Kidney transplant patients with SARS-CoV-2 infection: The Brescia Renal COVID task force experience.

The outcome of kidney transplant patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still unclear. Here we describe the clinical characteristics, disease outcome, and risk factors for acute respiratory distress syndrome (ARDS) and death of a cohort of 53 kidney transplant patients with coronavirus disease 2019 (COVID-19). Eight of 53 have been handled as outpatients because of mild disease, on average with immunosuppression reduction and the addition of hydroxychloroquine and azithromycin; no patients required admission, developed ARDS, or died. Because of severe symptoms, 45/53 required admission: this cohort has been managed with immunosuppression withdrawal, methylprednisolone 16 mg/d, hydroxychloroquine, and antiviral drugs. Dexamethasone and tocilizumab were considered in case of ARDS. About 33% of the patients developed acute kidney injury, 60% ARDS, and 33% died. In this group, thrombocytopenia was associated to ARDS whereas lymphopenia at the baseline, higher D-dimer, and lack of C-reactive protein reduction were associated with risk of death. In the overall population, dyspnea was associated with the risk of ARDS and age older than 60 years and dyspnea were associated with the risk of death with only a trend toward an increased risk of death for patients on tacrolimus. In conclusion, SARS-CoV-2 infection may have a variable outcome in renal transplant patients, with higher risk of ARDS and death in the ones requiring admission.

A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection.

The SARS-CoV-2 epidemic is pressuring healthcare systems worldwide. Disease outcomes in certain subgroups of patients are still scarce, and data are needed. Therefore, we describe here the experience of four dialysis centers of the Brescia Renal COVID Task Force. During March 2020, within an overall population of 643 hemodialysis patients, SARS-CoV-2 RNA positivity was detected in 94 (15%). At disease diagnosis, 37 of the 94 (39%) patients (group 1) were managed on an outpatient basis, whereas the remaining 57 (61%) (group 2) required hospitalization. Choices regarding management strategy were made based on disease severity. In group 1, 41% received antivirals and 76% hydroxychloroquine. Eight percent died and 5% developed acute respiratory distress syndrome (ARDS). In group 2, 79% received antivirals and 77% hydroxychloroquine. Forty two percent died and 79% developed ARDS. Overall mortality rate for the entire cohort was 29%. History of ischemic cardiac disease, fever, older age (over age 70), and dyspnea at presentation were associated with the risk of developing ARDS, whereas fever, cough and a C-reactive protein higher than 50 mg/l at disease presentation were associated with the risk of death. Thus, in our population of hemodialysis patients with SARS-CoV-2 infection, we documented a wide range of disease severity. The risk of ARDS and death is significant for patients requiring hospital admission at disease diagnosis.

A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia.

The outcome of SARS-CoV2 infection in patients who have received a kidney allograft and are being treated with immunosuppression is unclear. We describe 20 kidney transplant recipients (median age 59 years [inter quartile range 51-64 years], median age of transplant 13 years [9-20 years], baseline eGFR 36.5 [23-47.5]) with SARS-CoV2 induced pneumonia. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/day, all but one was commenced on antiviral therapy and hydroxychloroquine with doses adjusted for kidney function. At baseline, all patients presented fever but only one complained of difficulty in breathing. Half of patients showed chest radiographic evidence of bilateral infiltrates while the other half showed unilateral changes or no infiltrates. During a median follow-up of seven days, 87% experienced a radiological progression and among those 73% required escalation of oxygen therapy. Six patients developed acute kidney injury with one requiring hemodialysis. Six of 12 patients were treated with tocilizumab, a humanized monoclonal antibody to the IL-6 receptor. Overall, five kidney transplant recipients died after a median period of 15 days [15-19] from symptom onset. These preliminary findings describe a rapid clinical deterioration associated with chest radiographic deterioration and escalating oxygen requirement in renal transplant recipients with SARS-Cov2 pneumonia. Thus, in this limited cohort of long-term kidney transplant patients, SARS-CoV-2 induced pneumonia is characterized by high risk of progression and significant mortality.

