Rapidly progressive glomerulonephritis and acute kidney injury associated with cocaine use - Case report / Glomerulonefrite rapidamente progressiva e lesão renal aguda associada ao uso de cocaína - Relato de caso

ABSTRACT A wide spectrum of renal complications can occur with acute and chronic use of cocaine. Most cases are related to rhabdomyolysis, but other mechanisms are malignant hypertension, renal ischemia, and rapidly progressive glomerulonephritis (RPGN) associated-ANCA vasculitis. In recent years, the use of cocaine adulterated with levamisole has been associated with ANCA vasculitis and pauci-immune RPGN. RPGN is clinically manifested as a nephritic syndrome with a rapid and progressive decline in renal function, and its histopathological finding is the presence of crescents in more than 50% of the glomeruli. We report a case of a 38-year-old man chronic user of cocaine, alcohol, and cigarettes who had red urine, oliguria, swollen legs and eyelids, as well as the uremic symptoms anorexia, emesis, and mental confusion. He was admitted with acute kidney injury and performed six hemodialysis sessions during the first 16 days of hospitalization and then was transferred to a tertiary hospital for diagnostic investigation. Tests of ANF (antinuclear factor), ANCA, anti-DNA, serology for hepatitis B, C, and HIV virus were negative. A renal percutaneous biopsy revealed crescentic glomerulonephritis with mild tubular atrophy. The patient underwent pulse therapy with methylprednisolone (for 3 days) and cyclophosphamide. Then he maintained daily prednisone and monthly intravenous cyclophosphamide and evolved with progressive improvement of renal function.

RESUMO Um amplo espectro de complicações renais pode ocorrer com o uso agudo e crônico de cocaína. A maioria dos casos está relacionada à rabdomiólise, mas outros mecanismos são hipertensão maligna, isquemia renal e glomerulonefrite rapidamente progressiva (GNRP) associada à vasculite por ANCA. Nos últimos anos, o uso de cocaína adulterada com levamisol tem sido associado à vasculite por ANCA e GNRP pauci-imune. A GNRP se manifesta clinicamente como uma síndrome nefrítica, com um declínio rápido e progressivo da função renal, e seu achado histopatológico é a presença de crescentes em mais de 50% dos glomérulos. Relatamos um caso de um homem de 38 anos, usuário crônico de cocaína, álcool e cigarros que apresentava urina vermelha, oligúria, pernas e pálpebras inchadas, além dos sintomas urêmicos, anorexia, êmese e confusão mental. Foi internado com lesão renal aguda e realizou seis sessões de hemodiálise durante os primeiros 16 dias de internação, e depois foi transferido para um hospital terciário para investigação diagnóstica. Os testes de ANF (fator antinuclear), ANCA, anti-DNA, sorologia para vírus da hepatite B, C e HIV foram negativos. Uma biópsia percutânea renal revelou glomerulonefrite crescente, com leve atrofia tubular. O paciente foi submetido à pulsoterapia com metilprednisolona (por 3 dias) e ciclofosfamida. Em seguida, ele manteve a prednisona diária e a ciclofosfamida intravenosa mensal e evoluiu com melhora progressiva da função renal.

Rapidly progressive glomerulonephritis and acute kidney injury associated with cocaine use - Case report.

A wide spectrum of renal complications can occur with acute and chronic use of cocaine. Most cases are related to rhabdomyolysis, but other mechanisms are malignant hypertension, renal ischemia, and rapidly progressive glomerulonephritis (RPGN) associated-ANCA vasculitis. In recent years, the use of cocaine adulterated with levamisole has been associated with ANCA vasculitis and pauci-immune RPGN. RPGN is clinically manifested as a nephritic syndrome with a rapid and progressive decline in renal function, and its histopathological finding is the presence of crescents in more than 50% of the glomeruli. We report a case of a 38-year-old man chronic user of cocaine, alcohol, and cigarettes who had red urine, oliguria, swollen legs and eyelids, as well as the uremic symptoms anorexia, emesis, and mental confusion. He was admitted with acute kidney injury and performed six hemodialysis sessions during the first 16 days of hospitalization and then was transferred to a tertiary hospital for diagnostic investigation. Tests of ANF (antinuclear factor), ANCA, anti-DNA, serology for hepatitis B, C, and HIV virus were negative. A renal percutaneous biopsy revealed crescentic glomerulonephritis with mild tubular atrophy. The patient underwent pulse therapy with methylprednisolone (for 3 days) and cyclophosphamide. Then he maintained daily prednisone and monthly intravenous cyclophosphamide and evolved with progressive improvement of renal function.

