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1.
Hipertens. riesgo vasc ; 37(3): 101-107, jul.-sept. 2020. tab, graf
Artigo em Inglês | IBECS | ID: ibc-193518

RESUMO

INTRODUCTION: Blood pressure (BP) control is fundamental to the care of patients with chronic kidney disease (CKD), and is relevant at all stages of CKD. Renin-angiotensin-aldosterone system (RAAS) blockers have shown to be effective, not only in BP control but also in reducing proteinuria and slowing CKD progression. However, there is a lack of evidence for recommending RAAS blockers in elderly patients with CKD without proteinuria. The primary outcome of the present study is to evaluate the impact of RAAS blockers on CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS: The PROERCAN trial (trial registration, NCT03195023) is a multicentre open-label, randomized controlled clinical trial with 110 participants over 65 years-old with hypertension and CKD stages 3-4 without proteinuria. Patients will be randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs, and will be followed up for three years. Primary outcome is the estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcomes include BP control, renal and cardiovascular events, and mortality. RESULTS AND CONCLUSIONS: The design of this trial is presented here. The results will show if antihypertensive treatment with RAAS blockers has an impact on CKD progression in elderly patients without proteinuria. Any differences in BP control, cardiovascular events, and mortality with each antihypertensive treatment will be also clarified


INTRODUCCIÓN: El control de la presión arterial (PA) es fundamental para los pacientes con enfermedad renal crónica (ERC) y es relevante en todos los estadios de ERC. Los bloqueantes del sistema renina-angiotensina-aldosterona (BSRAA) han demostrado su efectividad no solo en el control de la PA sino también en la reducción de la proteinuria y de la progresión de la ERC. Sin embargo, no existe evidencia para recomendar el uso de BSRAA en pacientes añosos con ERC sin proteinuria. El objetivo principal del estudio es evaluar el impacto de los BSRAA en la progresión de ERC en pacientes añosos sin proteinuria. MATERIAL Y MÉTODOS: El estudio PROERCAN (NCT03195023) es un ensayo clínico multicéntrico, abierto, aleatorizado de 110 pacientes hipertensos, mayores de 65 años con ERC estadios3 y4 sin proteinuria. Los pacientes son aleatorizados 1:1 a recibir tratamiento con BSRAA u otros antihipertensivos y el seguimiento será de 3años. La variable principal es el descenso del filtrado glomerular estimado durante el tiempo de seguimiento. Las variables secundarias incluyen las cifras de PA, eventos renales y cardiovasculares y mortalidad. RESULTADOS Y CONCLUSIÓN: El diseño del ensayo clínico se desarrolla en el presente artículo. Los resultados determinarán si el tratamiento antihipertensivo con BSRAA tiene un impacto en la progresión de la ERC en pacientes añosos sin proteinuria. Así mismo, se aclararán las diferencias en el control de la PA, los eventos cardiovasculares y la mortalidad con los distintos tratamientos antihipertensivos


Assuntos
Humanos , Idoso , Idoso de 80 Anos ou mais , Sistema Renina-Angiotensina/efeitos dos fármacos , Insuficiência Renal Crônica/terapia , Proteinúria/etiologia , Progressão da Doença , Proteinúria/terapia , Taxa de Filtração Glomerular
2.
Ann Rheum Dis ; 79(6): 713-723, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32220834

RESUMO

OBJECTIVE: To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS: Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS: The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours with (near-)normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS: We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.


Assuntos
Imunossupressores/uso terapêutico , Nefrite Lúpica/tratamento farmacológico , Sociedades Médicas , Antirreumáticos/uso terapêutico , Azatioprina/uso terapêutico , Inibidores de Calcineurina/uso terapêutico , Quimioterapia Combinada , Europa (Continente) , Taxa de Filtração Glomerular , Glucocorticoides/uso terapêutico , Humanos , Hidroxicloroquina/uso terapêutico , Falência Renal Crônica/etiologia , Falência Renal Crônica/terapia , Nefrite Lúpica/complicações , Nefrite Lúpica/patologia , Nefrite Lúpica/fisiopatologia , Ácido Micofenólico/uso terapêutico , Proteinúria/etiologia , Proteinúria/terapia
3.
Recenti Prog Med ; 111(2): 74-81, 2020 02.
Artigo em Italiano | MEDLINE | ID: mdl-32089556

