It is still unknown how the pharmacological inhibition of the Renin Angiotensin System (RAS) impacts the levels of inflammation and fibrosis biomarkers.
This study sought to evaluate the effect of enalapril, candesartan and aliskiren on urinary levels of cytokines in a model of chronic kidney disease (CKD).
Male Wistar rats were submitted to surgical removal of ¾ of renal parenchyma to induce CKD (¾ nephrectomy), or subjected to sham surgery (control). Animals were then randomized into five groups: Sham surgery receiving vehicle; ¾ Nephrectomy receiving vehicle; ¾ Nephrectomy receiving enalapril (10 mg/kg); ¾ Nephrectomy receiving candesartan (10 mg/kg) and ¾ Nephrectomy receiving aliskiren (10 mg/kg). Urine output, water intake, mean arterial pressure (MAP) and urinary concentrations of creatinine, urea, albuminuria, Na+, K+, interleukin (IL) -1β, IL-6, IL-10 and transforming growth factor beta (TGF-β) were measured.
Nephrectomy significantly impaired renal function, increased MAP and altered the levels of all evaluated cytokines in urine. Enalapril, candesartan and aliskiren improved renal function and decreased MAP and IL-6 when compared to vehicle-treated nephrectomized group. Candesartan and aliskiren decreased IL-1β, while only candesartan reduced TGF-β and only aliskiren increased IL-10.
Enalapril, candesartan and aliskiren presented similar effects on improving renal function and reducing MAP and urinary levels of IL-6 in rats with CKD. On the other hand, cytokine profile differed according to the treatment, suggesting that differential mechanisms were triggered in response to the site of RAS blockade.
Keywords: angiotensinas; antagonistas de receptores de angiotensina; falência renal crônica; inibidores da enzima conversora de angiotensina; nefrectomia;
Patients with acute kidney injury (AKI) in developing countries are described in a profile of young age, with less comorbidities, with unifactorial, and with a lower mortality compared to patients in developed countries.
To assess mortality in patients with acute kidney injury undergoing hemodialysis (HD) and its associated factors in a developing country setting.
Retrospective study. Demographic, clinical, and mortality variables were collected from patients who presented AKI and underwent HD between January 2014 and December 2015 at a national reference hospital in Lima, Peru. Risk ratios (RR) and 95% confidence intervals (95%CI) were estimated through Poisson regressions.
Data from 72 patients with AKI that underwent HD were analyzed, 66.7% of them were < 64 years old, and 40.2% of all patients died undergoing HD. Crude analysis showed higher mortality among those who used vasopressors, but lower mortality among those with creatinine values > 8.9 mg/dL. The adjusted analysis showed that having had a creatinine level of > 8.9 mg/dL, compared to a creatinine level of < 5.2 mg/dL at the time of initiating HD, was associated with 74% less probability of death.
Four out of every ten AKI patients undergoing HD die. Higher levels of creatinine were associated with lower probability of mortality.
Keywords: diálise renal; lesão renal aguda; mortalidade; unidades de terapia intensiva;
Chronic kidney disease (CKD) is a worldwide public health alarming problem.
This study investigated the estimated prevalence of kidney disease in diabetic and high-risk hypertensive patients to cardiovascular disease registered in Hiperdia program of a city of southeast of Brazil.
It is a transversal study conducted between May 2014 and August 2015. The study has included randomly 243 diabetic and high-risk hypertensive patients to cardiovascular disease which were originally referred from primary health care to the Hiperdia. CKD was classified based on cause, Glomerular Filtration Rate (GFR), and albumin creatinine ratio (ACR). Were considered abnormalities GFR < 60 mL/min/1.73m2 and/or ACR ≥ 30 mg/g.
Of the 243 patients, 89 (36.6%) showed alterations in renal function markers in the first collection. Of these, 60 patients had a GFR < 60 mL/min/1.73 m2 and 25 the GFR was < 45 mL/min/1.73 m2. The ACR was ≥ 30 mg/g in 43 patients and eight of the values were > 1000 mg/g. In 15 patients studied were found both changes. Of the 89 participants with abnormal renal function markers in the first collection 63 held the second test and 42 kept the changes being diagnosed with CKD. None of these patients had prior knowledge of the diagnosis of kidney disease and the need for consultation with the nephrologist.
The prevalence of CKD was 17.3% of disease in the population studied.
Keywords: albuminúria; insuficiência renal crônica; prevalência; taxa de filtração glomerular;
There is possibility of a supernumerary hyperplastic parathyroid gland in dialysis patients after total parathyroidectomy and autograft in dialysis patients.
To test if the early postoperative measure of parathyroid hormone (PTH) can identify persistent hyperparathyroidism.
