João Egidio Romão Junior

Lymphocele: a possible relationship with acute cellular rejection in kidney transplantation

CONTEXT The incidence of lymphocele after renal transplantation varies between 0.6 and 18% of cases, and many factors have been associated to its etiology. Cellular rejection of the kidney allograft has been described as a possible causal factor of lymphocele. OBJECTIVE To analyze the possible relationship between lymphocele and acute cellular rejection. DESIGN A retrospective study. SETTING A referral hospital center. SAMPLE 170 patients submitted to kidney transplantation from March 1992 to January 1997. A standard technique for renal transplantation was used. RESULTS Of the 19 patients that developed lymphocele, 16 presented at least one episode of acute cell rejection (84%), and were treated with methylprednisolone. The relation between lymphocele and rejection was statistically significant (p = 0.04). Treatment of lymphocele consisted of peritoneal marsupialization in 3 patients (15.3%), percutaneous drainage in 7 (36.8%), laparoscopic marsupialization in 2 (10.5%), and conservative treatment in 7 patients (36.8%). Evolution was favorable in 15 patients (78.9%), 1 patient (5.3%) died due to a cause unrelated to lymphocele, and 3 (15.8%) lost the graft due to immunological factors. The average follow-up period was 24.5 months. CONCLUSION The high incidence of acute cell rejection in patients with lymphocele suggests a possible causal relationship between both conditions.

Insuficiência e deficiência de vitamina D em pacientes portadores de doença renal crônica

INTRODUCAO: Hipovitaminose D e bem documentada em pacientes portadores de doenca renal cronica (DRC). Espera-se niveis inferiores em habitantes de regioes nao tropicais em relacao aos habitantes de regioes tropicais, pela infericao de uma maior exposicao solar e maior producao de vitamina D. OBJETIVO: Analisar os niveis sericos de vitamina D, como 25-hidroxivitamina D - 25(OH)D, de 125 pacientes brasileiros portadores de DRC em fase pre-dialitica. METODOS: Foram estudados 125 pacientes (57,4 ± 16,2 anos, 78 brancos e 55,2% homens), com creatinina de 2,67 ± 1,73 mg/dL e o clearance estimado 43,7 ± 34,5 mL/min. O indice de massa corporal era de 27,4 ± 4,7 kg/m² e a circunferencia abdominal de 95,0 ± 14,0 cm. O calcio era de 9,3 ± 0,6 mg/dL, o paratormonio intacto (PTHi) 212,6 ± 221,2 pg/mL e a albumina serica 4,2 ± 0,6 g/dL. A media de 25(OH)D era de 23,9 ± 10,7 ng/mL. RESULTADOS: Dos 125 pacientes, 92 (72,6%) apresentavam niveis de 25(OH)D < 30 ng/mL, sendo que 65 (52%) apresentavam insuficiencia (15-29 ng/mL); 27 (21,5%) apresentavam deficiencia (5-14 ng/mL) e apenas um paciente apresentava deficiencia severa < 5 ng/mL. Nao foram observadas diferencas entre os niveis de 25(OH)D nos pacientes estratificados quanto ao estagio de DRC. Os niveis de 25(OH)D foram maiores nos homens (38,1 ± 20,6 versus 22,4 ± 9,7 ng/ml; p < 0,0001), havendo tambem uma correlacao inversa entre os niveis de 25(OH)D e de PTHi, proteinuria e circunferencia abdominal, e uma correlacao positiva entre 25(OH)D e calcio total e albumina serica. Na analise multivariada, encontrou-se apenas correlacao inversa entre 25(OH)D e circunferencia abdominal e PTHi. CONCLUSAO: A despeito de a populacao do Brasil estar em um clima tropical, a maioria dos pacientes analisados apresentou niveis sericos subotimos de vitamina D, podendo este achado estar relacionado ao desenvolvimento de hiperparatireoidismo.

Fibrose sistêmica nefrogênica: uma complicação grave do uso do gadolínio em pacientes com insuficiência renal

Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD), is a condition that has occurred only in patients with renal insufficiency. Besides lesions of the skin, this syndrome include fibrosis of skeletal muscle, joints, liver, lung, and heart, with possible fatal outcomes. This disease was first described in 1997 and several reports described the development of NSF after the exposure to gadolinium-based magnetic resonance imaging contrast agents. This review aims to alert physicians and nephrologists about this new pathology that affects patients with renal dysfunction, describing its demographic and epidemiologics aspects, clinic presentation, diagnosis and prognosis, beyond options to prevent and current treatment. We concluded that in all patient with elevated serum creatinine physicians should estimade his kidney function (creatinine clearence) in order to safety of magnetic resonance.

Tuberculosis in patients with chronic renal failure

Nine cases of tuberculosis (TB) were diagnosed among 800 uremic patients, followed-up during 11 years, a prevalence of 1125%, 2.5 times higher than that in the general population. Six patients (66.7%) had lymph node involvement (4 cervical and 2 mediastinal). Three patients (33.3%) had pulmonary involvement (2 pleuro-pulmonary and 1 bilateral apical pulmonary). Eight patients were undergoing dialysis and 1 was pre-dialytic. The duration of dialysis ranged from 1 to 60 months. Three patients had previously received immunosuppressive drugs for unsuccessful renal transplantation. Daily fever was present in all but one patient; he was asymptomatic and TB was suspected after routine chest radiography. Biopsy was the diagnostic procedure in 7 patients (77.8%), four by direct cervical lymph node biopsy, 2 by mediastinal, performed by mediastinoscopy and 1 by pleural biopsy. In 2 other patients TB was confirmed by the presence of tubercle bacilli; in sputum (1 patient) and in a bronchial flushing specimen (the other patient). Triple therapy was used in all patients (isoniazid and ethambutol in all), plus rifampicin in 8 and streptomycin in 1. One patient had jaundice and another had optical neuritis. Five patients were cured. The other four died during treatment of causes unrelated to TB or its treatment.

