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ABSTRACT BACKGROUND: Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. OBJECTIVES: To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. DESIGN AND SETTING: Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. METHODS: PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. RESULTS: One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CONCLUSIONS: CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.
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Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Triagem/métodos , Medição de Risco/métodos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Escore de Alerta Precoce , COVID-19/terapia , Turquia , Uremia/etiologia , Uremia/epidemiologia , Pressão Sanguínea , Estudos Retrospectivos , Taxa Respiratória/fisiologia , Pandemias , SARS-CoV-2 , COVID-19/diagnóstico , COVID-19/epidemiologiaRESUMO
BACKGROUND: Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. OBJECTIVES: To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. DESIGN AND SETTING: Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. METHODS: PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. RESULTS: One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CONCLUSIONS: CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.
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COVID-19/terapia , Escore de Alerta Precoce , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pneumonia , Medição de Risco/métodos , Triagem/métodos , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , COVID-19/diagnóstico , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pandemias , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Taxa Respiratória/fisiologia , Estudos Retrospectivos , SARS-CoV-2 , Turquia , Uremia/epidemiologia , Uremia/etiologiaRESUMO
The observation that unhealthy diets (those that are low in whole grains, fruits and vegetables, and high in sugar, salt, saturated fat and ultra-processed foods) are a major risk factor for poor health outcomes has boosted interest in the concept of 'food as medicine'. This concept is especially relevant to metabolic diseases, such as chronic kidney disease (CKD), in which dietary approaches are already used to ameliorate metabolic and nutritional complications. Increased awareness that toxic uraemic metabolites originate not only from intermediary metabolism but also from gut microbial metabolism, which is directly influenced by diet, has fuelled interest in the potential of 'food as medicine' approaches in CKD beyond the current strategies of protein, sodium and phosphate restriction. Bioactive nutrients can alter the composition and metabolism of the microbiota, act as modulators of transcription factors involved in inflammation and oxidative stress, mitigate mitochondrial dysfunction, act as senolytics and impact the epigenome by altering one-carbon metabolism. As gut dysbiosis, inflammation, oxidative stress, mitochondrial dysfunction, premature ageing and epigenetic changes are common features of CKD, these findings suggest that tailored, healthy diets that include bioactive nutrients as part of the foodome could potentially be used to prevent and treat CKD and its complications.
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Dieta Saudável/métodos , Insuficiência Renal Crônica/terapia , Uremia/prevenção & controle , Progressão da Doença , Humanos , Fenótipo , Insuficiência Renal Crônica/complicações , Uremia/etiologiaRESUMO
OBJECTIVES: To assess whether salivary urea and creatinine levels accurately reflect their serum levels in blood samples of adults to detect chronic kidney disease. MATERIALS AND METHODS: A systematic review was conducted in eight electronic databases. The protocol was registered in PROSPERO. Only diagnostic test studies were included. The JBI critical appraisal tools assessed the risk of bias. A meta-analysis of proportions was performed. The GRADE tool assessed the quality of evidence and strength of recommendation across the studies included. RESULTS: Eight studies met the eligibility criteria and were included. Six studies assessed salivary urea, and six studies assessed salivary creatinine. All studies presented moderate risk of bias. The meta-analysis depicted an overall sensitivity of 93.3% (95% CI = 88.6; 97.9) for salivary creatinine levels and 87.5% (95% CI = 83.2; 91.8) for salivary urea levels, while the overall specificity was 87.1% (95% CI = 82.8; 91.3) and 83.2% (95% CI = 65.0; 101.4) for salivary creatinine and urea levels, respectively. The overall accuracy of salivary creatinine was 5.2 percentage points higher compared with salivary urea levels (90.8% vs. 85.6%). According to the GRADE tool, the analysed outcomes were classified as having low to moderate level of certainty. CONCLUSION: Compared with blood samples, salivary urea and creatinine levels presented high diagnostic values for chronic kidney disease screening, but should not be considered equivalent to levels obtained from blood at stages three, four, or five of the disease. CLINICAL SIGNIFICANCE: Chronic kidney disease patients could receive a clinically significant benefit from replacing blood with saliva for potentially monitoring renal function. Saliva collection presents greater simplicity, comfort, safety, and lower collection cost.
