Elisa de Albuquerque Sampaio

Situação do hiperparatireoidismo secundário autônomo no Brasil: dados do Censo Brasileiro de Paratireoidectomia

INTRODUCTION Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.INTRODUCTION: Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE: To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS: This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS: Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS: Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.

Protocolo clínico e diretrizes terapêuticas para o tratamento do hiperparatireoidismo secundário em pacientes com doença renal crônica

INTRODUCAO A doenca renal cronica (DRC) afeta 5-10% da populacao mundial e sua incidencia no Brasil tem aumentado, devido ao numero crescente de pacientes diagnosticados, principalmente os portadores de diabetes mellitus, hipertensao arterial, bem como pelo aumento da longevidade da populacao. […] Protocolo clinico e diretrizes terapeuticas para o tratamento do hiperparatireoidismo secundario em pacientes com doenca renal cronica1 Serviço de Nefrologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil. 2 Serviço de Nefrologia da Universidade Federal de São Paulo, São Paulo, Brasil. 3 Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil. 4 Departamento de Medicina Interna da Universidade Federal da Bahia, Brasil. 5 Serviço de Nefrologia da Universidade Federal do Rio Grande do Sul, Brasil. 6 Serviço de Nefrologia da Universidade Federal Fluminense, Niterói, RJ, Brasil. 7 Serviço de Nefrologia da Universidade Federal de Pernambuco, Brasil.

Guidelines on Bone Mineral Disorder in Chronic Kidney Disease - Addendum Chapter 2

1 – AVALIACAO DOS NIVEIS DE PARATORMONIO (PTH) E FOSFATASE ALCALINA (FA) NA DRC 1.1 – Os niveis sericos de PTH devem ser analisados em todos os pacientes com DRC, cuja taxa de filtracao glomerular (TFG) for inferior a 60 mL/min/1,73 m2 (Evidencia). Deve-se modificar a frequencia de avaliacao dos niveis sericos de PTH se os resultados das analises mostrarem uma tendencia de elevacao ou de descenso ou apos a instituicao do tratamento, seja ele para reduzir ou elevar os [...]

Distúrbio mineral e ósseo após o transplante renal

O transplante renal (TxR) e a melhor alternativa de tratamento para os pacientes com DRC avancada. Entretanto, apesar do sucesso dessa terapia, os pa-cientes submetidos ao TxR podem apresentar elevada incidencia de complicacoes, dentre elas a persistencia da doenca ossea, piorando a qualidade de vida e au-mentando a morbimortalidade. O TxR bem sucedido geralmente corrige ou melhora os disturbios do meta -bolismo mineral e osseo (DMO) da DRC, e a persis-tencia dessas alteracoes sao determinadas pela magni -tude das anormalidades no periodo dialitico, disfun-cao do enxerto e acao de drogas imunossupressoras. Muitas das alteracoes do metabolismo mineral que ocorrem logo apos o TxR tendem a se normali-zar no decorrer do primeiro ano. A hipofosfatemia, acompanhada de fosfaturia, ocorre em 90% dos pa-cientes transplantados, e geralmente apresenta reso-lucao do quadro ate o terceiro mes, permanecendo no limite inferior da normalidade.

Prevalência e correlatos de doença vascular no exame de ultrassom em pacientes em hemodiálise

