Hospital Civil De Guadalajara Research Articles

The Role of Kt/V and Creatinine clearance on Assisting Optimization of Serum Phosphorus Levels among Patients on PD.

Hyperphosphatemia is associated with poor outcome and is still very common in peritoneal dialysis (PD) patients. Since peritoneal phosphate clearance is closer to peritoneal creatinine clearance than urea clearance, we hypothesized that weekly creatinine clearance (CrCl) could be a better marker of serum phosphate in PD. In a retrospective observational study, data from adult PD patients were collected across five institutions in North and South America: LATAM, RRI, Mount Sinai Hospital, Hospital Civil de Guadalajara, and the BRAZPD cohort. All centers analyzed routinely available laboratory data, with exclusions for missing data on serum phosphate, CrCl, or urea Kt/V. A unified statistical protocol was employed across centers. Linear mixed-effect models examined associations between longitudinal serum phosphate levels, CrCl, and Kt/V. Adjustments were made for age, gender, and baseline phosphate binder usage. Mixed-effects meta-analysis determined the pooled effect size of CrCl and Kt/V on serum phosphate trajectories, adjusted for confounders. There were 16,796 incident PD patients analyzed. Age, BMI, gender, PD modality, Kt/V and CrCl as well as serum phosphate varied significantly across the different cohorts, but >70% had residual renal function. For most cohorts, both CrCltotal and urea Kt/V associated negatively with serum phosphorus levels, and log-likelihood ratio tests demonstrate that models including CrCltotal have more predictive information than those including only urea Kt/V for the largest cohorts. Models including CrCltotal increase information predicting longitudinal serum phosphate levels irrespective of baseline urea Kt/V, age, use of phosphorus binder, and gender. CrCl was not more accurate in predicting serum phosphate than urea Kt/V, but its inclusion in multivariable models predicting serum phosphate added accuracy. In conclusion, both creatinine clearance and Kt/V are associated with phosphate levels, and using both biomarkers, instead of just one, may better assist in the optimization of serum phosphate levels.

Challenges in treating children with optic pathway gliomas: an 18-year experience from a middle-income country.

Patients with optic pathway gliomas (OPG) have good survival rates although their long-term quality of life can be affected by the tumor or treatment-related morbidity. This retrospective study sought to describe the clinical presentation and outcomes of children with OPG at a tertiary center in Mexico. Consecutive patients <18 years-of-age with newly diagnosed OPG between January 2002 and December 2020 at the Hospital Civil de Guadalajara Dr. Juan I. Menchaca in Guadalajara, Mexico were included. Thirty patients were identified with a median age of six years. The most frequent clinical manifestations were loss of visual acuity (40%) and headaches (23%). Neurofibromatosis-1 was found in 23.3% of the patients. Surgery, either biopsy or resection, was done in 20 of 30 patients. Two patients died shortly after initial surgery. The 5-year event-free survival (EFS) was 79.3% ± 10.8% and the 5-year overall survival was 89.5% ± 6.9%. Lower EFS was associated with age less than 3 years, intracranial hypertension at presentation, and diencephalic syndrome. Patients who received surgery as first-line treatment had a 3.1 times greater risk of achieving a performance score of less than 90 points at 6 months after diagnosis (p=0.006). Of 10 patients with vision testing, 5 had improvement in visual acuity, 4 had no changes, and one patient showed worsening. Our data suggests that favorable outcomes can be achieved with OPG in low- and middle-income countries, although a high rate of surgical complications was described leading to a lower overall survival. These data can be used prospectively to optimize treatment at this institute and other middle-income countries through a comprehensive, multidisciplinary approach.

Soluble and Membrane P-Glycoprotein Expression in Lymphocytes from Diffuse Large B Cell Non-Hodgkin's Lymphoma Patients Treated with R-CHOP

