS: Thrombocytopenia is a frequent complication in leptospirosis, and this condition was present in more than half of patients at the time of hospital admission. Lengthy disease and acute kidney injury are risk factors for thrombocytopenia. There was no significant association between thrombocytopenia and mortality.

TP53 Codon 72 and Intron 3 Polymorphisms and Mutational Status in Gastric Cancer: An Association with Tumor Onset and Prognosis

Although TP53 alterations have been studied in human tumors, data considering the role of two common TP53 polymorphisms (Pro72Arg in codon 72 and Ins16bp in intron 3) and their associations with TP53 mutations in gastric cancer are very limited. Thus, we analyzed these parameters taking into consideration the clinicopathological data. DNA from 106 gastric tumor samples was available for TP53 Pro72Arg and TP53 Ins16bp polymorphism genotyping by PCR-RFLP and PCR, respectively. The mutational status of the TP53 exons 5–7 was assessed by the single-strand conformational polymorphism test. The TP53 72ArgArg genotype was statistically associated with patients aged ≥65 years (p = 0.039), and the intron 3 A2A2 genotype was correlated with late-stage tumors (III and IV; p = 0.043). Considering both polymorphisms, a negative correlation between the TP53 Pro-A1 haplotype and age <65 years (r = –0.211; p = 0.030) was found. Taking into account the TP53 mutations, the Pro/Pro genotype was positively correlated with the presence of exon 7 mutations (p = 0.049), and a correlation between this genotype and the number of mutations in TP53 was observed (p = 0.019). This study corroborates the understanding of TP53 polymorphisms in gastric carcinogenesis, especially regarding the genetic features in tumor onset and prognosis.

Comparative analysis of pediatric and adult visceral leishmaniasis in Brazil.

Background: The aim of this study was to compare clinical manifestations, laboratory data, morbidity and mortality between adults and children with visceral leishmaniasis, with a focus on kidney function. Methods: This was a retrospective cohort study with 432 patients with visceral leishmaniasis diagnosed at 1 center in the northeast of Brazil. Patients were divided into 2 groups according to age (>21 years and ⩽21 years old). Results: The time between onset of symptoms and beginning of treatment was longer in adults (89.5 versus 48.5 days, P < 0.001); signs and symptoms were similar in both groups. Failure of treatment with glucantime was more common in adults (17.6% versus 8.8%, P = 0.008). Acute kidney injury was observed in 160 patients (37.0%), and it was more severe in adults. Risk factors for acute kidney injury in adults were hypokalemia, leukopenia, chills and amphotericin B use. In children, secondary infections were found to increase the risk for acute kidney injury. Overall mortality was 8.8%, and it was significantly higher in adults (12.6% versus 4.1%, P = 0.002). Conclusions: The adult population had more severe laboratory abnormalities and a worse prognosis, possibly due to delay in diagnosis. Acute kidney injury is prevalent in both groups, and it is usually more severe in adults.

Differences among children, adolescents and adults with severe leptospirosis: A comparative analysis

Leptospirosis is a zoonosis of global importance caused by Leptospira interrogans. The aim of this study was to compare the data between children, adolescents and adults with leptospirosis. This is a retrospective study including a total of 373 consecutive patients with leptospirosis, admitted to tertiary hospitals in Northeast of Brazil, from May 1985 to August 2010. The patients were divided into two groups (age ≤21 years and >21 years). The adults were 304 (81.5%) of the population, with a mean ge of 41 ± 13 (range 22-84) years. The pediatric group was 16 ± 3 (range 9-21) years. Signs and symptoms where similar between the groups, excepting arrhythmia, which was more frequent in adults and vomiting, more common in children (16% vs. 0%, P = 0.04 and 65% vs. 79%, P = 0.02), respectively. Adult group presented with higher serum urea (137 vs. 97 mg/dl, P = 0.002) and creatinine (4.3 vs. 3.0 mg/dl, P = 0.007). Acute kidney injury (AKI) was observed in 80%, mainly in adults (83% vs. 70% P < 0.005). Adults required renal replacement therapy more frequently than children (38% vs. 11%, P < 0.0001). Mortality was higher in adults (14.8% vs. 2.8%, P = 0.005) and in adults with AKI (93% vs. 7%, P < 0.05). There are important differences between the adults and children with leptospirosis. AKI was more frequent in adults and it was associated with increased mortality.

