Reduction of estimated glomerular filtration rate after COVID-19-associated acute kidney injury / Redução da taxa de filtração glomerular estimada após injúria renal aguda associada à COVID-19

ABSTRACT Introduction: Acute Kidney Injury (AKI), a frequent manifestation in COVID-19, can compromise kidney function in the long term. We evaluated renal function after hospital discharge of patients who developed AKI associated with COVID-19. Methods: This is an ambidirectional cohort. eGFR and microalbuminuria were reassessed after hospital discharge (T1) in patients who developed AKI due to COVID-19, comparing the values with hospitalization data (T0). P < 0.05 was considered statistically significant. Results: After an average of 16.3 ± 3.5 months, 20 patients were reassessed. There was a median reduction of 11.5 (IQR: -21; -2.1) mL/min/1.73m2 per year in eGFR. Forty-five percent of patients had CKD at T1, were older, and had been hospitalized longer; this correlated negatively with eGFR at T1. Microalbuminuria was positively correlated with CRP at T0 and with a drop in eGFR, as well as eGFR at admission with eGFR at T1. Conclusion: There was a significant reduction in eGFR after AKI due to COVID-19, being associated with age, length of hospital stay, CRP, and need for hemodialysis.

RESUMO Introdução: A Injúria Renal Aguda (IRA), uma manifestação frequente na COVID-19, pode comprometer a função renal em longo prazo. Avaliamos a função renal após a alta hospitalar de pacientes que desenvolveram IRA associada à COVID-19. Métodos: Esta é uma coorte ambidirecional. A TFGe e a microalbuminúria foram reavaliadas após a alta hospitalar (T1) em pacientes que desenvolveram IRA devido à COVID-19, comparando os valores com dados de hospitalização (T0). P < 0,05 foi considerado estatisticamente significativo. Resultados: Após uma média de 16,3 ± 3,5 meses, 20 pacientes foram reavaliados. Houve uma redução média de 11,5 (IIQ: -21; -2,1) mL/min/1,73m2 por ano na TFGe. Quarenta e cinco por cento dos pacientes apresentaram DRC no T1, eram mais velhos e haviam sido hospitalizados por mais tempo; isso se correlacionou negativamente com a TFGe no T1. A microalbuminúria foi positivamente correlacionada com a PCR no T0 e com uma queda na TFGe, assim como a TFGe na admissão com a TFGe no T1. Conclusão: Houve uma redução significativa na TFGe após IRA devido à COVID-19, sendo associada à idade, tempo de internação, PCR e necessidade de hemodiálise.

Reduction of estimated glomerular filtration rate after COVID-19-associated acute kidney injury.

INTRODUCTION: Acute Kidney Injury (AKI), a frequent manifestation in COVID-19, can compromise kidney function in the long term. We evaluated renal function after hospital discharge of patients who developed AKI associated with COVID-19. METHODS: This is an ambidirectional cohort. eGFR and microalbuminuria were reassessed after hospital discharge (T1) in patients who developed AKI due to COVID-19, comparing the values with hospitalization data (T0). P < 0.05 was considered statistically significant. RESULTS: After an average of 16.3 ± 3.5 months, 20 patients were reassessed. There was a median reduction of 11.5 (IQR: -21; -2.1) mL/min/1.73m2 per year in eGFR. Forty-five percent of patients had CKD at T1, were older, and had been hospitalized longer; this correlated negatively with eGFR at T1. Microalbuminuria was positively correlated with CRP at T0 and with a drop in eGFR, as well as eGFR at admission with eGFR at T1. CONCLUSION: There was a significant reduction in eGFR after AKI due to COVID-19, being associated with age, length of hospital stay, CRP, and need for hemodialysis.

Influência da modalidade dialítica na cognição: uma revisão integrativa / Influence of the dialysis modality in cognition: an integrative review

A doença renal crônica é uma condição clínica caracterizada pela queda progressiva da função renal, interferindo na homeostase de todo o corpo, incluindo o sistema nervoso central. Nesses pacientes, o comprometimento cognitivo é um achado comum, em comparação com a população geral, e mais frequente nos pacientes em diálise. O objetivo deste estudo foi identificar, por meio de revisão integrativa, se há diferença entre a modalida- de dialítica (hemodiálise e diálise peritoneal) e a presença de comprometimento cognitivo nesses pacientes. Foi feito levan- tamento bibliográfico nas plataformas PubMed® e Bireme, com buscas padronizadas de 2014 até abril de 2019, utilizando-se pa- lavras-chave. Para a seleção e a avaliação dos estudos científicos levantados, foram estabelecidos critérios, contemplando os seguintes aspectos: autor, ano/local, grau de recomendação/ nível de evidência científica, amostra, faixa etária, média de idade em anos, métodos de avaliação, resultados e conclusão. Dos 561 artigos encontrados, 365 foram excluídos pela data de publicação, 87 foram excluídos pelo título, 17 pelo resumo, 49 pela leitura do artigo, 36 eram repetidos e oito foram selecio- nados para o estudo. Os pacientes em diálise peritoneal apre- sentaram menor comprometimento cognitivo e menor risco para demência que os pacientes em hemodiálise.

Chronic kidney disease is a clinical condition characterized by progressive decline in renal function, interfering with whole-bo- dy homeostasis, including the central nervous system. Cognitive impairment is a common finding in these patients, compared to the general population, besides being more frequent in dialysis patients. The objective of this study was to identify, through an integrative review, if there is difference between the dialysis mo- dality (hemodialysis and peritoneal dialysis) and the presence of cognitive impairment in these patients. A bibliographic search on the PubMed® and Bireme platforms, with standard searches from 2014 to April 2019, using keywords, was conducted. For the selection and evaluation of scientific studies found in the sear- ch, criteria have been established, considering the following as- pects: author, year/location, grade of recommendation/level of evidence, sample, age, mean age in years, evaluation methods, results, and conclusion. Among 561 articles found, 365 were ex- cluded based on the date of publication, 87 based on the title, 17 on the abstract, 48 on the article reading, 36 were repeated, and eight were selected for the study. Patients on peritoneal dialysis have less cognitive impairment and lower risk for dementia than patients on hemodialysis.

