Surgical complications and technical failure of simultaneous pancreas-kidney transplantation: A 22-year experience from a single center.

Simultaneous pancreas-kidney transplantation (SPKT) is the best treatment for selected individuals with type 1 diabetes mellitus and end-stage renal disease. Despite advances in surgical techniques, donor and recipient selection, and immunosuppressive therapies, SPKT remains a complex procedure with associated surgical complications and adverse consequences. We conducted a retrospective study that included 263 SPKT procedures performed between May 2000, and December 2022. A total of 65 patients (25%) required at least one relaparotomy, resulting in an all-cause relaparotomy rate of 2.04 events per 100 in-hospital days. Lower donor body mass index was identified as an independent factor associated with reoperation (OR .815; 95% CI:  .725-.917, p = .001). Technical failure (TF) occurred in 9.9% of cases, primarily attributed to pancreas graft thrombosis, intra-abdominal infections, bleeding, and anastomotic leaks. Independent predictors of TF at 90 days included donor age above 36 years (HR 2.513; 95% CI 1.162-5.434), previous peritoneal dialysis (HR 2.503; 95% CI 1.149-5.451), and specific pancreas graft reinterventions. The findings highlight the importance of carefully considering donor and recipient factors in SPKT. The incidence of TF in our study population aligns with the recent series. Continuous efforts should focus on identifying and mitigating potential risk factors to enhance SPKT outcomes, thereby reducing post-transplant complications.

Severe Acute Kidney Injury in Hospitalized Cancer Patients: Epidemiology and Predictive Model of Renal Replacement Therapy and In-Hospital Mortality.

BACKGROUND: Acute kidney injury (AKI) is a common complication among cancer patients, often leading to longer hospital stays, discontinuation of cancer treatment, and a poor prognosis. This study aims to provide insight into the incidence of severe AKI in this population and identify the risk factors associated with renal replacement therapy (RRT) and in-hospital mortality. METHODS: This retrospective cohort study included 3201 patients with cancer and severe AKI admitted to a Comprehensive Cancer Center between January 1995 and July 2023. Severe AKI was defined according to the KDIGO guidelines as grade ≥ 2 AKI with nephrological in-hospital follow-up. Data were analyzed in two timelines: Period A (1995-2010) and Period B (2011-2023). RESULTS: A total of 3201 patients (1% of all hospitalized cases) were included, with a mean age of 62.5 ± 17.2 years. Solid tumors represented 75% of all neoplasms, showing an increasing tendency, while hematological cancer decreased. Obstructive AKI declined, whereas the incidence of sepsis-associated, prerenal, and drug-induced AKI increased. Overall, 20% of patients required RRT, and 26.4% died during hospitalization. A predictive model for RRT (AUC 0.833 [95% CI 0.817-0.848]) identified sepsis and hematological cancer as risk factors and prerenal and obstructive AKI as protective factors. A similar model for overall in-hospital mortality (AUC 0.731 [95% CI 0.71-0.752]) revealed invasive mechanical ventilation (IMV), sepsis, and RRT as risk factors and obstructive AKI as a protective factor. The model for hemato-oncological patients' mortality (AUC 0.832 [95% CI 0.803-0.861]) included IMV, sepsis, hematopoietic stem cell transplantation, and drug-induced AKI. Mortality risk point score models were derived from these analyses. CONCLUSIONS: This study addresses the demographic and clinical features of cancer patients with severe AKI. The development of predictive models for RRT and in-hospital mortality, along with risk point scores, may play a role in the management of this population.

Renal Artery Stenosis in Living Donor Kidney Transplantation: A Rare Cause of "Flash Edema".

Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplantation, with an incidence ranging from 1% to 23%. TRAS often presents with clinical features such as refractory hypertension, de novo hypertension, allograft dysfunction, and the presence of a bruit over the graft. A rare manifestation of TRAS is flash pulmonary edema. Here, we present a case of a 37-year-old male who received a living donor kidney. Four years after the transplant, he presented with acute kidney injury, hypertensive crisis, and flash pulmonary edema. Initially, methylprednisolone pulses were administered due to suspicion of acute rejection, which was later ruled out after a kidney graft biopsy. Computed tomography angiography showed findings suggesting stenosis or thrombus in the renal artery. The patient developed sudden acute pulmonary edema, requiring hemodialysis, with notable clinical improvement. Subsequently, stent placement was performed without complications, resulting in the complete recovery of renal function and effective blood pressure control. The incidence of renal artery stenosis is higher in living donor kidney transplantation, mainly due to technical complexities during surgery. Acute presentations, such as flash edema, are exceptionally rare but can occur years after transplantation. Prompt intervention can lead to favorable outcomes.

Peritoneal Protein Loss With Time in Peritoneal Dialysis.

Longitudinal evolution of peritoneal protein loss (PPL), a reflection of hydrostatic pressure-driven leak of plasma proteins through the large-pore pathway, is not clear. Time on PD causes loss of mesothelial cells, vasculopathy, and increased thickness of the submesothelial fibrous layer. Are these structural changes associated with progressive increase of PPL, in a parallel with the rise in the D/P creatinine? The aim of the present study was to identify longitudinal changes of PPL over time. This single-center, longitudinal study included 52 peritoneal dialysis (PD) patients with a median follow-up of 26.5 months, evaluated at two different time points with a minimum interval of 6 months. Repeated measures analysis was performed using paired sample t-test or the nonparametric Wilcoxon signed-rank test, depending on the distribution. After a median interval of 15.5 months, lower levels of residual renal function and urine volume, lower Kt/V, and creatinine clearance were found. D/P creatinine and PPL were stable, but a decrease in ultrafiltration was present. Systemic inflammation, nutrition, and volume overload showed no significant change with time on PD. Analysis of a subpopulation with over 48 months between initial and subsequential assessment (n = 11) showed again no difference in inflammation, nutritional and hydration parameters from baseline, but importantly PPL decreased after more than 4 years on PD (mean difference 1.2 g/24, p = 0.033). D/P creatinine and dip of sodium remained unchanged. The absence of deleterious effects of time on PD is reassuring, pointing to the benefit of updated PD prescription, including the standard use of more biocompatible solutions towards membrane preservation and adjusted prescription avoiding overhydration and inflammation while maintaining nutritional status. After controlling for confounders, PPL may act as a biomarker of acquired venous vasculopathy, even if small pore fluid transport rates and free water transport are preserved.

A Rare Geriatric Diagnosis of Eosinophilic Granulomatosis With Polyangiitis: A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of systemic disease characterized by inflammation and necrotizing effects of the small and medium blood vessels. It is a vasculitis found in all age groups and both genders, although its etiology is unknown. The mean age at diagnosis is 40 years, consisting of an uncommon cause of vasculitis in people older than 65 years. It is the least common of the three antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (EGPA, granulomatosis with polyangiitis (GPA), and microscopic polyangiitis). The characteristic features of EGPA include extravascular eosinophilic granulomas, peripheral eosinophilia, and asthma, usually responsive to steroid treatment. In this article, we discuss a case of an 83-year-old male with a history of undetermined etiology of chronic kidney disease, chronic obstructive pulmonary disease (COPD), and severe chronic rhinosinusitis with nasal polyposis. First hospitalized with the suspicion of community-acquired pneumonia (CAP), based on worsening blood eosinophilia and unresolving respiratory symptoms, a suspicion for EGPA was raised. The development of an eosinophilic pleural effusion, later upon admission, was a predominant factor for its confirmation, as it constitutes a rare finding, only present in about 30% of patients. Laboratory tests showed elevated IgE, the presence of antineutrophil cytoplasmic antibodies directed against myeloperoxidase with a perinuclear staining pattern (ANCA-MPO), and the absence of antiproteinase 3 (anti-PR3) ANCA, which were consistent with the diagnosis. A pleural biopsy was then made, revealing fibrosis with the presence of eosinophils, although with no evidence of granulomas. According to the most recent and accepted classification criteria, the "2022 American College of Rheumatology and European Alliance of Associations for Rheumatology (ACR/EULAR) for EGPA," this patient presented with a score of 13 (a score greater than or equal to 6 is needed for the classification of EGPA). Hence, a diagnosis of EGPA was assumed, and the patient was initiated on corticosteroid therapy, with a favorable response. The aim of this article is to present a rare case of EGPA diagnosis made at the age of 83 years old, although there was evidence that could point to this disease years before the diagnosis was made. In the present case, it is important to point out the long diagnostic delay in a geriatric patient, much older than the median age of diagnosis for EGPA, culminating in a curious case of uncommon pleuroparenchymal involvement.

