Causa rara de dolor abdominal recurrente; coexistencia del síndrome de Wilkie y el síndrome del cascanueces / A rare cause of recurrent abdominal pain; the coexistence of Wilkie's syndrome and nutcracker syndrome

El síndrome del cascanueces es un síndrome que presenta síntomas clínicos como hematuria, proteinuria ortostática, congestión pélvica, varicocele del lado izquierdo, hipertensión y dolor en fosa renal. Estos síntomas se producen por la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior. En el síndrome de Wilkie, la tercera porción del duodeno está comprimida entre la arteria mesentérica superior y la aorta abdominal, lo que provoca diversos síntomas gastrointestinales. La coexistencia de estos dos síndromes constituye una afección rara y se incluye como casos clínicos en la bibliografía. En este artículo, se presentan los resultados clínicos y radiológicos de un paciente de 17 años que presentaba dolor abdominal recurrente debido al síndrome de Wilkie, acompañado del síndrome del cascanueces que le provocaba proteinuria, por lo que el paciente fue derivado a los consultorios externos de reumatología pediátrica con un diagnóstico preliminar de fiebre mediterránea familiar.

Nutcracker syndrome is a syndrome that has clinical symptoms such as hematuria, orthostatic proteinuria, pelvic congestion, left-sided varicocele, hypertension, and flank pain. These symptoms occur because of the compression of the left renal vein between the aorta and the superior mesenteric artery. In Wilkie's syndrome, the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, causing various gastrointestinal symptoms. The coexistence of these two syndromes is a rare condition and is included as case reports in the literature. This article presents the clinical and radiological results of a 17-year-old male patient who had recurrent abdominal pain due to Wilkie's syndrome, which was accompanied by nutcracker syndrome that caused proteinuria, and for this reason, the patient was referred to the Pediatric Rheumatology outpatient clinic with a preliminary diagnosis of familial Mediterranean fever.

Patología hipertensiva durante el embarazo y el producto de la concepción / Hypertensive pathology during pregnancy and the product of conception

El Hospital Nacional Dr. Mario Catarino Rivas (hospital de segundo nivel de atención), sirve como centro de atención para embarazos de alto riesgo de la zona noroccidental de Honduras; reportó 1,702 casos de trastor-nos hipertensivos del embarazo en 2017 y 2,070 casos en 2018. Se caracterizó pacientes con signos y síntomas de trastornos hipertensivos del embarazo agrupadas desde un punto de vista obstétrico, epidemiológico y clínico. Se realizó un estudio, descriptivo de corte transversal en gestantes que presentaron cefalea, cifras tensionales elevadas (≥ 140/90mmHg); registrando ausencia o presencia de proteinuria, atendidas en la emergencia de labor y parto de un hospital nacional de segundo nivel de atención en San Pedro Sula, Honduras, desde junio hasta octubre del 2019. Se incluyeron 110 pacientes de entre 18-43 años, mestizas y amas de casa, la edad gestacional promedio por fecha de ultima menstruación de 37.7 semanas; el 28.2% presentó preeclampsia severa. Las manifestaciones clínicas frecuentes fueron edema de miembros inferiores y cefalea. El 57.3% desarrolló trabajo de parto espontá-neo, la resolución del embarazo fue cesárea en el 57.3% de las gestantes. Respecto al producto de la concepción, 66.4% tenían peso normal y talla apropiada para la edad gestacional, un APGAR de 8 al primer minuto y de 9 a los 5 minutos. En este estudio, se reporta una prevalencia del 13.72% con respecto a los trastornos hipertensivos del embarazo. Particularmente en pacientes mayores de 35 años, multípara, con índice de masa corporal ≥ 32 kg/m2, presentando antecedentes de hipertensión arterial, diabetes mellitus y preeclampsia.