A Arte como Estratégia de Coping em Tempos de Pandemia / Art as a Coping Strategy During the Pandemic

Resumo: Introdução: O momento da pandemia por Covid-19 tem um impacto direto na formação dos estudantes de Medicina, tanto pela modificação repentina na metodologia presencial para remota quanto pelo estresse e pela ansiedade gerados. A saúde mental dos estudantes necessita de estratégias de coping para que eles possam lidar com situações de extrema ansiedade. Relato de experiência: O grupo Estudo de Literatura e Arte na Medicina (Elam) criou, durante o período da pandemia, momentos de discussão de literatura por meio de produção textual e discussões em mídia social, e principalmente por meio de atividades artísticas com pintura em aquarela e artes plásticas, para lidar com os conflitos apresentados pelos alunos na quarentena. Foram 24 telas de aquarela, vídeos, telas de colagem em artes plásticas e textos de crônicas e poesias. Os temas abordados nos textos foram principalmente: amor (N = 2), envelhecer (N = 2), pecado e religiosidade (N = 4), ciclo da vida (N = 6), câncer, caos, sabedoria, mortalidade (N = 3), tempo, olhar e ver (N = 2) e regionalismo (N = 2). Discussão: O enfrentamento da Covid-19 impõe o isolamento social, o distanciamento físico e a restrição à mobilidade das pessoas como medidas fundamentais para evitar a rápida disseminação do vírus. Quando o jovem não dispõe de mecanismos para lidar com a situação estressante propiciada pela situação, pode haver o desencadeamento de uma série de psicopatologias, como depressão, ansiedade e distúrbios do humor. É uma tendência mais ampla na educação médica: cada vez mais, as escolas de Medicina estão investindo em currículo e programação em torno das artes, e, no momento atual, essa estratégia de coping se torna importante no enfrentamento da pandemia pelo estudante de Medicina. Conclusão: Atravessar esse momento de pandemia pela Covid-19 exigiu uma estratégia de coping para ajudar os alunos a vivenciar e extravasar seus medos, sendo a arte a melhor forma de expressão, o que foi atingido pelo grupo Elam.

Abstract: Introduction: The Covid-19 pandemic has had a direct impact on medical student training, through the sudden change from face-to-face to remote learning and the stress and anxiety caused. Students need coping strategies for the sake of their mental health and to deal with situations of extreme anxiety. Experience Report: during the pandemic the ELAM (Study of Literature and Art in Medicine) group has sought to help students in lockdown deal with their mental struggles by promoting discussions on literature through texts it has produced, debates on social media and, primarily, through art activities such as watercolor painting and visual arts. Twenty-four watercolor paintings, videos, collages, chronicles and poems were produced. The main themes addressed were: love (N=2), ageing (N=2), sin and religion (N=4), life cycle (N=6), cancer, chaos, wisdom, mortality (N=3), time, looking and seeing (N=2) and regionalism (N=2). Discussion: Essential measures to tackle Covid-19 include social isolation, physical distancing and restrictions on people's movements to prevent the rapid spread of the virus. When youngsters lack the mechanisms to cope with the resulting stressful situation, a series of mental disorders can be triggered, such as depression, anxiety and mood swings. Reflecting a broader trend in medical training, medical schools are increasingly investing in curricular content involving arts, and at this particular moment in time this represents an important coping strategy for students trying to deal with the pandemic. Conclusion: Getting through this difficult period of the Covid-19 pandemic has demanded a coping strategy to help students experience and vent their fears, where art has been the best form of expression, and the ELAM group has achieved such a strategy.