Management of Patients on Dialysis and With Kidney Transplantation During the SARS-CoV-2 (COVID-19) Pandemic in Brescia, Italy.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease (COVID-19), is a major pandemic challenging health care systems around the world. The optimal management of patients infected with COVID-19 is still unclear, although the consensus is moving toward the need of a biphasic approach. During the first phase of the disease (from onset of the symptoms up to 7-10 days) viral-induced effects are prominent, with the opportunity to institute antiviral therapy. In the second inflammatory phase of the disease, immunosuppressive strategies (for example with glucocorticoids or anticytokine drugs) may be considered. This latter stage is characterized by the development of progressive lung involvement with increasing oxygen requirements and occasionally signs of the hemophagocytic syndrome. The management of the disease in patients with kidney disease is even more challenging, especially in those who are immunosuppressed or with severe comorbidities. Here we present the therapeutic approach used in Brescia (Italy) for managing patients infected with COVID-19 who underwent kidney transplantation and are receiving hemodialysis. Furthermore, we provide some clinical and physiopathological background, as well as preliminary outcome data of our cohort, to better clarify the pathogenesis of the disease and clinical management.

[Managing patients in dialysis and with kidney transplant infected with Covid-19].

We are in the midst of a health emergency that is totally new for us all and that requires a concerted effort, especially when it comes to safeguarding patients on hemodialysis, and kidney transplant recipients. Brescia is currently a very active cluster of infections (2918 cases on the 17/03/2020), second only to Bergamo. The way our structure is organised has allowed us to treat nephropathic patients directly within the Nephrology Unit, following of course a great deal of reshuffling; at the moment, we are treating 21 transplanted patients and 17 on hemodialysis. This has led us to adopt a systematic approach to handling this emergency, not only in managing inpatients, but also in researching the new disease. Our approach is mirrored in the guidelines attached to this article, originally intended for internal use only but potentially very useful to our colleagues, as they face the same exact problems. We have also started collecting data on our positive patients with the aim of understanding better the functioning of this disease and how best to manage it. If anyone is interested, we ask you to please get in touch with us, so we can coordinate our efforts.

Role of dialysis sodium gradient on intradialytic hypertension: an observational study.

