Kátia de Paula Farah

Life‐threatening thrombocytopenia and nephrotic syndrome due to focal segmental glomerulosclerosis associated with pegylated interferon α‐2b and ribavirin treatment for hepatitis C

Abstract: Background: Interferon‐α (IFN‐α)and ribavirin combination therapy for chronic infection with hepatitis C virus produces a number of well‐described side effects. Combination therapy with pegylated interferon (PEG‐IFN) yields an adverse event profile similar to that observed with the standard IFN, although the frequency of certain adverse events may vary according to the preparation.

Gender in the allocation of organs in kidney transplants: meta-analysis

OBJECTIVE To analyze whether gender influence survival results of kidney transplant grafts and patients. METHODS Systematic review with meta-analysis of cohort studies available on Medline (PubMed), LILACS, CENTRAL, and Embase databases, including manual searching and in the grey literature. The selection of studies and the collection of data were conducted twice by independent reviewers, and disagreements were settled by a third reviewer. Graft and patient survival rates were evaluated as effectiveness measurements. Meta-analysis was conducted with the Review Manager® 5.2 software, through the application of a random effects model. Recipient, donor, and donor-recipient gender comparisons were evaluated. RESULTS : Twenty-nine studies involving 765,753 patients were included. Regarding graft survival, those from male donors were observed to have longer survival rates as compared to the ones from female donors, only regarding a 10-year follow-up period. Comparison between recipient genders was not found to have significant differences on any evaluated follow-up periods. In the evaluation between donor-recipient genders, male donor-male recipient transplants were favored in a statistically significant way. No statistically significant differences were observed in regards to patient survival for gender comparisons in all follow-up periods evaluated. CONCLUSIONS The quantitative analysis of the studies suggests that donor or recipient genders, when evaluated isolatedly, do not influence patient or graft survival rates. However, the combination between donor-recipient genders may be a determining factor for graft survival.

Hanseníase multibacilar em paciente transplantado renal: relato de caso

Leprosy is still a public health concern in Brazil, where more than 30,000 new cases are detected every year. There are few reports of this mycobacteriosis in immunosuppressed patients, despite the increasing number of solid organ transplantation and the use of post-transplant drugs in this country. The authors describe a case of multibacillary leprosy in a renal transplant recipient, detected 12 years after the procedure, and discuss the therapy, adverse effects and management of leprosy reactions in patients immunosuppressed by drugs.

Prevalence of latent tuberculosis infection and risk of infection in patients with chronic kidney disease undergoing hemodialysis in a referral center in Brazil

OBJECTIVE: To determine the prevalence of latent tuberculosis infection (LTBI) and the risk of infection in patients with chronic kidney disease treated at a hemodialysis center. METHODS: We included 307 patients with chronic kidney disease undergoing hemodialysis at the Mineiro Institute of Nephrology, located in the city of Belo Horizonte, Brazil. All of the patients were submitted to tuberculin skin tests (TSTs). We investigated the booster effect and TST conversion. If the initial TST (TST1) was negative, a second TST (TST2) was performed 1-3 weeks later in order to investigate the booster effect. If TST2 was also negative, a third TST (TST3) was performed one year after TST2 in order to determine whether there was TST conversion. RESULTS: When we adopted a cut-off induration of 5 mm, the prevalence of LTBI was 22.2% on TST1, increasing by 11.2% on TST2. When we adopted a cut-off induration of 10 mm, the prevalence of LTBI was 28.5% on TST1, increasing by 9.4% on TST2. The prevalence of LTBI increased significantly from TST1 to TST2 (booster effect), as well as from TST2 to TST3 (p < 0.01 for both). In our sample, the mean annual risk of infection was 1.19%. CONCLUSIONS: In the population studied, the prevalence of LTBI was high, and the mean annual risk of infection was similar to that reported for the general population of Brazil, which suggests recent infection.

Tacrolimus-induced symmetric drug-related intertriginous and flexural exanthema (SDRIFE): TACROLIMUS-INDUCED SDRIFE

Conflict of interests: None declared. use, and very few following systemic administration (1, 2). Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) results from systemic drug exposure. The diagnosis is established if four of the following five criteria are met: exposure to a systemic drug; erythema of the gluteal, inguinal or axillary area; involvement of at least one intertriginous site; symmetry; and the absence of systemic toxicity (2, 3).

