Efficacy and safety of mycophenolate mofetil versus cyclophosphamide in the treatment of Henoch-Schönlein purpura nephritis with nephrotic-range proteinuria in children: a prospective randomized controlled trial / 中国当代儿科杂志

OBJECTIVE@#To study the efficacy and safety of mycophenolate mofetil (MMF) versus cyclophosphamide (CTX) in the treatment of children with Henoch-Schönlein purpura nephritis (HSPN) and nephrotic-range proteinuria.@*METHODS@#A prospective clinical trial was conducted in 68 pediatric patients who were admitted to the Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics and who were diagnosed with HSPN and nephrotic-range proteinuria from August 2016 to November 2019. The patients were randomly divided into two groups:MMF treatment (@*RESULTS@#At months 3, 6, and 12 of treatment, there was no significant difference in the complete remission rate and the response rate between the MMF treament and CTX treatment groups (@*CONCLUSIONS@#MMF and CTX have similar efficacy and safety in the treatment of HSPN children with nephrotic-range proteinuria.

Renal changes and acute kidney injury in covid-19: a systematic review

SUMMARY OBJECTIVE We aimed to present a review of renal changes in patients with COVID-19. METHODS We performed a systematic review of the literature to identify original articles regarding clinical, laboratory, and anatomopathological kidney changes in patients infected with SARS-CoV-2 published until May 7, 2020. The search was carried out across PubMed, Scopus, and Embase using the keywords "COVID-19", "coronavirus", "SARS-CoV-2", "kidney injury" and "kidney disease". Fifteen studies presented clinical and laboratory renal changes in patients with COVID-19, and three addressed anatomopathological changes. DISCUSSION Acute kidney injury (AKI) was a relevant finding in patients with COVID-19. There were also significant changes in laboratory tests that indicated kidney injury, such as increased serum creatinine and blood urea nitrogen (BUN), proteinuria, and hematuria. The presence of laboratory abnormalities and AKI were significant in severely ill patients. There was a considerable prevalence of AKI among groups of patients who died of COVID-19. Histopathological analysis of the kidney tissue of patients infected with SARS-CoV-2 suggested that the virus may directly affect the kidneys. CONCLUSION Although COVID-19 affects mainly the lungs, it can also impact the kidneys. Increased serum creatinine and BUN, hematuria, proteinuria, and AKI were frequent findings in patients with severe COVID-19 and were related to an increased mortality rate. Further studies focusing on renal changes and their implications for the clinical condition of patients infected with the novel coronavirus are needed.

RESUMO OBJETIVO Apresentar uma revisão sobre as alterações renais nos pacientes com COVID-19. MÉTODOS Foi realizada uma revisão sistemática de literatura para buscar estudos referentes a pacientes com alterações renais clínicas, laboratoriais e anatomopatológicas durante a infecção por SARS-CoV-2. A busca foi realizada nas bases de dados eletrônicos PubMed, Scopus e Embase, com as palavras-chaves: "COVID-19", "coronavirus", "Sars-CoV-2", "kidney injury" e "kidney disease", para identificar artigos originais publicados na literatura até 07 de maio de 2020. Quinze estudos trouxeram alterações renais clínicas e laboratoriais dos pacientes com COVID-19, e três abordaram análises anatomopatológicas. DISCUSSÃO A Lesão renal aguda (LRA) foi um achado relevante nos pacientes com COVID-19. Houve também alterações significativas nos exames laboratoriais que indicam lesão renal, como o nível de creatinina e ureia séricas, proteinúria e hematúria. As alterações laboratoriais e a LRA foram importantes nos pacientes que desenvolveram o quadro grave da doença. Há considerável prevalência de LRA nos grupos de pacientes que vieram a óbito. Na análise histopatológica de pacientes com SARS-CoV-2 foram encontrados achados renais sugestivos que o vírus poderia ter efeitos diretos sobre o rim. CONCLUSÃO A COVID-19 é uma doença que, apesar de acometer principalmente os pulmões, também acomete os rins. Aumento das escórias nitrogenadas, hematúria, proteinúria e LRA foram achados frequentes em pacientes com quadros graves da COVID-19. Esses achados foram relacionados a maior mortalidade. É necessária a realização de mais estudos com enfoque nas alterações renais e suas implicações no quadro clínico causadas pelo novo coronavírus.

T-lymphocyte-expressing inflammatory cytokines underlie persistence of proteinuria in children with idiopathic nephrotic syndrome / Os linfócitos T que expressam citocinas inflamatórias são subjacentes à persistência de proteinúria em crianças com síndrome nefrótica idiopática

Abstract Objective: There is evidence of an important role of immune system changes in the triggering and maintenance of idiopathic nephrotic syndrome (INS). The aim of this study was to investigate the expression of cytokines in lymphocyte populations of patients with INS in comparison to healthy individuals, according to proteinuria. Methods: This cross-sectional study included 44 patients with INS and eight healthy children, matched for age and sex (controls). Patients were subdivided according to proteinuria: persistent proteinuria or partial remission (PP ≥ 300 mg/24 h, n = 17) and low proteinuria or complete remission (LP < 300 mg/24 h, n = 27). Ex vivo analysis of peripheral blood leukocytes by flow cytometry was performed using surface markers for T-lymphocytes, TCD4, TCD8, natural killer (NK) cells, NKT, and B-lymphocytes. Frequencies of intracellular cytokines were analyzed in these cells. Results: The frequencies of B-lymphocytes, NK cells, and NKT cells were lower in INS than in controls, whereas INS patients had a higher frequency of CD4+tumor necrosis factor (TNF)-α+ cells than controls. Cytotoxic-T-lymphocytes expressing IFN-γ were lower in INS than in controls. Patients with PP showed higher frequencies of CD4-T-lymphocytes expressing IFN-γ and TNF-α than controls. CD8-lymphocytes expressing TNF-α were increased in PP group when compared with LP and controls, while CD8+interferon (IFN)-γ+ cells were lower than in LP and in controls. Conclusion: Regardless the level of proteinuria, INS patients had increased expression of TNF-α in CD4-lymphocytes and reduced expression of IFN-γ in CD8-lymphocytes. Persistence of proteinuria was associated with higher levels of inflammatory markers.