The National Hospital Dr. Mario Catarino Rivas (second-level care hospital), serves as a care center for high-risk pregnancies in the northwestern part of Honduras; it reported 1,702 cases of hypertensive disorders of pregnancy in 2017 and 2,070 cases in 2018. Patients with signs and symptoms of hypertensive disorders of preg-nancy were characterized grouped from an obstetric, epidemiological and clinical point of view. A descriptive cross-sectional study was carried out in pregnant women who presented headache, high blood pressure (≥ 140 / 90mmHg); registering the absence or presence of proteinuria in urine, attended in the labor and delivery emer-gency of a national hospital of second level of care in San Pedro Sula, Honduras; from June to October 2019. 110 patients between 18-43 years old, mixed race and housewives were included, the average gestational age by date of last menstruation of 37.7 weeks, 28.2% presented severe preeclampsia. The frequent clinical manifestations were lower limb edema and headache. 57.3% developed spontaneous labor, the pregnancy termination route was cesarean section in 57.3% of pregnant women. Regarding the product of conception, 69.1% had weight and height appropriate for gestational age, an APGAR of 8 at the first minute and of 9 at 5 minutes. In this study, a prevalence of 13.72% is reported with respect to hypertensive disorders of pregnancy. Particularly in patients older than 35 years, multiparous, with a body mass index ≥ 32 kg / m2, presenting a history of arterial hypertension, diabetes mellitus and pre-eclampsia.

Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy

ABSTRACT Purpose We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). Patients and Methods We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. Results Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). Conclusion Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Síndrome nefrótico del lactante: presentación de caso clínico / Nefrotic infant syndrome: clinical case report

El síndrome nefrótico se define por proteinuria de rango nefrótico (40 mg/m2/hora o relación proteína/creatinina de orina 200 mg/ml o 3+ proteína en tira reactiva de orina), hipoalbuminemia (25 g/L) y edema. El presente caso clínico se centra en la clasificación, epidemiología, fisiopatología, estrategia de manejo y pronóstico del síndrome nefrótico exclusivo del lactante, como etiología los más frecuentes asociados son mutaciones en genes que codifican las proteínas reguladoras y estructurales de la barrera de filtración glomerular. Estas mutaciones han sido identificadas en: NPHS1, NHPS2, WTI, LAMB2, mediante Biopsia Renal la lesión histológica más frecuente es la Glomerulonefritis mesangial difusa proliferativa con esclerosis, suele ser de mal pronóstico y con tendencia a fallo de tratamiento o cortico-resistencia terminando en falla renal y diálisis. Se presenta paciente femenina lactante mayor de 17 meses de edad, sin antecedentes durante el periodo perinatal, con síntomas característicos de síndrome nefrótico, a su corta edad, sin antecedentes infecciosos, presentando relación proteína/creatinina en orina positiva, llamando la atención los resultados de biopsia renal de la misma, ya que se sale de las lesiones histológicas más frecuentes a esta edad...(AU)

Daño hepatocelular, proteinuria y autoinmunidad: ¿enfermedad multisistémica o coincidencia de enfermedades? Caso clínico / Hepatocellular damage, proteinuria and autoimmunity: multisystemic disorder or coexistence of diseases?

We report a 19 years old male presenting with knee pain, elevated liver enzymes and proteinuria. Further investigation found positive antinuclear and anti-smooth muscle antibodies and a liver biopsy revealed the presence of an autoimmune hepatitis. Treatment with corticosteroids and azathioprine was started, resulting in normalization of liver enzymes but proteinuria persisted and a kidney biopsy disclosed a focal segmental glomerulosclerosis. The use of lisinopril resulted in a significative reduction of proteinuria and, after 30 months of follow up, he continues with azathioprine, lisinopril and a low prednisone dose without evidence of liver or kidney disease activity.

Hemoglobinuria paroxística nocturna / Paroxysmal nocturnal hemoglobinuria

ResumenLa hemoglobinuria paroxística nocturna es una anemia hemolítica crónica, adquirida, poco común, que afecta con igual frecuencia ambos sexos. Se manifiesta a cualquier edad y con mayor incidencia en países del sudeste asiático. Es el resultado de la expansión clonal no maligna de células progenitoras hematopoyéticas. Se caracteriza por anemia hemolítica intravascular, tendencia a la trombosis y un componente variable de insuficiencia medular.Se asocia a otras patologías hematológicas como anemia aplásica y síndrome mielodisplásico. La citometría de flujo es el método de elección para diagnóstico. El eculizumab y el trasplante de médula ósea alogénico son las únicas terapias efectivas.

