Eficacia de la administración de cloruro sódico oral e intravenoso en la profilaxis de la nefropatía inducida por contraste yodado en pacientes ambulantes

El aumento de disponibilidad de técnicas de tomografía computarizada (TC) ha extendido el uso de medios de contraste yodado intravenoso que pueden ocasionar fracaso renal agudo asociado a contraste (CA-AKI). La diabetes, insuficiencia cardiaca y enfermedad renal crónica se han descrito como factores de riesgo para su desarrollo. Así, la incidencia de CA-AKI en población sin factores de riesgo que se realiza una TC varía entre 0,6 y 2,5% frente a 5 – 13% en aquellos con factores predisponentes. Además de los marcadores tradicionales, disponemos de proteínas en sangre y orina que podrían predecir de forma precoz el CA-AKI. La hidratación intravenosa profiláctica está indicada en pacientes de alto riesgo. Según la guía clínica consultada a partir de filtración glomerular menor de 60, 45 o 30 mL/min/1,73m2. En los últimos estudios se ha llegado a plantear si es suficiente realizar hidratación oral e incluso si realmente es necesario administrar profilaxis o no. El objetivo de nuestro estudio es valorar la no inferioridad de la hidratación con cloruro sódico oral y agua frente a la pauta intravenosa estándar en la profilaxis de CA-AKI en pacientes que se iban a realizar una TC de forma ambulatoria. De forma secundaria se pretende explorar las características clínicas de los pacientes que desarrollan CA-AKI y la evolución de los nuevos biomarcadores de función renal en este contexto. El ensayo clínico no consiguió demostrar la no inferioridad del cloruro de sodio oral frente a la pauta estándar. La incidencia global de CA-AKI en nuestra población fue baja, 2,4%. Siendo llamativo que en los mayores de 80 años fue de hasta el 8,7%. En cuanto a los factores de riesgo asociados a CA-AKI destaca la edad y la presencia de L-FABP elevado. El marcador KIM-1 fue predictor precoz de CA-AKI

Cefalea y fiebre: no todo es lo que parece

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis, is an uncommon condition, usually benign and self-limited. However, it is sometimes associated with different systemic manifestations that can lead to significant mortality if they are not identified and treated. We present an adult woman who suffered from fever and adenopathies. She developed hemophagocytic syndrome and aseptic meningitis. The histopathological diagnosis was Kikuchi-Fujimoto disease. A brief review of the literature on this pathology and its associated systemic manifestations are also included in the case.La Kikuchi-Fujimoto o linfadenitis histiocítica necrotizante es una enfermedad rara, habitualmente benigna y autolimitada. Sin embargo, en ocasiones se asocia a diferentes manifestaciones sistémicas que pueden condicionar una mortalidad significativa si no se identifican y tratan. Presentamos el caso de una paciente adulta con fiebre y adenopatías con diagnóstico histopatológico de enfermedad de Kikuchi-Fujimoto asociado a síndrome de activación macrofágica y meningitis aséptica. Se realiza también una breve revisión de la literatura sobre esta patología y sus manifestaciones sistémicas asociadas

Oral Sodium Chloride in the Prevention of Contrast-Associated Acute Kidney Injury in Elderly Outpatients: The PNIC-Na Randomized Non-Inferiority Trial

Descuentos MDPI 2023Objective: We aimed to test the non-inferiority of oral versus intravenous hydration in the incidence of contrast-associated acute kidney injury (CA-AKI) in elderly outpatients undergoing a contrast-enhanced computed tomography (CE-CT) scan. Methods: PNIC-Na (NCT03476460) is a phase-2, single-center, randomized, open-label, non-inferiority trial. We included outpatients undergoing a CE-CT scan, >65 years having at least one risk factor for CA-AKI, such as diabetes, heart failure, or an estimated glomerular filtration rate (eGFR) of 30–59 mL/min/1.73 m². Participants were randomized (1:1) to oral sodium-chloride capsules or intravenous hydration. The primary outcome was an increase in serum creatinine >0.3 mg/dL or a reduction in eGFR >25% within 48 h. The non-inferiority margin was set at 5%. Results: A total of 271 subjects (mean age 74 years, 66% male) were randomized, and 252 were considered for the main analysis (per-protocol). A total of 123 received oral hydration and 129 intravenous. CA-AKI occurred in 9 (3.6%) of 252 patients and 5/123 (4.1%) in the oral-hydration group vs. 4/129 (3.1%) in the intravenous-hydration group. The absolute difference between the groups was 1.0% (95% CI −4.8% to 7.0%), and the upper limit of the 95% CI exceeded the pre-established non-inferiority margin. No major safety concerns were observed. Conclusion: The incidence of CA-AKI was lower than expected. Although both regimens showed similar incidences of CA-AKI, the non-inferiority was not shown.Ministerio de Sanidad (España)Instituto de Salud Carlos IIIDepto. de MedicinaFac. de MedicinaTRUEpubDescuento UC

Predicting critical illness on initial diagnosis of COVID-19 based on easily obtained clinical variables: development and validation of the PRIORITY model

Objectives: We aimed to develop and validate a prediction model, based on clinical history and examination findings on initial diagnosis of coronavirus disease 2019 (COVID-19), to identify patients at risk of critical outcomes. Methods: We used data from the SEMI-COVID-19 Registry, a cohort of consecutive patients hospitalized for COVID-19 from 132 centres in Spain (23rd March to 21st May 2020). For the development cohort, tertiary referral hospitals were selected, while the validation cohort included smaller hospitals. The primary outcome was a composite of in-hospital death, mechanical ventilation, or admission to intensive care unit. Clinical signs and symptoms, demographics, and medical history ascertained at presentation were screened using least absolute shrinkage and selection operator, and logistic regression was used to construct the predictive model. Results: There were 10 433 patients, 7850 in the development cohort (primary outcome 25.1%, 1967/7850) and 2583 in the validation cohort (outcome 27.0%, 698/2583). The PRIORITY model included: age, dependency, cardiovascular disease, chronic kidney disease, dyspnoea, tachypnoea, confusion, systolic blood pressure, and SpO2 ≤93% or oxygen requirement. The model showed high discrimination for critical illness in both the development (C-statistic 0.823; 95% confidence interval (CI) 0.813, 0.834) and validation (C-statistic 0.794; 95%CI 0.775, 0.813) cohorts. A freely available web-based calculator was developed based on this model (https://www.evidencio.com/models/show/2344). Conclusions: The PRIORITY model, based on easily obtained clinical information, had good discrimination and generalizability for identifying COVID-19 patients at risk of critical outcomes