Background and objectivesSecondary hyperparathyroidism (SHPT) in CKD is associated with an increased risk for mortality, but definitive data showing that parathormone control decreases mortality is still lacking. This study aimed to compare the mortality of patients with severe SHPT submitted to parathyroidectomy(PTX) with those who did not have access to surgery.MethodsThis is a retrospective study in a cohort of 251 CKD patients with severe SHPT who were referred to a CKD-MBD Center for PTX from 2005 until 2012.ResultsMost of our patients had indication of PTX, but only 49% of them had access to this surgical procedure. After a mean follow-up of 23 months, 72 patients had died. Non-survivors were older; more often had diabetes, lower serum 25 vitamin D and mostly had not been submitted to surgery. The relative risk of death was lower in the PTX patients (0.428; 95% CI, 0.28 to 0.67; p<0.0001). After adjustments, mortality risk was dependent on age (1.04; 95% CI, 1.01 to 1.07; p = 0.002), 25 vitamin D (0.43; 95% CI, 0.24 to 0.81; p = 0.006) and no access to PTX (4.13; 95% CI, 2.16 to 7.88; p<0.0001). Results remained the same in a second model using the PTX date as the study start date for the PTX group.ConclusionsOur data confirms the benefit of PTX on mortality in patients with severe SHPT. The high mortality encountered in our population is significant and urges the need to better treat these patients.

Sepsis-induced organ failure is characterized by a massive inflammatory response and oxidative stress. Acute kidney injury (AKI) occurs in approximately half of patients in septic shock, and the mortality associated with sepsis-induced AKI is unacceptably high. Klotho is a protein expressed by renal cells and has anti-senescence properties. Klotho has also been shown to protect the kidneys in ischemia-reperfusion injury and to have antioxidant properties. To analyze the role of Klotho in sepsis-related organ dysfunction and AKI, we used a cecal ligation and puncture (CLP) model of sepsis in heterozygous Klotho-haploinsufficient mice and their wild-type littermates (CLP- Kl/+ and CLP-WT mice, respectively). In comparison with the CLP-WT mice, CLP- Kl/+ mice showed lower survival, impaired renal function, impaired hepatic function, greater oxidative stress, upregulation of inflammatory pathways (at the systemic and kidney tissue levels), and increased NF-κB activation. It is noteworthy that CLP- Kl/+ mice also showed lower heart-rate variability, less sympathetic activity, impaired baroreflex sensitivity to sodium nitroprusside, and a blunted blood pressure response to phenylephrine. We also demonstrated that sepsis creates a state of acute Klotho deficiency. Given that low Klotho expression exacerbates sepsis and multiple organ dysfunction, Klotho might play a protective role in sepsis, especially in elderly individuals in whom Klotho expression is naturally reduced.

Cancer patients are living longer. The sequelae of cancer treatment and the role of comorbid conditions present before the diagnosis, such as CKD, have been increasingly recognized. The interface between CKD and cancer is multifaceted. CKD is frequently observed in patients with cancer, and cancer treatment contributes to CKD development and progression. In addition, CKD has been recognized as an important risk factor for cancer development and reduced specific cancer survival. In this context, an accurate evaluation of the glomerular filtration rate (GFR) during oncologic treatment is pivotal and is used to define surgery strategies, program prophylactic management of contrasted examinations, make decisions on cisplatin eligibility, and adjust drug prescriptions, particularly chemotherapy agents. Although the most commonly used equations to estimate GFR based on serum creatinine levels in clinical practice (Cockcroft-Gault, Modification of Diet in Renal Disease Study, and CKD Epidemiology Collaboration equations) have not been validated in patients with cancer in large prospective studies, there is increasingly evidence supporting the use of CKD Epidemiology Collaboration equation to assess the GFR in patients with cancer, including for the use of chemotherapy prescriptions. Many patients with cancer may have changes in nutrition status and clearance measurements such as exogenous filtration markers might be extremely useful when clinical decisions differ depending on the GFR level. Future perspectives include the advent of new serum GFR biomarkers such as cystatin C, beta-trace protein, and beta-2 microglobulin as well as the GFR assessment by measuring total kidney parenchymal volume through image examinations.

