Renal osteodystrophy and clinical outcomes: a prospective cohort study / Osteodistrofia renal e desfechos clínicos: um estudo de coorte prospectivo

Abstract Introduction: Renal osteodystrophy (ROD) refers to a group of bone morphological patterns that derive from distinct pathophysiological mechanisms. Whether the ROD subtypes influence long-term outcomes is unknown. Our objective was to explore the relationship between ROD and clinical outcomes. Methods: This study is a subanalysis of the Brazilian Registry of Bone Biopsies (REBRABO). Samples from individual patients were classified as having osteitis fibrosa (OF), mixed uremic osteodystrophy (MUO), adynamic bone disease (ABD), osteomalacia (OM), normal/minor alterations, and according to turnover/mineralization/volume (TMV) system. Patients were followed for 3.4 yrs. Clinical outcomes were: bone fractures, hospitalization, major adverse cardiovascular events (MACE), and death. Results: We enrolled 275 participants, of which 248 (90%) were on dialysis. At follow-up, 28 bone fractures, 97 hospitalizations, 44 MACE, and 70 deaths were recorded. ROD subtypes were not related to outcomes. Conclusion: The incidence of clinical outcomes did not differ between the types of ROD.

Resumo Introdução: Osteodistrofia renal (OR) refere-se a um grupo de padrões morfológicos ósseos que decorrem de mecanismos fisiopatológicos distintos. É desconhecido se os subtipos de OR influenciam desfechos em longo prazo. Nosso objetivo foi explorar as relações entre OR e desfechos. Métodos: Este estudo é uma subanálise do Registro Brasileiro de Biópsias Ósseas (REBRABO). As amostras de cada paciente foram classificadas em osteíte fibrosa (OF), osteodistrofia urêmica mista (MUO), doença óssea adinâmica (ABD), osteomalácia (OM), alterações normais/menores, e pelo sistema Remodelação / Mineralização / Volume (RMV). Os pacientes foram acompanhados por 3,4 anos. Os eventos clínicos foram: fraturas ósseas, hospitalizações, eventos cardiovasculares adversos maiores (MACE), e óbito. Resultados: Analisamos 275 indivíduos, 248 (90%) deles estavam em diálise. No acompanhamento, 28 fraturas ósseas, 97 hospitalizações, 44 MACE e 70 óbitos foram registrados. Os subtipos de OR não foram relacionados aos desfechos clínicos. Conclusão: A incidência de desfechos clínicos não diferiu entre os tipos de OR.

Desordens hiperostóticas em American Bully / Hiperostotic disorders in american bully

O complexo de desordens hiperostóticas é uma condição rara e autolimitante, que tem as mesmas características histopatológicas, que cursa com proliferação óssea de caráter não neoplásico. Acomete cães jovens de raças distintas, com variabilidade quanto ao tipo de proliferação óssea e quanto aos ossos acometidos. O complexo é composto pela osteopatia craniomandibular, hiperostose da calota craniana e osteodistrofia hipertrófica. Podendo estar presente nos ossos da calota craniana, mandíbulas, coluna cervical e esqueleto apendicular. O presente relato, descreveu o quadro de uma cadela, da raça American Bully, não castrada, três meses de idade, que foi atendida com queixa de aumento de volume doloroso das mandíbulas, hiporexia e sialorreia há 15 dias, apresentando ao exame físico, amplitude de movimento diminuída e sensibilidade dolorosa da articulação temporomandibular, espessamento firme bilateral do crânio em região de fossa temporal, espessamento palpável de consistência firme das mandíbulas e crepitação respiratória. Após avaliação clínica e realização de exames complementares, chegou-se ao diagnóstico presuntivo, de complexo de desordens hiperostóticas. Foi instituído como conduta terapêutica o suporte analgésico, sendo eficaz para a manutenção das necessidades fisiológicas até a paciente alcançar a fase adulta. O prognóstico para esta paciente foi considerado bom, uma vez que não havia indícios de anquilose da articulação temporomandibular e/ou manifestações neurológicas.

The complex of hyperostotic disorders is a rare and self-limiting condition, which has the same histophatological characteristics, which courses with non-neoplastic bone proliferations. It affects young dogs of different breeds, with variability the bones affected. The complex is composed of craniomandibular osteopathy, calvarial hyperostotic syndrome and hypertrophic osteodystrophy. It may be present in the bones of the skullcap, jaws, cervical spine and appendicular skeleton. The present report describes the condition of a female dog, American Bully breed, entire, three months old, with a complaint of painful swelling of the jaws, hyporexia and drooling for 15 days, presenting on physical examination, reduced amplitude and pain of the temporomandibular joint, bilateral firm thickening of the skull in the temporal fossa region, palpable firm-consistent thickening of the mandibles and respiratory crackle. After clinical evaluation and complementary tests, a presumptive diagnosis of hyperostotic disorders complex was reached. It was instituted pain management as a treatment, being effective for the maintenance of physiological needs until the patient reaches the adulthood. The prognosis for this patient was considered good, since there was no evidence of temporomandibular joint ankylosis and/or neurological manifestations.

Abordaje quirúrgico de tumor pardo de maxilar en síndrome de Sagliker / Surgical approach of brown maxillary tumor in Sagliker syndrome

El síndrome de Sagliker es el conjunto de alteraciones craneofaciales y esqueléticas producidas por la elevación de la hormona paratiroidea y la alteración en el metabolismo del calcio, secundarios a la insuficiencia renal crónica. Consiste en una osteodistrosfia renal que se manifiesta como apariencia desfigurada del rostro, entre las más comunes, la protrusión del maxilar y de la mandíbula, la hiperplasia de los tejidos blandos del paladar, la pérdida de la anatomía nasal, la deformidad dental y de los dedos y una estatura baja. Este síndrome fue descrito por Sagliker et al. en 2004. Se ha reportado una incidencia del 0,5 % de los pacientes que se encuentran en hemodiálisis y se presenta con mayor frecuencia en el sexo femenino entre los 18 y los 39 años de. En este caso se presenta el manejo y tratamiento de un paciente con tumor pardo de maxilar con síndrome de Sagliker que acude al servicio de cirugía oral y maxilofacial del Hospital Nacional Rosales de El Salvador

Sagliker syndrome is the set of craniofacial and skeletal alterations produced by elevated parathyroid hormone and altered calcium metabolism, secondary to chronic renal failure. It consists of a renal osteodystrophy that manifests itself as a disfigured appearance of the face, among the most common, the protrusion of the maxilla and mandible, hyperplasia of the soft tissues of the palate, loss of nasal anatomy, dental deformity and fingers and short stature. This syndrome was described by Sagliker et al. in 2004. An incidence of 0.5% of patients on hemodialysis has been reported and it occurs more frequently in females between 18 and 39 years of age. In this case, the management and treatment of a patient with a brown maxillary tumor with Sagliker syndrome who attends the oral and maxillofacial surgery service of the Rosales National Hospital in El Salvador.

