Sonographically determined kidney measurements are better able to predict histological changes and a low CKD-EPI eGFR when weighted towards cortical echogenicity.

BACKGROUND: The renal length and cortical echogenicity have shown correlation to the renal function and histological changes in CKD patients. The aim of this study was to assess the accuracy of crude and composite ultrasound parameters based on kidney measurements and cortical echogenicity to detect renal dysfunction and histological changes. METHODS: Kidney sonography and biopsy were performed in 112 patients. Histological changes were graded in 0, < 25%, ≥25%, ≤50 and > 50% of the sample. Cortical echogenicity was graded relative to liver or spleen parenchyma: less than, equal to and higher than the liver/spleen. Kidney length, the kidney length/body height ratio (KL/H) and cortical thickness were obtained. Each parameter was multiplied by a cortical echogenicity-weighting arbitrary factor: 1.17, 1 or 0.69 for cortex less than, equal to or higher than the liver, respectively. The GFR was estimated using the CKD-EPI formula. The accuracy of crude and composite parameters to identify patients with a high creatinine, a low GFR and histological changes were evaluated. RESULTS: The discriminative power of kidney length and cortical thickness for renal dysfunction and histological changes was improved after weighting for cortical echogenicity. However, the best discriminative was the kidney length to height ratio weighted towards renal echogenicity (w-KL/H). CONCLUSION: w-KL/H exceeded the other parameters as a marker of renal impairment and histological changes in CKD. Calculation of the w-KL/H index may be of help as a non-invasive tool to identify patients with significant renal disease and might be useful to guide therapeutic decisions.

Um índice clínico preditor de sobrevida renal / A clinical predictor index for renal survival

Introdução: Um índice capaz de antecipar a progressão da doença renal independente dos achados histológicos seria de inestimável valor para a indicação da biópsia renal. Objetivo: Avaliar se um índice clínico baseado na ecogenicidade cortical renal, na relação diâmetro longitudinal do rim/altura do indivíduo (KL/H) e na creatinina sérica pode predizer a sobrevida renal. Métodos: As lesões crônicas (obsolesc~encia glomerular, esclerose segmentar e focal, atrofia tubular e fibrose intersticial) e agudas (proliferação mesaginal, permeação leucocitária, necrose fibrinoide e crescentes e infiltrado intersticial) das biópsias de 154 pacientes foram graduadas e somadas para geração de índices. Um índice clínico de cronicidade foi criado pela soma da gradação da ecogenicidade cortical relativa a do fígado ou baço, dos níveis de creatinina sérica e da relação KL/H. O desfecho do estudo foi a necessidade de iniciar a diálise. Resultados: Os maiores graus do índice clínico de cronicidade e do índice crônico de biópsia foram associados com sobrevida renal mais curta. Dos seis pacientes com creatinina sérica >2,5 mg/dL, maior ecogenicidade cortical e KL/H<0,60 antes da biópsia, cinco iniciaram diálise e um elevou a creatinina para 4,5 mg/dL. O índice clínico apresentou boa correlação com o índice crônico de biópsia. Conclusões: O índice clínico pode ser útil para predizer uma situação na qual a biópsia mostrará lesões crônicas avançadas e irreversíveis. Nos pacientescom os graus mais altos dos parãmetros clínicos, a biópsia pode ser descartada. Para grupos de pacientes, o índice pode ser utilizado na comparação de desfechos e eficácia terapêutica.

