The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) : characterization of the cohort.

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months-ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54+/-19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context.

[Efficiency of D-xilose and triglycerides absorption tests in the investigation of chronic diarrhea]. / Eficiência das provas de absorção da D-xilose e dos triglicérides na investigação da diarréia crônica.

The D-xylose and triglyceride absorption tests have been widely used as screening tests to characterize malabsorption and indicate intestinal biopsy. In this paper we report the efficiency of these tests in the differential diagnosis of the various causes of chronic diarrhea and their possible relationship to jejunal villous atrophy. Two hundred and fifteen children with chronic diarrhea were submitted to the D-xylose and triglyceride absorption tests, and small intestinal biopsy. The patients were divided into 5 groups, that is: I--celiac disease, 53; II--protracted diarrhea, 24; III--environmental enteropathy, 50: IV--celiac disease under gluten free diet, 11; V--irritable bowel syndrome, 77. D-xylose and triglyceride absorption tests were within normal limits in 3.8% and 4.2% patients belonging respectively to groups I and II. On the other hand, only 7.8% of the patients belonging to group V would be included in the group of patients that would have indication for intestinal biopsy, since both tests revealed abnormal results. Moreover, both tests showed an excellent relationship with the intensity of villous atrophy.

[Congential malabsorption of glucose and galactose in 2 brothers]. / Mabsorção congênita de glicose e galactose em dois irmãos.

Congeneeital glucose-galactose malabsorption is a rare clinical entity transmitted by autossomic recessive gen. The defect is in the small intestinal active transport system which is shared by glucose and galactose. Diarrhea and failure to thrive from the first week of life are the prominent symptoms. We report two sibs from consaguineous parents with diarrhea and failure to thrive since they were born. Both children had glucose and galactose malabsorption but tolerated well formula containing fructose as the only source of carbohydrate. They showed flat blood glucose curves when tested with glucose and galactose loads but normal increments of the sugar blood levels with fructose load. The small intestinal biopsy performed in both patients revealed normal villous pattern. When put under a diet containing fructose as the only source of carbohydrate, both patients had their symptoms subsided and reassumed the normal pattern of growth.

[Tropical enteropathy: morphologic and functional changes of the small intestine and their effects on nutritional status]. / Enteropatia tropical: alterações morfológicas e funcionais do intestino delgado e suas repercussões sobre o estado nutricional.

Tropical enteropathy has been described in children and adults that live in developing countries. This disease may be symptomatic or may present without symptoms. We studied 66 patients with tropical enteropathy with special reference to the nutritional status and the intestinal function. The follow-up of the nutritional status revealed that 63 (95.49%) presented current malnutrition. The D-xylose absorption test was significantly lower than those found in the control group. The mean plasmatic triglyceride increment after the margarine load was significantly lower than that found in the control group. Carbohydrate tolerance tests revealed 51.3% lactose malabsorption, 35.07% sucrose malabsorption and 5% glucose malabsorption. Small bowel biopsy showed partial villous atrophy as the most frequent morphological characteristic observed. These children constitute an homogenous group representative of the majority of the population of the Third World.

Absorption of D-xylose in full term newborns adequate for gestational age: prospective study up to third month.

Studies of the D-xylose absorption capacity in newborns are scarce and the results reported are controversial. We evaluated the xylose absorption in full term newborns adequate for gestational age in the first days of life and prospectively up to the third month. D-xylosemia values of the first and second hours at birth and at 3-5 days are significantly lower than on the 15th day at one month and at three months. On the other hand, the values obtained in these last three groups showed no differences among themselves. The comparison of first hour D-xylose values between a control group and those children investigated on the 15th day at one month and at three months, revealed significant differences, but second hour values did not show statistic differences. We concluded that enterocyte absorption capacity is already completely developed at 15 days of life in full term newborns adequate for gestational age.

Qualidade do leite e perfil das propriedades leiteiras no sul de Santa Catarina: abordagem multivariada / Milk quality and profile of dairy farms in southern Santa Catarina: multivariate approach