RESUMO

The presence of proteinuria, i.e. an abnormal amount of proteins in the urine is a well documented cardiovascular (CV) and renal risk factor either in the general population or in high-risk populations such as patients with type 2 diabetes, previous CV disease and patients under regular nephrology care. Indeed, the increase in proteinuria levels, even if of small entity, is associated to a faster decline in renal function over time, increased risk of End-Stage-Kidney-Disease and CV mortality. The deleterious effect of proteinuria on the kidney is attributable to the primitive glomerular damage as well as to the direct toxicity the proteinuria exerts on the tubule-interstitium. In addition, the more general association with the increased CV risk can be explained by the evidence that proteinuria can be considered a marker of systemic and renal endothelial damage. A reduction in proteinuria over time (a 30% decrease after 6 months of treatment in proteinuria is considered acceptable) as response to antihypertensive or antiproteinuric drugs protects against the development of all mentioned endpoints. Further studies are needed to better clarify: what is the normal value of proteinuria excretion, how many measures should be done during follow-up to truely assess the risk of future outcomes, what is the exact prognostic role of proteinuria.


Assuntos
Doenças Cardiovasculares/fisiopatologia , Nefropatias/fisiopatologia , Proteinúria/complicações , Doenças Cardiovasculares/mortalidade , Diabetes Mellitus Tipo 2/fisiopatologia , Humanos , Falência Renal Crônica/fisiopatologia , Prognóstico , Proteinúria/terapia , Fatores de Risco
4.
Amyloid ; 27(1): 17-24, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31595786

RESUMO

Background: The diagnostic utility of repeat kidney biopsy in AL amyloidosis patients in complete (CR) or very good partial hematologic response (VGPR) but with renal organ relapse is not clear.Methods: We present eight patients with AL amyloidosis who had a repeat kidney biopsy performed.Results: AL amyloidosis was initially diagnosed by a kidney biopsy. All patients had a favorable response to treatment (CR/VGPR) and five of them also had initially a renal organ response. A repeat kidney biopsy was done due to gradual deterioration of kidney function and/or proteinuria while maintaining a hematologic response. Repeat kidney biopsies showed findings consistent with amyloid deposits in all patients. Seven patients had renal progression with four of them requiring dialysis initiation. Only one patient had a favorable renal outcome. This patient had subacute kidney injury with decreasing proteinuria and was found to have granulomatous interstitial nephritis in addition to amyloid deposits and responded well to steroid treatment with rapid improvement in renal function.Conclusions: In AL amyloidosis patients who achieve a favorable hematologic response to treatment (CR/VGPR) but subsequently develop worsening renal insufficiency or proteinuria, a repeat kidney biopsy should generally not be performed. Amyloid deposits persist in the kidneys even after successful hematologic treatment and it is impossible to differentiate between new versus old amyloid deposits, which makes performing a repeat kidney biopsy unnecessary in most cases. Demonstration of amyloid deposits on repeat kidney biopsy would not aid in the decision making regarding re-initiation of hematologic treatment. A kidney biopsy should be considered only in cases when a specific alternative diagnosis is suspected.


Assuntos
Amiloidose de Cadeia Leve de Imunoglobulina , Rim/patologia , Placa Amiloide , Proteinúria , Adulto , Idoso , Biópsia , Feminino , Humanos , Cadeias Leves de Imunoglobulina , Amiloidose de Cadeia Leve de Imunoglobulina/patologia , Amiloidose de Cadeia Leve de Imunoglobulina/terapia , Masculino , Pessoa de Meia-Idade , Placa Amiloide/patologia , Placa Amiloide/terapia , Proteinúria/patologia , Proteinúria/terapia , Estudos Retrospectivos
5.
Mod Rheumatol ; 30(1): 125-131, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30557058

RESUMO

AbstractsBackground: Recent studies have identified the significance of proteinuria levels after initial induction therapies on the renal outcomes in patients with proliferative lupus nephritis, but the issue has not been evaluated in Japanese patients.Methods: Based on the ISN/RPS classification, only patients diagnosed with lupus nephritis class III or IV were included. The remission of proteinuria 12 months after diagnosis, as well as the clinicopathological features at diagnosis, on renal outcomes was examined retrospectively. Renal progression was defined as a 50% decrease in the estimated glomerular filtration rate or the development of end-stage renal disease.Results: This study included 82 Japanese patients with a median follow-up period of seven years. Although all patients received intensive induction therapy, 15 patients (18%) showed progression. Proteinuric remission 12 months after diagnosis predicted a good renal outcome by multivariate analysis. A receiver-operating characteristic analysis of 38 patients whose quantitative urinary protein excretion levels at 12 months were available for analysis showed that a cut-off value of 0.8 g/day predicted renal progression most effectively. Neither the renal function nor proteinuria level at diagnosis were associated with the renal outcomes.Conclusion: In Japanese patients with lupus nephritis class III or IV, proteinuria levels after 12 months under intensive therapy predicted renal outcomes more accurately than did factors identified at diagnosis.