Abstract:Paroxysmal nocturnal hemoglobinuria is a rare acquired chronic hemolytic anemia, which affects both sexes with equal frequency. It occurs at any age and more frequently in Southeast Asian countries. It is the result of non malignant clonal expansion of hematopoietic progenitor cells. It is characterized by intravascular hemolytic anemia, recurrent thrombosis and a variable component of bone marrow failure. It is associated with other hematologic disorders such as aplastic anemia and myelodysplastic syndrome. Flow cytometry is the method of choice for diagnosis. Eculizumab and allogeneic bone marrow transplantation is the only effective therapies.

Association Between High Platelet Indices and Proteinuria in Patients With Hypertension

BACKGROUND: We aimed to determine the association between platelet indices including plateletcrit (PCT), mean platelet volume (MPV), platelet distribution width (PDW), and proteinuria associated with hypertension (HT) as well as the relative power of each to predict proteinuria. METHODS: The study included 223 patients (68 men and 155 women) with primary HT. PCT, MPV, PDW, and proteinuria levels were measured. The patients were divided into two groups according to proteinuria status based on 24-hr urinary protein excretion: proteinuria (+) group (15 men and 40 women) and proteinuria (-) group (53 men and 115 women). RESULTS: The mean and SD of platelet count, PDW, PCT, and MPV were 278.8+/-49.6x10(9)/L, 13.5+/-1.8%, 0.31+/-0.07%, and 11.3+/-2.6 fL, respectively. The mean platelet count, PCT, MPV, and PDW were significantly higher in the proteinuria (+) group than in the proteinuria (-) group (P<0.05); there were no significant differences in the other blood parameters between the two groups. The platelet count, PCT, MPV, and PDW were independent risk factors predictive of proteinuria according to a stepwise regression analysis of PDW, PCT, and MPV. PCT was the strongest independent predictor of proteinuria. CONCLUSIONS: The platelet indices PCT, PDW, and MPV were significantly higher in patients with proteinuria than in those without it. Among these three indices, PCT was the strongest predictor of proteinuria.

The Clinical Association of the Blood Pressure Variability with the Target Organ Damage in Hypertensive Patients with Chronic Kidney Disease

It is known that blood pressure variability (BPV) can independently affect target organ damage (TOD), even with normal blood pressure. There have been few studieson chronic kidney disease (CKD) patients. We evaluated the relationship between BPV and TOD in a cross-sectional, multicenter study on hypertensive CKD patients. We evaluated 1,173 patients using 24-hr ambulatory blood pressure monitoring. BPV was defined as the average real variability, with a mean value of the absolute differences between consecutive readings of systolic blood pressure. TOD was defined as left ventricular hypertrophy (LVH) (by the Romhilt-Estes score > or =4 in electrocardiography) and kidney injury (as determined from an estimated glomerular filtration rate [eGFR]<30 mL/min/1.73 m2 and proteinuria).The mean BPV of the subjects was 15.9+/-4.63 mmHg. BPV displayed a positive relationship with LVH in a univariate analysis and after adjustment for multi-variables (odds ratio per 1 mmHg increase in BPV: 1.053, P=0.006). In contrast, BPV had no relationship with kidney injury. These data suggest that BPV may be positively associated with LVH in hypertensive CKD patients.

Analysis of Correlation between 24-Hour Urinary Sodium and the Degree of Blood Pressure Control in Patients with Chronic Kidney Disease and Non-Chronic Kidney Disease

We investigated the association between 24-hr urinary sodium (24UNA) and adequacy of blood pressure (BP) control in patients with chronic kidney disease (CKD) and nonCKD. All data were collected retrospectively by accessing the electrical medical records in patients with 24-hr urine collection and serum creatinine. Enrolled 400 subjects were subgrouped by the amount of 24UNA, or CKD stage. The appropriate BP was defined as BP or =90 mEq/day was 2.441 (1.249-4.772, P=0.009) higher than that of 24UNA <90 mEq/day among participants with proteinuria. There was difference in the amount of 24UNA between CKD and non-CKD except each stage of CKD group. In conclusion, salt intake estimated by 24-hr urine sodium excretion is a risk factor to achieve appropriate BP control.

