Urinary tract infection

Urinary tract infection (UTI) is more frequent in female patients. It may be complicated,when associated with an underlying condition that increases the risk of therapeutic failure, and the length of treatment. The most frequent etiologic agent that causes UTI is Escherichia coli. The recurring UTI may be due to several factors, and must be investigated.A infecção do trato urinário (ITU) é mais freqüente no sexo feminino. Pode ser complicada, quando se associa a condição subjacente, que eleva o risco de falha terapêutica e, conseqüentemente, o tempo de tratamento necessário. O microorganismo que mais freqüentemente causa ITU é Escherichia coli. A ITU de repetição deve-se a inúmeros fatores, e deve ser investigada

Fluid and electrolyte disorders

O sódio e o potássio são os principais íons dos meios extra e intracelular, respectivamente. Os distúrbios relacionados a esses íons são freqüentes e podem ser causados por inúmeras condições clínicas. A fisiopatologia e a gravidade das alterações indicam o tratamento a ser instituído.Sodium and potassium are the main extracellular and intracellular space electrolytes respectively. The disorders related to these electrolytes are frequent and may be caused by several clinical conditions. The physiopathology and severity of the changes determine the treatment to be instituted

Acute renal failure in intensive care unit

A insuficiência renal aguda (IRA) tem incidência em torno de 2 a 5%, em pacientes hospitalizados, influenciada por fatores como: choque séptico, hipovolemia, uso de aminoglicosídeos, insuficiência cardíaca e radiocontrastes. Uma parte desses pacientes tem sido tratados em Unidades de Terapia Intensiva e, dependendo do quadro, altas taxas de mortalidade, podem ser atingidas. Nesse capítulo, apresentamos as causas mais comuns de IRA, enfatizando a sua prevenção no meio hospitalar. É importante, nesses casos, a distinção entre causas pré-renais e renais. Entre as causas renais, destacamos a necrose tubular aguda (NTA), geralmente provocada por hipoperfusão renal e/ou nefrotoxinas endógenas e exógenas. No tratamento, o balanço hídrico, aspectos nutricionais e diálise são fatores importantes a serem considerados. O tratamento dialítico, quando necessário, é realizado através de diálise peritoneal, hemodiálise intermitente, ultrafiltração, ou métodos contínuos de reposição da função renal.In hospitalized patients, acute renal failure(ARF) has an incidence from 2 % to 5%, mostly due to: septic shock, hypovolemia, aminoglycoside use, cardiac failure and radiocontrast media. Some of these patients are in the intensive care unit (ICU) and show high rates of mortality despite the advances of treatment. In this paper, we discuss the most common causes of ARF, emphasizing prevention in the hospitalized patients and the importance of the differencial diagnosis between pre-renal and renal causes of ARF. Among the renal causes, acute tubular necrosis (ATN) has a high incidence provoked by either hypoperfusion and/or exogen and endogen nephrotoxins. Hydro-eletrolytic balance, nutritional assessment and dialysis are the main topics to be considered in the treatment. The dialytic treatment, when required, can be instituted as peritoneal dialysis, hemodialysis and the continuous renal replacement methods of therapy

