RESUMEN
BACKGROUND: Henoch-Schönlein purpura (HSP) is a fairly common disease in children and adolescents. There are only limited data available for adults. METHODS: A retrospective analysis was conducted to study renal manifestations in patients with HSP treated in our institution between 1982 and 2007. We divided our adult cohort according to age - under or over 60 years - to examine differences in elderly patients. RESULTS: HSP was identified in 2.2% of patients referred to us for kidney biopsy. Purpuric lesions and renal involvement were found in all patients. An important triggering factor for the development of HSP in our series was chronic alcohol intake. Forty percent of our patients fulfilled the WHO criteria for alcoholics. Renal involvement was particularly prominent in patients over 60 years of age. At disease onset, estimated glomerular filtration rate (eGFR) was 63% lower in the elderly. Within a median follow-up of 8 years, renal function was significantly better in younger adults than in the elderly. 32% of the elderly have shown Modification of Diet in Renal Disease (MDRD) < 20 ml/min/1.73 m2 in contrast to only 7% in patients < 60 years. Furthermore, significantly more elderly patients reached end-stage renal failure. CONCLUSION: The data indicate that renal manifestation of HSP in the elderly is severe and its outcome relatively poor, and worsens when compared to patients < 60 years.
Asunto(s)
Vasculitis por IgA/patología , Enfermedades Renales/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Envejecimiento , Biopsia , Femenino , Tasa de Filtración Glomerular , Humanos , Vasculitis por IgA/fisiopatología , Vasculitis por IgA/terapia , Riñón/patología , Enfermedades Renales/fisiopatología , Enfermedades Renales/terapia , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Piel/patología , Adulto JovenAsunto(s)
Angioedema/diagnóstico , Angioedema/etiología , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades del Nervio Hipogloso/diagnóstico , Enfermedades del Nervio Hipogloso/etiología , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Diagnóstico Diferencial , HumanosRESUMEN
The treatment of idiopathic membranous nephropathy (MN) with nephrotic syndrome comprises immunosuppressive therapy and antihypertensive treatment with the blockade of the renin-angiotensin system (RAS). Given the relatively benign natural history of MN, an immunosuppressive-free therapeutic regimen should be considered as the primary treatment option. In a single-center, retrospective analysis we compared the outcome of 54 patients with biopsy-proven idiopathic MN 12, 24 and 60 months after initiation of therapy. All patients had RAS-blocking agents and 36 patients received additionally an immunosuppressive regimen. In both groups the patients initially had a nephrotic proteinuria (median 8.7 vs. 6.0 g/day, n.s.). Median blood pressure reduction was comparable after 12, 24 and 60 months in both groups. The median evolution of proteinuria during therapy after 12, 24 and 60 months was 3.4, 1.7 and 1.1 g/day in the group with immunosuppression compared to 3.0, 1.1 and 0.32 g/day in the non-immunosuppressive group. After 60 months no patient developed endstage renal failure. The number of severe side effects was significantly higher in patients with immunosuppression. Regarding renal function and reduction of proteinuria, patients with idiopathic MN treated without immunosuppressive therapy but with measures to ensure optimal blood pressure control and the full blockade of RAS had a similar outcome after 60 months as compared to patients who received additional immunosuppressive therapy.
Asunto(s)
Antihipertensivos/uso terapéutico , Presión Sanguínea , Glomerulonefritis Membranosa/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Femenino , Glomerulonefritis Membranosa/patología , Glomerulonefritis Membranosa/fisiopatología , Glomerulonefritis Membranosa/orina , Humanos , Inmunosupresores/efectos adversos , Riñón/patología , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Síndrome Nefrótico/tratamiento farmacológico , Síndrome Nefrótico/fisiopatología , Síndrome Nefrótico/orina , Proteinuria , Sistema Renina-Angiotensina/efectos de los fármacos , Adulto JovenRESUMEN
Acute renal failure in critically ill patients in the intensive care unit is associated with high morbidity and mortality which is independent of the underlying etiology. Despite improvements in intensive care medicine and renal replacement therapy, patients with acute renal failure have much higher morbidity and mortality rates than patients without acute renal failure in the intensive care unit. In this overview, we summarize the literature on the incidence and mortality of patients with acute renal failure in the intensive care unit. Furthermore, we discuss timing of the initiation of renal replacement therapy, patient outcome with different renal replacement therapies and the adequate dialysis dose to be delivered.
