Idiopathic focal segmental glomerulosclerosis and HLA antigens

The objective of the present study was to investigate a possible association between HLA class II antigens and idiopathic focal segmental glomerulosclerosis (FSGS), HLA-A, -B, -DR and -DQ antigens were determined in 19 Brazilian patients (16 white subjects and three subjects of Japanese origin) with biopsy-proven FSGS. Comparison of the HLA antigen frequencies between white patients and white local controls showed a significant increase in HLA-DR4 frequency among FSGS patients (37.7 vs 17.2 percent, P<0.05). In addition, the three patients of Japanase extraction, not included in the statistical analysis, also presented HLA-DR4. In conclusion, our data confirm the association of FSGS with HLA-DR4 previously reported by others, thus providing further evidence for a role of genes of the HLA complex in the susceptibility to this disease.

Late diagnosis of chronic renal failure

A comparison was made between patients with a late diagnosis chronic renal failure (1 month or less before starting dialysis, N = 9 and those with an early diagnosis (6 months or more, N = 45) in terms to of the following aspects: referral characteristics during the pre-dialysis phase, demographic details and patient biochemistry prior to maintenance dialysis. Information was obtained by surveying consecutive patients with primary renal disease admitted to a university dialysis unit in Sao Paulo. Fifty-three percent of all patients surveyed had a late diagnosis. These patients had a lower median duration of symptoms (2 vs 6 months, P<0.01) and were less likely to be referred for dialysis by a nephrologist (9 per cent vs 51 per cent, P<0.001) than early diagnosis patients. In the early diagnosis group, 7 patients (16 per cent) had follow-up care for less than 6 months and 11 (24 per cent) did not receive any follow-up; 21 patients (47 per cent) did not follow a low-protein diet. At the start of dialysis, patients with a late diagnosis had higher blood pressure and a higher rate of pulmonary infections (19 per cent vs 4 per cent, P= 0.03). Mean concentrations of BUN, serum creatinine and potassium were significantly higher and mean blood bematocrit was lower for the late diagnosis group. After 3 months of dialysis, the mortality rate was higher in the late than in the early diagnosis group (22.9 per cent vs 6.7 per cent, = 0.02). Late diagnosis of chronic renal failure and lack of adequate follow-up care, prior to the start of dialysis, are common. Interventions to promote early diagnosis of chronic renal failure and to improve compliance with regular nephrological follow-up can be important to reduce the morbidity and the mortality of patients with chronic renal insufficiency.

Late diagnosis of chronic renal failure and the quality of life during dialysis treatment

We evaluated the quality of life of 101 hemodialysis patients who had a late (( 3 months before starting dialysis, N=47) or early (( 6 months), N= 54) diagnosis of chronic renal failure. At the time of the survey patients had been stable on dialysis for at least 3 months and for less than 24 months; median duration of dialysis was 9.1 months. Quality of life was measured by the kidney disease questionnaire (including the intensity and duration of physical symptoms, fatigue, depression, relationship with others and frustation), the health and life satisfaction indices, functional status (Karnofsky scale), and the time trade-off method. Scores for the several indicators of quality of life were closely similar for the late and early diagnosis groups. Health satisfaction compared to one year prior to dialysis was slighly better for the early diagnosis group. For both groups, functional status was a little worse during the first year of dialysis than one year before its start. In the late diagnosis group, elderly patients and diabetics had more impairment in several dimensions assessed. In addition, in this group greater income was significantly correlated with better physical performance (r = 0.52, P<0.001) and with health satisfaction (r = 0.36, P= 0.027). These findings suggest that after a median duration of 9 months on a dialysis program, patients with a late and early diagnosis of chronic renal failure have a similar performance in terms of quality of life parameters. Age, diabetes and income are associated with the quality of life of pataients with a late diagnosis.

