RESUMO
Cytomegalovirus (CMV) infections posttransplant may increase the risk of acute rejection, graft failure, patient death, opportunistic infections, malignancy, diabetes, and cardiovascular complications. ECTAZ, a multicenter, randomized trial compared safety and efficacy at 12 months (M12) of two doses daclizumab (54 patients, group D) with thymoglobulin (55 patients, group T), plus cyclosporine (CsA), mycophenolate mofetil and steroids in first cadaveric kidney transplant patients. D+/R- patients received oral ganciclovir prophylaxis for 90 days. Post-ECTAZ is a 36-month, multicenter, observational study including recipients who participated in ECTAZ trial. We studied the indirect effects of CMV infections, whether recipients experienced (CMVi+) or not (CMVi-) a CMV infection/syndrome/disease. We compared 49 patients in the group CMVi+ with 54 patients in the group CMVi-. At month 36 (M36), patient survival, graft survival and renal function were comparable. The incidence of biopsy-proven acute rejection was 16.3% in the CMVi+ group versus 24.1% in the CMVi- group (not significant). The incidence of infections was increased in the CMVi+ group (P = .004), but not diabetes, malignancies, and cardiovascular complications. Our study shows at M36 that CMV infection/syndrome/disease episodes were associated with a higher incidence of infections but no difference for other long-term complications. Our data suggest that anti-CMV prophylaxis could decrease the risk for long-term related CMV complications.
Assuntos
Infecções por Citomegalovirus/fisiopatologia , Sobrevivência de Enxerto , Transplante de Rim , Resultado do Tratamento , Administração Oral , Antivirais/uso terapêutico , Infecções por Citomegalovirus/prevenção & controle , Ganciclovir/uso terapêutico , Rejeição de Enxerto , Humanos , Taxa de SobrevidaRESUMO
Calcineurin inhibitor (CNI) withdrawal has been used as a strategy to improve renal allograft function. We previously reported that conversion from cyclosporine A (CsA) to sirolimus (SRL) 3 months after transplantation significantly improved renal function at 1 year. In the Postconcept trial, 77 patients in the SRL group and 85 in the CsA group were followed for 48 months. Renal function (Cockcroft and Gault) was significantly better at month 48 (M48) in the SRL group both in the intent-to-treat population (ITT): 62.6 mL/min/1.73 m(2) versus 57.1 mL/min/1.73 m(2) (p = 0.013) and in the on-treatment population (OT): 67.5 mL/min/1.73 m(2) versus 57.4 mL/min/1.73 m(2) (p = 0.002). Two biopsy proven acute rejection episodes occurred after M12 in each group. Graft and patient survival were comparable (graft survival: 97.4 vs. 100%; patient survival: 97.4 vs. 97.6%, respectively). The incidence of new-onset diabetes was numerically increased in the SRL group (7 vs. 2). In OT, three cancers occurred in the SRL group versus nine in the CsA group and mean proteinuria was increased in the SRL group (0.42 ± 0.44 vs. 0.26 ± 0.37; p = 0.018). In summary, the renal benefits associated with conversion of CsA to SRL, at 3 months posttransplantation, in combination with MMF were maintained for 4 years posttransplantation.
Assuntos
Ciclosporina/uso terapêutico , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim , Sirolimo/uso terapêutico , Adulto , Ciclosporina/efeitos adversos , Ciclosporina/farmacologia , Feminino , Sobrevivência de Enxerto , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/farmacologia , Falência Renal Crônica/tratamento farmacológico , Falência Renal Crônica/fisiopatologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Sirolimo/efeitos adversos , Sirolimo/farmacologia , Taxa de SobrevidaRESUMO
OBJECTIVE: Evaluate epidemiology, diagnosis and outcome of de novo renal cell carcinoma in renal transplanted patients. PATIENTS AND METHOD: From June 1989 to December 2007, 824 renal transplantations were carried out and followed in annual consultation by an urologist with abdominal echography or tomodensitometry. The suspect renal lesions were treated by a widened nephrectomy. Incidence, diagnosis, treatment, histological type, and outcome of all patients were analysed. RESULTS: Thirty-three patients had nephrectomy for suspect renal lesions. Twenty-two de novo tumours of native kidneys among 21 patients were diagnosed (15 renal clear cell carcinoma and seven papillary tumours) with mean time after transplantation of 25,6 months (2.3-105.5). All tumours were classified pT1aN0M0. Only one patient died at 8 months of metastatic dissemination of a papillary tumour classified initially pT1aN0M0. All the other patients are alive with mean follow-up of 34.8 months (2.8-113.9). Specific survival to 5 years was 93.3%. CONCLUSION: The increase risk of tumour at the renal transplanted patient led to propose in the event of suspect lesions of the native kidneys, a widened nephrectomy. In our series, 65% of the operated patients carried a cancer. The good forecast of these localized tumours justifies a regular radiological monitoring and an aggressive therapeutic attitude despite of absence of tumours in 35% of the transplanted patients.
