Causes of hypercalcemia in renal transplant recipients: persistent hyperparathyroidism and others.

Hypercalcemia is common in patients after kidney transplantation (KTx) and is associated with persistent hyperparathyroidism in the majority of cases. This retrospective, single-center study evaluated the prevalence of hypercalcemia after KTx. KTx recipients were evaluated for 7 years after receiving kidneys from living or deceased donors. A total of 301 patients were evaluated; 67 patients had hypercalcemia at some point during the follow-up period. The median follow-up time for all 67 patients was 62 months (44; 80). Overall, 45 cases of hypercalcemia were classified as related to persistent post-transplant hyperparathyroidism (group A), 16 were classified as "transient post-transplant hypercalcemia" (group B), and 3 had causes secondary to other diseases (1 related to tuberculosis, 1 related to histoplasmosis, and 1 related to lymphoma). The other 3 patients had hypercalcemia of unknown etiology, which is still under investigation. In group A, the onset of hypercalcemia after KTx was not significantly different from that of the other groups, but the median duration of hypercalcemia in group A was 25 months (12.5; 53), longer than in group B, where the median duration of hypercalcemia was only 12 months (10; 15) (P<0.002). The median parathyroid hormone blood levels around 12 months after KTx were 210 pg/mL (141; 352) in group A and 72.5 pg/mL (54; 95) in group B (P<0.0001). Hypercalcemia post-KTx is not infrequent and its prevalence in this center was 22.2%. Persistent hyperparathyroidism was the most frequent cause, but other important etiologies must not be forgotten, especially granulomatous diseases and malignancies.

Causes of hypercalcemia in renal transplant recipients: persistent hyperparathyroidism and others

Hypercalcemia is common in patients after kidney transplantation (KTx) and is associated with persistent hyperparathyroidism in the majority of cases. This retrospective, single-center study evaluated the prevalence of hypercalcemia after KTx. KTx recipients were evaluated for 7 years after receiving kidneys from living or deceased donors. A total of 301 patients were evaluated; 67 patients had hypercalcemia at some point during the follow-up period. The median follow-up time for all 67 patients was 62 months (44; 80). Overall, 45 cases of hypercalcemia were classified as related to persistent post-transplant hyperparathyroidism (group A), 16 were classified as "transient post-transplant hypercalcemia" (group B), and 3 had causes secondary to other diseases (1 related to tuberculosis, 1 related to histoplasmosis, and 1 related to lymphoma). The other 3 patients had hypercalcemia of unknown etiology, which is still under investigation. In group A, the onset of hypercalcemia after KTx was not significantly different from that of the other groups, but the median duration of hypercalcemia in group A was 25 months (12.5; 53), longer than in group B, where the median duration of hypercalcemia was only 12 months (10; 15) (P<0.002). The median parathyroid hormone blood levels around 12 months after KTx were 210 pg/mL (141; 352) in group A and 72.5 pg/mL (54; 95) in group B (P<0.0001). Hypercalcemia post-KTx is not infrequent and its prevalence in this center was 22.2%. Persistent hyperparathyroidism was the most frequent cause, but other important etiologies must not be forgotten, especially granulomatous diseases and malignancies.

Renal and extrarenal manifestations of autosomal dominant polycystic kidney disease.

The objective of the present study was to determine the frequency of the most common clinical features in patients with autosomal dominant polycystic kidney disease in a sample of the Brazilian population. The medical records of 92 patients with autosomal dominant polycystic kidney disease attended during the period from 1985 to 2003 were reviewed. The following data were recorded: age at diagnosis, gender, associated clinical manifestations, occurrence of stroke, age at loss of renal function (beginning of dialysis), and presence of a family history. The involvement of abdominal viscera was investigated by ultrasonography. Intracranial alterations were prospectively investigated by magnetic resonance angiography in 42 asymptomatic patients, and complemented with digital subtraction arteriography when indicated. Mean age at diagnosis was 35.1 +/- 14.9 years, and mean serum creatinine at referral was 2.4 +/- 2.8 mg/dL. The most frequent clinical manifestations during the disease were arterial hypertension (63.3%), lumbar pain (55.4%), an abdominal mass (47.8%), and urinary infection (35.8%). Loss of renal function occurred in 27 patients (mean age: 45.4 +/- 9.5 years). The liver was the second organ most frequently affected (39.1%). Stroke occurred in 7.6% of the patients. Asymptomatic intracranial aneurysm was detected in 3 patients and arachnoid cysts in 3 other patients. In conclusion, the most common clinical features were lumbar pain, arterial hypertension, abdominal mass, and urinary infection, and the most serious complications were chronic renal failure and stroke. Both intracranial aneurysms and arachnoid cysts occurred in asymptomatic patients at a frequency of 7.14%.

