Efficacy and safety of aldosterone synthase inhibition with and without empagliflozin for chronic kidney disease: a randomised, controlled, phase 2 trial.

BACKGROUND: Excess aldosterone accelerates chronic kidney disease progression. This phase 2 clinical trial assessed BI 690517, an aldosterone synthase inhibitor, for efficacy, safety, and dose selection. METHODS: This was a multinational, randomised, controlled, phase 2 trial. People aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 30 to less than 90 mL/min/1·73 m2, a urine albumin to creatinine ratio (UACR) of 200 to less than 5000 mg/g, and serum potassium of 4·8 mmol/L or less, taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, were enrolled. Participants were randomly assigned (1:1) to 8 weeks of empagliflozin or placebo run-in, followed by a second randomisation (1:1:1:1) to 14 weeks of treatment with once per day BI 690517 at doses of 3 mg, 10 mg, or 20 mg, or placebo. Study participants, research coordinators, investigators, and the data coordinating centre were masked to treatment assignment. The primary endpoint was the change in UACR measured in first morning void urine from baseline (second randomisation) to the end of treatment. This study is registered with ClinicalTrials.gov (NCT05182840) and is completed. FINDINGS: Between Feb 18 and Dec 30, 2022, of the 714 run-in participants, 586 were randomly assigned to receive BI 690517 or placebo. At baseline, 33% (n=196) were women, 67% (n=390) were men, 42% (n=244) had a racial identity other than White, and mean participant age was 63·8 years (SD 11·3). Mean baseline eGFR was 51·9 mL/min/1·73 m2 (17·7) and median UACR was 426 mg/g (IQR 205 to 889). Percentage change in first morning void UACR from baseline to the end of treatment at week 14 was -3% (95% CI -19 to 17) with placebo, -22% (-36 to -7) with BI 690517 3 mg, -39% (-50 to -26) with BI 690517 10 mg, and -37% (-49 to -22) with BI 690517 20 mg monotherapy. BI 690517 produced similar UACR reductions when added to empagliflozin. Investigator-reported hyperkalaemia occurred in 10% (14/146) of those in the BI 690517 3 mg group, 15% (22/144) in the BI 690517 10 mg group, and 18% (26/146) in the BI 690517 20 mg group, and in 6% (nine of 147) of those receiving placebo, with or without empagliflozin. Most participants with hyperkalaemia did not require intervention (86% [72/84]). Adrenal insufficiency was an adverse event of special interest reported in seven of 436 study participants (2%) receiving BI 690517 and one of 147 participants (1%) receiving matched placebo. No treatment-related deaths occurred during the study. INTERPRETATION: BI 690517 dose-dependently reduced albuminuria with concurrent renin-angiotensin system inhibition and empagliflozin, suggesting an additive efficacy for chronic kidney disease treatment without unexpected safety signals. FUNDING: Boehringer Ingelheim.

Finerenone in patients across the spectrum of chronic kidney disease and type 2 diabetes by glucagon-like peptide-1 receptor agonist use.

AIMS: To explore the modifying effect of glucagon-like peptide-1 receptor agonist (GLP-1RA) use on outcomes with finerenone across a wide spectrum of patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the pooled analysis of FIDELIO-DKD and FIGARO-DKD. MATERIALS AND METHODS: Patients with T2D and CKD treated with optimized renin-angiotensin system blockade were randomized to finerenone or placebo. Effects of finerenone on a cardiovascular composite outcome (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) and a kidney composite outcome (kidney failure, sustained ≥57% estimated glomerular filtration rate [eGFR] decline, or renal death), change in urine albumin-to-creatinine ratio (UACR), and safety were analysed by GLP-1RA use. RESULTS: Of 13 026 patients, 944 (7.2%) used GLP-1RAs at baseline. Finerenone reduced the risk of the cardiovascular composite outcome (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.52-1.11 with GLP-1RA; HR 0.87, 95% CI 0.79-0.96 without GLP-1RA; P-interaction = 0.63) and the kidney composite outcome (HR 0.82, 95% CI 0.45-1.48 with GLP-1RA; HR 0.77, 95% CI 0.67-0.89 without GLP-1RA; P-interaction = 0.79) irrespective of baseline GLP-1RA use. Reduction in UACR with finerenone at Month 4 was -38% in patients with baseline GLP-1RA use compared with -31% in those without GLP-1RA use (P-interaction = 0.03). Overall safety and incidence of hyperkalaemia were similar, irrespective of GLP-1RA use. CONCLUSIONS: The cardiorenal benefits of finerenone on composite cardiovascular and kidney outcomes and UACR reduction in patients with CKD and T2D appear to be maintained, regardless of GLP-1RA use. Subsequent studies are needed to investigate any potential benefit of this combination.

Genome-Wide Association Study of Diabetic Kidney Disease Highlights Biology Involved in Glomerular Basement Membrane Collagen.

