Alexandre T. Bignelli

Impact of Residual Renal Function on Volume Status in Chronic Renal Failure

During the past few years, it has become increasingly evident that residual renal function (RRF) is an important and independent predictor of poor outcome in patients with chronic kidney disease (CKD). Although the causes of this observation are not fully understood, it appears that the loss of RRF impairs both fluid removal and clearance of solutes, which in turn leads to uremic toxicity and increased morbidity and mortality. There is increasing evidence that patients with CKD develop signs of fluid overload already in the early phases of the disease, and this may be a stimulus for inflammatory activation. Recently, an inflammatory component was identified in uremic atherosclerotic and non-atherosclerotic cardiovascular disease (CVD), which have been consistently associated with poor clinical outcome in patients with CKD. Signs of systemic inflammation occur in parallel to the impairment in renal function, and the pathophysiology is most likely multifactorial, including a decrease in cytokine clearance, advanced glycation end-product accumulation, oxidative stress, and principal fluid overload. Additionally, inflammation seems to be a predictor of accelerated loss of renal function. In this article, we discuss the evidence showing that patients with CKD generally have fluid overload, the mechanisms by which impaired renal function may lead to a chronic inflammatory state, and the available information linking fluid overload to accelerated loss of renal function and CVD through inflammation. Inflammation may lead to the development of complications of CKD, in particular CVD, but on the other hand may also lead to a faster progression of renal disease. Strategies aiming to reduce fluid overload may be useful to reduce cardiovascular morbidity and mortality, but also preserve RRF.

Association between Biomarkers of Carbonyl Stress with Increased Systemic Inflammatory Response in Different Stages of Chronic Kidney Disease and after Renal Transplantation

Background: Chronic kidney disease (CKD) is characterized by progressive kidney dysfunction accompanied by accumulation of uremic toxins and a potential disequilibrium between the redox status and the generation of prooxidants, resulting in oxidative stress and chronic inflammation which is associated with complications (particularly cardiovascular disease) in this population. We aimed to analyze the concentration of total plasma thiols (indicator of antioxidant capacity) and the protein carbonyl content (a marker of carbonyl stress) in relation to kidney function and inflammation in a group of patients with CKD. Patients and Methods: A group of 68 patients with CKD (stages 2–5; mean age 57 ± 12 years, 46% male, 34% diabetics) and another group of 21 patients who underwent living donor kidney transplantation (mean age 36 ± 17 years, 50% male, 10% diabetics, and 9 ± 2 months after renal transplantation) were included in the study. Total plasma thiol and protein carbonyl levels were determined by the DTNB and DNPH methods, respectively, and were adjusted to the plasma albumin concentrations. Plasma levels of fibrinogen and C-reactive protein (CRP) were measured by routine methods and used as markers of inflammation. Results: Mean glomerular filtration rate (GFR) was 48 ml/min, and there was a positive correlation between GFR and thiol (r = 0.25, p < 0.05) and a negative correlation between GFR and carbonyl (r = –0.26, p < 0.05), fibrinogen (r = –0.45, p < 0.0001) and CRP (r = –0.14, p = ns). Carbonyl strongly correlated with CRP (0.49, p < 0.0001) and fibrinogen (0.30, p < 0.01). There was a significant reduction in plasma carbonyl after renal transplantation (1.4 ± 0.4 nmol/mg albumin), compared with the levels before the procedure (2.0 ± 1.4 nmol/mg albumin, p < 0.05), which parallels an improvement in thiol levels (15 ± 4 vs. 21 ± 5 nmol/mg albumin, p < 0.001). In addition, there was a significant correlation between CRP and carbonyl after the transplantation (r = 0.65; p < 0.005). Conclusion: We observed that patients with CKD present an altered redox status and increased signs of carbonyl stress and inflammatory activity as kidney function deteriorates, which was partially but significantly improved after renal transplantation. These findings indicate the importance of renal function in the complications of CKD related to oxidative stress and inflammation.

Hand-Assisted Laparoscopic Donor Nephrectomy: Comparison to Pure Laparoscopic Donor Nephrectomy

Hand-assisted laparoscopic surgery is assumed to be easier to learn than the standard approach and simplifies intact kidney removal. Herein we have presented our experience performing hand-assisted laparoscopic donor nephrectomy (HALDN) compared with contemporary pure laparoscopic donor nephrectomy (LDN). We retrospectively analyzed 55 patients who underwent LDN. Among the procedures, 21 were HALDN and 34 were pure LDN. We compared the two groups with regard to operative time, warm ischemic time (WIT), estimated blood loss, conversion rate, postoperative stay, and complications. For the HALDN group, the mean operative time was 191 minutes, WIT varied from 2 to 11 minutes, and bleeding estimates varied from 100 to 4000 mL. The overall complication rate of 28.6% included: vessel injury, urinary leakage, and paralytic ileus. In the LDN group, the mean operative time was 184 minutes, WIT varied from 2 to 10 minutes, and bleeding estimated varied 100 to 3000 mL. Three patients (8.8%) had complications including ureteral obstruction (n = 1) and vessel injury (n = 2). There was no significant difference between the two groups about the procedure and the complications. Our series suggested that HALDN and LDN were similar, with a tendency toward better results in LDN group, which also shows lower costs.