Marcadores FGF-23 y Klotho en enfermedad renal crónica y su implicación cardiovascular, una revisión sistemática / FGF-23 and Klotho markers in chronic kidney disease and its cardiovascular implication, a systematic review

La principal causa de mortalidad en enfermedad renal crónica (ERC), en el 80% de pacientes se da por enfermedad cardiovascular asociada, los parámetros bioquímicos clásicos del metabolismo óseomineral aún no logran explicar la progresión patológica por tanto, se ha empezado a estudiar nuevos marcadores con relación al daño cardiovascular, donde se ha encontrado al marcador FGF-23 y su correceptor Klotho, implicados en la génesis del daño cardiovascular y enfermedad óseomineral asociada al fosforo, que en conjunto causan remodelamiento cardiovascular, lo que ha empezado aclarecer aún más esta dinámica fisiopatológica. Esta revision busca conocer la implicación de los marcadores FGF-23 y Klotho en ERC y el riesgo cardiovascular asociado y para ello realizó una revision sistemática de literatura, indagando en bases biomédicas como COCHRANE, Embase, LILACS, Scielo, Pub-Med, EBSCO, Hinari, Sociedades médicas, así como tesauros MeSH propios de esta investigación.

The main cause of mortality in chronic kidney disease (CKD), in 80% of patients, is due to associated cardiovascular disease, the classic biochemical parameters of bone-mineral metabolism will not yet be able to explain the pathological progression, therefore, new markers have begun to be studied in relation to cardiovascular damage, where the marker FGF-23 and its co-receptor Klotho have been found, involved in the genesis of cardiovascular damage and bone-mineral disease associated with phosphorus, which together cause cardiovascular remodeling , which has begun to further clarify this pathophysiological dynamic.This review seeks to know the implication of the FGF-23 and Klotho markers in CKD and the associated cardiovascular risk and for this purpose, a systematic review of the literature was carried out, investigating biomedical bases such as COCHRANE, Embase, LILACS, Scielo, Pub-Med, EBSCO, Hinari, Medical Societies, as well as MeSH thesauri specific to this research.

Manejo de vía aérea en paciente con leontiasis ossea. Reporte de caso / Airway management in a patient with leontiasis ossea. Case report

Leontiasis ossea is an uncommon complication of advanced chronic kidney disease that alters the facial bone and the airway, making its perioperative management more complex. We present a clinical case of a female with Leontiasis ossea presenting a difficult airway which requires parathyroidectomy. Assessment, planning and management of the airway by awake intubation is described.

La leontiasis ossea es una complicación infrecuente de la enfermedad renal crónica avanzada que altera el macizo facial óseo y la vía aérea, complejizando su manejo perioperatorio. Presentamos caso clínico de mujer portadora de leontiasis ossea con vía aérea difícil requiriendo paratiroidectomía. Se describe valoración, planificación y manejo de vía aérea mediante intubación vigil.

Experiencia con paratiroidectomía quirúrgica en pacientes con enfermedad renal crónica e hiperparatiroidismo terciario / Experience with surgical parathyroidectomy in patients with chronic kidney disease and tertiary hyperparathyroidism

Resumen Introducción: el hiperparatiroidismo terciario es la consecuencia final de las alteraciones del metabolismo calcio-fósforo en pacientes con enfermedad renal crónica. Aquellos pacientes que no logran controlarlo con el tratamiento médico, requieren paratiroidectomía. Objetivo: describir la evolución clínica y paraclínica en pacientes con enfermedad renal crónica y diagnóstico de hiperparatiroidismo terciario, que fueron llevados a paratiroidectomía. Metodología: estudio prospectivo, que incluyó pacientes con hiperparatiroidismo terciario llevados a paratiroidectomía entre los años 2006 y 2015. Se realizaron estudios bioquímicos pre y post quirúrgicos y se evaluó la presencia y progresión de síntomas. Resultados: se incluyeron 32 pacientes, 68.8% mujeres, con media de edad de 46.2 años. Se identificaron diferencias estadísticamente significativas en el cambio en los valores de calcio, fósforo y PTH pre y post quirúrgicos. El 81.5% de los pacientes reportaron presencia de síntomas. El 34.6, 26.9, y 23% presentaron mejoría total de dolor óseo, dolor articular y prurito, respectivamente. El 28% presentaron hipocalcemia sintomática post operatoria. No hubo casos de muerte durante el seguimiento. Conclusiones: la paratiroidectomía se constituye en un alternativa segura y confiable para los pacientes con hiperparatiroidismo terciario, mejorando significativamente los síntomas y las alteraciones en el metabolismo óseo y mineral. Vigilar los niveles de calcio en el post operatorio es importante para evitar las complicaciones del síndrome de hueso hambriento.

Abstract Introduction: tertiary hyperparathyroidism is the final consequence of alterations in calcium-phosphorus metabolism in patients with chronic kidney disease. Those patients who fail to control it with medical treatment require parathyroidectomy. Objective: go describe the clinical and paraclinical evolution in patients with chronic kidney disease and diagnosis of tertiary hyperparathyroidism, who underwent parathyroidectomy. Methodology: prospective study, which included patients with tertiary hyperparathyroidism taken to parathyroidectomy between 2006 and 2015. Pre and post-surgical biochemical studies were performed and the presence and progression of symptoms was evaluated. Results: 32 patients were included. 68.8 (%) were women with an average age of 46.2 years. Statistically significant differences were identified in the change in calcium, phosphorus and PTH values before and after surgery. 81.5% of patients reported the presence of symptoms. 34.6, 26.9, and 23% presented total improvement of bone pain, joint pain and pruritus, respectively. 28% presented postoperative symptomatic hypocalcemia. There were no deaths during follow-up. Conclusions: parathyroidectomy is a safe and reliable alternative for patients with tertiary hyper-parathyroidism, significantly improving symptoms and alterations in bone and mineral metabolism. Monitoring calcium levels in the postoperative period is important to avoid the complications of the hungry bone syndrome.