BACKGROUND: Although diabetic kidney disease demonstrates both familial clustering and single nucleotide polymorphism heritability, the specific genetic factors influencing risk remain largely unknown. METHODS: To identify genetic variants predisposing to diabetic kidney disease, we performed genome-wide association study (GWAS) analyses. Through collaboration with the Diabetes Nephropathy Collaborative Research Initiative, we assembled a large collection of type 1 diabetes cohorts with harmonized diabetic kidney disease phenotypes. We used a spectrum of ten diabetic kidney disease definitions based on albuminuria and renal function. RESULTS: Our GWAS meta-analysis included association results for up to 19,406 individuals of European descent with type 1 diabetes. We identified 16 genome-wide significant risk loci. The variant with the strongest association (rs55703767) is a common missense mutation in the collagen type IV alpha 3 chain (COL4A3) gene, which encodes a major structural component of the glomerular basement membrane (GBM). Mutations in COL4A3 are implicated in heritable nephropathies, including the progressive inherited nephropathy Alport syndrome. The rs55703767 minor allele (Asp326Tyr) is protective against several definitions of diabetic kidney disease, including albuminuria and ESKD, and demonstrated a significant association with GBM width; protective allele carriers had thinner GBM before any signs of kidney disease, and its effect was dependent on glycemia. Three other loci are in or near genes with known or suggestive involvement in this condition (BMP7) or renal biology (COLEC11 and DDR1). CONCLUSIONS: The 16 diabetic kidney disease-associated loci may provide novel insights into the pathogenesis of this condition and help identify potential biologic targets for prevention and treatment.

Glomerular structural-functional relationship models of diabetic nephropathy are robust in type 1 diabetic patients.

Studies of structural-functional relationships have improved understanding of the natural history of diabetic nephropathy (DN). However, in order to consider structural end points for clinical trials, the robustness of the resultant models needs to be verified. This study examined whether structural-functional relationship models derived from a large cohort of type 1 diabetic (T1D) patients with a wide range of renal function are robust. The predictability of models derived from multiple regression analysis and piecewise linear regression analysis was also compared. T1D patients (n = 161) with research renal biopsies were divided into two equal groups matched for albumin excretion rate (AER). Models to explain AER and glomerular filtration rate (GFR) by classical DN lesions in one group (T1D-model, or T1D-M) were applied to the other group (T1D-test, or T1D-T) and regression analyses were performed. T1D-M-derived models explained 70 and 63% of AER variance and 32 and 21% of GFR variance in T1D-M and T1D-T, respectively, supporting the substantial robustness of the models. Piecewise linear regression analyses substantially improved predictability of the models with 83% of AER variance and 66% of GFR variance explained by classical DN glomerular lesions alone. These studies demonstrate that DN structural-functional relationship models are robust, and if appropriate models are used, glomerular lesions alone explain a major proportion of AER and GFR variance in T1D patients.

Preventing Early Renal Loss in Diabetes (PERL) Study: A Randomized Double-Blinded Trial of Allopurinol-Rationale, Design, and Baseline Data.

OBJECTIVE: Higher serum uric acid (SUA) is associated with diabetic kidney disease (DKD). Preventing Early Renal Loss in Diabetes (PERL) evaluates whether lowering SUA with allopurinol slows glomerular filtration rate (GFR) loss in people with type 1 diabetes (T1D) and mild to moderate DKD. We present the PERL rationale, design, and baseline characteristics. RESEARCH DESIGN AND METHODS: This double-blind, placebo-controlled, multicenter trial randomized 530 participants with T1D, estimated GFR (eGFR) of 40-99.9 mL/min/1.73 m2, SUA ≥4.5 m/dL, and micro- to macroalbuminuric DKD or normoalbuminuria with declining kidney function (NDKF) (defined as historical eGFR decline ≥3 mL/min/1.73 m2/year) to allopurinol or placebo. The primary outcome is baseline-adjusted iohexol GFR (iGFR) after 3 years of treatment plus a 2-month washout period. RESULTS: Participants are 66% male and 84% white. At baseline, median age was 52 years and diabetes duration was 35 years, 93% of participants had hypertension, and 90% were treated with renin-angiotensin system inhibitors (median blood pressure 127/71 mmHg). Median HbA1c was 8%, SUA 5.9 mg/dL, iGFR 68 mL/min/1.73 m2, and historical eGFR slope -3.5 mL/min/1.73 m2/year. Compared with participants with albuminuria (n = 419), those with NDKF (n = 94) were significantly older (56 vs. 52 years), had lower HbA1c (7.7 vs. 8.1%) and SUA (5.4 vs. 6.0 mg/dL), and had higher eGFR (82 vs. 74 mL/min/1.73 m2) and historical eGFR loss (-4.7 vs. -2.5 mL/min/1.73 m2/year). These differences persisted when comparing groups with similar rates of historical eGFR loss. CONCLUSIONS: PERL will determine the effect of allopurinol on mild to moderate DKD in T1D, with or without albuminuria. Participants with normoalbuminuria and rapid GFR loss manifested many DKD risk factors of those with albuminuria, but with less severity.