Pattern, clinical features and response to corticoids of glomerular diseases in a Brazilian population. An analytical cross-sectional study / Perfil, características clínicas e resposta a corticoides das doenças glomerulares em uma população brasileira. Um estudo transversal analítico

CONTEXT AND OBJECTIVE: Glomerular disease registries are increasing all around the world. The aim of this study was to evaluate the clinical characteristics and treatment response among patients with glomerular diseases followed up in a tertiary hospital in Brazil. DESIGN AND SETTING: Analytical cross-sectional study; tertiary-level public hospital. METHODS: This study included patients with glomerular diseases followed up at a tertiary hospital in Fortaleza, northeastern Brazil. Clinical and laboratory data on each patient were registered. The response to specific treatment was evaluated after 3, 6 and 12 months. RESULTS: The study included 168 patients of mean age 37 ± 14 years. The most prevalent glomerular diseases were focal segmental glomerulosclerosis FSGS] (19.6%), minimal change disease MCD] (17.9%), membranous nephropathy MN] (16.7%) and lupus nephritis LN] (11.9%). The main clinical presentations were nephrotic proteinuria (67.3%) and renal insufficiency (17.9%). The mean proteinuria value decreased after the treatment began. Regarding 24-hour proteinuria on admission, there was no significant difference between patients with a good response and those with no response (7,448 ± 5,056 versus 6,448 ± 4,251 mg/24 h, P = 0.29). The glomerular disease with the highest remission rate was MCD (92%). Absence ...

CONTEXTO E OBJETIVO: Registros de glomerulopatias estão aumentando em todo o mundo. O objetivo deste estudo é avaliar as características clínicas e a resposta do tratamento de pacientes com glomerulopatias acompanhados em um hospital terciário no Brasil. TIPO DE ESTUDO E LOCAL: Estudo transversal analítico. Hospital público terciário. MÉTODOS: O estudo incluiu pacientes com glomerulopatias acompanhados em um hospital terciário de Fortaleza, Ceará, Brasil. Foi realizado registro dos dados clínicos e laboratoriais para cada paciente. A resposta ao tratamento específico foi avaliada após 3, 6 e 12 meses. RESULTADOS: Foram incluídos 168 pacientes, com média de idade de 37 ± 14 anos. A glomerulopatia mais prevalente foi a glomerulosclerose segmentar e focal GESF] (19,6%), seguida pela doença de lesão mínima DLM] (17,9%), nefropatia membranosa NM] (16,7%) e nefrite lúpica NL] (11,9%). As principais manifestações clínicas foram proteinúria nefrótica (67,3%) e insuficiência renal (17,9%). A média dos valores de proteinúria diminuiu após o início do tratamento. Com relação à proteinúria de 24 horas na admissão, não houve diferença significativa entre os pacientes com boa resposta ao tratamento ...

Pattern, clinical features and response to corticoids of glomerular diseases in a Brazilian population. An analytical cross-sectional study.

CONTEXT AND OBJECTIVE: Glomerular disease registries are increasing all around the world. The aim of this study was to evaluate the clinical characteristics and treatment response among patients with glomerular diseases followed up in a tertiary hospital in Brazil. DESIGN AND SETTING: Analytical cross-sectional study; tertiary-level public hospital. METHODS: This study included patients with glomerular diseases followed up at a tertiary hospital in Fortaleza, northeastern Brazil. Clinical and laboratory data on each patient were registered. The response to specific treatment was evaluated after 3, 6 and 12 months. RESULTS: The study included 168 patients of mean age 37 ± 14 years. The most prevalent glomerular diseases were focal segmental glomerulosclerosis FSGS] (19.6%), minimal change disease MCD] (17.9%), membranous nephropathy MN] (16.7%) and lupus nephritis LN] (11.9%). The main clinical presentations were nephrotic proteinuria (67.3%) and renal insufficiency (17.9%). The mean proteinuria value decreased after the treatment began. Regarding 24-hour proteinuria on admission, there was no significant difference between patients with a good response and those with no response (7,448 ± 5,056 versus 6,448 ± 4,251 mg/24 h, P = 0.29). The glomerular disease with the highest remission rate was MCD (92%). Absence of interstitial fibrosis presented a strong correlation with remission (remission in patients without fibrosis = 83.4% versus 16.3% in those with fibrosis, P = 0.001). CONCLUSIONS: The present study found that the most frequent glomerular disease was FSGS, followed by MCD, MN and LN. The presence of interstitial fibrosis was a predictor of poor therapeutic response.

