Bilateral nephrectomy of huge polycystic kidneys associated with a rectus abdominis diastasis and umbilical hernia.

BACKGROUND: Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision. METHODS: Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia. RESULTS: The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome. CONCLUSION: A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.

The relationship between ultrafiltrate volume with icodextrin and peritoneal transport pattern according to the peritoneal equilibration test.

OBJECTIVE: To establish a relationship between peritoneal transport membrane pattern, analyzed by the peritoneal equilibration test (PET), and drained volume using icodextrin (7.5% Ico) and glucose (3.86% Glu) solutions. DESIGN: Thirty peritoneal dialysis patients were submitted to a standard 4-hour PET and divided into 4 transport categories based on dialysate-to-plasma ratio of creatinine (D/Pcr) and dialysate ratio of glucose at 4 and zero hours of the dwell (D4/D0). Patients were asked to perform exchanges for 2 consecutive nights in 10-hour dwells (2 L 3.86% Glu solution on the first night, and 2 L 7.5% Ico solution on the second night). The drained volume was measured and dialysate samples from the overnight exchanges were obtained for beta2-microglobulin (B2M) levels. RESULTS: PET classification using D/Pcr showed that 46.6% of the patients were high and high-average transporters, or 23.3% when D4/D0 was used. In spite of this difference, both methods showed significant correlation (p = 0.0001, r = 0.862). The mean drained volumes were similar for both solutions (for 3.86% Glu, 2696 +/- 369 mL; for 7.5% Ico, 2654 +/- 424 mL). The high and high-average transport patients classified by D4/D0 achieved a higher ultrafiltration with 7.5% Ico than with 3.86% Glu (p = 0.0235). When classified by D/Pcr, the difference was not significant (p = 0.2243). In the low and low-average transport patients classified by D/Pcr, we observed a significantly lower ultrafiltration when 7.5% Ico was used compared to 3.86% Glu solution (p = 0.0197). Using D4/D0, we saw a tendency toward lower ultrafiltration (p = 0.0719) in the same group. We then correlated the PET results and the difference between drained volume with 7.5% Ico and 3.86% Glu solution [deltaV (I-G)]. We found a significant negative correlation between D4/D0 and deltaV (I-G) (p = 0.002, r = -0.5390), and a positive correlation between D/Pcr and deltaV (I-G) (p = 0.005, r = 0.4932). The levels of B2M obtained with 7.5% Ico were higher than those obtained with 3.86% Glu solution (for 7.5% Ico, 9.47 +/- 6.71 microg/vol; for 3.86% Glu, 7.29 +/- 4.91 microg/vol; p = 0.004). Furthermore, we found significant correlation between the total amount of B2M obtained with 7.5% Ico solution and D4/D0 (p < 0.0001, r = -0.4493), and D/Pcr (p < 0.0001, r = 0.5431). CONCLUSION: Mean drained volume was similar between the two solution groups. High transporters, as defined by D4/D0, achieved higher ultrafiltration with 7.5% Ico than with 3.86% Glu solution. This is most likely due to the higher number of small pores in the peritoneal membrane. Low transporters, as classified by D/Pcr, achieved lower ultrafiltration with 7.5% Ico than with 3.86% Glu solution. The deltaV (I-G) and the PET results showed significant correlation, confirming that high transporters have a higher ultrafiltration volume with 7.5% Ico. The total B2M mass obtained with 7.5% Ico was greater than with 3.86% Glu solution and significantly higher in the high transport patients, indicating a larger number of small pores. Thus, the deltaV (I-G) could give us an idea of the peritoneal transport pattern in peritoneal dialysis patients.

Kidney transplantation in Brazil and its geographic disparity.

