Márcio W. Lauria

Beribéri pós bypass gástrico: uma complicação não tão rara. Relato de dois casos e revisão da literatura

The number of patients submitted to bariatric surgery to treat morbid obesity is increasing, therefore, some nutritional deficiencies, with which many physicians are no longer familiarized, are reappearing. Postoperatively, many nutritional disorders may occur, one of them is thiamine deficiency (beriberi). The thiamine and/or vitamin B12 deficiency can correspond to 40% of the neuropathy cases after bariatric surgery. Two patients with the clinic of peripheral neuropathy and Wernicke-Korsakoff syndrome will be reported. Some months after the surgery, they presented prostration, depression, mental confusion and nystagmus, associated with pain and paresthesia in limbs (especially lower limbs). With the diagnostic hypothesis of beriberi, the treatment with thiamine started. One of the patients presented complete improvement of the neurological symptoms, however the other one remained with motor deficiency, exactly the one who spent a longer period of time between the symptoms appearance and the treatment beginning. These cases serve to alert us about the importance of nutritional vigilance after bariatric surgery.

Metabolic long-term follow-up of functioning simultaneous pancreas-kidney transplantation versus pancreas transplantation alone: insights and limitations.

Background. Pancreas transplantation involves a set of procedures that, in some cases, lead to different complications and outcomes. The aim of this study was to analyze the long-term effects of pancreas transplantation regarding carbohydrate and lipid metabolism parameters to determine differences between simultaneous pancreas-kidney (SPK) transplantation and pancreas transplantation alone (PTA). Methods. Sixty-four patients (46 SPK and 18 PTA), with an immunosuppression protocol based on tacrolimus plus mycophenolate mofetil and prednisone, were evaluated for at least 1 year after transplantation. No patient made use of any hypoglycemic or hypolipidemic drugs. Comparisons were performed between SPK and PTA patients using the chi-square test, Fischers exact test, and unpaired Students t test, as appropriate. Results. Patients were 39.8±9.3 years old, predominantly male (60.9%), with a mean follow-up of 25.4±10.4 months after transplantation. The PTA group exhibited worse renal function and higher tacrolimus levels than the SPK group. Fasting glucose, 2 hr plasma glucose after overload, C-peptide, and HbA1C were within the normal range, with no statistically significant differences between the PTA and SPK groups. Insulin (INS) and the homeostasis model assessment of INS resistance index were above the normal range in both the groups. Lipids were also similar between groups. Conclusions. The majority of patients with long-term functioning pancreas transplant achieved good glucose control without use of exogenous INS or oral antidiabetic drugs, although they were hyperinsulinemic. There were no significant differences concerning glucose and lipid parameters between the SPK and PTA groups, even though the PTA patients exhibited higher tacrolimus levels and worse renal function.

The impact of functioning pancreas-kidney transplantation and pancreas alone transplantation on the lipid metabolism of statin-naive diabetic patients

Abstract: Objective:  To compare the lipid profile (total cholesterol – TC, triglycerides – TG, high density lipoprotein cholesterol – HDL‐c, low density lipoprotein cholesterol – LDL‐c and non‐HDL cholesterol – NHDL‐c) of patients with functioning pancreas–kidney transplantation (PKT) or pancreas transplantation alone (PTA) after one (T1) and two yr (T2) following their pre‐transplantation data (T0).

Glucose control in pancreas transplantation assessed by 72-hr continuous glucose monitoring.

ing procedures (RIPostC plus LIPostC). After 48 hr, blood, urine, and renal tissue samples were analyzed to assess renal function and damage. Renal IRI caused a decline in renal function, as reflected by an increase in plasma creatinine level, plasma urea level, and fractional excretion of sodium. These detrimental effects were only partially reduced by RIPostC or LIPostC alone. However, the combined application of RIPostC and LIPostC significantly reduced the IRI-induced decrease in renal function (Fig. 1AYC). Furthermore, a similar synergistic effect of RIPostC plus LIPostC was observed for renal histologic damage, as assessed by scoring periodic acidYSchiffYstained sections of renal cortex on a 0 to 5 scale by an investigator blinded to treatment allocation (Fig. 1D) (3). In contrast with a previous report (3), RIPostC did not significantly reduce plasma creatinine and urea levels in our model. This may be explained by the use of a shorter sustained ischemic stimulus (25 vs. 45 min) and hind limb occlusion by blood pressure cuff, rather than clamping of the iliac vessels. Nevertheless, we demonstrate that RIPostC effectively prevents an IRI-induced increase in fractional excretion of sodium. More importantly, we show that RIPostC and LIPostC have synergistic protective effects on IRI of the kidney. Although both strategies have been shown to influence the status of the mitochondrial permeability transition pore, it has been postulated that LIPostC does so by delaying the normalization of the intracellular pH (5), whereas RIPostC is believed to cause the release of various signaling molecules, such as adenosine, opioids, and cytokines, which act on the mitochondrial permeability transition pore through the activation of the cyclic guanosine monophosphate, Protein Kinase G (cGMP/PKG), Reperfusion Injury Salvage (RISK), or Survivor Activating Factor Enhancement (SAFE) pathway (6). Our present finding supports the theory that the mechanisms of action could be different for LIPostC versus RIPostC. For the implementation of IPostC into the clinical practice of kidney transplantation, we believe that its efficacy should be tested further in animal models of renal transplantation. Our data suggest that the combination of LIPostC and RIPostC is a highly interesting approach for further preclinical studies.