Osteoma cutis, a propósito de un caso / Osteoma cutis, about a case

El osteoma cutis (OC) es una lesión compuesta de tejido óseo en dermis y/o hipodermis. Se clasifican en primarios, cuando se desarrollan en piel sana, y secundarios, cuando aparecen sobre lesiones preexistentes. Mujer de 61 años con antecedente de linfoma de Hodgkin en remisión, presentó una lesión de larga data, desarrollada en piel sana, en primer dedo de la mano izquierda, que cursaba con brotes recurrentes y autolimitados de dolor y aumento de temperatura local. La exploración física mostró un nódulo pétreo, con úlcera de fondo calcáreo. El estudio histopatológico de la biopsia escisional reveló tejido óseo, sin otras lesiones cutáneas asociadas. El estudio complementario, incluyendo hemograma, función renal y hepática, calcio y fósforo séricos, PTH, TSH, vitamina D y calciuria fue normal. Descartándose alteraciones en el metabolismo calcio-fosforo y otras lesiones cutáneas preexistentes, se realizó el diagnostico de OC primario en forma de placa. El OC es una lesión benigna, pudiendo ser primario o secundario. Los secundarios representan cerca del 85% y se originan por la osificación de lesiones preexistentes tumorales o inflamatorias. Los OC primarios se presentan aislados o formando parte de síndromes como la fibrodisplasia osificante progresiva, la osteodistrofia hereditaria de Albright y la heteroplasia osificante progresiva. A pesar de la asociación a mutaciones en GNAS de OC y estos síndromes, el diagnóstico de ambos es fundamentalmente clínico. Los OC primarios sin síndrome asociado, se dividen en osteomas miliares de la cara y osteomas en forma de placa (plate-like OC), como este caso. Ante un OC primario, debemos descartar síndromes asociados a osificaciones heterotópicas.

Osteoma cutis (OC) is a lesion composed of bone tissue located in the dermis and/or hypodermis. It is classified as primary when it develops over healthy skin; and secondary when it develops over preexisting lesions. A 61-year-old woman with history of Hodgkin lymphoma in remission, presents a longstanding lesion located on the first finger of her left hand which developed over healthy skin, associated with recurrent and self-limited episodes of pain and increased local temperature. Physical examination reveals a stone-hard nodule, with a calcareous-bottomed ulcer. The histopathological evaluation of the excisional biopsy revealed bone tissue. Complementary studies included: complete blood count, renal and hepatic function, plasma calcium and phosphorus, PTH, TSH, vitamin D, and urinary calcium, all of them in normal ranges. Once systemic disease was ruled out, platelike OC was diagnosed. OC is a benign lesion which can be primary or secondary. Secondary OC represent nearly 85% of cases, and it corresponds to an ossification of preexisting tumoral or inflammatory lesions. Primary OC is less frequent, it appears isolated or as part of syndromes like fibrodysplasia ossificans progressiva, Albright hereditary osteodystrophy, and progressive osseous heteroplasia. GNAS mutations have been described in primary OC as in these syndromes, but the final diagnosis relies on the clinical picture. Isolated primary OC is classified in milliary osteomas of the face and plate-like OC, like our case. When facing primary OC, syndromes that present with heterotopic ossification must be ruled out.

Osteodistrofia renal y trastornos del metabolismo y la mineralización ósea asociados a enfermedad renal crónica: manifestaciones en radiología / Renal osteodystrophy and disorders of bone metabolism and mineralisation associated with chronic kidney disease: radiological manifestations

Abstract. Chronic kidney disease is a public health problem worldwide, with disorders of bone mineralisation and metabolism being common problems associated with this disease, causing significant morbidity and impaired quality of life. The expression of the findings in the chronic kidney disease can be categorised based on the classification proposed by the international conference Kidney Disease: Improving Global Outcomes, that divides them into metabolic disorders of calcium and phosphorus (without findings in radiology), bone structure and composition disorders, and extra-skeletal calcifications. These conditions give characteristic radiographic patterns, such as bone resorption and sclerosis, brown tumours, osteomalacia-rickets, osteopenia, and extra-skeletal calcifications, in addition to treatment related disorders of chronic kidney failure. In this article, concepts related to metabolism disorders and bone mineralisation associated with chronic renal disease and renal osteodystrophy will be categorised and updated, showing their various manifestations in radiology.

La enfermedad renal crónica es un problema de salud pública a nivel mundial, siendo los trastornos de la mineralización y el metabolismo óseo problemas comunes asociados a esta enfermedad, que causan una importante morbilidad y un deterioro de la calidad de vida. La expresión de los hallazgos en la enfermedad renal crónica puede sistematizarse con base en la clasificación propuesta por la conferencia internacional Kidney Disease: Improving Global Outcomes, que las divide en trastornos del metabolismo del calcio y el fósforo (sin hallazgos en imágenes), alteración de la estructura y la composición del hueso, y calcificaciones extraesqueléticas. Estos trastornos otorgan patrones radiológicos característicos, como son la resorción y esclerosis ósea, tumores pardos, osteomalacia-raquitismo, osteopenia y calcificaciones extraesqueléticas, además de los trastornos asociados al tratamiento de la falla renal crónica. En el presente artículo se sistematizarán y actualizarán los conceptos relacionados con los trastornos del metabolismo y la mineralización ósea, asociados a la enfermedad renal crónica y la osteodistrofia renal, mostrando sus diversas manifestaciones en radiología.

Bilateral spontaneous fracturing of the femoral neck in a patient with renal osteodystrophy

We report a case of bilateral fracturing of the femoral neck in a patient with renal osteodystrophy who was treated by means of osteosynthesis. In this type of patient, there is a need to remain watchful for the possibility of occurrences of spontaneous fracturing of the femoral neck, even if the initial radiographic examination is normal...

Relatamos um caso de fratura bilateral do colo femoral em paciente com osteodistrofia renal tratada com osteossíntese. Nesse tipo de paciente, é necessário estar atento à possibilidade de ocorrência de fraturas espontâneas do colo femoral, mesmo com exame radiográfico inicial normal...