Renal and extrarenal manifestations of autosomal dominant polycystic kidney disease

The objective of the present study was to determine the frequency of the most common clinical features in patients with autosomal dominant polycystic kidney disease in a sample of the Brazilian population. The medical records of 92 patients with autosomal dominant polycystic kidney disease attended during the period from 1985 to 2003 were reviewed. The following data were recorded: age at diagnosis, gender, associated clinical manifestations, occurrence of stroke, age at loss of renal function (beginning of dialysis), and presence of a family history. The involvement of abdominal viscera was investigated by ultrasonography. Intracranial alterations were prospectively investigated by magnetic resonance angiography in 42 asymptomatic patients, and complemented with digital subtraction arteriography when indicated. Mean age at diagnosis was 35.1 ± 14.9 years, and mean serum creatinine at referral was 2.4 ± 2.8 mg/dL. The most frequent clinical manifestations during the disease were arterial hypertension (63.3 percent), lumbar pain (55.4 percent), an abdominal mass (47.8 percent), and urinary infection (35.8 percent). Loss of renal function occurred in 27 patients (mean age: 45.4 ± 9.5 years). The liver was the second organ most frequently affected (39.1 percent). Stroke occurred in 7.6 percent of the patients. Asymptomatic intracranial aneurysm was detected in 3 patients and arachnoid cysts in 3 other patients. In conclusion, the most common clinical features were lumbar pain, arterial hypertension, abdominal mass, and urinary infection, and the most serious complications were chronic renal failure and stroke. Both intracranial aneurysms and arachnoid cysts occurred in asymptomatic patients at a frequency of 7.14 percent.

Transforming growth factor beta activity in urine of patients with type 2 diabetes and diabetic nephropathy.

Diabetic nephropathy (DN) is characterized structurally by progressive mesangial deposition of extracellular matrix (ECM). Transforming growth factor-ss (TGF-ss) is considered to be one of the major cytokines involved in the regulation of ECM synthesis and degradation. Several studies suggest that an increase in urinary TGF-ss levels may reflect an enhanced production of this polypeptide by the kidney cells. We evaluated TGF-ss in occasional urine samples from 14 normal individuals and 23 patients with type 2 diabetes (13 with persistent proteinuria >500 mg/24 h, DN, 6 with microalbuminuria, DMMA, and 4 with normal urinary albumin excretion, DMN) by enzyme immunoassay. An increase in the rate of urinary TGF-ss excretion (pg/mg U Creat.) was observed in patients with DN (296.07 +/- 330.77) (P<0.001) compared to normal individuals (17.04 +/- 18.56) (Kruskal-Wallis nonparametric analysis of variance); however, this increase was not observed in patients with DMMA (25.13 +/- 11.30) or in DMN (18.16 +/- 11.82). There was a positive correlation between the rate of urinary TGF-ss excretion and proteinuria (r = 0.70, alpha = 0.05) (Pearson's analysis), one of the parameters of disease progression.

Transforming growth factor beta activity in urine of patients with type 2 diabetes and diabetic nephropathy

Diabetic nephropathy (DN) is characterized structurally by progressive mesangial deposition of extracellular matrix (ECM). Transforming growth factor-ß (TGF-ß) is considered to be one of the major cytokines involved in the regulation of ECM synthesis and degradation. Several studies suggest that an increase in urinary TGF-ß levels may reflect an enhanced production of this polypeptide by the kidney cells. We evaluated TGF-ß in occasional urine samples from 14 normal individuals and 23 patients with type 2 diabetes (13 with persistent proteinuria >500 mg/24 h, DN, 6 with microalbuminuria, DMMA, and 4 with normal urinary albumin excretion, DMN) by enzyme immunoassay. An increase in the rate of urinary TGF-ß excretion (pg/mg UCreat.) was observed in patients with DN (296.07 + or - 330.77) (P<0.001) compared to normal individuals (17.04 + or - 18.56) (Kruskal-Wallis nonparametric analysis of variance); however, this increase was not observed in patients with DMMA (25.13 + or - 11.30) or in DMN (18.16 + or - 11.82). There was a positive correlation between the rate of urinary TGF-ß excretion and proteinuria (r = 0.70, a = 0.05) (Pearson's analysis), one of the parameters of disease progression.