A prospective cohort of dialysis patients submitted to parathyroidectomy had PTH measured up to one week after operation. The absolute value and the relative decrease were analyzed according to clinical outcome of satisfactory control of secondary hyperparathyroidism or persistence.
Of 51 cases, preoperative PTH varied from 425 to 6,964 pg/mL (median 2,103
pg/mL). Postoperatively, PTH was undetectable in 28 cases (54.9%). In eight
individuals (15.7%) the PTH was lower than 16 pg/mL, in 10 (19.6%) the PTH
values were between 16 and 87pg/mL, and in five (9.8%), PTH was higher than
87 pg/mL. Undetectable PTH was more common in patients with preoperative PTH
below the median (
Measurement of PTH in the first days after parathyroidectomy in dialysis patients may suggest good clinical outcome if a decrease of at least 95% of the preoperative value is observed. Less than 80% PTH decrease is highly suggestive of residual hyperfunctioning parathyroid tissue with persistent hyperparathyroidism, and an early reintervention may be considered.
Keywords: hiperparatireoidismo secundário; hipocalcemia; hormônio paratireóideo; paratireoidectomia; recidiva;
Vaccination is the most effective tool in preventing transmission of Hepatitis B Virus (HBV). The patient with chronic kidney disease (CKD) on dialysis appear to be at greater risk of becoming infected with this virus and does not show the same vaccine response when compared to patients without uremia.
To evaluate the results related to the HBV vaccine and identify factors associated with the response in patients with CKD on hemodialysis.
Individuals with HBsAG and negative anti-HBC, under hemodialysis were
assessed in two units of São Luis, Maranhão and were undergone full
vaccination schedule for HBV. They were divided in groups: anti-HBs10 mUI/mL
and compared as to age, gender, presence of
The rate of vaccine response to HBV in patients with CKD on dialysis was 70% and the lack of anti-HCV infection was associated with seroconversion of anti-HBs suggesting that infection by the hepatitis C virus may be a factor that decreases the response of the HBV vaccine in dialysis CKD patients.
Keywords: hepatite C; insuficiência renal crônica; vacinação; vacinas contra hepatite B; vírus da hepatite B;
The variability of arterial blood pressure (BP) is considered an important cardiovascular risk factor.
To verify the possible associations between the postprandial and the sleeping blood pressure variability.
This study evaluated systolic, diastolic, mean, pulse pressures and heart variability in 69 elderly patients in preprandial, postprandial and sleeping periods. One 24 hours ambulatory blood pressure monitoring was used for measurements and the results were showed in the time-rate index.
We observed a decrease in the systolic blood pressure values from preprandial
to postprandial and to the sleeping periods (124.7 ± 14.6, 113.2
± 15.3 and 108.5 ± 13.9mmHg, respectively;
The correlation between postprandial and sleeping BP variability has rarely been demonstrated in the literature. These correlations between BP changes after eating and during sleep might suggest that both events could coexist in other clinical situations.
Keywords: idoso; hipertensão; hipotensão; monitorização ambulatorial da pressão arterial;
Dietary regimen for hemodialysis (HD) patients is complicate and identifying characteristics and reasons of those most likely to experience difficulty in adhering to dietary restrictions is important.
To quantify HD patient's perceptions about dietary and fluid restrictions, acknowledge individual reasons that facilitate or complicate their adherence, and also their relationship with demographic, nutritional and clinical characteristics.
Multi-center cross-sectional study in five dialysis facilities. HD patients (n = 147; 48% male; age: 51,3 ± 13,6 years) were encouraged to score on a scale of 0 to 10 their perception of the degree of difficulty to adhere the nutritional advice regarding control of sodium, fluid, potassium and phosphorus intake.
Sodium score was 4(1-7), fluids 6(3-8), potassium 4(2-6) and phosphate 6(3-8). Percentage of patients who perceived a greater difficulty (score ≥ 6) to control fluids and phosphate intake was higher than for sodium and potassium. Participants with excessive % interdialytic weight gain (%IDWG) had a higher score for fluids; the ones with hypercalemia perceived more difficulty to control potassium intake than others as well as hyperphosphatemic patients compared to normophosphatemic to control phosphorus intake. Participants with a greater difficulty to control sodium intake also perceived a greater difficulty to control fluids, potassium and phosphate intake.
Participants perceived a greater difficulty to control fluid and phosphate intake rather than sodium and potassium, higher perceptions scores were associated with subgroups and with worse control of clinical parameters. Moreover, patients with a greater difficulty to control some dietary item also found harder to control the other ones.
Keywords: dieta; hemodiálise; terapia nutricional;
Chronic kidney disease (CKD) is a major health problem, determining the reduction in life expectancy and an increased risk of cardiovascular disease.
