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Las vasculitis asociadas a anticuerpos contra el citoplasma del neutrófilo configuran patologías multisistémicas caracterizadas por afectar pequeños vasos. Se ha reportado compromiso de sistema nervioso central en 2% a 8% de los casos, rara vez al inicio del cuadro clínico. Se reporta el caso de un hombre de 67 años de edad con vasculitis p-ANCA, quien debutó con proptosis, paquimeningitis y disfagia severa. Posteriormente deterioro renal, necesidad de hemodiálisis, ciclofosfamida y recambio plasmático terapéutico con lo cual alcanza criterios de remisión parcial y egresa de diálisis. Las vasculitis ANCA se relacionan con una amplia gama de signos y síntomas inespecíficos. La edad de aparición, creatinina inicial y requerimiento de diálisis, son factores pronósticos. El inicio oportuno del tratamiento es fundamental, requiriendo por tanto un alto índice de sospecha

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Background Acid-base disorders have been previously described in patients with chronic hemodialysis, with metabolic acidosis being the most important of them; however, little is known about the potential changes in acid-base status of patients on dialysis living at high altitudes. Methods Cross-sectional study including 93 patients receiving chronic hemodialysis on alternate days and living in Bogotá, Colombia, at an elevation of 2,640 meters (8,661 feet) over sea level (m.o.s.l.). Measurements of pH, PaCO2, HCO3, PO2, and base excess were made on blood samples taken from the arteriovenous fistula (AVF) during the pre- and postdialysis periods in the midweek hemodialysis session. Normal values for the altitude of Bogotá were taken into consideration for the interpretation of the arterial blood gases. Results 43% (n= 40) of patients showed predialysis normal acid-base status. The most common acid-base disorder in predialysis period was metabolic alkalosis with chronic hydrogen ion deficiency in 19,3% (n=18). Only 9,7% (n=9) had predialysis metabolic acidosis. When comparing pre- and postdialysis blood gas analysis, higher postdialysis levels of pH (7,41 versus 7,50, p<0,01), bicarbonate (21,7mmol/L versus 25,4mmol/L, p<0,01), and base excess (-2,8 versus 2,4, p<0,01) were reported, with lower levels of partial pressure of carbon dioxide (34,9 mmHg versus 32,5 mmHg, p<0,01). Conclusion At an elevation of 2,640 m.o.s.l., a large percentage of patients are in normal acid-base status prior to the dialysis session (“predialysis period”). Metabolic alkalosis is more common than metabolic acidosis in the predialysis period when compared to previous studies. Paradoxically, despite postdialysis metabolic alkalosis, PaCO2 levels are lower than those found in the predialysis period.

Acute Kidney Injury (AKI) affects more than 40% of patients in intensive care units (ICU), increasing morbidity, and mortality. Diagnosis is made using serum creatinine levels and urinary output (UO). However, the diagnostic yield of each individual approach is not well known. We aimed to compare the diagnostic performance of creatinine versus UO for AKI in critically-ill patients. METHODS: Systematic review (SR) using MEDLINE, EMBASE, LILACS, and the Cochrane Library databases without language restriction. All studies that evaluated the diagnostic accuracy of creatinine and UO for the diagnosis of AKI in adult ICU patients were initially included. Original data for study design, population inclusion, measurement and timing of AKI occurrence, biomarker performance, and bias risk was extracted. UO was used as the index test and serum creatinine as the reference test. For the meta-analysis, KDIGO criteria were used as the diagnostic gold standard construct. RESULTS: 12 studies were included in the SR and 4 studies in the meta-analysis, for a total of 36,309 patients. Sensitivity and specificity of UO versus creatinine were evaluated in 4 studies based on the KDIGO definition, finding a sensitivity of 0.66 [95% CI 0.51-0.78] and a specificity of 0.65 [95% CI 0.48-0.79]. The diagnostic odds ratio (OR) for UO was 4 (95% CI:3-5), positive likelihood ratio (LR +) was 1.89 (95% CI:1.4-2.51), and LR-was 0.53 (95% CI: 0.44-0.63) and an area under the ROC curve of 0.70.Patients identified by UO were more likely to be falsely classified as false positives, which led us to compare both tools against the construct finding a sensitivity for UO of 0.80 (95% CI 0.70-0.87) and for creatinine levels of 0.59 (95% CI 0.54-0.65) CONCLUSIONS: In critically-ill patients, urine output is the most sensitive criteria among the ones used by the KDIGO definition. UO monitoring is a simple, inexpensive and widely available tool, given its high sensitivity, emphasizing its strict use could allow for earlier detection of AKI in critically ill patients. CLINICAL IMPLICATIONS: Urine output changes are able to detect more cases of AKI in critically ill patients than serum creatinine levels when used individually.