Sônia M.H.A. Araújo

Restless legs syndrome in end-stage renal disease: Clinical characteristics and associated comorbidities

BACKGROUND Despite being frequently described in patients with end-stage renal disease (ESRD), clinical characteristics and comorbidities in association with restless legs syndrome (RLS) are still to be confirmed. OBJECTIVES The aim of this study was to investigate clinical factors associated with RLS in ESRD patients in hemodialysis. METHODS This is a cross-sectional study of 400 patients on hemodialysis, evaluating RLS, clinical features and other sleep abnormalities. RESULTS Out of 400, 86 patients presented RLS (21.5%; mean age 48.8+/-13.8y), being more frequent in females (p<0.005). Forty-eight individuals (12% mean age 50.7+/-13.1y) had moderate/severe RLS, 14 reported symptoms prior to hemodialysis, 13 described family history of RLS, and eight described symptoms as disturbing during dialysis. RLS cases showed lower hemoglobin (p<0.005), poorer quality of sleep (Pittsburgh Sleep Quality Index >5, p=0.002), higher scores on the Beck Depression Inventory Scale (p<0.005), greater scores on the Charlson Comorbidity Index (p=0.01) and the Epworth Sleepiness Scale (p=0.001) and higher risk of obstructive sleep apnea (OSA; Berlin questionnaire, p=0.01). Hypertension was more frequent in cases with moderate/severe RLS (p=0.01) and remained after controlling for the risk of OSA (p=0.02). CONCLUSION In ESRD patients in hemodialysis, RLS is present in 21.5%; 16% report symptoms prior to hemodialysis and a family history of RLS. Symptoms are disturbing during hemodialysis in 9% of cases. RLS is associated with lower hemoglobin, worse sleep quality, excessive daytime sleepiness, depressive symptoms and higher risk of OSA. Hypertension is associated with moderate/severe RLS.

The relationship between religious coping, psychological distress and quality of life in hemodialysis patients.

OBJECTIVE No studies have evaluated the relationship among religious coping, psychological distress and health-related quality of life (HRQoL) in patients with End stage renal disease (ESRD). This study assessed whether positive religious coping or religious struggle was independently associated with psychological distress and health-related quality of life (HRQoL) in hemodialysis patients. METHODS This cross-sectional study recruited a random sample of 170 patients who had ESRD from three outpatient hemodialysis units. Socio-demographic and clinical data were collected. Patients completed the Brief RCOPE, the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization Quality of Life instrument-Abbreviated version (WHOQOL-Bref). RESULTS Positive or negative religious coping strategies were frequently adopted by hemodialysis patients to deal with ESRD. Religious struggle correlated with both depressive (r=0.43; P<.0001) and anxiety (r=0.32; P<.0001) symptoms. These associations remained significant following multivariate adjustment to clinical and socio-demographic data. Positive religious coping was associated with better overall, mental and social relations HRQoL and these associations were independent from psychological distress symptoms, socio-demographic and clinical variables. Religious struggle was an independent correlate of worse overall, physical, mental, social relations and environment HRQoL. CONCLUSION In ESRD, religious struggle was independently associated with greater psychological distress and impaired HRQoL, while positive religious coping was associated with improved HRQoL. These data provide a rationale for the design of prospective and/or intervention studies targeting religious coping in hemodialysis populations.

Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

Objectives  To identify the main clinical and laboratory features of disseminated histoplasmosis (DH) in human immunodeficiency virus (HIV) patients and compare them with those of HIV patients with other opportunistic diseases.

Acute kidney injury after trauma: Prevalence, clinical characteristics and RIFLE classification.