Association between indoxyl sulfate and bone histomorphometry in pre-dialysis chronic kidney disease patients / Associação entre indoxil sulfato e histomorfometria óssea em pacientes renais crônicos pré-diálise

Introduction: Experimental studies have suggested that indoxyl sulfate (IS), a protein-bound uremic toxin, may be involved in the development of renal osteodystrophy. Objective: evaluate the association between IS levels and biochemical parameters related to mineral metabolism and bone histomorphometry in a cohort of pre-dialysis chronic kidney disease (CKD) patients. Methods: This is a post-hoc analysis of an observational study evaluating the association between coronary calcification and bone biopsy findings in 49 patients (age: 52 ± 10 years; 67% male; estimated glomerular filtration rate: 36 ± 17 ml/min). Serum levels of IS were measured. Results: Patients at CKD stages 2 and 3 presented remarkably low bone formation rate. Patients at CKD stages 4 and 5 presented significantly higher osteoid volume, osteoblast and osteoclast surface, bone fibrosis volume and bone formation rate and a lower mineralization lag time than CKD stage 2 and 3 patients. We observed a positive association between IS levels on one hand and the bone formation rate, osteoid volume, osteoblast surface and bone fibrosis volume on the other. Multivariate regression models confirmed that the associations between IS levels and osteoblast surface and bone fibrosis volume were both independent of demographic and biochemical characteristics of the study population. A similar trend was observed for the bone formation rate. Conclusion: Our findings demonstrated that IS is positively associated with bone formation rate in pre-dialysis CKD patients. .

Introdução: Estudos experimentais indicam que o indoxil sulfato (IS), uma toxina urêmica ligada à proteína, pode estar envolvido no desenvolvimento da osteodistrofia renal. Objetivo: Avaliar a associação entre os níveis séricos de IS e parâmetros bioquímicos do metabolismo mineral e da histomorfometria óssea em uma coorte de pacientes com doença renal crônica (DRC) pré-diálise. Métodos: Análise post-hoc de um estudo que avaliou a associação entre calcificação coronariana e histomorfometria óssea em 49 pacientes (idade: 52 ± 10 anos; 67% sexo masculino; taxa de filtração glomerular estimada: 36 ± 17 ml/min). Os níveis séricos de IS foram dosados. Resultados: Pacientes com DRC estágio 2 e 3 apresentaram uma taxa de formação óssea baixa. Pacientes com DRC estágio 4 e 5 apresentaram volume osteoide, superfícies osteoblástica e osteoclástica, volume de fibrose e taxa de formação óssea significativamente maiores e intervalo de mineralização significativamente menor que os pacientes com DRC estágio 2 e 3. Os níveis séricos de IS associaram-se positivamente com a taxa de formação óssea, volume osteoide, superfície osteoblástica e volume de fibrose. A análise de regressão multivariada identificou que o IS é um fator independente determinante da superfície osteoblástica e fibrose. Uma tendência similar foi observada para a taxa de formação óssea. Conclusão: Nosso estudo sugere que, na DRC pré-dialítica, o IS correlaciona-se positivamente com a formação óssea. .

Cuidados paliativos para dor originada da doença mineral óssea da insuficiência renal crônica / Los cuidados paliativos para el dolor proveniente de la enfermedad ósea en la insuficiencia renal crónica / Palliative care for pain originated from the bone mineral disease of chronic renal failure

Objective: Identifying which effective palliative cares to the minimization of pain are used in household levelby patients with Mineral and bone Disease of Chronic Kidney Disease. Method: a descriptive research, of cross-sectional and quantitative approach and held in a hemodialysis clinic in the city of Natal, Rio Grande do Norte. The data collection occurred from December 2011 to January 2012, using a semi-structured questionnaire with 35 patients. Results: the patients had painful process damaging the quality of life and mostly used at home oral analgesics and anti-inflammatories, cold compress and resting place. Conclusion: due to the good efficiency of non-medicated palliative care, we propose, in this study, the use of rest and cold compresses as a choice of primary care, relegating to conduct drug as secondary or supporting options.

Objetivo: Identificar quais os cuidados paliativos que são eficazes à minimização da dor que são utilizados, em nível domiciliar, por pacientes portadores de Doença Mineral e Óssea da Doença Renal Crônica. Método: Pesquisa descritiva, de abordagem quantitativa e transversal, realizada em uma clínica de hemodiálise na cidade de Natal-RN. A coleta de dados ocorreu de dezembro de 2011 a janeiro de 2012, utilizando um questionário semiestruturado com 35 pacientes. Resultados:Os pacientes apresentaram processo doloroso prejudicial à qualidade de vida e,em maioria, utilizam em domicílio medicações analgésicas e anti-inflamatórias orais, compressa fria local e repouso. Conclusão: Devido à boa eficiência dos cuidados paliativos não medicamentosos, propomos, nestes estudos, a utilização do repouso e compressas frias como escolha de cuidado primário, relegando às condutas medicamentosas como opções secundárias ou coadjuvantes.

Objetivo: Determinar cuales los cuidados paliativos que son eficaces para reducir al mínimo el dolor que se utilizan en domicilio, por los pacientes con enfermedades óseas e minerales de la Enfermedad Renal Crónica. Método: Una investigación descriptiva, con enfoque cuantitativo y transversal, realizada en una clínica de hemodiálisis en la ciudad de Natal, Río Grande do Norte. Los datos fueron recolectados a partir de diciembre de 2011 hasta enero de 2012, mediante un cuestionario semi-estructurado con 35 pacientes. Resultados: Los pacientes presentaron un doloroso proceso dañoso a la calidad de vida y se utilizan, principalmente, en casa analgésicos orales y antiinflamatorios, compresas frías y descanso. Conclusión: Debido a la gran eficacia de los cuidados paliativos no medicamentosos, se propone, en este estudio, el uso de descanso y compresas frías para elegir la atención primaria, relegando a cabo las drogas como opciones secundarias o de apoyo.