Resumo Objetivo Há comprovação do importante papel das alterações no sistema imunológico no desencadeamento e manutenção da síndrome nefrótica idiopática (SNI). O objetivo deste estudo foi investigar a expressão das citocinas em populações de linfócitos de pacientes com SNI em comparação a indivíduos saudáveis e de acordo com a proteinúria. Métodos Este estudo transversal incluiu 44 pacientes com SNI e oito crianças saudáveis, pareados por idade e sexo (controles). Os pacientes foram subdivididos de acordo com a proteinúria: proteinúria persistente ou remissão parcial (PP ≥ 300 mg/24 h, n = 17) e proteinúria baixa ou remissão completa (PB < 300 mg/24 h, n = 27). A análise ex vivo de leucócitos no sangue periférico por citometria de fluxo foi feita utilizando marcadores de superfície para linfócitos T, TCD4, TCD8, células natural killer (NK), linfócitos NKT e B. As frequências das citocinas intracelulares foram analisadas nessas células. Resultados A frequência dos linfócitos B, células NK e células NKT foi menor em pacientes com SNI do que nos controles, ao passo que os pacientes com SNI apresentaram maior frequência de células CD4+fator de necrose tumoral (TNF)-α+ do que nos controles. Os linfócitos T citotóxicos que expressam interferon (IFN)-γ foram menores nos pacientes com SNI do que nos controles. Os pacientes com PP mostraram maiores frequências de linfócitos T CD4 que expressam IFN-γ e TNF-α que os controles. Os linfócitos CD8 que expressam TNF-α apresentaram aumento no grupo com PP, em comparação aos com PB e os controles, apesar de as células CD8+IFN-γ+ serem mais baixas nos pacientes com PB e nos controles. Conclusão Com relação ao nível de proteinúria, os pacientes com SNI apresentaram aumento na expressão de TNF-α nos linfócitos CD4 e expressão reduzida de IFN-γ nos linfócitos CD8. A persistência da proteinúria foi associada a maiores níveis de marcadores inflamatórios.

Captopril alleviates hypertension-induced renal damage, inflammation, and NF-κB activation

Hypertensive renal damage generally occurs during the middle and late stages of hypertension, which is typically characterized by proteinuria and renal inflammation. Captopril, an angiotensin-converting enzyme (ACE) inhibitor, has been widely used for therapy of arterial hypertension and cardiovascular diseases. However, the protective effects of captopril on hypertension-induced organ damage remain elusive. The present study was designed to explore the renoprotective action of captopril in spontaneously hypertensive rats (SHR). The 6-week-old male SHR and age-matched Wistar-Kyoto rats were randomized into long-term captopril-treated (34 mg/kg) and vehicle-treated groups. The results showed that in SHR there was obvious renal injury characterized by the increased levels of urine albumin, total protein, serum creatinine, blood urea nitrogen, renal inflammation manifested by the increased mRNA and protein expression of inflammatory factors including tumor necrosis factor-α, interleukin (IL)-1β, IL-6, and inducible nitric oxide synthase, and enhanced nuclear factor-κB (NF-κB) activation. Captopril treatment could lower blood pressure, improve renal injury, and suppress renal inflammation and NF-κB activation in SHR rats. In conclusion, captopril ameliorates renal injury and inflammation in SHR possibly via inactivation of NF-κB signaling.

El análisis de orina como herramienta diagnóstica en casos de malaria grave / Urinalysis as a diagnostic tool in severe malaria

Resumen La malaria produce complicaciones y muerte especialmente en poblaciones con acceso limitado a la atención en salud. La malaria grave puede reconocerse tempranamente mediante la detección en la orina de hallazgos como la hematuria, la coluria y la proteinuria. Se hizo una revisión narrativa basada en estudios sobre malaria grave y el empleo del análisis de orina mediante la consulta de 91 publicaciones. Mediante el análisis de la orina, se pueden detectar alteraciones metabólicas y lesiones en distintos órganos. En estudios recientes en Colombia se ha confirmado su utilidad como apoyo en el diagnóstico de la disfunción renal, la disfunción hepática y la anemia asociada con hemólisis, las cuales son complicaciones frecuentes en la malaria. El examen constituye una herramienta de fácil aplicación en la consulta ambulatoria y en pacientes hospitalizados para reconocer tempranamente casos complicados, y permite la detección oportuna de diferentes lesiones en el paciente con malaria, contribuyendo así a la reducción de la morbilidad grave y la mortalidad.

Abstract Malaria accounts for a significant morbidity and mortality rate around the world, especially in communities with limited access to healthcare. Some clinical signs in urine, like haematuria, coluria and proteinuria, help for the early diagnosis of severe malaria cases. A narrative review was conducted by analyzing 91 publications on studies about severe malaria cases and the use of urinalysis. A urinalysis can detect metabolic disturbances and organ injury. Its diagnostic utility for frequent complications caused by malaria, such as hepatic injury, kidney dysfunction and hemolysis, has been confirmed by recent Colombian studies. This test is an easy-to-use tool in outpatient clinics and with hospitalized patients to promptly recognize complicated cases, allowing the timely identification of different lesions in patients with malaria, thus contributing to the reduction of severe morbidity and mortality.