Early Graft Function in Kidney Transplantation: Comparison Between Laparoscopic Donor Nephrectomy and Open Donor Nephrectomy

Laparoscopic donor nephrectomy (LN) offers less postoperative pain and early recovery in living kidney donors, but graft kidney function in the recipients can be delayed due to prolonged warm ischemic time (WIT) and adverse effects of pneumoperitoneum. We compared the early function of the grafted kidney and the complications in kidney recipients after LN versus open nephrectomy (ON). We analyzed 109 kidney recipients from living donors, including 60 LN and 49 ON, comparing immediate diuresis after surgery, glomerular filtration rate (GFR) by MDRD formula (modification of diet in renal disease) at day 5, and complications. The recipient age among the LN group was 20 to 73 years with 51% men among whom 95% of patients had immediate diuresis with GFR at day 5 varying from 4.85 to 99.45 mL/min/1.73 m(2) by MDRD Surgical complications were renal artery stenosis (5%) and urinary leakage (5%). The recipient among age ON cases varied from 18 to 63 years with 63% men and immediate diuresis observed in 87% and GFR at day 5 varied from 4.75 to 101.1 mL/min/1.73 m(2) by MDRD. Renal artery stenosis was observed in 8.16%. The WIT was longer (P < .05) among the LN (1.4 to 11 minutes) compared with the ON group (1 to 4 minutes). GFR at day 5 showed no difference between the two groups. In conclusion, WIT was higher among LN compared with ON but did not seem to influence early function of the grafted kidney.

The Impact of Living Donor Kidney Transplantation on Markers of Cardiovascular Risk in Chronic Kidney Disease Patients

Background: Kidney transplant (Tx) patients present a reduced cardiovascular (CV) mortality in comparison to the dialysis population, but in comparison to the general population, it is still several-fold higher. Methods: We studied risk factors for CV disease in a group of 38 patients (50% males, median age 36 years) who underwent a living donor Tx at the baseline and after 3 ± 1 and 9 ± 2 months. Results: The prevalence of overweight increased from 26 to 54% after Tx (p < 0.001). The mean systolic blood pressure decreased significantly after the Tx (148 ± 27.6 vs. 126 ± 12.7 mm Hg). There was a significant increase in LDL (97 ± 30 vs. 114 ± 35) and hematocrit (33.8 ± 4.4 to 42 ± 5.7%) levels and a significant reduction in fibrinogen levels (394 ± 91 vs. 366 ± 100 mg/dl) after 9 months as compared to the baseline. Obesity and dislipidemia were significantly correlated with inflammation. Significant changes in left ventricle mass index (293 ± 116 vs. 241 ± 96) were observed after the Tx. Patients with a low glomerular filtration rate (GFR) in the follow-up evaluation presented higher LDL (128 ± 7 vs. 99 ± 7 mg/dl; p < 0.05) and higher fibrinogen levels (399 ± 21 vs. 332 ± 22 mg/dl; p < 0.05) compared to patients with a high GFR. Conclusion: Most of the risk factors analyzed (particularly the uremia-related) improved after the renal Tx, which could justify the positive impact of Tx on the development of CV disease. Inflammation and dyslipidemia were related to renal dysfunction after the Tx, suggesting that complete restoration of renal function may have an impact on reducing CV mortality in CKD patients treated with renal Tx.

Analysis of economic impact between the modality of renal replacementtherapy

INTRODUCTION Chronic kidney disease (CKD) is a major health problem, determining the reduction in life expectancy and an increased risk of cardiovascular disease. METHOD An observational, cohort, retrospective, based on patients 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. RESULTS The lowest cost of a kidney transplant in the first year was R

Analysis of economic impact among modalities of renal replacement therapy

40,743.03 when cyclosporine was used and the highest was R

Pelvic kidney for living transplantation: case report and review of the literature

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

Endovascular treatment of cerebral aneurysm after renal transplantation in polycystic kidney disease

67,023.39; Hemodialysis R

Effect of preload reduction by hemodialysis on left atrial volume and echocardiographic Doppler parameters in patients with end-stage renal disease

71,717.51 and automated peritoneal dialysis automatic R