Aquaporin-2 and NKCC2 expression pattern in patients with hepatosplenic schistosomiasis.

OBJECTIVE: Schistosoma mansoni infection is considered a public health problem. Glomerular involvement in schistosomiasis is a well-documented complication, especially in hepatosplenic schistosomiasis (HSS). However, renal tubular function is poorly understood. The aim of this study was to investigate, through urinary exosomes, tubular transporters functionally in HSS patients. METHODS: Cross-sectional study of 20 HSS patients who had isolated exosomes from urine samples. Protease inhibitor was added in the urine samples who were immediately frozen at -80 °C for further exosomes isolation. After urine had thawed, urinary exosomes were obtained using extensive vortexing, centrifugation and ultracentrifugation steps of urine. Urinary transporters expression from exosomes was evaluated by western blot, including NHE3, AQP2 and NKCC2. Charge amounts for gel electrophoresis were adjusted by urinary creatinine concentration of each patient to avoid urinary concentration bias. All protein expression of HSS patients was relative to healthy controls. RESULTS: The expression of aquaporin-2 (AQP2) was lower in HSS patients than in controls (46.8 ± 40.7 vs. 100 ± 70.2%, P = 0.03) and the expression of the NKCC2 co-transporter was higher (191.7 ± 248.6 vs. 100 ± 43.6%, P = 0.02). CONCLUSIONS: The decrease of AQP2 and the increase of NKCC2 expression in HSS patients seem to be involved with the inability of urinary concentration in these patients. These data show renal tubular abnormalities in HSS patients without manifest clinical disease.

OBJECTIF: L'infection à Schistosoma mansoni est considérée comme un problème de santé publique. L'atteinte glomérulaire dans la schistosomiase est une complication bien documentée, en particulier dans la schistosomiase hépatosplénique (SH). Cependant, la fonction tubulaire rénale est mal connue. Le but de cette étude était d'étudier, par le biais d'exosomes urinaires, les transporteurs tubulaires fonctionnellement chez les patients atteints de SH. MÉTHODES: Il s'agit d'une étude transversale sur 20 patients atteints de SH qui avaient des exosomes isolés d'échantillons d'urine. Un inhibiteur de protéase a été ajouté dans les échantillons d'urine qui ont été immédiatement congelés à -80°C pour un isolement supplémentaire des exosomes. Après décongélation de l'urine, des exosomes urinaires ont été obtenus en utilisant des étapes étendues de vortex, de centrifugation et d'ultracentrifugation d'urine. L'expression des transporteurs urinaires d'exosomes a été évaluée par western blot, y compris NHE3, AQP2 et NKCC2. Les quantités de charge pour l'électrophorèse sur gel ont été ajustées par la concentration de créatinine urinaire de chaque patient pour éviter un biais de concentration urinaire. Toute expression protéique des patients atteints de SH était relative à celle de témoins sains. RÉSULTATS: L'expression de l'aquaporine-2 (AQP2) était plus faible chez les patients SH que chez les témoins (46,8 ± 40,7 vs 100 ± 70,2%, P = 0,03) et l'expression du co-transporteur NKCC2 était plus élevée (191,7 ± 248,6 vs 100 ± 43,6%, P = 0,16). CONCLUSIONS: La diminution de l'AQP2 et l'augmentation de l'expression de NKCC2 chez les patients SH semblent être impliquées dans l'incapacité de concentration urinaire chez ces patients. Ces données montrent des anomalies tubulaires rénales chez les patients SH sans maladie clinique manifeste.

Kidney biomarkers in tropical infections: an update.

Neglected tropical diseases affect over 1 billion people, and cause 170,000 deaths each year. They result in disability, stigma and disfigurement, and also push families into poverty. Tropical infections can involve the kidney, presenting as a wide variety of ways, varying from transient urinary abnormalities to severe acute kidney injury (AKI). It is important to assess renal function in patients with tropical infections for earlier detection of AKI, appropriate treatment and prevention of Chronic Kidney Disease (CKD) outcome in some of them. There was an exponential increase in research on new kidney biomarkers that were earlier and specific for renal damage but few in the scope of tropical infections. In this review, we focus on kidney biomarkers that are being studied in some of the most prevalent tropical infections such as visceral leishmaniasis, leptospirosis, malaria, schistosomiasis and leprosy. Further studies are needed to evaluate the usefulness of renal biomarkers in the early diagnosis of renal diseases associated with tropical infections.

Acute kidney injury in schistosomiasis: a retrospective cohort of 60 patients in Brazil.

The aim of this study is to investigate renal involvement in schistosomiasis. This is a retrospective cohort of 60 consecutive patients with schistosomiasis admitted to a university hospital in Maceió, Brazil. The patients were divided into 2 groups: patients with and without acute kidney injury (AKI) according to the RIFLE criteria. We compared the groups for differences in clinical manifestations and laboratory tests. Patients' mean age was 58 ± 16 yr, and 56.7% were female. The average length of hospital stay was 16.4 ± 12.1 days. Patients with hypertension and diabetes were 35% and 21.7% respectively. The main clinical symptoms and signs presented were ascites (86.7%), splenomegaly (80%), and hepatomegaly (63.3%). Current or previous history of upper gastrointestinal bleeding was found in 45% of patients, esophageal varices on endoscopy were present in 92%, and periportal fibrosis on ultrasound examination in 81% of patients. AKI incidence was 43.3% during hospital stay. Mean age and length of hospitalization were higher in the AKI group. Diuretic use, such as furosemide and spironolactone, ascites, and AST levels were also associated with AKI. Death occurred in 5 cases (8.5%), 4 of them in the AKI group. The classifications Child-Pugh score (CHILD) and Model for End-Stage Liver Disease (MELD), used to assess the severity and prognosis of chronic liver disease, presented higher scores among patients with AKI (CHILD: 9.5 ± 1.5 vs. 8.4 ± 1.7, P = 0.02; MELD: 19 ± 5.8 vs. 13 ± 3.9, P < 0.001). Renal dysfunction is an important feature of schistosomiasis, which is associated with significant morbidity and possible increased mortality. Further studies are necessary to establish the mechanisms through which schistosomiasis can lead to renal dysfunction.

