Multidisciplinary approach for patients with nephropathic cystinosis: model for care in a rare and chronic renal disease / Abordagem multidisciplinar para pacientes com cistinose nefropática: modelo para atendimento em uma doença renal rara e crônica

Abstract Care for patients with chronic and rare diseases is complex, especially considering the lack of knowledge about the disease, which makes early and precise diagnosis difficult, as well as the need for specific tests, sometimes of high complexity and cost. Added to these factors are difficulties in obtaining adequate treatment when available, in raising patient and family awareness about the disease and treatment compliance. Nephropathic cystinosis is among these diseases. After more than 20 years as a care center for these patients, the authors propose a follow-up protocol, which has been used with improvement in the quality of care and consists of a multidisciplinary approach, including care provided by a physician, nurse, psychologist, nutritionist and social worker. In this paper, each field objectively exposes how to address points that involve the stages of diagnosis and its communication with the patient and their relatives or guardians, covering the particularities of the disease and the treatment, the impact on the lives of patients and families, the approach to psychological and social issues and guidelines on medications and diets. This protocol could be adapted to the follow-up of patients with other rare diseases, including those with renal involvement. This proposal is expected to reach the largest number of professionals involved in the follow-up of these patients, strengthening the bases for the creation of a national protocol, observing the particularities of each case.

Resumo A assistência a pacientes com doenças crônicas e raras é complexa, principalmente pela falta de disseminação de conhecimento sobre a doença, o que dificulta o diagnóstico preciso e precoce, além da necessidade da realização de exames específicos, por vezes de alta complexidade e custo. Somam-se a esses fatores dificuldades na obtenção de tratamento adequado quando disponível, na conscientização do paciente e da família sobre a doença e na aderência ao tratamento. A cistinose nefropática está entre essas doenças. Após mais de 20 anos como centro de atendimento a esses pacientes, os autores propõem um protocolo de seguimento, o qual vem sendo empregado com melhora na qualidade da assistência e consiste de uma abordagem multidisciplinar, incluindo, principalmente, atendimento prestado por médico, enfermeiro, psicólogo, nutricionista e assistente social. Neste artigo, cada área expõe de maneira objetiva como abordar pontos que envolvem as etapas do diagnóstico e sua comunicação ao paciente e a seus familiares ou responsáveis, abrangendo as particularidades da doença e do tratamento, o impacto na vida do paciente e de sua família, a abordagem das questões psicológicas e sociais e orientações quanto a medicamentos e dietas. Considera-se que este protocolo poderia ser adaptado ao seguimento de pacientes portadores de outras doenças raras, incluindo aquelas com envolvimento renal. Com essa proposta, espera-se alcançar o maior número de profissionais envolvidos no seguimento desses pacientes, fortalecendo as bases para a criação de um protocolo nacional, observando-se as particularidades de cada caso.

Ocular manifestations in adolescent cystinosis: case report in Thailand.

Three siblings with a family history of consanguinity presented with short stature and two of the patients had leg deformity. None of them experienced ocular or renal symptoms at presentation. After the pediatricians found characteristics of Fanconi syndrome, an ophthalmic consultation was requested Ocular examination revealed typical cystine crystals deposited in the cornea and conjunctivae. No crystal deposits were found elsewhere in the eyes. Fundoscopic examination was normal. Two patients who underwent a complete ocular examination were diagnosed as adolescent cystinosis. The youngest patient who lost to follow up before completed ocular examination was suspected for adolescent cystinosis. This is the first report of cystinosis with ocular manifestation from Thailand.

Infantile cystinosis.

Ten patients of nephropathic cystinosis were admitted during the period 1995-2000. Their mean age was 12 months. The signs of failure to thrive and advanced rickets were seen in all patients. Other features included polyuria, polydipsia, pathologic fractures and deafness. Laboratory findings included glucosuria, hyposthenuria, hypocalcemia, proteinuria and azotemia. Therapy with phosphocysteamine showed marked clinical improvement.

Cistinosis nefropática infantil / Nephropathic cystinosis in children

La cistinosis nefropática, rara afección recesiva, se produce por defecto en el transporte lisosomal de cistina, y depósitos de cristales intracelulares en riñón, córnea, y otros tejidos. Constituye la primera causa congénita de síndrome de Fanconi, y evoluciona en la primera década de la vida a insuficiencia renal crónica. El diagnóstico se confirma por una detección de cistina en leucocitos y linfoblastos circulantes. Su tratamiento consiste en la reposición de las pérdidas por la tubolopatía, administración de cisteamina, que depleta cistina y favorece su transporte por la pared lisosomal. El objetivo de la presentación es dar a conocer el primer caso de cistinosis documentado y tratado en Chile. Se presenta el caso de un menor hospitalizado a los quince meses de vida, con desnutrición avanzada, raquitismo clínico, deshidratación severa, acidosis metabólica, hipokalemia e hipofosfemia severas, comprobándose tubulopatía de Fanconi. Se detectó concentración elevada de cistina en polimorfonucleares, confirmando diagnóstico de cistinosis. En tratamiento desde hace dos años con cisteamina oral, muestra excelente evolución pondoestatural y conservación de la función renal, persistiendo la tubulopatía

Cystinosis: the importance of early diagnosis

Cystinosis is a leading cause of Fanconi syndrome in childhood. We report a 7-year-old Pakistani boy who presented at the age of 5 months with vomiting, failure to thrive and rickets. At the age of 15 months he had typical biochemical findings of Fanconi syndrome and was prescribed electrolyte supplements. At the age of 6 years he presented to us with photophobia and renal failure in addition to the previous complaints, and was found to have hazy corneas. Cystinosis was suspected and confirmed by finding typical corneal and bone marrow cystine crystals. Leukocyte cystine was 7.3 nmol 0.5 cystine/mg protein [normal < 0.2]. The patient was started on L-thyroxine, 1 -alpha-cholecalciferol, in addition to electrolyte supplements and it was planned to start him on phosphocysteamine and to proceed to renal transplant. However, his renal failure was rapidly progressive. At the age of 7 years, after taking phosphocysteamine for 10 days, he was admitted with epistaxis and haematemesis; he required haemodialysis, bled massively into his chest after central line insertion and died within 2 months after suffering from severe hypoxic brain damage. We conclude although Cystinosis is a leading cause of Fanconi syndrome in North America, it is quite rare in Saudi Arabia. Second, Cystinosis is a generalized disease, and the involvement of the blood vessels might have led to the intrathoracic bleeding in our patient. Third, the importance of early diagnosis and treatment is stressed

Cistinose nefropática: relato de 2 casos e revisäo da literatura / Nephropathic cystinosis: report of two cases and review of the literature

Os autores descrevem dois casos de cistinose nefropática, da forma infantil, que se apresentaram com síndrome de Fanconi e diabetes insipidus nefrogênico. Após a confirmaçäo diagnóstica através da identificaçäo de cristais de cistina pelo exame de lâmpada de fenda e aspirado de medula óssea, os pacientes receberam tratamento convencional de reposiçäo das perdas renais de eletrólitos e minerais. O paciente 1 evoluiu para óbito após quadro de broncopneumonia. No paciente 2 foi iniciado tratamento com cisteamina, que é eficaz na depleçäo de cistina dos tecidos, na dose média de 50 mg/kg/dia, sendo este o primeiro caso de terapêutica com cisteamina em nosso meio.