O objetivo do presente estudo foi caracterizar as propriedades leiteiras da região do Vale do Braço do Norte, sul de Santa Catarina, Brasil, quanto à qualidade do leite e ao perfil em infraestrutura, manejo e alimentação dos animais. Foram coletadas informações de 50 propriedades leiteiras, obtidas por meio da aplicação de um questionário estruturado, abrangendo questões socioeconômicas dos produtores, manejo do rebanho, estrutura da propriedade, caracterização dos animais, alimentação das vacas além de manejo e higiene da ordenha. As amostras de leite foram submetidas a análises de composição, contagem bacteriana total, contagem de células somáticas e estabilidade do leite ao teste do álcool. Os dados foram analisados pela análise fatorial, discriminante, canônica, e de agrupamento. As propriedades têm como principal característica a agricultura familiar, com área média de 30 hectares; destes, 15,1 são destinados à pecuária leiteira, com média de 23,1 vacas ordenhadas. Na análise fatorial, o primeiro fator representa as relações entre as práticas de higiene na ordenha e de controle/prevenção de mastite, o segundo fator compreende a infraestrutura da fazenda com o nível de produção e o terceiro fator demonstra a relação entre a suplementação concentrada, a produção e a estabilidade do leite ao teste do álcool. A análise de agrupamento formou três grupos, sendo dois compostos por produtores com maior nível tecnológico e outro constituído por pequenos produtores com menor infraestrutura e nível de tecnologia. As propriedades que apresentam infraestrutura mais adequada para a produção, maior adoção das práticas recomendadas de manejo de ordenha e critérios de alimentação mais adequados produzem leite com melhor qualidade.

The aim of this study was to characterize the dairy farms of the Vale do Braço do Norte region, south of Santa Catarina State, Brazil, regarding milk quality and profile of the farms for infrastructure, management and nutrition of the animals. Information about 50 dairy farms was obtained through a survey regarding socio-economic conditions of the farmers, farm structure, characterization of animals, cow feeding and also milking management and hygiene. The milk samples were analyzed for total bacterial count, somatic cell count and stability of milk to ethanol. The data were analyzed in factorial, discriminant, canonical and cluster analysis. The main characteristic of farms is family farming with an average area of 30 hectares, of which 15.1 are destined for dairy farming, where an average of 23.1 cows are milked. On the factor analysis, the first factor represents the relation between hygiene practices during milking and control / prevention of mastitis, the second factor comprises the infrastructure of the farm with the level of production and the third factor shows the ratio of concentrate supplementation, production and stability of the milk to the ethanol test. The cluster analysis formed three groups, two composed of producers with higher technological level and another by small producers with lower infrastructure and level of technology. The dairy farms that have more adequate infrastructure for production, greater adoption of practices recommended for milking management and more appropriate criteria for cow feeding produce better quality milk.

Protracted diarrhea in infancy: clinical aspects and ultrastructural analysis of the small intestine.

Protracted diarrhea is a clinical entity characterized by diarrhea lasting greater than 2 weeks, starting before 3 months of age, with severe nutritional aggravation and negative stool culture for enteropathogens. This report deals with the ultrastructural abnormalities found in the intestinal mucosa of children with protracted diarrhea. Forty children (mean age 5.1 months) were studied. They were submitted to the following tests of intestinal function: D-xylose, triglyceride tolerance, small bowel biopsy (light and electron microscope), sigmoidoscopy, and sweat test. D-Xylose absorption and triglyceride tolerance test in these patients were both significantly lower than controls. Ultrastructural analysis of the small bowel of 12 patients showed various degrees of alterations, mainly shortening of the microvilli, increased number of multivesicular bodies, and vacuolation of mitochondria and endoplasmic reticulum. These lesions were totally reversible after clinical and nutritional recovery as could be proven in two children. The most common cause of protracted diarrhea in these patients was secondary carbohydrate intolerance and dietary protein cow's milk and soy bean intolerance, which resulted in colitis or malabsorption as a consequence of intestinal mucosa injury due to acute gastroenteritis.

Giardiasis in childhood and its effects on the small intestine.

The effects of Giardia lamblia on small bowel function were studied. Thirty-three asymptomatic children were studied before and after treatment with metronidazole (Nimorazol). Patients had a small intestinal biopsy, bile salt determinations, and the following absorptive tests: D-xylose, triglyceride, and lactose and sucrose tolerance tests. Before treatment, 87% had unconjugated bile salts in duodenal fluid but afterwards only 60% did. Small bowel biopsy changes did not correlate with the pre- and posttreatment periods. Triglyceride absorption showed significant differences between patients at different periods of the study; D-Xylose absorption did not reveal differences between the periods of the study but was significantly impaired when compared with controls. Lactose malabsorption was detected in 56% and sucrose in 7% of the patients. G. lamblia may have some pathogenic role, although nonspecific to intestinal function. It probably acts more in a synergistic way with other pathogenic agents that inhabit the intestinal lumen of children living under unfavorable conditions producing the picture of tropical enteropathy.

