Health in Brazil 5 Violence and injuries in Brazil: the effect, progress made, and challenges ahead

Although there are signs of decline, homicides and traffic-related injuries and deaths in Brazil account for almost two-thirds of all deaths from external causes. In 2007, the homicide rate was 26.8 per 100 000 people and traffic-related mortality was 23.5 per 100 000. Domestic violence might not lead to as many deaths, but its share of violence-related morbidity is large. These are important public health problems that lead to enormous individual and collective costs. Young, black, and poor men are the main victims and perpetrators of community violence, whereas poor black women and children are the main victims of domestic violence. Regional differentials are also substantial. Besides the sociocultural determinants, much of the violence in Brazil has been associated with the misuse of alcohol and illicit drugs, and the wide availability of firearms. The high traffic-related morbidity and mortality in Brazil have been linked to the chosen model for the transport system that has given priority to roads and private-car use without offering adequate infrastructure. The system is often poorly equipped to deal with violations of traffic rules. In response to the major problems of violence and injuries, Brazil has greatly advanced in terms of legislation and action plans. The main challenge is to assess these advances to identify, extend, integrate, and continue the successful ones.

THE ROLE OF INNATE IMMUNITY IN SEPTIC ACUTE KIDNEY INJURIES

Acute kidney injury (AKI) is an important clinical syndrome characterized by abnormalities in the hydroelectrolytic balance. Because of high rates of morbidity and mortality (from 15% to 60%) associated with AKI, the study of its pathophysiology is critical in searching for clinical targets and therapeutic strategies. Severe sepsis is the major cause of AKI. The host response to sepsis involves an inflammatory response, whereby the pathogen is initially sensed by innate immune receptors (pattern recognition receptors [PRRs]). When it persists, this immune response leads to secretion of proinflammatory products that induce organ dysfunction such as renal failure and consequently increased mortality. Moreover, the injured tissue releases molecules resulting from extracellular matrix degradation or dying cells that function as alarmines, which are recognized by PRR in the absence of pathogens in a second wave of injury. Toll-like receptors (TLRs) and NOD-like receptors (NLRs) are the best characterized PRRs. They are expressed in many cell types and throughout the nephron. Their activation leads to translocation of nuclear factors and synthesis of proinflammatory cytokines and chemokines. TLRs` signaling primes the cells for a robust inflammatory response dependent on NLRs; the interaction of TLRs and NLRs gives rise to the multiprotein complex known as the inflammasome, which in turn activates secretion of mature interleukin 1 beta and interleukin 18. Experimental data show that innate immune receptors, the inflammasome components, and proinflammatory cytokines play crucial roles not only in sepsis, but also in organ-induced dysfunction, especially in the kidneys. In this review, we discuss the significance of the innate immune receptors in the development of acute renal injury secondary to sepsis.