Introduction: An index able to anticipate the progression of renal disease independent of histological findings would be invaluable for the indication of renal biopsy. Objective: To evaluate whether a clinical index based on renal cortical echogenicity in longitudinal diameter ratio of kidney / height of the individual (KL / H) and serum creatinine to predict renal survival. Methods: The chronic lesions (obsoletes ~ ence glomerular focal segmental sclerosis, tubular atrophy and interstitial fibrosis) and acute (mesaginal proliferation, leukocyte permeation, fibrinoid necrosis and crescents and interstitial infiltration) of biopsies from 154 patients were graded and summed to generate indices. A clinical index of chronicity was created by the sum of gradation on the echogenicity of the liver or spleen, the levels of serum creatinine and the ratio KL / H. The study endpoint was the need to start dialysis. Results: The highest degree of clinical index and chronicity index of chronic biopsy were associated with shorter renal survival. Of the six patients with serum creatinine> 2.5 mg / dL, increased cortical echogenicity and KL / H <0.60 before biopsy, five started dialysis and a raised creatinine to 4.5 mg / dL. The clinical index had good correlation with chronic biopsy. Conclusions: The clinical index may be useful to predict a situation in which the biopsy shows chronic lesions advanced and irreversible. In pacientescom the highest levels of clinical parameters, the biopsy may be discarded. For groups of patients, the index can be used to compare outcomes and therapeutic efficacy.

[A clinical predictor index for renal survival].

INTRODUCTION: A clinical index that discriminates disease progression independent of histopathologic features may be valuable in the best timing of biopsy. OBJECTIVE: This study addresses the question if a clinical index based on cortical echogenicity, renal length to body height ratio (KL/H), and serum creatinine levels predicts renal survival. METHODS: The study enrolled 154 patients. Biopsy specimens were graded for chronic (glomerular obsolescence, segmental glomerular sclerosis, tubular atrophy and interstitial fibrosis) and acute (mesangial proliferation, leucocyte permeation, crescent and fibrinoid necrosis and interstital infiltrate) index by the sum of scored lesions. A chronic clinical index was created by the sum of scored cortical echogenicity relative to liver or spleen, creatinine serum levels and KL/H. The study end point was start on dialisis. RESULTS: Higher grade of chronic clinical and biopsy indices were associated with poorer long-term renal survival. Five out of six patients with serum creatinine levels > 2.5mg/dL, highest cortical echogenicity and KL/H < 0.60, before biopsy, started on dialysis and one increased creatinine levels up to 4.5 mg/dL. The chronic clinical index correlates well with chronic biopsy index. CONCLUSIONS: The chronic clinical index could be useful to predict a clinical setting in which a renal biopsy will show advanced chronic and irreversible lesion. In patients with highest grade of clinical parameters renal biopsy can be obviate. As a chronicity of illness index for groups of patients with renal medical diseases, the system could be useful in outcome comparisons and evaluation of therapeutic efficacy.

[Renal parenchymal disease: histopathologic-sonographic correlation]. / Doença parenquimatosa renal: correlação histológico-sonográfica.

PURPOSE: This study was designed to address the correlation between sonography of a kidney with histological lesions and clinical findings in patients with renal parenchymal disease based on a multivariate logistic regression analysis. METHODS: Clinical and laboratory data, sonograms and renal biopsies were evaluated in 154 patients. Cortical echogenicity was graded as less than (0), equal to (1) or greater than (2) liver/spleen parenchyma. Histological lesions - mesangial proliferation (MP), leukocyte permeation (LP), fibrinoid necrosis and crescents (FNC), interstitial infiltrate (II), segmental glomerular sclerosis (SGS), glomerular obsolescence (GO), tubular atrophy (TA) interstitial fibrosis (IF) and interstitial edema (IE) - were graded according to extension and severity as normal (0%), mild (<25%), moderate (>25% <50%), and severe (>50%). RESULTS: a) II, IF, SGS, IE and increased creatinine occurred less in cortical echogenicity grade 0; b) MP, arterial hypertension and normal parenchymal thickness predict cortical echogenicity grade 1; c) IF, IE, increased creatinine and thin parenchyma predict occurrence of echogenicity grade 2; d) Excluding obese patients, both youth and hematocrit accounted for pyramid prominence; e) increased creatinine and GO was probable in patients with small kidneys. CONCLUSIONS: Increased cortical echogenicity was a very sensitive marker of renal parenchymal disease. Different lesions rather than degree of lesion severity accounted for progressive increase of cortical echogenicity. IE exponentially increased the effect of IF on cortical echogenicity.

