Altair Jacob Mocelin

Uremic hyperhomocysteinemia: a randomized trial of folate treatment for the prevention of cardiovascular events.

Homocysteine is a risk factor for atherosclerosis in the general population, and serum homocysteine levels are almost universally elevated in chronic renal failure patients. When such patients are treated with dialysis, cardiovascular disease accounts for more than 50% of their mortality, which, in some proportion, may be pathophysiologically related to the elevated serum homocysteine levels. From April 2003 to March 2005, we conducted a 2‐year, double‐blind, randomized, placebo‐controlled trial of 186 patients with end‐stage kidney disease due to any cause, who were older than 18 years and stable on hemodialysis. Patients were assigned to receive either oral folic acid 10 mg 3 times a week immediately after every dialysis session under nurse supervision or an identical‐appearing placebo for the entire study. On admission, plasma total homocysteine (tHcy) levels were above 13.9 μmol/L in 96.7% of patients (median 25.0 μmol/L, range 9.3–104.0 μmol/L). In the placebo group, tHcy levels remained elevated at 6, 12, and 24 months, while oral folate significantly decreased tHcy to a median value of 10.5 (2.8–20.3) μmol/L, (p<0.01). During the study, 38 patients (folic acid group 17 vs. placebo group 21; p=0.47) died from cardiovascular disease. Kaplan–Meier life table analysis dealing with the incidence of cardiovascular events, both fatal and nonfatal (myocardial infarction, arrhythmias, angina, heart failure, cerebrovascular accident), showed that 2 years of folic acid treatment and the lowering of the homocysteine blood levels had no effect on cardiovascular events (p=0.41; hazard ratio 1.24, 95% CI 0.74–2.10). However, the carotid artery intima‐media wall thickness measured in a blinded fashion decreased from 1.94 ± 0.59 mm to 1.67 ± 0.38 mm (p<0.01) after 2 years of folate therapy. In this short‐term study of uremic patients, 2 years of folic acid supplementation normalized the tHcy blood levels in 92.3% of patients but did not change the incidence of cardiovascular events compared with the control group. However, ultrasonography of the common carotid arteries performed at entry and 24 months later showed a significant decrease in intima‐media thickness with folate supplementation. This suggests that early folate supplementation may benefit patients with chronic renal failure by preventing cardiovascular deterioration.

Função pulmonar e força muscular respiratória em pacientes com doença renal crônica submetidos à hemodiálise

OBJECTIVE: To evaluate pulmonary function and respiratory muscle strength in chronic renal failure patients, correlating these variables with hemodialysis-related weight fluctuation; to study the correlation between the duration hemodialysis and potential respiratory alterations. METHODS: Seventeen patients (median age, 47 years; interquartile range, 41-52 years), submitted to three weekly hemodialysis sessions for a median of 27 months (interquartile range, 14-55) were evaluated. Twelve of the patients were male. The patients underwent spirometry. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured prior to and after the first hemodialysis session of the week. Body weight was quantified prior to and after each of the three weekly sessions. RESULTS: Before the first hemodialysis session of the week, 8 patients presented mild restrictive defect, which normalized after the session in 2 of those patients. After dialysis, there was a significant increase in forced vital capacity (p = 0.02) and a significant decrease in body weight (p = 0.0001). Weight fluctuation over 3 days without hemodialysis tended to correlate with the variation in forced vital capacity in the first weekly session (r = 0.47; p = 0.055). Duration of hemodialysis correlated with predialysis MIP (r = -0.3; p = 0.03) and MEP (r = -0.63; p = 0.006). CONCLUSIONS: More pronounced weight gain in the interdialytic period is associated with worsening of lung function, which is almost fully reversible by hemodialysis. In addition, longer duration of hemodialysis is associated with decreased respiratory muscle strength.

Kidney Transplantation: The Use of Abnormal Kidneys

We transplanted 6 anatomically abnormal kidneys: a horseshoe kidney that after division was transplanted into 2 recipients; 1 kidney with ureteral stones and hydronephrosis; 1 ectopic and 1 hydronephrotic kidney; 2 kidneys with extensive ureteric lesions, donated as free organs. All these kidneys ultimately had normal function in the recipients, long-term in 4.2 patients died but in neither was the death caused by the renal abnormality.