Nephrogenic systemic fibrosis: mini-review.

Nephrogenic systemic fibrosis is an uncommon but serious acquired systemic fibrosing disease that occurs in patients with chronic kidney disease and acute renal failure. It is linked to the administration of gadoliniumbased contrast. Predominantly there is progressive hardening of skin of extremities. Systemic involvement also has been described. The disease is progressive and may lead to disabling joint contractures. Prevention plays the major role as the therapeutic options are limited and mostly ineffective. Reversal of renal function to normal is the only effective modality.

Acute kidney injury due to oxalate nephropathy after star fruit ingestion

Background: Great quantity of star fruit (Averrhoa carambola) ingestion, or even smaller amounts in a patient with an empty stomach, may induce acute kidney injury (AKI). Case Presentation: We report a 65-year-old male patient with underlying multiple myeloma and normal kidney function, who developed alterations of consciousness and rapid increase in serum creatinine due to oxalate nephropathy after large ingestion of star fruit on an empty stomach. Kidney biopsy revealed the diagnosis of oxalate nephropathy. Conclusions: AKI due to oxalate nephropathy after star fruit ingestion is relatively uncommon (only eight other reported cases) but there is an increasing evidence of AKI associated with intoxication by star fruit. This case alerts health professionals, nephrologists in particular, to a new disease that is increasingly better known and diagnosed more frequently

Reviewing the Brazilian protocol for treatment of secondary hyperparathyroidism

At first, bone and mineral metabolism anomalies were thought to be a specific bone disease related to parathyroid dys-function, abnormal levels of parathyroid hormone (PTH), and osteitis fibrosa cystica, then called renal osteodystrophy. Recently, however, new bone tissue func-tions have been described in addition to the known role in locomotion, mineral metabolism regulation, and protection of internal organs. Osteoclasts actively participate in fat metabolism, energy homeostasis, and insulin secretion, all essential functions for the cardiovascular system.Correspondence to: João Egídio Romão Junior. Beneficência Portuguesa Hospital. Rua Cayowaa, no 560, apto 51. São Paulo, SP, Brazil. CEP: 05018-000. E-mail: joao.egidio@uol.com.br NA. The kidneys play an important role in bone and mineral metabolism. They are the target organs for various hormones involved in controlling calcium and phosphorus levels, in addition to being the site where vitamin D is activated.1 Therefore, a significant portion of patients with chronic kidney disease (CKD) is expected to present bone and mineral metabolism anomalies, particularly individuals on renal replacement therapy (RRT).2 At first, bone and mineral metabolism anomalies were thought to be a specific bone disease related to parathyroid dysfunction, abnormal levels of parathyroid hormone (PTH), and osteitis fibrosa cystica, then called renal osteodystrophy. Recently, however, new bone tissue functions have been described in addition to the known role in locomotion, mineral metabolism regulation, and protection of internal organs. Osteoclasts actively participate in fat metabolism, energy homeostasis, and insulin secretion, all essential functions for the cardiovascular system.3,4 The bone-vascular axis can be used to explain the high prevalence of vascular calcification observed in CKD patients, who are at increased risk of cardiovascular events and have higher levels of morbidity and mortality.2,5 In the last decade it has become widely accepted that bone mineral metabolism anomalies in patients with CKD reach far beyond bone tissue, which led to the introduction of a new concept: chronic kidney disease-mineral and bone disorder (CKD-MBD).6,7 CKD-MBD is a systemic condition that manifests in the form of PTH, calcium, phosphorus, fibroblast growth factor (FGF-23), and vitamin D alterations, in addition to bone anomalies and extraskeletal calcification.1,7 Secondary hyperparathyroidism (SHPT) is one of the most frequent findings in CKD patients. It has been correlated with high turnover bone disease, high risk of cardiovascular calcification, and death. SHPT is considered a modifiable risk factor.2,4,8 Early therapeutic intervention in CKD patients, administration of new therapeutic agents, and rational use of drugs have been proposed to manage it. Given that SHPT is a systemic disease, the management of anomalies should be aimed at reducing the risk of cardiovascular events and bone fractures and increasing patient survival.6,7,9 With these objectives in mind, several clinical guidelines for the diagnosis, prevention and treatment of CKD-MBD have been published.6-11 Guideline documents have stressed the need to improve CKD patient survival and quality of life, set target ranges for serum phosphorus, calcium and PTH based on survival data of patients on dialysis, in addition to suggesting an order for the events related to patient management, as follows: management of serum phosphorus levels, serum calcium levels, and parathyroid gland function. The guidelines have contributed significantly to a better understanding of CKD-MBD by physicians, health care workers in general, and patients. The earlier guidelines did not count on randomized controlled trials to describe the outcomes related to CKD-MBD. Most of the recommendations were considered weak or discretionary, and