Doença parenquimatosa renal: correlação histológico-sonográfica / Renal parenchymal disease: histopathologic-sonographic correlation

OBJETIVO: Este estudo foi planejado para avaliar a correlação da ecografia do rim com as lesões histológicas e com os achados clínico-laboratoriais na doença parenquimatosa renal, por análise de regressão logística multivariada. MÉTODOS: Os dados clínicos, laboratoriais, ecográficos e as biópsias foram avaliados em 154 pacientes. A ecogenicidade cortical foi graduada como menor que grau zero, igual a grau um ou maior que grau dois a do parênquima hepático ou esplênico. As lesões histológicas - proliferação mesangial (PM), permeação leucocitária (PL), crescente e necrose fibrinóide (CNF), infiltrado inflamatório intersticial (II), esclerose glomerular segmentar (ES), obsolescência glomerular (OG), atrofia tubular (AT), fibrose intersticial (FI) e edema intersticial (EI) - foram graduadas de acordo com a extensão, em normal (0 por cento), leve (<25 por cento), moderada (>25 por cento <50 por cento), e grave (>50 por cento). RESULTADOS: a) II, FI, ES, EI e creatinina elevada ocorreram menos no grau 0 de ecogenicidade cortical; b) PM, hipertensão arterial e espessura normal do parênquima foram preditores do grau 1 de ecogenicidade cortical; c) FI, EI, creatinina elevada e parênquima fino foram preditores do grau 2 de ecogenicidade cortical; d) Excluindos os obesos, em jovens com hematócrito baixo, a pirâmide proeminente foi mais comum; e) Creatinina elevada e OG foram preditores de rins pequenos. CONCLUSÃO: A ecogenicidade cortical foi um sensível marcador de doença parenquimatosa renal. Lesões distintas mais do que o grau de severidade da lesão contribuiram para o aumento da ecogenicidade cortical. O EI aumenta exponencialmente o efeito da FI na ecogenicidade cortical.

PURPOSE: This study was designed to address the correlation between sonography of a kidney with histological lesions and clinical findings in patients with renal parenchymal disease based on a multivariate logistic regression analysis. METHODS: Clinical and laboratory data, sonograms and renal biopsies were evaluated in 154 patients. Cortical echogenicity was graded as less than (0), equal to (1) or greater than (2) liver/spleen parenchyma. Histological lesions - mesangial proliferation (MP), leukocyte permeation (LP), fibrinoid necrosis and crescents (FNC), interstitial infiltrate (II), segmental glomerular sclerosis (SGS), glomerular obsolescence (GO), tubular atrophy (TA) interstitial fibrosis (IF) and interstitial edema (IE) - were graded according to extension and severity as normal (0 percent), mild (<25 percent), moderate (>25 percent <50 percent), and severe (>50 percent). RESULTS: a) II, IF, SGS, IE and increased creatinine occurred less in cortical echogenicity grade 0; b) MP, arterial hypertension and normal parenchymal thickness predict cortical echogenicity grade 1; c) IF, IE, increased creatinine and thin parenchyma predict occurrence of echogenicity grade 2; d) Excluding obese patients, both youth and hematocrit accounted for pyramid prominence; e) increased creatinine and GO was probable in patients with small kidneys. CONCLUSIONS: Increased cortical echogenicity was a very sensitive marker of renal parenchymal disease. Different lesions rather than degree of lesion severity accounted for progressive increase of cortical echogenicity. IE exponentially increased the effect of IF on cortical echogenicity.

Estudo da taxa de recorrência em pacientes com litíase renal / Recurrent rate study in patients with renal lithiasis

A taxa de recorrência (TR), em 107 pacientes com litíase renal, mostrou média de 1,43 cálculos/paciente. ano, em tempo médio de 7,3 anos. Em pacientes com menos de quatro anos de doença, a TR foi mais elevada do que no grupo com período mais longo. Observou-se queda progressiva na TR, que se estabiliza aos oito anos de doença até um período acima de 15 anos de doença. Os autores discutem que a TR é elevada em pacientes com menos de quatro anos de doença porque exclui o período de remissao natural. Pacientes operados com > 4 anos de doença e evidência atual de cálculo tiveram TR mais elevada, sugerindo a necessidade de profilaxia.