Diabetic nephropathy: diagnosis, prevention, and treatment.

Diabetic nephropathy is the leading cause of kidney disease in patients starting renal replacement therapy and affects approximately 40% of type 1 and type 2 diabetic patients. It increases the risk of death, mainly from cardiovascular causes, and is defined by increased urinary albumin excretion (UAE) in the absence of other renal diseases. Diabetic nephropathy is categorized into stages: microalbuminuria (UAE >20 microg/min and < or =199 microg/min) and macroalbuminuria (UAE > or =200 microg/min). Hyperglycemia, increased blood pressure levels, and genetic predisposition are the main risk factors for the development of diabetic nephropathy. Elevated serum lipids, smoking habits, and the amount and origin of dietary protein also seem to play a role as risk factors. Screening for microalbuminuria should be performed yearly, starting 5 years after diagnosis in type 1 diabetes or earlier in the presence of puberty or poor metabolic control. In patients with type 2 diabetes, screening should be performed at diagnosis and yearly thereafter. Patients with micro- and macroalbuminuria should undergo an evaluation regarding the presence of comorbid associations, especially retinopathy and macrovascular disease. Achieving the best metabolic control (A1c <7%), treating hypertension (<130/80 mmHg or <125/75 mmHg if proteinuria >1.0 g/24 h and increased serum creatinine), using drugs with blockade effect on the renin-angiotensin-aldosterone system, and treating dyslipidemia (LDL cholesterol <100 mg/dl) are effective strategies for preventing the development of microalbuminuria, in delaying the progression to more advanced stages of nephropathy and in reducing cardiovascular mortality in patients with type 1 and type 2 diabetes.

Value of diagnostic tools for myocardial ischemia used in routine clinical practice to predict cardiac events in patients with type 2 diabetes mellitus: a prospective study.

OBJECTIVE: To analyze tests used in routine clinical practice for the diagnosis of myocardial ischemia to predict the development of cardiac events in type 2 diabetic patients. METHODS: The occurrence of cardiac events (new myocardial infarct, myocardial re-vascularization procedures, congestive heart failure, acute pulmonary edema, sudden death, and death after myocardial infarction or pulmonary edema) were prospectively assessed in a cohort of 135 type 2 diabetic patients after up to seven years of follow-up. At baseline, coronary artery disease was assessed by the WHO cardiovascular questionnaire, resting electrocardiogram, and stress myocardial scintigraphy. RESULTS: Forty-eight cardiac events were observed in 41 patients (10.5 events/100 patients-year). In a Cox's proportional-hazard model only the presence of symptoms of coronary artery disease on the WHO cardiovascular questionnaire alone (RR = 2.13, 95% CI 1.11-4.07, P= 0.022) or in combination with abnormalities on resting ECG (RR= 2.03, 95% CI 1.05-3.92, P= 0.034) or on myocardial scintigraphy (RR= 1.89, 95% CI 1.001-3.57, P= 0.050) predicted cardiac events, adjusted for fasting plasma glucose, mean blood pressure, body mass index, peripheral vascular disease and diabetic nephropathy. CONCLUSION: The WHO cardiovascular questionnaire, a simple tool for the diagnosis of coronary artery disease, is a significant predictor of cardiac events in type 2 diabetic patients.

The human peroxisome proliferator-activated receptor gamma2 (PPARgamma2) Pro12Ala polymorphism is associated with decreased risk of diabetic nephropathy in patients with type 2 diabetes.

The peroxisome proliferator-activated receptor gamma2 (PPARgamma2) Pro12Ala polymorphism has been associated with a decreased risk of type 2 diabetes and a lower albumin excretion rate (AER) in patients with established diabetes. We performed a case-control study aiming to evaluate the association between the Pro12Ala polymorphism and diabetic nephropathy. Genomic DNA was obtained from 104 type 2 diabetic patients (case subjects) with chronic renal insufficiency (78 on dialysis and 26 with proteinuria [AER >or=200 microg/min] and serum creatinine >or=2.0 mg/dl) and 212 normoalbuminuric patients (AER <20 microg/min) with known diabetes duration >or=10 years (control subjects). The genotypic distribution of the PPARgamma2 Pro12Ala polymorphism in these diabetic patients was in Hardy-Weinberg equilibrium, and the Ala allele frequency was 9%. The frequency of Ala carriers (Ala/Ala or Ala/Pro) was 20.3% in control subjects and 10.6% in case subjects (P = 0.031). The odds ratio of having diabetic nephropathy for Ala carriers was 0.465 (95% CI 0.229-0.945; P = 0.034). Carriers of the Ala allele were not different from noncarriers (Pro/Pro) regarding sex (38.9 vs. 44.1% males) or ethnicity (77.4 vs. 71.7% white) distribution, age (61 +/- 10 vs. 61 +/- 10 years), known diabetes duration (17 +/- 7 vs. 16 +/- 7 years), BMI (27 +/- 4 vs. 28 +/- 5 kg/m(2)), fasting plasma glucose (184 +/- 81 vs. 176 +/- 72 mg/dl), HbA(1c) (6.7 +/- 2.3 vs. 6.9 +/- 2.4%; high-performance liquid chromatography reference range: 2.7-4.3%), and systolic (145 +/- 27 vs. 0.144 +/- 24 mmHg) or diastolic (87 +/- 14 vs. 85 +/- 14 mmHg) blood pressure, respectively. In conclusion, the presence of the Ala allele may confer protection from diabetic nephropathy in patients with type 2 diabetes.