Candidíase em pacientes transplantados renais / Candidiasis in kidney transplant patients

O objetivo do trabalho foi verificar a prevalência de candidíase em transplantados renais. Foram avaliados os prontuários dos pacientes transplantados no Hospital das Clínicas de Ribeirão Preto de fevereiro de 1968 a fevereiro de 1995. Nesse período foram transplantados 620 pacientes. Destes, 87 apresentaram 107 episódios de candidíase. Locais mais acometidos: trato urinário com 55 episódios, trato respiratório com 28, e trato gastrointestinal com 16. O agente etiológico mais freqüente foi C. albicans com 65 casos seguido de C. tropicalis com 12 e C. glabrata com 11 casos. As infecções do trato urinário mostraram incidência maior (61,7%) nos primeiros 6 meses. A maioria se apresentou clínicamente como infecção bacteriana. No trato respiratório, as infecções foram caracterizadas por recuperação do agente no escarro. No trato gastrointestinal, 9/16 episódios foram esofágicos, com epigastralgia, dor retroesternal, às vezes acompanhados de candidíase oral ou odinofagia. Nos outros episódios o agente foi recuperado nas fezes com quadro clínico de gastroenterite. Nas infecções dos tratos urinário e respiratório, houve associação da candidíase com antibioticoterapia prévia (76% e 67% respectivamente), além de infecções bacterianas concomitantes (34% e 64% respectivamente). As infecções por Candida sp tiveram prevalência geral em torno de 14,5%. A localização predominante foi no trato urinário e, em seguida, nos tratos respiratório e gastrointestinal, apresentando alto índice de associação com antibioticoterapia prévia e infecções bacterianas.

The medical records of 620 patients submitted to renal transplant from February 1968 to February 1995 were surveyed for Candida infection. Of these, 87 presented 107 episodes of candidiasis. In 42.9% the infection appeared up to 6 months after the transplant. The most frequent involved sites were: urinary tract, respiratory tract, and gastrointestinal tract. The most frequent etiological agents were: C. albicans, C. tropicalis and C. glabrata. Most urinary tract infections occurred in the first 6 months (61.7%) and manifested clinically as a bacterial infection. In the respiratory tract infections were characterized by isolation of the agent in sputum. In the gastrointestinal infections, 9/16 episodes were esophageal. There were 3 deaths directly related to Candidiasis (one pulmonary and 2 disseminated cases). In the urinary tract, and respiratory tract infections there was association of candidiasis with previous antibiotic treatment (76% and 67%, respectively), and with concomitant bacterial infections (34% and 64%, respectively). The overall prevalence of Candida infections was 14.5%. The predominant location was in the urinary tract (51.0%), followed by the respiratory (26.0%) and gastrointestinal tract (15.0%), with a high rate of association with previous antibiotic treatment and bacterial infections.

Use of ciprofloxacin as a prophylactic agent in urinary tract infections in renal transplant recipients.

The most common form of bacterial infection in renal transplant recipients is urinary tract infection (UTI), and some studies have shown that prophylaxis can reduce this incidence. In the present investigation we evaluated 80 patients submitted to renal transplantation at the Renal Transplant Unit of the University Hospital of Ribeirao Preto, SP. The study was prospective, double blind and randomized. The patients were divided into two groups, one receiving placebo and the other ciprofloxacin at the dose of 250 mg twice a day for the first 10 d and 250 mg/d for 6 months after transplantation. Of the 41 patients who received ciprofloxacin 28 completed the study, and of the 39 patients who received placebo 30 completed the study. The largest number of UTI occurred in the placebo group, with a significant difference from the ciprofloxacin group during the first month after surgery (p < 0.05). In the group treated with ciprofloxacin, only 6/40 patients (15%) developed UTI, as opposed to 19/39 (48.7%) for the placebo group. The total number of infectious episodes was higher in the placebo group (26) than in the ciprofloxacin group (12). The medication was well tolerated throughout the study period.

[Candidiasis in kidney transplant patients]. / Candidíase em pacientes transplantados renais.