Asunto(s)
Lesión Renal Aguda/terapia , Cuidados Críticos , Terapia de Reemplazo Renal/métodos , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/mortalidad , Anticoagulantes/uso terapéutico , Enfermedad Crítica , Hemodiafiltración , Humanos , Diálisis Peritoneal , Diálisis Peritoneal Ambulatoria Continua , Diálisis RenalRESUMEN
Real-time contrast-enhanced sonography (RT-CES) can assess microvascular tissue perfusion using gas-filled microbubbles. The study was performed to evaluate the feasibility of RT-CES in detecting chronic allograft nephropathy (CAN) in comparison to color Doppler ultrasonography (CDUS). A total of 26 consecutive renal transplant recipients were prospectively studied using RT-CES and conventional CDUS. Transplant tissue perfusion imaging was performed by low-power imaging during i.v. administration of the sonocontrast Optison. Renal tissue perfusion was assessed quantitatively using flash replenishment kinetics of microbubbles to estimate renal blood flow A *beta (A = peak signal intensity, beta= slope of signal intensity rise). In contrast to conventional CDUS resistance and pulsatility indices, renal blood flow estimated by CES was highly significant related to S-creatinine (r =-0.62, p = 0.0004). Determination of renal blood flow by CES reached a higher sensitivity (91% vs. 82%, p < 0.05), specificity (82% vs. 64%, p < 0.05) and accuracy (85% vs. 73%, p < 0.05) for the diagnosis of CAN as compared to conventional CDUS resistance indices. Perfusion parameters derived from RT-CES significantly improve the early detection of CAN compared to conventional CDUS. RT-CES using low-power real-time perfusion imaging is a feasible method to evaluate microvascular perfusion in renal allograft recipients.
Asunto(s)
Albúminas , Medios de Contraste/administración & dosificación , Fluorocarburos , Fallo Renal Crónico/diagnóstico por imagen , Trasplante de Riñón/diagnóstico por imagen , Adolescente , Adulto , Anciano , Albúminas/administración & dosificación , Velocidad del Flujo Sanguíneo/fisiología , Femenino , Fluorocarburos/administración & dosificación , Estudios de Seguimiento , Humanos , Inyecciones Intravenosas , Fallo Renal Crónico/etiología , Fallo Renal Crónico/fisiopatología , Masculino , Microesferas , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Sensibilidad y Especificidad , Factores de Tiempo , Trasplante Homólogo , UltrasonografíaRESUMEN
Sickle cell trait (SCT) is an usually asymptomatic hemoglobinopathy. Cases of sudden excertional deaths in individuals with SCT have been described. We here report an exceptional case of excessive rhabdomyolysis and acute renal failure triggered by a sauna visit in a 29 year-old African American with SCT.