Negative findings for use of coconut water as an oral rehydration solution in childhood diarrhea.

This study reports the chemical composition of coconut water during its maturation. Composition was measured at 5, 6, 7, 8, 9, 10, 11 and 12 months maturation. Concentrations of sodium and glucose, and the osmolality values showed great variation throughout maturation. The concentration of sodium remained constant between the 5th and 7th months (mean 2.9 mEq/l), but increased after the 8th month (mean 12.5 mEq/l). The concentration of glucose remained constant between the 5th and 8th months (mean 3392.4 mg%), but abruptly decreased after the 9th month (mean 820 mg%). Osmolality followed the variation of the glucose concentration averaging 377.3 mOsm/l up to the 8th month, then decreasing to 310.3 mOsm/l after the 9th month. This study showed great variability in coconut water composition during maturation of the fruit. In no instance did the coconut water contain sodium and glucose concentrations of potential value as an oral rehydration solution.

Asymptomatic giardiasis does not affect iron absorption in children with iron deficiency anemia.

OBJECTIVE: Malabsorption of iron has been reported in children with symptomatic giardiasis. The aim of this study was to evaluate intestinal absorption of iron in children with asymptomatic giardiasis and iron deficiency anemia. SUBJECTS: Based upon results of blood hemoglobin and stool examination, two groups were established: asymptomatic giardiasis and anemia, and anemia without intestinal parasitosis (control group). Patients were aged 1-6 years. There was no difference in age, weight, height, or iron nutritional status between the asymptomatic giardiasis and control groups on admission to the study. MEASURES: Intestinal absorption of iron was evaluated using the iron tolerance test and the hemoglobin response to iron therapy. The serum iron tolerance test was based on the increment of iron level 2 hours after administering an iron load of 1 mg/kg of elemental iron in the form of ferrous sulfate, in comparison to the fasting iron level. Hemoglobin response to oral iron therapy was determined by the increment of hemoglobin on day 30 of therapy with ferrous sulfate (5 mg/kg/day of elemental iron). RESULTS: There was no statistical difference between the asymptomatic giardiasis and control groups with reference to the iron tolerance test (159.1 +/- 73.1 micrograms/dl and 154.5 +/- 76.5 micrograms/dl, respectively) and to the hemoglobin response to iron therapy (1.5 +/- 0.7 g/dl and 1.8 +/- 1.1 g/dl, respectively). The presence or absence of trophozoites of Giardia lamblia on duodenal aspirate did not affect intestinal absorption of iron. CONCLUSION: Asymptomatic giardiasis did not affect the intestinal absorption of iron and the hemoglobin response to oral iron therapy in iron-deficient anemic children.

Absorcao da D-Xilose em recem-nascidos de termo adequados para a idade gestacional: estudo prospectivo ate o terceiro mes. / D-xylose absorption in full term newborn infants adequate for gestacional age: prospective study up to the third month

Estudos da capacidade de absorcao da D-xilose em recem-nascidos, sao escassos e os resultados sao contraditorios. Avaliamos a capacidade de absorcao da D-xilose em recem-nascidos de termo adequados para a idade gestacional no primeiros dias de vida e acompanhamos prospectivamente os niveis de maturacao do enterocito ate o terceiro mes. Os valores da D-xilosemia de primeira e segunda horas ao nascimento e aos 3-5 dias sao significativamente inferiores aos observados aos 15 dias, um mes e tres meses. Por outro lado, os valores obtidos nestes tres ultimos grupos nao apresentam diferencas significativas entre si. A comparacao da D-xilosemia de primeira hora entre grupo-controle e aquelas investigadas aos 15 dias, um mes e tres meses revela diferencas significativas, mas os valores de segunda hora nao apresentam diferencas significativas. Concluimos que a capacidade de absorcao do enterocito provavelmente ja se encontra plenamente desenvolvida aos 15 dias de vida em recem-nascidos de termo adequados para a idade gestacional

Diarreia protraida. I. Aspectos clinicos e funcionais do intestino delgado. / Protracted diarrhea. I. Clinical and functional aspects of the small intestine

