Primary glomerular diseases in Brazil (1979-1999): is the frequency of focal and segmental glomerulosclerosis increasing?

AIMS: Different patterns of glomerulonephritis (GN) are reported from all over the world and the occurrence of primary GN is changing in the course of time. We report the frequencies of primary GN in a major teaching hospital in Brazil, from 1979-1999. METHODS: The case files of renal biopsies of primary GN were reviewed. The included patients were > 14 years of age, with native kidneys, and the specimens were examined with at least light and immunofluorescence microscopy. We excluded biopsy results of patients with any kind of known secondary glomerular involvement. Differences in proportions of diagnoses between the periods over time were evaluated using Chi-square test for trend. RESULTS: We considered 943 patients for the analysis. Focal and segmental glomerulosclerosis (FSGS) was the most common lesion (n = 279), followed by membranous GN (n = 140), membranoproliferative type I GN (n = 109) and IgA nephropathy (n = 109). FSGS (32.1%) was the most frequent diagnosis among nephrotic patients whereas IgAN (29.4%) predominated in non-nephrotic ones. The occurrence of FSGS increased from the earlier to the later periods: 22.3% (1979-1983), 23.7% (1984-1988), 35.7% (1989-1993), 33.9% (1994-1999), p < 0.05. The increase in frequency of FSGS was proportionally higher in non-nephrotic patients and FSGS became as common as IgA nephropathy in this group (31.6% and 28.0%, respectively) from 1994-1999. CONCLUSIONS: FSGS was the most common pattern of primary glomerulonephritis and its relative frequency seems to be increasing in biopsied patients over time. The reasons for this behavior are unclear and warrant further investigations.

Lamivudine therapy for hepatitis B in renal transplantation.

Antiviral therapies are associated with an increased risk of acute rejection in transplant patients. The aim of the present study was to evaluate the efficacy and safety of lamivudine therapy for hepatitis B virus (HBV) infection in renal transplant patients. Six patients were included in this study. They received 150 mg/day of lamivudine during a follow-up period of 24 months. The laboratory tests monitored were HBV DNA, HBsAg, HBeAg, ALT, gamma-GT, serum creatinine and blood cyclosporine levels. The HBV DNA became undetectable in four patients as early as in the third month of treatment. After six months, the viral load was also negative in the other two patients, and remained so until 18 months of follow-up. The medication was well tolerated with no major side effects. Lamivudine was safe and effective in blocking HBV replication in renal transplant patients without any apparent increase in the risk of graft failure for the 24-month period of study.

Lamivudine therapy for hepatitis B in renal transplantation

Antiviral therapies are associated with an increased risk of acute rejection in transplant patients. The aim of the present study was to evaluate the efficacy and safety of lamivudine therapy for hepatitis B virus (HBV) infection in renal transplant patients. Six patients were included in this study. They received 150 mg/day of lamivudine during a follow-up period of 24 months. The laboratory tests monitored were HBV DNA, HBsAg, HBeAg, ALT, gamma-GT, serum creatinine and blood cyclosporine levels. The HBV DNA became undetectable in four patients as early as in the third month of treatment. After six months, the viral load was also negative in the other two patients, and remained so until 18 months of follow-up. The medication was well tolerated with no major side effects. Lamivudine was safe and effective in blocking HBV replication in renal transplant patients without any apparent increase in the risk of graft failure for the 24-month period of study

[Causes and prognosis of acute renal failure in elderly patients]. / Causas e prognóstico da insuficiência renal aguda hospitalar em pacientes idosos.

UNLABELLED: The prolonged life span of populations is the obvious reason for an increasing proportion of elderly patients with acute renal failure (ARF). The role of age as a factor indicative of a poor prognosis is a matter of controversy. OBJECTIVE: To evaluate this role we have analyzed the final outcome of elderly patients with ARF treated in our Nephrology Service. MATERIAL AND METHODS: Among 361 ARF cases prospectively studied during a two-year period (January 1995 to December 1996), 130 (36%) occurred in patients over 70 years of age. Etiology, clinical course and prognosis were analyzed. The average age was 76.0 +/- 4.7 years, varying from 70 to 94 years; 84 patients (65%) were male, and surgical causes accounted for 51% of geriatric ARF. RESULTS: The most frequent causes were: ischemic (volume depletion, arterial hypotension, and/or low cardiac output) in 48 patients (38%), sepsis in 40 (312%), nephrotoxic drugs in 46 (35%) and obstructive abnormalities in 10 (7.7%); in other 14 (11%) they were diagnosed more than a causal agent. Oliguria was present in 37. 2% (81 patients), and dialysis was needed in 50 patients (39%). The mortality in the population with age below 70 years was 43% and in the elderly patients was 53.8%; total mortality was similar in both groups of patients (p=0.085). Oliguria, need for dialysis, presence of surgical causes of ARF, and ARF acquired within the intensive care unit were associated with poor prognosis in elderly group. CONCLUSION: We concluded that the percentile of elderly patients with ARF is elevated; they presented mortality about of 50%, and this is not superior to the observed in the youngest population; oliguria, dialysis need, ICU cares and surgery are factors of unfavorable prognostic in these patients.

