Frederico Ruzany

Thalidomide for the Treatment of Uremic Pruritus: A Crossover Randomized Double-Blind Trial

Our observation that thalidomide administration to a dialysis patient with leprosy alleviated his pruritus led us to conduct this short-term study to assess the efficacy of the drug in this regard. From 210 hemodialysis patients, 29 cases of refractory uremic pruritus were entered into the study. Patients were instructed to score their symptoms from 0 to 3, three times a day and assigned to receive thalidomide or placebo at bed time for 7 days. After a washout period of 7 days, drugs were crossed over. Response was defined as a reduction of at least 50% in the pruritus scoring. Eighteen patients finished the study. In the first phase, 55% of patients responded showing a mean reduction in their pruritus scoring of 78% (p < 0.05 vs. placebo); no response to placebo was observed. A similar proportion of patients responded to thalidomide in the second phase with a mean reduction in their pruritus scoring of 81%. In conclusion, thalidomide can be a precious tool in the handling of uremic pruritus unresponsive to available therapy.

Hepatitis C virus in chronic hemodialysis patients with non-A, non-B hepatitis.

Sixteen of 110 hemodialysis (HD) patients fulfilling criteria of non-A, non B hepatitis (NANBH), i.e. alanine aminotransferase (ALT) greater than 50 U/ml in the absence of both serologic markers for acute HBV and HAV infections and clinical evidence of another cause of hepatitis, were tested for the presence of antibodies against hepatitis C virus (anti-HCV) by enzyme immunoassay (Ortho, Diagnostics). All (100%) were anti-HCV-positive. There were 5 patients with a monophasic (M) rise pattern (1 or 2 ALT rises), and 11 cases demonstrated a polyphasic (P) rise elevation pattern (more than 2). The mean ALT value of the M group was 202.3 +/- 209 U/ml and that of the P group was 116.6 +/- 39.1 U/ml. The patients received a mean of 19.1 +/- 16.2 units of packed red cells during the follow-up period (69.9 months). Only 1 patient received no blood transfusion. Six patients had a past HBV infection and 3 became HIV-infected in the course of this study. The high rate of infection of hemodialysis patients with hepatitis C virus in our setting points to the need for improved control measures.

Calcium acetate versus calcium carbonate in the control of hyperphosphatemia in hemodialysis patients

CONTEXT Hyperphosphatemia has an important role in the development of bone and mineral abnormalities in end-stage renal disease (ESRD). OBJECTIVE To compare the phosphorus binding power and the hypercalcemic effect of calcium acetate and calcium carbonate in hemodialysis patients. TYPE OF STUDY Crossover, randomized, double-blind study. PLACE A private hospital dialysis center. PARTICIPANTS Fifty-two patients who were undergoing regular hemodialysis three times a week ([Ca++] dialysate = 3.5 mEq/L). PROCEDURES Half of the patients were started on 5.6 g/day of calcium acetate and, after a 2 week washout period, received 6.2 g/day of calcium carbonate. The other half followed an inverse protocol. MAIN MEASUREMENTS Clinical interviews were conducted 3 times a week to monitor for side effects. Determinations of serum urea, calcium, phosphorus, hematocrit, Kt/V and blood gas analysis were obtained before and after each treatment. RESULTS Twenty-three patients completed the study. A significant increase in calcium plasma levels was only observed after treatment with calcium carbonate [9.34 mg/dl (SD 0.91) vs. 9.91 mg/dl (SD 0.79), P < 0.01]. The drop in phosphorus levels was substantial and significant for both salts [5.64 mg/dl (SD 1.54) vs. 4.60 mg/dl (SD 1.32), P < 0.01 and 5.89 mg/dl (SD 1.71) vs. 4.56 mg/dl (SD 1.57), P < 0.01, for calcium acetate and calcium carbonate respectively]. The percentage reduction in serum phosphorus (at the end of the study) per milliequivalent of salt administered per day tended to be higher with calcium acetate but statistical significance was not found. CONCLUSION Calcium acetate can be a good alternative to calcium carbonate in the handling of hyperphosphatemia in ESRD patients. When calcium acetate is used, control of hyperphosphatemia can be achieved with a lower administration of calcium, perhaps with a lower risk of hypercalcemia.

Associação do índice tornozelo-braço com inflamação e alterações minerais ósseas em pacientes em hemodiálise

BACKGROUND: Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE: To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS: This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: 1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS: Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p 6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION: In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.BACKGROUND Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: <0.9, normal: 0.9 to 1.3, and high: >1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p<0.001), diabetes (p= 0.001), and C-reactive protein levels >6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.