The Brazilian National Transplantation System coordinates and regulates perhaps the largest public transplantation program worldwide. Since its implementation in 1997, the number of kidney transplantations increased from 920 (5.8 pmp) in 1998, to 4,630 (24.1 pmp) in 2010. This growth was primarily due to the increased number of effective donors (from 1.8 pmp in 1998 to 9.3 pmp in 2010), with a corresponding increased number of kidneys transplanted from deceased donors (3.8 pmp in 1999 versus 9.9 pmp in 2010).The number of kidney transplantations from living donors has not increased significantly, from 1,065 (6.7 pmp) in 1998 to 1,641 (8.6 pmp) in 2010, either as a consequence of the observed increase in the deceased donor program or perhaps because of strict government regulations allowing only transplantations from related donors. From 2000 to 2009, the mean age of living donors increased from 40 to 45 years, while it increased from 33 to 41 years for deceased donors, of whom roughly 50% die of stroke. There are clear regional disparities in transplantation performance across the national regions. While the state of São Paulo is ranked first in organ donation and recovery (22.5 pmp), some states of the Northern region have much poorer performances. These disparities are directly related to different regional population densities, gross domestic product distribution, and number of trained transplantation physicians. The initial evaluation of the centers with robust outcomes indicates no clear differences in graft survival in comparison with centers in the USA and Europe. Ethnicity and time on dialysis, but not the type of immunosuppressive regimen, decisively influence the measured outcomes. Since the implementation of national clinical research regulations in 1996, Brazilian centers have participated in a number of national and international collaborative trials for the development of immunosuppressive regimens. Besides the challenge of reducing the regional disparities related to access to transplantation, further improvements can be obtained by the creation of a national registry of the outcomes of transplanted patients and living donors, and also by the promotion of clinical and experimental studies to better understand the transplantation-related immune response of the Brazilian population.

Renal cell carcinoma in renal transplant patients.

OBJECTIVES: To report our experience with renal cell carcinoma in patients with end-stage renal failure receiving dialysis at two institutions that perform a large number of transplantations. Renal cell carcinoma is more frequent in patients with end-stage renal failure treated with dialysis and in renal transplant patients than in the population at large. METHODS: We reviewed the case histories of 1375 consecutive patients who had transplanted kidneys functioning for more than 1 year. RESULTS: Eleven renal tumors were found in 10 patients (1.37%); 10 of the tumors (90%) were in the native kidney (9 unilateral and 1 bilateral) and 1 (10%) was in the transplanted kidney. The tumors in the native kidneys were discovered incidentally. Three were in organs removed for treatment of arterial hypertension and the other seven were found by ultrasonography. The tumor in the transplanted kidney was found after nephrectomy for the treatment of hematuria. The tumor types were clear cell in six, papillary in four, and chromophobe in one. Of the 9 patients who were treated with radical nephrectomy, 7 were alive with no evidence of the disease and 2 had died of other causes, also with no evidence of the disease. One patient who already had metastases at the diagnosis did not undergo surgery and died 4 months later. CONCLUSIONS: The native kidneys of renal transplant patients should be examined by ultrasonography annually because they are at greater risk of renal cell carcinoma. Radical nephrectomy cures those cases in which the tumors are clinically localized and 6 cm or less in size.

O contexto do transplante renal no Brasil e sua disparidade geográfica / Kidney transplantation in Brazil and its geographic disparity

