Maria Aparecida Pachaly

Interleukin-6 Is a Better Predictor of Mortality as Compared to C-Reactive Protein, Homocysteine, Pentosidine and Advanced Oxidation Protein Products in Hemodialysis Patients

Inflammatory markers predict mortality in hemodialysis (HD) patients, whereas a possible association between oxidative stress (OS) markers and survival is less clear. We assessed the impact on all-cause mortality of baseline inflammatory [high-sensitivity C-reactive protein and interleukin-6 (IL-6)] and OS markers (advanced oxidation protein products, pentosidine, homocysteine) in 112 HD patients. We found no significant correlations between inflammatory and OS markers. During the 5.5 years of follow-up, 51 patients died. In a Kaplan-Meier analysis, the survival rate was reduced in patients with IL-6 higher than the median (IL-6 >4.2 pg/ml) (log- rank = 6.47; p = 0.01), in diabetics (log-rank = 12.26; p = 0.0005) and in older patients (log-rank = 11.22; p = 0.0008). Moreover, in Cox analysis only IL-6 and age were independently associated with mortality. We conclude that in this group of prevalent Brazilian HD patients, IL-6 was a better predictor of survival than other inflammatory and OS markers.

Effect of hepatitis C serology on C-reactive protein in a cohort of Brazilian hemodialysis patients.

Hepatitis C (HCV) is not an uncommon feature in hemodialysis (HD) patients and may be a cause of systemic inflammation. Plasma cytokine interleukin-6 (IL-6) is mainly produced by circulating and peripheral cells and induces the hepatic synthesis of C-reactive protein (CRP), which is the main acute phase reactant. The aim of this study was to investigate the influence of HCV on two markers of systemic inflammation, serum CRP and IL-6, in HD patients. The study included 118 HD patients (47% males, age 47 +/- 13 years, 9% diabetics) who had been treated by standard HD for at least 6 months. The patients were divided into two groups depending on the presence (HCV+) or absence (HCV-) of serum antibodies against HCV. Serum albumin (S-Alb), plasma high sensitivity CRP (hsCRP), IL-6, and alanine aminotransferase (ALT) were measured and the values were compared with those for 22 healthy controls. Median hsCRP and IL-6 values and hsCRP/IL-6 ratio were: 3.5 vs 2.1 mg/l, P < 0.05; 4.3 vs 0.9 pg/ml, P < 0.0001, and 0.8 vs 2.7, P < 0.0001, for patients and controls, respectively. Age, gender, S-Alb, IL-6 and hsCRP did not differ between the HCV+ and HCV- patients. However, HCV+ patients had higher ALT (29 +/- 21 vs 21 +/- 25 IU/l) and had been on HD for a longer time (6.1 +/- 3.0 vs 4.0 +/- 2.0 years, P < 0.0001). Moreover, HCV+ patients had a significantly lower median hsCRP/IL-6 ratio (0.7 vs 0.9, P < 0.05) compared to the HCV- group. The lower hsCRP/IL-6 ratio in HCV+ patients than in HCV- patients suggests that hsCRP may be a less useful marker of inflammation in HCV+ patients and that a different cut-off value for hsCRP for this population of patients on HD may be required to define inflammation.

Left ventricular mechanical dyssynchrony in patients with different stages of chronic kidney disease and the effects of hemodialysis