Acesso ao tratamento dialítico crônico: deficiente e desigual / Access to chronic dialysis treatment: deficient and unequal

OBJETIVO. Determinar a fraçao de pacientes com insuficiência renal crônica (IRCT) tratada por meio de diálise no Município de Sao Paulo e investigar a influência da idade em relaçao ao acesso a diálise. MATERIAL E MÉTODOS. Foram estudados todos os pacientes que receberam diálise para IRCT durante o ano de 1991, registrados junto à Secretaria de Saúde do Estado. No mesmo ano, foram também coletadas informaçoes dos indivíduos que morreram tendo com causa básica de óbito doença relacionada a insuficiência renal crônica. Estes últimos dados foram obtidos do Serviço Funerário da Prefeitura de Sao Paulo. Cruzando-se os dados destes bancos de dados foi possível descobrir os pacientes que morreram de IRCT sem ter realizado diálise e calcular a fraçao tratada nas diversas faixas etárias. RESULTADOS. De forma global, 25,6 por cento dos pacientes com IRCT nao receberam tratamento. A partir da idade de 40 anos, houve reduçao progressiva e significante (p<0,001) da fraçao de pacientes tratados conforme aumentou a idade. Até os nove anos de idade a percentagem de tratamento também foi reduzida (29 por cento). Indivíduos nas faixas etárias de 60-69 e 70-79 anos apresentaram chance cerca de 5 e 11 vezes maior, respectivamente, de morrer sem receber tratamento dialítico do que aqueles no grupo etário de 20-29 anos. CONCLUSOES. Os autores estimam que pelo menos um quarto dos pacientes com IRCT morreram em Sao Paulo, em 1991, sem ter recebido tratamento dialítico. Idade é um fator importante de discriminaçao para aceitaçao em programas de diálise crônica.

Assessment of glomerular filtration rate utilizing subcutaneously injected Cr-EDTA

1. 51Cr-EDTA injected with lidocaine and epinephrine, as a subcutaneous button, is slowly absorbed, and a plasma level that is relatively stable can be maintained for a time sufficient to permit measurement of the renal clearance of EDTA, which is a measure of glomerular filtration rate (GFR). We studied this procedure in 32 normal volunteers and 24 patients with different glomerulopathies, comparing EDTA and creatinine clearances. In 20 patients these measurements were also compared with inulin clearance. 2. Creatinine clearance overestimates GFR due to tubular secretion of creatinine. This secretion is present even in patients with significantly reduced glomerular filtration rates. As a consequence, the lower the GFR the higher the overestimation will be. 3. A good correlation was obtained between the 51Cr-EDTA and inulin clearance: y(EDTA) = 4.21 + 0.88 x (inulin), r = 0.98. The procedure is simple to perform, and the radiotracer utilized is significantly less expensive than iothalamate

Farmacocinética da ciclosporina e de seus metabólicos em pacientes submetidos a transplante renal / Pharmacokinetics of cyclosporine and its metabolites in patients undergoing kidney transplantation

A farmacocinética da ciclosporina demosntra grande variaçäo inter e intra-individual e profundas mudanças säo, freqüentemente, observadas após o transplante renal. OBJETIVO. analisar seriadamente a farmacocinética da ciclosporina e de seus metabólitos através da determinaçäo de sua concentraçäo sanguínea, em pacientes submetidos a transplante renal. MÉTODOS. Foram realizados 70 estudos em 29 pacientes, sendo 26 antes e 44 após o transplante renal. Em cada estudo a curva de absorçäo foi analisada mediante a determinaçäo da concentraçäo sanguínea da ciclosporina, utilizando radioimunoensaio com anticorpos monoclonais específicos (RIE-MoSP) e inespecíficos (RIE-MoNP), em 17 amostras colhidas após a sua administraçäo oral ou endovenosa (0; 0,5; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 12; 16; 20; 23; 24h). Resultados. A área sob a curva da concentraçäo sanguínea de ciclosporina em funçäo do tempo (AUC), a biodisponibilidade (F), a concentraçäo máxima (Cmax) e as concentraçöes sanguíneas obtidas 12 e 24 horas após a sua administraçäo (C12 e C24), determinadas com RIE-MoSP, foram inferiores àquelas encontradas com RIE-MoNP, enquanto a depuraçäo (CL) e o volume de distribuiçäo (Vd) foram maiores. A meia-vida de eliminaçäo foi semelhante utilizando os dois métodos (t1/2). A absorçäo seguiu uma cinética de ordem zero, sendo observada uma correlaçäo inversa entre a dose de ciclosporina e a AUC/dose (r = 0,55, RIE-MoSP e r = 0,42, RIE-MoNP). A fraçäo de absorçäo (F) variou entre 18 por cento e 68 por cento (RIE-MoSP), sendo superestimada quando determinada com RIE-MoNP (38 por cento a 100 por cento), conseqüência da extensa metabolizaçäo na primeira passagem pelo intestino e fígado...

