RESUMEN
Intoxicações acidentais e intencionais constituem- se em fonte significativa de morbimortalidade. Em emergências ou UTIs, frequentemente o Nefrologista é chamado como consultor para auxiliar na indicação de medidas de aumento da depuração renal de agentes tóxicos. Revisamos o emprego de diálise nas intoxicações agudas por medicamentos ou pesticidas, cujo suporte especializado toxicológico foi realizado por telefone pelo Centro de Informação Toxicológica do Rio Grande do Sul (CIT-RS). Avaliamos a correlação entre necessidade de diálise e óbitos em coorte retrospectivo (1998- 2000). Dos 36.055 atendimentos, 337 foram identificados como graves, 245 preenchendo os critérios de inclusão exigidos. A idade média foi 30 ± 18 anos; 53 por cento mulheres. Medicamentos frequentemente envolvidos foram anticonvulsivantes e antidepressivos, entre outros; quanto aos pesticidas, organofosforados, bipiridílicos e glifosato. Métodos de aumento da eliminação incluíram alcalinização urinária (n = 37) e métodos dialíticos. Diálise entre intoxicações severas ocorreu em 4,5 por cento (n = 11), 3,67 procedimentos/ano (1/22,7 relatos de casos severos). No grupo que dialisou, em 91 por cento, a circunstância foi tentativa de suicídio (principalmente fenobarbital e paraquat). Dois casos requereram hemoperfusão (cloranfenicol e paraquat). Óbitos entre pacientes graves não submetidos a diálise ocorreram em 25,6 por cento, versus 36,3 por cento entre dialisados (RR = 0,89; IC 95 por cento = 0,54-1,35). Os achados podem ser explicados pelo poder estatístico associado ao número de procedimentos realizados. O Nefrologista deve estar atento para situações que requerem o emprego de medidas dialíticas, ainda que não necessariamente para substituição renal, mas para aumento da depuração do agente tóxico.
Accidental and intentional poisonings or drug overdoses constitute a significant cause of aggregate morbidity and mortality, and health care expenditures. The nephrologist is frequently called to the emergency room and ICU as a consultant to help with the indication of measures to enhance renal depuration of toxic agents. This study reviews the use of dialysis in acute poisonings due to medications or pesticides, whose specialized toxicological support was provided via telephone by the poison control center of the state of Rio Grande do Sul (CIT-RS from Portuguese). The correlation between need for dialysis and death was assessed in a retrospective cohort (1998-2000). Of the 36,055 cases registered, 337 were identified as severe, and 245 met the inclusion criteria required. Mean age was 30 ± 18 years, and 53 percent of the patients were women. The most commonly involved medications were anticonvulsants and antidepressants, and the pesticides were organophosphates, bipyridyl compounds, and glyphosate. Techniques to enhance elimination included urinary alkalinization (n = 37) and dialysis. In severe poisonings, dialysis was performed in 4.5 percent of the cases (n = 11), 3.67 procedures/year (1/22.7 reports of severe cases). In the group undergoing dialysis, 91 percent involved a suicide attempt (mainly phenobarbital and paraquat). Two cases required hemoperfusion (chloramphenicol and paraquat). Death among non-dialyzed severely ill patients occurred in 25.6 percent, versus 36.3 percent of dialyzed patients (RR = 0.89; 95 percent CI = 0.54-1.35). The findings can be explained by the statistic power associated with the number of procedures performed. The nephrologist should be aware of situations requiring the use of dialysis, even if not necessarily aimed at renal replacement, but at enhancing depuration of a toxic agent.
Asunto(s)
Adulto , Femenino , Humanos , Masculino , Intoxicación/epidemiología , Intoxicación/terapia , Diálisis Renal , Enfermedad Aguda , Brasil/epidemiología , Estudios de Cohortes , Riñón/metabolismo , Nefrología , Intoxicación/metabolismo , Derivación y Consulta , Índice de Severidad de la EnfermedadRESUMEN
Multiple organ failure syndrome and acute renal dysfunction share many of physiologic factors involved in their development. Recent studies correlate the susceptibility to organ dysfunction in critically ill patients with genetic inheritance. Many of them consider ACE gene could be a possible candidate to elucidate a genetic predisposition or a genetic risk factor. We aimed to examine the effects of I/D and -262A > T ACE polymorphisms in the renal function in severely ill southern Brazilians patients. A multi-organic worldwide known failure score, the SOFA (sequential organ failure assessment), was used to determine the basal health state at first day (ICU admission). Considering admission SOFA score and trend of renal function (measured by daily renal SOFA scores, with daily measure of serum creatinine and diuresis), we hypothesize that ACE polymorphisms could influence in the trend of renal function in ICU patients. A total of 153 critically ill adult patients (79 men) were included in this study. We monitored the patients daily during their entire ICU and post-ICU (hospital) stay (measured from the ICU admission day to a maximum of 224 days). We observed progression to renal failure (SOFA scores 3 and 4) in first seven days of ICU stay and need for dialysis. The general genotypic frequencies in our sample were II = 0.17; ID = 0.46; DD = 0.37 and AA = 0.30; AT = 0.55; TT = 0.15, and the allelic frequencies were I = 0.40; D = 0.60 and A = 0.56; T = 0.44. This is the first study to verify the influence of I/D and -262A > T ACE polymorphisms in acute renal dysfunction among critically ill patients. No significant association was found between genotypes or allele frequencies and the trend of the renal function. The I/D and -262A > T ACE polymorphisms have no significant impact on the trend of renal function during the first week of ICU stay, neither any influence in mortality in critically ill patients.