Validação dos testes de Ewing para avaliação de disfunção autonômica

A necessidade de padronizacao dos testes para avaliar a disfuncao autonomica tornou-se evidente a partir dos resultados contraditorios observados nas ultimas duas decadas. Os testes propostos por Ewing e col., com este objetivo, tem ampliado sua aceitacao; avaliam os reflexos cardiovasculares, mas podem refletir dano em qualquer outro ponto do sistema nervoso autonomo. Propusemos valida-los em nosso meio, aplicando-os em 30 individuos sadios e 23 diabeticos, representando os parâmetros de normalidade e anormalidade, respectivamente. Os 5 testes demonstraram alto grau de sensibilidade e especificidade, sao reprodutiveis, realizados com um minimo de material simples, servindo a sua proposta.The medical literature on the evaluation of autonomic dysfunction accumulated discordant results in the past decades, accentuating the need of validating the proposed tests. The Ewings tests for studying autonomic abnormalities received increasing acceptance, as they recognize not only cardiovascular reflexes damage but lesions in any other segments of the autonomic nervous system. We proposed to validate them in our population by analysing their results on 30 normal individuals and 23 long-standing diabetics. Our results show that the five tests are highly sensitive and specific, reproducible, use simple and available office material, and fulfil their purpose.

Transplante de Pâncreas e de Ilhotas Pancreáticas: Visão de Nefrologista

The authors after presenting the magnitude of the problem of diabetes mellitus and diabetic nephropathy in Brazil and in the world made a review upon the point of view of the nephrologist about pancreas and pancreatic islet transplantation centered on the risks and benefits of the simultaneous pancreatic kidney transplantation (SPKT) for the diabetic with end-stage renal failure. In the paper it is stressed the importance of the interaction between the endocrinologist and the nephrologist for improving the survival of the diabetic patient with nephropathy and for a local definition about the viability and validity of establishing a SPKT program.

Nephrocalcinosis in a patient with Sjögren's syndrome/systemic lupus erythematosus

A 46-year-old white woman has been followed in this nephrology clinic since 1995 due to recurrent nephroli-thiasis and medullary nephrocalcinosis resulting from renal tubular acidosis (urinary pH of 8 in the context of systemic normal anion gap acidosis; serum potassium at lower limit, and 24-hour urine with normocalciuria but no detectable citrate) due to Sjogren’s syndrome (SS). During follow-up, her adherence to alkali therapy had been suboptimal due to gastric intolerance to Shohl’s solution, potassium citrate, and sodium bicarbonate. As consequence, she had progression in her nephrocal-cinosis and passed several urinary calculi (biochemical analysis showed them to be composed of calcium phos-phate and calcium oxalate). Currently, she presents nor-mal estimated GFR (MDRD, 82 mL/min/1.73 m

Hypernatremia secondary to post-stroke hypodipsia: just add water!

Disorders in water metabolism may occur in stroke patients. When hypernatremia arises in this setting, it is usually secondary to the development of central diabetes insipidus or it is the result of neurologic lesions that prevent patients from having free access to water. Much rarer are the cases of post-stroke hypernatremia caused by hypodipsia secondary to lesions of the thirst center. We report the case of a patient with severe hypernatremia, probably secondary to post-hemorrhagic stroke hypodipsia. The hypernatremia seen in this case was corrected by scheduling the patient’s water intake.

Indinavir-associated toxicity mimicking urinary tuberculosis in a patient with AIDS.

This case reported to a patient with AIDS who presented persistent sterile leukocyturia and hematuria, lower back pain, bladder suffering symptoms, and renal papillary necrosis which were thought to be secondary to urinary tuberculosis but were demonstrated to be indinavir-associated side effects. The intention of this report is to remind medical professionals involved in the care of HIV+ patients of this possible association in order to avoid unnecessary investigation and to stress the need of careful periodical assessment of renal function and urinalysis in patients treated with indinavir.