Asunto(s)
Lesión Renal Aguda/etiología , Rabdomiólisis/etiología , Rasgo Drepanocítico/complicaciones , Baño de Vapor/efectos adversos , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/terapia , Adulto , Humanos , Masculino , Rabdomiólisis/diagnóstico , Rabdomiólisis/terapia , Índice de Severidad de la EnfermedadAsunto(s)
Enfermedades Cardiovasculares/complicaciones , Fallo Renal Crónico/complicaciones , Fármacos Cardiovasculares/uso terapéutico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Ensayos Clínicos como Asunto , Humanos , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/prevención & control , Prevalencia , Factores de RiesgoRESUMEN
Organ transplant recipients display a high cardiovascular mortality rate. The type of immunosuppression has a major impact on cardiovascular risk factors (e.g., hypertension [HTN]). We assessed 24-hour blood pressure (BP) and metabolic profiles in a cohort of 106 long-term liver allograft recipients treated with either tacrolimus (Tac) or cyclosporine (CyA). The median age of patients was 50.8 years (range, 11 to 77) and the median time of follow-up was 65.4 months (ranges 12 to 168). Immunosuppression included low-dose steroids and either Tac (n = 46) or CyA (n = 60). Twenty-four-hour BP measurements revealed a significant difference in systolic BP (127.1 mmHg [94 to 163] Tac versus 132.7 mmHg [103 to 177] CyA; P <.03), and in mean arterial and diastolic blood pressures. In addition, the relative number of normotensive patients was significantly higher among Tac-treated patients (69.6% versus 34.8%). It is of note that the true incidence of HTN was higher after the number of patients with a pathological 24-h BP measurement was added to the initial number of patients already known to have HTN. No less than 76.4% of all long-term liver transplanted patients showed HTN. The results were unrelated to cumulative steroid dosage, frequency of antirejection therapy or underlying primary liver disease. In summary, immunosuppression-induced HTN is more common in CyA-treated than Tac-based regimens. Moreover, we found a substantial lack of detection of HTN in long-term liver transplant patients who received an insufficient quality of antihypertensive treatment. These findings have implications for the early diagnosis and treatment of HTN in liver transplant recipients.
Asunto(s)
Presión Sanguínea/efectos de los fármacos , Ciclosporina/uso terapéutico , Trasplante de Hígado/fisiología , Tacrolimus/uso terapéutico , Monitoreo Ambulatorio de la Presión Arterial , Ritmo Circadiano , Estudios de Cohortes , Estudios Transversales , Humanos , Inmunosupresores/uso terapéutico , Trasplante de Hígado/inmunología , SobrevivientesRESUMEN
With current immunosuppression elevated blood pressure is found in almost 90% of renal graft recipients. Major causes of this finding are impairment of renal function, secondary to chronic allograft nephropathy or (less frequently) recurrence of primary renal disease, the use of calcineurin inhibitors as immunosuppresants, uncontrolled renin secretion by the shrunken kidneys of the recipient, stenos- ing lesions of the transplant artery (or the upstream arteries of the recipient), polycytemia and (genetic predisposition to) hypertension of the graft donor. Even minor degrees of blood pressure elevation have a significant impact on survival of the recipient and on graft survival, presumably by amplifying vascular injury to the graft. In this respect, elevation of systolic blood pressure and an abnormal circadian blood pressure profile are of particular relevance. In contrast to previous opinion, ACE inhibitors are indicated in the treatment, but, given the causal role of sodium retention in graft vasoconstriction, diuretics and calcium channel blockers remain main stays of antihypertensive treatment in the renal allograft recipient.
Asunto(s)
Hipertensión/etiología , Trasplante de Riñón/efectos adversos , Antihipertensivos/uso terapéutico , Supervivencia de Injerto , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Trasplante de Riñón/mortalidad , Prevalencia , Tasa de SupervivenciaRESUMEN
HISTORY: A 22 year old patient had noted progressive flank pain without recognizable urinary abnormalities for five days. INVESTIGATIONS: A urologist had noted increased serum creatine (2.1 mg/dl), hypertension (180/100 mmHg) and microhematuria. A post-renal cause was excluded by excretory urography. An interview revealed that the patient had consumed cocaine on weekends since age 19; the acute episode was preceded by a rave party with consumption of a total of 3 g of street quality cocaine. DIAGNOSIS AND TREATMENT: Because of microhematuria with a suggestive nephritic urinary sediment, the patient underwent renal biopsy. It showed acute tubular necrosis and interstitial edema, but no signs of glomerulonephritis and negative immunohistology. The patient received antihypertensive treatment. This led to rapid reversal of elevated serum creatinine and microhematuria was noted, but hypertension persisted. Currently the patient receives ACE inhibitors. CONCLUSION: Similar to what is seen in the US, cocaine use has to be considered in the differential diagnosis of acute renal failure with hypertension.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Trastornos Relacionados con Cocaína/complicaciones , Cocaína/efectos adversos , Hipertensión Maligna/inducido químicamente , Drogas Ilícitas/efectos adversos , Lesión Renal Aguda/complicaciones , Adulto , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Cocaína/administración & dosificación , Humanos , Hipertensión Maligna/complicaciones , Hipertensión Maligna/tratamiento farmacológico , Riñón/patología , MasculinoRESUMEN
Recent studies have shown the beneficial effects of a blockade of the renin-angiotensin system (RAS) not only for blood pressure reduction but also end organ protection. One of the markers that is closely correlated with the increased cardiovascular risk is microalbuminuria. A common mediator for the development of both, microalbuminuria and end organ damage seems to be Angiotensin II, the blockade of which apparently reduces microalbuminuria as well as end organ damage. Therefore we had a closer look into pathophysiology of microalbuminuria and the relevance for end organ damage and discuss current medical strategies to alleviate these diseases.