The Oxford Classification predictors of chronic kidney disease in pediatric patients with IgA nephropathy / Preditores da doença renal crônica segundo a Classificação de Oxford em pacientes pediátricos com nefropatia por IgA

Abstract Objective: The Oxford Classification for Immunoglobulin A nephropathy (IgAN) identifies pathological variables that may predict the decline of renal function. This study aimed to evaluate the Oxford Classification variables as predictors of renal dysfunction in a cohort of Brazilian children and adolescents with IgAN. Methods: A total of 54 patients with IgAN biopsied from 1982 to 2010 were assessed. Biopsies were re-evaluated and classified according to the Oxford Classification. Multivariate analysis of laboratory and pathological data was performed. The primary outcomes were decline of baseline estimated glomerular filtration rate (eGFR) greater than or equal to 50%. Results: Mean follow-up was 7.6 ± 5.0 years. Mean renal survival was 13.5 ± 0.8 years and probability of decline ≥50% in baseline eGFR was 8% at five years of follow-up and 15% at ten years. Ten children (18.5%) had a decline of baseline eGFR ≥ 50% and five (9.3%) evolved to end-stage renal disease. Kaplan-Meier analysis showed that baseline proteinuria, proteinuria during follow-up, endocapillary proliferation, and tubular atrophy/interstitial fibrosis were associated with the primary outcome. Multivariate Cox analysis showed that only baseline proteinuria (HR, 1.73; 95% CI, 1.20-2.50, p = 0.003) and endocapillary hypercellularity (HR, 37.18; 95% CI, 3.85-358.94, p = 0.002) were independent predictors of renal dysfunction. No other pathological variable was associated with eGFR decline in the multivariate analysis. Conclusion: This is the first cohort study that evaluated the predictive role of the Oxford Classification in pediatric patients with IgAN from South America. Endocapillary proliferation was the unique pathological feature that independently predicted renal outcome.

Resumo Objetivo: A Classificação Oxford para a Nefropatia por Imunoglobulina A (IgAN) identificou variáveis patológicas de risco para disfunção renal. O presente estudo teve como objetivo avaliar as variáveis da Classificação de Oxford como preditores de disfunção renal em crianças brasileiras com IgAN. Métodos: Foram analisados 54 pacientes com diagnóstico de IgAN entre 1982-2010. As biópsias renais foram reavaliadas pela Classificação de Oxford. Foram feitas análises uni e multivariada das variáveis clínicas e patológicas. O desfecho primário foi queda da taxa de filtração glomerular (TFG) ≥ 50% da filtração basal. Resultados: O acompanhamento médio foi de 7,6 ± 5,0 anos. A sobrevida renal média foi de 13,5 ± 0,8 anos e a probabilidade de atingir o desfecho primário foi de 8% em cinco anos e 15% em 10 anos de seguimento. Dez crianças (18,5%) apresentaram queda na TFG basal ≥ 50% e cinco (9,3%) evoluíram para doença renal crônica terminal. A análise de Kaplan-Meier mostrou que a proteinúria basal e de seguimento, a proliferação endocapilar e a atrofia tubular/fibrose intersticial foram associadas com o desfecho primário. A análise multivariada de Cox mostrou que a proteinúria basal (HR = 1,73; IC95% 1,20-2,50, p = 0,003) e a proliferação endocapilar (HR = 37,18; IC95% 3,85-358,94, p = 0,002) foram preditores independentes de disfunção renal. Nenhuma outra variável patológica foi associada com declínio da TFG na análise multivariada. Conclusão: Este é o primeiro estudo brasileiro que avaliou a Classificação Oxford em crianças com IgAN. A proliferação endocapilar foi a única característica patológica capaz de predizer independentemente o declínio da função renal.

Tres casos de mieloma múltiple de novo después de trasplante renal / Three cases of de novo multiple myeloma after kidney transplantation

RESUMEN La enfermedad renal asociada a cadenas ligeras es frecuente en el contexto de las gammapatías monoclonales, afecta los glomérulos o los túbulos renales, y su causa más común es el mieloma múltiple. Puede desarrollarse después de un trasplante renal por recurrencia de un mieloma múltiple ya existente, o puede ser de diagnóstico nuevo y presentarse con deterioro de la función renal y proteinuria. Siempre se requiere una biopsia renal para confirmar el diagnóstico.

ABSTRACT Light chain-associated kidney compromise is frequent in patients with monoclonal gammopathies; it affects the glomeruli or the tubules, and its most common cause is multiple myeloma. It may develop after a kidney transplant due to recurrence of a preexisting multiple myeloma or it can be a de novo disease manifesting as graft dysfunction and proteinuria. A kidney biopsy is always necessary to confirm the diagnosis.

Proteinúria pós-transplante renal - prevalência e fatores de risco / Proteinúria after kidney transplantation - prevalence and risk factors