Assuntos
Glucocorticoides/uso terapêutico , Imunossupressores/uso terapêutico , Rim/patologia , Nefrite Lúpica/terapia , Proteinúria/terapia , Indução de Remissão/métodos , Adolescente , Adulto , Idoso , Biópsia , Criança , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Japão/epidemiologia , Rim/fisiopatologia , Nefrite Lúpica/complicações , Nefrite Lúpica/diagnóstico , Masculino , Pessoa de Meia-Idade , Proteinúria/epidemiologia , Proteinúria/etiologia , Curva ROC , Estudos Retrospectivos , Adulto Jovem
6.
Medicine (Baltimore) ; 98(47): e17819, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31764774

RESUMO

INTRODUCTION: Diabetic nephropathy (DN) is one of the microvascular complications of diabetes (DM). Proteinuria is the most important clinical feature of DN and an independent risk factor for the progression of DN. Therefore, reducing urinary protein is the primary goal of DN treatment. Acupuncture has long been widely used in the treatment of DN. Therefore, this paper conducted a meta-analysis of the clinical efficacy of acupuncture in the treatment of DN proteinuria, in order to comprehensively analyze the role of acupuncture in the treatment of DN. METHODS AND ANALYSIS: We will search for PubMed, Cochrane Library, AMED, EMbase, WorldSciNet; Nature, Science online and China Journal Full-text Database (CNKI), China Biomedical Literature CD-ROM Database (CBM), and related randomized controlled trials included in the China Resources Database. The time is limited from the construction of the library to September 2019.We will use the criteria provided by Cochrane 5.1.0 for quality assessment and risk assessment of the included studies, and use the Revman 5.3 and Stata13.0 software for meta-analysis of the effectiveness, recurrence rate, and symptom scores of DN proteinuria. ETHICS AND DISSEMINATION: This systematic review will evaluate the efficacy and safety of acupuncture for DN proteinuria. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process Trial. TRIAL REGISTRATION NUMBER: PROSPERO CRD42019139705.


Assuntos
Terapia por Acupuntura , Nefropatias Diabéticas/terapia , Metanálise como Assunto , Proteinúria/terapia , Projetos de Pesquisa , Revisões Sistemáticas como Assunto , Nefropatias Diabéticas/complicações , Humanos , Proteinúria/etiologia , Resultado do Tratamento
7.
Sci Rep ; 9(1): 15467, 2019 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-31664077

RESUMO

Injury to podocytes is a principle cause of initiation and progression of both immune and non-immune mediated glomerular diseases that result in proteinuria and decreased function of the kidney. Current advances in regenerative medicine shed light on the therapeutic potential of cell-based strategies for treatment of such disorders. Thus, there is hope that generation and transplantation of podocytes from induced pluripotent stem cells (iPSCs), could potentially be used as a curative treatment for glomerulonephritis caused by podocytes injury and loss. Despite several reports on the generation of iPSC-derived podocytes, there are rare reports about successful use of these cells in animal models. In this study, we first generated a model of anti-podocyte antibody-induced heavy proteinuria that resembled human membranous nephropathy and was characterized by the presence of sub-epithelial immune deposits and podocytes loss. Thereafter, we showed that transplantation of functional iPSC-derived podocytes following podocytes depletion results in recruitment of iPSC-derived podocytes within the damaged glomerulus, and leads to attenuation of proteinuria and histological alterations. These results provided evidence that application of iPSCs-derived renal cells could be a possible therapeutic strategy to favorably influence glomerular diseases outcomes.


Assuntos
Glomerulonefrite Membranosa/terapia , Células-Tronco Pluripotentes Induzidas/transplante , Proteinúria/terapia , Transplante de Células-Tronco , Animais , Modelos Animais de Doenças , Glomerulonefrite Membranosa/complicações , Camundongos , Proteinúria/complicações
8.
J Med Case Rep ; 13(1): 298, 2019 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-31540583

RESUMO

BACKGROUND: Focal segmental glomerulosclerosis is characterized by partial (segmental) sclerotic lesions in some glomeruli (focal). Primary focal segmental glomerulosclerosis is generally considered resistant to steroid therapy. However, acromegaly is a disease that causes peculiar facial features, body types, and metabolic abnormalities due to the excessive secretion of growth hormone by a pituitary adenoma. Growth hormone has been reported to be involved in glomerular cell growth, mesangial proliferation, and glomerulosclerosis in the kidney. CASE PRESENTATION: We report a case of a Japanese patient with focal segmental glomerulosclerosis in whom decreased urinary protein was observed after surgical treatment for acromegaly. CONCLUSION: The patient's urinary protein improved as the concentration of growth hormone/insulin-like growth factor 1 decreased.