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

Proteinuria as a Risk Factor for Mortality in Patients with Colorectal Cancer

PURPOSE: We investigated the effects of proteinuria and renal insufficiency on all-cause mortality in patients with colorectal cancer, with special emphasis on cancer staging and cancer-related deaths. MATERIALS AND METHODS: We retrospectively studied a cohort of patients with colorectal cancer. In protocol 1, patients were classified into four groups based on the operability of cancer and proteinuria: group 1, early-stage cancer patients (colorectal cancer stage < or =3) without proteinuria; group 2, early-stage cancer patients with proteinuria; group 3, advanced-stage cancer patients without proteinuria (colorectal cancer stage=4); and group 4, advanced-stage cancer patients with proteinuria. In protocol 2, patients were classified into four similar groups based on cancer staging and renal insufficiency (eGFR <60 mL/min/1.73 m2). Between January 1, 1998 and December 31, 2009, 3379 patients were enrolled in this cohort and followed until May 1, 2012 or until death. RESULTS: The number of patients with proteinuria was 495 (14.6%). The prevalence of proteinuria was higher in advanced-stage cancer (n=151, 22.3%) than in early-stage cancer patients (n=344, 12.7%). After adjusting for age, gender and other clinical variables, the proteinuric, early-stage cancer group was shown to be associated with an adjusted hazard ratio of 1.67 and a 95% confidence interval of 1.38-2.01, compared with non-proteinuric early-stage cancer patients. However, renal insufficiency was not associated with colorectal cancer mortality. CONCLUSION: Proteinuria is an important risk factor for cancer mortality, especially in relatively early colorectal cancer.

Renal Manifestations in 2007 Korean Patients with Behcet's Disease

PURPOSE: Behcet's disease (BD) theoretically affects all sizes and types of blood vessels and results in multi-organ involvement. However, renal BD has not been fully characterized, though the kidneys are histologically rich in blood vessels. MATERIALS AND METHODS: A total of 2007 patients who fulfilled the diagnostic criteria for BD were enrolled in this study. We reviewed the medical records and test results of the BD patients and used univariate and multivariate logistic regression analyses to determine the clinical significance of renal involvement in BD. RESULTS: Among the 2007 BD patients, we noted hematuria in 412 (20.5%) and proteinuria in 29 (1.4%). Univariate analysis showed that the BD patients with hematuria were predominantly female and older, had higher erythrocyte sedimentation rates (ESRs), and more frequently presented with genital ulcerations. BD patients with proteinuria had higher ESR levels compared to BD patients without proteinuria. In the multivariate analysis, age, sex, and ESR were found to be significantly associated with hematuria in BD patients, whereas only ESR was associated with proteinuria in BD patients. We also found that IgA nephropathy was the most common pathologic diagnosis in 12 renal BD patients who underwent renal biopsies. CONCLUSION: We suggest that routine urinalysis and serum renal function tests be performed for the early detection of renal BD, especially in older female BD patients with recurrent hematuria, high ESR levels, and frequent genital ulcers, as well as in BD patients with proteinuria and high ESR levels.

Anti-Proteinuric Effect of Sulodexide in Immunoglobulin A Nephropathy

PURPOSE: We conducted a multi-center randomized double-blind study to determine the effects of 6-month therapy with sulodexide on urinary protein excretion in patients with idiopathic Immunoglobulin A (IgA) nephropathy. MATERIALS AND METHODS: A total of seventy-seven patients participated in the study. They were randomly allocated to one of three groups: sulodexide 75 mg or 150 mg daily or the placebo for 6 months. The primary end point was the achievement, at 6 months, of at least 50% reduction in urine protein/creatinine ratio (UPCR) from the baseline value. RESULTS: At 6 months, the primary end point was achieved by 12.5% of the patients assigned to the placebo, 4.0% of the patients assigned to sulodexide 75 mg daily and 21.4% of those assigned to 150 mg (p=0.308). Treatment with sulodexide 150 mg daily for 6 months significantly reduced log UPCR from 6.38+/-0.77 at baseline to 5.98+/-0.94 at 6 months (p=0.045), while treatment with sulodexide 75 mg daily and placebo did not. CONCLUSION: A 6-month treatment with sulodexide did not achieve 50% reduction of urinary protein excretion in IgA nephropathy patients, but showed a tendency to increase the time-dependent anti-proteinuric effect. Therefore, long-term clinical trials on a larger scale are warranted to elucidate the hypothesis that sulodexide affords renal protection in IgA nephropathy patients.