Avaliação do metabolismo mineral de pacientes com doença renal crônica em diálise peritoneal: correlação entre parâmetros clínicos, bioquímicos e de histologia óssea / Evaluation of mineral metabolism in peritoneal dialysis patients: correlation between bone histology, clinical features and biochemical parameters

Introdução: Os distúrbios minerais e ósseos da doença renal crônica (DMO-DRC) são influenciados por vários fatores, como idade, etiologia da DRC, toxinas urêmicas e modalidade dialítica. Os DMO-DRC são bem descritos em pacientes tratados com hemodiálise (HD). No entanto, na diálise peritoneal (DP) os estudos são escassos e, na maioria deles, não há dados de histologia óssea. Objetivos: caracterizar os DMO-DRC em uma coorte de pacientes em DP; comparar os resultados com aqueles obtidos da HD; e analisar o desempenho de marcadores séricos para o diagnóstico das doenças de alto e baixo remodelamento ósseo. Métodos: quarenta e um pacientes tratados com DP submeteram-se a avaliação clínica, bioquímica e biópsia óssea. Resultados: a doença óssea adinâmica (DOA) foi o tipo de osteodistrofia renal (OR) predominante, correspondendo a 49% da amostra. Ao se analisar separadamente diabéticos e não diabéticos, a prevalência de DOA foi de 77,7% no primeiro grupo e 26% no segundo (p=0,001). Na comparação entre DP e HD, observou-se que os pacientes do primeiro grupo apresentavam 25(OH) vitamina D mais baixa, mineralização óssea mais comprometida e melhor volume ósseo. A fosfatase alcalina óssea (FAO) apresentou a melhor sensibilidade e especificidade tanto para o diagnóstico de alto, quanto de baixo remodelamento ósseo. Conclusões: a DOA é o tipo de OR mais prevalente na DP. No entanto, a influência do diabetes como fator de risco parece ser maior do que a própria modalidade dialítica.

Introduction: Chronic kidney disease - mineral bone disorder (CKD-MBD) is a complex syndrome influenced by various factors, such as age, CKD etiology, uremic toxins and dialysis modality. CKD-MBD has been extensively studied in hemodialysis (HD) patients. However, for peritoneal dialysis (PD), only a few, older studies exist, most of which contain no bone biopsy data. The present study sought to: characterize CKD-MBD in a cohort of prevalent PD patients; compare the results with that obtained from HD patients; and analyse performance of bone turnover serum markers to make the diagnosis of high or low bone turnover disease in PD patients. Methods: Forty-one PD patients underwent to a clinical evaluation, biochemical analysis and bone biopsy. Results: The most prevalent pattern of renal osteodystrophy (ROD) was adynamic bone disease (ABD), comprising 49% of the sample population. When we separately analyzed diabetic and non-diabetic patients, the ABD prevalence was 77.7% in the former group and 26% in the latter group (p=0.001). The comparison between DP and HD patients revealed low 25(OH) vitamin D level, worst bone mineralization and better bone volume parameters in the former group. Bone alkaline phosphatase (BAP) demonstrated the best sensitivity and specificity values to detect both high and low turnover disease. Conclusion: ABD is the most frequent type of ROD. However, the effect of diabetes on the development of ABD is more important than the dialysis modality itself.

Avaliação fenotípica e de defeitos moleculares no GNAS em pacientes com pseudo-hipoparatireoidismo (PHP) e pseudopseudo-hipoparatireoidismo (PPHP) / Evaluation of the phenotype and molecular defect in GNAS in patients with pseudohypoparathyroidism (PHP) and pseudopseudohypoparathyroidism

INTRODUÇÃO: A primeira doença humana atribuída à resistência hormonal foi o pseudo-hipoparatireoidismo (PHP), uma doença rara caracterizada por hipocalcemia, hiperfosfatemia e níveis elevados de hormônio paratireoidiano (PTH) na presença de função renal normal, quadro condizente com resistência ao PTH. A classificação original do PHP leva em consideração a osteodistrofia hereditária de Albright (AHO): presente no PHP1a e ausente no PHP1b. Na medida em que as bases moleculares do PHP têm sido compreendidas, uma classificação baseada no genótipo tem surgido. Segundo ela, pacientes com PHP1a apresentam mutações na região codificadora da Gsalfa do GNAS e o padrão de herança é autossômico dominante relacionado à transmissão materna. Por outro lado, o PHP1b é caracterizado por alterações nas regiões diferencialmente metiladas (DMRs) do GNAS por mecanismos não completamente esclarecidos, limitando a previsão do seu padrão de herança. Pacientes que apresentam a AHO na ausência de resistência hormonal têm o diagnóstico de pseudopseudo-hipoparatireoidismo (PPHP) e seu padrão de herança é autossômico dominante relacionado à transmissão paterna de mutações na região codificadora da Gsalfa do GNAS. OBJETIVOS: Classificar 25 pacientes com PHP com base em defeitos no GNAS e caracterizar seu fenótipo. Pesquisar mutações no GNAS nos quatro pacientes com PPHP e também caracterizar seu fenótipo. MÉTODOS: A avaliação fenotípica incluiu análise das resistências hormonais, pesquisa de repercussões crônicas da hipocalcemia/hiperfosfatemia (calcificações em sistema nervoso central: SNC e catarata) e identificação da AHO. A análise do GNAS foi feita por sequenciamento automático e MLPA (região codificadora da Gsalfa) e por MS-MLPA (região regulatória: DMRs). RESULTADOS: Resistência ao PTH foi identificada nos 25 pacientes com PHP e resistência ao TSH em 17/25. Calcificações em SNC e catarata estiveram presentes em 18 e 10 pacientes com PHP, respectivamente. A...

BACKGROUND: The first human disease attributed to hormone resistance was pseudohypoparathyroidism (PHP), a rare disease characterized by hypocalcemia, hyperphosphatemia and elevated parathyroid hormone (PTH) levels in the presence of normal renal function, consistent picture of PTH resistance. The original classification of PHP takes into account the Albright hereditary osteodystrophy (AHO): present in PHP1a and absent in PHP1b. As the molecular bases of PHP have been understood, a classification based on genotype has emerged. According to it, PHP1a patients present mutations in the Gsalpha coding region of the GNAS and the pattern of inheritance is autosomal dominant related to maternal transmission. On the other hand, PHP1b is characterized by alterations in differentially methylated regions (DMRs) of the GNAS by mechanisms not completely clear, limiting the prediction of the pattern of inheritance. Patients who present AHO in the absence of hormone resistance have the diagnosis of pseudopseudohypoparathyroidism (PPHP) and their pattern of inheritance is autosomal dominant related to paternal transmission of mutations in the Gsalfa coding region of the GNAS. OBJECTIVE: To classify 25 patients with PHP based on GNAS molecular defects and to characterize their phenotype. To search for GNAS mutations in four patients with PPHP and also to characterize their phenotype. METHODS: The phenotypic evaluation included analysis of hormone resistances, research of chronic repercussions of hypocalcemia/hyperphosphatemia (calcifications in central nervous system: CNS and cataract) and identification of AHO. The analysis of the GNAS was done by automated sequencing and MLPA (Gsalphaa coding region) and by MS-MLPA (regulatory region: DMRs). RESULTS: PTH resistance was identified in 25 patients with PHP and TSH resistance in 17/25. Calcifications in CNS and cataract were present in 18 and 10 patients with PHP, respectively. AHO was characterized by: rounded face (n=18),...