An observational, cohort, retrospective, based on patient's medical records data with CKD under hemodialysis, peritoneal dialysis and kidney transplantation in the city of Curitiba, in the period from January to June 2014, evacuativo the financial impact on the Unified Health System (SUS) and the supplementary health.
The lowest cost of a kidney transplant in the first year was R$ 40,743.03 when cyclosporine was used and the highest was R$ 48,388.17 with the use of tacrolimus. In the second year post-transplant, hemodialysis and peritoneal dialysis have a higher cost compared to kidney transplant. Transplantation with deceased donor, treated with tacrolimus: R$ 67,023.39; Hemodialysis R$ 71,717.51 and automated peritoneal dialysis automatic R$ 69,527.03.
After the first two years of renal replacement therapy, transplantation demonstrates lower costs to the system when compared to other modalities evaluated. Based on that, this therapy justifies improvements in government policies in this sector.
Keywords: diálise renal; insuficiência renal crônica; saúde suplementar; Sistema Único de Saúde; transplante de rim;
Hemodialysis contributes to increased oxidative stress and induces transitory hypoxemia. Compartmentalization decreases the supply of solutes to the dialyzer during treatment. The aim of this study was to investigate the acute effects of intradialytic aerobic exercise on solute removal, blood gases and oxidative stress in patients with chronic kidney disease during a single hemodialysis session.
Thirty patients were randomized to perform aerobic exercise with cycle ergometer for lower limbs during 30 minutes with intensity between 60-70% of maximal heart rate, or control group (CG). Blood samples were collected prior to and immediately after exercise or the equivalent time in CG. Analysis of blood and dialysate biochemistry as well as blood gases were performed. Mass removal and solute clearance were calculated. Oxidative stress was determined by lipid peroxidation and by the total antioxidant capacity.
Serum concentrations of solutes increased with exercise, but only phosphorus
showed a significant elevation (
The acute intradialytic aerobic exercise increased phosphorus serum concentration and decreased total antioxidant capacity, reversing hypoxemia resulting from hemodialysis. The intradialytic exercise did not change the blood acid-base balance and the removal of solutes.
Keywords: estresse oxidativo; exercício; diálise renal;
Immunosuppression of T lymphocytes is required for preventing acute rejection after transplantation and for the treatment of chronic autoimmune and inflammatory diseases. The laboratory monitoring for this therapy is the measurement of T cells by immunophenotyping, aiming the target value of less than 20 cells per µL.
To establish a cut-off point for the total number of lymphocytes in the automated blood cell count that reflects less than twenty T cells µL by immunophenotyping.
We studied and evaluated 242 kidney transplant patients that had results of automated blood cell count and quantification of T cells by immunophenotyping technique. The patients were divided into two groups, depending on the T lymphocyte immunophenotyping rates established by lower and higher than 20 cells per µL. After, we evaluated the cut-off point for lymphocytes in the blood cell count with a specificity of 100% to exclude patients with high levels of T lymphocytes.
We found that the cut-off point of 70 lymphocytes per µL obtained by automated blood cell count showed 100% of specificity to exclude patients with T-cell counts higher than 20 cells per µL by immunophenotyping.
The results found in this study may be helpful to monitor the immunosuppressive therapy in kidney transplant patients in places where a flow cytometer is not available, or when this equipment is not present in the full routine.
Keywords: citometria de fluxo; imunofenotipagem; imunossupressores; transplante de rim;
Patients with chronic kidney disease (CKD) are susceptible to the occurrence of ventricular arrhythmias. The leading cause of death in dialysis patients is cardiac arrhythmias. The pathophysiology of arrhythmias in this population is complex and seems to be related to structural cardiac abnormalities caused by CKD, associated with several triggers, such as water and electrolyte disorders, hormonal conditions, arrhythmogenic drugs, and the dialysis procedure itself. Little is known about the clinical outcomes in CKD patients with asymptomatic ventricular arrhythmias. The results of treatments with anti-arrhythmic drugs and invasive devices are controversial in these patients, according to the available literature. The aim of this study was to review this often-neglected topic, which is of special importance in the CKD population.
Keywords: arritmias cardíacas; epidemiologia; insuficiência renal crônica;
This systematic review has sought to identify the multidisciplinary scientific
production, addressing factors for proper
Keywords: diabetes mellitus; educação em saúde; conhecimento; autocuidado;
Calcineurin inhibitors (CNIs) are used widely for maintenance immunosuppression in renal transplant recipients. However, their side effect profile has led researchers to attempt to find safer alternatives that can maintain effective long-term immunosuppression with less toxicity. Belatacept is a CTLA4-Ig molecule designed to block the costimulatory B7-CD28 signal needed for activation of effector T cells. While it has shown great promise in clinical trials, it has made halting progress towards replacing CNIs in actual clinical practice. The BENEFIT trial revealed some of the advantages of belatacept in terms of maintaining renal function after transplant and reducing some of the metabolic side effects of CNIs related to hypertension and dyslipidemia. Despite that, some cautionary signals have emerged as well, in that belatacept-treated patients experience higher acute rejection rates and greater risk for PTLD. Furthermore, the requirement for monthly intravenous infusions has presented logistical and cost challenges for widespread adoption.
