Manuel E. Herrera-Gutiérrez

Epidemiología del fracaso renal agudo en las UCI españolas: Estudio prospectivo multicéntrico FRAMI

OBJECTIVE Multicenter study oriented at establishing the incidence and prognosis of acute kidney failure (AKF) in the ICU of our country. MATERIAL AND METHODS Prospective study of adult patients admitted over 8 months in 43 Spanish ICUs to detect AKF defined as creatinine>or=2 mg/dl or diuresis<400 ml/24 hours (in chronic patients 100% increase of creatinine, excluding those with baseline creatinine>or=4 mg/dl). RESULTS 901 episodes of AKF (AKF episodes (incidence 5.7%), 55% of which occurred on admission. A total of 38.4% of the episodes were due to acute tubular necrosis (ATN), 36.6% to prerenal, and 21.2% to mixed. Renal depuration (RC) was required in 38%. Mortality was 42.3% during the AKF episode (34.1% in those who were admitted with AKF versus 50.9% in those who developed it after admission), 80% in patients with Hepatorenal Syndrome, 51.6% in ATN and 29.9% in prerenal. We detect an independent relationship with mortality for age (OR 1.03), background of diabetes (OR 2.06), development of AKF in the ICU (OR 2.51), oliguria (OR 5.76) and RC (OR 2.32). Recovery of the kidney function occurred in 85.6% of the survivors and RC was maintained in only 1.1% on discharge from the ICU. We calculated the area under the curve of APACHE II on admission (0.62), SOFA on onset of AKF (0.68), Liaño index (0.7) and maximum SOFA (0.79). CONCLUSIONS AKF in ICU patients does not show an elevated incidence but does have high mortality, presenting greater seriousness when it appears after admission. However, recovery is elevated in patients who survive. The usual prognostic indexes are not exact in this patient group, the ISA and maximum SOFA being those which shows a closer relationship with mortality.

Seafood Intoxication by Tetrodotoxin: First Case in Europe

BACKGROUND Tetrodotoxin is considered the most lethal toxin in the marine environment. Prior cases of intoxication previously described correspond to consumption of tetrodotoxin in tropical or subtropical regions of Asia or the Pacific Islands. OBJECTIVES We present the first European case of tetrodotoxin intoxication in a patient who ingested part of a trumpet shellfish (Charonia sauliae) from the Atlantic Ocean in Southern Europe. CASE REPORT Our patient suffered general paralysis, including the respiratory muscles, a few minutes after the consumption of a few grams of C. sauliae. Intubation and mechanical ventilation were necessary for 52 h after the intoxication. The corresponding electrophysiologic studies showed complete non-excitability, with no recordable sensory or motor nerve conduction. We detected the presence of tetrodotoxin in the mollusk and the patients blood and urine by means of high-performance liquid chromatography-mass spectrometry analysis technique. A previous bioassay showed extremely high quantities of the toxin in the mollusk. CONCLUSIONS This case alerts us to the possibility of a very harmful biotoxin in European coastal waters. This now should be included in the differential diagnosis of similar cases in Europe, and we must be vigilant for its possible presence in Europe.

Valor de la determinación de la proteína C reactiva como marcador pronóstico y de infección en pacientes críticos

BACKGROUND AND OBJECTIVE: C-reactive protein (CRP) has been considered a marker for infection and an aid for diagnosing sepsis. We analyze the relation of CRP to infection and outcome in intensive care units (ICU) patients. PATIENTS AND METHOD: Prospective study on 77 ventilated patients. Expected short ICU stay or (suspected or confirmed) infection at admission were excluding criteria. 55 admissions after elective surgery were the controls. CRP measurement the first (CRP-1), third (CRP-3) and sixth (CRP-6) day of stay. APACHE II (Acute Physiology Score and Chronic Health Evaluation), SOFA (Sepsis-related Organ Failure Assessment), shock, respiratory or renal failure, leucocytes, platelets and albumin were registered. Follow-up until day 9 for infection and ICU discharge for outcome. RESULTS: CRP-1 in controls was 5.3 (3.9) mg/l and cases 67.8 (77.4) (p 100. Mortality was 23.4% in cases and 1.8% in controls. Age, shock, APACHE II and SOFA were related to mortality, but CRP-1 did not. ROC area under curve for CRP-1 as mortality predictor in all patients was 0.62 (0.76 for APACHE II and 0.77 for SOFA) but only in cases was of 0.49 (0.69 for APACHE II and 0.67 for SOFA). CONCLUSIONS: CRP level on admission is an useful marker for early infection but not for outcome in critically ill patients admited to the ICU.