Resumo Introdução: A proteinúria pós-transplante renal tem incidência variável, sendo um fator de risco cardiovascular e para a sobrevida do enxerto. Objetivo: Avaliar a prevalência de PTN pós-Tx em receptores de um único centro e fatores associados. Métodos: A prevalência de PTN foi avaliada segundo a definição ≥ 500 mg/24 hs. Os pacientes foram divididos em 3 grupos: grupo A, < 500 mg, B, 500-1000 mg e C, > 1000 mg. Foi testada a associação entre PTN pós-Tx e: idade/gênero do doador e receptor, tipo de doador, função retardada do enxerto, rejeição aguda, HAS e creatinina. As variáveis com valor de p < 0,20 na analise bivariada foram incluídas em modelo de regressão logística multivariado. Resultados: Foram avaliados 173 receptores, idade média 39 anos, 57,2% sexo masculino e 60,7% doador falecido. A prevalência de PTN pós-Tx foi de 24,3%. A distribuição dos pacientes foi de 75,7% para o grupo A, 15,6% para o grupo B e 8,7% para o grupo C. Foram associados a uma maior chance de PTN ≥ 500 mg/24hs: o sexo masculino do receptor, o doador falecido e a HAS pós-Tx. A creatinina aos 12 meses foi significativamente maior nos pacientes com PTN. 62% dos pacientes com PTN ≥ 500 mg/24 hs receberam tratamento com IECA/BRA. Conclusão: A prevalência de PTN pós-Tx renal foi 24,3% segundo a definição utilizada. O sexo masculino do receptor, o doador vivo e a HAS estiveram associadas à maior chance de PTN pós-Tx. O bloqueio do sistema renina-angiotensina deve ser intensificado.

Abstract Introduction: Proteinuria after kidney transplantation (Tx) has variable incidence and is associated with cardiovascular risk and graft survival. Objective: To evaluate the prevalence of proteinuria after kidney Tx and its associated factors. Methods: The prevalence of PTN was evaluated according to definition ≥ 500 mg/24 hours. Patients were divided into 3 groups: group A, < 500 mg, B, 500-1000 mg and C, > 1000 mg. We tested the association between PTN and: age/gender of the donor and recipient, type of donor, delayed graft function, acute rejection, hypertension and creatinine. The variables with a p value < 0.20 in the bivariate analysis were included in a multivariate logistic regression analysis. Results: 173 recipients were evaluated, mean age 39 years, 57.2% male and 60.7% deceased donor. The prevalence of PTN after kidney Tx was 24.3%. The distribution of patients according to PTN was 75.7% for group A, 15.6% for group B and 8.7% for group C. The following factors were associated with higher risk of PTN: male recipients, living donor and hypertension. Creatinine at month 12 moths post-Tx was higher among patients with proteinuria. 60% of patients with PTN ≥ 500 mg/24 hours were treated with ACEI/ARB. Conclusion: The prevalence of PTN after kidney Tx varied between 24.3%, according to the definition used. The male gender of the recipient, living donor and hypertension were associated with the occurrence of PTN after kidney Tx. Blockade of the renin-angiotensin system must be prescribed to more patients.

Proteinuria is common among HIV patients: what are we missing?

OBJECTIVES:HIV-related renal diseases are the leading causes of chronic kidney diseases worldwide. The present study aimed to investigate the prevalence of pathological proteinuria and its risk factors among HIV patients.METHODS:A review of the medical records of 666 HIV-infected individuals aged 18 years or older in an urban HIV/AIDS clinic based in Porto Alegre in southern Brazil. Overt proteinuria was defined as a protein-to-creatinine ratio greater than 150 mg/g according to Kidney Disease: Improving Global Outcomes.RESULTS:The prevalence of pathological proteinuria in the present study cohort was 20%. Characteristics associated with pathological proteinuria after univariate analysis included alcohol abuse, hepatitis C virus coinfection, the occurrence of diabetes and therapy including tenofovir. Adjusted residuals analysis indicated an association between pathological proteinuria and both a CD4 lymphocyte count below 200 cells/mm3 and a viral load higher than 1000 copies/mL. Additionally, an absence of pathological proteinuria was associated with a CD4 lymphocyte count higher than 500 cells/mm3. After adjustment for variables with p<0.2 in the univariate analysis using a Poisson regression model, tenofovir-containing regimens and a CD4 lymphocyte count below 200 cells/mm3 were significantly associated with pathological proteinuria.CONCLUSION:The risk of chronic kidney diseases in this large contemporary cohort of HIV-infected individuals appeared to be attributable to a combination of HIV-related risk factors. In addition to the traditional risk factors cited in the literature, both regimens containing tenofovir and HIV disease severity seem to be associated with chronic kidney diseases in patients with HIV. Assessment of proteinuria constitutes a novel method for chronic kidney disease staging in HIV-infected individuals and may be effectively used to stratify the risk of progression to end-stage renal disease.

Hypertension and its correlation with renal lesions in dogs with leishmaniosis / Hipertensão e sua correlação com lesões renais em cães com leishmaniose

To evaluate the prevalence of hypertension and its correlation with the severity of renal injury and proteinuria in dogs with leishmaniosis, sixty-six dogs were divided into two groups. Group 1 (G1) was composed of 54 dogs included in stage 1 of chronic kidney disease (CKD), and group 2 (G2) of twelve dogs in stages 2 and 3 of CKD. Prevalence of hypertension was 28.8%, comprising 22.2% of the dogs from G1 and 58.3% from G2 (P=0.011). The mean arterial blood pressure (BP) of dogs from G1 (135.7 ± 20.5) was lower than from G2 (170.0 ± 26.3) (P <0.001). Urine protein-creatinine ratio (UP/C) revealed values above 0.5 in 75.7% of the dogs, with 34% presenting hypertension. All dogs with hypertension had histopathological and laboratory evidence of glomerular disease. Although there was no statistically significant correlation between elevated BP and the severity of glomerular lesions (P=0.408), there was a statistically significant correlation between elevated BP and increased UP/C in the studied population (P=0.002). Thus, dogs with leishmaniosis and renal disease must be screened for the presence of hypertension so that treatment may be instituted as early as possible, in countries where treatment is allowed, to prevent the progression of renal damage.

