Divergences in antihypertensive therapy in special situations in nephrology

CONTEXT AND OBJECTIVE: The choice of an antihypertensive drug is based on several criteria and specific situations give rise to doubt and controversy. The aim here was to evaluate physicians’ approaches towards treatment with antihypertensive agents in specific situations. DESIGN AND SETTING: Cross-sectional study, at Universidade Federal de São Paulo, São Paulo. METHODS: A questionnaire was applied during a nephrology meeting to evaluate individual approaches towards each hypothetical clinical situation. The questionnaire consisted of five multiple-choice questions (clinical cases) concerning controversial aspects of antihypertensive therapy. RESULTS: A total of 165 questionnaires were analyzed. Most participants were nephrologists (93.2 percent). There was a preference for angiotensin-converting enzyme (ACE) inhibitors in at least two of the cases. Only 57.2 percent of the physicians were correct in choosing beta-blockers as the first-line drugs for patients with ischemic coronary disease. Moreover, 66.2 percent chose ACE inhibitors as the first-line drugs for patients with chronic kidney disease and proteinuria. About 5 percent of the physicians did not follow the current recommendations for the use of ACE inhibitors in diabetic patients with microalbuminuria. The most controversial question concerned the first-line drug for advanced chronic kidney disease. Most physicians were correct in choosing calcium channel blockers and avoiding ACE inhibitors in renovascular hypertension in the case of a patient with a single functioning kidney. CONCLUSIONS: Most physicians adopted the correct approach, but some had an alternative strategy for the same situations that was not based on evidence.

CONTEXTO E OBJETIVO: A escolha da droga anti-hipertensiva depende de diversos fatores. Determinadas situações geram dúvida e discordância entre médicos. O objetivo foi avaliar a conduta de nefrologistas e clínicos em situações hipotéticas relacionadas ao tratamento da hipertensão. TIPO DE ESTUDO E LOCAL: Estudo transversal, na Universidade Federal de São Paulo, São Paulo, Brasil. MÉTODO: Foi aplicado um questionário com cinco casos clínicos hipotéticos durante o X Encontro Paulista de Nefrologia, com o objetivo de avaliar a primeira escolha de droga anti-hipertensiva em cada situação, contemplando as principais dúvidas relacionadas. RESULTADOS: Foram analisados 165 questionários. A maior parte dos médicos era composta por nefrologistas (93,2 por cento). Houve preferência pelo uso dos inibidores da enzima conversora de angiotensina (IECA) em dois dos cinco casos. Apenas 57,2 por cento acertaram na escolha do beta-bloqueador como primeira opção nos pacientes com coronariopatia. Além disso, 66,2 por cento optaram por IECA como drogas de eleição em renais crônicos com proteinúria. Aproximadamente 5 por cento dos colegas não seguiram as recomendações quanto ao uso dos IECA ou ARA em diabéticos com microalbuminúria. A questão com mais divergências foi a que avaliou a droga de escolha na doença renal crônica em fase avançada. A maior parte dos médicos acertou ao evitar o uso dos IECA na hipertensão renovascular em pacientes com rim único funcionante. CONCLUSÕES: A maior parte dos colegas adota condutas coerentes com os consensos relacionados à hipertensão arterial e doença renal, contudo, uma parcela não desprezível diverge e adota condutas não recomendadas.

Trombosis de la arteria renal después de suspender la terapia anticoagulante en una trasplantada renal con trombofilia: Caso Clínico / Renal artery thrombosis after withdrawal from anticoagulation therapy in a kidney transplant recipient with thrombophilia: Report of one case

Kidney graft loss because arterial thrombosis is not common and is related to risk factors such as recurrent vascular hemodialysis access thrombosis, collagen-vascular disease, repeated miscarriage, diabetes mellitus and thrombophilia. Patients having this last disorder have an increased risk of repeated thrombosis in successive transplants unless they receive anticoagulation therapy. We report a 51 year-old diabetic woman who had a history of recurrent vascular hemodialysis access thrombosis (both native and prosthetic) while on dialysis and received a cadaveric donor kidney. One month after transplantation she had axillary vein thrombosis complicated with pulmonary embolism and received anticoagulants for six months. Just days after stopping the anticoagulation, she became suddenly anuric due to renal artery thrombosis and complete graft infarction. The coagulation study showed moderate hyperhomocysteinemia and a significant protein C deficiency (39 percent). Days after nephrectomy she suffered a femoral vein thrombosis and anticoagulation was prescribed for life.

Renal artery embolism: therapy with intra-arterial streptokinase infusion.

Two patients with acute renal artery embolism were reported. One patient had a history of rheumatic valvular heart disease and the other patient had hereditary cardiomyopathy. Both patients had atrial fibrillation on physical examination. Both patients presented with acute back pain and one patient had hematuria. The final diagnosis of acute renal artery embolism was made after one to three days of hospitalization and renal angiography was finally done documenting complete occlusion of the main branch of the renal artery on one side. Intra-arterial streptokinase infusion 5,000 unit per hour was given to both patients using an arterial pump for 17 hours to 30 hours with complete recanalization of the intrarenal branches and complete recovery of signs and symptoms of renal artery embolism although the renal scan still showed diminished renal function.

Estenosis de la arteria renal y embarazo / Stenosis of the renal artery and pregnancy

La hipertensión renovascular es una entidad de diagnóstico infrecuente en el embarazo y agrega un factor de riesgo grave para la madre y el feto. El manejo médico conservador es una de las alternativas terapéuticas en esta etapa y las opciones quirúrgicas (revascularización, angioplastia endoluminal percutánea y nefrectomía) se reservan para casos severos en que el tratamiento no es satisfactorio, habiendo en la literatura actual casos resueltos en forma invasiva durante la gestación. Presentamos un caso de hipertensión renovascular en una gestante joven, que fue manejado en forma conservadora