Aspectos atuais na abordagem do refluxo vésico-ureteral / Advances in management of vesicoureteral reflux

The advances of knowledge in the clinical course of vesicoureteral reflux and its consequences have allowed an improvement in the management of this common disease in children. In the last years, several facts have contributed for a better understanding of the etiology of reflux and of the associated renal damage. Among them, it is important to emphasize the neonatal diagnosis of the reflux in the investigation of fetal hydronephrosis, the precise detection of renal damage by renal scintigraphy and the advances of the genetic of primary vesicoureteral reflux. The aim of this study is review these aspects and the recent clinical trials...

Os avanços no conhecimento do curso clínico do refluxo vésico-ureteral e de suas consequências têm permitido um aperfeiçoamento na abordagem dessa doença freqüente na faixa etária pediátrica. Nos últimos anos, vários fatores têm contribuído para uma maior compreensão da genêse do refluxo e do dano renal associado. Entre esses destacam-se o diagnóstico neonatal do refluxo na investigação da hidronefrose fetal, a detecção mais precisa do dano renal através da cintilografia renal e os avanços no conhecimento da genética do refluxo vésico-ureteral primário. Esta revisão enfatiza esses avanços e os mais recentes estudos prospectivos controlados abordando a questão do tratamento do refluxo...

Premature acute myocardial infarction in a child with nephrotic syndrome.

We report a case of acute myocardial infarction in a nephrotic child. A 7-year-old boy with a 4-year history of steroid-unresponsive nephrotic syndrome due to mesangial proliferation disease presented with acute vomiting and chest pain. An electrocardiogram showed ST elevation and pathological Q waves in leads consistent with anterior and septal myocardial infarction. Subsequent cardiac catheterization showed no evidence of atherosclerotic coronary artery disease, and thrombotic occlusion of the anterior descending coronary artery was the likely cause of the event. Myocardial scintigraphy showed extensive myocardial damage. The child had no long history of extreme hypercholesterolemia or hypertriglyceridemia. The case suggests that children with long-lasting nephrotic syndrome may be at increased risk for ischemic cardiovascular events, due to hyperlipidemia as well as a hypercoagulability state. The literature is reviewed regarding the relationship between nephrotic syndrome and the incidence of ischemic heart disease.

Prognostic factors in prenatally-detected posterior urethral valves: a multivariate analysis.

To identify prognostic factors associated with chronic renal insufficiency in children with posterior urethral valves (PUV), 22 children with PUV were submitted to a systematic protocol and prospectively followed. Prognostic factors associated with fetal echography and clinical and laboratory findings were studied on admission. Median follow-up was 76 months. The analysis was conducted in two steps: in univariate analysis, variables associated with adverse outcome were identified by the Kaplan-Meier method. The variables that were significantly associated with adverse outcome were then included in a multivariate analysis using the Cox model. Eleven patients (50%) developed chronic renal failure (CRF) during follow-up. After adjustment by the multivariate model, four factors were identified as independent predictors of adverse outcome: oligohydramnios (relative risk [RR] = 10.6, 95% CI = 2.7 - 77, P = 0.02), ventilatory support (RR = 6, 95% CI = 2 - 24, P = 0.01), urea higher than 40 mg/dl (RR = 3.7, 95% CI = 0.92 - 15.0, P = 0.06), and bilateral vesicoureteral reflux (VUR) (RR = 6.1, 95% CI = 1.25 - 30, P = 0.02). On the other hand, the presence of unilateral VUR was a protective factor against the development of CRF or death during follow-up (RR = 0.92, 95% CI = 0.87 - 0.98, P = 0.05).

Curso clínico da válvula de uretra posterior detectada intra-útero: seguimento a longo prazo / Clinical course of posterior urethra detected intra-uterus : long follow-up

Com o objetivo de avaliar o curso clínico da VUP identificada na vida fetal, foram estudadas 15 crianças prospectivamente com o objetivo de avaliar o curso clínico da válvula de uretra posterior (VUP). Pacientes com hidronefrose detectada no pré-natal foram avaliados no período pós-natal, submetidos a um protocolo sistemático e seguidos prospectivamente. Após início daquimioprofilaxia, a avaliaçäo de imagens consistiu de ultrasonografia (US), uretrocistografia miccional (UCM) e cintilografia estática por DMSA. Nos casos confirmados de VUP, as crianças foram submetidas a vesicostomia e seguidas com avaliaçöes clínicas e laboratoriais periódicas. Quinze meninos foram identificados como portadores de VUP entre 1989 e 1998. A média de idade do diagnóstico pré-natal foi de 30 meses. O tempo médio de seguimento foi de 40 meses. Das 15 crianças acompanhadas, 7 (47 porcento) evoluíram com isuficiência renal crônica (IRC) e 6 (40 porcento) faleceram. O óbito esteve associado à perda da funçäo renal (RR = 7, p=0,001). Apesar do diagnóstico precoce, a VUP continua a representar um desafio para a área da nefrologia pediátrica, e os riscos de perda da funçäo renal e de óbito se mantêm elevado