Prevalence of acute kidney injury in intensive care units: the "COrte de prevalencia de disFunción RenAl y DEpuración en críticos" point-prevalence multicenter study.

PURPOSE This study aimed to measure the point prevalence of kidney dysfunction (KD) in the intensive care setting. MATERIALS AND METHODS A point-prevalence, single-day, prospective study was conducted. Of 919 patients present in 42 Intensive care units (ICUs) for 2 specific days (September 2009 and March 2010), 832 cases were included. Mild KD was defined as a measured creatinine clearance of 90 to 60 mL min(-1) 1.73 m(-2), and severe KD was defined as a creatinine clearance less than 60 mL min(-1) 1.73 m(-2). RESULTS Prevalence of mild KD was 15.9/100 patients/d (13.5-18.5), and severe KD was 42.4/100 patients/d (39.1-45.8). We considered as having a low probability of experiencing KD those patients without chronic kidney disease, acute kidney injury network stage 0, and a serum creatinine less than 1.2 mg/dL, but among them (557 patients), 18.1% (15.2%-21.6%) had mild KD and 24.2% (20.9%-28%) had severe KD. ICU mortality was 10.6% (7.81%-14.4%) for patients without dysfunction, 16.6% (11.2%-24%) for patients with mild KD, and 29.7% (25.2%-34.7%; P<.001) for patients with severe KD, with a relative risk for severe KD vs no KD of 2.54 (1.90-3.40). In 54.3% patients, at least 1 renal insult was reported. One nephrotoxic drug was administered to 34.4% and 2 or more to 14.9% patients, with a lower frequency among those with chronic kidney disease (30.6% vs 50.8%; P<.05). CONCLUSIONS Each day of study, more that half of the patients admitted to the ICU showed some derangement in kidney function. More than 25% of patients not fulfilling the KD criteria by serum creatinine or acute kidney injury network showed, in fact, a severe KD, and this finding was associated with higher mortality. More than 50% of the patients admitted to the ICU were subjected to at least 1 renal insult.

Early hemodynamic improvement is a prognostic marker in patients treated with continuous CVVHDF for acute renal failure.

We examined whether hemodynamic improvement after high-flow hemofiltration predicts survival in patients treated with standard continuous renal replacement therapy (CRRT). This was a prospective, observational cohort study of 169 patients, measuring the mean arterial pressure (MAP) and norepinephrine (NE) dosage before and 24 hours after CRRT. Responders were defined as having a 20% reduction in NE dosage or a 20% rise in MAP with no increase in NE, compared with nonresponders. Patients were considered to be unstable if they were receiving NE or their MAP was lower than 60 mm Hg before CRRT. Of the 169 patients, 68% were men; mean age was 53.8 years (52.7 to 54.9), with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II at admission of 21.8 (21.2 to 22.3), of whom 114 were unstable at the start of CRRT. Overall mortality rate 15 days after the end of CRRT was 54.3% (57.7% in stable vs. 52.9% in unstable patients, p = NS). There were 99 responders and 70 nonresponders, the only differences being NE dosage (higher in responders, p < 0.01) and mortality rate (responders 30% vs. nonresponders 74.7%, p < 0.001). In unstable patients, mortality rate was 30% in responders versus 87% in nonresponders (p < 0.001) (72% sensitivity and 86% specificity for predicting death). Logistic regression analysis showed that the only variables associated with death were APACHE II at admission (OR, 1.06; 95% CI, 1.0 to 1.12), percent creatinine decrease (OR, 0.98; CI, 0.96 to 1.0), and lack of hemodynamic response to CRRT (OR, 7.04; CI, 3.3 to 15.02). Hemodynamic improvement after 24-hour CRRT is a strong predictor of survival.

