José Nery Praxedes

Hypertensive Nephrosclerosis as a Relevant Cause of Chronic Renal Failure

It is currently unclear whether hypertensive nephrosclerosis (HN), usually diagnosed solely on clinical grounds, is a relevant cause of end-stage renal disease. We biopsied 81 hypertensive outpatients (blood pressure ≥160/95 mm Hg) with moderate renal insufficiency, who were referred to our service from 1988 to 1998. Patients with known causes of hypertension, systemic disorders, rheumatic disease, or nephrotic syndrome were excluded. In 65% of patients, HN was the sole histological abnormality associated with renal dysfunction. Benign nephrosclerosis (BN), defined as isolated arteriolar hyalinosis and/or intimal fibrosis, was found in 18 HN patients (22%), whereas malignant nephrosclerosis (MN), denoted mainly by myointimal cell proliferation, appeared in 35 HN patients (43%). Previously undiagnosed primary nephritis (PN) was found in 13 patients (16%), whereas focal and segmental glomerulosclerosis, which might be either primary or secondary to hypertension, appeared in 15 patients (19%). These findings suggest that HN, in both its BN and MN forms, can be a definite cause of chronic renal insufficiency and that a substantial fraction of patients with renal insufficiency and clinical diagnosis of HN may actually have PN.

Os médicos brasileiros seguem as diretrizes brasileiras de hipertensão

OBJECTIVE To evaluate whether procedures adopted by Brazilian physicians in the diagnosis and treatment of hypertension are in compliance with those advocated by the IV Brazilian Hypertension Guidelines. METHOD Survey carried out by means of telephone interviews with Brazilian physicians. The survey featured application of a questionnaire aimed to assess receipt of and compliance with the guidelines, and to evaluate various aspects regarding the treatment of hypertensive patients. RESULTS 68.3% of the respondents had received the guidelines and answered the questionnaire in full. The total sample consisted of 483 physicians--47% cardiologists, 31.7% internists, and 21.3% nephrologists. The survey showed high compliance with certain guideline topics such as more than one measurement at different times for the diagnosis of hypertension (94%), and providing guidance regarding lifestyle changes as a therapeutic strategy. As to arterial pressure levels used for diagnosis and therapeutic target, compliance with guideline recommendations lacks uniformity. The survey showed a clear preference for pressure levels lower than those recommended, especially in patients with comorbidities. Attempts to assess cardiovascular risk also proved to be low. Only 64.7% of the respondents reported that they seek to determine the presence of diabetes mellitus, and 56.4% check for dyslipidemia. The majority (59.3%) mentioned diuretics as the preferred drug class for initial drug treatment of hypertension. CONCLUSION We concluded that there is only partial compliance with Brazilian Hypertension Guidelines and that certain factors should be taken into consideration when drawing up future guidelines, such as: improved distribution; standardization of values for diagnosis and therapeutic target; more extensive coverage of ways for physicians to approach hypertensive patients to better evaluate their overall cardiovascular risk.

Surgery for adrenal tumours with thrombus in the supra-diaphragmatic infra-atrial inferior vena cava, with no cardiopulmonary bypass

To assess the result of surgery for adrenal neoplasia with thrombus in the supra‐diaphragmatic infra‐atrial inferior vena cava.

Multicentric pheochromocytoma and involvement of the inferior vena cava.

CONTEXT Extension of pheochromocytomas to the inferior vena cava is rare. Multicentric tumors are rare as well, being present in up to 10% of cases. Surgery is the treatment of choice because of the long-term survival free of disease. DESIGN Case report. CASE REPORT We report on a case of right adrenal pheochromocytoma with extension to the supra-diaphragmatic vena cava, which underwent surgical excision through thoracophrenic laparotomy without the need for cardiopulmonary bypass. In a 6-year follow-up, another pheochromocytoma was found in the infra-renal Zuckerkandls organ. Complete surgical excision of the tumor was performed by a median laparotomy and complete retroperitoneal dissection. In both cases, the total removal of the pheochromocytoma has been guaranteed by having margins free of tumor and a normal post-operative level of catecholamines. The pathological study revealed a malignant pheochromocytoma with margins free of neoplasia in both specimens.

Hand-assisted laparoscopic right nephrectomy and autotransplantation for treatment of renovascular hypertension

Renal autotransplantation has been described as an effective method for addressing complicated urological disorders, including debilitating ureteral injury or loss, upper ureteral malignancies, complex nephrolithiasis, loin pain hematuria syndrome, and branch or distal renal artery disease. Standard autotransplantation involves 2 distinct surgical procedures: nephrectomy and subsequent renal graft into the iliac fossa. The technique mimics standard allografting procedures and typically uses a separate flank incision for the live donor nephrectomy and an extraperitoneal pelvic incision for renal transplantation. Alternatively, a long midline incision from the xiphoid process to the symphysis pubis maybe used to perform the entire operation transperitoneally. In an effort to decrease the morbidity and improve the cosmetic results associated with traditional autotransplantation, we describe a laparoscopic hand-assisted approach to right nephrectomy and autotransplantation through the same handport incision in 2 patients with renovascular hypertension.