Glomerular hemodynamics during abortion induced by RU 486 and sepsis in rats

1. Acute renal failure is a very common consequence of septic abortion. Whole kidney and glomerular hemodynamics were evaluated in virgin (V), pregnant (PREG) and aborted (ABOR) euvolemic Munich-Wistar rats before and after E. coli (0111-B4) endotoxin (LPS) infusion in order to evaluate the effect of septic abortion on the renal microcirculation. 2. Abortion induced by RU 486 blunted the increase in glomerular filtration rate (GFR) induced by normal pregnancy (0.86 +/- 0.03 vs 0.63 +/- 0.07 ml/min, P < 0.05). In virgin rats, RU 486 did not modify the parameters of renal function. Significant alterations occurred in whole kidney and single nephron function. However, the changes in whole kidney function in the ABOR group were significantly higher than those observed for the V group (reductions in GFR were 42 in V and 80 in ABOR, RPF decreased 34 in V and 76 in ABOR, TRVR increased 82 in V and 400 in ABOR). 3. Mean single nephron glomerular filtration rate (SNGFR) was reduced in all groups after LPS (44 in V, 43 in V+RU, 55 in PREG, 60 in ABOR), due to significant decreases in glomerular plasma flow rate, QA (42 in V, 55 in V+RU, 53 in PREG, 57 in ABOR) and in glomerular ultrafiltration coefficient, Kf (46 in V, 47 in V+RU, 45 in PREG, 67 in ABOR). 4. These data show that LPS induced significant alterations in renal function in all groups. However, aborted rats were more sensitive to the effects of LPS than V rats. These results indicate that abortion may potentiate the effects of endotoxemia on renal function elevating the extent of acute renal failure and thus the mortality rate.

Correçäo da anemia da insuficiência renal crônica pela eritropoetina humana recombinante liofilizada por via subcutânea / Anemia correction of chronic kidney failures by recombinant human erythropoietin freeze drying by subcutaneous injections

A eritropoetina recombinante humana (rHuEPO) tem-se mostrado a medicaçäo de escolha na correçäo da anemiado paciente renal crônico. OBJETIVO. Analisar a eficácia de uma nova preparaçäo de rHuEPO na correçäo da anemia de pacientes renais crônicos mantidos em hemodiálise, exclusivamente administrada por via subcutânea, estudando seus efeitos colaterais e pesquisando fatores preditivos de resposta para a medicaçäo. MÉTODOS. Doze pacientes em programa regular de hemodiálise foram tratados com rHuEPO liofilizada por via subcutânea, durante 18 meses, com dose inicial de 20U/Kg/diálise, efetuando-se monitorizaçäo clínica e laboratorial adequada. RESULTADOS. Onze pacientes terminaram o protocolo, alcançando hematócrito (Htc) alvo de 30 por cento e mantendo-o durante todo o tempo de estudo. A dose média utilizada para a correçäo da anemia foi de 65U/Kg diálise e a de manutençäo de Htc alvo de 51U/Kg diálise. Já na 12ª semana do estudo, comprovou-se aumento significativo do Htc (18,4 ñ 3,5 por cento vs. 25,4 ñ 3,8 por cento, p < 0,5), acompanhado por hemoglobina e eritrócitos. Leucócitos e plaquetas aumentaram significativamente a partir da 24ª semana e mantiveram-se assim até o final do estudo. Na análise dos exames bioquímicos dos pacientes, apenas o potássio se elevou na 4ª e 12ª semanas, voltando ao basal na 24ª semana de estudo. A avoluçäo dos parâmetros séricos do metabolismo do ferro mostrou diminuiçöes intermitentes e estatisticamente significantes da saturaçäo de transferrina na 1ª, 12ª e 24ª semanas, voltando aos valores basais ao final do estudo; a ferritina sérica näo se alterou (582,7 ñ 700,9ng/mL vs. 700,0 ñ 651,6ng/mL). Peso e pressäo arterial näo se alteraram, porém dois pacientes, antes normotensos, tornaram-se hipertensos e dois outros, com hipertensäo controlada, necessitaram reajuste de droga para novo controle da pressäo (35 por cento). Um paciente apresentou convulsäo tipo grande mal, evoluindo sem seqüelas. CONCLUSAO. A rHuEPO utilizada neste protocolo comprovou ser uma droga eficaz, segura e com efeitos colaterais passíveis de controle