Asunto(s)
Albuminuria/etiología , Enfermedades Cardiovasculares/etiología , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Hipertensión/complicaciones , Albuminuria/diagnóstico , Albuminuria/epidemiología , Albuminuria/fisiopatología , Angiotensina II/antagonistas & inhibidores , Angiotensina II/fisiología , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Biomarcadores , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Ensayos Clínicos como Asunto , Enfermedad Coronaria/etiología , Enfermedad Coronaria/mortalidad , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/etiología , Nefropatías Diabéticas/mortalidad , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Losartán/uso terapéutico , Masculino , Metaanálisis como Asunto , Prevalencia , Proteinuria/etiología , Sistema Renina-Angiotensina/efectos de los fármacos , Sistema Renina-Angiotensina/fisiología , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidadRESUMEN
Microalbuminuria has been widely appreciated in recent years to be a valuable risk marker for an increased cardiovascular disease morbidity and mortality. Thus guidelines for the treatment of type-2-diabetes in Germany and the US recommend an annual screening as soon as the diagnosis of diabetes is established and a quarterly control when microalbuminuria is present. While nationally representative epidemiologic data from the US have been available, data from Germany, especially from the primary care sector are missing. This is especially important in light of the gatekeeper function of the primary care physician. The "Hypertension and Diabetes Risk Screening Study" (HYDRA) has been identifying 37.8% of patients with hypertension and diabetes to have a positive dipstick test for microalbuminuria on the study day while only 12.5% of these are diagnosed by the doctor as having nephropathy. These patients additionally show a high burden of associated comorbidities and thus call for early detection and intervention especially because effective therapy is available. Although screening for microalbuminuria is recommended in the guidelines the value of a routine screening for microalbuminuria in primary care is under recognized.
Asunto(s)
Albuminuria/complicaciones , Enfermedades Cardiovasculares/etiología , Complicaciones de la Diabetes , Hipertensión/complicaciones , Adulto , Factores de Edad , Albuminuria/diagnóstico , Albuminuria/epidemiología , Albuminuria/prevención & control , Antihipertensivos/uso terapéutico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Comorbilidad , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Nefropatías Diabéticas/complicaciones , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/epidemiología , Nefropatías Diabéticas/prevención & control , Femenino , Alemania , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Hipertensión/prevención & control , Masculino , Tamizaje Masivo , Estudios Multicéntricos como Asunto , Guías de Práctica Clínica como Asunto , Prevalencia , Atención Primaria de Salud , Proteinuria/complicaciones , Factores de Riesgo , Factores SexualesRESUMEN
The examination of renal function in the daily practice may give important information on the risk status of a given patient. For example, the diagnosis of microalbuminuria carries high predictive value for a future cardiovascular risk of patients with hypertension, diabetes, congestive heart failure, as well as myocardial infarction. The findings of the Hypertension and Diabetes Screening and Awareness Study (HYDRA) indicate that screening for microalbuminuria is performed not often enough in patients with diabetes or hypertension, respectively, and a positive screening finding often does not trigger necessary consequences as for additional diagnosis or therapy.
