Jornal brasileiro de nefrologia : ʹorgão oficial de Sociedades Brasileira e Latino-Americana de Nefrologia
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A previously healthy 19 year-old male presented to the hospital with anorexia, nausea, and vomiting. Laboratory studies were significant for hypercalcemia (peak calcium value of 14.8 mg/dL) and acute kidney injury (peak serum creatinine of 2.88 mg/dL). He admitted to using a parenteral formulation of vitamins A, D and E restricted for veterinary use containing 20,000,000 IU of vitamin A; 5,000,000 IU of vitamin D3; and 6,800 IU of vitamin E per 100 mL vial. ⋯ His PTH level was undetectable and other potential causes of hypercalcemia were excluded. Therefore, we posit that the severity of the hypercalcemia observed in this case was the result of a synergistic effect of vitamins A and D. The patient was treated with normal saline, furosemide and zolendronic acid, with rapid normalization of calcium levels and renal function.
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The emergence of the pandemic outbreak of influenza A (H1N1) in April, 2009, represented a logistic challenge for public health. Although most infected patients presented clinical and evolutionary manifestations which were very similar to seasonal influenza, a significant number of individuals developed pneumonia and severe acute respiratory failure. The impact of influenza A (H1N1) in immunocompromised patients is not well established yet. ⋯ Acute renal allograft dysfunction was a common finding. Clinical, laboratory, and evolutionary characteristics were comparable to those in the general population.
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Leptospirosis is the most important zoonosis in the world. Patients are typically young men. Several factors are involved in acute kidney injury (AKI) in leptospirosis, including direct nephrotoxic action of the leptospira, hyperbilirubinemia, rhabdomyolysis and hypovolemia. ⋯ Antibiotic treatment is efficient in the early and late and/or severe phases. For critically ill leptospirosis patients, the following measures are recommended: early and daily hemodialysis; low volume infusion (due to the risk of pulmonary hemorrhage); and lung-protective strategies. Mortality in leptospirosis-associated AKI is around 22%.
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Thrombotic microangiopathies (TMAs) are pathological conditions characterized by generalized microvascular occlusion by platelet thrombi, thrombocytopenia, and microangiopathic hemolytic anemia. Two typical phenotypes of TMAs are hemolytic- uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). Other disorders occasionally present with similar manifestations. ⋯ Although TMAs are highly heterogeneous pathological conditions, one-third of TMA patients have severe deficiency of ADAMTS13. Platelet transfusions are contraindicated. Plasma infusion or exchange (PE) is the only treatment of proven efficacy.
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A growing fraction of the clinical duties of Nephrologists is undertaken inside intensive care units. While assessing patients with acute renal failure in the context of circulatory collapse, which are also edematous and/or with impaired gas exchanges, the Nephrologist must decide between two opposing therapies: 1) remove volume with the aid of dialysis or diuretics to improve the edematous state; 2) volume expand to improve hemodynamics. To minimize the odds of making incorrect choices, the Nephrologist must be familiar with the tools available for determining the adequacy of volume status and for invasive hemodynamic monitoring in the critically ill patient. In this manuscript, we will briefly review the physiology of extra cellular fluid volume regulation and then tackle the issue of volume status assessment, based on clinical and hemodynamic criteria.