Specific and nonspecific aspects of humoral immune response in leprosy

1. We have studied some generic and specific aspects of the humoral immune response in 96 patients with leprosy (29 paucibacillary and 67 multibacillary individuals). We determined serum immunoglobulins (IgM, IgG and IgA), CH50, C1q, C3 and C4, circulating immune complexes (CIC), C-reactive protein (CRP), rheumatoid factor (RF) and antinuclear antibodies. No specific pattern of general humoral immune changes could be observed. 2. The specific immune response was studied by the detection of specific IgM anti-M. leprae antibodies. An immunoradiometric assay (IRMA) and an ELISA were compared for clinical effectiveness. IRMA showed greater sensitivity for the serodiagnosis of leprosy as compared to ELISA (88.1 percent vs 58.2 percent for multibacillary patients and 20.7 percent vs 10.3 percent for paucibacillary leprosy patients). Specificity was 96 percent for IRMA and 97 percent for ELISA. 3. Our results indicate that nonspecific changes in the humoral immune response are of little value in assessing leprosy patients and that immune assays for the detection of specific anti-M. leprae antibodies may be of value in the diagnosis, study and follow-up of these patients

Dietary habits of calcium stone formers

1. Since dietary factors are known to be related to nephrolithiasis, calcium stone-forming (CSF) patients were evaluated in terms of calcium, total protein of both animal and plant origin, carbohydrate and energy intakes, on the basis of 72-h dietary records during the week plus 24-h dietary records during the week-end. 2. The data for 77 calcium stone formers (57 with absorptive hypercalciuria and 20 with renal hypercalciuria) were compared to those for 29 age-matched healthy subjects. The body mass index of the CSF group was higher than that of healthy subjects (P < 0.05). Consumption of all nutrients was similar for both groups during the week but week-end dietary records for CSF showed higher calcium intake (586 +/- 38 vs 438 +/- 82 mg/day, P < 0.05), protein to body weight ratio (1.2 +/- 0.1 vs 1.0 +/- 0.5 g kg-1 day-1, P < 0.05) and animal protein (56 +/- 3 vs 40 +/- 3 g/day, P < 0.05) when compared with healthy subjects. 3. Comparison of hypercalciuria subtypes (renal hypercalciuria and absorptive hypercalciuria) did not indicate any difference in calcium or energy intake between groups, either during the week or during the week-end. However, the absorptive hypercalciuric group presented higher protein and animal protein consumption during the week-end. 4. These data suggest a low calcium intake in this population, even by stone formers. The higher animal protein consumption by our calcium stone formers observed during week-ends seems to be more important than calcium intake for stone formation

Otimizaçäo do uso da ciclosporina em transplante renal / Optimization of the use of cyclosporin in renal transplantation

Avaliamos retrospectivamente estratégias empregadas na otimizaçäo do uso clínico da ciclosporina (CSA) em transplante renal. Baseado na incidência de rejeiçäo aguda nos primeiros 15 dias do transplante, a administraçäo oral da CSA foi superior à infusäo endovenosa constante, apesar dos relatos divergentes na literatura. A falta de monitorizaçäo do nível sanguíneo da CSA e o uso de doses diferentes de esteróides podem ser responsáveis pelo encontro de tais resultados. A minitorizaçäo do nível sanguíneo de CSA foi útil no diagnóstico diferencial de rejeiçäo aguda (RA) e nefrotoxicidade por CSA (NTX), definindo faixas de concentraçäo sangüínea ideais onde o risco de desenvolvimento de algum tipo de disfunçäo foi menor. Esta "faixa terapêutica" ficou entre 200 e 400ng/mL, quando foi utilizado radioimunoensaio tricidado com anticorpo policlonal (PC-CSA-H3), e entre 100 e 250ng/mL, utilizando RIA com anticorpo monoclonal específico (ME-CSA-H3), observando-se uma correlaçäo com um r=0,82 entre os dois métodos em 122 determinaçöes simultâneas. Alteraçöes histológicas encontradas nas biópsias renais de pacientes com RA näo foram diferentes daquelas obtidas de pacientes com NTX, antes ou após 90 dias de transplante. Concluímos que, por näo dispormos, no momento, de um único método com elevada sensibilidade, especificidade e valor preditivo, a monitorizaçäo do nível sanguíneo de CSA associada à biópsia renal é a melhor forma de reduzir a incidência de disfunçäo do enxerto, assegurando uma maior sobrevida, a longo prazo