BACKGROUND Patients on hemodialysis present an increased risk of cardiovascular death. Intimal media thickness (IMT) and presence of arterial calcifications are well-known risk factors for cardiovascular death in hemodialysis patients. OBJECTIVE To assess the prevalence of IMT and arterial calcifications in HD patients and to correlate image findings with clinical and laboratory data. METHODS Cross-sectional study involving 75 patients on dialysis for >12 months. Patients underwent B-mode ultrasound scan (US) for determination of IMT of the distal third of the common carotid arteries. Arterial calcifications were assessed by US of carotids, femoral and tibial arteries, and labeled positive if calcification was found in any arterial site. RESULTS Patients were 52±13 years old, 57% were males and 16% were diabetics. IMT > 0.9 mm was found in 57% of cases and arterial calcifications at US in 48%. Aging (decades) and smoking were associated with both increased IMT (adjusted odds ratio [aOR] = 3.4, p < 0.001; aOR = 4.4, p = 0.045, respectively) and presence of vascular calcifications (aOR = 3.0, p < 0.001; aOR = 6.8, p = 0.011, respectively). High intact parathyroid hormone levels (per each 100 pg/ml) were significantly associated with increased IMT (aOR = 1.7, p = 0.021), but not with vascular calcification. In contrast, Diabetes and time on dialysis (years) were significant determinants for calcifications at US (aOR = 15.0, p = 0.009; aOR = 1.39, p = 0.020), but not for increased IMT. CONCLUSION Increased IMT and calcifications at US are common findings in hemodialysis patients. Aging and smoking are consistent determinants for both image alterations. Parathyroid hormone elevation is associated with increased IMT. Diabetes and time on dialysis substantially increase the risk for arterial calcification.FUNDAMENTO: Pacientes en hemodialisis (HD) presentan riesgo aumentado de muerte cardiovascular. El espesor intima-media (EIM) y la presencia de calcificaciones arteriales son factores de riesgo bien conocidos de muerte cardiovascular en pacientes en HD. OBJETIVO:Evaluar la prevalencia de EIM y calcificaciones en pacientes en HD y correlacionar hallazgos de imagen con datos clinicos y de laboratorio. METODOS:Estudio transversal de 75 pacientes en HD por >12 meses. Los pacientes fueron sometidos a ultrasonografia (US) modo-B para determinacion de la EIM del tercio distal de las arterias carotidas comunes. Las calcificaciones arteriales fueron evaluadas por US de arterias carotidas, femorales y tibiales y consideradas positivas si fuesen encontradas calcificaciones en cualquier sitio arterial. RESULTADOS:Los pacientes tenian 52±13 anos, 57% eran del sexo masculino y 16% eran diabeticos. EIM > 0,9mm fue encontrada en 57% de los casos y calcificaciones arteriales en la US en 48%. Envejecimiento (decadas) y tabaquismo estaban asociados a aumento de la EIM (odds ratio ajustado [aOR] = 3,4, p < 0,001; aOR = 4,4, p = 0,045, respectivamente) y presencia de calcificaciones vasculares (aOR = 3,0, p < 0,001; aOR = 6,8, p = 0,011, respectivamente). Altos niveles de hormona paratiroidea intacta (iPTH) (por 100 pg/ml) estaban asociados de forma significativa a aumento en la EIM (aOR = 1,7, p = 0,021), pero no a calcificacion vascular. En contraste, diabetes y tiempo de dialisis (anos) fueron determinantes significativos para calcificaciones en la US (aOR = 15,0, p = 0,009; aOR = 1,39, p = 0,020), pero no para el aumento de la EIM. CONCLUSION:EIM aumentada y calcificaciones en la US son hallazgos comunes en pacientes en HD. Envejecimiento y tabaquismo son determinantes consistentes para ambas alteraciones de imagen. Aumento en los niveles de iPTH esta asociado a aumento en la EIM. Diabetes y tiempo de dialisis aumentan de forma sustancial el riesgo de calcificacion arterial.

Brazilian Registry of Bone Biopsy (REBRABO): design, data elements and methodology

INTRODUCTION Mineral bone disorder (MBD) is a common condition in chronic kidney disease (CKD) patients and causes significant morbidity and mortality. Data involving prevalence of alterations in bone histological patterns, impact of different treatments and its repercussion in outcomes, such as bone fractures, hospitalization, cardiovascular disease and mortality, are scarce. Data bank registry can be a valuable tool to understand epidemiological aspects of MBD CKD. The Brazilian Registry of Bone Biopsy (REBRABO) will be a national registry, coordinating by the Brazilian Society of Nephrology - Committee of MBD-CKD. OBJECTIVE To describe REBRABOs design, elements of data and methodology. METHODS Will be an online national observational and multicentric data registry divided in two phases (retrospective, 1st phase) and prospective (2nd phase), including information from bone tissue histomorphometric analysis and demographics, clinical and laboratorial data from CKD-MBD patients. RESULTS The REBRABOs first phase will explore data on demographics, clinical, laboratorial and bone histomorphometric analysis data from January/1986 to December/2013. The first RESULTS are expected in early 2015. CONCLUSION Studies in the field of CKD-MBD are needed, particularly those analyzing its prevalence, associations between demographic, clinical, histological parameters, and major outcomes. The REBRABO will be a unique retrospective and prospective research platform including bone biopsy data in CKD-MBD patients.