Causas e prognóstico da insuficiência renal aguda hospitalar em pacientes idosos / Causes and prognosis of hospital acute renal failure in elderly patients

OBJETIVOS: O objetivo deste estudo foi analisar as causas e o prognóstico de pacientes idosos (>70 anos de idade) com IRA tratados em nosso Serviço. CASUISTICA E MÉTODOS: Dos 361 pacientes adultos e portadores de IRA, atendidos em nosso serviço no período de janeiro/95 a dezembro/96, acompanhamos 130 pacientes (36 por cento) com idade superior a 70 anos (média de 76,0 ± 4,7 anos, variando de 70 a 94 anos). Destes, 84 (65 por cento) eram do sexo masculino e 66 (51 por cento) estavam no pós-operatório de cirurgias diversas. Os dados foram obtidos através de formulários padronizados usados no Serviço. RESULTADOS: As causas mais freqüentes foram: isquêmicas 48 (38 por cento), sepsis 40 (31 por cento), nefrotóxicas 46 (35 por cento) e obstrutivas 10 (7,7 por cento); em outros 14 (11 por cento) foram diagnosticados mais de um agente causal. IRA nao-oligúrica ocorreu em 81 pacientes (62,8 por cento) e em 50 pacientes (39 por cento) houve necessidade de diálise. A mortalidade na populaçao com idade abaixo de 70 anos foi 43 por cento e nos idosos 53,1 por cento, nao havendo diferença estatística entre os grupos (p=0,085). A mortalidade foi maior (p<0,0001) nos pacientes idosos oligúricos (86 por cento) do que nos idosos nao-oligúricos (32 por cento); maior em casos de IRA cirúrgica (66,7 por cento) do que em IRA de origem médica (41,8 por cento), e em pacientes internados em UTI (69 por cento) do que nos internados em enfermaria (17 por cento). O número de óbitos também foi maior (p<0,0001) no grupo que necessitou de diálise (84 por cento) do que nos nao dialisados (33 por cento). CONCLUSAO: Concluímos que o percentual de pacientes idosos com IRA é elevado; apresentaram mortalidade ao redor de 50 por cento, nao superior ao observado na populaçao mais jovem; oligúria, cirurgia, necessidade de tratamento em UTI e necessidade de diálise foram fatores de prognóstico desfavorável nesta casuística

Intraperitoneal pressure and hernias in children on peritoneal dialysis.

Abdominal wall hernias have been increasingly recognized in patients on continuous ambulatory peritoneal dialysis (CAPD). They are also more frequent in children than in adults. The aim of this study was to determine the influence of intraperitoneal pressure (IPP) on the development of hernias in children on CAPD, and if there was a difference between IPP in children and adults. We studied 14 children aged 11.2 +/- 3.2 years, body weight 31.1 +/- 9.4 kg, who had undergone CAPD for 16.2 +/- 14.4 months. Also, 10 adults were studied, aged 48 +/- 18 years, body weight 62.4 +/- 13.9 kg, on the CAPD program for 35 +/- 27 months. The IPP was measured via a column of dialysate in the peritoneal dialysis line, immediately before the drainage of the peritoneal cavity. The pressure was measured with the patients in the supine position, at the level of the umbilical cicatrix with the zero point located on the mean axillary line. IPP was measured at inspiration and at expiration, and the mean of these two measurements was calculated. The children were divided in two groups: group 1 (n = 7) without hernias and group 2 (n = 7) with hernias (5 umbilical and 2 inguinal). The IPP of all children was 9.5 +/- 2.9 cm H2O. The IPP was 8.1 +/- 2.6 and 10.9 +/- 2.6 cm H2O in groups 1 and 2, respectively (P = 0.003). The instilled volume for test was similar in both groups. The IPP of the adults was 13.8 +/- 2.8 cm H2O, which was significantly greater than that of the children (P = 0.001). In conclusion, hernia is a common complication in children on CAPD and its prevalence is affected by IPP. Other associated factors may be the presence of anatomically weak sites in the abdominal wall of the children, since IPP is lower in children than in adults.