Para avaliar a prevalência de hipertensão arterial e sua correlação com a severidade da lesão renal e proteinúria em cães com leishmaniose, 66 cães foram divididos em dois grupos. O grupo 1 (G1), composto por 54 cães em estágio 1 de doença renal crônica (DRC), e o grupo 2 (G2) por 12 cães em estágios 2 e 3 de DRC. A prevalência de hipertensão foi de 28,8%, compreendendo 22,2% dos cães de G1 e 58,3% dos cães de G2 (p = 0,011). A pressão arterial média (PA) de G1 (135,7 ± 20,5) foi inferior a de G2 (170,0 ± 26,3) (P <0,001). A relação proteína creatinina urinária (P/C U) foi maior que 0,5 em 75,7% dos cães, dos quais 34% possuíam hipertensão. Todos os cães com hipertensão apresentavam doença glomerular. Embora não tenha sido observada correlação estatisticamente significativa entre elevação da PA e severidade das lesões glomerulares (P =0,408), houve uma correlação significativa entre PA elevada e aumento da UP/C (P = 0,002). Portanto, cães com leishmaniose e doença renal devem ser pesquisados ​​quanto à presença de hipertensão, para que o tratamento possa ser instituído o mais precocemente possível em países onde ele é permitido, para evitar a progressão da lesão renal.

Manifestaciones del dengue a nivel renal / Manifestations of dengue in the kidney

IIntroducción: el dengue es una infección con afectación multisistémica, autolimitada, con espectro clínico que varía de formas asintomáticas a graves y fatales. Hay descripciones de casos de afectación renal en todo el mundo. Objetivo: describir las manifestaciones renales por el dengue. Metodología: estudio observacional, descriptivo, prospectivo realizado en pacientes adultos con dengue grave internados en el Dpto. de Medicina Interna del Hospital Nacional (Itauguá, Paraguay) durante la epidemia del verano 2013-2013. Fueron evaluados parámetros clínicos y laboratoriales con énfasis en la función renal. Resultados: se reclutaron 135 pacientes, 69 varones y 66 mujeres, con edad media 42,7±18 años. En 37% de los casos había alguna comorbilidad. Se midió proteinuria de 24 hs en 34 sujetos, encontrándose en rango nefrótico en 8,8% y en rango elevado ( = 160 mg/día) en 67,6%. Otros hallazgos llamativos fueron la hematuria (38%) e hipertensión arterial transitoria (39%). Un solo paciente presentó alteración de urea y creatinina al alta. Conclusiones: las manifestaciones renales por el dengue grave son frecuentes, predominando la proteinuria, hematuria e hipertensión arterial, aunque son transitorias en la mayoría.

I Introduction: dengue fever is an infection with multisystem involvement, self-limiting, clinical spectrum ranging from asymptomatic to severe and fatal forms. There are descriptions of cases of renal disease worldwide. Objective: to describe renal manifestations of dengue. Methodology: observational, descriptive, prospective study in adult patients with severe dengue admitted to the Department of Internal Medicine, National Hospital (Itauguá, Paraguay) during summer 2013 to 2013 epidemic. We evaluated clinical and laboratory parameters with emphasis on renal function. Results: 135 patients, 69 men and 66 women were recruited, mean age 42.7 ± 18 years. In 37% of cases there was any comorbidity. 24 h proteinuria were measured in 34 subjects, being in nephrotic range at 8.8% and high range (= 160 mg / day) in 67.6%. Other striking findings were hematuria (38%) and transient hypertension (39%). Only one patient presented alterations in urea and creatinine at discharge. Conclusions: renal manifestations of severe dengue are common, predominantly proteinuria, hematuria and hypertension, although they are transient in most.

Renal Complications and Their Prognosis in Korean Patients with Middle East Respiratory Syndrome-Coronavirus from the Central MERS-CoV Designated Hospital

Some cases of Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) infection presented renal function impairment after the first MERS-CoV patient died of progressive respiratory and renal failure. Thus, MERS-CoV may include kidney tropism. However, reports about the natural courses of MERS-CoV infection in terms of renal complications are scarce. We examined 30 MERS-CoV patients admitted to National Medical Center, Korea. We conducted a retrospective analysis of the serum creatinine (SCr), estimated glomerular filtration rate (eGFR), urine dipstick tests, urinary protein quantitation (ACR or PCR), and other clinical parameters in all patients. Two consecutive results of more than trace (or 1+) of albumin and blood on dipstick test occurred in 18 (60%) (12 [40%]) and 22 (73.3%) (19 [63.3%]) patients, respectively. Fifteen (50.0%) patients showed a random urine ACR or PCR more than 100 mg/g Cr. Eight (26.7%) patients showed acute kidney injury (AKI), and the mean and median durations to the occurrence of AKI from symptom onset were 18 and 16 days, respectively. Old age was associated with a higher occurrence of AKI in the univariate analysis (HR [95% CI]: 1.069 [1.013-1.128], P = 0.016) and remained a significant predictor of the occurrence of AKI after adjustment for comorbidities and the application of a mechanical ventilator. Diabetes, AKI, and the application of a continuous renal replacement therapy (CRRT) were risk factors for mortality in the univariate analysis (HR [95% CI]: diabetes; 10.133 [1.692-60.697], AKI; 12.744 [1.418-114.565], CRRT; 10.254 [1.626-64.666], respectively). Here, we report renal complications and their prognosis in 30 Korean patients with MERS-CoV.