Introduction Diffuse large B cell lymphoma (DLBC) accounts for 25% of all Non-Hodgkin's Lymphoma (NHL) in the United States. Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) has been the first-line therapy for patients with DLBC-NHL since the early 2000s. Nearly 40% relapse in the following 2-years after complete response and 15% are refractory to first-line therapy. Despite many efforts, other chemotherapy combinations have failed to improve the response rate of NHL patients. Mechanisms of resistance to cytotoxic drugs are vast and include augmented drug efflux mediated through ATP-dependent pumpsas P-glycoprotein (P-gp), which has been related to lesser efficacy. This is due to an over-expression of the glycoprotein with the consequent increase of the drug's efflux from the cytosol. Almost all components of the R-CHOP therapy are P-gp substratesand thereby are affected by P-gp activity. Objectives Analyze serum, plasmatic levels, and membrane expression of P-gp in lymphocytes from patients with DLBC-NHL. Methods A case-control study was conducted to measure serum and plasmatic levels of P-gp, and membrane P-gp expression at the end of treatment on DLBC-NHL patients at “Hospital Civil de Guadalajara Fray Antonio Alcalde,” diagnosed from April to September 2022. Inclusion criteria were age ≥ 18 years, without cancer history and without P-gp inductors or inhibitors. Exclusion criteria were pregnancy, hepatitis, autoimmune disease, Richter syndrome and infection 15 days before blood draw. Using whole blood samples, we identified T and NK cells expressing membrane P-gp by flow cytometry on Attune® NxT (Life Technologies) using the following antibodies and fluorochrome conjugates: CD3-APC/Cy7, CD4-AlexaFlour488, CD8-APC, CD56-BrilliantViolet, CD243-PE. Data was analyzed with FlowJo v10 software. Serum and plasmatic P-gp measurement were done using the Human Permeability Glycoprotein (P-gp) ELISA kit (MyBioSource). Statistical Analysis Proportion comparison between groups was made using Chi-Square or Fisher exact tests. A quantitative variable comparison was done using the U Mann-Witney test. Correlation analysis was made using the Spearman correlation coefficient. Statistical significance was calculated using the p&amp;lt;0.05 two-tailed test. All statistical analysis was made using the software R version 4.1.2 and ggpurb/ggplot2 package. Results Only 15 patients and 30 control individuals were included. Group characteristics and comparisons are summarized in table 1. Regarding the DLBC-NHL group, 27% patients were classified as Lugano I, II and IV stages respectively and 20% as Lugano III stage. Nearly 27% of the patients received radiotherapy as consolidation therapy. Also, 40% of patients showed lymphopenia with a median of 1.23 x10 3/μL (IQR 0.94 - 1.34). Serum and plasmatic P-gp concentrations were similar between groups (p&amp;gt;0.05). The CD8+, CD4+, and CD56+ lymphocyte percentage with membrane P-gp expression comparison between the DLBC-NHL group and the control group presented no significant differences (p&amp;gt;0.05). However, the P-gp median fluorescence index (MFI) in CD8+, CD4+, and CD56+ lymphocytes was higher in the control group than DLBC-NHL group (p&amp;lt;0.05), as displayed in figure 1. Discussion When analyzing only the DLBC-NHL group, we identified a negative correlation between serum P-gp concentration and its expression in NK cell membrane and a positive correlation with membrane expression in CD4+ and CD8+ lymphocytes. Kato et al. reported that P-gp can be secreted through exosomes in patients with drug resistance. Lettau et al. found that CD4+ and CD8+ T lymphocytes have higher exosome expulsion compared to NK cells. These could be related to our finding of negative correlation between serum P-gp and membrane P-gp expression in NK lymphocytes. Ghetie et al. found that Rituximab-an anti-CD20 monoclonal antibody-inhibits P-gp efflux function and therefore makes multi-drug-resistant cell cultures chemosensitive again. B-cells affected by rituximab may influence T-cell P-gp expression and this may be the reason why MFI was lower on DLBC-NHL group than control group. This study helps to expand the understanding of P-gp's role in DLBC-NHL patients as well as R-CHOP therapy effects on the expression of the P-gp in circulating T-cells.

43457 Trichoscopy findings in the overweight and obese population from the Hospital Civil de Guadalajara

43457 Trichoscopy findings in the overweight and obese population from the Hospital Civil de Guadalajara

Poor Access to Liver Transplantation and Survival of Children With Acute Liver Failure, Acute-on-chronic Liver Failure or Chronic Liver Disease.

We describe the survival of children with acute liver failure (ALF), chronic liver disease (CLD), or acute-on-chronic liver failure (ACLF) with poor access to liver transplantation (LT). A retrospective cohort study of 42 patients <18 years of age was conducted in the Hospital Civil de Guadalajara "Dr. Juan I. Menchaca". The median age was 76 months; 57.1% were female, 40.5% presented with ALF, 35.7% with CLD, and 23.8% with ACLF. Also, 38.1% (16/42) presented liver disease of unknown etiology. Death occurred in 45.2%; 14.3% were transferred to another hospital, and none received LT. Mortality in ALF, CLD, and ACLF was 76%, 0%, and 60%, respectively. In the survival analysis, within the first 20 months after diagnosis, the mortality rate was greater than 50% with ALF. The importance of having referral programs that perform liver transplantation is highlighted by the poor prognosis of the patients, despite conservative treatment.