Assuntos
Acromegalia/cirurgia , Glomerulosclerose Segmentar e Focal/terapia , Proteinúria/terapia , Acromegalia/etiologia , Adenoma/complicações , Adenoma/cirurgia , Hormônio do Crescimento/sangue , Humanos , Fator de Crescimento Insulin-Like I/análise , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/cirurgia
9.
Cell Transplant ; 28(11): 1390-1403, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31409111

RESUMO

Progenitor/stem cell-based kidney regenerative strategies are a key step towards the development of novel therapeutic regimens for kidney disease treatment. However, the route of cell delivery, e.g., intravenous, intra-arterial, or intra-parenchymal, may affect the efficiency for kidney repair in different models of acute and chronic injury. Here, we describe a protocol of intra-aorta progenitor/stem cell injection in rats following either acute ischemia-reperfusion injury or acute proteinuria induced by puromycin aminonucleoside (PAN) - the experimental prototype of human minimal change disease and early stages of focal and segmental glomerulosclerosis. Vascular clips were applied across both renal pedicles for 35 min, or a single dose of PAN was injected via intra-peritoneal route, respectively. Subsequently, 2 x 106 stem cells [green fluorescent protein (GFP)-labeled c-Kit+ progenitor/stem cells or GFP-mesenchymal stem cells] or saline were injected into the suprarenal aorta, above the renal arteries, after application of a vascular clip to the abdominal aorta below the renal arteries. This approach contributed to engraftment rates of ∼10% at day 8 post ischemia-reperfusion injury, when c-Kit+ progenitor/stem cells were injected, which accelerated kidney recovery. Similar rates of engraftment were found after PAN-induced podocyte damage at day 21. With practice and gentle surgical technique, 100% of the rats could be injected successfully, and, in the week following injection, ∼ 85% of the injected rats will recover completely. Given the similarities in mammals, much of the data obtained from intra-arterial delivery of progenitor/stem cells in rodents can be tested in translational research and clinical trials with endovascular catheters in humans.


Assuntos
Lesão Renal Aguda/terapia , Transplante de Células-Tronco Mesenquimais/métodos , Células-Tronco Mesenquimais/citologia , Proteinúria/terapia , Traumatismo por Reperfusão/terapia , Doença Aguda/terapia , Lesão Renal Aguda/mortalidade , Animais , Feminino , Proteinúria/induzido quimicamente , Proteinúria/mortalidade , Puromicina Aminonucleosídeo , Ratos , Regeneração , Artéria Renal , Traumatismo por Reperfusão/mortalidade , Procedimentos Cirúrgicos Vasculares/métodos , Fluxo de Trabalho
10.
Saudi J Kidney Dis Transpl ; 30(4): 775-780, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31464233

RESUMO

Therapeutic plasma exchanges (TPE) is considered as one of the treatment modalities that is used in systemic autoimmune diseases. This study aimed to describe the early and late effect of TPE in patients with systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) presented with acute kidney injury (AKI). Retrospective study comprised patients with SLE and AAV with AKI seen between January 2000 and June 2014 at King Faisal Specialist Hospital and Research Center in Riyadh. All patients underwent TPE. Retrospectively, all patients were assessed for early and late renal outcome at 12- month and 24-month intervals. Renal outcome was assessed according to serum creatinine level, glomerular filtration rate, active urine sediment, and proteinuria. P <0.05 was considered significant. A total of 68 patients were included, 58 patients (51 females) had SLE and 10 patients (7 females) had AAV completed TPE. All patients had active disease and had AKI. At the first 12 months, 18 patients (17 SLE and 1 AAV) showed complete response and 14 patients had partial response while 22 patients did not show therapeutic benefit. The nonresponders (22 patients) entered the late assessment interval (24 months) without any therapeutic response. Statistically, there was no significant difference between the patient's response to TPE at the first and second assessment intervals and the baseline serum creatinine level. TPE might be an alternative rescue treatment in lupus nephritis with AKI.