Assuntos
Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Transplante de Rim , Nefrectomia , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: To evaluate the epidemiology, diagnosis, and outcome of de novo renal cell carcinoma in renal transplant recipients. PATIENTS AND METHODS: From June 1989 to August 2006, 800 renal transplant recipients were followed up annually by a urologist using abdominal ultrasonography or computed tomography. Renal lesions considered suspect were treated using extended nephrectomy. Incidence, diagnosis, histologic type, treatment, and outcome were analyzed in all patients. RESULTS: Thirty-three patients underwent nephrectomy because of suspect renal lesions including 22 de novo tumors in 21 native kidneys (renal clear-cell carcinoma in 15 and papillary carcinoma in 7). All tumors were classified as pT1aN0M0. Mean (range) time after diagnosis was 25.6 (2.3-105.5) months. Only 1 patient died, at 8 months after diagnosis. All other patients were alive at follow-up of 34.8 (2.8-113.9) months. Five-year survival was 92%. CONCLUSION: The increased risk of tumor in renal transplant recipients leads us to propose extended nephrectomy in the case of suspect lesions in the native kidney. In our patients, 65% of patients had malignant lesions. Good prognosis for these localized tumors justified aggressive therapy even though 35% of transplant recipients were tumor-free.
Assuntos
Carcinoma de Células Renais/epidemiologia , Neoplasias Renais/epidemiologia , Transplante de Rim/efeitos adversos , Abdome/diagnóstico por imagem , Adulto , Idoso , Carcinoma Papilar/epidemiologia , Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Humanos , Incidência , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Transplante de Rim/patologia , Pessoa de Meia-Idade , Nefrectomia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X , UltrassonografiaAssuntos
Histiocitoma Fibroso Benigno/patologia , Hospedeiro Imunocomprometido , Transplante de Rim/efeitos adversos , Neoplasias Cutâneas/patologia , Trombose Venosa/diagnóstico , Adulto , Biópsia por Agulha , Histiocitoma Fibroso Benigno/etiologia , Humanos , Imuno-Histoquímica , Falência Renal Crônica/cirurgia , Transplante de Rim/imunologia , Masculino , Prognóstico , Medição de Risco , Neoplasias Cutâneas/etiologiaRESUMO
INTRODUCTION: Post-transplant cutaneous lymphomas are the second skin cancer after cutaneous carcinoma and are usually of the B-cell type. Post-transplant cutaneous T-cell lymphomas are extremely rare. We described a case of a cutaneous T-cell lymphoma in a renal transplant recipient. CASE REPORT: A 52-year-old woman was hospitalized for an erythematous infiltrated eruption. Seven years earlier, she had undergone kidney transplantation. No palpable lymphadenopathy or hepatosplenomegaly was present. The patient's skin biopsy specimen was histologically suggestive of CD30- fungoid mycosis. The same clonal TCR-rearrangement was identified in the blood and in the skin. No EBV was detected within the cutaneous lesion on immunohistochemical analysis or by PCR in the blood. Chlorambucil (Chloraminophène) was associated with a topical treatment with chlormethine (Caryolysine) and corticosteroids while tacrolimus (Prograf) was reduced and stopped. There was no evidence of recurrence of the lymphoma after 12 months of follow-up. DISCUSSION: The particularity of our observation is the apparition, 7 years after transplantation, of a CD30-, EBV-fungoid mycosis with a blood and cutaneous clonal TCR-rearrangement. Despite this poor prognosis factor, the cutaneous lymphoma regressed after reduction of the immunosuppressive treatment reduction and institution of topical corticosteroids, chlormethine and chlorambucil.