Deterioro óseo en la cirrosis: fisiopatología de la osteodistrofia hepática / Bone loss in hepatic cirrhosis: phisiopathology of hepatic osteodystrophy

La cirrosis es un estado avanzado de fibrosis, consecuencia de la progresión de la enfermedad hepática crónica, que se caracteriza por destrucción de la arquitectura hepática y predispone al desarrollo de carcinoma hepatocelular. La cirrosis produce cambios metabólicos complejos que conducen al desarrollo de alteraciones en el metabolismo óseo, conocidas como osteodistrofia hepática. En general, el deterioro de la masa y de la calidad ósea obedecen a factores múltiples, como son: las deficiencias nutricionales, el hipogonadismo, el uso de medicamentos, la deficiencia de vitamina D, la inflamación crónica y la gravedad de la enfermedad. La incidencia de osteoporosis es dos veces más alta en los pacientes con enfermedad hepática crónica, comparada con la de la población general. La tasa de fracturas vertebrales y no vertebrales se encuentra incrementada en la enfermedad hepática crónica, especialmente en mujeres posmenopáusicas. La disponibilidad de la densitometría ósea por absorciometría de rayos X de energía dual ha llevado a un aumento en el diagnóstico de osteoporosis y baja masa ósea en pacientes con enfermedad hepática. Por otra parte, la morfometría vertebral tiene un gran rendimiento para el diagnóstico de fracturas vertebrales asintomáticas. Se hace una actualización de la literatura científica de la enfermedad ósea en casos de hepatopatía crónica y de las recomendaciones para el manejo de pacientes con cirrosis, enfocado en la salud ósea.

Cirrhosis is an advanced stage of fibrosis; it is a consequence of the progression of chronic liver disease, characterized by destruction of architecture and predisposes to the development of hepatocellular carcinoma. Cirrhosis cause complex metabolic changes that led to the development of alterations in bone metabolism known as hepatic osteodystrophy (HO). In general deterioration of bone mass and quality are due to multiple factors such as nutritional deficiencies, hypogonadism, use of medications, vitamin D deficiency, chronic inflammation and severity of the disease. The incidence of osteoporosis is twice as high in patients with chronic liver disease compared with the general population. The rates of vertebral and nonvertebral fractures are increased in chronic liver disease, especially in postmenopausal women. The availability of DXA bone densitometry (BMD-DXA) has led to an increase in the diagnosis of osteoporosis and low bone mass (LBM)in patients with liver disease. Moreover, vertebral morphometry (VMP) has a high diagnostic yield of asymptomatic vertebral fractures. This an update of the literature on bone disease in patient with chronic liver disease and recommendations for the management of patients with cirrhosis, focusing on bone health.

Fístula gastro-gástrica en posoperatorio de derivación gástrica por laparoscopia, serie de casos / Gastrogastric fistula after laparoscopic gastric bypass surgery

La fístula gastro-gástrica en el periodo posoperatorio de una derivación gástrica por laparoscopia es una complicación poco frecuente en la evolución de una cirugía bariátrica, pero potencialmente grave, la cual produce diversas manifestaciones clínicas, que incluyen dolor y recuperación del peso perdido. Se reportan cuatro casos de fístulas gastro-gástricas ocurridos entre enero de 1996 y diciembre de 2012, en dos servicios de cirugía bariátrica de la ciudad de Bogotá.

Gastrogastric fistula following a laparoscopic gastric bypass is a rare but potentially serious complication in the evolution of bariatric surgery, which can produce diverse clinical manifestations, including pain and regain of preopertive weigt. We report four cases of gastrogastric fistulae at two surgical services in the city of Bogotá occurring during the period January of 1996 and December of 2012.

Evaluación del metabolismo óseo pre y postrasplante renal en niños y adolescentes / Pre and post-renal transplant bone mineral metabolism in children and adolescents

Introducción. La enfermedad renal crónica presenta efectos sobre el tejido óseo que se conocen como enfermedad renal crónica-trastorno mineral óseo. Los pacientes con trasplante renal también presentan trastornos óseos, aun con la función normal del injerto. Se han atribuido a los medicamentos inmunosupresores (esteroides e inhibidores de calcineurina). Por lo anterior, es necesario conocer la prevalencia y evolución de trastorno mineral óseo pre y postrasplante renal en los niños. El objetivo de este trabajo fue describir la prevalencia y el tipo de alteraciones de metabolismo mineral pretrasplante y su evolución postrasplante. Métodos. El estudio fue aprobado por el Comité de Ética e Investigación del hospital. Se obtuvo el consentimiento informado de todos los participantes. Participaron pacientes con enfermedad renal crónica menores de 18 años, estudiados para recibir un primer trasplante renal. Al momento del trasplante, así como a los 6 y a los 12 meses postrasplante, se realizó la antropometría completa y se colectó sangre para determinar creatinina, niveles en valle de tacrolimus, calcio, fósforo, magnesio y fosfatasa alcalina. Se midió la hormona paratiroidea intacta (PTH) al momento del trasplante. Resultados. Se incluyeron 31 pacientes con edad promedio de 14.6 ± 3.2 años y predominio del sexo femenino (52%). Todos recibieron inducción con basiliximab y triple esquema con prednisona, micofenolato de mofetilo y tacrolimus. En cuanto a los valores de PTH, 51.6% tuvieron cifras pretrasplante <150 pg/ml (sugestivo de lesiones óseas de bajo remodelamiento); 38.7%, >300 pg/ml (sugestivo de alto remodelamiento); y tan sólo 9.6% tuvieron PTH en los valores recomendados. Al comparar los valores pre y postrasplante, la creatinina sérica disminuyó en forma significativa, no hubo diferencia en el calcio sérico y fosfatasa alcalina, pero se encontró una disminución significativa en fósforo y magnesio. Doce pacientes (38.7%) presentaron hipofosfatemia postrasplante. Diez pacientes (32%) cursaron con hipomagnesemia. Todos incrementaron el valor z de peso en forma significativa. La función renal tuvo correlación positiva con el calcio sérico y negativa con el fósforo y el magnesio (p <0.05). Los niveles de tacrolimus tuvieron una correlación negativa con el magnesio sérico (r =-0.431, p <0.0001). Conclusiones. La velocidad de filtración glomerular al momento del trasplante tuvo una correlación negativa con el fósforo sérico basal y la concentración de tacrolimus, con el magnesio sérico. El crecimiento fue mejor en los pacientes que no presentaron hipofosfatemia durante el postrasplante. Es necesario vigilar y tratar oportunamente las alteraciones minerales en el postrasplante renal.