Prevalence and correlates of vascular disease at ultrasound examination in patients on hemodialysis.

BACKGROUND Patients on hemodialysis present an increased risk of cardiovascular death. Intimal media thickness (IMT) and presence of arterial calcifications are well-known risk factors for cardiovascular death in hemodialysis patients. OBJECTIVE To assess the prevalence of IMT and arterial calcifications in HD patients and to correlate image findings with clinical and laboratory data. METHODS Cross-sectional study involving 75 patients on dialysis for >12 months. Patients underwent B-mode ultrasound scan (US) for determination of IMT of the distal third of the common carotid arteries. Arterial calcifications were assessed by US of carotids, femoral and tibial arteries, and labeled positive if calcification was found in any arterial site. RESULTS Patients were 52±13 years old, 57% were males and 16% were diabetics. IMT > 0.9 mm was found in 57% of cases and arterial calcifications at US in 48%. Aging (decades) and smoking were associated with both increased IMT (adjusted odds ratio [aOR] = 3.4, p < 0.001; aOR = 4.4, p = 0.045, respectively) and presence of vascular calcifications (aOR = 3.0, p < 0.001; aOR = 6.8, p = 0.011, respectively). High intact parathyroid hormone levels (per each 100 pg/ml) were significantly associated with increased IMT (aOR = 1.7, p = 0.021), but not with vascular calcification. In contrast, Diabetes and time on dialysis (years) were significant determinants for calcifications at US (aOR = 15.0, p = 0.009; aOR = 1.39, p = 0.020), but not for increased IMT. CONCLUSION Increased IMT and calcifications at US are common findings in hemodialysis patients. Aging and smoking are consistent determinants for both image alterations. Parathyroid hormone elevation is associated with increased IMT. Diabetes and time on dialysis substantially increase the risk for arterial calcification.FUNDAMENTO: Pacientes en hemodialisis (HD) presentan riesgo aumentado de muerte cardiovascular. El espesor intima-media (EIM) y la presencia de calcificaciones arteriales son factores de riesgo bien conocidos de muerte cardiovascular en pacientes en HD. OBJETIVO:Evaluar la prevalencia de EIM y calcificaciones en pacientes en HD y correlacionar hallazgos de imagen con datos clinicos y de laboratorio. METODOS:Estudio transversal de 75 pacientes en HD por >12 meses. Los pacientes fueron sometidos a ultrasonografia (US) modo-B para determinacion de la EIM del tercio distal de las arterias carotidas comunes. Las calcificaciones arteriales fueron evaluadas por US de arterias carotidas, femorales y tibiales y consideradas positivas si fuesen encontradas calcificaciones en cualquier sitio arterial. RESULTADOS:Los pacientes tenian 52±13 anos, 57% eran del sexo masculino y 16% eran diabeticos. EIM > 0,9mm fue encontrada en 57% de los casos y calcificaciones arteriales en la US en 48%. Envejecimiento (decadas) y tabaquismo estaban asociados a aumento de la EIM (odds ratio ajustado [aOR] = 3,4, p < 0,001; aOR = 4,4, p = 0,045, respectivamente) y presencia de calcificaciones vasculares (aOR = 3,0, p < 0,001; aOR = 6,8, p = 0,011, respectivamente). Altos niveles de hormona paratiroidea intacta (iPTH) (por 100 pg/ml) estaban asociados de forma significativa a aumento en la EIM (aOR = 1,7, p = 0,021), pero no a calcificacion vascular. En contraste, diabetes y tiempo de dialisis (anos) fueron determinantes significativos para calcificaciones en la US (aOR = 15,0, p = 0,009; aOR = 1,39, p = 0,020), pero no para el aumento de la EIM. CONCLUSION:EIM aumentada y calcificaciones en la US son hallazgos comunes en pacientes en HD. Envejecimiento y tabaquismo son determinantes consistentes para ambas alteraciones de imagen. Aumento en los niveles de iPTH esta asociado a aumento en la EIM. Diabetes y tiempo de dialisis aumentan de forma sustancial el riesgo de calcificacion arterial.