Lymphocele: a possible relationship with acute cellular rejection in kidney transplantation.

CONTEXT: The incidence of lymphocele after renal transplantation varies between 0.6 and 18% of cases, and many factors have been associated to its etiology. Cellular rejection of the kidney allograft has been described as a possible causal factor of lymphocele. OBJECTIVE: To analyze the possible relationship between lymphocele and acute cellular rejection. DESIGN: A retrospective study. SETTING: A referral hospital center. SAMPLE: 170 patients submitted to kidney transplantation from March 1992 to January 1997. A standard technique for renal transplantation was used. RESULTS: Of the 19 patients that developed lymphocele, 16 presented at least one episode of acute cell rejection (84%), and were treated with methylprednisolone. The relation between lymphocele and rejection was statistically significant (p = 0.04). Treatment of lymphocele consisted of peritoneal marsupialization in 3 patients (15.3%), percutaneous drainage in 7 (36.8%), laparoscopic marsupialization in 2 (10.5%), and conservative treatment in 7 patients (36.8%). Evolution was favorable in 15 patients (78.9%), 1 patient (5.3%) died due to a cause unrelated to lymphocele, and 3 (15.8%) lost the graft due to immunological factors. The average follow-up period was 24.5 months. CONCLUSION: The high incidence of acute cell rejection in patients with lymphocele suggests a possible causal relationship between both conditions.

Nephrology, dialysis and transplantation in Brazil.

The European Renal Association welcomes this opportunity and feels that European nephrologists should be informed about the state of nephrology in South America, with which particularly our Latin colleagues maintain close cultural relationships. The following report on Nephrology in Brazil is a welcome addition to a series of reports designed to provide to European nephrologists a global view of nephrology. It is hoped that this is not misconstrued as a violation of nephrological Monroe doctrine.

[Reversal of hepatorenal syndrome after liver transplantation. Considerations about 3 patients]. / Reversão da síndrome hepatorrenal após transplante de fígado. Considerações sobre três pacientes.

Hepatorenal syndrome was observed in 25% of the patients with end stage liver disease. In this situation they stayed longer time in intensive unit treatment, hemodialysis. This evolution was observed in 67% of them with this complication after surgery. In this report we describe three patients with hepatorenal syndrome reversible after liver transplant. We define the form of management of these patients after surgery, regard treatment with cyclosporine A, only 72 h after surgery, without administration of aminoglycosides and amphoterycin. This good evaluation also depends of absence of arterial hypotension or infection episodes during and after surgery. It also depends of the good conditions of the implanted liver.

Influence of spontaneous contractions of the lymphatic vessels on the lymphatic absorption rate of the peritoneal cavity in CAPD.

The lymphatic vessels have sympathetic innervation. Noradrenaline increases the number of spontaneous contractions of the lymphatic vessels, whereas isoprenaline slows these contractions. The purpose of this study was to analyze the influence of the blockade of spontaneous contractions of the lymphatic vessels on the lymphatic absorption rate (LAR) in 6 patients on continuous ambulatory peritoneal dialysis (CAPD) by using 0.12 mg of isoprenaline added to 2 L of 2.5% dextrose dialysis solution. This dose of isoprenaline has been shown to inhibit bovine mesenteric lymphatic contractions. The LAR was measured by the quantification of the intraperitoneal disappearance of dextran 70 added to this same dialysis solution during a 4-hour dwell. All patients were submitted to a control test without isoprenaline. The LAR was 0.57 +/- 0.19 and 0.65 +/- 0.38 mL/minute (p > 0.05), with and without isoprenaline, respectively. We conclude that spontaneous contractions of the lymphatic vessels do not play an important role in the lymphatic drainage mechanism of the peritoneal cavity. The diaphragmatic contractions seem to be more important, since drugs that interfere with such diaphragmatic mechanisms alter the LAR.

Influence of the hydrostatic intraperitoneal pressure and the cardiac function on the lymphatic absorption rate of the peritoneal cavity in CAPD.