[Amyloidosis and end-stage renal disease associated with leprosy]. / Amiloidose e insuficiência renal crônica terminal associada à hanseníase.

Renal involvement in leprosy includes glomerulonephritis, amyloidosis and tubulointerstitial nephritis. A 58-year-old man was admitted with complaints of lower limb edema and dyspnea. At admission, nitrogen retention, anemia, hyperkalemia and metabolic acidosis were observed, requiring hemodialysis. The patient had a history of lepromatous leprosy. A renal biopsy was performed that was compatible with amyloidosis. The patient had a stable outcome, but without renal function recovery and remained on regular hemodialysis. Leprosy should be investigated in every patient with renal function loss, particularly in those with cutaneous lesions or other manifestations suggestive of leprosy.

Amiloidose e insuficiência renal crônica terminal associada à hanseníase / Amyloidosis and end-stage renal disease associated with leprosy

O envolvimento renal na hanseníase é diverso, incluindo glomerulonefrites, amiloidose e nefrite túbulo-intersticial. Um homem de 58 anos foi admitido com edema de membros inferiores e dispnéia. Na admissão, havia retenção de escórias nitrogenadas, anemia, hipercalemia e acidose metabólica, com necessidade de hemodiálise. Referia história de hanseníase virchoviana. Foi realizada biopsia renal, compatível com amiloidose. O paciente evoluiu estável, sem recuperação da função renal, permanecendo em tratamento hemodialítico. A hanseníase deve ser investigada em todo paciente com perda de função renal, sobretudo naqueles que apresentam lesões cutâneas ou outras manifestações sugestivas de hanseníase.

Renal involvement in leprosy includes glomerulonephritis, amyloidosis and tubulointerstitial nephritis. A 58-year-old man was admitted with complaints of lower limb edema and dyspnea. At admission, nitrogen retention, anemia, hyperkalemia and metabolic acidosis were observed, requiring hemodialysis. The patient had a history of lepromatous leprosy. A renal biopsy was performed that was compatible with amyloidosis. The patient had a stable outcome, but without renal function recovery and remained on regular hemodialysis. Leprosy should be investigated in every patient with renal function loss, particularly in those with cutaneous lesions or other manifestations suggestive of leprosy.

Insuficiência renal aguda de origem obstétrica / Acute kidney failure of obstretic origin

Relatam-se onze casos de Insuficiência Renal Aguda de causa obstétrica, observados no período de Setembro de 1982 a Dezembro de 1984 e analisados quanto à etiologia, incidência, apresentaçäo clínica, evoluçäo e terapêutica. Os achados diferem dos já estabelecidos na literatura quanto à incidência e etiologia. Dos onze casos analisados nove casos (82%), ocorreram no período compreendido entre o último trimestre e o puerpério e somente dois casos (18%) no primeiro trimestre, näo obedecendo, portanto, o padräo bimodal. Quanto à etiologia, ocorreram quatro casos de Septicemia (36%), Eclampsia três casos (27%), L.E.S. um caso (9%), Nefroesclerose Benigna um caso (9%), choque hemorrágico um caso (9%) e um possível caso de Síndrome Hemolítico-Urêmica pós-parto (9%)