Prevalencia y correlatos de enfermedad vascular en el examen de ultrasonido en pacientes en hemodiálisis

BACKGROUND Patients on hemodialysis present an increased risk of cardiovascular death. Intimal media thickness (IMT) and presence of arterial calcifications are well-known risk factors for cardiovascular death in hemodialysis patients. OBJECTIVE To assess the prevalence of IMT and arterial calcifications in HD patients and to correlate image findings with clinical and laboratory data. METHODS Cross-sectional study involving 75 patients on dialysis for >12 months. Patients underwent B-mode ultrasound scan (US) for determination of IMT of the distal third of the common carotid arteries. Arterial calcifications were assessed by US of carotids, femoral and tibial arteries, and labeled positive if calcification was found in any arterial site. RESULTS Patients were 52±13 years old, 57% were males and 16% were diabetics. IMT > 0.9 mm was found in 57% of cases and arterial calcifications at US in 48%. Aging (decades) and smoking were associated with both increased IMT (adjusted odds ratio [aOR] = 3.4, p < 0.001; aOR = 4.4, p = 0.045, respectively) and presence of vascular calcifications (aOR = 3.0, p < 0.001; aOR = 6.8, p = 0.011, respectively). High intact parathyroid hormone levels (per each 100 pg/ml) were significantly associated with increased IMT (aOR = 1.7, p = 0.021), but not with vascular calcification. In contrast, Diabetes and time on dialysis (years) were significant determinants for calcifications at US (aOR = 15.0, p = 0.009; aOR = 1.39, p = 0.020), but not for increased IMT. CONCLUSION Increased IMT and calcifications at US are common findings in hemodialysis patients. Aging and smoking are consistent determinants for both image alterations. Parathyroid hormone elevation is associated with increased IMT. Diabetes and time on dialysis substantially increase the risk for arterial calcification.FUNDAMENTO: Pacientes en hemodialisis (HD) presentan riesgo aumentado de muerte cardiovascular. El espesor intima-media (EIM) y la presencia de calcificaciones arteriales son factores de riesgo bien conocidos de muerte cardiovascular en pacientes en HD. OBJETIVO:Evaluar la prevalencia de EIM y calcificaciones en pacientes en HD y correlacionar hallazgos de imagen con datos clinicos y de laboratorio. METODOS:Estudio transversal de 75 pacientes en HD por >12 meses. Los pacientes fueron sometidos a ultrasonografia (US) modo-B para determinacion de la EIM del tercio distal de las arterias carotidas comunes. Las calcificaciones arteriales fueron evaluadas por US de arterias carotidas, femorales y tibiales y consideradas positivas si fuesen encontradas calcificaciones en cualquier sitio arterial. RESULTADOS:Los pacientes tenian 52±13 anos, 57% eran del sexo masculino y 16% eran diabeticos. EIM > 0,9mm fue encontrada en 57% de los casos y calcificaciones arteriales en la US en 48%. Envejecimiento (decadas) y tabaquismo estaban asociados a aumento de la EIM (odds ratio ajustado [aOR] = 3,4, p < 0,001; aOR = 4,4, p = 0,045, respectivamente) y presencia de calcificaciones vasculares (aOR = 3,0, p < 0,001; aOR = 6,8, p = 0,011, respectivamente). Altos niveles de hormona paratiroidea intacta (iPTH) (por 100 pg/ml) estaban asociados de forma significativa a aumento en la EIM (aOR = 1,7, p = 0,021), pero no a calcificacion vascular. En contraste, diabetes y tiempo de dialisis (anos) fueron determinantes significativos para calcificaciones en la US (aOR = 15,0, p = 0,009; aOR = 1,39, p = 0,020), pero no para el aumento de la EIM. CONCLUSION:EIM aumentada y calcificaciones en la US son hallazgos comunes en pacientes en HD. Envejecimiento y tabaquismo son determinantes consistentes para ambas alteraciones de imagen. Aumento en los niveles de iPTH esta asociado a aumento en la EIM. Diabetes y tiempo de dialisis aumentan de forma sustancial el riesgo de calcificacion arterial.