Serum Potassium Trajectory during Acute Kidney Injury and Mortality Risk

Background: The association between potassium (sK) level trajectory and mortality or the need for kidney replacement therapy (KRT) during acute kidney injury (AKI) has not been adequately explored. Methods: In this prospective cohort, AKI patients admitted to the Hospital Civil de Guadalajara were enrolled. Eight groups based on the sK (mEq/L) level trajectories during 10 days of hospitalization were created (1) normokalemia (normoK), defined as sK between 3.5–5.5; (2) hyperkalemia to normoK; (3) hypokalemia to normoK; (4) fluctuating potassium; (5) persistent hypoK; (6) normoK to hypoK; (7) normoK to hyperK; (8) persistent hyperK. We assessed the association of sK trajectories with mortality and the need for KRT. Results: A total of 311 AKI patients were included. The mean age was 52.6 years, and 58.6% were male. AKI stage 3 was present in 63.9%. KRT started in 36% patients, and 21.2% died. After adjusting for confounders, 10-day hospital mortality was significantly higher in groups 7 and 8 (OR, 1.35 and 1.61, p < 0.05, for both, respectively), and KRT initiation was higher only in group 8 (OR 1.38, p < 0.05) compared with group 1. Mortality in different subgroups of patients in group 8 did not change the primary results. Conclusion: In our prospective cohort, most patients with AKI had alterations in sK⁺. NormoK to hyperK and persistent hyperK were associated with death, while only persistent hyperK was correlated with the need for KRT.

Incidence of Intestinal Obstruction Secondary to Petersen's Hernia after Laparoscopic Roux-en-Y Gastric Bypass

Objective: Identify the incidence of Petersen's hernia in gastric bypass patients at our institution. Summary: Laparoscopic gastric bypass has proved to be the best treatment for obesity and the resolution of their complications, however, it presents long-term complications such as Petersen's hernia. Methods: A retrospective study of a single center, with a total of 225 gastric bypass performed in the bariatric and metabolic surgery clinic of the Hospital Civil de Guadalajara “Dr. Juan I. Menchaca” from January 2014 to March 2020. Results: Of the 225 operated patients, a global follow-up of 80.44% was obtained, with an average postoperative follow-up of 31 (+/-20.92) months, it was found that in 10 patients (4.44%) presented a symptomatic internal hernia. Of these, 9 patients was admitted to the emergency room and 1 detected in the outpatient clinic. These patients presented at the time of surgery a BMI of 27.65 (+/- 5.01) with a percentage of excess weight lost of 62.35% (+/- 25.60). The laparoscopic approach could be completed in 100% of the cases. Regarding hospital stay, an average of 1.1 (+/- 0.31) days was presented. No trans-surgical complications or mortality were reported in the group studied. The mean time between primary surgery and reoperation was 21.3 (+/- 12.98) months. Conclusion: In a 6-year period with a global follow-up of 80.44%, where the Petersen defect was not closed. An incidence of 4.44% was found, with an average follow-up of 31 (+/- 20.92) months. However, the percentage of Petersen's hernia may be underestimated since only those with symptoms that lead the patient to emergency care are usually diagnosed, so a high index of suspicion must always be had.

Systolic Blood Pressure and the Risk of Kidney Replacement Therapy and Mortality in Patients with Chronic Kidney Disease Stages 4–5

Introduction: In patients with chronic kidney disease stages 4 and 5 (CKD stages 4–5) without dialysis and arterial hypertension, it is unknown if the values of systolic blood pressure (SBP) considered in control (<120 mm Hg) are associated with kidney replacement therapy (KRT) and mortality. Methods: In this retrospective cohort study, hypertensive CKD stages 4–5 patients attending the Renal Health Clinic at the Hospital Civil de Guadalajara were enrolled. We divided them into those that achieved SBP <120 mm Hg (controlled group) and those who did not (>120 mm Hg), the uncontrolled group. Our primary objective was to analyze the association between the controlled group and KRT; the secondary objective was the mortality risk and if there were subgroups of patients that achieved more benefit. Data were analyzed using Stata software, version 15.1. Results: During 2017–2022, a total of 275 hypertensive CKD stages 4–5 patients met the inclusion criteria for the analysis: 62 in the controlled group and 213 in the uncontrolled group; mean age 61 years; 49.82% were male; SBP was significantly lower in the controlled group (111 mm Hg) compared to the uncontrolled group (140 mm Hg); eGFR was similar between groups (20.41 mL/min/1.73 m2). There was a tendency to increase the mortality risk in the uncontrolled group (HR 6.47 [0.78–53.27]; p = 0.082) and an association by the Kaplan-Meir analysis (Log-rank p = 0.043). The subgroup analysis for risk of KRT in the controlled group revealed that patients ≥61 years had a lower risk of KRT (HR 0.87 [95% CI, 0–76-0.99]; p = 0.03, p of interaction = 0.005), but no differences were found in the subgroup analysis for mortality. In a follow-up of 1.34 years, no association was found in the risk of KRT according to the controlled or uncontrolled groups in a multivariate Cox analysis. Conclusion: In a retrospective cohort of patients with CKD stages 4–5 and hypertension, SBP >120 mm Hg was not associated with risk of KRT but could be associated with the risk of death. Clinical trials are required in this group of patients to demonstrate the impact of reaching the SBP goals recommended by the KDIGO guidelines.