Background: Acute kidney injury (AKI) is an uncommon but serious complication after trauma. The objective of this study was to evaluate the prevalence, clinical characteristics and outcome of AKI after trauma. Patients and Methods: This was a retrospective study performed from January 2006 to January 2008 in an emergency specialized hospital in Fortaleza city, northeast of Brazil. All patients with AKI admitted in the study period were included. Prevalence of AKI, clinical characteristics and outcome were investigated. Results: Of the 129 patients admitted to the intensive care unit (ICU), 52 had AKI. The mean age was 30.1 ± 19.2 years, and 79.8% were males. The main causes of AKI were sepsis in 27 cases (52%) and hypotension in 18 (34%). Oliguria was observed in 33 cases (63%). Dialysis was required for 19 patients (36.5%). Independent risk factors associated with AKI were abdominal trauma [odds ratio (OR) = 3.66, P = 0.027] and use of furosemide (OR = 4.10, P = 0.026). Patients were classified according to RIFLE criteria as Risk in 12 cases (23%), Injury in 13 (25%), Failure in 24 (46%), Loss in 1 (2%) and End-stage in 2 (4%). Overall in-hospital mortality was 95.3%. The main cause of death was sepsis (24%). Mortality was 100% among patients with AKI. Conclusions: AKI is a fatal complication after trauma, which presented with a high mortality in the studied population. A better comprehension of factors associated with death in trauma-associated AKI is important, and more effective measures of prevention and treatment of AKI in this population are urgently needed.

Quality of sleep and day-time sleepiness in chronic hemodialysis: A study of 400 patients

Abstract Objective. Impaired sleep has potential health consequences in chronic hemodialysis patients. To date, this issue has not been examined in studies involving a large number of subjects. This study aimed to identify factors associated with poor sleep quality and excessive day-time sleepiness (EDS) in dialysis patients. Material and methods. This cross-sectional observational study involved 400 patients (59% male) from three hemodialysis centers (SD-HEMOFOR). Quality of sleep was evaluated by the Pittsburgh Sleep Quality Index (PSQI), EDS by the Epworth Sleepiness Scale (ESS), risk of obstructive sleep apnea (OSA) by the Berlin questionnaire and comorbidity severity by the Charlson Comorbidity Index (CCI). Results. Poor sleep quality (PSQI >5) was found in 227 individuals (57%) and was associated with older age (p = 0.001), diabetes (p = 0.03), heart failure (p < 0.005), hypoalbuminemia (p = 0.01), low transferrin saturation (TSAT) (p = 0.009), higher CCI score (p = 0.01) and depression (p < 0.005). Independent factors were older age, heart failure, low TSAT and depressive symptoms. Day-time somnolence was present in 108 patients (27%) and was independently associated with stroke [odds ratio (OR) = 2.84, CI 1.03–7.76), lower hemoglobin concentration (OR = 2.45, CI 0.95–3.03) and high risk of OSA (OR = 1.65, CI 1.03–2.63). High risk of OSA (n = 120; 30%), was associated with hypertension (p < 0.001), overweight/obesity (p = 0.001), older age (p = 0.003) and symptoms of depression (p = 0.01). Conclusions. Poor sleep quality and EDS were prevalent on chronic hemodialysis. Heart failure, low TSAT and depressive symptoms were independently associated with poor sleep quality. Stroke, anemia and high risk of OSA were independently associated with EDS. These results provide new insight into possible treatment strategies.

Nefrotoxicidade por lítio

Lithium is widely used in the therapy of bipolar disorder. Its toxicity includes urinary concentration deficit and natriuresis, renal tubular acidosis, tubulointerstitial nephritis which complicates with chronic kidney disease and hypercalcemia. The most common adverse effect is diabetes insipidus, which occurs in 20-40% of patients some weeks after initiation of treatment. Such chronic nephropathy correlates with duration of lithium use. Early detection of renal dysfunction should be achieved by rigorous monitoring of patients and collaboration between the psychiatrist and nephrologist. Recent experimental and clinical studies are now clarifying the mechanisms by which lithium induces renal abnormalities. The aim of this work is to review the pathogenesis, clinical presentation, histopathologic aspects and treatment of lithium nephrotoxicity.