Prevalence of Patients Receiving Publicly Funded Renal Replacement Therapy in Brazil: Regional Inequities and Costs

From 2008 to 2013 there was a 25% increase in the absolute number of hemodialysis sessions (10,022,962; 12,561,623). This resulted in an estimated overall increase of 18% in the ratio of patients on hemodialysis per million population (352 pmp; 416 pmp). There were considerable differences among Brazilian States regarding the prevalence of patients with ESRD on hemodialysis. In 2013, the prevalence ranged from 173 pmp (State of Amazonas) to 531 pmp (State of Minas Gerais). The leading Brazilian States, in absolute number of patients, were São Paulo (19,301), Minas Gerais (10,940) and Rio de Janeiro (8,510), all of them in the southeast region. In 2013, the overall mean mortality rate was 18.4%. From 2008 to 2013, the renal transplantation rate increased from 35.2 to 41.6 transplants per year per million inhabitants. In 2013, hemodialysis was the most frequent modality of therapy, corresponding to 87.1% of the cases, followed by CAPD (9.2%) and APD (3.7%).

Complete reversal of bone marrow fibrosis after parathyroidectomy for secondary hyperparathyroidism

A 17-year-old man was referred for a haematology consultation because of pancytopenia. On physical examination, he had marked pallor and massive hepatosplenomegaly. He was on haemodialysis because of chronic renal failure of undetermined aetiology, diagnosed 4 years earlier. In the previous 3 years, he had become dependent on monthly blood transfusions, despite using erythropoietin. Ferritin level was 1500 lg/l and a full blood count showed pancytopenia (Hb 54 g/l, WBC 2 1 9 10/l, platelet count 57 9 10/l). A blood film showed teardrop poikilocytes, a few mature erythroblasts and neutropenia. Parathyroid hormone (PTH) level was 3027 ng/l (reference range, 15 0–68 3). An initial bone marrow aspiration was a dry tap; the second attempt yielded a hypocellular sample with several osteoclasts and osteoblasts. A trephine biopsy showed increased bone remodelling with fibrosis (top left, white arrow), osteosclerosis, new bone formation and bone reabsorption, increased osteoclasts and osteoblast rimming (top left, black arrow). Increased diffuse coarse reticulin was confirmed by silver staining (top right). Cytogenetic/molecular tests for JAK2 V617F and BCR-ABL1 rearrangement were negative. The possibility of renal osteodystrophy and myelofibrosis due to secondary hyperparathyroidism was considered. A total parathyroidectomy was performed and an implant of the gland was inserted in the patient’s forearm. The biopsy showed hyperplasia of parathyroid glands. Six months after surgery, the patient reported major improvement, with weight gain and no transfusion requirement in that period. Hepatosplenomegaly had disappeared, PTH was 50 0 ng/l, ferritin <1000 lg/l, Hb 83 g/l, WBC 4 7 9 10/l and platelet count 102 9 10/l. Bone marrow aspirate and trephine biopsy showed a complete reversal of fibrosis (bottom). Myelofibrosis resulting from hyperparathyroidism is uncommon. The mechanism is likely to be multifactorial. Haematologists should be aware of this condition, as the differential diagnosis is primary myelofibrosis and other causes of secondary myelofibrosis. More importantly, as parathyroidectomy can lead to a reversal of fibrosis, prompt recognition of this condition has major implications for treatment.

Hepatic siderosis in a patient with hepatitis C on hemodialysis

A 49-year-old man with chronic renal failure (CRF) who was on hemodialysis was admitted to hospital for treatment of hepatitis C. Clinical examination revealed hepatomegaly. The Elisa test was positive for anti-HCV antibodies and HCV-PCR gave a positive result on serum. Genotype 1a was identified and the serum alanine aminotransferase level was normal. The patient had received parenteral iron to treat anemia. His iron and ferritin levels in serum were high (255mmol/l and 3840mg/l, respectively). Prussian blue staining showed siderosis in Kupfer cells and hepatocytes (Figure A). Iron granules were visible with the naked eye (siderosis level IV). Liver biopsy revealed severe inflammatory activity and fibrosis (Figures B and C – arrows). Treatment of anemia in CRF patients on hemodialysis includes the use of erythropoietin and high doses of iron, and this may aggravate the fibrosis of hepatitis C.O paciente, de 49 anos, com insuficiencia renal cronica (IRC) em hemodialise, apresentava hepatite C, a admissao hospitalar. O exame clinico revelou hepatomegalia. O anti-HCV (Elisa) e o PCR-HCV eram positivos no soro. Identificou-se o genotipo 1a e os niveis de alanina-aminotransferase eram normais. O paciente havia recebido ferro parenteral para o tratamento de anemia e apresentava elevados niveis de ferro e ferritina no soro (255mmol/L e 3840mg/L, respectivamente). A coloracao azul da Prussia revelou siderose em celulas de Kupfer e em hepatocitos (Figura A). Grânulos de ferro foram vistos sem aumento (siderose grau IV). A biopsia revelou atividade inflamatoria e fibrose hepatica graves (Figuras B e C – setas) . O tratamento da anemia em pacientes com IRC em hemodialise inclui o uso de eritropoietina e altas doses de ferro que pode agravar a fibrose da hepatite C.