Luiz Paulo José Marques

Glomerular disease and human immunodeficiency virus infection in Brazil

Clinically overt glomerular disease was detected in 6 (1.1%) of 543 patients with HIV infection followed at a Brazilian National Referral Center for AIDS. In 4 cases, glomerulosclerosis was present (focal and segmental in 3, diffuse and global in 1) and rapid progression to terminal renal failure was observed 1-10 months after clinical presentation. The other 2 patients died with normal renal function, and autopsy studies suggested the diagnosis of minimal change disease. Clinically overt glomerular disease was significantly more common among Black patients, whether all the cases with glomerulopathy (p < 0.001) or just the cases with glomerular sclerosis were considered (p = 0.011). Autopsy study of renal fragments from patients without clinical evidence of glomerular disease was additionally performed and revealed the presence of focal and segmental glomerulosclerosis in 3 cases (7.5%). We concluded that a glomerulopathy with clinicopathological features which match the definition of HIV nephropathy can be found among Brazilian patients with HIV infection. Accordingly to what has been described in American series, Brazilian Black patients seem to be at increased risk of the development of that nephropathy.

AIDS-Associated Renal Tuberculosis

In order to study the prevalence and the clinical features of renal tuberculosis associated with AIDS, we studied the renal tissue of the necropsies made in 46 AIDS patients under light microscopy. We found renal tuberculous granuloma in 11 (23%) patients (in 3 without previous diagnosis of renal or extrarenal tuberculosis) and only 4 of them presented moderate hematuria or pyuria sterile. As subclinical renal tuberculosis was frequent in this group of AIDS patients, the urine culture for Mycobacterium tuberculosis may be useful for diagnosing tuberculosis in AIDS patients.

Obstructive Renal Failure due to Therapy with Sulfadiazine in an AIDS Patient

Luiz Paulo J. Marques, MD, University of Rio de Janeiro, Rua Major Avila 455/312, 20511 Rio, de Janeiro (Brasil) Dear Sir, Toxoplasmosis in one of the most common opportunistic infections in AIDS patients, and the treatment of choice is the synergistic combination of sulfadiazine and pyrimethamine for a prolonged period. Cry-stalluria and acute renal failure due to sulfadiazine have been described by several authors [1,2]. We report a case of obstructive renal failure due to the administration of sulfadiazine that resolved with rapid infusion of intravenous sodium bicarbonate and fluids without discontinuation of sulfadiazine therapy. A 35-year-old female AIDS patient was referred for evaluation of generalized seizure and weakness of the right arm that presented 3 days before admission. When she was admitted, her serum creatinine level was 0.6 mg%; total serum protein; 7.3 g%; albumin: 4.2%; globulin: 3.1 g%; hemoglobin level: 13.6 g/dl; hematocrit: 41%; normal urinalysis. Serology for toxoplasmosis was: IgG 1/2,048 and negative IgM. Cerebrospinal fluid examination showed only anti-HIV I (Elisa) posi-tivity and IgG 11.6%. Computed tomography scan revealed contrast enhancing left cerebral lesion. On day 3 hospitalization, she presented an other episode of generalized seizure and developed right hemiplegia. Oral sulfadiazine (1.0 g every 6 h), oral pyrimethamine (25 mg daily) and folinic acid were begun for suspected toxoplasmosis. On day 7 of therapy, she presented abdominal pain, dysuria and oliguria (36-hour urine output: 300 ml). Serum creatinine was 3.9 mg%; urinalysis revealed sulfa crystals and numerous red blood cells per high-power field, and renal ultrasound detected bilateral lithiasis with moderate hydronephrosis. Administration of intravenous sodium bicarbonate, 3 liters of fluids and furosemide (20 mg every 6 h were begun, without discontinuation of sulfadiazine. After few days of therapy, renal function returned of a normal level and she was discharged on day 19 of therapy with partial remission of neurologic signs; serum creatinine was 0.6 mg%, and she had normal urinalysis without the presence of sulfa crystals. Obstructive acute renal failure associated with sulfadiazine has been previously described due to the low solubility of the sulfo-namides as well as under appropriated conditions, such as dehydration and hypoalbu-minemia [3]. However, with adequate hydra-tion and alcalinization of urine, renal failure may be resolved without discontinuation of sulfadiazine. Physicians using sulfadiazine for the treatment of toxoplasmosis should be aware of the risk for crystalluria and renal failure, especially during

Effect of ultrafiltration on placental-fetal blood flow in pregnancy of woman undergoing chronic hemodialysis: Ultrafiltration in pregnant patients

Introduction: Patient who was undergoing hemodialysis (HD) thrice weekly usually gain 1 to 4 kg of weight in interdialytic period, mainly due to fluid accumulation by ingestion of water. Ultrafiltration (UF) during HD will be need to remove fluid excess to avoid severe medical complications secondary to fluid overload. However, in pregnant woman UF can increase the episodes of intradialytic hypotension which may lead to placental ischemic injury and predispose to fetal distress. There is little information about safe fluid amount withdrawn by UF during pregnancy.