Renal function in hepatosplenic schistosomiasis--an assessment of renal tubular disorders.

BACKGROUND: Renal involvement in Schistosoma mansoni infection is not well studied. The aim of this study is to investigate the occurrence of renal abnormalities in patients with hepatosplenic schistosomiasis (HSS), especially renal tubular disorders. METHODS: This is a cross-sectional study with 20 consecutive patients with HSS followed in a medical center in Maceió, Alagoas, Brazil. Urinary acidification and concentration tests were performed using calcium chloride (CaCl2) after a 12-h period of water and food deprivation. The biomarker monocyte chemoattractant protein 1 (MCP-1) was quantified in urine. Fractional excretion of sodium (FENa+), transtubular potassium gradient (TTKG) and solute-free water reabsorption (TcH2O) were calculated. The HSS group was compared to a group of 17 healthy volunteers. RESULTS: Patients' mean age and gender were similar to controls. Urinary acidification deficit was found in 45% of HSS patients. Urinary osmolality was significantly lower in HSS patients (588 ± 112 vs. 764 ± 165 mOsm/kg, p = 0,001) after a 12-h period of water deprivation. TcH2O was lower in HSS patients (0.72 ± 0.5 vs. 1.1 ± 0.3, p = 0.04). Urinary concentration deficit was found in 85% of HSS patients. The values of MCP-1 were higher in HSS group than in control group (122 ± 134 vs. 40 ± 28 pg/mg-Cr, p = 0.01) and positively correlated with the values of microalbuminuria and proteinuria. CONCLUSIONS: HSS is associated with important kidney dysfunction. The main abnormalities found were urinary concentrating ability and incomplete distal acidification defect, demonstrating the occurrence of tubular dysfunction. There was also an increase in urinary MCP-1, which appears to be a more sensitive marker of renal damage than urinary albumin excretion rate.

Índice tornozelo-braço em pacientes hemodialíticos / Ankle-brachial index in hemodialysis patients

INTRODUÇÃO: Apesar da elevada mortalidade dos pacientes em hemodiálise devido às doenças cardiovasculares, é incomum a realização de exames diagnósticos para doença arterial obstrutiva periférica e artérias pouco compressíveis. OBJETIVOS: Analisar a prevalência de doença arterial obstrutiva periférica e artérias pouco compressíveis em hemodialisados, comparando-os com o Grupo Controle. MÉTODOS: Tratou-se de um estudo transversal, com 78 hemodialisados e 88 pacientes que não faziam hemodiálise com, pelo menos, dois fatores de risco para doença arterial obstrutiva periférica (Grupo Controle). Para aferição da pressão arterial sistólica, utilizou-se Doppler vascular portátil e esfigmomanômetro. Esta foi aferida somente nos membros que não possuíam fístula arteriovenosa. O índice tornozelo-braço foi calculado utilizando cada artéria do membro inferior. Foram considerados normais os valores de 0,9 a 1,3. RESULTADOS: Diagnosticou-se doença arterial obstrutiva periférica e artérias pouco compressíveis em 26,9 e 30,8%, dos hemodialisados, e em 33 e 22,7%, do Grupo Controle. Nos hemodialisados, verificou-se o índice tornozelo-braço alterado em 75% dos sintomáticos (p=0,005), em 67,3% dos homens e 31% das mulheres (p<0,005), em 78,6% dos idosos, 34,8% dos adultos jovens (p<0,01) e em 76,9% dos diabéticos (p<0,005 versus não diabéticos). Esses pacientes apresentaram maior prevalência de doença arterial obstrutiva periférica grave do que o Grupo Controle (p<0,01). CONCLUSÕES: O índice tornozelo-braço anormal foi muito prevalente nos grupos estudados; entretanto, os hemodialisados apresentaram alterações mais graves quando comparados ao Grupo Controle. Diabetes melito, sexo masculino e idade avançada foram fatores de risco importantes para a alteração do índice tornozelo-braço nos hemodialisados. O índice tornozelo-braço foi um bom método de rastreio para alterações pesquisadas. Portanto, a utilização deste na rotina de manejo de pacientes em hemodiálise é sugerida.

INTRODUCTION: Despite the high mortality in hemodialysis patients due to cardiovascular diseases, it is unusual performing diagnostic tests for peripheral arterial disease and poorly compressible arteries. OBJECTIVES: To analyze the prevalence of peripheral arterial disease and poorly compressible arteries in hemodialysis patients, by comparing them to the Control Group. METHODS: It was a cross-sectional study with 78 hemodialysis patients and 88 non-hemodialysis patients with at least two risk factors for peripheral arterial disease (Control Group). To evaluate blood pressure, portable vascular Doppler and sphygmomanometer were used. The pressure was measured from the limb without arteriovenous fistula. The ankle-brachial index was calculated for each artery of the lower limb. It was considered normal ankle-brachial index from 0.9 to 1.3. RESULTS: We diagnosed peripheral arterial disease and poorly compressible arteries in 26.9 and 30.8% of hemodialysis patients and in 33 and 22.7% of the Control Group. In hemodialysis patients, we found abnormal ankle-brachial index in 75% of symptomatic patients (p=0.005), in 67.3% of men and 31% of women (p<0.005), in 78.6% of the elderly, 34.8% of young adults (p<0.01), and 76.9% of diabetics (p<0.005 versus nondiabetic). These patients had a higher prevalence of severe peripheral arterial disease than the Control Group. CONCLUSIONS: Abnormal ankle-brachial index was very prevalent in the groups studied; however, hemodialysis patients had more severe changes, when compared to the Control Group. Diabetes mellitus, male gender, and advanced age were important risk factors for abnormal ankle-brachial index in hemodialysis patients. The ankle-brachial index was a good method of screening for the studied changes; therefore, we suggest the routine use in the management of hemodialysis patients.

