Renal Insuficiency Research Articles

In-Depth Review of the Influence of Renal Insuficiency on Major Adverse Cardiovascular Event (MACE) and Mortality in Patients with Acute St-Segment Elevation Myocardial In- farction (STEMI)

The widespread implementation of invasive procedures such as coronary angiography and primary percutaneous coronary intervention (PCI) into the routine management of patients with acute ST-segment elevation myocardial infarction (STEMI) in the last 10 years has led to a significant improvement in patient prognosis. At the same time, this also raises new problems and questions, mostly related to the fact that there are many elderly patients and/or patients with comorbidities who need to undergo this invasive procedure. One of the most important comorbidities is renal insufficiency. STEMI patients with renal insufficiency typically present with more extensive atherosclerotic lesions, including diffuse coronary calcification, which poses a challenge to the interventional cardiologist due to a higher risk of periprocedural complications, higher risk of restenosis, major adverse cardiovascular event (MACE) , and patient mortality. This review discusses in depth the influence of renal insufficiency on MACE and mortality in STEMI patients. Keywords: renal insufficiency, STEMI, MACE, mortality.

Maillard reaction. Pathogenic effects.

Certain organoleptic modifications by way of processing and cooking foods at high temperatures in dry heat, make them especially appetizing and objects of addiction. It results from Maillard reaction, or glycation, consisting of the non-enzymatic union between carbonyl groups, mainly from reducing sugars as glucose and fructose, with the amino group of proteins and nucleic acids. In addition to physical changes, also the chemical structure and function of these compounds are changed. Besides exogenous glycation generated during the cooking of foods, recently in situ glycation has been reported in the intestinal lumen during digestion, when certain non-glycated foods are combined with fructose at the time of ingestion. In addition, endogenous glycation, which correlates in the extracellular mainly with blood glucose and in the intracellular with glycolysis metabolites and fructose, is specially significant. Since the 70s, with the frequent sucrose replacement by fructose, much more reactive than glucose, the presence of glycation products in processed foods and soft drinks increased.Pathogenic effects of these compounds, also called glycotoxins, are known to contribute to oxidative stress and inflammation. This increases progression of chronic diseases, well documented in diabetes, renal insuficiency, cardiovascular disease and aging process, and are being explore d in many other chronic diseases as neurodegenerative disorders and early aging. Based on the knowledge achieved so far, measures to preserve health are described by attending ways of cooking and processing foods, besides recommendations for life habits and antioxidants dietary intakes for inhibition or antagonism on glycotoxins.

Socio-Demographic Features and Societal Perspective of Relapse and/or Refractory Multiple Myeloma (RRMM) Patients in Spain: An Interim Analysis of Charismma Study

