Acetazolamide and N-acetylcysteine in the treatment of chronic mountain sickness (Monge's disease).

Patients suffering from chronic mountain sickness (CMS) have excessive erythrocytosis. Low -level cobalt toxicity as a likely contributor has been demonstrated in some subjects. We performed a randomized, placebo controlled clinical trial in Cerro de Pasco, Peru (4380m), where 84 participants with a hematocrit (HCT) ≥65% and CMS score>6, were assigned to four treatment groups of placebo, acetazolamide (ACZ, which stimulates respiration), N-acetylcysteine (NAC, an antioxidant that chelates cobalt) and combination of ACZ and NAC for 6 weeks. The primary outcome was change in hematocrit and secondary outcomes were changes in PaO2, PaCO2, CMS score, and serum and urine cobalt concentrations. The mean (±SD) hematocrit, CMS score and serum cobalt concentrations were 69±4%, 9.8±2.4 and 0.24±0.15µg/l, respectively for the 66 participants. The ACZ arm had a relative reduction in HCT of 6.6% vs. 2.7% (p=0.048) and the CMS score fell by 34.9% vs. 14.8% (p=0.014) compared to placebo, while the reduction in PaCO2 was 10.5% vs. an increase of 0.6% (p=0.003), with a relative increase in PaO2 of 13.6% vs. 3.0%. NAC reduced CMS score compared to placebo (relative reduction of 34.0% vs. 14.8%, p=0.017), while changes in other parameters failed to reach statistical significance. The combination of ACZ and NAC was no better than ACZ alone. No changes in serum and urine cobalt concentrations were seen within any treatment arms. ACZ reduced polycythemia and CMS score, while NAC improved CMS score without significantly lowering hematocrit. Only a small proportion of subjects had cobalt toxicity, which may relate to the closing of contaminated water sources and several other environmental protection measures.

Síndrome cardiorrenal tipo 1 en la unidad de cuidados intensivos coronarios del Hospital Nacional Arzobispo Loayza / Cardiorenal syndrome type 1 in the intensive coronary care unit of the Hospital Nacional Arzobispo Loayza

Objetivos: Evaluar la incidencia de síndrome cardiorrenal tipo 1 (SCR1) en una unidad de cuidados intensivos coronarios y su asociación a mortalidad intrahospitalaria a 30 días, así como a otras características epidemiológicas. Métodos: Se revisaron las historias clínicas de todos los pacientes hospitalizados con diagnóstico de falla cardíaca aguda en un periodo de 4 años. Se definió como SCR1 la presencia de falla cardíaca aguda más una creatinina al ingreso ≥ 0.3 mg/dL con respecto a la creatinina basal calculada por la fórmula MDRD75, y/o una elevación ≥ 50% de la creatinina al ingreso en un periodo de 48 h. Resultados: La incidencia de SCR1 fue del 27.87%, IC95%: 20.13-36.71 (34 de 122). Hubo una mayor frecuencia de SCR1 en los pacientes que ingresaron con diagnóstico de shock cardiogénico (RR: 2.02; IC95%: 1.20-3.93; p = 0.0378) y en los que tenían niveles más altos de hemoglobina (p = 0.0412). El SCR1 se asoció a una mayor mortalidad intrahospitalaria a 30 días (HR: 4.11; IC95%: 1.20-14.09; p = 0.0244). Conclusiones: La incidencia de SCR1 en la unidad de cuidados intensivos coronarios encontrada en nuestro estudio es similar a la descrita en estudios extranjeros. La presencia de shock cardiogénico como causa de falla cardíaca y valores más altos de hemoglobina se asociaron a una mayor incidencia de SCR1. Los pacientes con SCR1 tuvieron mayor mortalidad intrahospitalaria a 30 días.

Objectives: This study sought to evaluate the incidence of cardiorenal syndrome (CRS) type 1 in a coronary care unit and its association with hospital mortality within 30 days of admission, as well as other epidemiological characteristics. Methods: The medical records of all the patients who were hospitalized with the diagnosis of acute heart failure in a 4-year period were reviewed. CRS type 1 was characterized by the presence of acute heart failure and an elevation of serum creatinine ≥ 0.3 mg/dL in comparison to the baseline creatinine calculated by the MDRD75 equation and/or the elevation of ≥ 50% of the admission serum creatinine within a 48 h period. Results: The incidence of CRS type 1 was 27.87%, 95% CI: 20.13-36.71 (34 of 122). There was a higher frequency of CRS type 1 in those patients who were admitted with the diagnosis of cardiogenic shock (adjusted RR 2.02, 95% CI: 1.20-3.93, p = 0.0378) and in those with higher hemoglobin levels (p = 0.0412). The CRS type 1 was associated with an increase of 30-day mortality (HR: 4.11, 95% CI: 1.20-14.09, p = 0.0244). Conclusions: The incidence of CRS type 1 in the coronary care unit found in our study is similar to those found in foreign studies. The history of stroke and the higher values of hemoglobin were associated with a higher incidence of cardiorenal syndrome type 1. Patients with CRS type 1 had a higher hospital mortality within 30 days of admission.

