Uropatía obstructiva recurrente en arteritis de Takayasu / Recurrent upper urinary tract obstruction in takayasu arteritis

La arteritis de Takayasu (AT) es una enfermedad inflamatoria infrecuente de vasos grandes. A menudo, el daño crónico originado en las grandes arterias requiere de revascularización mediante prótesis vasculares. Excepcionalmente la implantación de las prótesis origina lesiones en otros órganos, como los uréteres, los cuales pueden obstruirse por compresión extrínseca por el tejido fibroso retroperitoneal originado como reacción a la presencia de la prótesis vascular.Se comunica el caso de una mujer que presentó hidronefrosis bilateral en forma asincrónica después de los 2 años de la instalación de una prótesis aorto-ilíaca con insuficiencia renal aguda, la cual pudo revertirse mediante. (AU)

Takayasu's arteritis is a rare inflammatory disease of large vessels. Often, chronic damage resulting in large arteries stenosis requires revascularization with vascular prostheses. Exceptionally, the presence of prostheses causes lesions in other organs, such as ureters, which are subject to extrinsic compression caused by retroperitoneal fibrous tissue originated as a reaction to the presence of vascular prostheses. We report the case of a woman who presented bilateral asynchronous hydronephrosis after 2 years of the installation of an aorto- iliac graft with acute renal failure, which could be reversed by releasing the ureter from the periprosthetic fibrous retroperitoneal tissue.(AU)

Heparinas de bajo peso molecular en pacientes con enfermedad renal crónica ¿Es seguro su uso? / Are low-molecular-weight heparins safe in patients with chronic kidney disease?

Due to their effcacy and convenience, low-molecular-weight heparins (LMWH) are used as sustitutes of unfractionated heparin. Unfortunately, most of the evidence about safety and usefulness of LMWH have excluded patients with chronic kidney disease (CKD), in whom their elimination clearance is reduced, allowing an increased anticoagulant effect. Accordingly, there is a growing number of reports about major and fatal bleeding episodes in this group of patients using LMWH. At the present stage of knowledge, there is no defnitive cut-off value of renal function to adjust the doses or avoid the administration of LMWH, making their effects unpredictable in patients with CKD. Hence, it is reasonable to avoid the use of these drugs in patients with CKD, while awaiting for more evidence that supports their safer use.

Prevalencia de enfermedades crónicas no transmisibles; en 520 fallecidos en un servicio de medicina interna / Prevalence of nontransmissible chronic diseases; in 520 patients who died in an internal medicine service

Antecedentes: En Chile han ocurrido cambios biodemográficos importantes en las últimas décadas aumentando las expectativas de vida al nacer sobre los 76 años. Ello ha provocado un cambio en la morbilidad. Objetivo: Conocer la prevalencia de enfermedades crónicas no transmisibles (ECNT) en los enfermos fallecidos en un Servicio de Medicina (SDM). Material y método: En 520 pacientes consecutivos se registró la prevalencia en ECNT, según criterios diagnósticos estrictos. Se correlacionaron utilizando regresión logística a los diagnósticos entre sí, con la edad y género. Resultados: Un 54 por ciento eran hombres y la mediana de edad 78 años. Setenta por ciento tenía hipertensión arterial (HTA), 37 por ciento deterioro cognitivo (DOC), 34,2 por ciento cáncer, 29,6 por ciento diabetes mellitus (DM), 20.6 por ciento secuelas de accidente cerebrovascular, 19.2 por ciento enfermedad coronaria, 16.5 por ciento fibrilación auricular, 15.6 por ciento insuficiencia cardíaca y 15.6 por ciento daño hepático crónico. Uno de cada 3 estaba postrado crónicamente y 1 de cada 4 estaba desnutrido al ingresar al hospital. En el análisis multivariado la HTA se asoció a DM, fibrilación auricular e insuficiencia renal crónica (IRC). El DOC se asoció sólo a la enfermedad de Parkinson. No hubo ninguna patología que se asociara significativamente al cáncer. La DM se asoció a la cardiopatía coronaria, HTA e IRC. Las secuelas de un accidente cerebrovascular se asociaron a fibrilación auricula e HTA. El hipotiroidismo se asoció a cardiopatía coronaria y fibrilación auricular. Conclusiones: La mayoría de los fallecidos en un SDM son ancianos mayores de 70 años (75 por ciento) y portadores de múltiples ECNT. Una proporción elevada tienen DOC, desnutrición, están postrados crónicamente y tienen escaras de decúbito. Las enfermedades neurológicas están presentes en el 50.2 por ciento y el cáncer o enfermedades cardiovasculares en un tercio de los fallecidos.