IntroductionMultiple myeloma (MM) is a plasma cell malignancy, with a range of clinical features including hypercalcaemia, renal insuficiency, anaemia and bone lesions1 (CRAB). MM progression often involves multiple rounds of remissions after treatment followed by subsequent relapses2. Although MM accounts for only a small percentage of all cancer types, the costs associated with treating and managing it are among the highest3.RRMM population is heterogeneous, their characteristics depend on the number and type of treatment used, and the type of relapse3.Selection of treatment for MM patients is challenging due to increased age and the often associated comorbid conditions4. RRMM patients are more symptomatic, vulnerable to adverse events and, more likely to incur a dose reduction or early discontinuation of therapy. Balancing expected efficacy of therapy vs potential toxicities, health care resources and impact on patients' Health Related Quality of Life (HRQOL) is therefore critical in this patient population5.CharisMMa study objective (NCT03188536) is to understand and provide an accurate epidemiological and societal characterization of RRMM patients. Hematologist's choice of therapeutic strategy is crucial, and must be made in consideration of the patient as a whole, and not only in terms of their disease.MethodsCharisMMa is an observational, cross-sectional, multicentre study, involving 30 public hospitals around Spain, which include MM patients that require treatment at any relapse of the disease. An interim analysis has been conducted evaluating socio-demographic characteristics and burden of the disease in the 169 patients with relapse/refractory MM enrolled up to June 2018 (expected n=350). On average, information was collected 2.15 (SD: 1.76) months after the last relapse.ResultsThe median age in the moment of the study visit, was 69.0 (57.0, 75.0) years, being 55.2% male. 71.8% of them lived in urban areas and 88% with their families. Most of them were retired (64.2%) and non-dependent (73.1%). Patients included have been treated with a median of 2.0 (1.0, 3.0) previous lines. Approximately half of them (56.7%) had received stem cell transplant (97.8% autologous). The stage ISS was I (36.3%), II (35.6%) and III (28.1%) and 74.0% presented CRAB symptoms, being bone lesions (65.6%) the most frequent ones. 85.4% were considered intermediate or high risk patients presenting extramedullary plasmocytomas in 16.5% of the cases. 67.5% of the patients suffered from any comorbidity, being the most frequent one cardiovascular (48.1%), diabetes (23.1%) and neuropathy (22.1%).Symptomatic patients are treated mainly with doublets both in second (59.7%) and third/+ lines while those asymptomatic ones with no CRAB symptoms at relapse are treated with doublets in second but with monotherapy (62.5%) in third/+ lines (Table 1).In terms of societal perspective, on average, patients are living 23.9 (40.4) km far from their hospital and they attend 5.4 (5.0) times per month in order to visit the haematologist being 3.8 (2.7) times treatment related. In most of the visits (90.3%) patients attended accompanied by a caregiver who is occupationally active (57.4%). Only during the last relapse patients have been admitted 1.5 (1.0) times to the hospital having spent 15.2 (15.5) days until discharge. The patients are also visiting other specialist during the last relapse due to the disease as primary health care professionals (21.3%), psychologists (4.7%) and others (33.1%).ConclusionsThe heterogeneity in the MM patient´s characteristics is a major factor that should be considered during the management and the evolution of the disease and it has a direct impact in the resources needed. An individual approach including patients and disease characteristics should be considered in order to maximize clinical outcomes and guarantee an appropriate use of the resources in order to maximize patient´s benefit and reduce indirect costs of the disease.ReferencesPalumbo, K. Anderson. N. Engl. J. Med. 364 (2011)1046-1060.National Cancer Institute. SEER Program. Cancer stat facts: myeloma. 2016. Available at https://seer.cancer.gov/statfacts/html/mulmy.htmlLaubach J et al. Leukemia 2016; 30(5):1005-1017.Sonneveld P, Broijl A. Haematologica 101(4):396-406.Larocca A, Palumbo A. Blood 2015; 126 (19):2179-2185. [Display omitted] DisclosuresOcio:BMS: Consultancy; Seattle Genetics: Consultancy; AbbVie: Consultancy; Pharmamar: Consultancy; Janssen: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Sanofi: Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Mundipharma: Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Array Pharmaceuticals: Research Funding. Rosinol:Janssen, Celgene, Amgen, Takeda: Honoraria. Grande:Takeda: Employment. Ruiz-Zorrilla:Takeda: Employment. Fernandez:Takeda: Employment. Montoto:Takeda: Employment.

Case report: patient with Weil’s disease, chest pain, hepatitis b, hepatorenal syndrome, and electrolyte imbalance

A 48-years-old man was hospitalized due to febrile for 5 days accompanied by headache and left chest pain radiating into the back. Pain calf, abdominal pain and tea color urine has occured since 1 week before admission. Physical examination revealed temperature 38.5° C, conjungtival suffusion, jaundice sclera, irregularheart sound, hepatomegaly, gastrocnemius tenderness, Faine score 23. Laboratory tests showed leukocytosis, thrombocytopenia, elevated transaminase enzyme, ureum 181 mg/dl, creatinine 4.3 mg/dl, albumin 2.4 g/dl, sodium 110 mmol/L, potassium 2.3 mmol/L, reactive HbsAg, CKMB 68.06 ng/ml, increased HBV-DNA, negative IgM anti Leptospira. MAT demonstrated 4 positive serovar. Electrocardiography revealed AF rapid ventrikel response. Chest x-ray showed cardiomegaly. Abdominal ultrasound revealed hepatomegaly with chronic parenchimal liver disease, renal insuficiency. Fibroscan showed severe fibrosis. Patient was diagnosed with Weil’s disease and hepatorenal syndrome as complication. Patient was given clavulanate amoxicillin injections. This patient was not dialysis, only fluid balance monitoring and checked ureum-creatinine per 3 days, and there was improvement of ureum-creatinine. Hepatorenal syndrome in Weil’s disease contributed to electrolyte imbalance. In addition, chronic hepatitis B on this patient was treated with tenofovir.