[Cardiorenal syndrome type 1 in the intensive coronary care unit of the Hospital Nacional Arzobispo Loayza]. / Síndrome cardiorrenal tipo 1 en la unidad de cuidados intensivos coronarios del Hospital Nacional Arzobispo Loayza.

OBJECTIVES: This study sought to evaluate the incidence of cardiorenal syndrome (CRS) type 1 in a coronary care unit and its association with hospital mortality within 30 days of admission, as well as other epidemiological characteristics. METHODS: The medical records of all the patients who were hospitalized with the diagnosis of acute heart failure in a 4-year period were reviewed. CRS type 1 was characterized by the presence of acute heart failure and an elevation of serum creatinine ≥0.3mg/dL in comparison to the baseline creatinine calculated by the MDRD75 equation and/or the elevation of ≥50% of the admission serum creatinine within a 48 h period. RESULTS: The incidence of CRS type 1 was 27.87%, 95% CI: 20.13-36.71 (34 of 122). There was a higher frequency of CRS type 1 in those patients who were admitted with the diagnosis of cardiogenic shock (adjusted RR 2.02, 95% CI: 1.20-3.93, p=0.0378) and in those with higher hemoglobin levels (p=0.0412). The CRS type 1 was associated with an increase of 30-day mortality (HR: 4.11, 95% CI: 1.20-14.09, p=0.0244). CONCLUSIONS: The incidence of CRS type 1 in the coronary care unit found in our study is similar to those found in foreign studies. The history of stroke and the higher values of hemoglobin were associated with a higher incidence of cardiorenal syndrome type 1. Patients with CRS type 1 had a higher hospital mortality within 30 days of admission.

Niveles de hemoglobina en pacientes en hemodiálisis a nivel del mar y a mayor altitud, y su relación con la calidad de vida / Hemoglobin levels in hemodialysis patients at sea level and high altitude, and its relation with the quality of life

Objetivo. Determinar si los niveles de hemoglobina se relacionan con la calidad de vida a diferentes altitudes en pacientes en hemodiálisis (HD) crónica. Pacientes y Métodos. Se seleccionó pacientes con enfermedad renal crónica (ERC) en HD crónica que vivían a nivel del mar (Lima, 150 metros sobre el nivel del mar ûmsnmû; Chiclayo, 27 msnm) y a mayor altitud (Arequipa, 2 327 msnm; Puno, 3 827 msnm). Los pacientes fueron reevaluados a los tres y seis meses, se registró el nivel de hemoglobina, la presión arterial y las dosis de eritropoyetina y de fierro. A los seis meses, se seleccionó a los pacientes que tuvieron hemoglobina que no varió más de 1,5 g/dL entre el primer, tercero y sexto mes del estudio y se aplicó el test SF-36de calidad de vida. Resultados. Se evaluó 54 pacientes de nivel del mar y 48 de mayor altitud. Los primeros tuvieron mayor edad, menor prevalencia de hipertensión arterial, menores niveles de hemoglobina y de hematócrito, mayor promedio de KT/V y menor uso de medicamentos que interfieren con angiotensina. No hubo diferencia en la dosis semanal de eritropoyetina ni en la mensual de hierro. Los resultados del test SF-36 no mostraron diferencia entre los dos grupos; y, en pacientes de nivel del mar se encontró correlación entre el resultado del test SF-36 y el nivel de hemoglobina, no así en pacientes de mayor altitud. Conclusiones. Los pacientes en HD que viven a mayor altitud tienen un mayor nivel de hemoglobina. Hubo correlación entre el nivel de hemoglobina y la calidad de vida en los pacientes en HD que viven a nivel del mar, pero no en los pacientes en HD que viven a mayor altitud.