Acute renal failure

A insuficiência renal aguda (IRA) tem incidência, em torno de 2 a 5%, em pacientes hospitalizados com grande influência de fatores como: choque séptico, hipovolemia, uso de aminoglicosídeos, insuficiência cardíaca e contrastes para R-X. Uma parte desses pacientes tem sido tratada em unidades de terapia intensiva e, dependendo do quadro, pode haver alta taxa de mortalidade. Neste capítulo, apresentamos as causas mais comuns de IRA, enfatizando sua prevenção no meio hospitalar. É importante distinguir nesses casos, as causas pré-renais das renais. Entre as causas renais, destacamos a necrose tubular aguda (NTA), geralmente provocada por hipoperfusão renal e/ou nefrotoxinas endógenas e exógenas. O manitol, furosemide e dopamina têm sua ação discutida nos casos de IRA, especialmente nas primeiras 24 a 48 h que é quando, aparentemente, teriam sua maior utilidade. Com relação ao tratamento conservador, o balanço hídrico exerce papel fundamental no seguimento, além das medidas que evitam a ocorrência de infecções, que são a causa principal de complicação nos quadros de IRA. O tratamento dialítico, quando necessário, é realizado através de ultrafiltração, hemodiálise intermitente, diálise peritoneal, ou hemodiálise venovenosa contínua (“hemolenta”), além de outros métodos que são descritos na literatura.In hospitalized patients, acute renal failure (ARF) has an incidence from 2 % to 5%, mostly due to: septic shock, hypovolemia, aminoglycoside use, cardiac failure and radiocontrast media. Some of these patients are in the intensive care unit (ICU) and show high rates of mortality despite the advances of treatment. In this paper we discuss the most common causes of ARF, emphasizing prevention in the hospitalized patients and the importance of the differential diagnosis between pre-renal and renal causes of ARF. Among the renal causes, acute tubular necrosis (ATN) has a high incidence provoked by either hypoperfusion and/or exogen and endogen nephrotoxins. In the treatment, hydro-electrolytic balance, nutritional aspects and dialysis are the main topics to be considered. The dialytic treatment, whenever required, can be instituted as peritoneal dialysis, hemodialysis and the continuous renal replacement methods of therapy

Glomerulopatia de lesões mínimas associada ao diabetes melito do tipo 1 e do tipo 2

A 19-year-old female with type 1 diabetes for four years, and a 73-year-old female with type 2 diabetes for twenty years developed sudden-onset nephrotic syndrome. Examination by light microscopy, immunofluorescence, and electron microscopy (in one case) identified minimal change disease (MCD) in both cases. There was a potential causative drug (meloxicam) for the 73-year-old patient. Both patients were treated with prednisone and responded with complete remission. The patient with type 1 diabetes showed complete remission without relapse, and the patient with type 2 diabetes had two relapses; complete remission was sustained after associated treatment with cyclophosphamide and prednisone. Both patients had two years of follow-up evaluation after remission. We discuss the outcomes of both patients and emphasize the role of kidney biopsy in diabetic patients with an atypical proteinuric clinical course, because patients with MCD clearly respond to corticotherapy alone or in conjunction with other immunosuppressive agents. Arq Bras Endocrinol Metab. 2012;56(5):331-5Uma paciente de 19 anos de idade com diabetes tipo 1 durante quatro anos e uma paciente de 73 anos de idade com diabetes tipo 2 durante vinte anos desenvolveram quadro súbito de síndrome nefrótica. O exame histológico à microscopia de luz, imunofluorescência e microscopia eletrônica (em um caso) diagnosticou glomerulopatia de lesões mínimas (GLM) em ambos os casos. Na paciente de 73 anos de idade, houve uma associação com o uso de meloxicam. As duas pacientes foram tratadas com corticosteroides e responderam com remissão completa do quadro. A paciente de 19 anos com diabetes tipo 1 apresentou remissão completa sem recidivas, e a paciente de 73 anos com diabetes tipo 2 apresentou dois episódios de recidiva; a remissão completa foi conseguida após associação ao tratamento com ciclofosfamida. As duas pacientes foram seguidas dois anos após a remissão completa. Os casos descritos enfatizam o papel da biópsia renal em pacientes diabéticos com evolução atípica do aparecimento de proteinúria, pois pacientes com GLM respondem bem à corticoterapia como único tratamento ou associado a outro agente imunossupressor. Arq Bras Endocrinol Metab. 2012;56(5):331-5Fundacao de Apoio ao Ensino, Pesquisa e Assistencia (FAEPA)Fundacao de Apoio ao Ensino, Pesquisa e Assistencia (FAEPA