Vestigial Tail Associated to Spinal Lipomas: Report of Seven Cases

Objective: Vestigial tail is a rare form of cutaneous stigmata often related to occult spinal dysraphism. We present 7 cases of vestigial tail associated to tethered cord and spinal lipomas in the Pediatric Neurosurgery Service of the Hospital Civil de Guadalajara. Methods: In this retrospective study from 2017-2022 we reviewed the spinal dysraphism data base of the Hospital de Guadalajara and included the cases of vestigial tails. Results: 7 patients, 5 female and 2 males with vestigial tails were included. Six different morphologies of tails are described so as their location and relationship to occult spinal dysraphism. All the patients received surgical treatment. Complete resection of the cutaneous stigmata and cord detethering were performed in four cases related to fatty filum terminale and the remaining three of the patients required radical resection of associated complex conus medullaris lipomas. All the surgical procedures were performed with microsurgical techniques and neurophysiological monitoring. Conclusions: The different classifications include two main forms of tails, true tail and false tail. Most true tails represent only a cosmetic issue, while the false ones are often in close relationship with spinal dysraphism. Considering the risk of underlying malformations associated with false human tails, the preoperative assessment should include a thorough neurological examination, and a spine magnetic resonance imaging. We present the association of several forms of spinal lipomas related to vestigial tails. Keywords: Vestigial tail, Tethered cord, Spinal lipoma, Pseudo tail, Occult spinal dysraphism.

Urea Reduction in Acute Kidney Injury and Mortality Risk

Introduction: Urea is a toxin present in acute kidney injury (AKI). We hypothesize that reduction in serum urea levels might improve clinical outcomes. We examined the association between the reduction in urea and mortality. Methods: Patients with AKI admitted to the Hospital Civil de Guadalajara were enrolled in this retrospective cohort study. We create 4 groups of urea reduction ratio (UXR) stratified by their decrease in urea from the highest index value in comparison to the value on day 10 (0%, 1–25%, 26–50%, and >50%), or at the time of death or discharge if prior to 10 days. Our primary endpoint was to observe the association between UXR and mortality. Secondary observations included determination of which types of patients achieved a UXR >50%, whether the modality of kidney replacement therapy (KRT) effected changes in UXR, and if serum creatinine (sCr) value changes were similarly associated with patient mortality. Results: A total of 651 AKI patients were enrolled. The mean age was 54.1 years, and 58.6% were male. AKI 3 was present in 58.5%; the mean admission urea was 154 mg/dL. KRT was started in 32.4%, and 18.9% died. A trend toward decreased risk of death was observed in association with the magnitude of UXR. The best survival (94.3%) was observed in patients with a UXR >50%, and the highest mortality (72.1%) was observed in patients achieving a UXR of 0%. After adjusting for age, sex, diabetes mellitus, CKD, antibiotics, sepsis, hypovolemia, cardio-renal syndrome, shock, and AKI stage, the 10-day mortality was higher in groups that did not achieve a UXR of at least 25% (OR: 1.20). Patients achieving a UXR >50% were most likely initiated on dialysis due to a diagnosis of the uremic syndrome or had a diagnosis of obstructive nephropathy. Percentage change in sCr was also associated with increased mortality risk. Conclusions: In our retrospective cohort of AKI patients, the percent decrease in UXR from admission was associated with a stratified risk of death. Patients with a UXR >25% had the best associated outcomes. Overall, a greater magnitude in UXR was associated with improved patient survival.

Frequency of chromosome 22q11.2 deletion among newborns with non-syndromic congenital heart defects from western Mexico.