Objective. To determine whether hemoglobin levels are related to the quality of life at different altitudes in hemo- dyalisis (HD) patients. Material and MethOds. We selected patients with chronic kidney disease (CKD) in chronicHD who were living at sea level (Lima at 150 meters above sea level (masl) and Chiclayo 27 masl) and at high altitude (Arequipa 2 327 masl and Puno 3 827 masl). The patients were re-evaluated at 3 and 6 months recording: hemoglobin, blood pressure, doses of erythropoietin and iron levels. Six months later, patients who had hemoglobin which did not vary more than 1,5 g/dL among the first, third and sixth month of the study were selected; and the quality of life Test SF-36 was applied. results. We assessed 54 HD patients at sea level and 48 at high altitude. Sea level HD patients were older, had a lower prevalence of arterial hypertension, lower levels of hemoglobin and hematocrit, higher KT/V average and less use of medicines that interfere with angiotensin. There was no difference in the weekly dose of erythropoietin or monthly dose of iron. SF-36 test results showed no difference between the two groups. In sea level HD patients, a correlation was found between the SF-36 test result and their hemoglobin level. This was not found among high altitude HD patients. Conclusion. Higher hemoglobin levels are found in HD patients living at high altitude; and, in HD patients from sea level, there was a correlation between the hemoglobin level and the quality of life, which was not found in HD patients who live at high altitude. Key wOrds. Anemia, hemodialysis, high altitude, chronic kidney disease, quality of life.

Cardiovascular and renal effects of chronic exposure to high altitude.

Over 140 million people live at high altitude, defined as living at an altitude of 2400 m or more above sea level. Subjects living under these conditions are continuously living under hypoxic conditions and, depending on the population, various adaptations have developed. Interestingly, subjects living chronically at high altitude appear to have a decreased frequency of obesity, diabetes and coronary artery disease. However, these benefits on health are balanced by the frequent development of systemic and pulmonary hypertension. Recently, it has been recognized that subjects living at high altitude are at risk for developing high-altitude renal syndrome (HARS), which is a syndrome consisting of polycythemia, hyperuricemia, systemic hypertension and microalbuminuria, but with preserved glomerular filtration rate. More studies should be performed to characterize the mechanisms and etiology of HARS; as such studies may be of benefit not only to the high-altitude population, but also to better understanding of the renal consequences of acute and chronic hypoxia.

[Prevalence of anti hepatitis C antibodies in patients with chronic renal failure receiving conservative therapy]. / Prevalencia de anticuerpos anti hepatitis C en pacientes con insuficiencia renal crónica en terapia conservadora.

UNLABELLED: The prevalence of hepatitis C varies according to geographical areas and risk groups. Patients with terminal chronic renal failure (TCRF) under dialysis are an important risk group. In Peru, hepatitis C virus (HCV) infection rates in patients under hemo-dialysis reach 90%, and are associated with transfusions and time under dialysis as risk factors. Little is known about the prevalence of HCV in patients with TCRF receiving non dialysis therapy. The purpose of this study is to know the prevalence of HCV infection in these patients and to determine the risk factors. METHODOLOGY: Prospective study, anti-hepatitis C (anti HCV) antibodies were assessed in patients with TCRF in non-dialysis conservative therapy at the Department of Nephrology of the Arzobispo Loayza Hospital. RESULTS: Ninety nine (99) patients were studied, 54.1% male and 45.8% female, with an average age of 56.6 + 17.9 years, with an average time of CRF diagnosis of 9.28 + 14.35 months. The most frequent cause of CRF was the unknown cause, followed by diabetes. A rate of anti HCV of 1.01% (1/99) was found. CONCLUSION: A low prevalence of antiHCV was found in the population studied. It was similar to the rates found in populations without CTRF.

Prevalencia de anticuerpos anti hepatitis C en pacientes con insuficiencia renal crónica en terapia conservadora / Prevalence of anti hepatitis C antibodies in patients with chronic renal failure receiving conservative therapy