Renal diseases in the elderly underwent to percutaneous biopsy of native kidneys

INTRODUÇÃO: Tem ocorrido aumento da população de idosos e estes vêm envelhecendo em melhores condições clínicas do que no passado. Entretanto, a distribuição e evolução das doenças renais nos idosos ainda são pouco conhecidas, em parte devido à resistência em indicar biópsia renal. OBJETIVO: Avaliar a distribuição, a evolução e as características clínicas das nefropatias diagnosticadas por biópsia em pacientes idosos. PACIENTES E MÉTODOS: Foram avaliadas todas as biópsias renais percutâneas de rins nativos. Elas foram realizadas entre janeiro de 1990 e dezembro de 2006 em 71 pacientes com idade mínima de 60 anos (67,3 ± 6,5 anos), sendo 47 do gênero masculino e 24 do feminino. Os pacientes foram agrupados conforme a indicação clínica da biópsia. RESULTADOS: Síndrome nefrótica foi verificada em 35 pacientes (49,3%) associada, na maioria dos casos, à nefropatia membranosa (17 casos), seguida por amiloidose e glomeruloesclerose segmentar e focal com 7 casos cada. Hipótese diagnóstica de injúria renal aguda (IRA), com 19 pacientes, teve como principais diagnósticos a necrose tubular aguda (6 casos) e a nefropatia do cilindro (3 casos). Dentre os 19 casos, apenas dois tiveram evolução satisfatória, enquanto os demais morreram precocemente ou evoluíram para doença renal avançada. Doze pacientes biopsiados por hematúria ou proteinúria assintomática tiveram diagnósticos variados, mas a maioria já apresentava nefropatia crônica relevante. Biópsia por síndrome nefrítica ocorreu em 5 casos, também com diagnósticos variados. CONCLUSÕES: Síndrome nefrótica foi a principal indicação de biópsia renal com a nefropatia membranosa como diagnóstico mais frequente. Entre os pacientes com IRA e hematúria ou proteinúria assintomática os diagnósticos foram variados com elevadas taxas de nefropatia crônica avançada.INTRODUCTION: The elderly population is growing and aging in better clinical conditions than in the past. However, the distribution and course of kidney diseases in elderly patients are not well known partially due to reluctance to indicate renal biopsies in those patients. OBJECTIVE: To evaluate the distribution, clinical features, and outcomes of nephropathies diagnosed by biopsy in the elderly. PATIENTS AND METHODS: Seventyone patients (47 males, 24 females) aged 60 years or older (67.3 ± 6.5 years), undergoing biopsy from January 1990 to December 2006, were evaluated. They were grouped according to their clinical syndromes. RESULTS: Nephrotic syndrome was observed in 35 patients (49.3%), mainly associated with membranous nephropathy (17 patients), followed by amyloidosis and focal segmental glomerulosclerosis (seven patients each). Acute kidney injury (AKI) was diagnosed in 19 patients, and the main histopathological diagnoses were acute tubular necrosis (six patients) and cast nephropathy (three patients). Of those 19 patients, only two had a favorable course, while the others died early or progressed toward advanced chronic kidney disease. Twelve patients undergoing biopsy because of asymptomatic hematuria or proteinuria had different diagnoses, but most of them already had significant chronic nephropathy. In five patients with nephritic syndrome, the biopsies also showed several diagnoses. CONCLUSIONS: Nephrotic syndrome was the major indication for renal biopsy, and membranous nephropathy was the most frequent diagnosis. Among patients with AKI and asymptomatic hematuria or proteinuria, different diagnoses were found with high levels of advanced chronic nephropathy.CNPq(FAEPA) USP - Fundação de Apoio ao Ensino, Pesquisa e Assistência do HCFMR

Hypercalcemia and renal function impairment associated with vitamin D toxicity: case report