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Insuficiência Renal Crônica , Saliva , Uremia , Adulto , Biomarcadores , Creatinina , Humanos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Ureia , Uremia/diagnóstico , Uremia/etiologiaRESUMO
Parathyroid hormone (PTH) has an important role in the maintenance of serum calcium levels. It activates renal 1α-hydroxylase and increases the synthesis of the active form of vitamin D (1,25[OH]2D3). PTH promotes calcium release from the bone and enhances tubular calcium resorption through direct action on these sites. Hallmarks of secondary hyperparathyroidism associated with chronic kidney disease (CKD) include increase in serum fibroblast growth factor 23 (FGF-23), reduction in renal 1,25[OH]2D3 production with a decline in its serum levels, decrease in intestinal calcium absorption, and, at later stages, hyperphosphatemia and high levels of PTH. In this paper, we aim to critically discuss severe CKD-related hyperparathyroidism, in which PTH, through calcium-dependent and -independent mechanisms, leads to harmful effects and manifestations of the uremic syndrome, such as bone loss, skin and soft tissue calcification, cardiomyopathy, immunodeficiency, impairment of erythropoiesis, increase of energy expenditure, and muscle weakness.
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Hiperparatireoidismo Secundário/etiologia , Hormônio Paratireóideo/metabolismo , Insuficiência Renal Crônica/complicações , Uremia/etiologia , Remodelação Óssea , Osso e Ossos/metabolismo , Cálcio/metabolismo , Metabolismo Energético , Fator de Crescimento de Fibroblastos 23 , Fatores de Crescimento de Fibroblastos/metabolismo , Humanos , Hiperparatireoidismo Secundário/metabolismo , Fósforo/sangue , Insuficiência Renal Crônica/metabolismo , Uremia/metabolismoRESUMO
INTRODUCTION: Indoxyl sulfate (IS) and p-cresyl sulfate (p-CS) are albumin-bound uremic toxins that are difficult to remove by hemodialysis (HD). Human serum albumin (HSA) carries several compounds, including fatty acids that can bind to site II of HSA and represent competing ligands for uremic toxins. The aim of this study was to investigate the association between fatty acids and uremic toxin plasma levels in patients undergoing HD. METHODS: Thirty-three HD patients (51.5% male, 54.9 ± 10.2 years old, 44.63 ± 28.4 months on HD, albumin level of 3.8 ± 0.3 g/dL) were evaluated. The erythrocyte fatty acid content (saturated fatty acid [SFA], monounsaturated fatty acid [MUFA], and polyunsaturated fatty acid [PUFA]) was measured by gas chromatography, and total IS and p-CS plasma levels were measured by reversed-phase high-performance liquid chromatography. FINDINGS: The mean percentages of docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA) + DHA and gamma-linolenic (GLA) acid in the erythrocyte membrane were 1.35% ± 0.74%, 1.85% ± 0.79%, and 0.33% ± 0.26%, respectively. The mean levels of IS and p-CS were 19.4 ± 11.9 mg/dL and 101.5 ± 57.2 mg/dL, respectively. There was no significant association between SFA and MUFA and IS and p-CS; however, a negative correlation was found between p-CS and specific PUFAs, and the association between GLA and p-CS levels was retained after adjusting for potential confounding variables (ß = -0.49, P = 0.007). DISCUSSION: Polyunsaturated fatty acids may contribute to the decrease in p-CS uremic toxin plasma levels in patients with chronic kidney disease undergoing HD.
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Ácidos Graxos Insaturados/efeitos adversos , Microbioma Gastrointestinal/fisiologia , Diálise Renal/efeitos adversos , Insuficiência Renal Crônica/complicações , Uremia/etiologia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos , Insuficiência Renal Crônica/patologia , Adulto JovemRESUMO
There are 2 major categories of patients with seizures and chronic kidney disease (CKD): patients who develop acute symptomatic seizures in the setting of CKD and patients with epilepsy who at some point develop CKD. The incidence of uremic seizures with kidney failure is â¼10%. These seizures are often nonconvulsive and may mimic uremic encephalopathy. Recognition and management of such situations may be challenging for treating physicians who are non-neurologists. Furthermore, practitioners caring for patients with seizures with or without an established diagnosis of epilepsy in the setting of CKD frequently encounter challenges in the selection, loading, titration, and maintenance of antiepileptic drugs (AEDs) due to potentially altered pharmacokinetics of the AEDs. We review the pathophysiology of uremia, uremic seizures, and other neurologic complications of kidney failure; management approaches to the treatment of such complications; the relevant mechanisms of action and pharmacokinetics of AEDs with their use in CKD; and in particular, the management of AEDs in patients requiring hemodialysis therapy.
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Anticonvulsivantes/uso terapêutico , Epilepsia/complicações , Epilepsia/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/metabolismo , Convulsões/complicações , Convulsões/tratamento farmacológico , Anticonvulsivantes/farmacocinética , Humanos , Uremia/etiologia , Uremia/metabolismo , Uremia/fisiopatologiaRESUMO
RESUMEN: La Estomatitis Urémica es una lesión oral poco frecuente que se presenta generalmente en pacientes con insuficiencia renal crónica avanzada o no tratada. A continuación, se reporta un caso clínico de un paciente masculino de 22 años de edad que acude a un servicio de urgencia con la presencia de placas blanquecinas indoloras en piso de boca, cara interna de mejilla, y lengua. Las probables causas, presentaciones clínicas, y manejo odontológico son discutidos.