Introducción: La prevalencia de hepatitis C varía según el área geográfica y los grupos de riesgo. Los pacientes con insuficiencia renal crónica terminal (IRCT) en diálisis constituyen un grupo importante de riesgo. En el Perú las tasas de infección por el virus de la hepatitis C (HCB) en pacientes en hemodiálisis llegan hasta 90 por ciento, asociándose a las transfusiones y al tiempo en diálisis como factores de riesgo. Poco se sabe sobre la prevalencia de la infección por el HCV en pacientes con IRCT en terapia no dialítica. El objetivo de este estudio es conocer la prevalencia de la infección por HCV en estos pacientes y determinar los factores de riesgo. Metodología: Estudio prospectivo, se evaluaron los anticuerpos anti-hepatitis C (antiHCV), en los pacientes con IRCT en terapia conservadora, no dialítica, del Servicio de Nefrología del Hospital Arzobispo Loayza. Resultados: Se estudiaron 99 pacientes, 54.1 por ciento varones y 45.8 por ciento de mujeres, con una edad promedio de 56.60 más menos 17.9 años, con un tiempo de diagnóstico de IRC promedio de 9.28 más menos 14.35 meses. La causa más frecuente de IRC fue la no identificada seguida de la diabetes. Se halló una tasa de antiHCV de 1.01 por ciento (1/99). Conclusión: Se halló una prevalencia baja de antiHCV en la población estudiada, comparable con las tasas de la población general sin IRCT.

The prevalence of hepatitis C varies according to geographical areas and risk groups. Patients with terminal chronic renal failure (TCRF) under dialysis are an important risk group. In Peru, hepatitis C virus (HCV) infection rates in patients under hemodialysis reach 90 per cent, and are associated with transfusions and time under dialysis asrisk factors. Little is known about the prevalence of HCV in patients with TCRF receiving non dialysis therapy. The purpose of this study is to know the prevalence of HCV infection in these patients and to determine the risk factors. METHODOLOGY: Prospective study, anti-hepatitis C (anti HCV) antibodies were assessed in patients with TCRF in non-dialysis conservative therapy at the Department of Nephrology of the Arzobispo Loayza Hospital. RESULTS: Ninety nine (99) patients were studied, 54.1 per cent male and 45.8 per cent female, withan average age of 56.6 more 17.9 years, with an average time of CRF diagnosis of 9.28 more 14.35 months. The most frequent cause of CRF was the unknown cause, followed by diabetes. A rate of anti HCV of 1.01 per cent (1/99) was found. CONCLUSION: A low prevalence of antiHCV was found in the population studied. It was similar to the rates found in populations without CTRF.

Hygiene hypothesis and prevalence of glomerulonephritis.

The hygiene hypothesis was proposed to explain the marked increase in allergies that has been observed in industrialized (Westernized) societies. This hypothesis proposes that early and frequent exposure to bacterial and other antigens, such as is common in developing nations, leads to a normal Th1 response, but that better public hygiene and less infections observed in industrialized nations may lead to persistence of the Th2 phenotype and thereby increase our risk for developing allergies. Infection early in life with measles or hepatitis A virus, immunization with bacille Calmette-Guérin, certain gastrointestinal bacteria (lactobacillus), and environmental endotoxin exposure may protect individuals from developing allergy in adulthood. Paradoxically, infestation by parasites stimulates a Th2-cell response; however, the incidence of allergic disease is very low, perhaps due to the stimulation of T-regulatory lymphocytes that can downregulate Th1 and Th2 responses. Some types of human glomerulonephritis (GN) have Th1-predominant immune responses, including crescentic and membranoproliferative GN, whereas other types of GN have a predominant Th2 immune response, including membranous nephropathy, minimal change disease, and immunoglobulin A nephropathy. A review of the prevalence of specific GN shows that the higher prevalence of membranoproliferative GN in developing countries and the higher frequency of immunoglobulin A nephropathy and minimal change disease in industrialized countries could be explained by the hygiene hypothesis. We suggest that studies examining Th1/Th2 balance, particularly as it develops in childhood, should be performed to determine if early polarization of the immune response is responsible for the later development of specific forms of GN.

Genetic association analysis of chronic mountain sickness in an Andean high-altitude population.