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Rev Bras AnestesiolARTIGO CIENTÍFICO 2008; 58: 4: 330-341 SCIENTIFIC ARTICLE RESUMO Silva Neto WV, Azevedo GS, Coelho FO, Netto EM, Ladeia AM -Avaliação das Variações Hemodinâmicas Durante a Indução Anestésica em Pacientes Hipertensos Tratados. JUSTIFICATIVA E OBJETIVOS:Devido à alta prevalência da hipertensão arterial sistêmica, ao aumento da expectativa de vida e ao aprimoramento dos métodos diagnósticos e das técnicas cirúr-gicas, essa comorbidade tornar-se-á comum em pacientes cirúrgicos. O objetivo deste estudo foi avaliar o comportamento das variáveis hemodinâmicas dos pacientes hipertensos tratados durante a indução anestésica. MÉTODO:Estudo observacional sobre o comportamento das variáveis hemodinâmicas (pressão arterial sistólica, pressão arterial diastólica e freqüência cardíaca) durante a indução anestésica dos pacientes hipertensos e normotensos, escalados para operações eletivas submetidos à anestesia geral em quatro momentos consecutivos durante a indução anestésica: preparo (MP), fármaco (MF), laringoscopia/intubação (ML) e laringoscopia/intubação 5 min (ML5). RESULTADOS:A amostra foi composta por 128 pacientes distribuídos nos grupos de pacientes hipertensos (GH) e normotensos (GN). Houve diminuição da PAD no momento MF em ambos os grupos, com menor redução percentual no GH (18,3 ± 14,0% versus 23,0 ± 11,4%, p = 0,04). Houve aumento das PAS e PAD no momento ML em ambos os grupos, com menores elevações percentuais no GH (8,2 ± 16,3% versus 18,2 ± 21,2%, p < 0,01; 8,6 ± 20,2% versus 25,0 ± 27,9%, p < 0,01; respectivamente para PAS e PAD). Quanto à PAS e PAD, após ML5, e à FC não houve diferença entre os grupos. CONCLUSÕES:Os pacientes hipertensos tratados com níveis pressóricos controlados apresentaram maior estabilidade hemodinâmica durante a indução anestésica. Unitermos BACKGROUND AND OBJECTIVES:Due to the high prevalence of hypertension, the increase in life expectancy, and improvement of diagnostic methods and surgical techniques, this comorbidity will be increasingly more common in surgical patients. The objective of this study was to evaluate the behavior of the hemodynamic variables during anesthetic induction in treated hypertensive patients. METHODS:This is an observational study on the behavior of hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and heart rate) during the anesthetic induction of hypertensive and normotensive patients scheduled for elective surgeries under general anesthesia, at four moments: preparation (MP), drug (MD), laryngoscopy/intubation (ML), and 5 minutes after laryngoscopy/intubation (ML5). RESULTS:The sample was composed of 128 patients divided into two groups: hypertensive (GH) and normotensive (GN). Diastolic blood pressure was reduced at MD in both groups, with a smaller percentage reduction in GH (18.3 ± 14.0% versus 23.0 ± 11.4%, p = 0.04). There was an increase in SBP and DBP at ML in both groups, with smaller percentage reductions in GH (8.2 ± 16.3% versus 18.2 ± 21.2%, p < 0.01; 8.6 ± 20.2% versus 25.0 ± 27.9%, p < 0.01, re...

The klotho gene, which encodes a single-pass transmembrane protein and a secreted protein, is expressed predominantly by the distal renal tubules and is related to calcium phosphorus metabolism, ion channel regulation, intracellular signaling pathways, and longevity. Klotho deficiency aggravates acute kidney injury and renal fibrosis. Exposure to nicotine also worsens kidney injury. Here, we investigated renal Klotho protein expression in a mouse model of chronic (28-day) nicotine exposure, in which mice received nicotine or vehicle (saccharine) in drinking water, comparing wild-type (WT) mice, klotho-haploinsufficient ( kl/+) mice, and their respective controls, in terms of the effects of that exposure. Nicotine exposure was associated with a significant decline in renal Klotho expression in WT and kl/+ mice as well as a reduction in the glomerular filtration rate in WT mice. Although plasma electrolytes were similar among the groups, fractional excretion of sodium was reduced in both nicotine-exposed groups. The nicotine-WT mice presented augmented baroreflex sensitivity to nitroprusside and augmented sympathetic cardiac modulation. However, nicotine- kl/+ mice presented higher plasma levels of urea and aldosterone together with a higher α-index (spontaneous baroreflex) and higher peripheral sympathetic modulation, as evaluated by spectral analysis. We can conclude that nicotine downregulates Klotho expression as well as that renal and autonomic responses to nicotine exposure are modified in kl/+ mice.

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Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which began as an outbreak in Wuhan, China and has spread rapidly across the globe. Although most infections are mild, patients with severe and critical COVID-19 infections face deterioration of respiratory function and may also have extrapulmonary manifestations, mostly affecting the kidney, digestive tract, heart, and nervous system. Here, we prospectively evaluated the presence of SARS-CoV-2 genetic material using reverse-transcription polymerase chain reaction in urine samples obtained from patients with COVID-19 receiving critical care. Among 51 included patients, we found higher serum creatinine levels, a longer hospital stay, and more frequent need for dialysis in urine-positive patients. These findings could suggest that, in predisposed patients, a direct viral cytopathic effect may contribute to a more severe disease phenotype.