Función renal en pacientes pediátricos con trasplante alogénico de progenitores hematopoyéticos / Renal function in pediatric patients with allogeneic hematopoietic progenitor cell transplantation

Patients with hematopoietic stem cell transplantation can develop some degree of renal failure. The aim of this descriptive study is to evaluate markers of kidney injury in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation between 1991 and 2011. Patients and Method: A descriptive study of pediatric patients with allogeneic transplant of hematopoietic precursors between 1991 and 2011. The patients were between 1 month and 18 years of age at the time of the study and had at least 6 months of follow up. Clinical and nutritional history, continuous blood pressure monitoring (ABPM), urine tests, proteinuria, creatinine and renal and bladder ultrasonography imaging were evaluated. Results: During this period 65 patients were transplanted, of which 13 patients were included. 46% (n = 6) showed diverse degrees of renal compromise defined by altered renal parenchymal echogenicity, clinic or masked hypertension and/or microalbuminuria. Conclusion: In this clinical group, almost half of the patients patients had some degree of renal injury in their evolution. We consider essential to assess the renal function in the follow-up of these patients.

Introducción: Los pacientes con trasplante de progenitores hematopoyéticos pueden evolucionar con algún grado de compromiso renal. El objetivo de este estudio descriptivo fue evaluar marcadores de injuria renal en pacientes pediátricos sometidos a trasplante alogénico de progenitores hematopoyéticos entre 1991 y 2011. Pacientes y Método: Estudio descriptivo en pacientes pediátricos con Trasplante alogénico de Precursores Hematopoyéticos entre los años 1991 y 2011 con edad entre 1 mes y 18 años al momento de realizar el estudio y que tuviesen al menos 6 meses de seguimiento. Se evaluaron antecedentes clínicos, nutricionales, presión arterial por monitoreo continuo (MAPA), exámenes de orina, proteinuria, creatininuria y estudio de imágenes por ecotomografía renal y vesical. Resultados: Durante este período se trasplantaron 65 pacientes, de los cuales se incluyeron 13 pacientes. Un 46% (n = 6) presentó compromiso renal de grado variable definido por alteración en la ecogenicidad del parénquima renal, hipertensión arterial clínica o enmascarada y/o microalbuminuria. Conclusión: En la serie clínica estudiada con el 50% de los pacientes presentó algún grado de injuria renal en su evolución. Consideramos importante evaluar función renal en el seguimiento de este grupo de pacientes.

Treatment of Bartter syndrome. Unsolved issue, / Tratamento da síndrome de Bartter. Problema não resolvido,

Objective: To describe the results of a long-term follow-up of Bartter syndrome patients treated with different drugs. Method: Patients were diagnosed according to clinical and laboratory data. Treatment protocol was potassium supplementation, sodium, spironolactone, and non-steroidal anti-inflammatory drug. Patients who developed proteinuria were converted to angiotensin conversion enzyme inhibitor. The variables evaluated for each drug were Z-score for weight and stature, proteinuria, creatinine clearance, gastrointestinal complaints, amount of potassium supplementation, serum potassium and bicarbonate levels, and findings of upper digestive endoscopy. Results: 20 patients were included. Follow-up was 10.1 ± 5.2 years. 17 patients received indomethacin for 5.9 ± 5.3 years; 19 received celecoxib, median of 35 months; and five received enalapril, median of 23 months. During indomethacin, a statistically significant increase was observed in the Z-score for stature and weight, without a change in the creatinine clearance. Seven of 17 patients had gastrointestinal symptoms, and upper digestive endoscopy evidenced gastritis in three patients and gastric ulcer in four patients. During celecoxib use, a significant increase was detected in the Z-score for stature and weight and a reduction of hyperfiltration; seven patients presented gastrointestinal symptoms, and upper digestive endoscopy evidenced mild gastritis in three. During enalapril use, no significant changes were observed in the Z-score for stature, weight and creatinine clearance. The conversion to enalapril resulted in a significant reduction in proteinuria. Conclusion: The authors suggest starting the treatment with celecoxib, and replacing by ACEi if necessary, monitoring the renal function. The safety and efficacy of celecoxib need to be assessed in larger controlled studies. .

Objetivo: Descrever os resultados de um acompanhamento de longo prazo de pacientes com síndrome de Bartter tratados com diferentes medicamentos. Método: Pacientes diagnosticados segundo os dados clínicos e laboratoriais. Protocolo de tratamento: suplementação de potássio, sódio, espironolactona e medicamento anti-inflamatório não esteroidal. Os pacientes que desenvolveram proteinúria foram submetidos a inibidor da enzima de conversão da angiotensina. As variáveis avaliadas durante o uso de cada medicamento foram: escore Z para peso e estatura, proteinúria, depuração da creatinina, queixas gastrointestinais, quantidade da suplementação de potássio, níveis séricos de potássio e bicarbonato e achados da endoscopia digestiva alta. Resultados: Foram incluídos 20 pacientes. O acompanhamento foi de 10,1 ± 5,2 anos. No total, 17 pacientes receberam indometacina por 5,9 ± 5,3 anos, 19 receberam celecoxib por aproximadamente 35 meses e cinco receberam enalapril por aproximadamente 23 meses. Durante o uso de indometacina, observamos um aumento estatístico significativo no escore Z para estatura e peso, sem alteração na depuração da creatinina. 7/17 pacientes apresentaram sintomas gastrointestinais, e a endoscopia digestiva alta mostrou gastrite em três pacientes e úlcera gástrica em quatro. Durante o uso de celecoxib, detectamos um aumento significativo no escore Z para estatura e peso e uma redução da hiperfiltração; sete pacientes apresentaram sintomas gastrointestinais e a endoscopia digestiva alta mostrou gastrite leve em três pacientes. Durante o uso de enalapril, não observamos alterações significativas no escore Z para estatura, peso e depuração da creatinina. A mudança da medicação para enalapril resultou em uma ...