BACKGROUND AND OBJECTIVES: Millions of people live above an altitude of 2,500 m and are at risk of chronic mountain sickness (CMS), a disorder of excessive red cell and hemoglobin production. Preferential ethnic backgrounds, familial character, and heritability studies have suggested that genetic factors make a major contribution to the pathogenesis of CMS, thus our goals were to exploit a probable founder or population admixture effect in the Andean population to determine the genetic determinants of the extreme erythropoietic responses and CMS. DESIGN AND METHODS: The association of functional candidate genes with severe polycythemia was studied in Andean subjects from Cerro de Pasco, Peru (altitude 4,438 m). We used microsatellites linked to candidate genes known to be involved in hypoxia sensing and erythropoiesis: erythropoietin, erythropoietin-receptor, hypoxia-inducible factor-1a, von Hippel-Lindau, prolyl hydroxylase domain containing 1, 2, 3, and phosphatase and tensin homolog deleted on chromosome ten. Analysis of co-variance (ANCOVA) was used to test the effect of genotypes on hemoglobin values. RESULTS: Case-control comparisons revealed no significant difference in genotype and allele frequencies at any marker. Initial analysis, with age as a covariate, showed a possible association between PHD3 (marker D14S1049) and severe polycythemia (p=0.05). After the inclusion of alternative co-variates and after adjusting for multiple comparisons, no p values could be considered statistically significant. INTERPRETATION AND CONCLUSIONS: Our study does not find evidence of associations between the polymorphisms linked to the candidate genes and severe polycythemia; this does not, however, exclude that variations in these genes contribute to polycythemia and possibly CMS.

Increased oxidative stress following acute and chronic high altitude exposure.

The generation of reactive oxygen species is typically associated with hyperoxia and ischemia reperfusion. Recent evidence has suggested that increased oxidative stress may occur with hypoxia. We hypothesized that oxidative stress would be increased in subjects exposed to high altitude hypoxia. We studied 28 control subjects living in Lima, Peru (sea level), at baseline and following 48 h exposure to high altitude (4300 m). To assess the effects of chronic altitude exposure, we studied 25 adult males resident in Cerro de Pasco, Peru (altitude 4300 m). We also studied 27 subjects living in Cerro de Pasco who develop excessive erythrocytosis (hematocrit > 65%) and chronic mountain sickness. Acute high altitude exposure led to increased urinary F(2)-isoprostane, 8-iso PGF(2 alpha) (1.31 +/- 0.8 microg/g creatinine versus 2.15 +/- 1.1, p = 0.001) and plasma total glutathione (1.29 +/- 0.10 micromol versus 1.37 +/- 0.09, p = 0.002), with a trend to increased plasma thiobarbituric acid reactive substance (TBARS) (59.7 +/- 36 pmol/mg protein versus 63.8 +/- 27, p = NS). High altitude residents had significantly elevated levels of urinary 8-iso PGF(2 alpha) (1.3 +/- 0.8 microg/g creatinine versus 4.1 +/- 3.4, p = 0.007), plasma TBARS (59.7 +/- 36 pmol/mg protein versus 85 +/- 28, p = 0.008), and plasma total glutathione (1.29 +/- 0.10 micromol versus 1.55 +/- 0.19, p < 0.0001) compared to sea level. High altitude residents with excessive erythrocytosis had higher levels of oxidative stress compared to high altitude residents with normal hematological adaptation. In conclusion, oxidative stress is increased following both acute exposure to high altitude without exercise and with chronic residence at high altitude.

Hypothesis: dysregulation of immunologic balance resulting from hygiene and socioeconomic factors may influence the epidemiology and cause of glomerulonephritis worldwide.

Glomerular diseases show diverse epidemiological characteristics throughout the world, which has been suggested to be caused by differences in genetics of the underlying populations or environmental exposure to the putative antigens or agents that either trigger or induce the disease. Recently, an alteration in immune balance of the T helper 1 (T(H)1) and T helper 2 (T(H)2) subsets has been implicated as a mechanism to explain the relative increase in allergic diseases in industrialized nations. According to the Hygiene Hypothesis, overcrowding and poor hygiene early in life may protect from atopic diseases because exposure to microbes predisposes in favor of a T(H)1-dominant response. Conversely, dominance of the T(H)2 subset would be responsible for the increasing incidence of allergies. We present the hypothesis that this imbalance may help explain the predilection for membranoproliferative glomerulonephritis (GN) and mesangial proliferative GN to be associated with developing and/or poor nations, whereas immunoglobulin A nephropathy and minimal change disease are observed more commonly in industrialized nations. The implication of the Hygiene Hypothesis is that clinical expression of immune-mediated renal disease would depend on the prevailing T(H)1/T(H)2 balance, rather than the etiologic agent, and it may help explain the epidemiological pattern of glomerular diseases worldwide.

Hyperuricemia, hypertension, and proteinuria associated with high-altitude polycythemia.