The purpose of this study was to determine the influence of hydrostatic intraperitoneal pressure (IPP) and cardiac function (CF) on the lymphatic absorption rate (LAR) in 9 patients on continuous ambulatory peritoneal dialysis (CAPD). The LAR was measured by estimation of the intraperitoneal disappearance of dextran 70 added to 2 L of 2.5% dextrose dialysis solution. The patients remained in the supine position during the 4-hour dwell. The IPP was obtained by measuring a column of dialysate in the peritoneal dialysis line, immediately before the drainage of the peritoneal cavity. The pressure was measured at the level of the umbilical cicatrix with point zero located on the mid axillary line of the patient. IPP was measured at inspiration and expiration, and the average of these two measurements was taken. These patients also underwent an echocardiographic examination. The LAR was 0.46 +/- 0.25 mL/minute, and the IPP was 13.07 +/- 2.61 cm H2O. The IPP correlated positively with the LAR (r = 0.80, p < 0.05). The intraperitoneal volume at the 4-hour dwell correlated inversely with the IPP (r = -0.68, p < 0.05). The left ventricular circumferential shortened fraction was 36 +/- 6% (27%-43%) and did not correlate with the LAR. These data suggest that the LAR is higher in patients with more elevated IPP. In addition, the CF, in the range studied, does not affect the lymphatic absorption rate.

[Use of recombinant human erythropoietin in the treatment of anemia in hemodialyzed patients: a multicentric study]. / Uso da eritropoetina recombinante humana no tratamento da anemia do paciente em hemodiálise: um estudo multicêntrico.

Recombinant human erythropoietin (rHu-EPO) therapy was given to 25 patients undergoing long-term hemodialysis, for 12 weeks, in 5 Brazilian dialysis centers. The dose of rHu-EPO was given intravenously thrice weekly, initially at 50 Units/kg/dose. If the target hemoglobin concentration (10g/dL) was not achieved by four weeks the dose was increased to 75 and 100 Units/kg/dose. After 4 weeks hemoglobin concentration had achieved 10g/dL in only one patient, and, after 8 weeks, 10 patients (40% of all cases) had hemoglobin levels higher than the target concentration. After 12 weeks, the hemoglobin increased from 7.1 +/- 1.1 to 9.6 +/- 1.2 g/dL, the target hemoglobin concentration was achieved in 15 patients (60% of all cases). There was a significant (p < 0.05) increase in hematocrit (from 22 +/- 4 to 31 +/- 4 vol%), in body weight (from 55.03 +/- 12.24 to 56.16 +/- 12.86kg), and in serum phosphorus (from 5.85 +/- 2.02 to 6.82 +/- 2.34 mg/dL). There were no significant changes in blood pressure, serum levels of creatinine, of potassium, and of transferrin. Increase in blood pressure (in 3 patients), fever (in 2 patients), increase in the heparin dose needs (in 2 cases), and vascular access thrombosis (in 1 patient) were the most important adverse effects observed during rHu-EPO therapy. Thus, the anemia of chronic renal failure may be easily corrected with adequate amounts of recombinant human erythropoietin. Attention must be paid to some adverse effects during reversal of anemia.

Use of dextran 70 to estimate peritoneal lymphatic absorption rate in CAPD.

Peritoneal lymphatic absorption rate (LAR) in 15 patients on a CAPD program was measured by estimation of the disappearance of dextran 70 from the peritoneal cavity. The LAR was 1.03 +/- 0.45 ml/min. The cumulative lymphatic absorption, cumulative net transcapillary ultrafiltration, calculated net ultrafiltration (CUF) and measured net ultrafiltration (MUF) at 4 h exchange were respectively: 261 +/- 127 ml, 694 +/- 134 ml, 446 +/- 135 ml and 409 +/- 136 ml. Calculated and measured net ultrafiltration didn't differ significantly. An inverse correlation between MUF and LAR and a positive correlation between MUF and the ratio for dialysate glucose concentration at 4 hand dialysate glucose at 0 h (G4/G0) were observed (r = -0.522 and 0.547, respectively, p < 0.05). The multiple correlation coefficient between the MUF and LAR plus G4/G0 was higher (r = 0.617, p < 0.05). Peritonitis and the presence of diabetes didn't interfere with LAR. We have concluded that lymphatic absorption plus peritoneal transfer rate of glucose are important determinants of intraperitoneal volumes and that dextran 70 is a useful marker to measure lymphatic absorption.