Evaluation of renal function in patients with psoriasis using immunobiologicals

The aim of this study was to evaluate renal function in patients with psoriasis using immunobiologicals. A prospective study was conducted with 15 patients with confirmed diagnosis of psoriasis who were starting to use immunobiologicals. The mean age was 41±11 years, with 60% females. The mean time of disease was 11±6.6 years. Significant changes in creatinine and creatinine clearance were not observed in the course of the study. There was an increase in transaminases and a decrease in magnesium levels.

Hemophagocytic Syndrome in Children With Visceral Leishmaniasis.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a serious complication of visceral leishmaniasis (VL). The aim of this study is to describe demographical, clinical and laboratory features of HLH in children with VL. Methods: This is a retrospective cohort of children with HLH and VL admitted to a tertiary hospital in Northeast, Brazil, from January 2012 to April 2014. Clinical and laboratory data at admission and during hospital stay were reviewed. Acute kidney injury (AKI) was defined according to the pediatric Risk, Injury, Failure, Loss, End-stage kidney disease criteria. Results: A total 127 VL children were admitted, and 35 children had diagnosis of HLH. Mean age was 4.2 ± 4.3 years, with 62.9% males. Mean hospital stay was 29 ± 12 days. Main signs and symptoms were fever (100%), splenomegaly (94.2%) and hepatomegaly (60%). Laboratory findings showed pancytopenia, albumin 3.03 ± 0.77 g/dL, fibrinogen 236.1 ± 117.2 mg/dL, total calcium 8.2 ± 1.2 mEq/L, lactate dehydrogenase 1804 ± 1019 mg/dL, alkaline phosphatase 1275.4 ± 2160.5 IU/L, total bilirubin 1.9 ± 2.4 mg/dL, direct bilirubin 0.67 ± 1.02 mg/dL, indirect bilirubin 1.2 ± 2.2 mg/dL, aspartate aminotransferase 140.0 ± 145.3 IU/L, alanine aminotransferase 71.4 ± 81.1 IU/L, ferritin 4296.5 ± 8028.8 ng/dL and triglycerides 333 ± 141 mg/dL. AKI was observed in 16 children (45.7%), predominantly mild forms (93.75% “risk”). AKI group presented lower levels of platelets (69,131 ± 40,247 vs. 138,678 ± 127,494/mm3, P = 0.035) than non-AKI. No patient required dialysis and there was no death. Conclusions: HLH was not a rare complication of VL. Main symptoms were compatible with both VL and HLH. Main laboratory findings reflected HLH pathophysiology. Mild forms of AKI were a common complication of HLH. Despite the disease severity and complications, mortality was low.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy

OBJECTIVE To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission. METHODS A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared. RESULTS Sixty-three patients were included. Mean age was 5.3±4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9±0.8 vs. 4.5±0.7mEq/L, p=0.019) and bicarbonate (19.1±4.9 vs. 23.5±2.2mEq/L, p=0.013) and had a higher estimated glomerular filtration rate (102.2±36.7 vs. 77.0±32.8mL/min/1.73m2, p=0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p=0.036; OR=0.30; 95% CI=0.097-0.926). CONCLUSION AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

Acute kidney injury in visceral leishmaniasis: a cohort of 10 patients admitted to a specialized intensive care unit in northeast of Brazil

Objective: To describe co-infections, clinical manifestations, comorbidities and outcome of patients with visceral leishmaniasis and AKI. Methods: This is a case study with ten patients with confirmed diagnosis of VL admitted to the reference ICU of Northeast of Brazil during 6 years, with renal injury. Clinical and laboratory parameters were evaluated in admission, period of hospitalization and outcome. Results: This study found 10 patients with VL in a group of 253 patients admitted to the ICU with AKI. The main signs and symptoms presented at admission were weight loss, fever, splenomegaly, jaundice, anorexia, asthenia, bleeding and vomits. The main co-infections were: AIDS, tuberculosis and leprosy. Patients were classified in RIFLE criteria. RIFLE-F patients were younger and had a longer time between onset of symptoms and hospital admission. Death was observed in 60% of cases. The causes of death were septic shock, respiratory insufficiency and multiple organ dysfunction. Conclusions: AKI is an important complication in VL. The progression of the disease and their complications can achieve high level of severity, even in the absence of comorbidities or co-infections. The high mortality in this group alerts to the importance of adequate management of these patients.