Hemorragia pulmonar secundaria a una reactivación tardía de un síndrome de Churg-Strauss en un paciente en hemodiálisis crónica: Report of one case / Late reactivation of Churg-Strauss syndrome

We report a 22 years old male with chronic allergic rhinitis, who presented with asthma, prolonged fever, eosinophilia, cutaneous vasculitis, subcutaneous nodules, polyarthritis, ulcers in the nasal mucosa and external auditory canal, hematuria, proteinuria, renal failure, severe hypertension, pulmonary infiltrates and mesenteric ischemia with a perforation of the sigmoid colon. Arteriography showed multiple aneurysmae of intrarenal arteries and a skin biopsy showed a leukocytoclastic vasculitis. A diagnosis of Churg-Strauss syndrome was made. He was initially treated with steroids and cyclophosphamide but abandoned therapy. Eighteen years after the onset of the disease, he required hemodialysis. Eight months after being on dialysis, he suffered a reactivation of the disease with lung hemorrhage and finally died, due to an upper gastrointestinal bleeding caused by a duodenal ulcer.

Aplasia medular tratada exitosamente con ciclosporina en un paciente en hemodiálisis crónica / Bone marrow aplasia during hemodialysis successfully treated with cyclosporine: report of one case

A 28 years old male on chronic hemodialysis for 40 months due to a IgA crescentic glomerulonephritis developed pancytopenia (hematocrit 16 percent, white blood cell count 3.800 mm3 and platelets 11.000 mm3. The bone marrow aspirate showed erythropoietic hyperplasia. Hemolytic anemia, folate or vitamin B12 deficiency and paroxysmal nocturnal hemoglobinuria were ruled out. Steroids were given with a transient elevation of red cells and platelets, which lasted only for some weeks. Afterwards, intravenous immunoglobulin was given without benefit. Two months after, a bone marrow biopsy and a bone marrow magnetic resonance imaging showed severe aplasia. Cyclosporine was started with a rapid increase in blood cells count. Eight months later, he received a renal transplant from a cadaveric donor. Immunosupression was achieved with cyclosporine, prednisone and mycofenolate mofetil. The patient required hemodialysis for the first three weeks and a mild acute cellular rejection was treated with methylprednisolone. At discharge, 6 weeks later, serum creatinine was 2.4 mg/dl and creatinine clearance 37.6 ml/min. During the first months after transplant, platelet count and hemoglobin decreased and a bone marrow biopsy showed only mild hypoplasia. Four months after renal transplant the hematocrit was 43 percent, white blood cell count 6.600 mm3 and platelets, 150.000 mm3 and did not change during the first year of follow up (Rev Méd Chile 2004; 132: 989-94).

Relación entre el motivo de ingreso y la causa de muerte en pacientes fallecidos en un Servicio de Medicina Interna / Relationship between the cause of admission and the cause of death in patients admitted to an internal medicine departament

Background: When patients are admitted to an internal medicine ward, they and their relatives believe that they will leave the internal medicine service in a better health condition or, if they die, their cause of death will be the same that motivated the hospital admission. Sometimes, patients die due to a different disease than the cause of admission or due to complications of diagnostic or therapeutic procedures. Aim: To assess the proportion of deaths that occurred in internal medicine wards for causes that differ from the cause for admission and the proportion of deaths related to complications of diagnostic or therapeutic procedures. Patients and methods: Three hundred and three consecutive patients were studied during 28 months. Their cause of death was classified in four groups: A. If it was the same illness of admission; B. A frecuent or expected complication of the illness that motivated the admission; C. A complication of one of their chronic diseases and not the one of admission; D. If it was not related to an already present chronic illness or the cause for admission. Results: Sixty nine percent of deaths corresponded to group A, 7.9 percent to group B, 11.2 percent to group C and 11.9 percent to group D. Diagnostic or therapeutic procedures were the cause of death in 0.7 and 3.6 percent of cases respectively. Conclusions: Twenty three percent of patients died due to causes that differ from the cause of admission. A low percentage of deaths were related to procedures and most of them were due to complications of therapeutic measures (Rev Méd Chile 2004; 132: 707-17).

Evaluación de gravedad en 1000 pacientes críticos / Evaluation of seriousness in 1.000 critical patients

Evaluamos 1000 pacientes críticos según la escala de gravedad APS-2 (2) descrita por William Knaus (desde 1988 a 1991) con elo objeto de conocer su capacidad para estimar la mortalidad en nuestro medio. La mortalidad global fue de un 28 por ciento en esta serie, superior a las series extranjeras de comparación, utilizadas (5,6). Se analizan los factores que explican estas diferencias, y se evaluó la utilización de el APS-2, como herramienta en la selección de las admisiones a la Unidad de Cuidados Intensivos (UCI)