Assuntos
Transplante de Rim/efeitos adversos , Linfoma Cutâneo de Células T/etiologia , Neoplasias Cutâneas/etiologia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
1. Renal osteodystrophy is a general term encompassing all the disturbances of the phosphocalcic metabolism and their associated bone and soft tissue abnormalities, which progressively occur in chronic renal failure. In this article we detail their main histopathological and etiopathogenic aspects as well as their invasive and non invasive diagnostic approach. 2. Osteitis fibrosa is characterized by extensive medullary fibrosis and osteoclastic hyperresorption linked to PTH hypersecretion. 3. Adynamic bone disease is mainly related to iatrogenic oversuppression of PTH secretion. It is favored by aluminum overload which directly inhibits the osteoblasts. It is characterized by a low bone formation rate without primary mineralization defect so that the osteoid seam thickness is normal or low, in contrast to osteomalacia in which by definition osteoid thickness is increased. 4. Osteomalacia is mainly due to aluminum intoxication, vitamin D insufficiency, hypocalcemia, acidosis and exceptionally to hypophosphatemia. 5. The differential diagnosis between the histopathological entities may be oriented on clinical, radiological and biochemical means. Only the bone biopsy can make the diagnosis with certainty. This latter is however necessary for appropriate treatment only in the patients who have been exposed to aluminum and who are symptomatic or hypercalcemic in order to distinguish severe osteitis fibrosa from aluminic bone disease, and more particularly from mixed osteopathy. Indeed surgical parathyroidectomy in patients with mixed osteopathy associating bone hyperremodeling and mineralization defect with inappropriately thick osteoid seam may induce fracturing low turn over aluminic bone disease.
Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/patologia , Rim/patologia , Osso e Ossos/patologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/classificação , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Osteomalacia/patologia , RadiografiaRESUMO
This article reviews the clinical, biological, radiological, and pathological procedures and their respective indications for the practical diagnosis of the following various histological patterns of renal osteodystrophy: osteitis fibrosa due to parathyroid hormone (PTH) hypersecretion: osteomalacia or rickets due to native vitamin D deficiency and/or aluminum overload; and adynamic bone disease (ABD) due to aluminum overload and/or PTH secretion oversuppression. Our advice regarding bone biopsy is to restrict it to patients with symptoms and hypercalcemia, especially those who have been previously exposed to aluminum. In other cases, we propose relying merely on the determination of the plasma concentrations of calcium, protide, phosphate, bicarbonate, intact PTH, aluminum, 25(OH)D3, and alkaline phosphatase (total and bony if hepatic disease is associated) to choose the appropriate treatment. Because of the danger of the desferrioxamine treatment necessary to chelate and remove aluminum, the suspicion of aluminic bone disease (osteomalacia or ABD) will always be confirmed by a bone biopsy. In the case of nonaluminic osteomalacia, correction of the vitamin D deficiency by native vitamin D or 25(OH)D3, and of the calcium deficiency and acidosis by alkaline salts of calcium and if necessary sodium bicarbonate are sufficient to cure the disease. In the case of nonaluminic ABD, the stimulation of PTH secretion by the discontinuation of 1alpha hydroxylated vitamin D and the induction of a negative calcium balance during dialysis by decreasing the calcium concentration in the dialysate will allow an increase of the CaCO3 dose to correct for hyperphosphatemia without inducing hypercalcemia. For hyperparathyroidism, i.e., plasma intact PTH levels greater than two- or four-fold the upper limit of normal levels (according to the absence or presence of previous aluminum exposure), the treatment will consist in increasing the CaCO3 dose to correct for hyperphosphatemia together with a decrease of the calcium concentration in the dialysate if the dose of CaCO3 is so high that it induces hypercalcemia. When the hyperphosphatemia has been corrected and there is still a low or normal corrected plasma calcium level, 1alpha(OH)D3 in an oral bolus 2 or 3 times a week should be given at the minimal dose of 1 microg. When the PTH level stays above 400 pg while hypercalcemia occurs and hyperphosphatemia persists, surgical subtotal parathyroidectomy is recommended or the injection of calcitriol into the big nodular hyperplastic parathyroid glands under sonography control in high surgical risk patients. Special recommendations are given for children.
Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Diálise Renal , Adulto , Fosfatase Alcalina/sangue , Alumínio/análise , Alumínio/sangue , Alumínio/intoxicação , Bicarbonatos/sangue , Biópsia , Calcifediol/sangue , Cálcio/sangue , Cálcio/deficiência , Cálcio/uso terapêutico , Carbonato de Cálcio/administração & dosagem , Carbonato de Cálcio/uso terapêutico , Criança , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico por imagem , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/patologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Soluções para Diálise/uso terapêutico , Displasia Fibrosa Óssea/etiologia , Humanos , Hidroxicolecalciferóis/administração & dosagem , Hidroxicolecalciferóis/uso terapêutico , Hipercalcemia/diagnóstico , Hipercalcemia/tratamento farmacológico , Hiperparatireoidismo/complicações , Hipoparatireoidismo/complicações , Osteomalacia/etiologia , Osteomalacia/terapia , Hormônio Paratireóideo/sangue , Hormônio Paratireóideo/metabolismo , Paratireoidectomia , Fosfatos/sangue , Fósforo/sangue , Radiografia , Deficiência de Vitamina D/complicações , Deficiência de Vitamina D/tratamento farmacológicoRESUMO
UNLABELLED: We report a series of 27 patients included on the basis of either thrombotic microangiopathy (TMA) at renal histology (13 cases) or, in the absence of histology, non-immunological hemolytic anemia with schizocytes and thrombopenia (14 cas). The etiopathogenic treatment consisted in the administration of antiagregating agents (in all patients except 3 of group I because of the severity of thrombopenic), corticosteroids (1 case), intravenous immunoglobulins (2 cases) fresh frozen plasma (FFP) without plasma exchange (PE) in 7 cases and PE with FFP in 13 patients. According to the 6 months outcome, 4 groups were considered I: death due to neurological damage; II: chronic hemodialysis; III: partial renal recovery; IV: complete renal recovery. COMMENTS AND CONCLUSIONS: a/Patients with neurological complications have poor prognosis in spite of minor renal involvement and use of PE whose indication is validated in these cases. b/When renal involvement predominates, accelerated hypertension is linked to arteriolar or mixte type of TMA, exposes to an increased risk of hemorrhagic complications of the renal biopsy (4 out fo 5) which questions the usefulness of such biopsy (group II). c/TMA may precede cancer. It has per se a favorable outcome even when metastases are already present, warranting aggressive treatment.
Assuntos
Síndrome Hemolítico-Urêmica/terapia , Púrpura Trombocitopênica Trombótica/terapia , Adolescente , Adulto , Idoso , Feminino , Síndrome Hemolítico-Urêmica/complicações , Síndrome Hemolítico-Urêmica/fisiopatologia , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Púrpura Trombocitopênica Trombótica/complicações , Púrpura Trombocitopênica Trombótica/fisiopatologia , Estudos RetrospectivosRESUMO
The use of 1 alpha-hydroxyvitamin D3 [1 alpha(OH)D3] derivatives in a uremic patient is justified only in the treatment of hyperparathyroidism (i.e. when plasma intact parathyroid hormone - PTH - levels are above five or three times the upper limit of normal according to whether the patient is on continuous ambulatory peritoneal dialysis or on hemodialysis and between 0.5-1.5, 1-2 and 2-3 times the upper limit of normal for a creatinine clearance of, respectively, 30, between 30 and 10, or below 10 ml/min/1.73 m2). The following prerequisites have however to be satisfied: (1) a good vitamin D3 repletion should be secured by plasma 25(OH(D) levels of 20-30 ng/ml (if necessary by administration of native vitamin D or 25(OH)D3), and (2) phosphate retention (which is aggravated by the increased phosphate intestinal absorption induced by the 1 alpha (OH)D derivatives) and the consequent possible hyperphosphatemia should be prevented or corrected by the oral administration of alkaline salts of calcium given before the meals as phosphate binders without inducing hypercalcemia. These