Glomerulopatía por C3: algoritmo diagnóstico en gestantes

La enfermedad glomerular comprende un grupo heterogéneo de entidades que se caracterizan por la pérdida de la arquitectura o función del glomérulo secundario a proceso inflamatorio del mismo de etiología autoinmune, infecciosa, paraneoplásica, que puede ser identificada con estudios de histopatología. Su reconocimiento durante la gestación representa un reto diagnóstico por la sobreposición de cambios fisiológicos, el debut de enfermedades autoinmunitarias o de enfermedades genéticas, entre otros. La presentación clínica suele encajar en grupos sindromáticos específicos, sin embargo, es frecuente que sean clínicamente indistinguibles o sobrepuestos. El debut de la enfermedad renal con curso clínico de rápida instauración y de evolución desfavorable con respecto a la función renal, hace mandatorio un estudio completo desde el abordaje clínico hasta la interpretación de los hallazgos histopatológicos, encaminado en la distinción de causas primarias y secundarias. Si bien las glomerulonefritis primarias no son las más frecuentes en la gestación, la identificación certera del diagnóstico y su adecuada clasificación permite el manejo dirigido y óptimo de las mismas. Se presentan los casos clínicos de dos gestantes con enfermedad glomerular primaria, con discrepancia en su diagnóstico, enfatizando en sus manifestaciones durante el curso de la gestación, el algoritmo diagnóstico utilizado, el tratamiento inicial y de mantenimiento utilizado. Se resalta la utilidad de la biopsia renal, específicamente la inmunofluorencia para aclarar el mismo.

Glomerular disease involves a heterogeneous group of entities that are characterized by loss of the architecture and function of the glomerulus and this can be caused by immunity, infectious and paraneoplastic etiologies. The aforementioned can be identified in histopathological studies. The recognition of this entity during pregnancy represents a diagnostic challenge due to the superposition of physiological changes, the development of autoimmune diseases and / or genetic disease, among others. Clinical manifestations can be into specific syndromic groups; however we can find indistinguishable manifestations and overlapping of this. When the disease is present its common to find rapidly establishment and unfavorable evolution about renal function. With this it's necessary to complete studies involving the initial clinical approach until histopathological findings with the goal to find primary and secondary causes. As it's known primary glomerulonephritis is not the most frequent in pregnancy, the accuracy in the diagnosis and the proper classification allows the direct and soon management. In this case report we describe 2 pregnant women with primary glomerular disease with discrepancy in their diagnosis. We talk about manifestations during pregnancy, the algorithm used in the diagnosis and finally the initial treatment and the maintenance used in these patients.

Aféresis terapéutica. Con una nueva técnica de reposición con hidroxietil almidón (voluven) / Therapeutic apheresis. With a new hydroxyethyl starch (Voluven) replacement technique

Resumen Introducción: la aféresis plasmática, ampliamente utilizada, con indicaciones renales y no renales, así mismo con diferentes niveles de evidencia descritos por la Sociedad Americana de Aféresis, siendo un tratamiento antiguo y muy utilizado, en la literatura se disponen de escasos estudios que comparen el uso de las diferentes soluciones de reposición (cristaloides, coloides, plasma, albúmina) en cuanto a su respuesta clínica y paraclínica, específicamente en resultados de la función renal. Objetivo: describir la experiencia de pacientes llevados a aféresis plasmática en una institución de cuarto nivel, haciendo énfasis en los desenlaces de función renal y seguridad, con una nueva estrategia de solución de reposición con voluven. Métodos: estudio tipo serie de casos, se incluyeron pacientes tratados con plasmaféresis, quienes ingresaron entre enero 2012 y abril 2019 al servicio de nefrología del Hospital San José. Se realizó un análisis descriptivo. Resultados: se realizaron 608 sesiones de plasmaféresis. La indicación más frecuente el rechazo humoral agudo en el trasplante renal. Al final del periodo de tratamiento, los pacientes en plasma e hidroxietil almidón (hydroxyethyl starch, HES por sus siglas en inglés) presentaron similar proporción de hipocalcemia y trombocitopenia, las pruebas de función renal se conservan normales después del tratamiento. Conclusión: los efectos secundarios de la aféresis terapéutica como los trastornos hematológicos (alteración de los factores de coagulación, trombocitopenia o anemia), además de hipocalcemia, o posibles alteraciones de la función renal comparados entre los diferentes líquidos de reemplazo plasmático, albúmina o HES, en nuestro trabajo demostró que las alteraciones no son mayores y la función renal se mantiene conservada durante la terapia, además, se encontró que el uso de HES no generó lesión renal aguda, al contrario, se observa estabilidad de la función renal, por lo tanto se debe considerar su uso, siendo un producto de bajo costo, con excelentes resultados clínicos. (Acta Med Colomb 2021; 46. DOI: https://doi.org/10.36104/amc.2021.2028).

Abstract Introduction: while plasma apheresis is a longstanding, widely used treatment for renal and non-renal indications, with different levels of evidence described by the American Society for Apheresis, there are few studies in the literature comparing the use of different replacement solutions (crystalloids, colloids, plasma, albumin) with regard to their clinical and paraclinical response, specifically in kidney function results. Objective: to describe the experience of patients undergoing plasma apheresis in a quaternary care institution with a new replacement solution strategy using Voluven, emphasizing kidney function and safety outcomes. Methods: a case series which included patients treated with plasmapheresis who were admitted to the nephrology service at Hospital San José between January 2012 and April 2019. A descriptive analysis was performed. Results: 608 plasmapheresis sessions were performed. The most common indication was acute humoral rejection in kidney transplantation. At the end of treatment, patients receiving plasma and hydroxyethyl starch (HES) had a similar proportion of hypocalcemia and thrombocytopenia. Kidney function tests remained normal after treatment. Conclusion: our study's comparison between the different plasma replacement fluids (albumin or HES) with regard to the side effects of therapeutic apheresis such as blood disorders (altered coagulation factors, thrombocytopenia or anemia), hypocalcemia or possible kidney function disorders, showed no major disorders and preserved kidney function during treatment. In addition, we found that HES did not cause acute kidney injury; on the contrary, kidney function was stable. Therefore, its use should be considered as a low-cost product with excellent clinical results. (Acta Med Colomb 2021; 46. DOI: https://doi.org/10.36104/amc.2021.2028).