O Sistema Nacional de Transplantes (SNT) Brasileiro coordena e regulamenta o, provavelmente, maior programa de transplantes públicos do mundo. Desde o seu estabelecimento, em 1997, o número de transplantes renais aumentou de 920 (5,8 pmp), em 1988, para 4.630 (24,1 pmp), em 2010. Esse crescimento foi primariamente devido ao aumento no número de doadores efetivos (de 1,8 pmp em 1998 para 9,3 pmp em 2010), com aumento correspondente no número de rins transplantados de doadores falecidos (3,8 pmp em 1999 versus 9,9 pmp em 2010). O número de rins transplantados com órgãos de doadores vivos não aumentou significativamente, 1.065 (6,7 pmp), em 1998, para 1.641 (8,6 pmp), em 2010, tanto em consequência do melhor desempenho do programa de doadores falecidos, como talvez também devido a mais restrita regulamentação, permitindo apenas doação entre doadores vivos relacionados. De 2000 a 2009, a idade média dos doadores vivos aumentou de 40 para 45 anos, e a dos doadores falecidos, de 33 para 41 anos, com eventos cerebrovasculares sendo responsáveis por 50 por cento dos episódios de óbito atualmente. Existem disparidades geográficas evidentes nos desempenhos entre as 5 regiões nacionais. Enquanto o estado de São Paulo ocupa a primeira posição em doação e captação de órgãos (22,5 pmp), alguns estados da região Norte apresentam pequena ou nenhuma atividade de transplante. Essas disparidades estão diretamente relacionadas à densidade populacional regional, ao produto interno bruto e ao número de médicos com treinamento em transplante. A avaliação inicial de desfechos clínicos robustos não indica diferenças nas sobrevidas do enxerto em comparação com as observadas nos EUA e na Europa. A etnia e o tempo em diálise, mas não o tipo de imunossupressão, apresentam influência decisiva nos desfechos medidos. A regulamentação nacional da pesquisa clínica foi implementada a partir de 1996, permitindo a participação de centros brasileiros em numerosos estudos clínicos nacionais e internacionais para o desenvolvimento de regimes imunossupressores. Acompanhando o desafio de atenuar as disparidades regionais no acesso ao transplante, o sistema pode ser aperfeiçoado pela criação de um registro nacional para receptores de transplante e de doadores vivos de rins e também pela promoção de estudos clínicos e experimentais voltados a melhor compreender a resposta imune relacionada ao transplante em nossa população.

The Brazilian National Transplantation System coordinates and regulates perhaps the largest public transplantation program worldwide. Since its implementation in 1997, the number of kidney transplantations increased from 920 (5.8 pmp) in 1998, to 4,630 (24.1 pmp) in 2010. This growth was primarily due to the increased number of effective donors (from 1.8 pmp in 1998 to 9.3 pmp in 2010), with a corresponding increased number of kidneys transplanted from deceased donors (3.8 pmp in 1999 versus 9.9 pmp in 2010).The number of kidney transplantations from living donors has not increased significantly, from 1,065 (6.7 pmp) in 1998 to 1,641 (8.6 pmp) in 2010, either as a consequence of the observed increase in the deceased donor program or perhaps because of strict government regulations allowing only transplantations from related donors. From 2000 to 2009, the mean age of living donors increased from 40 to 45 years, while it increased from 33 to 41 years for deceased donors, of whom roughly 50 percent die of stroke. There are clear regional disparities in transplantation performance across the national regions. While the state of São Paulo is ranked first in organ donation and recovery (22.5 pmp), some states of the Northern region have much poorer performances. These disparities are directly related to different regional population densities, gross domestic product distribution, and number of trained transplantation physicians. The initial evaluation of the centers with robust outcomes indicates no clear differences in graft survival in comparison with centers in the USA and Europe. Ethnicity and time on dialysis, but not the type of immunosuppressive regimen, decisively influence the measured outcomes. Since the implementation of national clinical research regulations in 1996, Brazilian centers have participated in a number of national and international collaborative trials for the development of immunosuppressive regimens. Besides the challenge of reducing the regional disparities related to access to transplantation, further improvements can be obtained by the creation of a national registry of the outcomes of transplanted patients and living donors, and also by the promotion of clinical and experimental studies to better understand the transplantation-related immune response of the Brazilian population.

Coronary angiography is the best predictor of events in renal transplant candidates compared with noninvasive testing.

Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (>or=70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (>or=50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were <75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (P=0.007) and CA (P=0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with <70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with >or=70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (P=0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised.