Tratamento endovascular da isquemia crónica dos membros inferiores dos doentes em hemodiálise: resultados clínicos

IntroductionThe peripheral vascular atherosclerotic disease is a characteristic complication in patients with end‐stage renal disease (ESRD) and shows a particular predilection for diffuse, calcifying and infra‐popliteal involvement. Despite the advances in endovascular revascularization, the clinical efficacy in these patients is limited and poor results are expected. PurposeDetermine the clinical outcomes after endovascular revascularization for chronic limb ischemia in patients with ESRD on dialysis and compare the results with patients not on dialysis. Material and methodsWe retrospectively evaluate the results of patients who underwent endovascular revascularization for chronic limb ischemia, between January 2010 and December 2013. The patients were divided into two groups: those with normal renal function and those with end stage renal disease on dialysis. The primary end points were: limb salvage and mortality and the secondary endopoints: technical success, wound healing rate, time for wound healing and complications. ResultsOf the total of 217 patients, 32 patients were excluded due to absence of data and 9 patients with renal insuficiency but not end‐stage. 176 patients underwent endovascular revascularization (a total of 182 limbs, median age of 65 years old, 78% males). 45 patients were on dyalisis program. Median follow‐up was 26,6 months.In patients with Rutherford categories 4, 5 and 6, the limb salvage rate, at 12 months, was 90,4% in patients not on dialysis, and 69,6% in patients on dialysis. The survival rate at 12 monts was lower in patients on dialysis (86% vs 97,1%)The wound healing rate was also lower in patients on dialysis (60% vs 80%) and with longer median healing times (96 vs 61 days) DiscussionThe presence of end stage renal disease is associated with a higher rate of limb loss and mortality. Despite the discouraging results, for these patients, it should be offered the less invasive endovascular revascularization treatment and an earlier referral.

Analysis of the characteristics of patients suffering from acute kidney injury following severe trauma receiving renal replacement therapy

To analyze the characteristics of severe trauma patients with acute kidney injury (AKI) receiving renal replacement therapy (RRT), in order to look for the risk factors of AKI and the opportune time for the initiation of RRT on prognosis. A retrospective cohort study involving consecutive patients with severe trauma in emergency intensive care unit (ICU) in the Second Affiliated Hospital of Zhejiang University School of Medicine, from August 2011 to December 2014, was conducted. Inclusion criteria included age≥18 years, injury severity score (ISS) > 16, AKI receiving RRT, and the duration of hospital stay > 24 hours. The general data, the risk factors of AKI, the prognostic indicators, and the information of RRT were recorded. All patients were divided into two groups according to the prognosis, the time of onset of AKI and the initiation time of RRT. The independent risk factors for prognosis were screened by binary logistic regression analysis. Seventy-three patients were eligible for enrollment, including 48 deaths ( 65.8% ); 49 patients suffered from AKI≤48 hours after trauma (early stage group), and in 24 patients it was longer than 48 hours (late stage group). In 55 patients RRT was routinely started (routine RRT group), 18 patients underwent RRT ahead of routine criteria decided by the judgment of the attending doctor ( earlier RRT group). The main risk factors of RRT in traumatic patients with AKI were shock and sepsis, each accounted for 90.4% and 53.4%. Compared with survival group, in death group, the proportion of male patients was lower (70.8% vs. 100.0%, χ² = 7.238, P = 0.007), acute physiology and chronic health evaluation II ( APACHEII) scores were higher (23.7±5.1 vs. 14.4±3.7, t = 8.031, P < 0.001), Glasgow coma score (GCS) was lower [5.0 (3.0, 15.0) vs. 15.0 (8.0, 15.0 ), U = 320.000, P = 0.001 ], incidence of shock and sepsis was higher (97.9% vs. 76.0%, χ² = 6.755, P = 0.009; 64.6% vs. 32.0%, χ² = 7.014, P = 0.008), the rate of use of contrast medium was lower (27.1% vs. 56.0%, χ² = 5.898, P = 0.015), the time for the diagnosis of AKI post trauma was delayed [ days: 2 (1, 5) vs. 2 (1, 2), U = 762.000, P = 0.049 ], the time for the initiation of RRT post trauma was later [ days: 6.0 (3.0, 12.0) vs. 3.0 (2.0, 4.5), U = 868.500, P = 0.002 ], the recovery rate of renal function at discharge was lower (10.4% vs. 100.0%, χ² = 54.497, P < 0.001). Compared with late stage group, in early stage group, the mortality was lower (55.1% vs. 87.5%, χ² = 7.509, P = 0.006 ), and the incidence of sepsis before AKI was also lower (38.8% vs. 83.3%, χ² = 12.854, P < 0.001). Compared with routine RRT group, the recovery of renal function at discharge was better with a lower mortality rate in the earlier RRT group, but the difference was considered to be insignificant ( 55.6% vs. 36.4%, χ² = 2.064, P = 0.151; 50.0% vs. 70.9%, χ² = 2.633, P = 0.105). Logistic regression analysis showed GCS [odds ratio (OR) = 0.852, 95% confidence interval (95%CI) = 0.747-0.972, P = 0.017], shock before AKI (OR = 85.350, 95%CI = 5.682-1 282.073, P = 0.001), and sepsis before AKI (OR = 11.499, 95%CI = 2.127 - 62.161, P = 0.005) were independent risk factors for the judgment of prognosis. Shock and sepsis are the major risk factors of RRT in trauma patients with AKI. Shock, sepsis and traumatic brain injury are the independent risk factors of death. Perhaps early initiation of routine RRT cannot improve the outcome of the patients with posttraumatic renal insuficiency.

