Acute Renal Injury in polytrauma patients

Abstract

A Injúria Renal Aguda (IRA) no contexto do paciente politraumatizado ocorre, na maioria das vezes, por uma conjuntura de fatores que passam por eventos correlacionados à ressus-citação volêmica inicial, ao grau de resposta inflamatória sistêmica associada ao trauma, ao uso de contraste iodado para procedimen-tos diagnósticos, à rabdomiólise e à síndro-me compartimental abdominal. Atualmente, passamos por uma fase de uniformização dos critérios diagnósticos da IRA com o Acute Kidney Injury Network (AKIN), sendo a referência mais aceita. Consequentemente, o estudo da IRA no politraumatismo também passa por uma fase de reformulação. Esta re-visão da literatura médica visa trazer dados epidemiológicos, fisiológicos e de implicação clínica para o manuseio destes pacientes, bem como expor os riscos do uso indiscriminado de expansores volêmicos e particularidades sobre a instituição de terapia renal substitu-tiva em indivíduos sob risco de hipertensão intracraniana. Introdução A injúria renal aguda (IRA) no contex-to do cuidado ao paciente crítico é sabi-damente relacionada a maior tempo de internação hospitalar e a maior mortali-dade, 1,2 quanto a sua importância na as-sistência ao indivíduo politraumatizado. Dados de literatura médica apontam pa-ra a mesma direção. Em estudo observacional com cerca de 430 pacientes vítimas de politrauma, Gomes et al. 3 demonstraram que 50% deles apresentavam IRA e que aque-les com maiores comprometimentos de função renal permaneciam mais tempo Acute Kidney Injury (AKI) in trauma is, in most cases, multifactorial. Factors related to the initial ressuscitation protocol , degree of the systemic inflamatory response to trauma, contrast nephropa-thy in diagnostic procedures, rhabdo-myolysis and abdominal compartment syndrome are some of those factors. Nowadays a uniformization in diagnostic criteria for AKI has been proposed by the Acute Kidney Injury Network (AKIN) and as a result the incidence of AKI and its impact in outcomes in trauma patients also needs to be reconsider. In this review we aim to approach epi-demiologic, physiologic and clinical relevant data in the critical care of patients victims of trauma and also to expose the risks of indiscriminate use of volume expanders and the interaction between renal replacement theraphy and intra-cranial hypertension. Injúria Renal Aguda no paciente politraumatizado Acute Renal Injury in polytrauma patients resumo Palavras-chave: diálise renal, rabdomiólise, renal aguda, traumatismo múltiplo. AbstrAct Keywords: acute kidney injury, multiple trauma, renal dialysis, rhabdomyolysis.

Association Between Increased Levels of Cystatin C and the Development of Cardiovascular Events or Mortality: A Systematic Review and Meta-Analysis

“…36 Thus, elderly patients have a lower GFR, which may be associated with higher levels of cystatin C and an increased risk of cardiovascular events. 28 As most of the studies that performed the multivariate regression analysis [66.66% (n = 4)] 15 , 17 , 18 , 23 included age in this analysis, and nonetheless found a significant association between high levels of cystatin C and the development of adverse outcomes, it is possible to conclude that this association is age-independent. It should be noted that the two studies 20 , 25 that were included in the meta-analysis are among these studies that included age in the multivariate regression analysis, indicating that the association between high levels of cystatin C and any cause-related mortality observed in meta-analysis is age-independent.…”

“…Another possible mechanism is related to the fact that cystatin C presents a greater sensitivity for the detection of the initial stages of renal dysfunction than serum creatinine or creatinine-based GFR. 28 , 29 Several authors have already demonstrated that renal dysfunction is associated with an increased risk of cardiovascular events. 30 , 31 Thus, it is possible to suggest that patients who have normal renal function assessed by GFR based on creatinine or serum creatinine but who have high levels of cystatin C may present with renal dysfunction at an earlier stage, which could be associated with an increased risk of cardiovascular events.…”

Acute Tubulointerstitial Nephritis due to Phenytoin: Case Report

“…The patient had a CT scan on admission to hospital, without radiological contrast, and throughout his hospital stay, he never received antibiotics, vasoactive drugs or NSAIDs, which are the substances most commonly connected to AKI [7][8][9][10][11]. It is important to note that the initial leukocytosis normalized rapidly, proving that it resulted of syndrome of the in lammatory response to stress [3]. It was considered that the AKI could have originated from medication secondary to the use of phenytoin, which, according to some previous related cases, could lead to nephrotoxicity [8,[12][13][14][15][16].…”

“…Here we stress the progressive and acute nature of the worsening of his renal function (Graph 1), as this was a patient who had been in perfect previous health, without any history of glomerulopathies or auto-immune diseases. Other possibilities that were ruled out [Immediately right away] include: crush syndrome, rhabdomyolysis, compartment syndrome, shock with harm to haemodynamics, and sepsis, which could have happened because of the accident [3].…”

“…In patients who have suffered multiple trauma, AKI can be caused by a multiplicity of factors, involving: poor volemia, rhabdomyolysis, abdominal compartment syndrome, sepsis; exposure to radiological contrast and to potentially nephrotoxic drugs, particularly antibiotics and antifungal agents [3].…”