Cellular basis of diabetic nephropathy: II. The transforming growth factor-beta system and diabetic nephropathy lesions in type 1 diabetes.

Transforming growth factor-beta (TGF-beta) may be critical in the development of diabetic nephropathy (DN), and genetic predisposition is an important determinant of DN risk. We evaluated mRNA expression levels of TGF-beta system components in cultured skin fibroblasts (SFs) from type 1 diabetic patients with fast versus slow development of DN. A total of 125 long-standing type 1 diabetic patients were ranked by renal mesangial expansion score (MES) based on renal biopsy findings and diabetes duration. Patients in the highest quintile of MES who were also microalbuminuric or proteinuric (n = 16) were classified as "fast-track" for DN, while those in the lowest quintile who were also normoalbuminuric (n = 23) were classsified as "slow-track" for DN. Twenty-five normal subjects served as control subjects. SFs were cultured in medium with 25 mmol/l glucose for 36 h. SF mRNA expression levels for TGF-beta1, TGF-beta type II receptor (TGF-beta RII), thrombospondin-1, and latent TGF-beta binding protein-1 (LTBP-1) were measured by real-time RT-PCR. LTBP-1 mRNA expression was reduced in slow-track (0.99 +/- 0.38) versus fast-track patients (1.65 +/- 0.52, P = 0.001) and control subjects (1.41 +/- 0.7, P = 0.025). mRNA levels for TGF-beta1, TGF-beta RII, and thrombospondin-1 were similar in the three groups. Reduced LTBP-1 mRNA expression in SFs from slow-track patients may reflect genetically determined DN protection and suggests that LTBP-1 may be involved in the pathogenesis of DN through the regulation of TGF-beta activity.

ACE and PC-1 gene polymorphisms in normoalbuminuric Type 1 diabetic patients: a 10-year prospective study.

The aim of this study was to analyze the role of ACE gene insertion/deletion (I/D) and PC-1 gene K121Q polymorphisms in the changes of glomerular filtration rate (GFR), urinary albumin excretion rate (UAER), and blood pressure (BP) levels in a cohort of normoalbuminuric Type 1 diabetic patients. This is a 10.2+/-2.0-year prospective study of 30 normotensive normoalbuminuric Type 1 diabetic patients. UAER (immunoturbidimetry), GFR ((51)Cr-EDTA single injection technique), GHb (ion exchange chromatography), and BP levels were measured at baseline and at 1.7+/-0.6-year intervals. The presence of ACE gene I/D and PC-1 gene K121Q polymorphisms was determined by polymerase chain reaction (PCR) and restriction enzyme techniques. Three patients developed diabetic nephropathy (DN), all carriers of allele D. The presence of allele D was the only predictor (R(2)=.15, F=4.92, P=.035) of the observed GFR decline (-0.29+/-0.34 ml/min/month, P<.05). UAER increased during the study (log UAER=0.0275+/-0.042 microg/min/month, P=.002) and was associated with baseline UAER levels only (R(2)=.17, F=5.72, P=.024). A significant increase (P<.05) in cases of hypertension and retinopathy were observed in ID/DD (n=19) and not in II patients (n=11). Patients with the KQ/QQ genotype (n=8) presented a significant increase (P=.045) in new cases of retinopathy. In conclusion, the presence of the ACE gene D allele in this sample of normoalbuminuric normotensive Type 1 diabetic patients was associated with a higher proportion of microvascular complications and hypertension.

Microalbuminuria in patients with cystic fibrosis.