Fenómeno y síndrome de cascanueces asociado a hematuria y proteinuria ortostática / Nutcracker phenomenon and syndrome associated to hematuria and orthostatic proteinuria

El fenómeno cascanueces es una compresión de la vena renal izquierda, lo más frecuente es el ángulo formado por la arteria aorta y la mesentérica superior, por una emergencia anormal de la mesentérica. Cuando aparecen síntomas derivados de esta anomalía se le denomina síndrome de cascanueces. Este síndrome puede producir síntomas y signos muy variados, pero entre ellos, la hematuria, la proteinuria ortostática, el varicocele, la congestión pélvica crónica, el dolor abdominal y en flanco, y la intolerancia ortostática son los más frecuentes. La hematuria y la proteinuria ortostática son 2 manifestaciones que frecuentemente tienen que enfrentar el médico general integral y el pediatra, y es necesario tener en cuenta al síndrome de cascanueces en el diagnóstico diferencial de estas alteraciones. La hematuria es muy frecuente y la proteinuria ortostática tiene como causa principal el síndrome cascanueces. Por tal motivo consideramos importante esta breve revisión del tema, para poder enfrentar estas situaciones teniendo en cuenta todas sus posibilidades diagnósticas

Nutcracker phenomenon is left renal vein compression, more frequently in the angle formed by the aorta artery and the superior mesenteric artery due to abnormal emergency of the mesentery. When symptoms derived from this anomaly occur, this situation is called nutcracker syndrome. It may cause very varied symptoms and signs such as hematuria, orthostatic proteinuria, varicocele, chronic pelvic congestion, abdominal pain and flank pain, and orthostatic intolerance as the most common ones. Hematuria and orthostatic proteinuria are two frequent manifestations that the family physician and the pediatrician must face, so it is necessary to take the nutcracker syndrome into account for the differential diagnosis of these alterations. Hematuria is more frequent and orthostatic proteinuria is mainly caused by the nutcracker syndrome. Therefore, we consider that this brief review on this topic is important to cope with these situations and to bear in mind all their diagnostic possibilities

Púrpura Schõnlein Henoch con compromiso renal: reporte de un caso / Henoch Schõnlein purpura with renal involvement: case report

INTRODUCCIÓN: El Púrpura Schõnlein Henoch es una vasculitis sistémica que afecta principalmente a la piel, articulaciones, sistema gastrointestinal y renal. Es una de las vasculitis más comunes en la infancia. El compromiso renal se da en aproximadamente el40 por ciento de los casos, y en la mayoría se presenta con hematuria, sin embargo, también puede manifestarse como proteinuria, síndrome nefrótico y nefrítico. PRESENTACIÓN DEL CASO: Se presenta el caso de una paciente de 6 años que consulta en Servicio de Urgencia por dolor en el tarso del pie izquierdo de 4 días de evolución, sin antecedentes de trauma, acompañándose de dolor en rodilla izquierda con limitación a la movilización, y lesiones purpúricas en extremidades inferiores. Durante la hospitalización, la paciente presentó al inicio presiones arteriales altas y oliguria, manejándose con antihipertensivos, además del inicio del tratamiento con corticoides. Luego de la mejoría del compromiso articular y cutáneo, se evidenció compromiso renal con proteinuria, que al persistir se aumentó las dosis de corticoides, teniendo favorable respuesta al disminuir sus niveles. Al encontrarse en mejores condiciones, se decidió manejo ambulatorio manteniendo tratamiento corticoidal y antihipertensivo, controlándose en Nefrología y Reumatología Infantil. DISCUSIÓN: Se concluye de este trabajo que la corticoterapia y el manejo de la presión arterial fueron pilares fundamentales para el tratamiento en este caso, mejorando su evolución clínica y principalmente la disminución de la proteinuria con el uso de los corticoides, evitando un compromiso mayor a pesar de que no esté comprobado su beneficio en la literatura.

INTRODUCTION: The Henoch Schõnlein Purpura is a systemic vasculitis that mainly affects the skin, joints, gastrointestinal system and renal system. It is one of the most common vasculitis in childhood. Renal involvement occurs in approximately40 percent of cases, and in most cases it occurs with hematuria. However, it may also manifest as proteinuria, nephrotic and nephritic syndrome. CASE REPORT: We report the case of a 6-year old patient who consulting in the emergency service for 4 days with pain in left foot tarsal, without a history of trauma, accompanied by pain in left knee with limited mobilization, and purpuric lesions in lower extremities. During hospitalization, the patient presented at the beginning high blood pressure and oliguria, handling itself with antihypertensive, in addition to the initiation of treatment with corticosteroids. After improvement of cutaneus and articular involvement, renal involvement was evident with proteinuria, at persist was increased doses of corticosteroids, with favorable response to decrease levels. Being in better conditions was decided ambulatory management keeping antihypertensive and corticosteroid treatment, controlling in Nephrology and Child Rheumatology. DISCUSSION: It can be concluded from this study that the steroids and blood pressure management were fundamental pillars for the treatment in this case, improving their clinical course and mainly the proteinuria decreased with the use of corticosteroids, preventing a greater commitment although is not verified in the literature their advantage.