Background. Information regarding chronic kidney disease-mineral bone disorder (CKD-MBD) in children who undergo renal transplant is scarce. Despite successful renal transplantation, bone disorders have been described and attributed to immunosuppressive drugs (steroids and calcineurin inhibitors). Therefore, it is important to determine the prevalence and outcome of bone mineral disorders pre- and post-renal transplant. The aim was to describe the prevalence and type of bone mineral disorders in children pre-renal transplant and outcomes. Methods. The Institutional Review Board and Ethics Committee approved the study. Signed consent/assent was obtained from all participants. Patients <18 years of age and under investigation for a first renal transplant were invited to participate. At transplant and 6 and 12 months after transplantation, anthropometric data were collected and blood samples were collected for serum creatinine, slope levels of tacrolimus, serum calcium, phosphorus, magnesium and alkaline phosphatase. Intact parathyroid hormone (PTH) was measured before transplant. Results. Thirty-one patients were included with a mean age of 14.6 ± 3.2 years. Females represented 52%. All received induction with basiliximab and triple maintenance therapy with prednisone, mycophenolate mofetil and tacrolimus. Pre-transplant PTH values were <150 pg/ml in 51.6%, suggestive of low turnover bone lesions, 38.7% had PTH >300 pg/ml, suggestive of high turnover bone lesions and only 9.6% had PTH between 150 and 300 pg/ml. When pre- and post-transplant studied parameters were compared, serum creatinine was statistically lower during follow-up. No difference was found in serum calcium and alkaline phosphatase, but magnesium and phosphorus values were significantly lower after transplant. Twelve patients (38.7%) had post-transplant hypophosphatemia and required supplementation. Ten patients (32%) had hypomagnesemia, seven of them with concomitant hypophosphatemia. Z-score for weight increased significantly after renal transplant; nevertheless, only patients with no hypophosphatemia during follow-up improved their Z-score for height. Glomerular filtration rate had a positive correlation with serum calcium and a negative correlation with phosphorus and magnesium (p <0.05). Tacrolimus slope levels had a significantly negative correlation with serum magnesium (r =-0.431, p <0.0001). Conclusions. Glomerular filtration rate had a negative correlation with serum phosphorus at transplant. Tacrolimus slope levels had a negative correlation with magnesium serum values. Patients with no hypophosphatemia during the first year had better growth than those with hypophosphatemia. It is important to monitor and opportunely treat bone mineral disorders in children who undergo transplantation.

Facial lesions caused by renal osteodystrophy in a patient with chronic renal insufficiency: a case report / Lesões faciais por osteodistrofia renal em paciente com insuficiência renal crônica: relato de caso

PURPOSE: Chronic renal insufficiency (CRI) is the last stage of a chronic renal condition in which the kidney loses its filtration and endocrine functions. Chronic endocrine hypofunction causes generalized damage to the body known as Uremic Syndrome, which affects the central nervous system as well as the cardiovascular, hematologic, dermatologic, ophthalmic, endocrine, respiratory, gastrointestinal and skeletal systems. The present study reports the case of a female patient with CRI who presented facial osteodystrophy of the osteitis fibrosa type, and highlights the main features of this condition. CASE DESCRIPTION: A 24-year old, female, Caucasian patient presented chronic glomerulonephritis recurrence and lost the transplanted kidney five years before, undergoing arteriovenous fistula hemodialysis three times a week. She presented swelling of the left masseter area with a hard consistency on palpation, covered by intact skin, swelling at the bottom of the left atrium, with a hard consistency on palpation, a mucosa-like color and absence of inflammation signs, suggesting expansive bone lesions on the face. These features were compatible with hyperparathyroidism brown tumor and/or osteodystrophy. The CT scan showed expansive bone lesions of heterogeneous appearance on the left jaw, maxilla/nasal floor, and right frontotemporal suture areas. The clinical and histopathological characteristics of the lesion, in association with PHT hormone high serum levels led to renal osteodystrophy diagnosis. The patient was referred to the nephrology services. CONCLUSION: Osteodystrophic bone alterations have a high prevalence in renal disease patients, and the dentist must take these alterations into consideration in bone lesion diagnosis for this specific group of patients.

OBJETIVO: A Insuficiência Renal Crônica (IRC) é o último estágio da doença renal crônica, na qual o rim perde sua função de filtração e endócrina. A hipofunção endócrina renal ocasiona danos generalizados ao organismo, que no conjunto são conhecidos como Síndrome Urêmica, sendo composta por danos que comprometem o sistema nervoso central, assim como os sistemas cardiovasculares, hematológicos, dermatológicos, oftálmicos, endócrinos, respiratórios, gastrointestinais e ósseos. O presente estudo irá relatar o caso de uma paciente portadora de IRC apresentando osteodistrofia em face do tipo osteíte fibrosa, evidenciando as principais características dessa doença. DESCRIÇÃO DO CASO: Uma paciente de 24 anos, sexo feminino, caucasiana, apresentou glomerulonefrite recorrente após perda do rim transplantado, estando sob hemodiálise três vezes por semana. Apresentou inchaço da área do m. masseter esquerdo com consistência dura à palpação, coberto por pelo de aspecto normal, inchaço do átrio esquerdo, com consistência dura e ausência de sinais inflamatórios, sugerindo lesões ósseas na face. Estas características eram compatíveis com tumor marrom de hiperparatireoidismo e/ou osteodistrofia. A imagem de tomografia computadorizada mostrou lesões ósseas expansivas de aparência heterogênea na mandíbula esquerda, assoalho da maxila e nasal, e nas áreas de sutura frontotemporal direita. As características clínicas e histopatológicas da lesão, em associação com níveis séricos elevados de hormônio PHT conduziram ao diagnóstico de osteodistrofia renal. A paciente foi encaminhada para o serviço de nefrologia. CONCLUSÃO: As alterações ósseas osteodistróficas são de grande prevalência em pessoas com doença renal, tendo o cirurgião-dentista o dever de levá-las em consideração no diagnóstico de lesões ósseas neste grupo específico de pessoas.