OBJECTIVE: We previously found that microalbuminuria (MA) is present in 14% of patients with long-standing cystic fibrosis-related diabetes (CFRD). However, others have reported much higher rates of MA in CF patients with and without diabetes (32-67%), suggesting this test is not sufficiently specific for diabetic nephropathy screening in CF. We investigated transient (TMA) and persistent (PMA) microalbuminuria in CF patients to resolve these contradictory findings. RESEARCH DESIGN AND METHODS: We reviewed 1,449 outpatient urinary albumin measurements from 467 patients aged ≥10 years, which were collected over a decade. TMA was defined as a single episode of MA that subsequently was resolved. PMA was defined as two consecutive or two out of three consecutive measurements in the MA range. RESULTS: The prevalence of TMA that subsequently was resolved in CF patients was similar to the general population. It was found in 7.6% of patients, including 5% of youth (aged 10-17 years) and 9% of adults. PMA was found in 6.1% of the overall CF population, including 2% of youth and 8% of adults. The odds of PMA were increased sevenfold in patients with CFRD (95% CI 2.5-20, P=0.0002) and 48-fold in patients with both CFRD and organ transplant (95% CI 13-177, P<0.0001). The five patients with PMA in the absence of CFRD or transplant included two youths with presumed benign orthostatic MA and three adults with hypertension. CONCLUSIONS: The spot urine albumin-to-creatinine ratio is specific enough to be a valid screening test for diabetic kidney disease in CFRD.

Risk factors for recurrence of tuberculosis.

OBJECTIVE: To identify risk factors for recurrence of tuberculosis. METHODS: We studied a cohort of 610 patients with active pulmonary tuberculosis who were enrolled for treatment between 1989 and 1994 and cured using a three-drug treatment regimen of rifampin, isoniazid and pyrazinamide (RHZ). The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of disease, diabetes mellitus, alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and medication doses. In order to detect recurrence, the patients were monitored through the Rio Grande do Sul State Healt Department Information System for 7.7 +/- 2.0 years after cure. Data were analyzed using the Student's t-test, the chi-square test or Fisher's exact test, and Cox regression models. RESULTS: There were 26 cases of recurrence (4.3%), which corresponds to 0.55/100 patients-year. The recurrence rate was 5.95 and 0.48/100 patients-year in HIV-positive and HIV-negative patients, respectively (p < 0.0001). In the multivariate analysis, HIV infection [RR = 8.04 (95% CI: 2.35-27.50); p = 0.001] and noncompliance [RR = 6.43 (95% CI: 2.02-20.44); p = 0.002] proved to be independently associated with recurrence of tuberculosis. CONCLUSIONS: Recurrence of tuberculosis was more common in HIV-positive patients and in patients who did not comply with the self-administered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation of a post-treatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with tuberculosis treatment would be the use of supervised treatment.

Differences in the clinical and radiological presentation of intrathoracic tuberculosis in the presence or absence of HIV infection.

OBJECTIVE: To describe the differences in the clinical and radiological presentation of tuberculosis in the presence or absence of HIV infection. METHODS: A sample of 231 consecutive adults with active pulmonary tuberculosis admitted to a tuberculosis hospital were studied, assessing HIV infection, AIDS, and associated factors, as well as re-evaluating chest X-rays. RESULTS: There were 113 HIV-positive patients (49%) Comparing the 113 HIV-positive patients (49%) to the 118 HIV-negative patients (51%), the former presented a higher frequency of atypical pulmonary tuberculosis (pulmonary lesions accompanied by intrathoracic lymph node enlargement), hematogenous tuberculosis, and pulmonary tuberculosis accompanied by superficial lymph node enlargement, as well as presenting less pulmonary cavitation. The same was found when HIV-positive patients with AIDS were compared to those without AIDS. There were no differences between the HIV-positive patients without AIDS and the HIV-negative patients. Median CD4 counts were lower in HIV-positive patients with intrathoracic lymph node enlargement and pulmonary lesions than in the HIV-positive patients with pulmonary lesions only (47 vs. 266 cells/mm3; p < 0.0001), in HIV-positive patients with AIDS than in those without AIDS (136 vs. 398 cells/mm3; p < 0.0001) and in patients with atypical pulmonary tuberculosis than in those with other forms of tuberculosis (31 vs. 258 cells/mm3; p < 0.01). CONCLUSION: Atypical forms and disseminated disease predominate among patients with advanced immunosuppression. In regions where TB prevalence is high, the presence of atypical pulmonary tuberculosis or pulmonary tuberculosis accompanied by superficial lymph node enlargement should be considered an AIDS-defining condition.

Cellular basis of diabetic nephropathy: IV. Antioxidant enzyme mRNA expression levels in skin fibroblasts of type 1 diabetic sibling pairs.