Chronic exposure to high altitude is associated with the development of erythrocytosis, proteinuria, and, in some cases, hyperuricemia. We examined the relationship between high-altitude polycythemia and proteinuria and hyperuricemia in Cerro de Pasco, Peru (altitude, 4,300 m). We studied 25 adult men with hematocrits less than 65% and 27 subjects with excessive erythrocytosis (EE; hematocrit > 65%) living in Cerro de Pasco, Peru and compared them with 28 control subjects living in Lima, Peru (at sea level) and after 48 hours of exposure to high altitude. Serum urate levels were significantly elevated in patients with EE at altitude, and gout occurred in 4 of 27 of these subjects. Urate level strongly correlated with hematocrit (r = 0.71; P < 0.0001). Urate production (24-hour urine urate excretion and urine urate-creatinine ratio) was increased in this group compared with those at sea level. Fractional urate excretion was not increased, and fractional lithium excretion was reduced, in keeping with increased proximal reabsorption of filtrate. Significantly higher blood pressures and decreased renin levels in the EE group were in keeping with increased proximal sodium reabsorption. Serum urate levels correlated with mean blood pressure (r = 0.50; P < 0.0001). Significant proteinuria was more prevalent in the EE group despite normal renal function. Hyperuricemia is common in subjects living at high altitude and associated with EE, hypertension, and proteinuria. The increase in uric acid levels appears to be caused by increased urate generation secondary to systemic hypoxia, although a relative impairment in renal excretion also may contribute.

Excessive erythrocytosis, chronic mountain sickness, and serum cobalt levels.

In a subset of high-altitude dwellers, the appropriate erythrocytotic response becomes excessive and can result in chronic mountain sickness. We studied men with (study group) and without excessive erythrocytosis (packed-cell volume >65%) living in Cerro de Pasco, Peru (altitude 4300 m), and compared them with controls living in Lima, Peru (at sea-level). Toxic serum cobalt concentrations were detected in 11 of 21 (52%) study participants with excessive erythrocytosis, but were undetectable in high altitude or sea-level controls. In the mining community of Cerro de Pasco, cobalt toxicity might be an important contributor to excessive erythrocytosis.

Amiloidosis renal: estudio clínico y patológico / Renal amyloidosis: study pathologic and clinic

Se realizó un estudio retrospectivo de corte transversal en 28 pacientes con amiloidosis renal primaria y secundaria, evaluados en el Hospital Arzobispo Loayza entre enero de 1985 y febrero de 1994. La edad promedio fue 38.6 ñ 13.9 años; 26 pacientes (92.8 por ciento) fueron de sexo femenino y 2 de sexo masculino; el tiempo de enfermedad promedio fue de 7.2 ñ 8.15 años. La presentación clínica fue: edema en el 100 por ciento, hipertensión arterial 7.1 por ciento, proteinuria 100 por ciento e insuficiencia renal 71.4 por ciento. Las causas de amiloidosis secundaria fueron: tuberculosis pulmonar en 20 pacientes (71.4 por ciento), bronquiectasias en 3 (10.7 por ciento ); otras causas fueron osteomielitis en 2 pacientes (7.1 por ciento) y linfoma no-Hodking en 1 (3.5 por ciento). En 2 pacientes no se encontró enfermedad asociada. En los pacientes con tuberculosis pulmonar se encontró que el 100 por ciento presentaba lesiones fibrocavitarias, 75 por ciento BK en esputo positivo y 85 por ciento había recibido tratamiento en forma incompleta. Los hallazgos anatomopatológicos fueron: infiltrado amiloide a nivel glomerular en el 100 por ciento, sin relación con el grado de proteinuria ni con el nivel de función renal; la nefritis intersticial crónica se encontró en 10 pacientes evidenciándose relación entre ésta y el deterioro de la función renal (p<0.01). La intensidad de la atrofia tubular guarda relación con la severidad. Los resultados de este estudio permiten establecer que la amiloidosis renal es secundaria a cuadros inflamatorios crónicos en particular a la tuberculosis, siendo la presentación clínica más frecuente el síndrome nefrótico. La nefritis intesticial crónica y atrofia tubular guardan una mejor relación con el deterioro de la función que el compromiso amiloideo a nivel glomerular.

Ofidismo y Falla Renal / Ophidysm and renal failure

Se presenta el caso de una paciente que sufre mordedura de serpiente (Bothrops atrox) en Iquitos, siendo derivada a Lima por desarrollo de insuficiencia renal aguda, recibió apoyo dialítico, recuperando la función renal. En la biopsia renal se encontró Necrosis Tubular Aguda. Se revisa la clínica, fisiopatología y tratamiento de la falla renal aguda