Aneurisma de artéria renal / Renal artery aneurysm

Pacientes com história de hematúria devem ser submetidos a detalhado protocolo de investigaçäo para a obtençäo de um diagnóstico preciso. Assim, relatamos um caso de hematúria macroscópica e a seqüência de exames complementares que nos levaram ao diagnóstico desta patologia rara. Em uma breve revisäo de literatura, salientamos: classificaçäo (etiológica ou morfológica), diagnóstico, indicaçöes cirúrgicas e o tratamento (embolizaçäo ou cirúrgico). O diagnóstico de certeza é obtido através de arteriografia renal digital, após avaliaçäo morfológica do trato urinário (UGE e US renal) normal e a constataçäo de sangramento unilateral (cistoscopia)

Metabolic factors for urolithiasis in acromegalic patients

Acromegaly is associated with metabolic disturbances of calcium and phosphorus which can also contribute to renal lithogenesis. In order to characterize these disturbances more precisely, an oral calcium load test was performed on 14 active acromegalic patients. Serum and urinary levels of calcium, phosphorus, uric acid, creatinine and urinary cyclic AMP were determined. Of the 14 patients, 5 (36%) presented hypercalciuria, 5 (36%) presented intestinal calciumhyperabsorption and 6 (43%) had uric acid hyperexcretion. Two patients (14%) presented nephrolithiasis. The medical records of 32 additional acromegalic patients with or without active disease were reviewed for a history of previous stones, which was observed in three cases (9.5%). The present data suggest that nephrolithiasis occurs more frequently among acromegalic patients because of the underlying metabolic disturbances of calcium presented by this population

Renal disease in the elderly: etiology and evolution of 24 cases

We retrospectively analyzed the histological data, clinical presentations, and outcome of 24 patients aged 60 years or older at the initial evaluation for renal disease. The study setting was a referral-based nephrology clinic at a tertiary care center. Twenty-three out of the 24 patients had a mean follow-up of 16 months (range 3-48). Their mean age was 65 years (range 60-75). The most common histological diagnoses were crescentic glomerulonephritis (GN) (n = 4), membranoproliferative GN (n = 4), diffuse endocapillary proliferative GN (n = 3), and minimal change (n = 3). Clinical presentation included renal insufficiency in 16 patients, the nephrotic syndrome in 8 patients (associated in 4 with decreased renal function), and hematuria with subnephrotic rang proteinuria in 4 cases. Ten out of the 23 patients developed end-stage renal disease (ESRD). Median serum creatinine at presentation in the group that developed ESRD was significantly higher than in the group that did not develop ESRD (490 vs 270 mumol/l; p < 0.05). Seven patients died, 5 of whom had developed ESRD. A variety of renal diseases affect the kidneys of the elderly; prognosis was unfavorable in about half of the patients in this series. Larger prospective studies are needed to clarify the natural history of GN in the elderly.

Alguns fatores na progressäo da doença renal / Some factors in evolution of chronic renal failure

Adaptaçöes estruturais e funcionais foram demonstradas em néfrons remanescentes após lesäo renal. O grau destas adaptaçöes correlaciona-se diretamente com a quantidade de parênquima renal perdido. No entanto, várias observaçöes sugerem que a evoluçäo para insuficiência renal crônica (IRC), após esta perda de massa renal funcionante, é progressiva. Porém, os fatores responsáveis por esta evoluçäo ainda näo estäo estabelecidos. A hipertensäo e o hiperfluxo glomerulares que ocorrem nos néfrons remanescentes, especialmente em pacientes ou animais alimentados com dieta hiperprotéica, foram identificados como fatores que aceleram esta evoluçäo. Sabe-se também que as prostaglandinas (PGs) vasodilatadoras encontram-se elevadas na urina de humanos e animais de experimentaçäo com IRC, e que participam da manutençäo da filtraçäo glomerular. Alguns estudos recentes têm sugerido que estas PGs exercem um papel fundamental na manutençäo da vasodilataçäo renal que ocorre nos néfrons remanescentes. Sugere-se que as PGs teriam um papel fundamental na evoluçäo da IRC paralelamente com a dieta hiperprotéica. Finalmente, mecanismos hemodinâmicos da progressäo da IRC säo sugeridos e possivelmente novos enfoques terapêuticos conservadores (näo dialíticos) deveräo ser indicados