CALCINOSE CUTIS, INSUFICIÊNCIA RENAL E HEPARINAS DE BAIXO PESO MOLECULAR CONTENDO CÁLCIO

Foi solicitada observação por Dermatologia de uma doente de 35 anos de idade, de raça negra, por 2 nódulos subcutâneos localizados na região paraumbilical direita e flanco direito com 2 semanas de evolução. Da história prévia, destaque para doença renal crónica em programa de hemodiálise e infeção pelo vírus da imunodeficiência humana (VIH-1). Ao exame objetivo observaram-se 2 nódulos bem delimitados, subcutâneos, sem alteração da coloração; à palpação, estes eram dolorosos, de consistência pétrea e não aderentes aos planos profundos. Foi realizada biópsia incisional para exame histopatológico, que confirmou a hipótese diagnóstica de calcinose cutis. Uma revisão cuidadosa de toda a medicação realizada permitiu estabelecer a relação entre este achado e a administração subcutânea de nadroparina cálcica nessa localização, umas semanas antes. A dermatose regrediu espontaneamente em 2 meses após a suspensão das injeções subcutâneas de nadroparina cálcica. A calcinose cutis devida à administração de heparinas de baixo peso molecular contendo cálcio é rara, admitindo-se que elevação do produto fósforo-cálcio possa ser determinante na sua fisiopatologia. É geralmente autolimitada, resolvendo espontaneamente.

BPC 157 Counteracts Gastric Lesions after Bilateral Nephrectomy and Attenuates Deleterious Course in Rats

Aim. Stable gastric pentadecapeptide BPC 157 is an antiulcer peptide tested in clinical trials, for inflammatory bowel disease and multiple sclerosis, effective against a variety of different ulcerogens, NSAIDs, absolute alcohol, restraint stress, insulin, alloxan, acute pancreatitis. However, BPC 157 was not tested against gastric lesions that might be induced with bilateral nephrectomy. Of note, chronic renal insuficiency might be associated with increased peptic ulcer presentation. Materials and methods. Rats were subjected to bilateral nephrectomy, sacrificed at 24h and at 48h, BPC 157 was given (10µg/kg, 10ng/kg i.p.) immediately after nephrectomy and 24h after nephrectomy. Assessment included gastric lesions, gross clinical presentation, urea, creatinine, AST, ALT, bilirubin, K, Na, Mg, Ca, inorganic phosphates in serum as described (Sikiric et al, Curr Pharm Des. 2014;20(7):1126‐35). Results. Gastric lesions were consistently attenuated (means±SD, sum of the longest lesions diameters, 1.8±0.5 mm µg (24h), 1.0±0.5 mm µg (48h) vs. 10.5±1.5 mm control (24h), 15.0±3.0 mm control (48h), *P&lt;0.05, at least, the increased values of the urea, creatinine, AST, inorganic phosphates were lessened while K, Na, Mg, Ca, were not affected. All controls rats were edematous (scored 0‐3) (Min/Med/Max, scored 3/3/3) while BPC 157 were markedly less affected (scored 1/1/1 µg, at 24h and 48h; 1/1/1 ng, at 24h and 48h). Conclusions. Applied after nephrectomy, the deleterious course was attenuated after BPC 157 administration, and particularly, gastric lesions markedly attenuated. Supported by Grant 108‐1083570‐3635, Croatia.