O contexto do transplante de órgãos no Brasil em 2011 / The context of organ transplantation in Brazil in 2011

O Sistema Nacional de Transplantes (SNT) brasileiro coordena e regulamenta o maior programa de transplantes público do mundo. Com o seu estabelecimento, em 1997, o número de transplantes renais aumentou de 920 (5,8 por milhão de população - pmp), em 1998, para 4.957 (26 pmp) em 2011. Existem disparidades geográficas evidentes nos desempenhos entre as cinco regiões nacionais. Estas disparidades são diretamente relacionadas à densidade populacional regional, ao produto interno bruto e ao número de médicos com treinamento em transplante. Acompanhando o desafio de atenuar as disparidades regionais no acesso ao transplante, o sistema pode ser aperfeiçoado pela criação de um registro nacional para receptores de transplante e de doadores vivos de rim, e também pela promoção de estudos clínicos e experimentais voltados a melhor compreender a resposta imune relacionada ao transplante em nossa população.

The Brazilian National Tranplant System (SNT) coordinates and regulates perhaps the largest public transplant program worldwide. Since its establishment in 1997, the number of kidney transplants increased from 920 (5.8 pmp) in 1998 to 4,957 (26 pmp) in 2011. There are clear regional disparities in performance across all national regions. These disparities are directly related to regional population density, gross domestic product, and number of tranplant physicians. Besides the challenge of reducing the regional disparities related to the access to transplantation, it can be further improved by creating a national outcome registry for transplant recipient and for living kidney donors, and also by promoting clinical and experimental studies aimed to better understand the immune response related to transplantation in our population.

Bilateral nephrectomy of huge polycystic kidneys associated with a rectus abdominis diastasis and umbilical hernia / Nefrectomia bilateral para doença renal policística gigante associada à diástase do reto abdominal e hérnia umbilical

BACKGROUND: Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision. METHODS: Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia. RESULTS: The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome. CONCLUSION: A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.

INTRODUÇÃO: Pacientes com insuficiência renal terminal por Doença Renal Policística Autossômica Dominante geralmente apresentam hérnia umbilical e diástase de músculo reto abdominal, que são muito problemáticas. Técnicas de nefrectomia bilateral pré-transplante não dão atenção à hérnia umbilical e à diástase do músculo reto abdominal. Relatamos nossa experiência com nefrectomia bilateral e correção da diastase de músculo reto abdominal e hérnia umbilical através de uma única pequena incisão. MÉTODOS: Quatro pacientes com idade entre 37 a 43 anos com Doença Renal Policística Autossômica Dominante gigante, hérnia umbilical e diástase do múculo reto abdominal foram submetidos à nefrectomia bilateral pré-transplante através de incisão mediana supra-umbilical incluindo o defeito herniário umbilical. Os rins foram removidos através da pequena incisão mediana. A incisão foi fechada com transposição do músculo reto abdominal tipo jaquetão para corrigir a diastase e a hernia umbilical. RESULTADOS: O tempo operatório médio foi 160 minutos (130-180); o tamanho médio do maior rim foi 33cm (32-34); não ocorreram grandes complicações; um paciente, que tinha baixo nível de hemoglobina pré-operatório e precisou de transfusão sangüínea. Pacientes receberam alta hospitalar no 7° pós-operatório com abdome de boa aparência, sem diástase de músculo reto abdominal e sem hérnia umbilical. Os pacientes receberam enxerto renal de doador vivo um ou dois meses após a nefrectomia bilateral, sem intercorrências. CONCLUSÃO: A incisão mediana supra-umbilical é uma abordagem excelente para nefrectomia bilateral de rins policísticos gigantes. Além disso, a hernia umbilical e a diastase de músculo reto abdominal podem ser corrigidas com sucesso pela mesma incisão, com bons resultados cosméticos.