Protein Loss in Peritoneal Effluent: Different Meaning for 24-h versus PET Samples.

INTRODUCTION: Quantification of peritoneal protein loss (PPL) may be expressed according to a timely collection (24-h measurement or 4-h PET assessment) and as a concentration. The aim of this study was to compare the quantification methods of 24-h and 4-h collections. METHODS: This study included 81 prevalent peritoneal dialysis patients. Demographics and clinical and bioelectrical impedance features were registered. PPL was measured (4-h PET and 24-h results) and peritoneal protein clearance was calculated. A linear regression model was performed. RESULTS: Age and continuous ambulatory peritoneal dialysis (compared to cycler) were positively associated with greater PPL on 24-h collections. Neither cardiovascular disease, hypertension, diabetes nor the comorbidity Charlson Index was significantly associated with PPL. There was a consistent univariable relationship with D/P creatinine, whichever sampling method was used. Only 24-h measurements of PPL correlated with body composition variables. In multiple linear regression analysis, D/P creatinine association with PPL stands out. On the other hand, 24-h determinations (in grams or clearance) were associated with overhydration. PET protein quantification was associated with peritoneal creatinine clearance. DISCUSSION/CONCLUSION: Different methods sign different pathophysiological pathways. PET protein loss quantification should be regarded as a marker of peritoneal membrane intrinsic permeability. Measurements of a 24-h sample might be closer to patients' clinical status and prognosis, signalizing opportunities for therapy intervention.

Ascites, Pleural, and Pericardial Effusion in Primary Hypothyroidism: A Rare Case Report.

Hypothyroidism is caused by a deficiency of thyroid hormones and is a common endocrine disorder worldwide. It can affect nearly every organ, resulting in multiple clinical manifestations. Ascites, pleural effusion, and pericardial effusion, although less frequent than peripheral edema, can also be present. These manifestations are thought to be caused by increased vascular permeability to albumin, extravasation of mucopolysaccharides, and inappropriate antidiuretic hormone secretion. Most effusions in hypothyroid patients resolve with thyroxine replacement therapy. However, due to the insidious and nonspecific nature of these symptoms, hypothyroidism is seldom considered a differential diagnosis. We report a case of a 48-year-old male with pericardial effusion, pleural effusion, and ascites due to primary hypothyroidism. Although isolated effusions can be frequent in patients with hypothyroidism, the presentation of Hashimoto's thyroiditis as a combination of pericardial effusion, pleural effusion, and ascites is extremely rare. With this case report, we highlight the importance of considering hypothyroidism as a possible cause of unexplained polyserositis, even in the absence of other signs and symptoms.

The Usefulness of Calcium/Magnesium Ratio in the Risk Stratification of Early Onset of Renal Replacement Therapy.