Infecçäo pelo vírus da AIDS numa populaçäo de renais crônicos hemodialisados / Infection by AIDS virus in chronic renal patients submitted to hemodialysis

Estudamos a incidência de anticorpos HIV em nossa unidade de hemodiálise localizada em Säo Joäo do Meriti, município do Rio de Janeiro. Inicialmente, foram testados, para a presença de anticorpos, soros de 132 pacientes do programa regular de hemodiálise de e 19 médicos e paramédicos, através do método enzimático de radioimunoensaio (ELISA - Abbot Laboratories). Nenhum dos soros do pessoal médico e paramédico foi possitivo, porém 28 (21%) dos pacientes foram considerados positivos, com grau variável de reatividade. Em 24 desses pacientes, o ELISA (antígeno bruto) foi repetido em novas amostras de soro, sete meses após; por essa ocasiäo, somente 19 (14,8%) foram considerados positivos. Essas amostras de soro foram submetidas a outras técnicas imunológicas de pesquisa de anticorpos para o HIV: 17/17 foram positivas no ELISA (env/core)-Abbot; 13/15 positivos na imunofluorescência e 11/11 positivas no Western-blot. Com exeçäo de um paciente, os 18 pacientes infectados com HIV haviam recebido transfusöes sanguíneas: 36,9% tendo recebido até cinco unidades e 57,9% com mais de cinco unidades de sangue transfundidas. Nenhum dos pacientes a outro grupo de risco. Por ocasiäo deste relato, três pacientes morreram com infecçöes oportunistas com relaçäo T4/T8 muito baixas: 0,2; 0,3 e 0,6. Os pacientes em HD que necessitaram transfusöes de sangue no passado devem ter seus soros pesquisados para a presença de anticorpos HIV, porque eles estäo em risco de desenvolvimento AIDS e medidas para evitar a disseminaçäo do vírus numa unidade de diálise devem ser tomadas

Insuficiência renal aguda como forma de apresentação do mieloma múltiplo: relato de um caso / Acute renal failure as presentation form of multiple myeloma: a case report

A insuficiência renal aguda é uma complicação do mielona múltiplo observada em 2 a 8% dos pacientes. Pode surgir como manifestação inicial da doença, estando ausentes os achados clínicos, laboratoriais e radiológicos usuais. Quando a medula óssea é estudada nos casos que apresentam essas características, a infiltração plasmocítica da mesma tem sido observada em todos, estabelecendo-se, assim, o diagnóstico. Os autores relatam o caso de um paciente portador de mieloma de cadeia leve do tipo kappa que se manifestou com insuficiência renal aguda e irreversível. A suspeita de mieloma foi possível graças a biópsia renal, cujo resultado revelou os achados do "rim mieloma". a medula óssea, obtida por aspiração e histoquímica e imunofluorescência. Foram afastadas outras causas que cursam com os aspectos histológicos do "rim do mieloma". o surgimento de fratura patológica em uma das costelas e de pequena erosão no maxilar inferior só foi demonstrado nos últimos dias de vida do paciente, em que pese repetidos estudos radiológicos do esqueleto.

Acute renal failure is a complication of multiple mielona observed in 2-8% of patients. May arise as a manifestation of the disease, being absent the clinical, laboratory and radiological usual. When bone marrow is studied in cases with these characteristics, the same plasmacytic infiltration has been observed in all, establishing thus the diagnosis. The authors report the case of a patient with myeloma of kappa light chain which was manifested with acute renal failure and irreversible. The suspicion of myeloma was made possible by a renal biopsy, which revealed the findings of "myeloma kidney". bone marrow obtained by aspiration and immunohistochemistry and immunofluorescence. Ruling out other causes were concomitant with the histological aspects of "myeloma kidney". the emergence of pathologic fracture in the ribs and a small erosion in the lower jaw has only been shown in the last days of life of patients, despite repeated radiological studies of the skeleton.