Tratamento da eritrocitose pós-transplante renal com bloqueadores da enzima de conversäo / Treatment of erythocytosis post kidney transplantation with blocking converting-enzyme

Os autores administraram captopril a 21 pacientes transplantados de rim, com funçäo renal normal e eritrocitose (hematócrito > 50 por cento e hemoglobina > 16,3 g/dl) e a 12 pacientes igualmente transplantados de rim, com funçäo renal normal e sem eritrocitose. Após 2 meses de tratamento, houve queda estatisticamente significativa do hematócrito (56,1 + 3,9 para 47,8 + 3,6 por cento; p<0,0001) e da hemoglobina (18,2 + 1,3 para 15,4 + 1,3 g/dl; p<0,0001) no grupo com eritrocitose; a manutençäo da terapia näo provocou anemia neste grupo. A interrupçäo em 4 pacientes provocou recorrência da eritrocitose, havendo resposta favorável após a reintroduçäo do captopril. No grupo normoglobúlico näo houve queda significativa dos níveis de hematócrito (43,0 + 3,8 para 43,1 + 4,4 g/dl; p=0,8944) e de hemoglobina (13,6 + 1,3 para 13,6 + 1,4 por cento; p=0,9311). Os pacientes que necessitaram manter a terapia com captopril por tempo mais prolongado näo apresentaram anemia. Concluímos que o uso de captopril constitui terapia eficaz, segura e livre de efeitos colaterais para a eritrocitose pós-transplante renal. Por outro lado, seu uso em pacientes normoglobúlicos näo provoca anemia.

Seasonal variation of blood pressure in maintenance hemodialysis

Context: Seasonal variation in arterial blood pressure has been reported in studies with hypertensive and normotensive subjects. However, the influence of seasonal change on blood pressure of hemodialysis patients has not been reported. Objective: To investigate the seasonal variation of blood pressure in Brazil, a tropical country, in patients on hemodialysis. Design: Prospective, cohort study. Setting: Dialysis unit of a tertiary medical center (a teaching hospital of the University of Sao Paulo School of Medicine, Sao Paulo). Patients: Sixteen patients with chronic renal failure undergoing hemodialysis. Outcomes: blood pressure, body weight, and ambient temperature were evaluated during 6 hemodialysis sessions carried out on 13 days during the four seasons. Results: The diastolic blood pressure was lower in summer than in fall and winter (95 + 8 vs 107 + 10 and 101 + 10 mmHg, respectively; p < 0.05). The same was observed with mean blood pressure (116 + 8 vs 130 + 11 and 124 + 9 mmHg, respectively; p < 0.01). On the other hand, the ambient temperature was higher in summer than in fall and winter (23.0 + 1.6 vs 19.5 + 3.0 and 15.8 + 1.9 degrees Celsius, respectively; p < 0.01). Conclusions: We concluded that for patients with chronic renal failure the blood pressure has a seasonal variation with higher pressures in fall and winter than in summer. Thus, further studies are needed to elucidate the impact of this observation on the adjustment of antihypertensive treatment and on morbidity and mortality in maintenance dialysis patients.

Choque cardiogênico irreversível após captopril em portador de insuficiência cardíaca congestiva refrataria. Relato de caso / Irreversible cardiogenic shock after captopril in patient with refractory congestive cardiac insufficiency. Report of a case

Os autores relatam a evolucao de um paciente com insuficiencia cardiaca congestiva de dificil controle, que apresentou hipotensao arterial grave e fibrilacao ventricular irreversivel apos uma unica dose oral de 25 mg de captopril. Discutem o uso de vasodilatadores como auxiliares terapeuticos em pacientes portadores de insuficiencia cardiaca congestiva refrataria

Preparo de vegetais para utilização em dieta restrita em potássio / Vegetables for low potassium diet

O presente estudo teve como objetivo analisar comparativamente a concentração de potássio em vegetais após uma e duas cocções, para utilização em dieta restrita em potássio. Para tanto, determinou-se a concentração de potássio po fotometria de chama em 10 amostras de 50g de 17 alimentos crus, cozidos uma vez em 500mL de água e cozidos uma segunda vez no mesmo volume de água, após desprezar-se a água da primeira cocção. Em comparação aos alimentos crus, a concentração de potássio reduziu significativamente após a primeira cocção, em média 59 por cento, e 20 por cento adicionalmente na segunda cocção. A perda total média de potássio após as duas cocções foi de 79 por cento...