The role of nephrectomy of the atrophic kidney in bearers of renovascular hypertension

PURPOSE Evaluation of the beneficial effect of nephrectomy of the atrophic kidney on blood pressure (BP) and renal function. MATERIALS AND METHODS A retrospective study of 51 patients with renovascular hypertension (RVH), bearers of atrophic kidney due to severe stenosis or occlusion of the renal artery. Average age was 47.1 +/- 15 years, the median creatinine clearance was 54 mL/min, average systolic BP (SBP) 149.6 +/- 22.5 mm Hg, average diastolic BP (DBP) 90.8 +/- 17 mm Hg and the median number of hypotensors 3 (1 to 5) per patient per day. Blood pressure and serum creatinine were analyzed from 12 to 60 months after the nephrectomy. RESULTS There was a significant improvement in the average SBP in the periods from 12 to 36 months (p < or = 0.028) and for the average DBP from 12 to 48 months after the nephrectomy (p < or = 0.045), accompanied by a significant reduction in the use of hypotensors from 12 to 48 months (p < 0.05). One year after the nephrectomy, there was a 69% improvement in blood pressure and 63.8% improvement in renal function of patients. CONCLUSION The removal of atrophic kidney in patients with RVH is a safe procedure which presents benefits for the control of arterial hypertension and renal function in bearers of renovascular hypertension.

Three cases of hypertension and Renal Arteriovenous fistula with a de novo fistula

Fistula Arteriovenosa Renal (FAVR) e uma causa rara e potencialmente reversivel de hipertensao e insuficiencia renal e/ou cardiaca. O tratamento da FAVR visa preservar o maximo de parenquima renal e, concomitantemente, erradicar os sintomas e efeitos hemodinâmicos decorrentes da FAVR. No presente estudo, serao relatados tres casos de FAVR, incluindo um caso de FAVR idiopatica de novo, que se apresentaram com hipertensao e insuficiencia renal e/ou cardiaca, e descrever a terapeutica adotada e os resultados obtidos.The Renal Arteriovenous Fistula (RAVF) is a rare and potentially reversible cause of hypertension and kidney and/or heart failure. The treatment of RAVF aims at preserving the most of the renal parenchyma and, concomitantly, eradicating the symptoms and hemodynamic effects caused by the RAVF. The present study reports three cases of RAVF, including one case of a de novo idiopathic RAVF, which presented with hypertension and kidney and/or heart failure and describes the therapeutic measures used to treat these patients as well as the outcomes.

Qual a diretriz de hipertensão arterial os médicos brasileiros devem seguir? Análise comparativa das diretrizes brasileiras, européias e norte-americanas (JNC VII)

Hospital das Clinicas da FMUSP e Comissao Permanente das IV DiretrizesBrasileiras de Hipertensao ArterialEndereco para Correspondencia: Decio Mion Junior - Av. Dr. Eneas deCarvalho Aguiar, 255 - Inst. Central do HC - 7o andar, s/ 7032Cep 05403-000 - Sao Paulo - SP - E-mail: deciomion@uol.com.brRecebido para Pulbicacao em 02/12/2003Aceito em 9/03/2004

Tratamento endovascular da síndrome da aorta média causada por arterite de Takayasu: relato de caso

Middle aortic syndrome (MAS) is a clinical condition characterized by segmental or diffuse narrowing of the aorta, hypertension, and lower limb claudication. The main cause of MAS is Takayasu’s arteritis. Segmental aortic stenosis may be located at the suprarenal, renal or infrarenal aorta with high tendency to concomitant stenosis in both the renal and visceral arteries. Severity of hypertension is the primary indication for intervention. Endovascular therapy is a minimally invasive treatment for MAS and may provide good results. In the present report, we describe a successful endovascular treatment of stenosis of the thoracoabdominal aorta with recanalization of the superior mesenteric artery using angioplasty in a 34-year-old woman with Takaysu’s arteritis and severe hypertension.

Três casos de hipertensão e Fístula Arteriovenosa Renal: com uma fístula de novo

Fistula Arteriovenosa Renal (FAVR) e uma causa rara e potencialmente reversivel de hipertensao e insuficiencia renal e/ou cardiaca. O tratamento da FAVR visa preservar o maximo de parenquima renal e, concomitantemente, erradicar os sintomas e efeitos hemodinâmicos decorrentes da FAVR. No presente estudo, serao relatados tres casos de FAVR, incluindo um caso de FAVR idiopatica de novo, que se apresentaram com hipertensao e insuficiencia renal e/ou cardiaca, e descrever a terapeutica adotada e os resultados obtidos.The Renal Arteriovenous Fistula (RAVF) is a rare and potentially reversible cause of hypertension and kidney and/or heart failure. The treatment of RAVF aims at preserving the most of the renal parenchyma and, concomitantly, eradicating the symptoms and hemodynamic effects caused by the RAVF. The present study reports three cases of RAVF, including one case of a de novo idiopathic RAVF, which presented with hypertension and kidney and/or heart failure and describes the therapeutic measures used to treat these patients as well as the outcomes.