INTRODUCTION: The causes of intradialytic hypertension (IDHyper) are not well understood and this condition can complicate the clinical management of hemodialysis (HD) patients. AIM: To evaluate the potential role of intradialytic sodium gradient (NaG) on blood pressure values and IDHyper during HD. PATIENTS AND METHODS: 206 prevalent HD patients on 3 times weekly HD treatment for at least 6 months (dialytic vintage 6-240 months) followed at our institution were studied. Mean age was 68 ± 14 years, 129 were men. For 2 consecutive months (24 HD sessions) after the start of observation, the following variables were evaluated in predialysis after the long interdialysis interval: pre-HD plasma sodium (pNa, mmol/l) and potassium (pK, mmol/l) concentrations (mean value of 8 determinations), pre- and post-HD systolic (SBP, mm Hg) and diastolic (DBP, mm Hg) blood pressure, dry body weight (dBW, kg), interdialytic weight gain (IDWG, kg), ultrafiltration rate (UFR, ml/kg/h), dialysis dose (Kt/V), protein catabolic rate (PCRn, g/kg/day), hemoglobin (Hb, g/dl). SBP, DBP, IDWG, UFR are the mean values of the 24 HD sessions. 76% of patients were on antihypertensive therapy, 171 patients were on bicarbonate HD, and 35 on HDF. Dialysate Na concentration was set at 140 mmol/l in all patients. Duration of HD and the blood and dialysate flow rate were kept constant during observation. STATISTICAL ANALYSIS: Data are expressed as mean ± SD; linear and multiple regression analysis and t test for unpaired data were employed. Significant differences were defined as p < 0.05. RESULTS: Pre-HD pNa was 138.1 ± 2.3 mmol/l, pK 5.0 ± 0.4 mmol/l, dBW 67 ± 14 kg, IDWG 2.9 ± 0.8 kg, UFR 11.2 ± 3.7 ml/kg/h, Kt/V 1.43 ± 0.18, PCRn 1.13 ± 0.17 g/kg/day, and Hb 11.2 ± 0.8 g/dl. Pre- and post-HD SBP values were 139 ± 13 and 134 ± 12 mm Hg (p < 0.0001); pre- and post-HD DBP did not change significantly. A dialysis Na gradient (NaG) (dialysate Na - pre-HD pNa) was calculated, as well as the delta of SBP (ΔSBP) (post-HD SBP - pre-HD SBP). IDHyper was defined as ΔSBP >0. A significant direct correlation was found between NaG and ΔSBP (p < 0.0001) and multiple regression analysis with ΔSBP as dependent variable confirmed the strong correlation with NaG (p < 0.00001). According to ΔSBP behavior, 171 patients (83%) had a decrease or no change in post-HD SBP (group 1; no IDHyper); 35 patients (17%) increased their post-HD SBP (group 2; IDHyper). NaG values were significantly greater in patients in group 2 (group 1: 1.5 ± 2.2 vs. group 2: 3.3 ± 2.5, p < 0.0001). CONCLUSIONS: This study shows that the intradialytic ΔSBP is independently and strongly associated with the dialytic NaG. The more positive the NaG (net intradialytic Na gain), the more positive the ΔSBP and IDHyper.

Magnitude of end-dialysis overweight is associated with all-cause and cardiovascular mortality: a 3-year prospective study.

BACKGROUND: We hypothesized that the difference between the prescribed end-dialysis body weight, defined end-dialysis over-weight (edOW; kg), and the body weight which is actually attained could impact survival in hemodialysis (HD) patients. The aim of this prospective observational study was to evaluate if edOW could influence survival in a cohort of prevalent HD patients, controlled for multiple dialysis and clinical risk factors and followed for 3 years. METHODS: One hundred and eighty-two patients (117 men, age 65 ± 13 years) on regular HD treatment for at least 6 months [median 48 months (range: 6-366)] were followed from January 1, 2008 to December 31, 2010. Eighty-four patients (46%) did not achieve their prescribed dry body weight (dBW); their median edOW was 0.4 kg (range: 0.1-1.4). Ninety-eight died during observation, mainly from cardiovascular reasons (69%). Multivariate Cox regression analysis was utilized to evaluate the effect edOW, ultrafiltration rate (UFR), interdialytic weight gain (IDWG), age, sex, dialytic vintage, cardiovascular disease, antihypertensive therapy, diabetes, duration of HD, dBW, BMI, mean arterial blood pressure, Kt/V, and protein catabolic rate (PCRn) had on mortality. RESULTS: Age (HR: 1.04; CI: 1.03-1.05; p <0.0001), IDWG (HR: 2.62; CI: 2.06-3.34; p < 0.01), UFR (HR: 1.13; CI: 1.09-1.16; p< 0.01), PCRn (HR: 0.02; CI: 0.01-0.04; p <0.001), and edOW (HR: 2.71; CI: 1.95-3.75; p < 0.02) were independently correlated to survival. The relative receiver operating characteristic curve identified a cutoff value of 0.3 kg for edOW in predicting death. CONCLUSIONS: High edOW is independently associated with an increased long-term risk of all-cause and cardiovascular mortality in HD patients. Better survival was observed in patients with edOW <0.3 kg. For patients with higher edOW, longer or more frequent dialysis sessions should be considered in order to prevent the deleterious consequences of excessive body fluid expansion.

Effect of post-dilutional on-line haemodiafiltration on serum calcium, phosphate and parathyroid hormone concentrations in uraemic patients.