Endolymphatic irradiation in preparation for renal transplantation: a 26-year follow-up

The aim of the present study was to analyze the long-term evolution of patients submitted to endolymphatic irradiation as a pre-transplant preparation. Setting: Referral center of university hospital. Design: Case-control study. Main outcomes measures: The study was designed to evaluate the incidence of rejection, kidney loss, leukopenia, infection, and graft survival in the group treated (group 1) prior to surgery, compared to a control group (group 2) composed of patients under identical clinical conditions (Sex, age, type of donor, immunosuppresive therapy and time of transplant) that did not undergo treatment preparation. Patients: Patients were selected from amongst transplatation candidates on a long-term waiting list, some with a high level of antibodies against panel. The control group was chosen from amongst recently transplanted patients. Patients in the treated group received lipoidine containing I with specific activity ranging between 4 and 6 mCu/ml. Results: A significant difference between the two groups was found with regard to the incidence of rejection crises (21.0 per cent in group 1 and 73.6 per cent in group 2; P=0.003), and the maintenance dose of azathioprine (smaller in group 1; P<0.01). As to kidney graft loss due to rejection, a tendency to significance could be identified (10.5 per cent in group 1 and 42.1 per cent in group 2; P=0.063); however, the difference was not significant the two groups in terms of reversibility of rejection episodes during the first 60 post-transplant days. Conclusions: The authors concluded that this method, besides being relatively innocuous (there was no compromising of either the thyroid gland or of gonad function and there was no increase in tumor incidence), has na extended immunosuppressive effect, and can be indicated for cadaveric renal allograft recipients, especially those showing high panel reactivity.

Tempo ideal pós-diálise para dosagem da uréia em diálise de alto fluxo e alta eficiência: importância do rebote da uréia no cálculo do Kt/V / POst-dialysis ideal time for urea dosage in dialysis of flow and frequency hight: importance of the urea rebound in Kt/V calculi

O Kt/V de uréia é um dos métodos mais utilizados para adequaçao da hemodiálise. Entretanto, esse índice se baseia na distribuiçao da uréia em um único compartimento e nao leva em consideraçao o rebote da uréia pós-diálise. Nesse sentido, analisamos o rebote de uréia em nove pacientes em hemodiálise de alto fluxo e alta eficiência, com o objetivo de determinar o tempo ideal para a coleta da amostra de uréia pós-diálise. Nossos resultados revelaram que aos 20 minutos após o término da hemodiálise o rebote da uréia já está praticamente completo. Conseqüentemente, esta informaçao permite concluir que, após esse intervalo, dosagens subseqüentes de uréia nao irao superestimar o Kt/V.

Infecçäo por Listeria monocytogenes pós-transplante renal: relato de seis casos / Infection by Listeria monocytogenes following renal transplantation: report of 6 cases

Säo relatados 6 casos de listeriose em pacientes transplantados renais, que ocorreram entre 13 dias e 57 meses após iniciarem imunossupressäo clássica, sendo 3 casos classificados como meningite, 2 casos como meningoencefalite e 1 caso como bacteremia. Houve um óbito e os 5 pacientes restantes apresentaram boa evoluçäo. Com dados adicionais da literatura, säo discutidos a epidemiologia, o diagnóstico e tratamento, da listeriose pós-transplante renal