ABSTRACT: Uremic stomatitis is a rare oral lesion that usually occurs in patients with advanced or untreated chronic renal failure. Here we report a case of a 22-year-old male patient who comes to an emergency department with the presence of painless whitish plaques on the floor of the mouth, internal cheek face, and tongue. Probable causes, clinical presentations, and dental management are discussed.
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Humanos , Masculino , Adulto Jovem , Uremia/complicações , Gengivite Ulcerativa Necrosante/etiologia , Falência Renal Crônica/complicações , Língua/patologia , Uremia/etiologia , Nitrogênio da Ureia Sanguínea , Creatinina/sangue , Palato Duro/patologia , Gengivite Ulcerativa Necrosante/patologia , Gengivite Ulcerativa Necrosante/sangue , Falência Renal Crônica/sangue , Mucosa Bucal/patologiaRESUMO
PURPOSE: Uremic toxins produced by gut microbiota (indoxyl sulfate-IS, p-cresyl sulfate-p-CS, and indole-3-acetic acid-IAA) accumulate in hemodialysis (HD) patients and exhibit potent inflammatory effects. However, the impact of these toxins on nuclear E2-related factor 2 (Nrf2) and nuclear factor-kappa B (NF-κB) expression in HD patients remains poorly defined. The aim of this study was to evaluate the association between uremic toxins and Nrf2/NF-κB expression in vitro (RAW 264.7 macrophage-like cells) and in peripheral blood mononuclear cells from HD patients. METHODS: Uremic toxins, C-reactive protein (CRP), interleukin-6 (IL-6) and malondialdehyde (MDA) levels were measured in fifteen HD patients and nine healthy individuals. RAW 264.7 macrophage-like cells were incubated with IS, as a prototype of protein-bound uremic toxin. Nrf2 and NF-κB expressions were analyzed by RT-qPCR. RESULTS: HD patients presented high levels of inflammatory markers, MDA and uremic toxins. In addition, they presented high NF-κB and low Nrf2 expression. Uremic toxins were positively correlated with NF-κB expression (IS, ρ = 0.58, p < 0.003; p-CS, ρ = 0.71, p < 0.001; IAA, ρ = 0.62, p < 0.001) and negatively with Nrf2 (IS, ρ = - 0.48, p = 0.01; p-CS, ρ = - 0.46, p < 0.02). Uremic toxins also exhibited positive correlations with CRP and MDA levels. Multivariate analysis revealed that p-CS is a determinant factor of NF-κB expression. In RAW 264.7 culture, NF-κB mRNA expression was stimulated by IS, while Nrf2 was downregulated. CONCLUSIONS: Thus, uremic toxins may stimulate NF-κB mRNA and decrease Nrf2 expression in HD patients and, consequently, trigger inflammation and oxidative stress.
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Fator 2 Relacionado a NF-E2/metabolismo , NF-kappa B/metabolismo , Insuficiência Renal Crônica , Uremia , Idoso , Animais , Técnicas de Cultura de Células , Feminino , Humanos , Inflamação/sangue , Inflamação/metabolismo , Interleucina-6/sangue , Masculino , Malondialdeído/sangue , Camundongos , Pessoa de Meia-Idade , Estresse Oxidativo/fisiologia , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Transdução de Sinais , Uremia/etiologia , Uremia/metabolismoRESUMO
PURPOSE:: To characterize an experimental model of progressive renal disease induced by different degrees of nephrectomy in rats. METHODS:: Eighty male Wistar rats were divided into four experimental groups (n=20/group): sham surgery (control group), progressive degrees of nephrectomy leading to mild uremia (group 1), moderate uremia (group 2) and severe uremia (group 3). Ten animals of each group were followed for two or four weeks. At the end, blood and 24-hour urine samples were collected to determine renal function parameters. Urine output and water and food intake were daily monitored. RESULTS:: In rats of group 1, serum levels of creatinine and urea and microalbuminuria were increased, while reduced creatinine clearance (p<0.05, compared with control group), without changing blood pressure. Animals of group 2 had more accentuated alterations: increases in urinary output, blood pressure, serum concentrations of urea, creatinine, sodium, potassium, and in microalbuminuria, and reduction of creatinine clearance (p<0.05). Group 3 exhibited even more increased serum concentrations of urea, creatinine, sodium and potassium, blood pressure and microalbuminuria, and decreased creatinine clearance (p<0.05) in comparison with control group and unilateral nephrectomy. CONCLUSION:: Progressive nephrectomy in rats seems to be useful to study the physiopathology of chronic kidney disease and its mechanisms of progression.