Manejo con dispositivo Watchman en un paciente con fibrilación auricular y en terapia de diálisis. Reporte de caso y revisión narrativa / Management with the Watchman device in a patient with atrial fibrillation and on dialysis therapy. Case report and narrative review

Resumen La anticoagulación es la terapia de elección para la mayoría de pacientes con fibrilación auricular no valvular; sin embargo, en pacientes con enfermedad renal crónica con alto riesgo de sangrado se deben considerar terapias antitrombóticas locales como el cierre percutáneo de la orejuela izquierda con dispositivo Watchman. A continuación, se reporta el primer caso de implante de este dispositivo llevado a cabo en el Hospital de San José de Bogotá, Colombia, y se hace una revisión narrativa sobre este tema. El uso del dispositivo Watchman se asocia con menos accidentes cerebrovasculares hemorrágicos (0,15 vs. 0,96 eventos / 100 pacientes-año HR=0,22; p=0,004), menos muertes cardiovasculares o inexplicadas (1,1 vs. 2,3 eventos / 100 paciente-año; HR=0,48; p=0,006) y menos casos de sangrado no asociado al procedimiento (6,0 % vs. 11,3 %; HR=0,51; p=0,006) en comparación con la warfarina.

Resumen Anticoagulation remains the therapy of choice for the majority of patients with non-valvular atrial fibrillation, however, in patients with chronic kidney disease at high risk of bleeding, local antithrombotic therapies such as the left atrial closure with Watchman device should be considered. We report the first case of implant of this type device in the Hospital de San José at the City of Bogotá, Colombia, and a narrative review of the literature is made. Watchman's use is associated with fewer hemorrhagic strokes (0.15 versus 0.96 events / 100 patients-year HR: 0.22; p = 0.004), cardiovascular death / unexplained death (1.1 vs. 2.3 events / 100 patient-year; HR: 0.48; p = 0.006), and bleeding not associated with the procedure (6.0 % vs. 11.3 %; HR: 0.51; p = 0.006) compared to warfarin.

Abordaje clínico y diagnóstico de la glomerulonefritis membranoproliferativa. Reporte de caso / Clinical approach and diagnosis of membranoproliferative glomerulonephritis, case report

Resumen La glomerulonefritis membranoproliferativa es una lesión poco frecuente que abarca un grupo de patologías que comparten un patrón histológico en común y pueden originarse a partir de diversos mecanismos patogénicos. Mediante biopsias renales se ha establecido que en estas lesiones el daño renal inicial ocurre por el depósito de inmunoglobulinas que generan depósitos subendoteliales, subepiteliales y/o en la membrana basal glomerular, con lo cual el glomérulo adopta frecuentemente un aspecto lobulado. Se presenta el caso de un hombre de 48 años, quien ingresó al servicio de urgencias del Hospital de San José de Bogotá, Colombia, sin antecedentes relevantes y presentó proteinuria en rango nefrótico severo (62 gramos en 24 horas), elevación de nitrogenados y reporte de biopsia con glomerulonefritis membranoproliferativa. Se describe el enfoque clínico y diagnóstico de esta entidad.

Abstract The membranophroliferative glomerulonephritis is a rare lesion that covers a group of pathologies that share a histologic pattern, and can generate from diverse pathogenic mechanisms. Based on the findings of the kidney biopsy, starts a process to search the etiology of the lesion. The initial kidney damage occurs due to the deposit of immunoglobulins, complement elements or both in the mesangium and in the capillary endothelium, generating sub endothelial, sub epithelial, and/or glomerular basal membrane deposits, frequently adopting glomerulus a lobed aspect. We present a case of a man 48 years old admitted in the emergency of the San Jose Hospital in Bogotá, without relevant pathological background that debuts with proteinuria in severe nephrotic range (62 grams in 24 hours), nitrogenous elevation and biopsy report with membranophroliferative glomerulonephritis, we describe de clinical and diagnostic approach of this entity.

Eficácia de uma estratégia diagnóstica para pacientes com dor torácica e sem supradesnível do segmento ST na sala de emergência / Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17 per cent acute myocardial infarction and 43 per cent unstable angina, whereas in route 3 the rates were 2 per cent and 7 per cent, respectively. Patients with normal/non--specific ECG had 6 per cent probability of AMI whereas in those with negative first CKMB it was 7 per cent; the association of the 2 data only reduced it to 4 per cent. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52 per cent and 93 per cent, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

Dor torácica na sala de emergência: a importância de uma abordagem sistematizada / Chest pain in the emergency room: importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74 per cent of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12 per cent) had AMI without ST segment elevation and 202 (31 per cent) had unstable angina (UA). In route 2 (high probability of ACS) 17 per cent of patients had AMI and 43 per cent had UA, whereas in route 3 (low probability) 2 per cent had AMI and 7 per cent had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49 per cent), with a positive predictive value considered only satisfactory (79 per cent). CONCLUSION : A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

HTLV-I en la costa del Pacífico de Colombia y Ecuador

Datos y muestras serológicas tomados en 1957 y 1962, y controles tomados a partir de 1994, permiten obtener una visión más completa de la acción de retrovirus que atacan al ser humano