Osteoporosis en pacientes con hepatopatías crónicas: una complicación tardía poco conocida / Osteoporosis in patients with chronic liver disease: An unfamiliar late complication

La osteodistrofia hepática es una complicación tardía frecuente en las enfermedades hepáticas crónicas; los pacientes comúnmente presentan disminución de la densidad mineral ósea, osteopenia, osteoporosis y fracturas. En la práctica clínica aún no se han implementado estrategias para disminuir su incidencia y evitar comorbilidades y mejorar la calidad de vida. La fisiopatología es pobremente entendida. Existe controversia acerca del uso de pruebas de tamización en esta población, con énfasis a quiénes se deben realizar, en qué momento de su enfermedad y cada cuánto tiempo. Se han encontrado factores de riesgo que son dependientes y no de las hepatopatías, los cuales influyen en la historia natural de la osteodistrofia hepática y deben ser tenidos en cuenta para la tamización, seguimiento y tratamiento. Las recomendaciones para el tratamiento son ampliamente discutidas, pero se centran principalmente en disminución de factores de riesgo, fármacos antirresortivos y suplementos de calcio y vitamina D.

Hepatic osteodystrophy is a frequent late complication in chronic liver diseases in which patients usually present bone mineral density reduction, osteopenia, osteoporosis and fractures. Strategies to decrease incidence, avoid comorbidity and improve patient quality of life have yet to be implemented in clinical practice. Hepatic osteodystrophy’s pathophysiology is poorly understood. There is controversy about the use of screening tests especially regarding which patients are eligible, at what moment of the disease and with what frequency. Risk factors which are dependent on liver disease and other risk factors which are not liver disease dependent have been identified, all of which affect the natural history of hepatic osteodystrophy and all of which must be taken into account for screening, checkups and treatment. Recommendations for treatment are widely discussed but focus mainly on reduction of risk factors, antiresorptive drugs, calcium supplements and vitamin D.

Osteodistrofia fibrosa nutricional em caprinos / Nutritional fibrous osteodystrophy in goats

Seven out of 25 goats from a southern Brazilian flock developed nutritional fibrous osteodystrophy. Affected animals were younger than 1 year of age and were confined in stalls and fed a concentrate ration containing 1:6 calcium:phosphorus ratio. The remaining flock (35 goats) was managed at pasture and showed no disease. Clinical signs were characterized by mandibular and maxillary enlargements, varying degrees of mouth opening and protruding tongue, dyspnea, apart of abnormalities of prehension and mastication. Affected animals had increased seric levels of phosphorus and parathormone, as well as higher alkaline phosphatase activity. Postmortem examination on three succumbed goats revealed bilateral enlargement of the maxilla and mandibula, and loose teeth, apart of multiple incomplete rib fractures in one of them. Severe diffuse proliferation of loose connective tissue surrounded the osteoid trabeculae, many of which were partially or completely non-mineralized. Mineralized osteoid trabeculae showed osteoclasts in the Howship's lacunae.

Sete de um total de 25 caprinos jovens (menos de um ano de idade) de um rebanho no sul do Brasil desenvolveram osteodistrofia fibrosa nutricional. Os animais afetados eram confinados em baias e alimentados com concentrado, cuja relação Ca:P era 1:6. O restante do rebanho (35 cabras) era mantido na pastagem e não desenvolveu a doença. Os sinais clínicos se caracterizaram por aumento de volume da mandibula e maxila, vários graus de abertura de boca com protrusão da língua, em associação com dispneia e anormalidades de apreensão de alimento e mastigação. Os animais afetados apresentaram os níveis séricos de fósforo e paratormônio aumentados, bem como maior atividade de fosfatase alcalina. Três caprinos foram necropsiados e os achados de necropsia incluíram aumento bilateral da maxi-la e mandíbula, dentes frouxos, além de múltiplas fraturas incompletas de costelas em um caprino. Microscopicamente, havia intensa proliferação de tecido conjuntivo frouxo ao redor de trabéculas ósseas, muitas das quais estavam parcial ou completamente não mineralizadas. Trabéculas ósseas mineralizadas apresentaram osteoclastos em lacunas de Howship.

Oral manifestations and radiographic changes in the jaw-bones of patients with end-stage renal disease onmaintenance hemodialysis: a descriptive study / Estudo descritivo das manifestações bucais e alterações radiográficas em maxilares de pacientes com doençarenal terminal e sob hemodiálise

Objectives: The purpose of the present study was to assess the oral manifestations and radiographic changes in the jawbones of patients undergoing hemodialysis, diagnosed with end-stage renal disease (ESRD). Methods: Forty patients on maintenance hemodialysis were clinically examined for oral manifestations and evaluated for radiographic changes in the jaws with panoramic and intra-oral periapical radiographs. Results were expressed as Percentage. Results: Out of 40 patients, 37 patients (92.5%) showed at least one or more oral manifestations. The most common oral manifestations were mucosal pallor (70%), xerostomia (57.5%), petechiae and ecchymoses (37.5%), and less common were taste alterations (15%), uremic odor (7.5%), coated tongue (10%) and mucosal pain (2.5%). Radiographic changes seen were loss of lamina dura (22.2%), altered trabecular pattern (5.5%), multiple radiolucent lesions (5%), and pulp calcification (2.7%). Conclusions: Most of the patients presented with oral signs and symptoms. However it was observed that patients demonstrating radiographic changes were mostly those who were on dialysis for a relatively long duration.

Objetivos: O objetivo do presente estudo foi avaliar as manifestações orais e alterações radiográficas nos maxilares de pacientes submetidos à hemodiálise e com diagnóstico de doença renal em estágio terminal (DRET). Métodos: 40 pacientes em hemodiálise de manutenção foram examinados clinicamente e avaliados radiograficamente por meio de radiografias panorâmicas e periapicais em busca de manifestações orais nas mandíbulas. Resultados: Dos 40 pacientes, 37 pacientes (92,5%) apresentaram pelo menos uma ou mais manifestações orais. As manifestações orais mais comuns foram: palidez da mucosa (70%), xerostomia (57,5%), petéquias e equimoses (37,5%); e menos comuns: alterações do paladar (15%), odor urêmico (7,5%), língua saburrosa (10%) e mucosa dolorida (2,5%). As alterações radiográficas observadas foram a perda da lâmina dura (22,2%), padrão trabecular alterado (5,5%), lesões radiolúcidas múltiplas (5%) e calcificação pulpar (2,7%). Conclusões: A maioria dos pacientes apresentava sinais e sintomas orais. Entretanto, foi observado que os pacientes demonstrando alterações radiográficas foram principalmente aqueles que estavam em diálise por um período relativamente longo.