BACKGROUND: Blunted cultured skin fibroblast (SF) antioxidant enzyme responses to hyperglycaemia are associated with diabetic nephropathy risk. The present study explores whether this association is, at least in part, genetically determined. METHODS: We measured glomerular structure and SF mRNA expression for catalase and glutathione peroxidase in 21 sibling pairs concordant for type 1 diabetes. All patients had four or more (mean 21.5) years of diabetes and glomerular filtration rate>40 ml/min/1.73 m2. Thirty-four patients were normoalbuminuric, four were microalbuminuric, three were proteinuric and one was not classifiable. Heritability of patient characteristics was assessed by intra-class correlation and by a genetic variance component model. RESULTS: Mesangial fractional volume, mesangial matrix fractional volume, glomerular basement membrane width and surface density of peripheral glomerular basement membrane per glomerulus were significantly correlated in these sibling pairs. Catalase mRNA expression levels were also related and highly heritable in these sibling pairs. The association between sibship and glutathione peroxidase mRNA expression levels did not reach statistical significance. CONCLUSIONS: This study suggests that SF catalase mRNA expression levels, known to be associated with diabetic nephropathy risk, are in part genetically determined.

An increase in the cell component of the cortical interstitium antedates interstitial fibrosis in type 1 diabetic patients.

BACKGROUND: Interstitial expansion is important in the progression of a variety of kidney diseases, including diabetic nephropathy (DN). However, the interstitial elements that constitute interstitial expansion in DN are unknown and are the subject of this report. METHODS: Interstitial composition was analyzed in 15 long-standing type 1 diabetic patients, 8 with mild ( congruent with 1.5 x normal) and 7 with moderate ( congruent with 2 x normal) increases in cortical interstitial fractional volume [Vv(Int/cortex]. The mild group was 29 +/- 5 (mean +/- SD) years old with diabetes duration of 17 +/- 5 years. The moderate group was older (41 +/- 7 years; P < 0.03), had longer diabetes duration (28 +/- 7 years; P = 0.002), lower creatinine clearance (90 +/- 14 mL/min/1.73 m2 vs. 109 +/- 18 mL/min/1.73 m2; P = 0.05) and used antihypertensive medications more frequently (0/8 vs. 4/7; P < 0.03) compared to the mild group. Age- and gender-matched normal controls (N = 9) also were studied. Interstitial composition was evaluated by morphometric analysis of electron microscopic (EM) micrographs systematically obtained without bias at high (x 7500) and low (x 1500) magnification. RESULTS: Mild interstitial expansion was associated with an congruent with 50% increase in fractional volume of interstitial cells (P < 0.001) and congruent with 70% increase in fractional volume of interstitial nuclei (P < 0.01). Numerical density of interstitial nuclei was normal in these patients, suggesting that the interstitial cells might be larger rather than simply more numerous. An increase over normal in the interstitial fractional volume of fibrillary collagen of congruent with 50% was seen only with moderate expansion (P < 0.001), when creatinine clearance was already decreased. Interstitial expansion was associated with a decrease in volume and surface of peritubular capillaries as well as with a reduction in surface ratio of capillaries to tubules. CONCLUSIONS: In contrast to early mesangial expansion where matrix accumulation plays a dominant role, mild interstitial expansion in long-standing type 1 diabetic patients is largely due to an increase in the cell component of the interstitium. Increased fractional volume of interstitial fibrillary collagen is only seen at later stages of the disease, when the glomerular filtration rate is already reduced. Different pathogenetic processes may be operative in early diabetic glomerular and interstitial diseases.

Fatores de risco para a recidiva da tuberculose / Risk factors for recurrence of tuberculosis

OBJETIVO: Identificar fatores de risco para a recidiva da tuberculose. MÉTODOS: Estudou-se uma coorte de 610 pacientes com tuberculose pulmonar bacilífera inscritos para tratamento entre 1989 e 1994 e curados com o esquema contendo rifampicina, isoniazida e pirazinamida (RHZ). Avaliaram-se os seguintes fatores de risco: idade, sexo, cor, duração dos sintomas, cavitação das lesões, extensão da doença, diabetes melito, alcoolismo, infecção pelo HIV, negativação tardia do escarro, adesão ao tratamento e doses dos fármacos. Para detecção das recidivas, os pacientes foram seguidos por 7,7 ± 2,0 anos, após a cura, pelo sistema de informação da Secretaria Estadual da Saúde do Rio Grande do Sul. Nas análises utilizaram-se os testes t de Student, qui-quadrado ou exato de Fisher e a regressão de Cox. RESULTADOS: Ocorreram 26 recidivas (4,3 por cento), correspondendo a 0,55/100 pessoas-ano. A taxa de recidiva foi de 5,95 e 0,48/100 pessoas-ano, respectivamente, nos pacientes HIV-positivos e nos HIV-negativos (p < 0,0001). Na análise multivariada, a infecção pelo HIV [RR = 8,04 (IC95 por cento: 2,35-27,50); p = 0,001] e o uso irregular da medicação [RR = 6,43 (IC95 por cento: 2,02-20,44); p = 0,002] mostraram-se independentemente associados às recidivas. CONCLUSÕES: A recidiva da tuberculose foi mais freqüente nos pacientes HIV-positivos e naqueles que não aderiram ao tratamento auto-administrado (esquema-RHZ). Pacientes com pelo menos um destes fatores de risco poderão se beneficiar com a implantação de um sistema de vigilância pós-tratamento para detecção precoce de recidivas. Para prevenir a não-adesão ao tratamento da tuberculose, a alternativa seria a utilização de tratamento supervisionado.