A comparison of the effect of convection against diffusion in hemodynamics and cytokines clearance in an experimental model of septic shock.

BACKGROUND Replacement therapies based on the use of convection have value for the removal of inflammatory mediators. Such therapies have been proposed for the management of septic shock, but diffusion has not proved useful in this scenario, unless high-flow membranes are used. The exact role of diffusion in these cases remains to be clarified because continuous replacement therapies are usually delivered with low-flow membranes and mixed convection-diffusion modalities. However, studies specifically addressing this problem have not been performed. Our aim was to define the efficacy of hemofiltration (convection) and hemodialysis (diffusion) in cytokine clearance and hemodynamic improvement in an experimental model of septic shock. METHODS Shock was induced in 15 beagle dogs (weight 10–15 kg) by infusion of 1 mg/kg of ultrapure Escherichia coli lipopolysaccharide diluted in 20 mL saline for 10 minutes. Five animals were followed without interventions (controls), five animals were treated with convection (100 mL kg−1 h−1) for 6 hours, and five animals were treated with diffusion (100 mL kg−1 h−) for 6 hours. RESULTS All subjects in the control group died during the study, whereas all treated subjects survived. Mean arterial pressure, cardiac output, systolic variability volume, systemic vascular resistances, dPMax, and pulmonary compliance improved in treated subjects. However, the differences in mean arterial pressure and cardiac output were significant only in the convection group and not in the diffusion-treated group. Tumor necrosis factor &agr; rose equally in all groups and decreased only in treated subjects. Interleukin 6 rose in the three groups but decreased only in the convection group and remained unchanged in the control and diffusion groups. CONCLUSION Convection and diffusion improved survival and hemodynamic parameters in a septic shock model. Improvement was more pronounced with convection, a difference that may be explained by convective clearance of cytokines.

Planteamientos generales para el mantenimiento del donante de órganos

235La mayor parte de los potenciales donantes de or-ganos proceden de las unidades de cuidados intensi-vos (UCI), lugar habitual de ubicacion de los pacien-tes con trastorno neurologico agudo y grave.Por ello es en nuestras UCI donde habitualmente se produce la deteccion de los pacientes cuyas afec-cion y circunstancias los hacen adecuados para con-siderarlos donantes potenciales.Las UCI que disponen de servicio de neurocirugia se perfilan como las mayores generadoras de donan-tes, ya que es en esos hospitales donde se aglutinan los pacientes neurotraumatizados y neuroquirurgicos en general.Pero tambien los hospitales sin neurocirugia son fuente potencial de donantes, de modo que cualquier hospital en un momento determinado puede generar un donante potencial de organos.En Espana, con la red de Coordinadores Hospitalarios de Trasplante, la deteccion puede ser mas eficaz que en otros paises, y son cada vez mas los que estan adoptando sistemas similares al nuestro, en la creencia de que la adopcion de un sistema organi-zado, entrenado y dirigido a la deteccion de los posi-bles donantes aumenta el numero de donaciones

Discrepancies in the RIFLE classification are due to the method used to assess the level of derangement of kidney function.