Atenuação da remodelação ventricular após infarto agudo do miocárdio / Attenuation of ventricular remodeling after myocardial acute infarction

Após o infarto agudo do miocárdio podem ocorrer complexas alterações da arquitetura ventricular, envolvendo tanto a região infartada como a região não infartada. Há alguns anos, essas alterações passaram a ser designadas como remodelação ventricular pós-infarto. Do ponto de vista clínico, a remodelação está associada ao pior prognóstico após a oclusão coronária. Assim, a remodelação predispõe o coração infartado à ruptura ventricular e é o substrato fisiopatológico para a posterior formação do aneurisma ventricular. Cronicamente, a remodelação está associada com maior prevalência de arritmias malignas, principalmente a taquicardia ventricular sustentada e a fibrilação ventricular. O aspecto mais relevante da remodelação pós-infarto, no entanto, é que esse processo desempenha papel fundamental na fisiopatologia da disfunção ventricular. Aspecto a ser considerado refere-se ao fato de que a evolução do processo de remodelação pode ser modificado por meio de diversas intervenções terapêuticas. Entre as estratégias para atenuar a remodelação ventricular destacam-se: terapia de reperfusão, inibidores da enzima conversora da angiotensina e antagonistas da angiotensina II, betabloqueadores, antagonistas da aldosterona e dispositivos de assistência circulatória.

After acute myocardial infarction (AMI), complex changes in ventricular architecture may occur involving the infarcted and the non-infarcted region. This set of adaptations, which includes changes in the composition, mass, volume and geometry of the heart, is known as myocardial remodeling. In relation to clinical significance, the intensity of the ventricular remodeling process is directly associated with worse prognosis, due to the higher incidence of aneurysm formation, ventricular rupture and arrhythmia, and is also associated with the progression of ventricular dysfunction. A relevant aspect to be considered is that a number of strategies have been employed to prevent or mitigate the process of ventricular remodeling following AMI, for instance: reperfusion therapy, angiotensin converting enzyme inhibitors and angiotensin II antagonists, beta-adrenergic receptor blockade, aldosterone antagonists, and left ventricular assist devices.

Retinoic acid prevents ventricular remodelling induced by tobacco smoke exposure in rats.

OBJECTIVE: Our objective was to test the hypothesis that retinoic acid supplementation could attenuate ventricular remodelling induced by tobacco smoke exposure in rats. METHODS AND RESULTS: Wistar rats were allocated into three groups: control (C, n = 8); exposed to tobacco smoke (ETS, n = 9); exposed to tobacco smoke and all-trans-retinoic acid (ETS-RA, n = 9). After two months, cardiac function and geometry were assessed by echocardiography, and geometry changes were confirmed by morphometric analysis. Data are expressed as mean +/- SD or medians (including the lower quartile and upper quartile). ETS showed higher normalized left ventricular diastolic diameters than groups C and ETS-RA (C = 18.4 +/- 3.57 mm/kg, ETS = 23.0 +/- 1.8, ETS-RA = 19.5 +/- 0.99; P <0.05) and systolic diameters (C = 8.25 +/- 2.16 mm/kg, ETS = 11.5 +/- 1.31, ETS-RA = 8.25 +/- 0.71 mm/kg; P < 0.05). ETS showed reduced ejection fraction (C= 91 +/- 2.0, ETS = 87 +/- 3.0, ETS-RA = 92 +/- 3.0; P < 0.05) and fractional shortening (C = 55.8 +/- 4.41%, ETS = 49.7 +/- 4.43%, ETS-RA = 57.6 +/- 5.15 %; P= 0.01) compared to C and ETS-RA. ETS had increased myocyte cross-sectional area (C = 294 +/- 21 mm2, ETS = 352 +/-44, ETS-RA = 310 +/- 35; P < 0.05) compared to C and ETS-RA. Considering all variables, there were no differences between groups C and ETS-RA. CONCLUSION: Retinoic acid prevented ventricular remodelling induced by tobacco smoke exposure.

Referral to the nephrology outpatient clinic: inappropriate referral to the nephrologist.

INTRODUCTION: There are scarce data in Brazil concerning the referral of the patients with renal diseases to the nephrologist care. OBJECTIVE: The aim of the present study was to describe the adequacy of early referral of these patients to a nephrology out-patient clinic. MATERIAL AND METHODS: It was a cross-sectional study. Data of the first visit of the patient to the nephrologists were collected. The decision of the nephrologist, regarding the admittance of the patient to the followup with the nephrology team was also described. RESULTS: We evaluated 150 patients, with mean age of 49 ± 16 years, and 56% of females. The need of a consultation and follow-up with the renal specialist was found in only 71 patients (47.3%) and all these patients were enrolled in the nephrology unit out-patient clinic for, at least, one visit a year. All the patients with chronic kidney disease stages 3 to 5 were recommended to maintaining visits to the nephrologist, whereas 60% of those with diabetes and/or hypertension and 50% of those with renal lythiasis were also enrolled in the same program. Approximately 50% of patients originated from public health system units and 70% of private doctors were adequately referred. CONCLUSION: There was inadequate use of the abilities of the nefrologist as a specialist in the care of the patient with early stages of renal diseases. Other studies are needed to evaluate the efficiency of referral systems to the nephrologists in other areas of Brazil, with the purpose to rationalize supply and demand in the nephrology care.

Influence of lisinopril on cardiac remodeling induced by tobacco smoke exposure.