Seventy two-hour glucose monitoring profiles in mild gestational diabetes mellitus: differences from healthy pregnancies and influence of diet counseling

OBJECTIVE To study glucose profiles of gestational diabetes (GDM) patients with 72 h of continuous glucose monitoring (CGM) either before (GDM1) or after (GDM2) dietary counseling, comparing them with nondiabetic (NDM) controls. DESIGN AND METHODS We performed CGM on 22 GDM patients; 11 before and 11 after dietary counseling and compared them to 11 healthy controls. Several physiological and clinical characteristics of the glucose profiles were compared across the groups, including comparisons for pooled 24-h measures and hourly median values, summary measures representing glucose exposure (area under the median curves) and variability (amplitude, standard deviation, interquartile range), and time points related to meals. RESULTS Most women (81.8%) in the GDM groups had fasting glucose <95mg/dL, suggesting mild GDM. Variability, glucose levels 1 and 2h after breakfast and dinner, peak values after dinner and glucose levels between breakfast and lunch, were all significantly higher in GDM1 than NDM (P<0.05 for all comparisons). The GDM2 results were similar to NDM in all aforementioned comparisons (P>0.05). Both GDM groups spent more time with glucose levels above 140mg/dL when compared with the NDM group. No differences among the groups were found for: pooled measurements and hourly comparisons, exposure, nocturnal, fasting, between lunch and dinner and before meals, as well as after lunch (P>0.05 for all). CONCLUSION The main differences between the mild GDM1 group and healthy controls were related to glucose variability and excursions above 140mg/dL, while glucose exposure was similar. Glucose levels after breakfast and dinner also discerned the GDM1 group. Dietary counseling was able to keep glucose levels to those of healthy patients.

Diabetes and other endocrine-metabolic abnormalities in the long-term follow-up of pancreas transplantation

Pancreas transplantation (PTX) has been demonstrated to restore long-term glucose homeostasis beyond what can be achieved by intensive insulin therapy or islet transplants. Moreover, PTX has been shown to decrease the progression of the chronic complications of diabetes. However, PTX patients require chronic use of immunosuppressive drugs with potential side effects. The long-term follow-up of PTX patients demands special care regarding metabolic deviations, infectious complications, and chronic rejection. Diabetes and other endocrine metabolic abnormalities following transplantation are common and can increase morbidity and mortality. Previous recipient-related and donor-related factors, as well as other aspects inherent to the transplant, act together in the pathogenesis of those abnormalities. Early recognition of these disturbances is the key to timely treatment; however, adequate tools to achieve this goal are often lacking. In a way, the type of PTX procedure, whether simultaneous pancreas kidney or not, seems to differentially influence the evolution of endocrine and metabolic abnormalities. Further studies are needed to define the best approach for PTX patients. This review will focus on the most common endocrine metabolic disorders seen in the long-term management of PTX: diabetes mellitus, hyperlipidemia, and bone loss. The authors here cover each one of these endocrine topics by showing the evaluation as well as proper management in the follow-up after PTX.

Análise de fatores que se associam a alterações no teste de tolerância oral à glicose, independentemente dos valores da glicemia de jejum