The medical records of 620 patients submitted to renal transplant from February 1968 to February 1995 were surveyed for Candida infection. Of these, 87 presented 107 episodes of candidiasis. In 42.9% the infection appeared up to 6 months after the transplant. The most frequent involved sites were: urinary tract, respiratory tract, and gastrointestinal tract. The most frequent etiological agents were: C. albicans, C. tropicalis and C. glabrata. Most urinary tract infections occurred in the first 6 months (61.7%) and manifested clinically as a bacterial infection. In the respiratory tract infections were characterized by isolation of the agent in sputum. In the gastrointestinal infections, 9/16 episodes were esophageal. There were 3 deaths directly related to Candidiasis (one pulmonary and 2 disseminated cases). In the urinary tract, and respiratory tract infections there was association of candidiasis with previous antibiotic treatment (76% and 67%, respectively), and with concomitant bacterial infections (34% and 64%, respectively). The overall prevalence of Candida infections was 14.5%. The predominant location was in the urinary tract (51.0%), followed by the respiratory (26.0%) and gastrointestinal tract (15.0%), with a high rate of association with previous antibiotic treatment and bacterial infections.

Effect of hemodialysis on peripheral glucose metabolism of patients with chronic renal failure.

Glucose intolerance has been shown in patients with chronic renal failure (CRF), probably associated with insulin resistance in peripheral tissues. The present study was thus designed to investigate the effect of hemodialysis on peripheral muscle glucose metabolism of patients with CRF. Nine normal subjects and 6 patients with CRF were studied after an overnight fast (12-14 h) and during 3 h after ingestion of 75 g of glucose. Peripheral glucose metabolism was analyzed by the forearm technique to estimate the muscle exchange of substrates combined with indirect calorimetry. The CRF patients were studied before and after at least 1 month of hemodialysis treatment. Plasma glucose levels (arterial and venous) were higher in uremic patients before dialysis than in normal controls. After the dialysis therapy there was improvement in the glycemic profile of the CRF patients. Decreased forearm muscle glucose uptake was observed in the uremic patients before dialysis compared to the normal subjects (234 +/- 71 vs. 858 +/- 52 mumol/100 ml forearm . 3 h, p < 0.05) with diminished nonoxidative glucose metabolism (128 +/- 78 vs. 686 +/- 58 mumol/100 ml forearm . 3 h, p < 0.05). After the hemodialysis treatment of the CRF patients, the forearm glucose uptake and the nonoxidative glucose metabolism increased significantly to values of 527 +/- 64 and 384 +/- 87 mumol/100 ml forearm . 3 h, respectively. Muscle glucose oxidation did not differ significantly between normals and CRF patients before and after dialysis, as well as the serum insulin levels. These data demonstrate that insulin resistance in the presence of chronic uremia is accompanied by impaired muscle glucose uptake and nonoxidative glucose metabolism, which are significantly improved by the hemodialysis treatment.

Peripheral glucose metabolism in patients with chronic renal failure.

The present study was designed to determine the effect of chronic renal failure on forearm muscle glucose uptake and oxidation during the postabsorptive state and after an oral glucose challenge. Twelve normal subjects and sixteen patients with chronic renal failure were studied after an overnight fast (12-14 h) and for 3 h after the ingestion of 75 g of glucose. Peripheral glucose metabolism was analyzed by the forearm technique to estimate muscle exchange of substrate combined with indirect calorimetry. Decreased forearm glucose uptake was observed in uremic patients compared to normal subjects (91.5 +/- 11.4 vs 154.8 +/- 7.8 mg 100 ml forearm-1 3 h-1) with diminished nonoxidative glucose metabolism (69.4 +/- 12.1 vs 117.2 +/- 12.8 mg 100 ml forearm-1 3 h-1). Muscle glucose oxidation did not differ significantly between groups. Both serum free fatty acid levels and lipid oxidation rates were similar in the normal subjects and the uremic patients, and declined in a similar fashion after glucose ingestion. Basal serum insulin levels did not differ significantly between normal and uremic patients, whereas the insulinemic response to glucose load was greater among the patients with chronic renal failure. These data show that insulin resistance occurring in patients with chronic renal failure is accompanied by impaired muscle glucose uptake and nonoxidative glucose metabolism.

Peripheral glucose metabolism in patients with chronic renal failure

The present study was designed to determine the effect of chronic renal failure on forearm muscle glucose uptake and oxidation during the postabsorptive state and after an oral glucose challenge. Twelve normal subjects and sixteen patients with chronic renal failure were studied after an overnight fast (12-14h) and for 3h after the ingestion of 75g glucose. Peripheral glucose metabolism was analyzed by the forearm technique to estimate muscle exchange of substrate combined with indirect calorimetry. decreased forearm glucose uptake was observed in uremic patients compared to normal subjects (9l.5 ñ 11,4 vs 154.8 ñ 7.8mg 100 ml forearm -1 3h-1) with diminished nonoxidative glucose metabolism (69.4 ñ 12.1 vs 117.2 ñ 12.8mg 100 ml forearm-1 3h-1). Muscle glucose oxidation did not difer significantly between groups. Both serum free fatty acid levels and lipid oxidation rates were similar in the normal subjects and the uremic patients, and declined in a similar fashion after glucose ingestion. Basal serum insulin levels did not differ significantly between normal and uremic patients, whereas the insulinemic response to glucose load was greater among the patients with chronic renal failure. These data show that resistance occurring in patients with chronic renal failure is accompanied by impaired muscle glucose uptake and nonoxidative glucose metabolism

Hepatitis B virus infection in hemodialysis units: clinical features, epidemiological markers and general control measures.