[Cyclosporin A: experience of the Renal Transplant Unit of the Clinical Hospital of the Medical College of the University of Sao Paulo]. / Ciclosporina A: experiência da Unidade de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.

The authors report their experience using cyclosporine-A (CsA) in renal transplant patients. When compared with azathioprine/prednisone, CsA contributed significantly to a better graft and patient survival, either if used associated with prednisone of with azathioprine plus prednisone. CsA was also used in substitution to azathioprine in patients with hepatopathy attributed to azathioprine toxicity. The initial results are promising. The association of CsA and azathioprine with corticosteroids withdrawal was used as an attempt to allow normal growth in children. This seems to be the best choice of treatment for children. Careful monitoring of CsA blood levels avoids, or at least, minimizes nephrotoxicity. To achieve therapeutic CsA levels, patients with liver damage need lower, while children need higher oral CsA doses. To summarise: when CsA in carefully used, it is an excellent immunosuppressive drug.

[Continuous ambulatory peritoneal dialysis: efficient treatment for children with terminal uremia]. / Diálise peritoneal ambulatorial contínua (DPAC): tratamento eficaz para crianças em uremia terminal.

We have reviewed records of 12 children underwent CAPD between January 84 and May 88, ranging in age from 7 month to 16 years (mean age 8.9 +/- 4.9 years). CAPD treatment lasted from 3 to 24 months (average 10.3 months). Exchanges of dialysis fluid were performed by parents (8 cases) or children (3); mean volume was 41.7 +/- 8.7 ml/kg/exchange (range 32-58 ml/kg). During 132 patient months of treatment laboratory data showed a good metabolic control expect a tendency to hypoalbuminemia. There were 3 catheter changes. Complications were: peritonitis (15 episodes or one infection every 8.8 patient/treatment/months), hypertension (5 cases), hypervolemia (2), cuff extrusion (4), local exit site (5) and tunnel (2) infections and hernias (2). CAPD has been continued in 3 children; 6 other received renal transplantation, one was switched to hemodialysis and 2 died. This study has demonstrated that CAPD was an effective treatment for renal failure in children waiting renal transplant. Cuff extrusion and hypoalbuminemia were common complications in our children.

[Peritonitis in intermittent peritoneal dialysis: microbiological aspects and the antibiogram]. / Peritonite em diálise peritonial intermitente: aspecto microbiológico e antibiograma.

Peritonitis is the most frequent complication in patients on peritoneal dialysis and bacteria are the major causative agents. Initial antibiotic therapy may be "blind" but the antimicrobial agent used should be related to the infecting organism and its sensitivities. This study was initiated in order to evaluate the microbiological characteristics and sensitivity of bacteria isolated from pre and post peritoneal dialysis effluents. Positive growth of microorganisms was observed in 52 out of 503 cultures. Staphylococcus aureus and Staphylococcus epidermidis were identified most frequently (29 per cent each). Antibiograms showed high sensitivity to aminoglycosides (netilmicin and amikacin) and to second and third generation cephalosporin. Vancomycin and netilmicin were the best choices for Staphylococcal infection. A high bacterial resistance to ampicillin, co-trimoxazole, cephalothin and gentamicin was verified. Characteristics of organisms causing peritonitis in patients on intermittent peritoneal dialysis is very important, for selection of the initial antibiotic therapy.

[Prevalence of anti-HIV antibodies in dialysis patients]. / Prevalência de anticorpos anti-HIV em pacientes dialisados.

Patients treated with chronic dialysis have a high risk of acquiring viral infections and blood transfusions are commonly considered to be the vehicle of transmission. In Brazil this source is implicated in infection of 15 percent of patients developing acquired immunodeficiency syndrome (AIDS). So, we evaluated the relative risk of our patients in dialysis becoming infected with human immunodeficiency virus (HIV), the virus associated with the AIDS. An enzyme immunoassay showed 6 of 104 patients on dialysis to have antibodies to HIV. In five infection with HIV was confirmed by Western blot tests. Investigation of other risk factors for AIDS showed that blood transfusion was the most likely cause of contamination. There was no correlation between HIV and HBV infections. Only one patient had leucopenia and low OKT4/T8 ratio and she died 90 days after sorologic diagnosis of HIV infection; the cause of death was encephalopathy and sepsis. Two patients died after 4 and 16 months victims of cardiocirculatory problems (non-AIDS related causes). Three patients remain asymptomatic on chronic hemodialysis 20, 36 and 37 months after diagnosis of HIV infection.