Congenital heart defects (CHD) are among the most frequent manifestations of 22q11.2 deletion syndrome. Although we found relatively few studies aimed at specifically detecting 22q11.2 deletion in newborns (NB) with CHD, none of them has been performed in Mexico. We conducted a prospective hospital-based study from January 2017 to March 2021 in the Genetics and Pediatric Cardiology Services of the Hospital Civil de Guadalajara Dr. Juan I. Menchaca (Guadalajara, Mexico). All consecutive NBs identified with any non-syndromic major CHD confirmed by echocardiography were eligible to participate. A total of 98 NBs were included, 51 males and 47 females. Fluorescence in situ hybridization (FISH) analysis was conducted to search for deletion of chromosome 22q11.2 in interphase nuclei of standard lymphocyte cultures. We found eight patients (8.2%) with CHD and the 22q11.2 deletion, all of them with conotruncal defects, particularly of the truncus arteriosus (p = 0.013), tetralogy of Fallot (p = 0.024), and pulmonary atresia with ventricular septal defect (p = 0.031) subtypes. With de exception of one infant with hypocalcemia and another with hypocalcemia and thymic aplasia, the diagnosis of 22q11.2 deletion was not clinically suspected in the other patients. Our results confirm the importance of excluding the presence of the 22q11.2 deletion in every NB with CHDs, particularly of the conotruncal subtype, even in the absence of other manifestations.

Frontal aslant tract: Anatomy and tractography description in the Mexican population.

Background: The aim of the study was to describe the origin, course, and termination of frontal aslant tract (FAT) in the Mexican population of neurosurgical referral centers.Methods: From January 2018 to May 2019, we analyzed 50 magnetic resonance imaging (MRI) studies in diffusion tensor imaging sequences of patients of the National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez.” Five brains were fixed by the Klingler method and dissected in the neurosurgery laboratory of the Hospital Civil de Guadalajara to identify the origin, trajectory, and ending of the FAT.Results: FAT was identified in 100% of the MRI and brain dissections. The origin of the FAT was observed in 63% from the supplementary premotor area, 24% from the supplementary motor area, and 13% in both areas. Its ending was observed in the pars opercularis in 81%, pars triangularis in 9%, and in both pars opercularis and ventral premotor area in 10% in the magnetic resonance images, with a left side predominance. In the hemispheres dissections, the origin of FAT was identified in 60% from the supplementary premotor area, 20% from the supplementary motor area, and 20% in both areas. Its ending was observed in the pars opercularis in 80% and the pars triangularis in 20%. It was not identified as an individual fascicle connected with the contralateral FAT.Conclusion: In the Mexican population, FAT has a left predominance; it is originated more frequently in the supplementary premotor area, passes dorsal to the superior longitudinal fascicle II and the superior periinsular sulcus, and ends more commonly in the pars opercularis.

A case-control study of infections caused by Klebsiella pneumoniae producing New Delhi metallo-beta-lactamase-1: Predictors and outcomes.

IntroductionInfections caused by antimicrobial-resistant bacteria are a significant cause of death worldwide, and carbapenemase-producing bacteria are the principal agents. New Delhi metallo-beta-lactamase-1 producing Klebsiella pneumoniae (KP-NDM-1) is an extensively drug-resistant bacterium that has been previously reported in Mexico. Our aim was to conduct a case–control study to describe the risk factors associated with nosocomial infections caused by K. pneumoniae producing NDM-1 in a tertiary-care hospital in Mexico.MethodsA retrospective case–control study with patients hospitalized from January 2012 to February 2018 at the Hospital Civil de Guadalajara “Fray Antonio Alcalde” was designed. During this period, 139 patients with a culture that was positive for K. pneumoniae NDM-1 (cases) and 486 patients hospitalized in the same department and on the same date as the cases (controls) were included. Data were analyzed using SPSS v. 24, and logistic regression analysis was conducted to calculate the risk factors for KP-NDM-1 infection.ResultsOne hundred and thirty-nine case patients with a KP-NDM-1 isolate and 486 control patients were analyzed. In the case group, acute renal failure was a significant comorbidity, hospitalization days were extended, and significantly more deaths occurred. In a multivariate analysis of risk factors, the independent variables included the previous use of antibiotics (odds ratio, OR = 12.252), the use of a urinary catheter (OR = 5.985), the use of a central venous catheter (OR = 5.518), the use of mechanical ventilation (OR = 3.459), and the length of intensive care unit (ICU) stay (OR = 2.334) as predictors of infection with NDM-1 K. pneumoniae. ConclusionIn this study, the previous use of antibiotics, the use of a urinary catheter, the use of a central venous catheter, the use of mechanical ventilation, and ICU stay were shown to be predictors of infection with NDM-1 K. pneumoniae and were independent risk factors for infection with NDM-1 K. pneumoniae.