Diarreia protraida e uma entidade clinica caracterizada por diarreia de mais de duas semanas, com inicio anterior aos tres meses de vida e intenso agravo nutricional e coprocultura negativa para bacterias enteropatogenicas. Neste trabalho estudamos 40 criancas com idade media de 5,1 meses que foram submetidas aos seguintes procedimentos: teste de absorcao da D-xilose, teste de sobrecarga de triglicerides, biopsia de intestino delgado, sigmoidoscopia e teste do suor. O teste de absorcao da D-xilose revelou: 1a. h - 19,5 +/- 10,6 mg% e 2a.19,5 +/- 9,6 mg%; o teste de sobrecarga de triglicerides revelou um incremento plasmatico medio de 25,6 +/- 14,2 mg%, ambos os testes significativamente mais baixos que o encontrado em controles (p < 0,001).Intolerancia secundaria aos carboidratos e intolerancia as proteinas da dieta (leite de vaca e soja) tanto como colite ou malabsorcao foram as causas mais comuns de diarreia protraida

Enteropatia tropical: alteracoes morfologicas e funcionais do intestino delgado e suas repercussoes sobre o estado nutricional.

Enteropatia tropical foi o termo introduzido para caracterizar individuos que vivem nos paises subdesenvolvidos e que apresentam anormalidades histologicas da mucosa jejunal e/ou alteracoes nos testes de absorcao. Foram estudados 66 pacientes portadores dessa afeccao com o objetivo de aferir possiveis alteracoes morfologicas e funcionais do intestino delgado associadas ao estado nutricional, que se revelou em 95,43% das criancas. O teste da D-xilosemia pos-absorcao revelou valores significativamente mais baixos que os encontrados em criancas normais. O incremento medio na concentracao plasmatica dos triglicerides, apos a sobrecarga de margarina, mostrou-se significativamente inferior ao do grupo controle. Os testes de sobrecarga de carboidratos, revelam intolerancia a lactose em 51,3% dos casos, a sacarose em 35,07% e a glicose em 5,0% Biopsia jejunal revelou distintos graus de alteracoes morfologicas, sendo a atrofia vilositaria parcial o padrao mais comum. O grupo de criancas estudado constituiu, no seu todo, um grupo homogeneo, representativo de populacoes carentes

Mabsorcao congenita de glicose e galactose em dois irmaos. / Congenital malabsorption of glucose and galactose in 2 brothers

Mabsorcao congenita de glicose-galactose e uma entidade clinica rara transmitida por um gene autossomico recessivo. O defeito absortivo encontra-se localizado no sistema de transporte ativo do intestino delgado que e utilizado igualmente pela glicose e pela galactose. Diarreia e parada de crescimento, desde as primeiras semanas de vida,constituem os sintomas mais proeminentes. Descrevemos dois irmaos, filhos de pais consaguineos, que apresentavam diarreia e parada de crescimento, desde o nascimento. Ambas as criancas apresentavam mabsorcao de glicose, e galactose, mas revelaram completa tolerancia a formula contendo frutos como unica fonte de carboidrato. Eles apresentaram curvas glicemicas planas quando submetidos a teste de tolerancia a glicose e galactose; por outro lado, os incrementos dos niveis glicemicos foram normais apos sobrecarga com frutos.Biopsia do intestino delgado realizada em ambos os pacientes evidenciou mucosa do intestino delgado compativel com os padroes de normalidade. Os pacientes, quando submetidos a dieta contendo frutose, como unica fonte de carboidratos, apresentaram remissao completa dos sintomas e retomaram seus ritmos normais de crescimento

Sindrome colestatica prolongada do lactante jovem. Estudo de 57 casos. / Prolonged cholestatic syndrome in the infant: study of 57 cases

O diagnostico etiologico da colestase prolongada do neonato e do lactante jovem continua sendo um dos grandes desafios em Pediatria. Relatamos nossa experiencia durante sete anos e seis meses estudando 57 criancas com sindrome icterico-colestatica Atresia de vias biliares foi diagnosticada em 10 pacientes e cisto de coledoco em um.Hepatite sensu lato foi caracterizada nos 46 pacientes. A etiologia da afeccao hepatica foi identificada em 13 (28,3%) dos casos, a saber: infeccao urinaria (5), sifilis (3), deficiencia de alfa 1 antitripsina (1), hepatite HBsAg (1), rubeola congenita (1), toxoplasmose congenita (1) e hepatoma (1). Salientamos a necessidade de um seguimento rigoroso dos pacientes portadores de hepatite neonatal porque ha evidencias de que um numero consideravel deles apresentava evolucao para cronicidade

Comparaçäo terapêutica entre o sulfato ferroso e o ferro trivalente em forma de complexo de hidróxido férrico polimaltosado na deficiência orgânica de ferro / Therapeutic comparison between ferrous sulfate and trivalent iron in form of polymaltosed ferric hydroxide complex in organic iron deficiency