Assuntos
Lesão Renal Aguda/terapia , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/terapia , Lúpus Eritematoso Sistêmico/terapia , Troca Plasmática , Lesão Renal Aguda/sangue , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/imunologia , Adulto , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/sangue , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/imunologia , Anticorpos Anticitoplasma de Neutrófilos/sangue , Biomarcadores/sangue , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Lúpus Eritematoso Sistêmico/sangue , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/imunologia , Masculino , Pessoa de Meia-Idade , Troca Plasmática/efeitos adversos , Proteinúria/sangue , Proteinúria/imunologia , Proteinúria/terapia , Estudos Retrospectivos , Arábia Saudita , Fatores de Tempo , Resultado do Tratamento
11.
Pediatr Transplant ; 23(6): e13538, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31271240

RESUMO

Focal segmental glomerulosclerosis (FSGS) occurring in association with cytomegalovirus (CMV) infection in a renal transplant patient with no previous history of FSGS has rarely been reported. We present a case of a 16-year-old renal transplant recipient who developed acute hepatitis, leukopenia, nephrotic syndrome, and progressive renal dysfunction in the setting of acute infection with CMV. The cytomegalovirus infection was successfully treated with IV ganciclovir followed by oral valganciclovir but renal function deterioration and massive proteinuria continued. Features of FSGS were found on two renal allograft biopsies. Plasmapheresis and cyclophosphamide treatment was instituted with no clear effect on disease progress.


Assuntos
Infecções por Citomegalovirus/complicações , Glomerulosclerose Segmentar e Focal/etiologia , Glomerulosclerose Segmentar e Focal/terapia , Transplante de Rim/efeitos adversos , Adolescente , Aloenxertos , Biópsia , Ciclofosfamida/uso terapêutico , Progressão da Doença , Humanos , Rim/fisiopatologia , Masculino , Síndrome Nefrótica/terapia , Diálise Peritoneal , Plasmaferese , Proteinúria/terapia , Transplantados
12.
Br J Cancer ; 121(3): 218-221, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31249394

RESUMO

BACKGROUND: Proteinuria monitoring is required in patients receiving lenvatinib, however, current methodology involves burdensome overnight urine collection. METHODS: To determine whether the simpler urine protein:creatinine ratio (UPCR) calculated from spot urine samples could be accurately used for proteinuria monitoring in patients receiving lenvatinib, we evaluated the correlation between UPCR and 24-hour urine protein results from the phase 3 REFLECT study. Paired data (323 tests, 154 patients) were analysed. RESULTS: Regression analysis showed a statistically significant correlation between UPCR and 24-hour urine protein (R2: 0.75; P < 2 × 10-16). A UPCR cut-off value of 2.4 had 96.9% sensitivity, 82.5% specificity for delineating between grade 2 and 3 proteinuria. Using this UPCR cut-off value to determine the need for further testing could reduce the need for 24-hour urine collection in ~74% of patients. CONCLUSION: Incorporation of UPCR into the current algorithm for proteinuria management can enable optimisation of lenvatinib treatment, while minimising patient inconvenience. CLINICAL TRIAL REGISTRATION: NCT01761266.


Assuntos
Carcinoma Hepatocelular/tratamento farmacológico , Creatinina/urina , Neoplasias Hepáticas/tratamento farmacológico , Compostos de Fenilureia/uso terapêutico , Proteinúria/terapia , Quinolinas/uso terapêutico , Sorafenibe/uso terapêutico , Carcinoma Hepatocelular/urina , Humanos , Neoplasias Hepáticas/urina
13.
Pediatr Nephrol ; 34(11): 2343-2350, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31250206

RESUMO

BACKGROUND: Focal segmental glomerulosclerosis (FSGS) in pediatric patients is typically difficult to treat and will progress to end-stage renal disease (ESRD) in about 10% of cases. Following kidney transplantation, FSGS can recur in up to 56% of renal allografts-with a near 100% recurrence in subsequent transplants. METHODS: Four different pediatric centers across the USA and the UK employed a protocol using LDL-apheresis (LDL-A) and pulse solumedrol to treat recurrent FSGS after transplantation in seven patients. All the patients included in this series demonstrated immediate, or early, recurrence of FSGS, which clinically presented as nephrotic-range proteinuria within hours to days after implantation of the kidney. RESULTS: All patients experienced reductions in urinary protein to creatinine ratios resulting in partial or complete remission. All patients demonstrated improvements in their estimated GFRs at their most recent follow-up since LDL-A discontinuation. CONCLUSIONS: This case series describes the successful treatment, across four different pediatric centers, of seven pediatric patients with recurrent post-transplant FSGS using the Liposorber® LA-15 in combination with pulse solumedrol.