Ocorrência de hepatites não-anão-B em unidade de hemodiálise

Through monthly monitorization of alanine amino transferase (ALT) in hemodialysis patients and serological tests for exclusion of HA V (hepatitis A virus), HBV(hepatitis B virus), CMV (cytomegalovirus) and EBV (Epstein-Barr virus) infections, it was possible to identify 11 cases of non-A, non-B hepatitis among 111 individuals evaluated in a period of 12 months and followed-up for 2 years. Three patterns of ALT activity were observed: an elevation in monophasic peak in 2 patients, biphasic andpolyphasic in 6 patients and elevation in plateau in three others. Patients with the monophasic pattern showed the most elevated levels of ALT. Five patients showed biochemical normalization within approximately 4.8 months after the beginning of acute elevation and 6 evolved with chronic intermittent elevation during the period of study. Hepatitis non-A, non-B was predominantly asymptomatic and anicteric, always preceeded by blood tranfusions and with higher incidence in the 6 first months after hemodialysis.

Asociación del índice Tobillo-Brazo con la inflamación y trastornos minerales óseos en pacientes en hemodiálisis

BACKGROUND: Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE: To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS: This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: 1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS: Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p 6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION: In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.BACKGROUND Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: <0.9, normal: 0.9 to 1.3, and high: >1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p<0.001), diabetes (p= 0.001), and C-reactive protein levels >6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.

Association of ankle-arm index with inflammation and mineral bone disorder in hemodialysis patients

BACKGROUND: Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE: To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS: This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: 1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS: Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p 6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION: In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.BACKGROUND Reduced ankle-arm index (AAI), inflammation and mineral bone disorder (MBD) are all associated with increased risk of death and cardiovascular complications in patients on hemodialysis (HD), but the association between them deserves clarification. OBJECTIVE To evaluate the association between abnormal AAI with MBD and inflammation in patients on HD. METHODS This was a cross-sectional analysis of 478 patients on hemodialysis for at least one year. The AAI was evaluated using a portable Doppler and mercury column manometer. Patients were divided into 3 groups, according to AAI (low: <0.9, normal: 0.9 to 1.3, and high: >1.3). C-reactive protein measurement was used as an inflammatory marker, whereas MBD was evaluated by calcium, phosphorus and intact parathyroid hormone levels. RESULTS Participants were 54 (18 to 75) years old, 56% males, 17% diabetics, and had been on hemodialysis for a mean of 5 (1 to 35) years. The prevalence of low, normal and high AAI was 26.8%, 64.6% and 8.6%, respectively. Using a backward conditional logistic regression model, age (p<0.001), diabetes (p= 0.001), and C-reactive protein levels >6 mg/L (p= 0.006) were associated with the presence of low AAI, whereas male gender (p<0.001), diabetes (p= 0.001) and elevated calcium x phosphorus product (p= 0.026) were associated with high AAI. CONCLUSION In patients on hemodialysis, the presence of diabetes was associated with both low and high AAI. The risk of having low AAI seems to be increased by aging and inflammation, whereas BMD was associated with high AAI.

Immunofluorescence Studies in Paraffin-Embedded Tissue

Euzenir Nunes Sarno, Disciplina de Patologia Geral, Faculdade de Ciências Médicas, Av. 28 de Setembro, 87 4° Andar – Vila Isabel, Rio de Janeiro (Brazil) Dear Sir, The recent requirement to carry out immunofluorescence (IF) studies in renal biopsies justifies all attempts made to simplify this procedure. Many authors have reported successful comparative studies between frozen sections and paraffin-embedded tissue [2–5]. We have previously reported that paraffin-embedded tissue has given a high rate of false-negative results. Therefore, we continue to use frozen sections [6]. The fact is that the traditional IF method, using frozen sections, is an easy, quick and efficient method in spite of some inherent problems. The major difficulty seems to occur in the handling of the specimen. Renal biopsies are very thin cylinders of tissue and must be divided lengthwise into two equal parts. Frequently, it is difficult to obtain equal samples for IF and light-microscopic studies and if the biopsy is not large enough to be divided, IF studies cannot be done. The other practical problem is that the biopsy must be immediately snap-frozen. In order to simplify the traditional IF study, a procedure that avoids biopsy division should be used, i.e., the same sample might be used for both studies (IF and light microscopy). The method reported by Bolton and Mesnard↓X¦ seems to fit in with the above criteria. The same specimen can be processed for IF, histochemical, and light-microscopic analysis. Recently, we tried to further simplify this method by skipping several steps. 10 consecutive needle biopsies from patients with kidney disease (their histologic diagnoses are included in table I) were processed as follows: immediately after its removal, the specimen was divided into two parts: one part was placed in a small vial and snap-frozen in liquid nitrogen and the second part was fixed in formol-sucrose at 4 °C. 3-μm-thick frozen sections were obtained by cutting Table I. Histologic Diagnosis