BACKGROUND: To investigate the effect of lisinopril on cardiac remodeling induced by smoking. MATERIAL/METHODS: Rats were allocated into 3 groups: group CON (n=8): control; group CSE (n=8): cigarette smoke exposure; group CSE-LIS (n=8): exposed to tobacco smoke and treated with lisinopril. RESULTS: After 2 months, the tail systolic pressure was lower in CSE-LIS (CON=116 +/-27 mm Hg, CSE=126+/-16, CSE-LIS=89+/-12; P<.001). CSE animals showed higher left ventricular systolic diameter (CON=8.25+/-2.16 mm/kg, CSE=11.5+/-1.3, CSE-LIS=9.27+/-2.00; P=.009) and myocyte cross-sectional area (CON=245+/-8 microm2, CSE=260+/-17, CSE-LIS=238+/-12; P=.01) than CON and CSE-LIS. The ejection fraction (CON =0.91+/-0.02, CSE=0.86+/-0.02, CSE-LIS=0.92+/-0.03; P=.002) and fractional shortening (CON=55.7+/-4.41%, CSE=48.7+/-3.43, CSE-LI=58.2+/-7.63; P=.006) were lower in CSE group than CON and CSE-LIS. CSE and CSE-LIS animals showed higher collagen amounts (CON=3.49+/-0.95%, CSE= 5.01+/-1.58, CSE-LIS=5.27+/-0.62; P=.009) than CON. CON group showed a higher connexin 43 amount in the intercalated disc (CON=3.70+/-0.38, CSE=2.13+/-0.53; CSE-LIS=2.17+/-0.73; P=.004) than CSE and CSE-LIS. There were no differences in IFN-gamma or TNF-alpha cardiac levels among the groups. CONCLUSIONS: Lisinopril attenuated both morphologic and functional abnormalities induced by exposure to tobacco smoke. In addition, this effect was associated with diminished blood pressure, but not alterations in connexin 43 distribution, cytokine production or collagen amount.

Referência para o ambulatório de nefrologia: inadequação da demanda para o especialista / Inappropriate referral to the nephrologist

INTRODUÇÃO: São escassos estudos sobre o encaminhamento dos pacientes em estágios mais precoces de nefropatia ao nefrologista. OBJETIVO: Investigar a adequação da referência dos pacientes para o ambulatório da nefrologia (Amb-N), no que diz respeito à pertinência da demanda para a avaliação com o especialista. MATERIAL E MÉTODOS: Estudo de corte transversal, com pacientes do ambulatório de primeira consulta de nefrologia. Após o atendimento habitual, as condutas poderiam ser: matricular no Amb-N para acompanhamento ou não fazê-lo por ausência de necessidade da avaliação/acompanhamento do especialista. Os dados foram relatados como média e desvio-padrão e frequências relativas. RESULTADOS: Dos 150 casos, a média de idade foi de 49 ± 16 anos, com predomínio (56 por cento) do sexo feminino. Apenas 71 pacientes (47,3 por cento) foi admitidos no Amb-N para ao menos uma avaliação anual. Foram matriculados 100 por cento dos pacientes com DRC estágios de 3 a 5, 60 por cento dos diabéticos e/ou hipertensos e 50 por cento daqueles com litíase renal. Cerca de 50 por cento dos pacientes procedentes de unidades do SUS e 70 por cento de médicos privados foram matriculados. Ao todo, em 52,7 por cento (n = 79) dos casos, na interpretação dos pesquisadores, não havia necessidade do nefrologista para o diagnóstico ou para a conduta clínica, bem como para o seguimento naquele momento. CONCLUSÃO: Houve inadequada utilização da qualificação do nefrologista como especialista no atendimento precoce do nefropata. Outros estudos são necessários para avaliar a eficiência dos modelos de referência e contrarreferência operantes em diferentes regiões do país, com o intuito de racionalizar oferta e demanda de atendimento de média complexidade em nefrologia.

INTRODUCTION: There are scarce data in Brazil concerning the referral of the patients with renal diseases to the nephrologist care. OBJECTIVE: The aim of the present study was to describe the adequacy of early referral of these patients to a nephrology out-patient clinic. MATERIAL AND METHODS: It was a crosssectional study. Data of the first visit of the patient to the nephrologists were collected. The decision of the nephrologist, regarding the admittance of the patient to the followup with the nephrology team was also described. RESULTS: We evaluated 150 patients, with mean age of 49 ± 16 years, and 56 percent of females. The need of a consultation and follow-up with the renal specialist was found in only 71 patients (47.3 percent) and all these patients were enrolled in the nephrology unit out-patient clinic for, at least, one visit a year. All the patients with chronic kidney disease stages 3 to 5 were recommended to maintaining visits to the nephrologist, whereas 60 percent of those with diabetes and/or hypertension and 50 percent of those with renal lythiasis were also enrolled in the same program. Approximately 50 percent of patients originated from public health system units and 70 percent of private doctors were adequately referred. CONCLUSION: There was inadequate use of the abilities of the nefrologist as a specialist in the care of the patient with early stages of renal diseases. Other studies are needed to evaluate the efficiency of referral systems to the nephrologists in other areas of Brazil, with the purpose to rationalize supply and demand in the nephrology care.

[Remodeling pattern and ventricular function in rats exposed to cigarette smoke].

BACKGROUND: The relevance of the remodeling pattern in the model of rats exposed to cigarette smoke is not known. OBJECTIVE: Analyzing the presence of different remodeling patterns in this model and its relation with the ventricular function. METHODS: Smoking rats (n=47) have been divided according to the geometry pattern, analyzed by echocardiogram: normal (normal mass index and normal relative wall thickness), concentric remodeling (normal mass index and increased relative wall thickness), concentric hypertrophy (increased mass index and increased relative wall thickness) and eccentric hypertrophy (increased mass index and normal relative wall thickness). RESULTS: Smoking rats presented one of the following geometry patterns: normal pattern, 51%; eccentric hypertrophy; 32%; concentric hypertrophy, 13% and concentric remodeling, 4%. The normal and eccentric hypertrophy groups presented smaller ejection fraction values and fractional shortening than the concentric hypertrophy group. Thirteen animals (28%) presented systolic dysfunction detected by the ejection fraction and by fractional shortening. In the single regression analysis, geometry patterns and mass index could not predict ventricular dysfunction (p<). On the other hand, the increased relative thickness of the wall could predict ventricular dysfunction in the single regression analysis (p<0.001) and in the multiple regression analysis after adjustment to the mass index (p=0.003). CONCLUSION: Rats exposed to cigarette smoke presented one of the four different remodeling patterns. Among the geometric variables analyzed, only the increased relative thickness of the left ventricle wall could predict ventricular dysfunction in this model.