Assuntos
Remoção de Componentes Sanguíneos/métodos , Glomerulosclerose Segmentar e Focal/terapia , Transplante de Rim , Lipoproteínas LDL/sangue , Hemissuccinato de Metilprednisolona/administração & dosagem , Proteinúria/terapia , Aloenxertos/patologia , Criança , Pré-Escolar , Terapia Combinada/métodos , Creatinina/urina , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Glomerulosclerose Segmentar e Focal/sangue , Glomerulosclerose Segmentar e Focal/diagnóstico , Glomerulosclerose Segmentar e Focal/patologia , Humanos , Lactente , Falência Renal Crônica/cirurgia , Glomérulos Renais/patologia , Masculino , Proteinúria/sangue , Proteinúria/diagnóstico , Proteinúria/patologia , Pulsoterapia , Recidiva , Indução de Remissão/métodos , Estudos Retrospectivos , Resultado do Tratamento
14.
J Prim Care Community Health ; 10: 2150132719843437, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31064291

RESUMO

A 19-year-old male presented to the clinic and was found to be prehypertensive and have proteinuria on urine testing. He was subsequently diagnosed with focal segmental glomerulosclerosis (FSGS). Initial workup for pediatric hypertension includes urinalysis, chemistry panel, lipid panel, and renal ultrasound. Abnormalities on urinalysis, including proteinuria, hypercholesterolemia, and low serum albumin in children are characteristic of nephrotic disease. FSGS is a type of kidney pathology that often contributes to nephrotic disease and results from a variety of causes. For the primary care provider, being aware of the guidelines for pediatric hypertension screening and evaluation is important as 20% of children with hypertensive disease are due to kidney disease. FSGS is the third leading cause of end-stage renal disease in children aged 12 to 19 years, and its incidence was found to be rising in a study of Olmsted County, MN residents. Treatment to complete or partial remission of the proteinuria can slow the progression of renal disease. In this case report, we will discuss the evaluation of pediatric hypertension workup with proteinuria, specifically due to FSGS, and review current management strategies.


Assuntos
Glomerulosclerose Segmentar e Focal/diagnóstico , Hipertensão/diagnóstico , Proteinúria/diagnóstico , Anti-Hipertensivos/uso terapêutico , Tratamento Conservador , Dieta com Restrição de Proteínas , Dieta Hipossódica , Feminino , Glomerulosclerose Segmentar e Focal/complicações , Glomerulosclerose Segmentar e Focal/terapia , Humanos , Hipertensão/etiologia , Hipertensão/terapia , Losartan/uso terapêutico , Nefrite Hereditária , Proteinúria/etiologia , Proteinúria/terapia , Adulto Jovem
16.
Am J Nephrol ; 49(6): 425-434, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30991390

RESUMO

BACKGROUND: Transplant glomerulopathy (TG) represents a major cause of long-term allograft failure and is the leading cause of overall post-transplant proteinuria. The extent to which histopathologic features predicts prognostication is uncertain. METHODS: A single-center retrospective cohort with biopsy-proven TG was investigated. Renal biopsies were scored according to Banff 2017. The primary outcome was death-censored graft failure defined as return to dialysis or estimated glomerular filtration rate (eGFR) decreased to <15 mL/min/1.73 m2. The prognostic significance of clinical and histopathologic parameters was determined using Cox proportional hazards models. RESULTS: Data from 180 cases were available for analysis with a median follow-up of 5.0 (2.6-8.2) years. In multivariable models, ci + ct score (HR 3.1; 95% CI 2.0-4.9), cg score (HR 1.7; 95% CI 1.1-2.8), eGFR (HR 2.1; 95% CI 1.4-3.2) and proteinuria (HR 2.4; 95% CI 1.6-3.7) were independent predictors of the primary outcome. Mesangial Immunoglobulin A deposition did not significantly affect allograft survival. The only significant pathologic factors for the severity of proteinuria were cg and g + ptc (adjusted R2 = 0.46) as determined by multivariable stepwise linear regression analysis. CONCLUSIONS: Severe ci + ct and cg at biopsy were predictors of unfavorable allograft prognosis in TG patients even after taking into consideration clinical characteristics. Histologic severity of cg and g + ptc was significantly associated with clinical proteinuria.