BACKGROUND: Strict control of serum calcium and phosphate concentrations is paramount to prevent secondary hyperparathyroidism in haemodialysis (HD) patients. Standard intermittent low-flux HD (Lf-HD) is not sufficient to reach this goal. The aim of this study was to evaluate the effect of on-line haemodiafiltration (Ol-HDF) on serum calcium (sCa), phosphate (sPO4) and parathyroid hormone (PTHint) concentrations. METHODS: Of the 220 patients screened, 65 met the inclusion criteria for the study; 30 of whom agreed to participate in the study (Study group), the others were considered as the control group (Controls). Protocol for Study the group consisted of 6 months conventional Lf-HD (Period 1) and 6 months of post-dilutional Ol-HDF (Period 2). Controls continued their usual Lf-HD and were followed for 12 months. The main variables evaluated at the start and at the end of each period were sCa, sPO(4) and PTHint. RESULTS: The switchover from Lf-HD to Ol-HDF resulted in a significant reduction of sPO4 (from 5.1 ± 1.0 to 4.0 ± 0.7; P < 0.0001) and PTHint concentrations (from 307 ± 167 to 194 ± 98; P < 0.0001), no significant changes were found in both sCa concentrations (from 9.1 ± 0.7 to 8.9 ± 0.6) and phosphate binder dose. Kt/Vurea increased significantly, and beta(2) microglobulin concentrations decreased significantly. In the Controls, no significant variations of the same variables were observed over time, except for a significant increase in sevelamer intake. CONCLUSION: This study supports the idea that Ol-HDF could be better than Lf-HD in controlling mineral metabolism in HD patients.

Regulação da atenção à saúde bucal no Brasil: ações regulatórias sobre os serviços públicos e privados / Oral health care regulation in Brasil: regulations acts on public and private services

Introdução - Para o Ministério da Saúde, sistemas de saúde são complexas estruturas sociais compostas por elementos que se inter-relacionam para produzir respostas em saúde. No Brasil, tais respostas ainda se mostram insuficientes e ineficazes no campo da Saúde Bucal, no que se refere à integralidade da atenção, ao acesso à assistência e aos índices epidemiológicos da população. A regulação estatal sobre a atenção à Saúde Bucal atua na produção de bens e serviços, através de regulamentações e ações específicas. Tais instrumentos, aliados aos projetos de grupos sociais, conformam o modelo de atenção, em determinado período. Objetivo - Identificar os instrumentos criados pelos poderes de Estado para fazer a regulação sobre a atenção à Saúde Bucal e analisar o seu emprego pelos órgãos e instituições competentes. Método - Pesquisa documental da produção Legislativa Federal publicada entre 1824 e julho de 2007, dos atos normativos ministeriais do setor Saúde publicados entre 1946 e julho de 2007 e dos documentos aprovados pelo Conselho Nacional de Saúde - CNS entre 1988 e julho de 2007. Foram identificadas em base de dados (SICON, SAUDE LEGIS e página da internet do CNS) regulamentações relacionadas ao objeto, empregando-se termos de busca como "bucal", "odontologia", "cárie", "dente", e derivações dos radicais "fluor", "dent", entre outros relacionados à odontologia. Os documentos foram submetidos à análise de conteúdo. Resultados - Localizaram-se 591 atos normativos ministeriais, 495 atos da produção Legislativa e 109 documentos do CNS. A temática emergente da análise demonstra que, até a Constituição Federal de 1988, as regulamentações relativas ao Ensino Superior da Odontologia, à Gestão de Pessoal na Administração Pública Civil e Militar e ao Exercício Profissional da Odontologia tiveram prioridade no processo de implementação das ações e serviços de Saúde Bucal no Brasil. A partir de 1989, com a regulamentação do Sistema Único de Saúde, ganharam destaque os temas como Transferências de Recursos, Tabelas e Procedimentos Odontológicos e Regulamentação sobre as Operadoras e Planos Odontológicos, a partir da criação de mecanismos financeiros para a indução da política nos estados e municípios e a partir da Regulamentação da Saúde Suplementar. Somente a partir de 2002, os Programas e as Ações de Saúde Bucal começaram a se inserir de forma mais consistente nos documentos selecionados, principalmente no CNS. Entre as instituições analisadas, constataram-se diferenças nas prioridades temáticas. Conclusões - As prioridades estabelecidas nas normas e nas regulamentações demonstram que o modelo de atenção à Saúde Bucal no Brasil foi conformado a partir de propostas técnicas e políticas de cada gestão de governo e por demandas de grupos corporativos, profissionais e de mercado, a cada período. A aplicação desses instrumentos de regulação deve ser reavaliada para a construção de uma Política Nacional de Saúde Bucal consistente e de longo prazo.