CLINICAL AND ECONOMIC ANALYSIS: FIXED COMBINATION PERINDOPRIL ARGININE/INDAPAMIDE RETARD VERSUS «TRADITIONAL TREATMENT» IN HYPERTENSIVE PATIENTS WITH RENAL INSUFFICIENCY

Objective. To perform a clinical and economic analysis in order to assess the beneits of antihypertensive and renal protective effects of the ixed combination perindopril arginine and indapamide in versus «traditional therapy» in hypertensive patients with renal insuficiency. Design and methods. We evaluated an indicator «costs-eficiency» by the cost of increase of glomerular iltration by 1 ml/hour (by Cockcroft-Gault formula, in each of group and decrease by 1 mg/l of proteinuria in both groups. Results and conclusions. Fixed combination of perindopril arginine/indapamide is economically beneicial according to the index «costs-eficiency» compared to traditional therapy.

Post-Transplant Long Term Management of Patients with Pre-Liver Transplantation Renal Insuficiency

Objective: Pre liver transplant renal insufficiency is a risk factor for bad outcome after liver transplantation (LT). The aim of this study is to analyze the long term management of these patients and to compare them with patients without renal insufficiency. Material and methods: From 1990 to 2010, 933 liver transplantations in 857 patients have been performed in our Unit. 149 patients (Group A) had pre-liver transplant renal insufficiency (creatinine >1,5mg/dl) and 679 patients (Group B) did not. Differences in pre-LT characteristics, postoperative management and outcome have been analysed between both groups. Results: Patients in Group A had more severe UNOS/Child-Pough status, had less HCV and HCC as indication to LT, more arterial hypertension and pre-LT cardiac complications, received younger donors, stayed more days in ICU and suffered less acute rejections. Half of the patients were induced with absence or low doses of CNI + MMF + antiCD25. At 1 year more patients were still on double or triple therapy with MMF/mTORi and ST and at 5 years more patients were on regimens without or with low doses of CNI. Patients in Group A had higher creatinine values at 1,3,5,10years: (1,8±9 - 1,7±0,8 - 1,9±1,5 - 3,5±2,5 vs 1,6±1 - 1,4±0,7 - 1,3±0,5 - 1,5±1,2) and more need of dialysis (13%-8%-9%-0% vs 5%-1%-1%-3%). Patients who finally were submitted to kidney transplantation were 3 (2%) in Group A vs 5(0,7%) in Group B. Patient actuarial survival at 1y,3y,5y,10y were: 84-75-69-56 vs 69-65-58-47 (p=0.001). 54 patients died with or because renal failure, 20 (13,4%) in Group A and 34 (5%) in Group B, more than 2/3 during the first year. Conclusion: Pre-LT renal insufficiency is one of the major challenge in the postoperative management of liver transplantation. With individualised immunosuppression, longterm results are acceptable and the majority recovered renal function.

腎機能障害を呈したサルコイドーシス症例の検討

腎機能障害を呈したサルコイドーシス症例の検討

On 10-year experience in the use of direct and antireflux techniques of anastomosis of ureter and orthotopic intestinal neobladder after radical cystectomy

Today, radical cystectomy is the method of choice in treatment of muscle invasive bladder carcinoma in stage T2-T4a, No-Nx, Mo, and orthotopic derivation is for patients the most comfortable derivation of urin. From 1888 when Tizzoni and Foggi performed the first orthotopic derivation on animals, and 1913 when Lemoin declared the first orthotopic derivation in humans there has been a constant improvement and modification of orthotopic urinary diversion after radical cystectomy which significantly decrease the number and severity of postoperative complications. The aim of this study was to compare complications regarding the direct and antireflux ureter-neobladder anastomosis. This retrospective study included 79 selected patients operated over the last ten years having medical records available. Previously, we excluded the patients with prior radiation therapy, systemic illness, diabetes mellitus, previous history of calculosis and metabolic disorders etc. Hautmann orthotopic technique was used in almost 70% of the patients. We analyzed complications regarding direct and antireflux ureter-neobladder anastomosis with a median follow-up period of 4.72 years. We followed-up the appearance of unilateral and bilateral hydronephrosis, forming of renal stones in the patients without previous history of renal calculosis, and renal insuficiency caused by stenosis on the site of anastomosis. We used the Kolmogorov Smirnov test, Mann-Whitney U test, Student's ttest i chi2 test for statistic analysis. The median age of the patients was 68.2 years. Totally 88.61% of the patients were male and 11.39% were female. The direct anastomotic technique secundum Wallace was used in 43.03% of the operated patients and antireflux technique secundum Le Duc in 56.97%s. Renal deterioration caused by stenosis on the site of the ureter-neobladder anastomosis was statistically significantly higher in the antireflux anastomosis compared to direct anastomosis (chi2= 4.71, p = 0.0299). No one of the patients with direct anastomosis had poucho-ureteral reflux higher grade than gr III. In our study, complication as renal deterioration as a result of stenosis on the site of the ureter anastomosis was significantly more common in the group of patients exposed to antireflux technique.