Tuberculosis in renal transplant patients

Tuberculose (TB) foi diagnosticada em 25 de 466 pacientes submetidos a transplante renal. A TB surgiu entre 1 mês e 9 anos pós-transplante. O pulmäo foi acometido em 76% dos casos, isoladamente (56%), ou associado a outras localizaçöes (20%). Os outros órgäos envolvidos foram: pele, articulaçöes, testículos, trato urinário, sistema nervoso central e linfonodos. O diagnóstico foi confirmado por biópsia em 64% dos casos, pela identificaçäo do bacilo em 24% e apenas à necrópsia em 12%. Três formas histológicas foram identificadas: exudativa (nos casos de aparecimento precoce e de maior gravidade) granulomatosa (naqueles benignos e de aparecimento tardio) e mista (naqueles intermediários). As doses de azotioprina foram constantes ao longo do período pós-transplante, tanto no grupo tyberculoso como no controle, bem como nos pacientes tuberculosos que faleceram e que se curaram. O número de crises de rejeiçäo tratadas foi maior no grupo TB do que no grupo controle. As doses de prednisoma e o número de crises de rejeiçäo foram maiores nos pacientes tuberculosos que faleceram do que naqueles que sobreviveram. Quinze pacientes se curaram e 10 faleceram, oito de causas relacionadas à TB. Seis destes óbitos ocorreram nos 6 primeiros meses pós-transplante. Em um paciente a TB foi transmitida pelo enxerto

Detecçäo de anticorpos IgM nas infecçöes primárias e secundárias pelo citomegalovírus em pacientes submetidos a transplante renal / IGM antibodies detection in primary and secundary cytomegalovirus infections in patients submeted a renal transplantation

Foram acompanhados 27 pacientes submetidos a transplante renal para avaliaçäo do comportamento dos anticorpos IgM e IgG CMV-específicos. Dos 27 casos estudados, 17 (63,0%) tinham anticorpos IgG, detectados pela reaçäo de fixaçäo de complemento (RFC), antes de serem submetidos ao transplante, e 10 (37,0%) eram soro negativos. A pesquisa de anticorpos IgM (técnica de imunofluorescência indireta) foi negativa em todas as amostras pré-transplante. Num período de acompanhamento que variou de 28 a 425 dias (média de 115 dias) após o transplante, observou-se que 20 dos 27 (74,1%) apresentaram evidências sorológicas de infecçäo pelo CMV, ocorrendo a maioria dos casos (14/20,70%) em pacientes que já tinham anticorpos para o CMV antes do transplante. A pesquisa de anticorpos IgM CMV-específicos foi positiva em 12 dos 14 pacientes com evidências sorológicas de reinfecçäo ou reativaçäo da infecçäo pelo CMV, e em 100% (6/6) dos pacientes com infecçäo primária. Dentre os 10 pacientes acompanhados por mais de 4 meses, somente 1 (10%) negativou o IgM neste período

Peritonite esclerosante e encapsulante secundária à diálise peritoneal ambulatorial contínua / sclerosing encapsulating peritonitis secundary by the continuous ambulatory peritoneal dialysis

A diálise peritoneal ambulatorial contínua (DPAC) é uma modalidade terapêutca eficiente para o tratamento da insuficiência renal crônica. A peritonite esclerosante e encapsulante (PEE) é uma conplicaçäo rara e grave da DPAC, associada com alta taxa de mortalidade e que ocorre, geralmente, após um tempo prolongado em tratamento complicado com episódios graves e recorrentes de peritonites. Relatamos três casos de PEE, entre 222 pacientes sob DPAC no Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo, no período de 1984 e 1997, diagnosticados nos últimos 3 anos: dois casos do sexo feminino e um, do masculino, com tempo médio em DPAC de 55,3 meses e média de 4,3 episódios de peritonite. Os três pacientes apresentaram quadro clínico de obstruçäo intestinal e dois deles usavam B-bloqueador. Enfocamos a necessidade de prevençäo da PEE, o diagnóstico precoce e as recentes opçöes terapêuticas para reduçäo de sua morbidade e de sua mortalidade.(au)