Introduction - In the Health Department's view health systems consist of complex social structures made up of elements that interact to find the answers to health issues. In Brasil, such answers are still immature and inefficient in the Oral Health field, regarding the completeness of the care, the access to assistance and to epidemiological indexes of the population. The official regulation on the Oral Health Care implies the production of goods and services according to specific regulations and acts. Such instruments, together with projects of social groups, conform to the care model in a definite period. Objective - Identify the instruments created by the Official Entities to create a regulation on the care with the Oral Health and analyse its employment by the proper institutions. Method - Documental research of the legislative production approved between 1824 and July 2007, of the normative production published by the Health Ministry (Executive Power) between 1946 and July 2007 and of the documents approved by the Health National Council - HNC between 1988 and July 2007. Regulations related to the object were identified in the database (SICON, SAUDELEGIS and CNS homepage) by means of searching terms like "bucal", "odontologia", "cárie", "dente", and derivatives of the radicals "fluor", "dent", and other dentistry terms. The documents were submitted to a content analysis. Results - Five hundred and ninety one Normative Acts of the Health Ministry were found, 495 of the Legislative Power and 109 HNC documents. The emerging matter of the analysis demonstrates that until the Federal Constitution back in 1988, the regulations related to Dentistry College Education, Human Resources issues in Military and non-military Administration and the Dentistry Professional Practice had priority in the implementation process of Oral Health actions and services in Brasil. Effective from 1989, with the regulation of the Health Central System, themes like Funds Transference, Tables and Dental Procedures and regulations on Service Centers and Dental Plans were highlighted after the creation of financial mechanisms for political induction in the states and cities and after the Supplementary Health regulation. Nevertheless, from 2002 on, the Programs and the Oral Health Actions started being introduced in a more consistent way in the selected documents, mainly at the HNC. Amongst the institutions under analysis, differences in thematic priority were seen. Conclusions - The priorities established in the norms and regulations have demonstrated that the model of care to Oral Health in Brasil was conformed as per technical and political proposals of each government administration and by requirement from corporative, professional and market groups in each period. The application of these regulation instruments must be reassessed for the construction of a solid, long-termed Oral Health National Policy.

Aspectos éticos do uso de produtos fluorados no Brasil: uma visão dos formuladores de políticas públicas de saúde / Ethical aspects of the use of fluoride products in Brazil: a view of public health policy formulators