Relationship between Chronic Kidney Disease and Risk of Coronary Heart Disease in Korean Men

There have been many epidemiological researches of chronic kidney disease (CKD), accompanied by an increase in the incidence of coronary heart disease (CHD). However, as far as we know, little research has been done to examine the extent of the relationship between CKD and CHD as estimated by Framingham risk score (FRS) in Korean men. CKD was defined as either proteinuria or an eGFR of or = 20% (high). We defined FRS > or = 10% as more-than-a-moderate CHD risk group and FRS > or = 20% as a high CHD risk group, respectively. After adjusting for covariates, multivariable-adjusted logistic regression analyses showed a strong statistical significant relationship between CKD and high risk of CHD (adjusted OR, 1.95 [95% CI, 1.32-2.87]). Dipstick urinalysis and eGFR can be readily measured in most clinical settings. The measurement of kidney function may represent a relatively inexpensive and efficient way to identify individuals at higher risk for CHD.

Gross proteinuria is a strong risk predictor for cardiovascular mortality in Brazilian type 2 diabetic patients

Increased proteinuria is recognized as a risk predictor for all-cause and cardiovascular mortality in diabetic patients; however, no study has evaluated these relationships in Brazilian patients. The aim of this study was to investigate the prognostic value of gross proteinuria for all-cause and cardiovascular mortalities and for cardiovascular morbidity in a cohort study of 471 type 2 diabetic individuals followed for up to 7 years. Several clinical, laboratory and electrocardiographic variables were obtained at baseline. The relative risks for all-cause, cardiovascular and cardiac mortalities and for cardiovascular and cardiac events associated with the presence of overt proteinuria (>0.5 g/24 h) were assessed by Kaplan-Meier survival curves and by multivariate Cox regression model. During a median follow-up of 57 months (range 2-84 months), 121 patients (25.7 percent) died, 44 from cardiovascular and 30 from cardiac causes, and 106 fatal or non-fatal cardiovascular events occurred. Gross proteinuria was an independent risk predictor of all-cause, cardiovascular and cardiac mortalities and of cardiovascular morbidity with adjusted relative risks ranging from 1.96 to 4.38 for the different endpoints. This increased risk remained significant after exclusion of patients with prior cardiovascular disease at baseline from the multivariate analysis. In conclusion, gross proteinuria was a strong predictor of all-cause, cardiovascular and cardiac mortalities and also of cardiovascular morbidity in a Brazilian cohort of type 2 diabetic patients. Intervention studies are necessary to determine whether the reduction of proteinuria can decrease morbidity and mortality of type 2 diabetes in Brazil.

Early diagnosis of CKD and its prevention.

Chronic kidney disease is associated with increased mortality and morbidity especially due to cardiovascular disease and imposes a huge economic burden to the family and health care delivery system. In both developing and developed countries, diabetes mellitus and hypertension are the leading causes of CKD. While dialysis and transplantation are excellent options for end stage kidney disease, they are costly. Renal transplant is again limited by organ shortage. The better strategy to tackle CKD will be early identification of the disease and adopt measures to slow its progression to ESRD. A comprehensive approach to the prevention of CKD and retarding its progression is outlined.

Glomerulonefrite aguda pós-estreptocócica com proteinúria nefrótica: relato de caso / Nephrotic proteinuria in post-streptococcal acute glomerulonephritis: case report

Refere-se a um caso atendido com quadro clínico e laborato­rial sugestivos de glomerulonefrite aguda pós-estreptocócica (GNPE) apresentando proteinúria em níveis nefróticos. Como em apenas 5% dos casos de GNPE há proteinúria em níveis nefróticos, foi necessário excluir outras doenças renais através da realização de biópsia renal com estudo por microscopia óptica, eletrônica e imunofluorescência, que confirmaram a suspeita clínica de GNPE

Proteinuria in a Boy with Infectious Mononucleosis, C1q Nephropathy, and Dent's Disease