1. A total of 140 patients and 41 staff members were submitted to periodic testing for HBsAg from January 1979 to December 1984 at the Hemodialysis Unit of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo. Twenty-two HBsAg-positive subjects were detected during this period, 15 of whom had acquired the hepatitis B virus (HBV) in the Unit (10 patients and 5 staff-members). 2. HBV prevalence was not uniform throughout the period of study, with an increase of hepatitis B cases occurring after September 1981 and reaching epidemic proportions which lasted until January 1983. 3. Among the preventive measures adopted, epidemiological alert, grouping patients and workers according to susceptibility or immunity to the infection, and setting up a separate area for the dialysis of infected patients appeared to be most important. 4. The use of HBV subtyping as an epidemiological marker permitted us to demonstrate that HBV was introduced into the Unit by chronic carrier patients and spread internally through the probable contamination of equipment and unit environment.

Influencia da glicose no liquido de dialise sobre os niveis sericos de colesterol, HDL colesterol e triglicerides em pacientes submetido a hemodialise. / Influence of glucose in the dialysis fluid on serum cholesterol, HDL cholesterol and triglycerides levels in patients subjected to hemodialysis

O trabalho avalia o efeito da glicose no liquido de dialese, na lipemia de 6 pacientes submetidos a hemodialise.Esses pacientes foram seguidos em um periodo de 6 meses, sem adicao de glicose no banho e em um 2o. periodo, tambem de 6 meses, com liquido contendo glicose numa concentracao de 200mg%. Nos dois periodos foram dosados colesterol, triglicerides e HDL colesterol A analise dos dados mostrou que nao houve diferenca significativa da lipemia no segundo periodo em relacao ao primeiro, indicando que a glicose no liquido de dialise nao influenciou os niveis da lipemia nesses pacientes

Antibody titers to Toxoplasma gondii in renal transplant patients.

Of 70 renal transplant patients submitted to the indirect immunofluorescence reaction test for toxoplasmosis, 16 (23%) had titers higher than 1/4,000, as compared to 0/41 for chronic hemodialysis patients and 0/50 for blood donors. The indirect immunofluorescence reaction titers in the renal transplant patients correlated with time since initiation of immunosuppressive therapy. Six percent (2/33) of the patients had been on immunosuppressors for less than one year, 30.7% (4/13) for 1 to 2 years, and 41.6% (10/24) for 2 or more years. The frequency of negative titers among the immunosuppressed patients was similar to that observed for blood donors and chronic hemodialysis patients. Fifty percent (8/16) of the patients with higher immunofluorescence reaction titers also had significantly high (greater than or equal to 320) positive titers in the complement fixation test. The results indicate that: 1) the immunosuppressive scheme used for the transplant patients may favor the reactivation of infection from latent Toxoplasma gondii foci, and 2) even though the patients were immunosuppressed, their antitoxoplasma antibody levels were high enough to be detected by the serologic test.

Influencia de dietas com carencias especificas de proteinas, potassio e magnesio sobre a capacidade de concentracao urinaria em ratos. / Influence of diets with specific protein, potassium and magnesium carence on the urinary concentration capacity in rats

Com o objetivo de realizar uma analise comparativa da capacidade urinaria, tres grupos de ratos, respectivamente, com carencia especifica de proteinas (GP), potassio (GK) e magnesio (GM), foram submetidos a uma prova padronizada de jejum total de 8 horas. Os resultados, confrontados com os do grupo de controle (GC),alimentados com dieta sem qualqer carencia, indicam que a metodologia utilizada discrimina as anormalidades de habilidade concentrante do rim; os animais GP e GK apresentaram nitidamente disturbios da capacidade de concentracao urinaria; a hipomagnesemia e a diminuicao do conteudo de potassio tissular renal nos ratos GP sao explicacoes plausiveis de pontenciacao da baixa concentracao de ureia no intersticio medular afetando a formacao TcH2O