Asunto(s)
Lesión Renal Aguda/genética , Peptidil-Dipeptidasa A/genética , Polimorfismo Genético , Lesión Renal Aguda/epidemiología , Enfermedad Crítica , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
A síndrome de disfunção de múltiplos órgãos e sistemas (DMOS) e a disfunção renal aguda compartilham muitos dos fatores fisiológicos envolvidos em seu desenvolvimento. Estudos recentes correlacionam suscetibilidades individuais, determinadas geneticamente, à disfunção de órgãos em pacientes criticamente enfermos, situação em que o gene da enzima conversora da angiotensina (ECA) poderia ser um candidato para elucidar predisposição ou risco genético. Nosso objetivo foi examinar os efeitos da presença de dois polimorfismos, I/D e -262A > T, na disfunção renal em pacientes agudamente graves do Sul do Brasil. O escore SOFA (sequential organ failure assessment) à admissão e a tendência da função renal (medida pelo escore renal diário do SOFA) foram determinados em pacientes de unidade de terapia intensiva (UTI). Um total de 153 pacientes adultos (79 homens) foi incluído no estudo. Houve monitoração diária da função renal durante toda a permanência na UTI e também pós-UTI. Observou-se a progressão para insuficiência renal (SOFA 3 e 4) nos primeiros sete dias de internação em UTI, bem como necessidade de diálise. As frequências genotípicas gerais em nossa amostra foram II = 0,17; ID = 0,46; DD = 0,37; e AA = 0,30; AT = 0,55; TT = 0,15; e as frequências alélicas foram I = 0,40, D = 0,60; e A = 0,56; T = 0,44. Este é o primeiro estudo para verificar a influência de polimorfismos I/D e -262A > T da ECA em disfunção renal aguda em pacientes críticos. Nenhuma associação significativa foi encontrada entre os genótipos ou as frequências alélicas e a evolução da função renal. Os polimorfismos I/D e -262A > T da ECA não têm impacto significativo sobre a evolução da função renal durante a primeira semana de internação na UTI nem exercem qualquer influência sobre a mortalidade em pacientes graves.
Multiple organ failure syndrome and acute renal dysfunction share many of physiologic factors involved in their development. Recent studies correlate the susceptibility to organ dysfunction in critically ill patients with genetic inheritance. Many of them consider ACE gene could be a possible candidate to elucidate a genetic predisposition or a genetic risk factor. We aimed to examine the effects of I/D and -262A > T ACE polymorphisms in the renal function in severely ill southern Brazilians patients. A multi-organic worldwide known failure score, the SOFA (sequential organ failure assessment), was used to determine the basal health state at first day (ICU admission). Considering admission SOFA score and trend of renal function (measured by daily renal SOFA scores, with daily measure of serum creatinine and diuresis), we hypothesize that ACE polymorphisms could influence in the trend of renal function in ICU patients. A total of 153 critically ill adult patients (79 men) were included in this study. We monitored the patients daily during their entire ICU and post-ICU (hospital) stay (measured from the ICU admission day to a maximum of 224 days). We observed progression to renal failure (SOFA scores 3 and 4) in first seven days of ICU stay and need for dialysis. The general genotypic frequencies in our sample were II = 0.17; ID = 0.46; DD = 0.37 and AA = 0.30; AT = 0.55; TT = 0.15, and the allelic frequencies were I = 0.40; D = 0.60 and A = 0.56; T = 0.44. This is the first study to verify the influence of I/D and -262A > T ACE polymorphisms in acute renal dysfunction among critically ill patients. No significant association was found between genotypes or allele frequencies and the trend of the renal function. The I/D and -262A > T ACE polymorphisms have no significant impact on the trend of renal function during the first week of ICU stay, neither any influence in mortality in critically ill patients.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Lesión Renal Aguda/genética , Polimorfismo Genético , Peptidil-Dipeptidasa A/genética , Lesión Renal Aguda/epidemiología , Enfermedad Crítica , Estudios Transversales , Factores de TiempoRESUMEN
Accidental and intentional poisonings or drug overdoses constitute a significant cause of aggregate morbidity and mortality, and health care expenditures. The nephrologist is frequently called to the emergency room and ICU as a consultant to help with the indication of measures to enhance renal depuration of toxic agents. This study reviews the use of dialysis in acute poisonings due to medications or pesticides, whose specialized toxicological support was provided via telephone by the poison control center of the state of Rio Grande do Sul (CIT-RS from Portuguese). The correlation between need for dialysis and death was assessed in a retrospective cohort (1998-2000). Of the 36,055 cases registered, 337 were identified as severe, and 245 met the inclusion criteria required. Mean age was 30 ± 18 years, and 53% of the patients were women. The most commonly involved medications were anticonvulsants and antidepressants, and the pesticides were organophosphates, bipyridyl compounds, and glyphosate. Techniques to enhance elimination included urinary alkalinization (n = 37) and dialysis. In severe poisonings, dialysis was performed in 4.5% of the cases (n = 11), 3.67 procedures/year (1/22.7 reports of severe cases). In the group undergoing dialysis, 91% involved a suicide attempt (mainly phenobarbital and paraquat). Two cases required hemoperfusion (chloramphenicol and paraquat). Death among non-dialyzed severely ill patients occurred in 25.6%, versus 36.3% of dialyzed patients (RR = 0.89; 95% CI = 0.54-1.35). The findings can be explained by the statistic power associated with the number of procedures performed. The nephrologist should be aware of situations requiring the use of dialysis, even if not necessarily aimed at renal replacement, but at enhancing depuration of a toxic agent.