C1q nephropathy is a proliferative glomerulopathy with extensive mesangial deposition of C1q. A three-year old boy presented with a nephrotic-range proteinuria during an acute phase of Epstein-Barr virus (EBV) infection, and he had a family history of Dent's disease. The renal biopsy findings were compatible with C1q nephropathy. However, EBV in situ hybridization was negative. The CLCN5 gene analysis revealed an R637X hemizygous mutation, which was the same as that detected in his maternal cousin, the proband of the family. The causal relationship between EBV infection and C1q nephropathy remains to be determined. Moreover, the effects of underlying Dent's disease in the process of C1q nephropathy has to be considered.

Increasing thyroxine requirements in primary hypothyroidism: don't forget the urinalysis!

Rising thyroid stimulating hormone (TSH) levels in patients being treated for primary hypothyroidism usually indicate poor compliance with thyroxine therapy. In rare instances, drugs or diseases affecting absorption of thyroxine or drugs that accelerate thyroxine metabolism can manifest in a similar fashion. Nephrotic syndrome is a rare cause of such a presentation though its presence can rapidly be suspected by dipstick urine testing. In this report we describe a patient with long-standing primary thyroid failure whose thyroxine dose requirements increased upon development of massive proteinuria. Biochemical testing and renal biopsy subsequently demonstrated nephrotic syndrome and amyloid deposition in association with myeloma. Dipstick urine testing should be considered in all hypothyroid patients with rising TSH levels, where good compliance with thyroxine therapy is likely.

Proteinúria nas síndromes hipertensivas da gestação: prognóstico materno e perinatal / Proteinuria in hypertensive syndrome of pregnancy: maternal and perinatal outcome

OBJETIVO: Avaliar o valor prognóstico da proteinúria nas gestantes com síndromes hipertensivas nos desfechos maternos e perinatais. MÉTODOS: Estudo transversal retrospectivo de 334 gestantes com síndromes hipertensivas que pariram no Hospital São Paulo na disciplina de Obstetrícia da UNIFESP/EPM, no período de 1° de janeiro de 1999 a 31 de dezembro de 2002. RESULTADOS: Após a revisão dos prontuários, as pacientes foram divididas em quatro grupos: I sem proteinúria (n-203), II com proteinúria de 0,3 a 1g (n-39), III de 1 a 2g (n-45) e grupo IV de 2g ou mais (n-47). Na ausência da proteinúria houve um caso de descolamento prematuro da placenta. Com proteinúria observou-se desfechos maternos adversos, com a presença das complicações, proporcional à elevação da proteinúria, sendo a síndrome HELLP a mais freqüente com 30,5 por cento (40/131) seguida da eclâmpsia com 3,8 por cento (5/131), DPP 3,01 por cento (4/131) e insuficiência renal 0,7 por cento (1/131). Foi constatado um óbito materno nesse grupo, perfazendo-se o CMM de 763100.000/n.v. Em relação aos desfechos perinatais, no grupo sem proteinúria não houve elevação dos efeitos adversos. Na presença da proteinúria e a elevação dos seus níveis observou-se pior prognóstico perinatal com os seguintes indicadores: aumento da prematuridade (62,2 por cento vs 11,5 por cento), recém-nascidos com peso < 2500g (6,5 por cento vs 1,5 por cento), Apgar < 7 no 5° minuto (30,4 por cento vs 3,5 por cento), restrição de crescimento intra-útero (41,9 por cento vs 6,5 por cento), cuidados intensivos na unidade neonatal (59,8 por cento vs 15,5 por cento), natimortos (14,4 por cento vs 1,4 por cento), e óbitos neonatais (6,1 por cento vs 0,98 por cento). O coeficiente de mortalidade perinatal foi maior com proteinúria (175 vs 19,7) e, quando > 2g (297,8 vs 19,7). CONCLUSÕES: A presença da proteinúria e a elevação dos seus níveis, aumentaram as complicações maternas, principalmente a síndrome HELLP e eclâmpsia. Observou-se incidência de complicações perinatais com elevação significativamente maior da prematuridade, recém-nascidos com Apgar < 7, peso < 2500g, CIUR, natimortos e óbitos neonatais.