Com o objetivo de estudar os efeitos terapêuticos do Hidróxido Férrico Polimaltosado, em crianças com deficiência orgânica de ferro, com anemia, realizou-se ensaio duplo-cego, comparativo entre o sal férrico e o sulfato ferroso como substância de referência. O Hidróxido de Ferro III Polimaltosado e o Sulfato Ferroso foram administrados na forma de xarope, sendo impossível distingui-los física e organolepticamente. De 30 crianças pré-escolares de ambos os sexos, 22 terminaram o período de 60 dias de observaçäo terapêutica, usando a dose de 4 mg de Fe elementar por kg de peso, por dia, via oral. Os dois grupos observados apresentaram características demográficas, nutricionais, estato-ponderais, clínicas e laboratoriais similares. As crianças eram avaliadas clínica e laboratorialmente antes do início e a cada 15 dias, durante os 2 meses de tratamento. As 12 crianças (8 meninos) tratadas com Fe III tinham média de idade de 31 meses, sendo 7 eutróficos e 5 D.P.C. 1§ grau (Critério de Gomez). O grupo controle constituiu-se de 10 crianças (dois meninos) com média etária de 33 meses, sendo 5 eutróficos e 5 D.P.C. 1§ grau. Na análise dos resultados observou-se que, após o tratamento, os dois grupos apresentaram normalizaçäo dos parâmetros inicialmente alterados. O estudo dos valores iniciais e finais de cada grupo em separado, utilizando-se o teste "t" pareado, demonstrou aumento significativo (p<0,05) da ferritina, hemoglobina e do ferro sérico, em ambos os grupos. O incremento médio do peso das crianças tratadas com Fe III foi discretamente superior ao grupo controle (diferença näo significante). A tolerabilidade foi boa para os dois medicamentos, no entanto 30% das crianças tratadas com sulfato ferroso, apresentaram manchas enegrecidas nos dentes, o que näo ocorreu com o Fe III

Absortion of D-xilose in full term newborns adequate for gestational age prospective study up to third month

Os estudos sobre a capacidade de absorcao da D-xilose em recem-nascido sao escassos e os seus resultados sujeitos a controversias. Os autores avaliaram a absorcao da D-xilose em recem-nascido de termo, adequados para a idade gestacionall, nos primeiros dias de vida e prospectivamente ate o terceiro mes. Os valores da D-xilosemia para as primeiras e segundas horas apos o nascimento e tres a cinco dias apos, foram significativamente menores do que do decimo quinto dia, com um e tres meses de vida. Por outro lado, os valores obtidos nestes tres ultimos grupos nao revelam diferencas entre si. A comparacao dos valores de D-xilose da primeira hora, entre o grupo de controle e as criancas investigadas no decimo quinto dia com um e tres meses, revelaram diferencas significativas, porem os valores da segunda hora nao mostraram diferencas estatisticamente significantes. Os autores concluem que a capacidade de absorcao do enterocito ja se encontra completamente desenvolvida no decimo quinto dia de vida em recem-nascidos de termo, adequados para a idade gestacional

Symptomatic environmental enteropathy in infancy: bacterial proliferation, funcional and morphological alterations of the small bowel

Asymptomatic Environmental enteropathy may occur in the low social economic stratum of the population temporarily, thus contributing to marginal malnutrition. Bacterial proliferation in the upper portions of the small bowel may be responsible for alterations in the digestive-absorptive function leading to nutritional dwarfism. Forty infants of the Cidade Leonor slum who were under one year of age and presented with asymptomatic environmental enteropathy were investigated for digestive-absorptive function, bacterial proliferation in the small bowel lumen, and jejunal morphology. The mean value of the D-xylose absorption test was 21.0 ñ 10.0 mg per cent, significantly lower than controls (48.0 ñ 13.8 mg per cent) (p < 0.001). Bacterial proliferation in the small bowel of the colonic type was identified in 25 (62,5 per cent) of the infants and jejunal mucosa abnormalities were found in 29(72.5 per cent) of the specimens. Grade II villous atrophy was the most frequent alteration found. The inflammatory infiltration in the lamina propria increased in the total group, varying from light to severe. Alterations in the microecology of the small intestine can occur even in the absence of diarrhea. Therefore, the nonexistence of symptoms does not necessarily imply a condition of weillbeing. If true measures are proposed to improve the quality of life in these poor communities the whole infant population must be taken into account and not only the group with overt symptoms