prerequisites explain the narrow therapeutical margin of 1 alpha (OH)D3 derivatives in uremic patients before dialysis (more so in the adult than in the child) and the possible broadening of this margin in the patients on dialysis by the use of low dialysate calcium concentrations (1.25-1.00 mmol/l) in order to prevent hypercalcemia by inducing a negative perdialytic calcium balance. Once hyperphosphatemia is prevented by oral calcium, 1 alpha (OH)D3 derivatives have the advantage to suppress the transcription of the prepro PTH gene by a mechanism independent of an increase in plasma calcium. Controlled randomized trials have not confirmed the claimed advantage in efficacy and safety of the parenteral versus the oral route nor of the intermittent versus the daily mode of their administration. The advantages of using the so called 'nonhypercalcemic hyperphosphatemic' vitamin D3 derivatives in combination with oral calcium over 1 alpha(OH)D3 derivatives in the treatment of uremic hyperparathyroidism are still waiting for clinical demonstration. Vitamin D derivatives have no place in the treatment of aluminic bone diseases which necessitate long term deferoxamine treatment and prevention of aluminum exposure by the dialysate and the phosphate binders. They are not indicated in the treatment of 'idiopathic' adynamic bone disease which is due to uremia per se combined with an excessive PTH suppression for the degree of renal failure. This low bone turnover pattern is associated with an increased risk of hypercalcemia and hyperphosphatemia and necessitates only a stimulation of PTH secretion by inducing a negative calcium balance with a lower dialysate calcium concentration or simply by discontinuing the oral calcium supplement in the uremic patient not yet dialyzed. In rare cases this pattern is due to a granulomatosis and is corrected by prednisone.
Assuntos
Doenças Ósseas/complicações , Doenças Ósseas/tratamento farmacológico , Hidroxicolecalciferóis/uso terapêutico , Insuficiência Renal/complicações , Uremia/complicações , Adulto , Amiloidose/tratamento farmacológico , Animais , Criança , Humanos , Hiperparatireoidismo/complicações , Hiperparatireoidismo/tratamento farmacológico , Modelos Biológicos , Osteomalacia/tratamento farmacológico , Hormônio Paratireóideo/sangueRESUMO
Besides defining the appropriate doses of frusemide in uraemic patients, A. Heidland's contribution to the treatment of hypertension in chronic renal failure consisted in the following demonstrations: (1) In patients on chronic haemodialysis, calcium antagonists have a beneficial effect on their glucose intolerance and decreased plasma levels of 25OH vitamin D while their effect on blood lipids is neutral. (2) In 5/6 nephrectomized rats, captopril, verapamil, and metoprolol have the same protective effect on their GFR and tubular secretion of protons, at equal blood-pressure-lowering effect. (3) In rats with streptozotocin-induced diabetes, atrial natriuretic peptide does not play a role in their hyperfiltration. (4) Severe retinopathy is observed in patients with uraemic nephropathies at a much smaller elevation of their blood pressure than in patients with essential hypertension. This article reviews the following points: (1) The role of hypertension in the loss of renal function is convincingly demonstrated only in a few experimental models, and in man only in malignant hypertension and diabetic nephropathy but not in essential hypertension nor in non-diabetic nephropathy. However, preliminary results suggests that antihypertensive treatment may retard the progression of renal disease in normotensive patients (DBP <90 mmHg) with either microalbuminuric diabetes and normal renal function or non-diabetic uraemic nephropathy. (2) Only the ACE inhibitors have been proved to have a specific renal protective effect, independent of their diurnal blood-pressure-lowering effect, both in diabetic nephropathy and in non-diabetic uraemic nephropathy.