LINC-04. Optic pathway gliomas in children: an 18-year experience in a middle-income country

Abstract BACKGROUND: Optic pathway gliomas (OPGs) have favorable survival outcomes, but can have significant morbidity, from the tumor or from its treatment. This retrospective study sought to describe the clinical presentation and outcomes of children with OPGs at a tertiary center in a middle-income country. METHODS: Patients younger than 18 years diagnosed with OPGs between 2002-2020 at the Hospital Civil de Guadalajara in Mexico, were included. Survival analyses and logistic regression were used to determine risk factors for progression. RESULTS: Thirty patients were identified with a median age of six years. Common clinical characteristics at presentation included: visual accuracy impairment (40%), headache (23.3%), nystagmus (20%), endocrine disturbances (16.6%), and diencephalic syndrome (13%). Neurofibromatosis-1 was present in 23.3% of the patients. Eight patients underwent resection at diagnosis, 7 of them had secondary complications. One died during surgery due to catecholamine-resistant shock, and the other developed neuro-infection and died due to septic shock after surgery. Five children developed neurological or endocrine sequelae. Fifteen total patients received chemotherapy as their first line treatment. The 5-year progression-free survival was 77.9±10% and overall survival was 89.5±5%. Patients who received chemotherapy or targeted therapy as the first line of treatment had higher PFS compared to those who received other therapies (p=0.03). The patients who received surgery as first-line treatment had a 3.1 times greater risk of achieving a Lansky/Karnofsky score of fewer than 90 points 6 months after diagnosis (p=0.006). Ten patients had pre- and post-treatment ophthalmologic assessment, either visual acuity or visual evoqued potentials. Five had no changes and 5 showed improvement after treatment. CONCLUSIONS: These results show inferior outcomes compared to high-income countries, influenced importantly due to morbidity after surgical resection. These data can be used to prospectively optimize treatment at our institute and other middle-income countries through a multidisciplinary neuro-oncology team.

MO416: Predicting Serum Bicarbonate in Non-Dialysis Dependent CKD Patients

Abstract BACKGROUND AND AIMS Metabolic acidosis (HCO3 &amp;lt; 22 mmol/L) is associated with an increased hazard of death in patients with chronic kidney disease (CKD) [1, 2]. It is further associated with muscle wasting, bone disease, hypoalbuminemia, increased inflammation, protein malnutrition, and progression of CKD [3]. Hospital Civil de Guadalajara is an urban public hospital serving a population of low socioeconomic status for whom HCO3 measurements are not included in their healthcare services and create costs around 70% of which our population cannot afford. We aimed to develop a model allowing us to predict HCO3 in CKD patients and tested its diagnostic performance. METHOD Patients at CKD stage 3–5 from our pre-dialysis clinic were included in this retrospective, cross-sectional study which served as a model development. Creatinine, weight, height, calcium, phosphorus, sodium, potassium, chloride, urea, presence of diabetes, total body water calculated by the Watson equation and eGFR calculated with the CKD-EPI formula were utilized. We performed uni- and multivariate linear regression between measured serum HCO3 and the available variables. A hypothesis-driven step-wise approach for parameter inclusion based on the Akaike Information criterion and optimization of the coefficient of determination was employed to construct the final model predicting serum HCO3. Diagnostic performance for detecting metabolic acidosis using the estimated HCO3 (eHCO3) was evaluated by receiver operating characteristics curve (ROC) analysis and computation of sensitivity, specificity and the positive and negative predictive values (PPV, NPV). Post-test probabilities at different pre-test probabilities (prevalence) were assessed using Bayes’ theorem. RESULTS We screened 1089 patients and included 284 patients [62 (21 IQR), 56% male, 69±14kg, 27% at CKD stage 3 and 34% and 40% at stage 4 and 5, respectively] in the analysis. The final model [eHCO] = 21.47 + 0.61 Ca + 0.43 Na + 0.95 TBW-0.61 Pi-0.51 K-0.53 Cl-0.008 Urea + 0.95 If diabetic had an adjusted R2:0.57, RMSE 2.4 on 275df, P-value: &amp;lt;0.001. The mean difference between HCO3 and eHCO was 0 (95% CI −4.9 to 4.9). Diagnostic performance quantified as AUC ROC 0.87 (95% CI 0.83–0.91). At a prevalence of metabolic acidosis of 56% with a chosen threshold of 20 mEq/L, the model has a sensitivity of 56% and specificity of 95% and a PPV of 94% and NPV of 63%, at a prevalence of 56%. Simulation of the post-test probabilities using Bayesian analysis is shown in Figure 1. CONCLUSION At a considerably high specificity of 95%, we can make predictions with a relatively low risk of treating subjects without metabolic acidosis with bicarbonate. Given the cost saving for the patients and the added insights and diagnostic capability, we believe that the prediction of serum HCO3 by biochemical parameters as done in our model will prove useful in settings with limited resources such as our uninsured urban population in Mexico. Validation of our model is the next step and planned future research.