Assuntos
Aloenxertos/patologia , Glomerulonefrite/diagnóstico , Rejeição de Enxerto/diagnóstico , Transplante de Rim/efeitos adversos , Proteinúria/diagnóstico , Adulto , Biópsia , China , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Glomerulonefrite/patologia , Glomerulonefrite/terapia , Glomerulonefrite/urina , Rejeição de Enxerto/patologia , Rejeição de Enxerto/terapia , Rejeição de Enxerto/urina , Sobrevivência de Enxerto , Humanos , Glomérulos Renais/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Proteinúria/patologia , Proteinúria/terapia , Proteinúria/urina , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Transplante Homólogo/efeitos adversos
17.
Ther Apher Dial ; 23(6): 575-583, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30993827

RESUMO

Low-density lipoprotein apheresis (LDL-A) has been used for nephrotic syndrome (NS) caused by focal segmental glomerulosclerosis in Japan. Idiopathic membranous nephropathy (iMN) can also cause treatment-resistant NS. Therefore, we investigated the effect of LDL-A during initial induction for it. This retrospective, observational, and single-center study enrolled consecutive iMN patients who received steroids from March 2000 to May 2015. We compared data between 11 patients treated with LDL-A (LDL-A group) and 27 patients without (non-LDL-A group) at baseline and 4 and 8 weeks later. Reduction rate of proteinuria and increase rate of serum albumin in LDL-A group were significantly higher than the other after 4 weeks (P = 0.036 and 0.030) and 8 weeks (P = 0.030 and <0.001), respectively. There was no adverse event caused by LDL-A and immunosuppressant dose was not significantly different. In conclusion, LDL-A may be an effective choice for initial induction of nephrotic iMN.


Assuntos
Remoção de Componentes Sanguíneos/métodos , Glomerulonefrite Membranosa/terapia , Imunossupressores/administração & dosagem , Lipoproteínas LDL/sangue , Idoso , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Proteinúria/etiologia , Proteinúria/terapia , Estudos Retrospectivos , Albumina Sérica Humana/metabolismo , Esteroides/administração & dosagem , Resultado do Tratamento
18.
Clin Exp Nephrol ; 23(8): 1031-1038, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31030309

RESUMO

BACKGROUND: The type of lifestyle guidance that is effective for preventing development of chronic kidney disease (CKD) is unknown. Here, we aim to investigate the effects of a participatory structured group education (SGE) program on the development of CKD in a population-based study. METHODS: We retrospectively analyzed 1060 adult special health check-up examinees with CKD. Examinees with an estimated glomerular filtration rate (eGFR) from 50 to 60 mL/min/1.73 m2 and/or proteinuria 1+ were encouraged to attend an SGE program. The SGE program included participatory small group discussions on the attendees' remaining risk factors. The primary outcome of this study was the change in eGFR per year. RESULTS: The changes in eGFR in examinees who attended the SGE program (n = 209, + 2.9 mL/min/1.73 m2 [95% confidence interval (CI) + 1.9 to + 3.9]) significantly improved compared with control (n = 383, + 1.2 mL/min/1.73 m2 [95% CI + 0.5 to + 1.9], p = 0.006). Attending an SGE program was independently and positively related to the changes in eGFR at 1 year after attendance, after adjusting for classical covariates (ß = 1.55 [95% CI 0.37-2.73], p = 0.01). Attending an SGE program was effective for the examinees with a lower eGFR compared with those with only proteinuria. CONCLUSIONS: Our SGE program showed the beneficial effects of preventing the development of CKD, independent of classical factors. The type of SGE program that is more effective for preventing development of CKD should be investigated in a long-term analysis.


Assuntos
Processos Grupais , Conhecimentos, Atitudes e Prática em Saúde , Educação de Pacientes como Assunto/métodos , Participação do Paciente , Proteinúria/terapia , Insuficiência Renal Crônica/prevenção & controle , Comportamento de Redução do Risco , Idoso , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/fisiopatologia , Masculino , Fatores de Proteção , Proteinúria/diagnóstico , Proteinúria/fisiopatologia , Proteinúria/psicologia , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/psicologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Kidney Int ; 96(1): 94-103, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30987838