Metastatic calcifications and severe hypercalcemia in a patient with parathyroid carcinoma

Primary hyperparathyroidism is rarely produced by parathyroid carcinoma. We present the case of a 63-yr-old man who was admitted due to recent onset of constipation, weakness and progressive lethargy. At physical examination, a left cervical mass was palpated. Marked hypercalcemia (serum calcium 25 mg/dl) (6.22 mmol/l) complicated by renal insuficiency (serum creatinine 4.4 mg/dl) (388 micromol/l) was found, but both were unresponsive to conventional therapy and hemofiltration. Autopsy examination showed a carcinoma of the upper left parathyroid gland, multiple foci of metastatic calficications in the vessel walls and parenchyma of both lungs and kidneys, and the myocardium, which contributed to multi-organ failure and death. In addition to describing the clinical presentation, we review the mechanism of metastatic calcifications as well as the role of renal function and hyperphosphatemia, and the basis for therapy of hypercalcemic crisis.

Soroprevalência e genótipos do vírus da hepatite C em pacientes com lúpus eritematoso sistêmico (LES) em Goiânia, Brasil

A infecção pelo vírus da hepatite C (HCV) desperta grande interesse em reumatologia por apresentar várias manifestações extra-hepáticas. Diversos estudos mostram associação elevada da infecção pelo HCV com manifestações reumáticas como dores musculares, crioglobulinemia mista, síndrome reumatóide, síndrome de Sjögren, vasculite, glomerulonefrite, fenômeno de Raynaud, poliarterite nodosa, miopatia, auto-anticorpos e outras manifestações de doença difusa do tecido conjuntivo. Em estudos anteriores realizados em nosso meio verificou-se a prevalência de 0,9% em gestantes, 1,4% em doadores de sangue, 1,8% em paciente com hanseníase e 2,0% em trabalhadores da área da saúde. OBJETIVO: determinar a prevalência da infecção pelo HCV em pacientes com lúpus eritematoso sistêmico (LES) atendidos no Serviço de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Goiás (HC-FM-UFG). MÉTODOS: foram entrevistados 175 pacientes com LES e amostras sangüíneas coletadas. Inicialmente, pesquisou-se a presença de anticorpos para o HCV (anti-HCV). As amostras anti-HCV positivas foram submetidas à detecção do RNA viral, pela reação em cadeia da polimerase (PCR) com primers complementares à região 5' não codificante do HCV. As amostras positivas foram genotipadas por line probe assay. RESULTADOS: a prevalência encontrada foi de 2,3% (4/175), e a identificação dos genótipos nas amostras RNA-HCV positivas revelou a presença do tipo 1 do HCV em três pacientes (75%) e do tipo 3 em um paciente (25%). Das quatro pacientes infectadas, três apresentaram evolução clínica favorável e uma evoluiu para óbito em razão de insuficiência renal por nefrite lúpica. CONCLUSÕES: a prevalência de HCV em pacientes com LES revelou-se um pouco maior que a encontrada anteriomente em gestantes, doadores de sangue e em hansenianos, comparável à encontrada em trabalhadores da saúde.

Reversal of advanced renal dysfunction on bortezomib treatment in multiple myeloma patients

6714 Background: Bortezomib is a highly active agent in multiple myeloma. Advanced stages of multiple myeloma are freqeuntly associated with progressive renal failure. We report here 6 cases of acute advanced deterioration of renal function on prior renal insuficiency in chronic MM patients, with complete or near complete reversal of severe renal dysfunction after treatment with Velcade and Dexamethasone. Methods: Pts received Velcade 1.0 mg/m2/d IV d1,4,8,11 and Dexamethasone 20 mg IV d1,4,8,11. Results: Rapid reversal of acute deterioration of renal dysunction was demonstrated after treatment with Velcade and Dexamethasone in this retrospective review of patient cases. Improvement of renal function was generally evident quickly, often less than 2 weeks, earlier than expected from general myeloma tumor response. A review of a trial of treatment with Velcade where Dexamethasone was added in later cycles may address possible evidence of synergy of Velcade and dexamethasone in reversal of renal dysfunction....