Left ventricular (LV) dyssynchrony is a known cause of mortality in patients with heart failure and may possibly play a similar role in patients with chronic kidney disease (CKD) in whom sudden death is one of the most common and as yet not fully explained cause of death. LV synchronicity and its relationship with increased volume load and various biomarkers was analyzed in 145 patients including 53 patients with CKD stages 3 and 4 and in 92 CKD stage 5 patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) using color tissue Doppler imaging and tissue synchronization imaging. The HD patients were evaluated both before and after a single HD session. LV dyssynchrony was defined as a regional difference in time to peak systolic myocardial velocity, between 12 LV segments > 105 milliseconds. LV dyssynchrony was present in 54% of the patients with no difference between CKD 3 and 4 (58%), HD (48%), and PD (51%). LV dyssynchrony was independently associated with LV mass index and increased estimation of LV end‐diastolic pressure. A single HD session resulted in significant changes in LV synchronicity variables—with improvement in 50% of the patients—especially in patients with higher myocardial systolic velocities and lower LV mass index. Abnormalities in LV synchronicity are highly prevalent in CKD patients already prior to dialysis treatment and are associated with LV hypertrophy, LV dysfunction and load conditions, underlining the importance of volume status for LV synchronicity in CKD patients.

Acute renal failure and haemorrhagic syndrome secondary to toxin of caterpillars (Lonomia obliqua)

Accidental poisoning with caterpillars has become increasingly frequent in southern Brazil, partly due to deforestation and elimination of natural predators [1]. Caterpillars are the larval stage of moths and butterflies and are found worldwide [2]. Accidental contact with caterpillars bristles induces allergic and toxic signs and symptoms that range from mild cutaneous reaction to severe systemic reactions, depending mainly on the number and species of the caterpillar involved. Symptoms include local irritation, urticarial dermatitis, allergy, ocular injuries, osteochondritis, haemorrhage secondary coagulopathy and acute renal failure. Haemorrhagic complications including intra-cerebral can result in mortality [2,3].

Effects of non-pharmacological interventions on urinary citrate levels: a systematic review and meta-analysis.

BACKGROUND Hypocitraturia is a known risk factor for nephrolithiasis, present in 20-60% of stone-forming patients. The administration of citrate or other alkali preparations has been demonstrated to benefit hypocitraturic stone formers. Dietary modifications that include citrate-containing fluids can be an alternative option to pharmacological agents. We aimed to systematically review, summarize and quantify available evidence on the effects of non-pharmacological interventions on urinary citrate and nephrolithiasis. METHODS Manual and electronic database searches (MEDLINE/PubMed, Embase, Cochrane Library, Scopus, Scielo, LILACS) were performed for studies published up to July 2014. Two reviewers independently identified studies for inclusion and extracted data on study characteristics, outcomes and quality assessments. We included controlled studies with non-pharmacological interventions that assessed urinary citrate levels or nephrolithiasis pre- and post-intervention. Meta-analysis was performed by random effects and subgrouped by the type of intervention, and heterogeneity was analysed by I(2). RESULTS Of the 427 studies identified, 13 studies were included (18 samples), involving 358 participants with a mean age of 43 ± 11.0 years across the studies. Interventions were grouped as commercial fruit juices, soft drinks, calcium-/magnesium-rich mineral water, high-fiber diet, low-animal-protein diet and plant extract. Almost half of the studies (6/13; 8/18 samples) reported effects in non-stone formers. Two studies included stone formers and non-stone formers. Commercial fruit juice interventions showed high I(2) (88.1%, P = 0.000) and an increase in citraturia levels ( 95% confidence interval) of 167.2 (65.4; 269) mg/day. Other types of intervention did not show important heterogeneity; however, pooled estimates were not significant. CONCLUSION Our review indicates that further larger scale trials are required to analyze whether non-pharmacological interventions can increase urinary citrate levels and act in kidney stone prevention.

Tratamento da nefrolitíase: onde está a evidência dos ensaios clínicos?

The prevalence of kidney stone disease is increasing worldwide with significant health and economic burden. Newer research is finding that stones are associated with several serious morbidities. Yet, few randomized clinical trials or high quality observational studies have assessed whether clinical interventions decrease the recurrence of kidney stones. Therefore, in this review we analyze the available evidence on medical expulsive therapy for ureteral stones; describe the evidence about non-pharmacological stone therapy including dietary modifications and citrus juice-based therapy; and discuss the efficacy of thiazide diuretics for the treatment of hypercalciuria in recurrent nephrolithiasis.