Keywords: calcineurina; Imunossupressão; Transplante renal;
Hypercalcemia is a rare condition in childhood; the most common causes are primary hyperparathyroidism, malignancy, prolonged immobilisation, thyrotoxicosis, thiazide diuretic, supplements containing calcium, milk-alkali syndrome, vitamin D intoxication, infections and idiopathic. We present three cases of severe hypercalcemia of unusual causes in children. The first patient had high fever, poor general condition, weight loss and myalgia. Extensive preliminary investigation did not define the etiology, but a review of medical history revealed prolonged contact with pet bird and a positive serology for Chlamydia confirmed the diagnosis of psittacosis. The second patient had generalized lymphadenopathy and hepatosplenomegaly with fever a month ago. Paracoccidioides brasiliensis was identified in myelogram; the patient showed partial improvement with the use of co-trimoxazole, with subsequent emergence of multiple osteolytic lesions. A smear of gastric lavage was positive for Mycobacterium tuberculosis and the patient was treated with rifampicin, isoniazid, ethambutol and pyrazinamide, with improvement of clinical condition. The third patient was treated by hypercalciuria and idiopathic hypomagnesiuria with daily use of cholecalciferol; the patient had a two quilograms of weight loss in the past two months. No cause of hypercalcemia could be detected in laboratory workout. The capsules of cholecalciferol were analyzed and presented an amount of 832,000 IU of vitamin D per capsule. Acute hypercalcemia in childhood may be due to exogenous vitamin D intoxication, as well as infectious causes. The possible causal relationship between psittacosis and occurrence of hypercalcemia alert to the need for detailed investigation of the epidemiological antecedents.
Keywords: hipercalcemia; infecção; psitacose; vitamina D;
Tumoral calcinosis is an uncommon type of extraosseous calcification characterized by large rubbery or cystic masses containing calcium-phosphate deposits. The condition prevails in the periarticular tissue with preservation of osteoarticular structures. Elevated calcium-phosphorus products and severe secondary hyperparathyroidism are present in most patients with uremic tumoral calcionosis (UTC). Case report of an obese secondary to chronic glomerulonephritis, undergoing continuous ambulatory peritoneal dialysis (CAPD) reported the appearance of painless tumors in the medial surface of fifth finger and left arm. Tumoral calcinosis was confirmed by left biceps biopsy. Poor adherence to CAPD. The patient was transferred to the "tidal" modality of peritoneal dialysis and after was treated by hemodialysis, despite the persistence of severe hyperparathyroidism progressive reduction of UTC until near to its complete disappearance. Nowadays, one year after patient received deceased-donor kidney transplantation, he presents with an improvement in secondary hyperparathyroidism. UTC should be included in the elucidation of periarticular calcification of every patient on dialysis. Relevant laboratory findings such as secondary hyperparathyroidism and elevated calcium- phosphorus products in the presence of periarticular calcification should draw attention to the diagnosis of UTC.
Keywords: distúrbios do metabolismo do cálcio; distúrbios do metabolismo do fósforo; nefrologia;
Ultrasonography (US) is a rapid, non-invasive and safe procedure that allows the nephrologist to obtain vital information to the bedside, as well as allows to guide the procedures for nephrology practice.
Male patient, elderly with hypertension,
POCUS assessment of the renal tract may become the new standard of care among nephrologists by enabling the expansion of clinical information in a timely fashion, allowing faster resolution of cases and permitting the monitoring of the treatment done.
Keywords: diabetes mellitus; divertículo; hidronefrose; hipertensão; insuficiência renal crônica; ultrassonografia;
Mycobacterium tuberculosis infection in renal transplant recipients is associated with significant morbidity and mortality. Genitourinary tuberculosis is a less frequent presentation and a high level of suspicion is needed to avoid treatment delay. Management is challenging due to the interaction of calcineurin inhibitors with antituberculous medications and the known side effects of these drugs, with higher prevalence in this population. The authors present a case of a renal transplant recipient with urinary and constitutional symptoms whom is diagnosed with tuberculosis after a prostatic biopsy in an already disseminated stage and develops hepatotoxicity to antituberculous therapy.
Keywords: doença iatrogênica; transplante de rim; tratamento primário; tuberculose urogenital;