IgA nephropathy

IgA nephropathy is glomerular disease first described in 1968 by Berger, named after him Morbus Berger. The disease is characterized by the presence of IgA dominant or codominant immunoglobulin deposits in glomerular mesangium which can be demonstrated by immunofluorescence. Clinical manifestations of IgA nephropathy in the majority of cases is hematuria which can be macro or microscopic, isolated or combined with proteinuria which can be of nephrotic range. In some cases nephrotic syndrome can be the first clinical presentation. In 10% renal insufficiency can be present at the onset of the disease. By light microscopy IgA can manifest any of the histologic phenotypes of immune complex mediated proliferative glomerulonephritis. According to light microscopy findings a classification system have been used to categorize the histologic patterns of IgA nephropathy. Glomerular changes in IgA nephropathy are proliferative and can be focal or diffuse accompanied by crescentic formation in many cases. Immune deposits seen by electron microscopy appear as electron dense deposits most numerous in mesangium.

Growth velocity, final height and bone mineral metabolism of short children treated long term with growth hormone.

Since human recombinant growth hormone (GH) became available a large number of short GH deficient and GH-sufficient children have been treated with growth hormone. Growth hormone deficient patients have been followed to final height and several studies have shown that even when treated with GH from very early on in life they tend to end up shorter than their target height. There is, however, a clear increase in their growth velocities particularly during the first 4-5 years of GH therapy so that patients end up with a height-SD score of aproximately -0.8. Recent studies have demonstrated decreased bone mineral densities (BMD) in children with growth hormone deficiency, both by areal and volumetric analysis. Therapy with growth hormone clearly increases their BMD with an increase in bone formation markers, as will be reviewed in detail. Growth hormone therapy of non-growth hormone deficient short children has increased their growth velocity short term, particularly in girls with Turner's syndrome and in children with chronic renal insuficiency. Recent final height data by Rosenfeld et al. and by Swedish and Dutch groups have demonstrated a gain of 8-12 cm in girls with Turner's syndrome treated with GH or with a combination of GH and oxandrolone. Neely et al. and we have demonstrated that growth hormone treated prepubertal age girls and adolescents with Turner's syndrome have normal BMD and Shaw et al. has suggested that they have normal BMD despite GH or estrogen therapy. However, we found the BMD of a group of previously GH treated young women with Turner's syndrome on estrogen replacement to be decreased compared to both age and gender matched controls and to controls of the same weight and pubertal status. Growth hormone therapy increases the growth velocity and the final height of children with chronic renal insuficiency, particularly in prepubertal children treated with GH before dialysis. We have demonstrated how the BMD of these patients, which at baseline is low when compared to healthy age matched controls, but normal when compared to height and bone age matched controls, increases with growth hormone treatment significantly, moreso than in untreated uremic controls or in untreated healthy controls paired for height and bone age. Short, slowly growing, non growth hormone deficient patients (idiopathic short stature) have been treated for prolonged periods of time with GH. We and others have demonstrated a clear increase in their growth velocity short term, but improvement of their final height remains unclear and controversial. After 4-8 years of GH treatment, Hintz et al. have found a 5-6 cm increase in final height compared to the predicted adult height before beginning therapy, but most patients did not reach their target heights. Other studies, however, have found no improvement in final height and Kawai et al. even suggests that GH therapy diminishes the final height of treated children due to an earlier puberty and a shorter pubertal growth spurt. We, have found decreased BMD in children with idiopathic short stature when compared to controls of their same height and bone age with a significant increase in BMD following 12 months of GH and with an increase in bone turnover as measured by bone formation and resorption markers. Recent short term studies in patients with hypophosphatemic rickets and osteogenesis imperfecta treated with rhGH have also yielded similar results which will be specified in the review. Some 10-20% of children born with intrauterine growth retardation (IUGR) end up short and we had already demonstrated 20 years ago how 2 years of GH therapy were capable of increasing their growth velocities significantly with an improvement of their height-SD scores. Recent studies mainly from Europe have corroborated this data long term, so that IUGR children have been shown by de Zegher et al. to increase their growth velocities and their height for age after 6 years of treatment, entering into the low normal centiles of their growth curves for age. Long term studies of these children to final height will be necessary to determine the usefulness and safety of this form of therapy.