MO324: Serum Potassium Trajectory During AKI and Mortality Risk

Abstract BACKGROUND AND AIMS Kidneys play a primary role in potassium homeostasis. The association between potassium (sK+) level and mortality or the need for kidney replacement therapy (KRT) during acute kidney injury (AKI) has not been adequately explored. METHOD In this prospective cohort study, AKI patients admitted to the Hospital Civil de Guadalajara were enrolled from August 2017 to June 2021 with AKI. We divided patients into eight groups based on the serum potassium level trajectories up to 10 days following hospitalization: (1) normokalemia (normoK), defined as sK + values between 3.5 and 5.5 mEq/L; (2) corrected hyperkalemia (hyperK), sK+ &amp;gt; 5.5 mEq/L on hospital admission and decreased to normoK; (3) corrected hypokalemia (hypoK), sK+ &amp;lt; 3.5 mEq/L on hospital admission and increased to normoK; (4) fluctuating potassium, sK + increased/decreased in and out of normoK parameters; (5) uncorrected hypoK, sK+ &amp;lt; 3.5 mEq/L; (6) normoK to hypoK, sK + that were normal on hospital admission and decreased to hypoK and never went back to normal; (7) normoK to hyperK, sK + that were normal on hospital admission and increased to hyperK and never went back to normal; and (8) uncorrected hyperK, sK+ &amp;gt; 5.5 mEq/L. We assessed the association of serum potassium trajectories with mortality and the need for KRT (secondary objective). RESULTS A total of 311 AKI patients were included. The mean age was 52.6 years, and 182 (58.6%) were male. AKI stage 3 was present in 199 (63.9%). KRT started in 112 (36%) patients, and 66 patients (21.2%) were died. After adjusting for confounders, 10-day hospital mortality was significantly higher in group 7 and 8 (OR 1.37 and 1.63; P = &amp;lt; .05 for both, respectively), and KRT initiation was higher only in group 8 (OR 1.40; P = &amp;lt; .05) compared with group 1. Mortality in different subgroups of patients in group 8 did not change the primary results. CONCLUSION In our prospective cohort, most patients with AKI had alterations in sK + . NormoK to hyperK and uncorrected hyperK were associated with death, while only uncorrected hyperK was correlated with the need for KRT.

Clinical characteristics and functional outcome of pediatric ocular trauma in a third level reference hospital in Guadalajara, Mexico.

Ocular trauma is one of the leading causes of decreased visual acuity and monocular blindness in the pediatric population. Since its occurrence is potentially preventable, it is essential to understand its demographic characteristics and risk factors to alert and implement prevention and health promotion programs. We conducted a retrospective study in which we reviewed 187 clinical records of patients ≤ 15 years old with the diagnosis of severe ocular trauma admitted in 2017 to the Hospital Civil de Guadalajara. We analyzed demographic variables, circumstances of the event, type of treatment, and the evolution of visual acuity and complications. In total, 187 patients and 188 eyes were included; the average age was 6.99 ± 4.1 years. Children of 2 to 5 years of age (41%) were the most affected, and a higher occurrence was observed in males (73%). Open ocular trauma was the most common type of injury (72.7%) caused by sharp objects (45.4%). Most injuries occurred at home (78.1%), without adult supervision (48.1%), and during leisure time (74.9%). Most events were accidental (80.4%), although 12.3% were direct aggression. Surgery was required in 179 patients, in whom corneal injury repair (43.2%) was the most commonly used procedure. Final visual acuity was quantified in 132 eyes, and visual acuity < 20/200 was found in 18.1%. Loss of 4.2% of the eyeballs was recorded. The highest proportion of cases was identified in male patients ≤5 years old, unsupervised by an adult. Many eye injuries are preventable, so it is necessary to implement socio-educational programs in alliance with pediatric organizations that alert the severity of the problem and promote safe environments.