PURPOSE We hypothesized that RIFLE based on creatinine clearance (CrCl) is superior to that based on serum creatinine (sCr) or Cockroft-Gault (C-G) because it is an earlier marker of kidney dysfunction. MATERIALS AND METHODS At day 3 of admission, we compared the RIFLE based on sCr, C-G, and CrCl with 28-day mortality and development of RIFLE-F during intensive care unit stay. RESULTS Percentages in the RIFLE levels were similar for the 3 estimates, but the patients included in each level were different; with CrCl as the reference, κ statistic was 0.29 (95% confidence interval, 0.15-0.43) for sCr and 0.21 (0.07-0.36) for C-G. Mortality at day 28 was 19.3%, with percentages of mortality increasing with RIFLE based in CrCl but not sCr or C-G (area under the curve, 0.57 [45-72] for C-G; 0.57 [44-72] for sCr; and 0.64 [52-79] for CrCl). Logistic regression only showed an independent relationship with mortality for RIFLE measured with CrCl. CONCLUSIONS RIFLE classification using sCr or C-G at the third day of admission predicts outcome less accurately than with the use of CrCl. Because of the delay in the rise of sCr after a sudden glomerular filtration rate decrease, RIFLE based in CrCl may represent an advantage in terms of precocity.

Estimating Kidney Function in the Critically Ill Patients

Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically ill patient, creatinine clearance is the method of reference for the estimation of the GFR, although this is often not measured but estimated by equations (i.e., Cockroft-Gault or MDRD) not well suited for the critically ill patient. Functional evaluation of the kidney rests in serum creatinine (Crs) that is subjected to multiple external factors, especially relevant overhydration and loss of muscle mass. The laboratory method used introduces variations in Crs, an important fact considering that small increases in Crs have serious repercussion on the prognosis of patients. Efforts directed to stratify the risk of acute kidney injury (AKI) have crystallized in the RIFLE or AKIN systems, based in sequential changes in Crs or urine flow. These systems have provided a common definition of AKI and, due to their sensitivity, have meant a considerable advantage for the clinical practice but, on the other side, have introduced an uncertainty in clinical research because of potentially overestimating AKI incidence. Another significant drawback is the unavoidable period of time needed before a patient is classified, and this is perhaps the problem to be overcome in the near future.

Complicaciones postoperatorias en el trasplante hepático. Relación con la mortalidad

Fundamento y objetivo: El trasplante ortotopico de higado es un tratamiento efectivo para la hepatitis fulminante o la hepatopatia cronica terminal que ofrece una adecuada calidad de vida pero, a pesar ser un tratamiento consolidado, los pacientes presentan aun complicaciones graves en el postoperatorio inmediato. Pacientes y metodo: Estudio prospectivo observacional en 131 pacientes ingresados en nuestra unidad de cuidados intensivos que recibieron un trasplante ortotopico de higado. Analizamos las complicaciones desarrolladas y los factores relacionados con su aparicion, asi como la relacion de estas con la mortalidad. Resultados: La mortalidad en la unidad de cuidados intensivos fue del 11,5% y la mediana de la estancia, de 4 dias. Desarrollo dos complicaciones o mas el 90% de pacientes. Las mas frecuentes fueron hiperglucemia, trombocitopenia e hipotermia, que sin embargo no tuvieron repercusion en la mortalidad; no asi el fracaso renal agudo (mortalidad del 23,6 frente al 1,3%; p < 0,01), el sindrome de distres respiratorio del adulto (el 63,6 frente al 6,7%; p < 0,01), el bajo gasto (el 71,4 frente al 4,3%, p < 0,01), el uso de dos o mas farmacos vasoactivos (el 61,9 frente al 1,8%; p < 0,01), la encefalopatia (el 37,5 frente al 9,8%; p < 0,05), la neumonia (el 80 frente al 8%; p < 0,01) y la hemorragia (el 29,4 frente al 8,8%; p < 0,05). La isquemia del organo, la coagulopatia, el sindrome de reperfusion y la transfusion de hemoderivados durante la cirugia se relacionaron con el desarrollo de complicaciones y la mortalidad. El analisis multivariante solo demostro relacion entre la mortalidad y el bajo gasto, el uso de dos o mas farmacos vasoactivos y el tiempo de isquemia total. Conclusiones: Las complicaciones en el postoperatorio inicial del trasplante hepatico son frecuentes, pero solo un pequeno porcentaje tiene impacto en el pronostico. Debe limitarse el efecto de estas ultimas, optimizar el tratamiento de soporte hemodinamico y reducir la isquemia de los organos que se van a trasplantar.