Cirugía conservadora de parénquima en neoformaciones renales

ObjectivesTo analize retrospectively a series of 60 nephron sparing surgeries (NSS) in patients presenting with renal masses. Material And MethodsThe clinical histories of 59 patients undergoing NSS between january 1978 and december 1997 were reviewed. 40 were males, the mean age 54.4 years (range 17-77 years). 10 (17%) had bilateral sinchronous tumors, 15 (25%) had a solitary kidney and 3 a renal insuficiency. In 25 patients NSS was obligatory, while in 34 it was elective. 30 (50%) of the renal masses had been diagnosed incidentally. Overall, 49 kidneys underwent an enucleation and 11 a partial nephrectomy. ResultsThe histopathological exam revealed 43 (71.6%) renal cell carcinomas (rcc), 2 (3.4%) urothelial carcinomas, 6 (10.2%) oncocytomas, 7 (11.6%) angiomyolipomas and 2 (3.4%) multilocular cystic nephromas. among the rcc, 8 had ??3 cm, 22 between 3.1- 5 cm, 10 between 5.1-8 cm and 3 more than 8 cm. 31 (72.1%) were well encapsulated and only 2 (4.6%) invaded the nearby parenchyma. 7 (16.2%) were pt1, 34 (79%) pt2 and 2 (4.6%) pt3. 39 (90.3%) were g1 or g2, and only 4 (9.3%) were g3.Two patients (3.3%) died perioperatively, both from the obligatory group. 3 (6.8%) of the patients with malignant tumors progressed and died, all with CCR and from the obligatory surgery group. Another 3 patients of this group developed local recurrences, but were rescued with iterative surgery (conservative in 1); 2 of these patients had sporadic CCR, another a von Hippel Lindau disease. None of the 34 patients who underwent elective NSS progressed, nor recurred locally and all are alive and disease free; only 14 (56%) of the 25 patients operated on by necessity survived, although 6 of them died of causes not related with the kidney tumor. The cancer specific survival at 58.3 months of follow-up (range 5-187 months) is 86.8% for the whole series, 100% for the elective NSS group and 68.7% for the obligatory NSS group. 19 (31.6%) patients developed complications, 14 among the obligatory group; two died (hemorrage and sepsis). 3 patients presented acute renal failure, but none required dyalisis; presently 4 (6.7%) patients have poor renal function and 1 requires dyalisis. ConclusionNSS affords good control of renal carcinoma; in the cases operated on electively, the 100% cause specific survival yielded by NSS supports the use of conservative surgery in patients with well delimited tumors and normal contralateral kidney.

慢性腎不全患者の血管および心臓手術時の体外循環

慢性腎不全患者の血管および心臓手術時の体外循環

Bacteremias por bacilos gram-negativos

São apresentados 31 casos de bacteremia por gram-negativos, assunto que vem merecendo muita atenção dos pesquisadores nos últimos anos. Os organismos etiológicos mais importantes que apareceram em igualdade de freqüência foram Escherichia coli e Klebsiella-Aerobacter, sendo responsáveis por 58% do total das infecções, seguidos por Pseudomonas. A porta de entrada mais freqüente foi o trato urinário em 61,3% dos casos. A infecção foi mais comum no sexo masculino e a faixa etária de 50 a 60 anos predominou. O uso prévio de antibióticos foi um fator predisponente muito importante, seguido pelo uso de esteróides e citostáticos. As principais doenças predisponentes foram diabetes mellitus e neoplasias malignas. Os principais fatores precipitantes foram a manipulação do aparelho urinário, com infecção prévia ou desencadeada, cirurgia do aparelho digestivo, uronatia obstrutiva e obstrução biliar. As principais manifestações clínicas foram a presença de febre, calafrios e hipotensão arterial. A complicação mais freqüente foi o choque bacteriano que incidiu em 58% dos casos, aproximadamente três vêzes aquela relatada na literatura. As outras foram a insuficiência renal aguda, superinfecção e infecção pulmonar metastática. Considerações terapêuticas gerais e esquemas de antibióticos são propostos para estes casos. A mortalidade da bacteremia simples foi de 30,7% e quando associada ao choque elevou-se para 72,2% . As infecções por Pseudomonas foram 100% fatais.