Background: A growing number of studies have reported a close relationship between high serum calcium (Ca)/low serum magnesium (Mg) and vascular calcification. Endothelial dysfunction and vascular inflammation seem plausible risk factors for the enhanced progression of kidney disease. The aim of this study was to evaluate the role of the Ca/Mg ratio as a predictor of the early onset of renal replacement therapy (RRT). Methods: This was a prospective study conducted in an outpatient low-clearance nephrology clinic, enrolling 693 patients with stages 4−5 of CKD. Patients were divided into two groups according to the start of renal replacement therapy (RRT). Results: The kidney's survival at 120 months was 60% for a Ca−Mg ratio < 6 and 40% for a Ca−Mg ratio ≥ 6 (p = 0.000). Patients who started RRT had lower levels of Hb, Ca, Mg, albumin, and cholesterol and higher values of phosphorus, the Ca/Mg ratio, and PTH. High values of phosphorus and the Ca/Mg ratio and low levels of Mg and GFR were independent predictors of entry into RRT. A high Ca/Mg ratio, high phosphorus levels, and low levels of GFR were associated with a cumulative risk for initiation of RRT. Conclusions: In our population, the Ca/Mg ratio is an independent predictive factor for the initiation of a depurative technique.

Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths.

Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162-31.854), LBMI (p = 0.008; 95%CI: 1.720-11.219) and performing CAPD (p = 0.023; 95%CI: 4.375-54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235-2.913), overhydration (HR: 10.034, 95%CI: 1.426-70.587) and lower PPL (HR: 0.576, 95%CI: 0.339-0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.

Tip Lesion Variant of Focal and Segmental Glomerulosclerosis in a COVID-19 Patient.

Acute kidney injury is a common complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Several pathologic findings are continually being reported, showing a probably multifactorial etiology. The authors present a case of a patient diagnosed with a tip lesion variant of focal segmental glomerulosclerosis (FSGS) in the setting of COVID-19. A 43-year-old African American female with no known renal disease presented to the emergency department with a 6-day history of fatigue, headache, hypoageusia, myalgia, cough, nausea, and vomiting. Laboratory tests confirmed SARS-CoV-2 infection. During hospitalization, there was a progressive decline in kidney function and evidence of nephrotic-range proteinuria without nephrotic syndrome. Biopsy specimen showed a tip lesion variant of FSGS. Genetic test revealed a homozygous variant of uncertain clinical significance (c.397G>A [p.V133M]) in the epithelial membrane protein 2 (EMP2) gene. To our knowledge, this is the first case report of a tip lesion in a COVID-19 patient with no renal history. More studies are warranted to define susceptible groups and identify the detailed mechanisms of COVID-19-related kidney disease that would allow for specific management of this complication.

Overhydration May Be the Missing Link between Peritoneal Protein Clearance and Mortality.

INTRODUCTION: Peritoneal protein loss (PPL) has been associated with mortality. Inflammation was assumed a putative cause with malnutrition as a consequence. Hydrostatic convection is a major drive for microvascular protein transport, but most studies in peritoneal dialysis (PD) patients overlooked this mechanism. An association between peritoneal protein clearance (PPCl) and venous congestion has been reported recently. The aim of this study was to explore the importance of fluid overload in PPCl in PD. METHODS: Sixty-seven prevalent PD patients were assessed with peritoneal equilibration test and multifrequency bioelectrical impedance assessment (BIA). PPL and PPCl were calculated from simultaneously obtained 24-h peritoneal effluent. RESULTS: PPL averaged 5.2 g/24 h. It was higher in patients on continuous treatment than in those without a long dwell. Significant associations between PPCl and BIA parameters of overhydration were found in both univariable and multivariable analyses. Lean mass index, partly dependent on hydration status, was associated with PPCl in univariable but not in multivariable analysis. A multiple linear model identified extracellular water excess and higher D/P creatinine as predictors of higher PPCl, independent of PD duration, type of PD, age, gender, albumin, cardiovascular disease, C-reactive protein, or lean mass index. CONCLUSIONS: The uni- and multivariable strong associations between fluid overload and PPCl support the importance of hydrostatic pressure-induced convection for PPCl. Also, peritoneal small solute transport was associated with PPCl. Both are amenable by adjusted dialysis prescription, especially focused on fluid status and avoidance of overhydration. The assumption of an association with inflammation and malnutrition was not confirmed.