Predictors of oliguric acute kidney injury in leptospirosis: a retrospective study on 196 consecutive patients.

Background: Acute kidney injury (AKI) occurs in 10 to 60% of patients with leptospirosis. The aim of this study is to investigate markers for oliguric AKI in leptospirosis. Methods: A retrospective study was performed with 196 consecutive patients with leptospirosis-associated AKI. These patients were categorized into either oliguric or non-oliguric according to their urine output. Clinical and laboratory characteristics were compared between the two groups. Results: Among these patients, 64 (32.6%) were oliguric and 132 (67.4%) nonoliguric. Markers for oliguria were age higher than 40 years (OR = 1.02, p = 0.04), hyponatremia (OR = 0.94, p = 0.03), elevated serum creatinine (OR = 1.11, p = 0.04), low arterial pH (OR = 1.0002, p = 0.01), high levels of AST (OR = 1.005, p = 0.01), crackles (OR = 3.83, p < 0.001) and direct bilirubin (OR = 1.03, p = 0.03). Elevated activated prothrombin time (OR = 0.97, p = 0.03) was a factor associated with nonoliguric AKI. Independent markers for oliguria were crackles (OR = 5.17, p = 0.0016) and direct bilirubin levels (OR = 1.051, p = 0.04). Mortality was significantly higher in oliguric than nonoliguric (27 vs. 8%, p < 0.001). Renal function at discharge was similar in oliguric and nonoliguric patients. Conclusion: Age higher than 40 years, hyponatremia, elevated serum creatinine, low arterial pH, high levels of AST, crackles and direct bilirubin levels would be useful to early identify patients with oliguric AKI in leptospirosis.

Neck circumference, a bedside clinical feature related to mortality of acute ischemic stroke

OBJECTIVE The aim of this study was to evaluate clinical/demographic factors, sleep alterations and one year mortality in acute ischemic stroke. METHODS This was a prospective study of 89 consecutive patients (mean age 64.39 ± 8.51 years) with acute ischemic stroke. High risk of obstructive sleep apnea (OSA) was evaluated by the Berlin questionnaire, daytime somnolence by the Epworth Sleepiness Scale (> 10) and subjective sleep quality by the Pittsburgh Sleep Quality Index (> 5). Clinical and anthropometric data including body mass index, hip-waist ratio, neck circumference (NC) were obtained. Increased NC was defined if > 43 cm in men and > 38 cm in women. Stroke severity was estimated by the Barthel Index and the modified Rankin Scale. The end-point was death after 12 months follow-up. RESULT One-year mortality was 8.9%. Non-survivors were older (p = 0.006) and had larger NC (p = 0.02). Among all cases, large NC was related to high risk of OSA, diabetes and hypertension (Fishers exact test). Compared to men, women showed relatively larger NC. Overall, family history of stroke (74.2 %), diabetes (33.7%) and hypertension (78.6%) were frequent; obesity (11.2%) was uncommon. Daytime sleepiness (34.8 %), poor sleep quality (65.2%) and risk of OSA (58.42%) were frequently found. CONCLUSION Poor sleep quality, excessive daytime sleepiness and high risk of OSA are frequent in this sample with acute ischemic stroke. One-year mortality was related to older age and large NC. As obesity is uncommon in acute stroke patients, a large NC should be taken as a significant clinical sign related to mortality.

RIFLE and Acute Kidney Injury Network classifications predict mortality in leptospirosis-associated acute kidney injury.

Aim:  Acute kidney injury (AKI) is a common complication in leptospirosis. The aim of this study is to investigate the association between RIFLE and AKIN classifications with mortality in leptospirosis‐associated AKI.

Leptospirosis-associated acute kidney injury: penicillin at the late stage is still controversial

What is known and Objective:  Some antimicrobial agents are active in vitro against Leptospiras. The use of penicillins at the late stage of leptospirosis is still controversial. We aimed to evaluate the use of penicillin in patients with leptospirosis‐associated acute kidney injury (AKI).