Asunto(s)
Albuminuria/diagnóstico , Complicaciones de la Diabetes , Nefropatías Diabéticas , Hipertensión/complicaciones , Adulto , Anciano , Albuminuria/complicaciones , Algoritmos , Enfermedades Cardiovasculares/etiología , Niño , Creatinina/sangre , Diabetes Mellitus/terapia , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/terapia , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/epidemiología , Nefropatías Diabéticas/fisiopatología , Nefropatías Diabéticas/terapia , Femenino , Tasa de Filtración Glomerular , Insuficiencia Cardíaca/etiología , Humanos , Hipertensión/terapia , Pruebas de Función Renal , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Modelos Teóricos , Infarto del Miocardio/etiología , Valor Predictivo de las Pruebas , Proteinuria/diagnóstico , Factores de RiesgoRESUMEN
Hypertension is extremely common in renal allograft recipients, mainly as the result of impaired renal function and cyclosporin A therapy. Blood pressure is a powerful independent predictor of longterm graft outcome. This adverse effect is presumably mediated by both hemodynamic and non-hemodynamic factors. There is also evidence for activation of the renin angiotensin system in the renal allograft. Antihypertensive treatment is of known benefit on graft outcome in experimental models, but this has so far not been documented in clinical trials. Proteinuria is another independent predictor of longterm graft outcome. There is recent documentation of a specific antiproteinuric effect of ACE inhibitors on proteinuria which is of interest since proteinuria is an independent predictor of longterm graft outcome.
Asunto(s)
Hipertensión/etiología , Terapia de Inmunosupresión/efectos adversos , Trasplante de Riñón/efectos adversos , Antihipertensivos/uso terapéutico , Supervivencia de Injerto/efectos de los fármacos , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatologíaRESUMEN
Pulsatile (burstlike) secretion of renin and aldosterone is positively coupled with a short time lag of about 10 to 20 minutes. We investigated how acute interruption of the renin-angiotensin-aldosterone axis, ie, acute angiotensin-converting enzyme (ACE) inhibition, alters the pattern of renin and aldosterone secretion. Eight healthy men (mean age, 22+/-1 years) were studied while on standardized salt intake. They were allocated on 2 occasions in random order to injection of placebo or 1.25 mg of the ACE inhibitor enalaprilat. Blood samples were obtained every 10 minutes for 24 hours for measurement of plasma renin and aldosterone concentrations. The hormone concentration profiles were analyzed using a multiparameter deconvolution technique; basal (tonic) and pulsatile hormone secretion was assessed. The regularity of pulsatile hormone secretion was analyzed using approximate entropy (ApEn). Cross-correlation and cross-ApEn analysis of renin and aldosterone secretion were performed to assess synchrony. Acute ACE inhibition caused an immediate burst of renin release and, in addition, significantly (P<0.01) increased 24-hour pulsatile and total renin secretion. It did not affect basal (nonpulsatile) renin secretion. The amplitude of renin bursts and the mass of hormone secreted per burst were significantly (P<0.01) increased, whereas the burst frequency (ie, number of secretory events) was unchanged. ApEn analysis revealed significantly (P<0.05) more regular renin secretion after ACE inhibition. In contrast, neither basal nor pulsatile aldosterone secretion was affected by administration of enalaprilat. Cross-ApEn analysis documented not only a maintained pattern of reproducibility (ie, synchrony) but also greater conditional regularity between pulsatile renin and aldosterone secretions with acute ACE inhibition. However, the quantitative strength of hormone coupling (assessed by cross-correlation analysis) was markedly diminished by enalaprilat treatment. The present findings suggest that the renin-angiotensin-aldosterone axis may not be completely uncoupled by acute ACE inhibition or that pulsatile renin and aldosterone secretion is driven by a common signal generator that is unaffected by ACE inhibition. In addition, a background basal and pulsatile aldosterone secretion not regulated by the renin-angiotensin axis may exist.