OBJECTIVE: To identify risk factors for recurrence of tuberculosis. METHODS: We studied a cohort of 610 patients with active pulmonary tuberculosis who were enrolled for treatment between 1989 and 1994 and cured using a three-drug treatment regimen of rifampin, isoniazid and pyrazinamide (RHZ). The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of disease, diabetes mellitus, alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and medication doses. In order to detect recurrence, the patients were monitored through the Rio Grande do Sul State Healt Department Information System for 7.7 ± 2.0 years after cure. Data were analyzed using the Student's t-test, the chi-square test or Fisher's exact test, and Cox regression models. RESULTS: There were 26 cases of recurrence (4.3 percent), which corresponds to 0.55/100 patients-year. The recurrence rate was 5.95 and 0.48/100 patients-year in HIV-positive and HIV-negative patients, respectively (p < 0.0001). In the multivariate analysis, HIV infection [RR = 8.04 (95 percent CI: 2.35-27.50); p = 0.001] and noncompliance [RR = 6.43 (95 percent CI: 2.02-20.44); p = 0.002] proved to be independently associated with recurrence of tuberculosis. CONCLUSIONS: Recurrence of tuberculosis was more common in HIV-positive patients and in patients who did not comply with the self-administered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation of a post-treatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with tuberculosis treatment would be the use of supervised treatment.

Diferenças na apresentação clínico-radiológica da tuberculose intratorácica segundo a presença ou não de infecção por HIV / Differences in the clinical and radiological presentation of intrathoracic tuberculosis in the presence or absence of HIV infection

OBJETIVO: Descrever as diferenças na apresentação clínico-radiológica da tuberculose segundo a presença ou não de infecção por HIV. MÉTODOS: Examinou-se uma amostra consecutiva de 231 adultos com tuberculose pulmonar bacilífera internados em hospital de tisiologia. A presença de infecção por HIV, AIDS e fatores associados foi avaliada e as radiografias de tórax foram reinterpretadas. RESULTADOS: Havia 113 pacientes HIV-positivos (49 por cento). Estes pacientes apresentavam maior freqüência de tuberculose pulmonar atípica (lesões pulmonares associadas a linfonodomegalias intratorácicas), tuberculose de disseminação hemática e tuberculose pulmonar associada a linfonodomegalias superficiais e menor freqüência de lesões pulmonares escavadas do que os pacientes HIV-negativos. Isto também ocorreu entre os pacientes HIV-positivos com AIDS e os HIV-positivos sem AIDS. Não se observaram diferenças entre os pacientes HIV-positivos sem AIDS e os HIV-negativos. Os valores medianos de CD4 foram menores nos pacientes HIV-positivos com linfonodomegalias intratorácicas e lesões pulmonares em comparação aos com lesões pulmonares exclusivas (47 vs. 266 células/mm³; p < 0,0001), nos pacientes HIV-positivos com AIDS em comparação aos HIV-positivos sem AIDS (136 vs. 398 células/mm³; p < 0,0001) e nos pacientes com tuberculose pulmonar atípica em comparação aos com outros tipos de tuberculose (31 vs. 258 células/mm³; p < 0,01). CONCLUSÃO: Há um predomínio de formas atípicas e doença disseminada entre pacientes com imunossupressão avançada. Em locais com alta prevalência de tuberculose, a presença de tuberculose pulmonar atípica ou de tuberculose pulmonar associada a linfonodomegalias superficiais é definidora de AIDS.

OBJECTIVE: To describe the differences in the clinical and radiological presentation of tuberculosis in the presence or absence of HIV infection. METHODS: A sample of 231 consecutive adults with active pulmonary tuberculosis admitted to a tuberculosis hospital were studied, assessing HIV infection, AIDS, and associated factors, as well as re-evaluating chest X-rays. RESULTS: There were 113 HIV-positive patients (49 percent) Comparing the 113 HIV-positive patients (49 percent) to the 118 HIV-negative patients (51 percent), the former presented a higher frequency of atypical pulmonary tuberculosis (pulmonary lesions accompanied by intrathoracic lymph node enlargement), hematogenous tuberculosis, and pulmonary tuberculosis accompanied by superficial lymph node enlargement, as well as presenting less pulmonary cavitation. The same was found when HIV-positive patients with AIDS were compared to those without AIDS. There were no differences between the HIV-positive patients without AIDS and the HIV-negative patients. Median CD4 counts were lower in HIV-positive patients with intrathoracic lymph node enlargement and pulmonary lesions than in the HIV-positive patients with pulmonary lesions only (47 vs. 266 cells/mm³; p < 0.0001), in HIV-positive patients with AIDS than in those without AIDS (136 vs. 398 cells/mm³; p < 0.0001) and in patients with atypical pulmonary tuberculosis than in those with other forms of tuberculosis (31 vs. 258 cells/mm³; p < 0.01). CONCLUSION: Atypical forms and disseminated disease predominate among patients with advanced immunosuppression. In regions where TB prevalence is high, the presence of atypical pulmonary tuberculosis or pulmonary tuberculosis accompanied by superficial lymph node enlargement should be considered an AIDS-defining condition.