RESUMO

The clinicopathological characteristics of kidney infiltration in B-cell lymphoproliferative disorders remain poorly described. We retrospectively studied 52 adults with biopsy-proven malignant B-cell kidney infiltration, including Waldenström's macroglobulinemia (n=21), chronic lymphocytic leukemia (n=11), diffuse large B-cell lymphoma (DLBCL) (n=8), other lymphoma (n=11), and multiple myeloma (n=1). Kidney disease varied according to the underlying lymphoproliferative disorder. In DLBCL, malignant kidney infiltration was prominent, resulting in acute kidney injury (AKI, 75%) and kidney enlargement (88%). In the other types, associated immunoglobulin-related nephropathy (most commonly AL amyloidosis) was more common (45%), and chronic kidney disease with proteinuria was the primary presentation. All patients received chemotherapy. Over a median follow-up of 31 months, 20 patients died and 21 reached end-stage kidney disease. Renal response, achieved in 25 patients (48%), was associated with higher overall survival (97 vs. 37 months in non-renal responders). In univariate analysis, percentage of sclerotic glomeruli, kidney enlargement, and complete hematological response at 6 months were predictive of renal response. In multivariate analysis, concomitant immunoglobulin-related nephropathy was the sole independent predictor of poor renal outcome. In conclusion, clinical presentation of renal lymphomatous infiltration depends on the nature of the underlying lymphoproliferative disorder. In DLBCL, massive renal infiltration manifests with enlarged kidneys and AKI, and the diagnosis primarily relies on lymph node biopsy. In other B-cell lymphoproliferative disorders, the clinicopathological spectrum is more heterogeneous, with a high frequency of immunoglobulin-related nephropathy that may affect renal outcome; thus kidney biopsy is required for early diagnosis and prognostic assessment.


Assuntos
Lesão Renal Aguda/epidemiologia , Córtex Renal/patologia , Transtornos Linfoproliferativos/complicações , Proteinúria/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/patologia , Lesão Renal Aguda/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Feminino , Humanos , Incidência , Transtornos Linfoproliferativos/urina , Masculino , Pessoa de Meia-Idade , Proteinúria/etiologia , Proteinúria/patologia , Proteinúria/terapia , Diálise Renal/estatística & dados numéricos , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/patologia , Insuficiência Renal Crônica/terapia , Estudos Retrospectivos , Adulto Jovem
20.
Minerva Urol Nefrol ; 71(6): 651-656, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30767491

RESUMO

BACKGROUND: Posterior urethral valve (PUV) is the most serious form of congenital anomalies of kidney and urinary tract (CAKUT) in boys with significant risk of progression to chronic kidney disease (CKD). We present our long-term results in children with PUV. METHODS: Retrospective chart review of 113 children with PUV followed within the years of 1996-2018 was performed. Clinical, laboratory and epidemiologic parameters were analyzed for their impact on renal outcome. RESULTS: The median age of diagnosis was 1.00 month (1.00-132.00) and the median follow-up period was 70 months (60.00-216.00). Antenatal diagnosis was present in 33 patients (51.5%) mainly with bilateral hydronephrosis and oligohydramnios. The most common postnatal presentation was recurrent urinary tract infection (UTI) in 14 cases (21.9%) and incontinence in three cases (4.7%). Vesicoureteral-reflux (VUR) was present in 31 cases (48.4%). All patients had surgery and urinary diversion was needed in 18 (28.2%). Varying stages of chronic kidney disease (CKD) developed in 23 cases (35.9%) and rise in serum creatinine was especially prominent after the 4th year of follow-up. Of 23 CKD patients, seven (10.9%) were in ESRD and on dialysis. Mortality occurred in one (1.5%) patient. Hypertension, proteinuria and high initial serum creatinine (>1.28 mg/dL) were statistically significant risk factors for CKD, as expected. Surprisingly VUR and UTI did not show such a significant impact on CKD development. Antenatal detection was with significantly less risk for CKD. CONCLUSIONS: Our results confirm that PUV has a considerable risk for CKD development. Antenatal diagnosis, management of proteinuria and hypertension may modify this progression. But already injured kidneys still have a potential risk. The need for further research to evaluate the impact of any intervention on long term renal outcome is obvious.


Assuntos
Uretra/anormalidades , Uretra/cirurgia , Obstrução Uretral/congênito , Obstrução Uretral/cirurgia , Idade de Início , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Hipertensão Renal/etiologia , Hipertensão Renal/terapia , Lactente , Recém-Nascido , Falência Renal Crônica/etiologia , Masculino , Gravidez , Diagnóstico Pré-Natal , Proteinúria/etiologia , Proteinúria/terapia , Insuficiência Renal Crônica/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Obstrução Uretral/diagnóstico , Derivação Urinária/métodos , Procedimentos Cirúrgicos Urológicos , Refluxo Vesicoureteral
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