Assuntos
Hipertensão/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/fisiopatologia , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Animais , Anti-Hipertensivos/farmacologia , Pressão Sanguínea , Bloqueadores dos Canais de Cálcio/farmacologia , Humanos , Hipertensão/tratamento farmacológico , Rim/efeitos dos fármacos , Nefropatias/complicações , Nefropatias/fisiopatologia , RatosAssuntos
Granuloma/etiologia , Hypocreales , Cetoconazol/uso terapêutico , Transplante de Rim , Perna (Membro) , Micoses/diagnóstico , Complicações Pós-Operatórias/microbiologia , Granuloma/cirurgia , Humanos , Hypocreales/isolamento & purificação , Masculino , Pessoa de Meia-Idade , Micoses/complicações , Micoses/tratamento farmacológicoRESUMO
In order to prevent aluminum toxicity induced by the association of aluminum phosphate binder with 1 alpha(OH) vitamin D3 derivatives and the use of deferoxamine with its own hazards to diagnose and treat this toxicity, we have shown in 1982 that it was possible to replace the iatrogenic association of aluminum phosphate binder with 1 alpha OH vitamin D derivatives by oral calcium carbonate taken with the meals in order to bind phosphate and correct the negative calcium balance. This led to the disappearance of the crippling aluminic osteomalacia and adynamic bone diseases in our center. The effectiveness of CaCO3 without 1 alpha(OH)D3 derivatives in the control of hyperparathyroidism in dialysis patients has been proven by the appearance in four patients of our dialysis population of an histological idiopathic adynamic bone disease associated with relative hypoparathyroidism, and by the finding that more than 50% of our dialysis population treated by this sole treatment have plasma concentration of intact PTH below twice the upper limit of normal (that is, the threshold above which only significant histological osteitis fibrosa is observed). Besides the compliance problem, the limit of CaCO3 is the occurrence of hypercalcemia which occurs in about 8% of the measurements. Since calcium acetate binds twice as much phosphate for the same dose of elemental calcium as CaCO3, its use has been recommended. However, clinical experience has shown that in spite of the fact that half the dose of calcium element given as acetate does actually control predialysis plasma phosphate as well as CaCO3, the incidence of hypercalcemia is not decreased, probably because calcium availability at the alkaline pH of the intestine is much greater with Ca acetate. When hypercalcemia is frequent (and not explained by autonomized hyperparathyroidism, adynamic bone disease, overtreatment with vitamin D, granulomatosis or neoplasia) it is necessary either to decrease the dose of calcium and complete the necessary binding of phosphate by adding small doses of Mg(OH)2 or Mg carbonate, provided the dialysate Mg is decreased to 0.2 to 0.35 mmol/liter to prevent hypermagnesemia or to decrease the dialysate calcium (DCa) concentration. The decrease of DCa can be made either just when hypercalcemia occurs or on a systemic basis according to the amount of CaCO3 used and to the necessity of associating 1 alpha(OH) vitamin D3 derivatives.(ABSTRACT TRUNCATED AT 400 WORDS)
Assuntos
Cálcio/uso terapêutico , Fosfatos/metabolismo , Uremia/terapia , Alumínio/efeitos adversos , Alumínio/metabolismo , Calcinose/induzido quimicamente , Calcitriol/uso terapêutico , Cálcio/efeitos adversos , Cálcio/metabolismo , Desferroxamina/uso terapêutico , Humanos , Hiperparatireoidismo Secundário/prevenção & controle , Diálise Renal , Uremia/metabolismoRESUMO
It may sometimes be difficult to distinguish Cushing's disease from ectopic ACTH syndrome. A case is described here of a patient with a Cushing's syndrome and diagnostic difficulties. Initial features were consistent with a Cushing's disease (in particular metopirone test was positive). Because of relapse of hypercortisolism after mitotane therapy, total adrenalectomy was performed. Thereafter features occurred that evoked Nelson's syndrome, including high plasma ACTH levels and a pituitary mass syndrome. Pituitary reserve testings by vasopressin or corticotropin-releasing factor were positive, although inconstantly, in that plasma ACTH increased. A lung tumor was discovered about 20 yr after the first clinical signs of hypercortisolism. Its removal led to the discovery of a bronchial carcinoid tumor and was followed by normalization of plasma ACTH levels. An analysis of proopiomelanocortin-related peptides was performed postoperatively on the blood drawn before and after the tumor resection and on the tumor; the results of this study would have been contributive to the diagnosis of occult ectopic ACTH tumor. In conclusion this case demonstrates the limitations of the conventional procedures in the diagnosis of the ectopic ACTH syndrome. At contrast the newer biochemical procedures may be very useful in determining the type of hypercortisolism.