Padrão de remodelação e função ventricular em ratos expostos à fumaça do cigarro / Estándar de remodelación y función ventricular en ratones expuestos al humo del cigarrillo / Remodeling pattern and ventricular function in rats exposed to cigarette smoke

FUNDAMENTO: A relevância do padrão de remodelação no modelo de ratos expostos à fumaça do cigarro não é conhecida. OBJETIVO: Analisar a presença de diferentes padrões de remodelação nesse modelo e sua relação com a função ventricular. MÉTODOS: Ratos fumantes (n=47) foram divididos de acordo com o padrão de geometria, analisado pelo ecocardiograma: normal (índice de massa normal e espessura relativa normal), remodelação concêntrica (índice de massa normal e espessura relativa aumentada), hipertrofia concêntrica (índice de massa aumentado e espessura relativa aumentada) e hipertrofia excêntrica (índice de massa aumentado e espessura relativa normal). RESULTADOS: Os ratos fumantes apresentaram um dos quatro padrões de geometria: padrão normal, 51 por cento; hipertrofia excêntrica:,32 por cento; hipertrofia concêntrica, 13 por cento e remodelação concêntrica, 4 por cento. Os grupos normal e hipertrofia excêntrica apresentaram menores valores de fração de ejeção e porcentagem de encurtamento que o grupo hipertrofia concêntrica. Treze animais (28 por cento) apresentaram disfunção sistólica, detectada pela fração de ejeção e pela porcentagem de encurtamento. Na análise de regressão univariada, os padrões de geometria e o índice de massa não foram fator de predição de disfunção ventricular (p>0,05). Por outro lado, o aumento da espessura relativa da parede foi fator de predição de disfunção ventricular na análise univariada (p<0,001) e na análise multivariada, após ajuste para o índice de massa (p=0,003). CONCLUSÃO: Ratos expostos à fumaça do cigarro apresentam um dos quatro diferentes padrões de remodelação. Entre as variáveis geométricas analisadas, somente o aumento da espessura relativa da parede do ventrículo esquerdo foi fator de predição de disfunção ventricular nesse modelo.

BACKGROUND: The relevance of the remodeling pattern in the model of rats exposed to cigarette smoke is not known. OBJECTIVE: Analyzing the presence of different remodeling patterns in this model and its relation with the ventricular function. METHODS: Smoking rats (n=47) have been divided according to the geometry pattern, analyzed by echocardiogram: normal (normal mass index and normal relative wall thickness), concentric remodeling (normal mass index and increased relative wall thickness), concentric hypertrophy (increased mass index and increased relative wall thickness) and eccentric hypertrophy (increased mass index and normal relative wall thickness). RESULTS: Smoking rats presented one of the following geometry patterns: normal pattern, 51 percent; eccentric hypertrophy; 32 percent; concentric hypertrophy, 13 percent and concentric remodeling, 4 percent. The normal and eccentric hypertrophy groups presented smaller ejection fraction values and fractional shortening than the concentric hypertrophy group. Thirteen animals (28 percent) presented systolic dysfunction detected by the ejection fraction and by fractional shortening. In the single regression analysis, geometry patterns and mass index could not predict ventricular dysfunction (p<). On the other hand, the increased relative thickness of the wall could predict ventricular dysfunction in the single regression analysis (p<0,001) and in the multiple regression analysis after adjustment to the mass index (p=0,003). CONCLUSION: Rats exposed to cigarette smoke presented one of the four different remodeling patterns. Among the geometric variables analyzed, only the increased relative thickness of the left ventricle wall could predict ventricular dysfunction in this model.

FUNDAMENTO: No se conoce la relevancia del estándar de remodelación en el modelo de ratones expuestos al humo del cigarrillo. OBJETIVO: Analizar la presencia de diferentes estándares de remodelación en este modelo y su relación con la función ventricular. MÉTODOS: Ratones fumadores (n=47) se dividieron según el estándar de geometría, analizado por el ecocardiograma: normal (índice de masa normal y espesor relativo normal), remodelación concéntrico (índice de masa normal y espesor relativo aumentado), hipertrofia concéntrica (índice de masa aumentado y espesor relativo aumentado) y hipertrofia excéntrica (índice de masa aumentado y espesor relativo normal). RESULTADOS: Los ratos fumadores presentaron uno de los cuatro estándares de geometría: estándar normal, el 51 por ciento; hipertrofia excéntrica: el 32 por ciento; hipertrofia concéntrica, el 13 por ciento y remodelación concéntrica, el 4 por ciento. Los grupos normal e hipertrofia excéntrica presentaron menores valores de fracción de eyección y porcentaje de acortamiento que el grupo hipertrofia concéntrica. Trece animales (28 por ciento) presentaron disfunción sistólica, detectada por la fracción de eyección y por el porcentaje de acortamiento. En el análisis de regresión univariado, los estándares de geometría y el índice de masa no fueron factor de predicción de disfunción ventricular (p > 0,05). Por otro lado, el aumento del espesor relativo de la pared fue factor de predicción de disfunción ventricular en el análisis univariado (p < 0,001) y en el análisis multivariado, tras ajuste para el índice de masa (p = 0,003). CONCLUSIÓN: Ratones expuestos al humo del cigarrillo presentan uno de los cuatro diferentes estándares de remodelación. Entre las variables geométricas analizadas, solamente el aumento del espesor relativo de la pared del ventrículo izquierdo del factor de predicción de disfunción ventricular en este modelo.

Halomonhystera parasitica n. sp. (Nematoda: Monhysteridae), a parasite of Talorchestia brito (Crustacea: Talitridae) in Portugal.

Halomonhystera parasitica n. sp. (Monhysterida: Monhysteridae) is described from the body-cavity and under the dorsal plates of the sandy beach amphipod Talorchestia brito Stebbing (Crustacea: Talitridae) in Portugal. The new species differs from previously described members of the genus by a combination of the following characters: four medium-sized cephalic setae; base of stoma with three blunt denticles; posterior dilated portion of stoma absent; amphids small, with width less than quarter of corresponding body width; amphids located less than two labial widths from anterior extremity; uterine eggs elliptical and unembryonated; gubernaculum lacks caudal process; and male tail with two separated pairs of postcloacal papillae and a single subterminal seta-like papilla. This is the first representative of the family Monhysteridae parasitic in the body-cavity of crustaceans. Approximately 48% of the amphipods examined contained various stages of H. parasitica.