Corticotherapy response in primary IgA nephropathy / Resposta à corticoterapia na nefropatia da IgA primária

INTRODUCTION: Some beneficial effects from long-term use of corticosteroids have been reported in patients with IgA nephropathy. OBJECTIVE: This retrospective study aimed to evaluate the outcome of proteinuria and renal function according to a protocol based on a 6-month course of steroid treatment. METHOD: Twelve patients were treated with 1 g/day intravenous methylprednisolone for 3 consecutive days at the beginning of months 1, 3, and 5 plus 0.5 mg/kg oral prednisone on alternate days for 6 months (treated group). The control group included 9 untreated patients. RESULTS: Proteinuria (median and 25th and 75th percentiles) at baseline in the treated group was 1861 mg/24h (1518; 2417 mg/24h) and was 703 mg/24h (245; 983) and 684 mg/24h (266; 1023) at the 6th (p < 0.05 vs. baseline) and 12th months (p < 0.05 vs. baseline), respectively. In the control group the proteinuria was 1900 mg/24h (1620; 3197) at baseline and was 2290 mg/24h (1500; 2975) and 1600 mg/24h (1180; 2395) at the 6th and 12th months, respectively (not significant vs. baseline). When compared with the control group, the treated group showed lower proteinuria (p < 0.05) during the follow-up and a higher number of patients in remission (p < 0.05) at the 6th and 12th months. Renal function did not change during the follow-up and the adverse effects were mild in most of the patients. CONCLUSION: The 6-month course of steroid treatment was effective in reducing proteinuria during the 12 months of the follow-up, and was well-tolerated by most of the patients.

INTRODUÇÃO: Tem sido sugerido que tratamento mais prolongado com corticosteroides pode ser benéfico em pacientes com nefropatia da IgA primária. OBJETIVO: Neste estudo retrospectivo avaliamos os efeitos na proteinúria e na função renal após 12 meses do protocolo baseado no uso por 6 meses de corticosteroides. MÉTODO: Doze pacientes receberam pulsos de 1 g/dia de metilprednisolona intravenosa por 3 dias consecutivos no início dos meses 1, 3 e 5, seguidos por prednisona (0,5 mg/kg) por via oral em dias alternados após cada pulso durante 6 meses (grupo tratado). O grupo controle foi composto por nove pacientes não tratados. RESULTADOS: A proteinúria (mg/24h; mediana; 25º; 75º percentis) no período basal no grupo tratado foi de 1861 (1518; 2417) e de 703 (245; 983) e de 684 (266; 1023) nos 6º (p < 0,05 vs. basal) e 12º (p < 0,05 vs. basal) meses, respectivamente. No grupo controle, a proteinúria foi de 1900 (1620; 3197) no período basal e de 2290 (1500; 2975) e de 1600 (1180; 2395) nos 6º e 12º meses, respectivamente (não significantes vs. basal). Comparado com o grupo controle, o grupo tratado teve menor proteinúria (p < 0,05) e número maior de pacientes em remissão (p < 0,05) nos 6º e 12º meses. A função renal não teve alteração significante e eventos adversos foram de pequena intensidade na maioria dos pacientes. CONCLUSÃO: O protocolo terapêutico base-ado no uso por 6 meses de corticosteroides foi efetivo em reduzir a proteinúria durante os 12 meses de seguimento e foi bem tolerado pela maioria dos pacientes.

Prevention of renal damage by treating hyperuricemia

Nephrolithiasis, obstructive renal failure, essential hypertension, and chronic tubulointerstitial nephritis have been considered as the renal complications of hyperuricemia. Massive proteinuria has been rarely reported as the primary manifestation of increased serum uric acid. This is the report of a child presented with proteinuira, hypertension, and glomerular scelrosis secondary to hypouricosuric hyperuricemia, who was treated by uric acid lowering management.

Analysis of ultrastructural glomerular basement membrane lesions and podocytes associated with proteinuria and sclerosis in Osborne-Mendel rats with progressive glomerulonephropathy

The renal glomeruli of 12 male Osborne-Mendel (OM) rats 3 to 24 weeks old were examined by electron microscopy. Effacement of podocyte foot processes (FPs) developed at 3 weeks of age and became progressively worse over time. Loss or dislocation of the slit membrane was also found. Vacuoles and osmiophilic lysosomes appeared in the podocytes starting at 6 weeks of age. Podocyte detachment from the glomerular basement membrane (GBM) was apparent at 18 weeks of age. Laminated GBM was occasionally observed in all animals. These features might lead to the development of spontaneous proteinuria and glomerulosclerosis in OM rats.

Manifestaciones sistémicas del dengue / Systemic manifestations of dengue

Introducción: el dengue es una infección que puede afectar múltiples órganos.Objetivo: determinar la afectación multisistémica por dengue. Metodología: estudio observacional, descriptivo, prospectivo realizado en sujetos adultos con dengue grave con signos de alarma internados en el Hospital Nacional entre diciembre 2012 y mayo 2013. La infección debía estar confirmada con antígeno NS1 y/o serología IgM (+). Resultados: se encontró 10,1% de hepatitis, 85,6% de transaminitis, 48% con relación CPKmb/CPK total >5%, 22,5% de alteraciones electrocardiográficas, 70,4% con proteinuria de 24 hs elevada y 9,3% con proteinuria en rango nefrótico. Conclusiones: la afectación multisistémica es frecuente, generalmente pasa desapercibida y en general es autolimitada aunque se requieren más estudios para evaluar la evolución a largo plazo en estos casos.

Introduction: dengue is an infection that could affect multiple organs. Objective: to determine the multisystem involvement of dengue. Methodology: observational, descriptive, prospective study conducted in adult subjects with severe and warning signs of dengue admitted to the National Hospital between December 2012 and May 2013. Infection should be confirmed with NS1 antigen and / or IgM serology (+). Results: we found 10.1% of hepatitis, 85.6% of transaminitis the relation CPKmb / total CPK > 5% in 48%, electrocardiographic alterations in 22.5%, elevated proteinuria in 70.4% and nephrotic proteinuria in 9.3%. Conclusions: multisystemic involvement is frecuent, usually asymptomatic and generally self-limited although more studies are needed to evaluate the long-term outcome in these cases.