Assuntos
Síndrome de ACTH Ectópico/diagnóstico , Neoplasias Brônquicas/metabolismo , Neoplasias Brônquicas/cirurgia , Tumor Carcinoide/cirurgia , Síndrome de Cushing/diagnóstico , Síndrome de Nelson/diagnóstico , Hormônio Adrenocorticotrópico/metabolismo , Adulto , Cromatografia em Gel , Diagnóstico Diferencial , Feminino , Humanos , Pulmão/diagnóstico por imagem , Radiografia , beta-Lipotropina/sangueRESUMO
UNLABELLED: To assess the prevalence of histologic bone disease in our center where Al(OH)3 intake is restricted, we reviewed 42 bone biopsies performed between 1975 and 1985 in patients dialyzed more than 29 months. Bone biopsies were performed systematically (2/3 of the cases) or because of a mild hypercalcemia (1/3 of the cases). Seventeen of these patients had been dialyzed before 1978 with softened water moderately contaminated by aluminum. Fifteen had always been dialyzed with reverse osmosis treated water and 10 had been exclusively treated by hemofiltration. The prevalence of osteitis fibrosa was 76%, that of osteomalacia null and that of adynamic bone disease 24% (but only 9.5% with positive Aluminon staining). When the 17 patients dialyzed with aluminum contaminated water before 1978 were excluded, only one patient among 25 had an aluminum adynamic bone disease (4%). This low prevalence can probably be explained by the restricted intake of Al(OH)3 thanks to the systematic administration of Ca CO3 and in a few cases of Mg (OH). The adynamic bone disease group has lower serum concentration of PTH and shorter duration on dialysis whereas the serum levels of calcium, phosphorus, magnesium and aluminum and daily dose of Ca CO3, Mg (OH)2 and Al(OH)3 do not differ. The frequency of the positivity of aluminum staining is not statistically different in the 2 groups. In 4 cases, adynamic bone disease without aluminum or iron intoxications is found, associated with a relative hypoparathyroidism. It is not explained by previous parathyroidectomy, diabetes or steroid therapy. CONCLUSIONS: 1) Restriction of aluminum intake and dialysis with reverse osmosis treated water lead to a low prevalence of aluminum bone disease. 2) A new bone disease in uremia is described: the idiopathic adynamic bone disease associated with a relative hypoparathyroidism.
Assuntos
Hidróxido de Alumínio/administração & dosagem , Doenças Ósseas/epidemiologia , Diálise Renal , Adulto , Hidróxido de Alumínio/efeitos adversos , Doenças Ósseas/induzido quimicamente , Doenças Ósseas/patologia , Osso e Ossos/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osmose , Hormônio Paratireóideo/sangueRESUMO
Estimation of urinary excretion of a ouabain displacing factor and dopamine was carried out immediately before delivery, and 7 days and 70 to 90 days after delivery in 12 normotensive pregnant women. Simultaneous estimation of plasma 99-126 atrial natriuretic factor, plasma renin activity, and plasma aldosterone were also undertaken. The data were compared with those obtained in a group of nonpregnant normotensive women (n = 14) and a group of pregnant normotensive women in the early phase of the third trimester (n = 14). Urinary ouabain displacing factor and dopamine levels were significantly higher in the early phase of the third trimester, as compared with nonpregnant women. But immediately before delivery, ouabain displacing factor excretion had fallen below nonpregnant values and dopamine excretion had dropped to control values. Both remained low after delivery. Plasma atrial natriuretic factor was higher in pregnant women, as compared with nonpregnant controls and remained high just before delivery and 7 and 70 to 90 days after delivery. Plasma renin activity and plasma aldosterone levels were higher during pregnancy and had fallen to nonpregnant values 7 days post partum. This drop in plasma renin activity and aldosterone by 7 days post partum, in contrast with the unchanged high values of atrial natriuretic factor, may contribute to negative sodium balance after delivery. It is concluded that there is considerable discrepancy in natriuretic and antinatriuretic factors before and after delivery.