A relação médico-paciente e a formação de novos médicos: análises de vivências de hospitalização / Doctor patient relationship and training of new doctors: experiences as an inpatient analysis / Relación médico-paciente y la formación de nuevos médicos: análisis del las vivencias como pacientes en un hospital

O estudo e o ensino da relação médico-paciente é uma estratégia valiosa para promover o encontro com valores fundamentais ao ser médico, além de superar o desencontro da medicina com sua essência. A criação de oportunidades para o desenvolvimento de habilidades de comunicação e promoção de empatia é fundamental para a educação médica, tanto no cenário da assistência primária ao paciente, na medicina familiar e comunitária, bem como em ambientes hospitalares, uma vez que são conhecimentos transversais. O objetivo principal deste estudo é desvendar as percepções dos estudantes do Curso de Medicina da Universidade do Oeste de Santa Catarina sobre a Vivência Hospitalar, atividade prática de ensino do componente curricular Relação Médico-paciente, no qual os alunos passam um dia internados no hospital escola para conhecerem de maneira prática como é ser um paciente. O método utilizado foi o de análise de conteúdo dos relatórios de internação, com abordagem qualitativa e quantitativa. O instrumento de pesquisa foram os relatórios de internação realizados pelos estudantes, com amostragem de 225 relatórios. Depois do processo de leituras e codificação das expressões-chave, bem como a contagem da frequência com que essas expressões se repetiam, os resultados puderam ser agrupados em categorias principais de significados que coincidem com os temas mais relevantes que surgiram após o processo de leitura e análise. As categorias são: sintomas, sentimentos, interações com outros pacientes, interações com o hospital escola, empatia, avaliação da experiência e "os alunos-pacientes". Foi possível concluir que a atividade pode ser uma ferramenta importante para a união da teoria e prática durante o ensino de técnicas de comunicação interpessoal e das relações entre médicos e pacientes.

Teaching Physician Patient Relationship is a valuable strategy to promote the meeting of fundamental values to a doctor, and overcome the mismatch of Medicine with its essence. The creation of opportunities for developing communication skills and promotion of empathy is essential for medical education, both in the setting of primary care to the patient, on family and community medicine, as well as in hospitals. The main objective of this study is to unveil the perceptions of medical students of Medical School of Universidade do Oeste de Santa Catarina, about the Hospital Experience as an Inpatient, practical activity on the discipline called Physician-patient Relationship, where the students spent one day hospitalized in their own School Hospital, in a practical way to learn how to be a patient. The method used was the analysis of the hospitalization reports, both qualitative and quantitative approaches. The research instrument was the hospitalization reports. The sample was 225 reports. After the process of reading and coding of key words, and counting the frequency with which these words were repeated, the results could be grouped into major categories of meanings that coincide with the major themes that emerged after the process of reading and analysis. The categories are: symptoms, feelings, and interactions with other patients, interactions with the hospital school, empathy, experience evaluation and the "student-patients". The activity may be an important tool for the integration of theory and practice during the teaching of communication skills and interpersonal relationships between doctors and patients.

La enseñanza de relación médico paciente es una estrategia valiosa para promover los valores fundamentales que se reunirán con un médico, y de eliminar las disparidades de la medicina con su esencia. La creación de oportunidades para el desarrollo de habilidades de comunicación y promoción de la empatía es esencial para la educación médica, tanto en el ámbito de la atención primaria de la medicina del paciente, familia y comunidad, así como en los hospitales, ya que son transversales del conocimiento. El objetivo principal de este estudio es descubrir las percepciones de los estudiantes de la Universidad de Medicina del Oeste de Santa Catarina en la estancia Experiencia en el Hospital, la actividad docente componente práctico de la disciplina Relación entre Médico y Paciente, que los estudiantes pasan un día ingresados en el Hospital Escuela como una manera práctica de aprender a ser paciente. El método utilizado fue el análisis del contenido de los informes de hospitalización, con enfoque cualitativo y cuantitativo. El instrumento de la encuesta fueron los reportes de hospitalización, con un muestreo de 225 informes. Después de que el proceso de lectura y codificación de palabras clave, y contando la frecuencia con que estas palabras se repitieron, los resultados pueden ser agrupados en las principales categorías de significados que coinciden con los principales temas que surgieron después de que el proceso de lectura y análisis. Las categorías son: síntomas, los sentimientos, las interacciones con otros pacientes, las interacciones con la escuela del hospital la empatía, la experiencia y la evaluación de los "estudiantes-pacientes". Se concluyó que la actividad puede ser una herramienta importante para la integración de la teoría y la práctica en la enseñanza de habilidades de comunicación y las relaciones interpersonales entre los médicos y pacientes.