649. Evaluation of the NG-Test CARBA 5® in Enterobacteriaceae and P. aeruginosa from Clinical Isolates

Abstract Background Identification of carbapenemase-producing organisms like Enterobacteriaceae and P. aeruginosa is important for treatment decisions and infection control. Identification methods require time and technical training. Lateral flow immunoassay NG-Test CARBA 5® exempt these needs. In Mexico there is no evaluation of it on clinical isolates. It is important to define their diagnostic accuracy. Methods We collected 103 clinical strains of Enterobacteriaceae and P. aeruginosa resistant to carbapenems, from 2019 to 2020 from: National Institute of Rehabilitation (INR), National Institute of Cancerology, General Hospital Dr. Manuel Gea González and Hospital Civil de Guadalajara Fray Antonio Mayor. Analyzed in INR’s microbiology laboratory, resistance was corroborated with broth Microdilution Method (CLSI 2020). The carbapenemases was demonstrated by phenotypic methods (CLSI 2021). A homemade PCR was done and sequencing for encoding genes: NDM, KPC, GES, VIM, IMP and OXA-48-like. We analyzed concordance of the NG-Test CARBA 5® versus PCR with kappa coefficient. Results Seven discarded, 96 strains entered the analysis: Enterobacteriaceae (73%), P. aeruginosa (27%) (Table1). The carbapenemase-producing organisms were: 1) 56 Enterobacteriaceae, 30% Class B; 2) 23 P. aeruginosa, 90% Class B. NG-Test CARBA 5® for Enterobacteriaceae demonstrated greater sensitivity, specificity, and NPV (table 2). Kappa coefficient of concordance was 0.92 for Enterobacteriaceae and 0.59 for P. aeruginosa (table 2), and discrepancies in table 3. Sequencing of carbapenemase-producing organisim can be find in table 4. Title 1. Clinical isolates by hospital N: No carbapenem-producing, Gea: General Hospital Dr. Manuel Gea González, Civil GDL: Hospital Civil de Guadalajara, INCAN: National Institute of Cancerology, INR: National Institute of Rehabilitation. Table 3. Discrepancies Enzyme gene secuencing Conclusion The most frequent enzyme were Ambler Class B, consistent with national reports. Sensitivity and specificity was like reported in other series. In P. aeruginosa, errors have already been reported in IMP-type enzymes, ours mainly with IMP-75. To our knowledge there are no reports of the following enzyme variants identified by NG-Test CARBA 5®: KPC-82, VIM-67, IMP-62, and IMP-75. NG-Test CARBA 5® showed high concordance with PCR for Enterobacteriaceae, it has the advantage of being a quick and easy-to-use detection tool. In P. aeruginosa despite the results without solid evidence, we recommend complementing the test with other phenotypic identification tests. Table 2. Kappa Concordance Coefficient of NG-Test CARBA 5® and PCR Se: sensitivity, Sp: specificity, PPV: positive predictive value, NPV: negative predictive value Disclosures All Authors: No reported disclosures

Prevalence and risk factors of chronic kidney disease in an HIV positive Mexican cohort

BackgroundHIV subjects have several kidney pathologies, like HIV-associated nephropathy or antiretroviral therapy injury, among others. The global prevalence of Chronic Kidney Disease (CKD) is 8–16%; however, in HIV subjects, the prevalence varies between geographic regions (2–38%). The aim was to determine the prevalence of CKD and identify the associated risk factors.MethodsA longitudinal descriptive study was carried out at the 'Hospital Civil de Guadalajara' Feb'18 – Jan'19. Basal clinical, demographic, opportunistic infections (OI), and laboratory data were obtained at months 0 and 3; inclusion criteria were ≥ 18 years old, naïve HIV + , urine albumin/creatinine ratio, serum creatinine & urine test, and signed informed consent. Descriptive and multiple logistic regression statistical analyses were made.ResultsOne hundred twenty subjects were included; 92.5% were male, 33 ± 9.5 years, 60% consumed tobacco, 73% alcohol, and 59% some type of drug. The CKD prevalence was 15.8%. CKD patients had a higher risk of hepatitis C virus coinfection, Relative Risk (RR):5.9; HCV infection, RR:4.3; ≥ 30 years old, RR:3.9; C clinical-stage, RR:3.5; CD4+ T cells count < 200 cells/μL, RR: 2.4; and HIV-1 viral load ≥ 100,000 cop/mL, RR: 2.7.ConclusionsOur study showed a higher CKD prevalence in patients with HIV; higher CKD development with coinfections as Hepatitis C Virus and Mycobacterium tuberculosis. The identification and prompt management of CKD and coinfections should be considered to avoid the progression and to delay renal replacement therapy as long as possible.

Palliative Care in Pediatric Pulmonology

Children with End Stage Lung Disease (ESLD) are part of the growing population of individuals with life-limiting conditions of childhood. These patients present with a diverse set of pulmonary, cardiovascular, neuromuscular, and developmental conditions. This paper first examines five cases of children with cystic fibrosis, bronchopulmonary dysplasia, neuromuscular disease, pulmonary hypertension, and lung transplantation from Texas Children’s Hospital. We discuss the expected clinical course of each condition, then review the integration of primary and specialized palliative care into the management of each diagnosis. This paper then reviews the management of two children with end staged lung disease at Hospital Civil de Guadalajara, providing an additional perspective for approaching palliative care in low-income countries.