Role of lipoperoxidation in the remodeling intensification induced by beta-carotene after infarction.

BACKGROUND: The mechanisms involved in the biggest remodeling caused by the post-infarct beta-carotene are unknown. OBJECTIVE: To analyze the role of lipoperoxidation in the ventricular remodeling after infarct of the myocardium in rats supplemented with beta-carotene. METHODS: Rats were infarcted and divided into two groups: C (control) and BC (500mg/kg/regimen). After six months, echocardiogram and biochemical evaluation were performed. The t test was used, with 5% significance. RESULTS: The animals from BC group presented highest means of the diastolic (C = 1.57 +/- 0.4 mm(2)/g, BC = 2.09 +/- 0.3 mm(2)/g; p < 0.001) and systolic (C = 1.05 +/- 0.3 mm(2)/g, BC = 1.61 +/- 0.3 mm(2)/g; p < 0.001) areas of LV, which were adapted according to the rat's body weight. The systolic function of LV, evaluated by the area variation fraction, was lower in the animals supplemented with beta-carotene (C = 31.9 +/- 9.3%, BC = 23.6 +/- 5.1%; p = 0.006). The animals supplemented with beta-carotene presented higher values of the E/A relation (C = 2.7 +/- 2.5, BC = 5.1 +/- 2.8; p = 0.036). No differences were found between the groups concerning the cardiac levels of the GSH (C = 21 +/- 8 nmol/mg of protein, BC = 37 +/- 15 nmol/mg of protein; p = 0.086), GSSG (C = 0.4 (0.3-0.5) nmol/g of protein, BC = 0.8 (0.4-1.0; p = 0.19) of protein; p = 0.246) and lipoperoxides (C = 0.4 +/- 0.2 nmol/mg of tissue, BC = 0.2 +/- 0.1 nmol/mg of tissue; p = 0.086). CONCLUSION: The highest remodeling in infarcted rats supplemented with beta-carotene does not depend on the lipoperoxidation.

Effects of the administration of beta-blockers on ventricular remodeling induced by cigarette smoking in rats.

BACKGROUND: The role of the adrenergic system on ventricular remodeling induced by cigarette smoking is unknown. OBJECTIVES: To investigate the influence of propranolol on ventricular remodeling induced by exposure to tobacco smoke. METHODS: Rats were divided into three groups: 1) C, n=10--control group; 2) F, n=10--animals exposed to tobacco smoke; 3) BB, n=10--animals receiving propranolol and exposed to tobacco smoke (40 mg/kg/day). After 2 months, the animals underwent echocardiographic and morphometric analyses. One-way ANOVA (mean +/- standard deviation) or the Kruskal-Wallis test (median and interquartile interval) was used. RESULTS: Group BB showed a lower heart rate than group F (C = 358 +/- 74 bpm, F = 374 +/- 53 bpm, BB = 297 +/- 30; P = 0.02). Group F showed greater end-diastolic diameters (C = 18.6 +/- 3.4 mm/kg, F = 22.8 +/- 1.8 mm/kg, BB = 21.7 +/- 1.8 mm/kg; P = 0.003) and left ventricular (LV) end-systolic diameters (C = 8.6 +/- 2.1 mm/kg, F = 11.3 +/- 1.3 mm/kg, BB = 9.9 +/- 1.2 mm/kg; P = 0.004), adjusted for body weight (BW) and a tendency towards a lower ejection fraction (C = 0.90 +/- 0.03, F = 0.87 +/- 0.03, BB =0.90 +/- 0.02; P = 0.07) than group C. Group BB showed a tendency towards a lower LV/BW ratio than group F (C = 1.94 (1.87 - 1.97), F = 2.03 (1.9-2.1) mg/g, BB = 1.89 (1.86-1.94); P = 0.09). CONCLUSION: Administration of propranolol attenuated some of the variables of ventricular remodeling induced by the exposure to tobacco smoke in rats.

The role of oxidative stress and lipid peroxidation in ventricular remodeling induced by tobacco smoke exposure after myocardial infarction.

OBJECTIVE: To evaluate the roles of oxidative stress and lipid peroxidation in the ventricular remodeling that is induced by tobacco smoke exposure after myocardial infarction. METHODS: After induced myocardial infarction, rats were allocated into two groups: C (control, n=25) and ETS (exposed to tobacco smoke, n=24). After 6 months, survivors were submitted to echocardiogram and biochemical analyses. RESULTS: Rats in the ETS group showed higher diastolic (C = 1.52 +/- 0.4 mm(2), ETS = 1.95 +/- 0.4 mm(2); p=0.032) and systolic (C = 1.03 +/- 0.3, ETS = 1.36 +/- 0.4 mm(2)/g; p=0.049) ventricular areas, adjusted for body weight. The fractional area change was smaller in the ETS group (C = 30.3 +/- 10.1 %, ETS = 19.2 +/- 11.1 %; p=0.024) and E/A ratios were higher in ETS animals (C = 2.3 +/- 2.2, ETS = 5.1 +/- 2.5; p=0.037). ETS was also associated with a higher water percentage in the lung (C = 4.8 (4.3-4.8), ETS = 5.5 (5.3-5.6); p=0.013) as well as higher cardiac levels of reduced glutathione (C = 20.7 +/- 7.6 nmol/mg of protein, ETS = 40.7 +/- 12.7 nmol/mg of protein; p=0.037) and oxidized glutathione (C = 0.3 +/- 0.1 nmol/g of protein, ETS = 0.9 +/- 0.3 nmol/g of protein; p=0.008). No differences were observed in lipid hydroperoxide levels (C = 0.4 +/- 0.2 nmol/mg of tissue, ETS = 0.1 +/- 0.1 nmol/mg of tissue; p=0.08). CONCLUSION: In animals exposed to tobacco smoke, oxidative stress is associated with the intensification of ventricular remodeling after myocardial infarction.