Manuseio da deiscência do esterno no pós-operatório de cirurgia cardíaca / Management of sternal dehiscence in the postoperative period of heart surgery

No período de dezembro de 1987 a dezembro de 1989, 906 pacientes foram submetidos a cirurgia cardíaca com circulaçao extracorpórea, no Instituto Dante Pazzanese de Cardiologia, sendo 43 por cento coronarianos, 37 por cento valvares, 17 por cento congênitos e 3 por cento outros. Dentre eles, observou-se, na fase intra-hospitalar de pós-operatório, a ocorrência de 19 casos de deiscência parcial ou total da toracotomia mediana (2 por cento), que ocorreu, em média, ao redor da 1( semana de pós-operatório, tendo sido a reintervençao cirúrgica por volta da 3( semana. As culturas mostraram predomínio de germes gram positivos e poucos casos de gram negativos e fungos. Em apenas um caso nao foi isolado qualquer agente infeccioso. Neste grupo de pacientes, constatou-se a presença de fatores predominantes, tais como diabetes, obesidade, doença pulmonar obstrutiva crônica (DPOC) e tempo prolongado de cirurgia (média de 6 horas). Houve predomínio de pacientes adultos, cujas idades variaram de 40 a 67 anos, média de 53 anos (89 por cento). Constatou-se que, em 84 por cento dos pacientes, a artéria mamária interna foi utilizada como enxerto na revascularizaçao cirúrgica do miocárdio. Além das medidas gerais de terapêutica local e sistêmica com antibióticos específicos, visando ao combate dos agentes infecciosos e à conseqüente esterilizaçao da ferida, os pacientes eram conduzidos à sala de operaçao, procedendo-se à limpeza e desbridamento dos planos cirúrgicos, incluindo o esterno, deixando-se, em alguns casos, irrigaçao contínua com soluçao de povidine. Em dois pacientes foi realizada rotaçao de retalho miocutâneo, devido à refratariedade ao tratamento. De cinco casos de mediastinite, três faleceram por falência de múltiplos órgaos e sepsis. O grupo restante apresentou boa evoluçao, tendo obtido alta hospitalar após a 3( semana da reintervençao, com boa cicatrizaçao da ferida operatória.

Análise do índice ultra-sonografico, comprimento do fêmur/circunferência abdominal, na identificaçäo de retardo de crescimento fetal / Analysis of the relationship between sonographically measured fetal femur and abdominal circunference in the ditaction of growth retarted fetics

Foram estudados 54 fetos de gestantes matriculadas no Hospsital de Clínicas da Universidade do Paraná, com a finalidade de se avaliar o índice ultra-sonográfico comprimento do fêmur/circunferência abdominal na identificaçäo do retardo do crescimento fetal. Os fetos e recem-nascidos avaliados foram divididos em dois subgrupos: 44 eutróficos e dez desnutridos. A média do índice (CF/CA) x 100 no subgrupo dos eutróficos foi 23,69 e o desvio padräo 1,65; no subgrupo dos desnutridos a média d=foi 26,03 e o desvio padräo 1,10. Os valores médios do índice (CF/CA) x 100 do grupo todo e dos dois subgrupos diferem muito dos valores encontrados por Hadlock e col. Diante dessas diferenças, propöe-se para essa populaçäo e semelhantes o valor máximo do índice, para fetos eutróficos, de 24,93