OBJECTIVE: To identify factors associated with changes in oral glucose tolerance test (OGTT), regardless of fasting glucose (FG). SUBJECTS AND METHODS: 377 patients (53.8 ± 15.2 years, 77.7% women and BMI = 31.4 ± 5.9 kg/m2) with no history of diabetes mellitus(DM), underwent OGTT and compared according to the results: normal (NGT), impaired (IGT) and DM. RESULTS: 202 patients (53.6%) had altered glucose tolerance: 69 with DM (18.3%) and 133 with IGT (35.3%). In multivariate analysis, factors regardless of FG that were associated (P < 0.05) with changes in the OGTT were age (DM = 58.7 ± 12.9; IGT = 56.7 ± 14.3; NGT = 49.6 ± 15.6 years), hypertension (DM = 69.6%; IGT = 63.9%; NGT = 43.4%), FG (DM = 111.9 ± 9.2; IGT = 103.5 ± 10.3; NGT = 96.6 ± 11.1 mg/dL), HbA1C (DM = 6.1 ± 0.7%; IGT = 6.1 ± 0.5%; NGT = 5.8 ± 0.4%), triglycerides (DM = 179.3 ± 169.9; IGT = 154.2 ± 84.1; NGT = 129.1 ± 71.9 mg/dL), HDL-c (DM =44.7 ± 9.2; IGT = 47.5 ± 12.3; NGT = 50.6 ± 13.4 mg/dL) and uric acid in women (DM = 5.3 ± 1.5; IGT = 5.3 ± 1.3; NGT = 4.7 ± 1.3 mg/dL). CONCLUSION: Age, hypertension, elevated triglycerides, HbA1C, uric acid (in women) and low HDL-C are associated with changes in the OGTT patients with overweight / obesity, irrespective of FG.

Histiocitose cutânea não-Langerhans como causa de diabetes insípido central

The histiocytoses are rare diseases caused by alterations in the monocyte-histiocytic series with several clinical findings. Among the cutaneous syndromes of non-Langerhans cells, xanthoma disseminatum is the only disease of this group that has been classically associated to the central diabetes insipidus (CDI). The case reported describes a 30-year-old man that two years after presenting with CDI developed non confluent disseminated cutaneous brown papular lesions throughout the body. The histopathology, immunohistochemistry, and electronic microscopy were compatible with the diagnosis of non-Langerhans histiocytoses, suggesting the diagnosis of juvenile xanthogranuloma. The endocrine-metabolic evaluation did not show other alterations besides CDI in a 10-year follow up. The magnetic resonance of hypophysis showed absence of the pituitary hyperintense sign (bright spot). The radiologic and scinthigraphic evaluation of the bones did not show the presence of osteolytic lesions. This case prints out the importance of skin examination in cases of CDI and its association with cutaneous non-Langerhans histiocytoses in a broader spectrum, rather then restricted to the cases of xanthoma disseminatum.

Assessment of adiposity in psoriatic patients by dual energy X-ray absorptiometry compared to conventional methods.

BACKGROUND Obesity is considered a chronic low-grade inflammatory disease that shares mediators of inflammation with psoriasis, such as TNF-α and IL-6. The relationship between these two conditions involves factors such as predisposition and response to therapy, in addition to an association with cardiovascular disease. OBJECTIVES The aim of the present study was to investigate the prevalence of adiposity as determined by body mass index (BMI), waist circumference (WC), and dual energy X-ray absorptiometry (DXA) evaluation in patients with psoriasis. METHODS BMI, WC and body composition by DXA were measured in 42 psoriatic patients without joint complaints and in 41 control patients using standard procedures. In the comparison between cases and controls, we used Pearson’s Χ2 test or Fisher’s exact test, and the nonparametric Mann-Whitney test. The difference between the diverse classification methods for obesity was evaluated using McNemar’s test. To test the level of agreement between those variables, we used the weighted kappa coefficient. RESULTS There was no difference in the prevalence of obesity among cases and controls. Both BMI and WC had low agreement with measures of body fat evaluated by DXA. With the use of DXA scanning, prevalence of overweight and obesity in patients with psoriasis was 83.3%, which constitutes a strong evidence of the need for intervention on this metabolic parameter. CONCLUSION Dual energy X-ray absorptiometry was more capable of identifying obesity compared with BMI and WC both in psoriatic and control patients.

Hipertensão Portopulmonar e Gravidez

The severity of the association of pulmonary hypertension with pregnancy is well known. Pulmonary arterial hypertension constitutes one of the highest risk conditions for maternal mortality in late pregnancy and postpartum. Patients with portal hypertension of varying etiology may develop pulmonary arterial hypertension (portopulmonary hypertension) and most cases present cirrhosis as the underlying disease; however, a few cases of noncirrhotic etiology have been described. Clinical and pathological findings in two cases of portopulmonary hypertension and pregnancy are presented here. The two patients (30 and 24 years old) developed severe right heart failure and shock just after the delivery and the disease progressed rapidly to death. Autopsy demonstrated fibrosis in hepatic portal tracts, as has been described in cases of idiopathic portal hypertension. Also, pulmonary hypertension classified as plexogenic was reported.