Papel da lipoperoxidação na intensificação da remodelação causada pelo betacaroteno após o infarto / Rol de la lipoperoxidación en la intensificación de la remodelación ocasionada por el betacaroteno tras infarto / Role of lipoperoxidation in the remodeling intensification induced by beta-carotene after infarction

FUNDAMENTO: Os mecanismos envolvidos na maior remodelação causada pelo betacaroteno após o infarto são desconhecidos. OBJETIVO: Analisar o papel da lipoperoxidação na remodelação ventricular após o infarto do miocárdio, em ratos suplementados com betacaroteno. MÉTODOS: Ratos foram infartados e distribuídos em dois grupos: C (controle) e BC (500mg/kg/dieta). Após seis meses, foram realizados ecocardiograma e avaliação bioquímica. Utilizamos o teste t, com significância de 5 por cento. RESULTADOS: Os animais do grupo BC apresentaram maiores médias das áreas diastólicas (C = 1,57 ± 0,4 mm²/g, BC = 2,09 ± 0,3 mm²/g; p < 0,001) e sistólicas (C = 1,05 ± 0,3 mm²/g, BC = 1,61 ± 0,3 mm²/g; p < 0,001) do VE, ajustadas ao peso corporal do rato. A função sistólica do VE, avaliada pela fração de variação de área, foi menor nos animais suplementados com betacaroteno (C = 31,9 ± 9,3 por cento, BC = 23,6 ± 5,1 por cento; p = 0,006). Os animais suplementados com betacaroteno apresentaram valores maiores da relação E/A (C = 2,7 ± 2,5, BC = 5,1 ± 2,8; p = 0,036). Não foram encontradas diferenças entre os grupos em relação aos níveis cardíacos de GSH (C = 21 ± 8 nmol/mg de proteína, BC = 37 ±15 nmol/mg de proteína; p = 0,086), GSSG (C = 0,4 (0,3-0,5) nmol/g de proteína, BC = 0,8 (0,4-1,0; p = 0,19) de proteína; p = 0,246) e lipoperóxidos (C = 0,4 ± 0,2 nmol/mg de tecido, BC = 0,2 ± 0,1 nmol/mg de tecido; p = 0,086). CONCLUSÃO: A maior remodelação em animais infartados e suplementados com betacaroteno não depende da lipoperoxidação.

BACKGROUND: The mechanisms involved in the biggest remodeling caused by the post-infarct beta-carotene are unknown. OBJECTIVE: To analyze the role of lipoperoxidation in the ventricular remodeling after infarct of the myocardium in rats supplemented with beta-carotene. METHODS: Rats were infarcted and divided into two groups: C (control) and BC (500mg/kg/regimen). After six months, echocardiogram and biochemical evaluation were performed. The t test was used, with 5 percent significance. RESULTS: The animals from BC group presented highest means of the diastolic (C = 1.57 ± 0.4 mm²/g, BC = 2.09 ± 0.3 mm²/g; p < 0.001) and systolic (C = 1.05 ± 0.3 mm²/g, BC = 1.61 ± 0.3 mm²/g; p < 0.001) areas of LV, which were adapted according to the rat's body weight. The systolic function of LV, evaluated by the area variation fraction, was lower in the animals supplemented with beta-carotene (C = 31.9 ± 9.3 percent, BC = 23.6 ± 5.1 percent; p = 0.006). The animals supplemented with beta-carotene presented higher values of the E/A relation (C = 2.7 ± 2.5, BC = 5.1 ± 2.8; p = 0.036). No differences were found between the groups concerning the cardiac levels of the GSH (C = 21 ± 8 nmol/mg of protein, BC = 37 ± 15 nmol/mg of protein; p = 0.086), GSSG (C = 0.4 (0.3-0.5) nmol/g of protein, BC = 0.8 (0.4-1.0; p = 0.19) of protein; p = 0.246) and lipoperoxides (C = 0.4 ± 0.2 nmol/mg of tissue, BC = 0.2 ± 0.1 nmol/mg of tissue; p = 0.086). CONCLUSION: The highest remodeling in infarcted rats supplemented with beta-carotene does not depend on the lipoperoxidation.

FUNDAMENTO: Los mecanismos implicados en la mayor remodelación ocasionada por betacaroteno tras el infarto son desconocidos. OBJETIVO: Analizar el rol que juega la lipoperoxidación en la remodelación ventricular tras el infarto de miocardio, en ratas suplementadas con betacaroteno. MÉTODOS: Se había inducido a un infarto a las ratas y se las distribuyó en grupos: C (control) y BC (500mg/kg/dieta). Tras seis meses, se realizaron ecocardiograma y evaluación bioquímica. Utilizamos la prueba t, con significancia del 5 por ciento. RESULTADOS: Los animales del grupo BC presentaron mayores promedios de las áreas diastólicas (C = 1,57 ± 0,4 mm²/g, BC = 2,09 ± 0,3 mm²/g; p < 0,001) y sistólicas (C = 1,05 ± 0,3 mm²/g, BC = 1,61 ± 0,3 mm²/g; p < 0,001) del VI, ajustadas al peso corporal de la rata. La función sistólica del VI, evaluada por la fracción de variación de área, fue menor en los animales suplementados con betacaroteno (C = 31,9 ± 9,3 por ciento, BC = 23,6 ± 5,1 por ciento; p = 0,006). Los animales suplementados con betacaroteno presentaron valores mayores de la relación E/A (C = 2,7 ± 2,5, BC = 5,1 ± 2,8; p = 0,036). No se encontraron diferencias entre los grupos con relación a los niveles cardiacos de GSH (C = 21 ± 8 nmol/mg de proteína, BC = 37 ±15 nmol/mg de proteína; p = 0,086), GSSG (C = 0,4 (0,3-0,5) nmol/g de proteína, BC = 0,8 (0,4-1,0; p = 0,19) de proteína; p = 0,246) y lipoperóxidos (C = 0,4 ± 0,2 nmol/mg de tejido, BC = 0,2 ± 0,1 nmol/mg de tejido; p = 0,086). CONCLUSIÓN: La mayor remodelación en animales infartados y suplementados con betacaroteno no depende de la lipoperoxidación.