Hyperhomocyst(e)inemia in chronic stable renal transplant patients

PURPOSE: Hyperhomocyst(e)inaemia is an important risk factor for atherosclerosis, which is currently a major cause of death in renal transplant patients. The aim of this study was to assess the influence of immunosuppressive therapy on homocyst(e)inemia in renal transplant recipients. METHODS: Total serum homocysteine (by high performance liquid chromatography), creatinine, lipid profile, folic acid (by radioimmunoassay-RIA) and vitamin B12 (by RIA) concentrations were measured in 3 groups. Group I patients (n=20) were under treatment with cyclosporine, azathioprine, and prednisone; group II (n=9) were under treatment with azathioprine and prednisone; and group III (n=7) were composed of renal graft donors for groups I and II. Creatinine, estimated creatinine clearance, cyclosporine trough level, lipid profile, folic acid, and vitamin B12 concentrations and clinical characteristics of patients were assessed with the aim of ascertaining determinants of hyperhomocyst(e)inemia. RESULTS: Patient ages were 48.8 ñ 15.1 yr (group I), 43.3 ñ 11.3 yr (group II); and 46.5 ñ 14.8 yr (group III). Mean serum homocyst(e)ine (tHcy) concentrations were 18.07 ñ 8.29 mmol/l in renal transplant recipients; 16.55 ñ 5.6 mmol/l and 21.44 ñ 12.1 mmol/l respectively for group I (with cyclosporine) and group II (without cyclosporine) (NS). In renal donors, tHcy was significantly lower (9.07 ñ 3.06 mmol/l; group I + group II vs. group III, p<0.008). There was an unadjusted correlation (p<0.10) between age (r=0.427; p<0.005) body weight (r=0.412; p<0.05), serum creatinine (r=0.427; p<0.05), estimated creatinine clearance (r=0.316; p<0.10), and tHcy in renal recipients (group I +II). Independent regressors (r2=0.46) identified in the multiple regression model were age (coefficient= 0.253; p=0.009) and serum creatinine (coefficient=8.07; p=0.045). We found no cases of hyperhomocyst(e)inemia in the control group. In contrast, 38 per cent of renal recipients had hyperhomocyst(e)inemia: 7 cases (35 per cent) on cyclosporine and 4 (45 per cent) without cyclosporine, based on serum normal levels. CONCLUSIONS: Renal transplant recipients frequently have hyperhomocyst(e)inemia. Hyperhomocyst(e)inemia in renal transplant patients is independent of the scheme of immunosuppression they are taking. The older the patients are and the higher are their serum creatinine levels, the more susceptible they are to hyperhomocyst(e)inemia following renal transplantation

Hepatopatia como causa de óbito pós-transplante renal / Liver disease as a cause of renal post-transplantation death

O objetivo do presente estudo é avaliar os casos de óbito por hepatopatia (cirrose, hepatoma e hepatite aguda) no pós-transplante renal de 1511 pacientes submetidos a 1670 tx renais, entre janeiro de 1965 e dezembro de 1990, com um tempo mínimo de seguimento de quatro anos. O número total de óbitos no período de observaçäo foi de 593 (39,17 por cento), sendo 41 casos (6,9 por cento) em consequência de hepatopatia: 28 casos por cirrose, 7 por hepatoma e 6 por hepatite aguda. Quanto aos dados demográficos, 38 pacientes (92,7 por cento) eram do sexo masculino, enquanto que na populaçäo geral de receptores de tx, 60 por cento dos pacientes sao deste sexo. O tempo médio do óbito pós-transplante nos casos de cirrose e hepatoma foi 115,05 + 60,6 meses, com uma mediana de 103 meses (15-255), ocorrendo 37,1 por cento deles após o 10§ ano e somente 17 por cento nos primeiros 5 anos pós-tx. Todos os óbitos por hepatite aguda ocorreram nos primeiros 5 anos pós-tx. Nos casos de cirrose verificou-se que 19 (67,8 por cento) pacientes eram portadores do HBsAg e 8 (28,6 por cento) apresentavam sorologia anti-HVC positiva. Nos 7 óbitos ocorridos por hepatoma 6 pacientes eram portadores do HBsAg.