O flúor tem sido empregado para prevenir cárie dentária, principalmente em águas de abastecimento e dentifrícios. Um efeito indesejável, a fluorose dentária leve, tem suscitado preocupações entre especialistas. Neste trabalho identificam-se, na literatura, aspectos éticos decorrentes do emprego de flúor em saúde pública relacionados à contradição "prevenção da cárie versus ocorrência de fluorose leve" e investiga-se a ocorrência de dilemas éticos entre profissionais envolvidos em decisões sobre o uso desses produtos. Foram identificadas publicações em bases de dados empregando-se os termos de busca ética, bioética, "ethics" e derivações do radical "fluor". O material subsidiou a construção de um questionário aplicado a pesquisadores e autoridades sanitárias, e os dados gerados submetidos à análise de conteúdo. O dilema ético emergente da análise pode ser sintetizado: "Empregar produto com flúor para prevenir cárie dentária tem o inconveniente de produzir graus leves de fluorose dentária, mas não utilizá-lo em saúde pública tem o inconveniente de não impedir o aparecimento de uma doença (cárie) evitável com o seu uso." Tal dilema tem sido resolvido admitindo-se que haveria justiça no emprego do flúor e que seu benefício seria maior do que o malefício ­ sendo este mínimo. Alguns entrevistados reconheceram que há violação do princípio ético da autonomia.

Uma proposta de esquema para a análise ética das ações de saúde pública / A Proposal for the Ethical Analysis of Public Health Measures

Programas de saúde pública implicam intervenções cujos benefícios e ônus, bem como as evidências científicas que os embasam, precisam ser claramente identificados, de modo a que se possa verificar se o balanço e a distribuição desses benefícios e danos são adequados e suficientes para justificá-los eticamente. Nos anos 1960, os questionamentos morais que agitaram a bioética, decorrentes dos avanços das tecnologias biomédicas e dos abusos na experimentação científica com seres humanos, fizeram com que o princípio da autonomia passasse a ter grande importância moral nos códigos de ética médica. A partir do início dos anos 1990, tal prioridade passa a receber críticas e a não se mostrar mais adequado à prática da saúde pública, uma vez que seus valores diferem moralmente - de diferentes maneiras - dos valores que definem a prática clínica e a pesquisa. A bioética, entao assume questionamentos morais e éticos impostos pelas opções escolhidas nas políticas sanitárias e ambientais sobre as populações, agregando novos princípios como a eqüidade, a participação, a solidariedade e a proteção, para validar as intervenções da saúde pública. Os dilemas morais relativos às tentativas de se implantar políticas públicas de saúde seriam mais bem reconhecidos por seus formuladores e pelos tomadores de decisão com a ajuda de um arcabouço para a discussão ética das propostas da saúde pública.

Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study.

Atheroembolic renal disease (AERD) is part of a multisystemic disease accompanied by high cardiovascular comorbidity and mortality. Interrelationships between traditional risk factors for atherosclerosis, vascular comorbidities, precipitating factors, and markers of clinical severity of the disease in determining outcome remain poorly understood. Patients with AERD presenting to a single center between 1996 and 2002 were followed-up with prospective collection of clinical and biochemical data. The major outcomes included end-stage renal disease (ESRD) and death. Ninety-five patients were identified (81 male). AERD was iatrogenic in 87%. Mean age was 71.4 yr. Twenty-three patients (24%) developed ESRD; 36 patients (37.9%) died. Cox regression analysis showed that significant independent predictors of ESRD were long-standing hypertension (hazard ratio [HR] = 1.1; P < 0.001) and preexisting chronic renal impairment (HR = 2.12; P = 0.02); use of statins was independently associated with decreased risk of ESRD (HR = 0.02; P = 0.003). Age (HR = 1.09; P = 0.009), diabetes (HR = 2.55; P = 0.034), and ESRD (HR = 2.21; P = 0.029) were independent risk factors for patient mortality; male gender was independently associated with decreased risk of death (HR = 0.27; P = 0.007). Cardiovascular comorbidities, precipitating factors, and clinical severity of AERD had no prognostic impact on renal and patient survival. It is concluded that AERD has a strong clinical impact on patient and renal survival. The study clearly shows the importance of preexisting chronic renal impairment in determining both renal and patient outcome, this latter being mediated by the development of ESRD. The protective effect of statins on the development of ESRD should be evaluated in a prospective study.

Cholesterol crystal embolic disease in renal allografts.