Assuntos
Fator Natriurético Atrial/sangue , Pressão Sanguínea , Parto Obstétrico , Digoxina , Gravidez/sangue , Saponinas , ATPase Trocadora de Sódio-Potássio/antagonistas & inibidores , Cardenolídeos , Dopamina/urina , Feminino , Humanos , Lactação/sangue , Lactação/urina , Gravidez/urina , Terceiro Trimestre da Gravidez , Valores de Referência , ATPase Trocadora de Sódio-Potássio/urinaRESUMO
Between 1 January 1976 and 31 December 1986, primary glomerulonephritis was histologically diagnosed in 319 patients, living in a region of 675,000 inhabitants at the time of renal biopsy. The prevalence of primary glomerulopathy was 0.4/1000 inhabitants. The annual incidence was determined during two 5 year periods: period A (1976-1980) and period B (1981-1985): they were, respectively, 3.4 and 4.5 for 100,000 inhabitants. Berger's focal glomerulonephritis was the most common (30 p. 100) and its incidence was increasing. In contrast, membranoproliferative and acute glomerulonephritides were sharply decreased (almost disappeared), while membranous glomerulonephropathies and glomerulopathies with minimal glomerular lesions or proliferative forms with crescents increased. All primary glomerulonephritides were more prevalent in men and their frequencies increased with age. Our findings lead to the following conclusions: a) the low prevalence and incidence of primary glomerulopathies (3 times less than in other published studies) probably reflect the under medicalization of our region and the attractiveness of neighbouring metropolis, rather than a real decrease in the disease; b) the quasi- disappearance of acute and membranoproliferative glomerulonephropathies and the high incidence of IgA glomerulonephropathies suggest that their pathogenetic associations with infections sensitive to antibiotics are different; c) the increased frequency of membranous glomerulonephropathy and the glomerulopathy with minimal glomerular lesions in aged subjects is most likely due to their polymedication.
Assuntos
Glomerulonefrite/epidemiologia , Adulto , Fatores Etários , Idoso , Biópsia por Agulha , Feminino , França , Glomerulonefrite/patologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Programas Médicos Regionais , Razão de MasculinidadeAssuntos
Hidróxido de Alumínio/uso terapêutico , Cálcio/uso terapêutico , Fosfatos/metabolismo , Administração Oral , Adulto , Idoso , Hidróxido de Alumínio/efeitos adversos , Hidróxido de Alumínio/metabolismo , Doenças Ósseas/induzido quimicamente , Calcinose/induzido quimicamente , Cálcio/efeitos adversos , Cálcio/metabolismo , Quimioterapia Combinada , Feminino , Humanos , Hidróxido de Magnésio/efeitos adversos , Hidróxido de Magnésio/uso terapêutico , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Estimation of urinary excretion of a ouabain displacing factor (ODF) and dopamine was carried out immediately before delivery, 7 days and 70-90 days after delivery in 12 normotensive pregnant women. Simultaneous estimation of plasma 99-126 atrial natriuretic factor (ANF), plasma renin activity (PRA) and plasma aldosterone were also undertaken. The data were compared with those obtained in a non pregnant normotensive group of women (n = 14) and a group of pregnant normotensive women in the early third trimester (n = 14). Urinary ODF and dopamine were significantly higher in the early third trimester when compared with non pregnant women but immediately before delivery, ODF excretion had fallen below non pregnant values and dopamine excretion had dropped to control values. Both remained low after delivery. Plasma ANF was higher in pregnant women when compared with non pregnant controls and remained high just before delivery and 7 and 70-90 days after delivery. PRA and plasma aldosterone were higher during pregnancy and had fallen to non pregnant values 7 days post-partum. It is concluded that there is considerable discrepancy in the evolution of natriuretic and antinatriuretic factors before and after delivery and that the drop of PRA and aldosterone by 7 days post-partum, contrasting with the unchanged high values of ANF, may contribute to negative sodium balance after delivery.