Value of diagnostic tools for myocardial ischemia used in routine clinical practice to predict cardiac events in patients with type 2 diabetes mellitus: a prospective study

OBJETIVO: Analisar os testes usados na prática clínica de rotina para diagnóstico de isquemia miocárdica na predição do desenvolvimento de eventos cardíacos em pacientes com diabetes mellitus tipo 2 (DM2). MÉTODOS: A ocorrência de eventos cardíacos (novo infarto do miocárdio [IM], procedimentos de re-vascularização miocárdica, insuficiência cardíaca congestiva, edema agudo de pulmão, morte súbita e morte após IM ou edema pulmonar) foi avaliada prospectivamente em uma coorte de 135 pacientes com DM2 após até 7 anos de acompanhamento. Na condição basal, a doença arterial coronariana (DAC) foi avaliada pelo questionário cardiovascular da OMS, eletrocardiograma de repouso e cintilografia do miocárdio sob stress. RESULTADOS: 48 eventos cardíacos foram observados em 41 pacientes (10,5 eventos/100 pacientes-ano). No modelo de risco proporcional de Cox apenas a presença de sintomas de DAC no questionário cardiovascular da OMS isoladamente (RR= 2,13, 95% CI 1,11­4,07, P= 0,022) ou em combinação com anormalidades no ECG de repouso (RR= 2,03, 95% CI 1,05­3,92, P= 0,034) ou cintilografia do miocárdio (RR= 1,89, 95% CI 1,001­3,57, P= 0,050) predisseram eventos cardíacos, ajustados para a glicemia de jejum, pressão arterial média, índice de massa corporal, doença vascular periférica e nefropatia diabética. CONCLUSÃO: O questionário cardiovascular da OMS, um procedimento simples para o diagnóstico da DAC, é um preditor significativo de eventos cardíacos em pacientes com DM2.

Hipertiroidismo com fibrilaçäo atrial: é necessário anticoagular todos os pacientes? / Hyperthyroidism with atrial fibrillation: is it necessary to make anticoagulation in all the patients?

O emprego da anticoagulaçao oral em pacientes com hipertiroidismo e fibrilaçao atrial ainda é controverso. O objetivo da presente revisao é propor uma conduta contemporânea sobre a necessidade de anticoagulaçao em pacientes com hipertiroidismo e fibrilaçao atrial, com base no conhecimento atual dos fatores de risco associados ao desenvolvimento de fenômenos troboembólicos. A fibrilaçao atrial ocorre em cerca de 13 a 35 por cento dos pacientes com hipertiroidismo, especialmente entre os pacientes com insuficiência cardíaca e após os 60 anos de idade. Provavelmente, há uma associaçao entre as manifestaçoes cardiovasculares do hipertiroidismo e a doença cardíaca intrínseca. A reversao para o rítmo sinusal ocorre espontaneamente em 60 por cento dos pacientes, usualmente cerca de 3 semanas após ter sindo atingido o eutiroidismo. Alguns estudos observacionais em pacientes com hipertiroidismo sugerem que estes indivíduos sejam mais suscetíveis ao desenvolvimento de fenômenos tromboembólicos. Entretanto, os pacientes com hipertiroidismo nao apresentam qualquer peculiaridade que justifique esta suposta suscetibilidade. Assim, estas observaçoes devem ser analizadas à luz de recentes ensaios prospectivos e randomizados que identificaram os seguintes fatores de risco para o desenvolvimento de acidente vascular cerebral isquêmico em pacientes com fibrilaçao atrial: idade maior que 60 anos; fenômeno tromboembólico prévio; diabete mélito; história de hipertensao arterial sistêmica; presença de insuficiência cardíaca; e, na ecocardiografia, átrio esquerdo aumentado (> 2,5 cm/m2 de superfície corporal) e disfunçao sistólica do ventrículo esquerdo. Embora nao existam estudos prospectivos e randomizados de pacientes com hipertiroidismo e fibrilaçao atrial, sugerimos que a anticoagulaçao oral seja empregada apenas em pacientes que apresentem pelo menos um dos fatores de risco mencionados. Pacientes sem fatores de risco podem ser tratados com ácido acetil salicílico.