Cholesterol embolic disease in the renal allograft is not recognized as an important cause of graft dysfunction. We describe here two renal transplant patients with cholesterol embolization in their allograft biopsies. The first, a 48-year-old patient, received a renal transplant from a 62-year-old donor with a history of hypertension and tobacco use. On account of initial non-function, a renal biopsy was taken, which showed acute tubular necrosis and cholesterol emboli. The second, a 55-year-old man, presented chronic allograft failure six years after transplantation; ultrasonography showed a solid renal mass. Nephrectomy specimens revealed renal carcinoma and a combination of chronic rejection and multiple cholesterol emboli. Cholesterol embolic disease is probably an under-reported cause of renal graft dysfunction. The source of the emboli may be either the donor or the recipient's vessels. Since the current tendency is to accept older donors and recipients with more advanced atherosclerotic disease, this condition is likely to become more frequent in the future. Particular care must be taken at the time of organ procurement and during the evaluation of organ donors, in order to reduce the risk of embolization.

Aspectos éticos do uso de produtos fluorados em saúde pública: uma visäo dos formuladores de políticas públicas de saúde e dos tomadores de decisäo / Ethical aspects of the use of fluoride products in public health: a view of the public health policy formulators and decision makers

Introduçäo. O flúor tem sido empregado em todo o mundo para prevenir cárie dentária. Emprega-se flúor principalmente em águas de abastecimento e dentifrícios. Um efeito indesejável tem sido detectado: ocorrência de fluorose dentária leve, com aparecimento de manchas brancas no esmalte dentário. Mesmo que nem sempre percebidas, têm suscitado preocupaçöes entre especialistas. Objetivo. Identificar na literatura aspectos éticos decorrentes do emprego de flúor em saúde pública relacionado à contradiçäo ôprevençäo da cárie versus ocorrência de fluorose leveö e verificar se, entre profissionais brasileiros envolvidos em decisöes sobre o uso desses produtos, pode ser constatado algum dilema ético. Metodologia. Foram identificadasem bases de dados (MEDLINE, LILACS, BBO), publicaçöes relacionadas ao tema, empregando-se termos de busca como ôéticaö, ôbioéticaö, öethicsö, e derivaçöes do radical ôfluorö. O material analisado subsidiou a construçäo de um questionário aplicado em pesquisadores, autoridades sanitárias e lideranças médico-sanitárias. Os dados gerados mas entrevistas foram submetidos à análise de conteúdo. Resultados. Localizaram-se 42 artigos e um livro. O dilema emergente da análise pode ser colocado nos seguintes termos: ôEmpregar produto que contém flúor para prevenir cárie dentária tem o inconveniente de produzir graus leves de fluorose dentária na populaçäo beneficiada, mas näo utilizar tal produto tem, nas estratégias de saúde pública, o inconveniente de näo impedir o aparecimento de uma doença (cárie) evitável com o seu usoö. Constatou-se que tal dilema tem sido resolvido, na maioria das vezes, admitindo-se que haveria justiça no emprego desses produtos e que seu benefício seria maior que o malefício - sendo este mínimo ou inexistente na maioria dos casos. Alguns entrevistados reconheceram, entretanto, que há violaçäo do princípio ético da autonomia.

Recovery of renal function after right nephrectomy, cavectomy and left renal vein ligation.

Right nephrectomy and ligation of the left renal vein often lead to acute renal failure, but not obligatorily to renal infarction and chronic uremia, thanks to the peculiar venous supply of the left kidney. A man underwent right nephrectomy, inferior cavectomy and ligation of the left renal vein and became anuric. Hemodialysis was necessary for some days, but he partially recovered his renal function. Proteinuria occurred a few days after the operation and decreased but had not disappeared after ten months. Eventually the patient died of brain metastases. There are a few reports of similar operations, some successful, others not, but very few papers report an adequate follow-up of subsequent changes in renal function. Nephrologists could be involved in the postoperative care of these cases. They should be aware of the possible recovery of renal function and should try all possible strategies to help the left kidney recover its function.