Abstract Nowadays vitamin D (25-OHD) deficiency is supposed to be a global epidemic condition. Expectedly, vitamin D measurement and intake exponentially increased in Brazil in this decade. Although the benefit of vitamin D to general health is still in debate, its indiscriminate use potentially may lead to enhance the incidence of vitamin D intoxication, which is considered a rare disorder. We report a case of a 70 year old diabetic male with chronic renal disease (blood creatinine of 1.6 mg/dL) who progressed suddenly to acute kidney injury (blood creatinine of 5.7 mg/dL) associated with hypercalcemia and high blood levels of vitamin D. Vitamin D and calcitriol were discontinued and hypercalcemia was managed by hydration followed by furosemide. Thereafter, disodium pamidronate was administered and the patient did not undergo on dialysis. It took approximately 14 months to normalize 25-OHD levels and blood creatinine returned to basal levels only after 24 months. The indicated labeling dosage was 2000 IU, but most likely the vitamin D manipulated preparation was higher as the vitamin D blood levels were very high. Although rare, vitamin D intoxication is becoming more frequent as the patients use frequently manipulated preparations that could be subject to errors in the manufacturing and labeling of the tablets or capsules. The present report alerts to the potential increase in the incidence of severe vitamin D intoxication due to the frequent use of this secosteroid as a nutritional supplement. At the same time, it is necessary to improve regulation on the nutrient supplement market

Corticotherapy response in primary IgA nephropathy Resposta à corticoterapia na nefropatia da IgA primária

INTRODUCTION: Some beneficial effects from long-term use of corticosteroids have been reported in patients with IgA nephropathy. OBJECTIVE: This retrospective study aimed to evaluate the outcome of proteinuria and renal function according to a protocol based on a 6-month course of steroid treatment. METHOD: Twelve patients were treated with 1 g/day intravenous methylprednisolone for 3 consecutive days at the beginning of months 1, 3, and 5 plus 0.5 mg/kg oral prednisone on alternate days for 6 months (treated group). The control group included 9 untreated patients. RESULTS: Proteinuria (median and 25th and 75th percentiles) at baseline in the treated group was 1861 mg/24h (1518; 2417 mg/24h) and was 703 mg/24h (245; 983) and 684 mg/24h (266; 1023) at the 6th (p < 0.05 vs. baseline) and 12th months (p < 0.05 vs. baseline), respectively. In the control group the proteinuria was 1900 mg/24h (1620; 3197) at baseline and was 2290 mg/24h (1500; 2975) and 1600 mg/24h (1180; 2395) at the 6th and 12th months, respectively (not significant vs. baseline). When compared with the control group, the treated group showed lower proteinuria (p < 0.05) during the follow-up and a higher number of patients in remission (p < 0.05) at the 6th and 12th months. Renal function did not change during the follow-up and the adverse effects were mild in most of the patients. CONCLUSION: The 6-month course of steroid treatment was effective in reducing proteinuria during the 12 months of the follow-up, and was well-tolerated by most of the patients.<br>INTRODUÇÃO: Tem sido sugerido que tratamento mais prolongado com corticosteroides pode ser benéfico em pacientes com nefropatia da IgA primária. OBJETIVO: Neste estudo retrospectivo avaliamos os efeitos na proteinúria e na função renal após 12 meses do protocolo baseado no uso por 6 meses de corticosteroides. MÉTODO: Doze pacientes receberam pulsos de 1 g/dia de metilprednisolona intravenosa por 3 dias consecutivos no início dos meses 1, 3 e 5, seguidos por prednisona (0,5 mg/kg) por via oral em dias alternados após cada pulso durante 6 meses (grupo tratado). O grupo controle foi composto por nove pacientes não tratados. RESULTADOS: A proteinúria (mg/24h; mediana; 25º; 75º percentis) no período basal no grupo tratado foi de 1861 (1518; 2417) e de 703 (245; 983) e de 684 (266; 1023) nos 6º (p < 0,05 vs. basal) e 12º (p < 0,05 vs. basal) meses, respectivamente. No grupo controle, a proteinúria foi de 1900 (1620; 3197) no período basal e de 2290 (1500; 2975) e de 1600 (1180; 2395) nos 6º e 12º meses, respectivamente (não significantes vs. basal). Comparado com o grupo controle, o grupo tratado teve menor proteinúria (p < 0,05) e número maior de pacientes em remissão (p < 0,05) nos 6º e 12º meses. A função renal não teve alteração significante e eventos adversos foram de pequena intensidade na maioria dos pacientes. CONCLUSÃO: O protocolo terapêutico base-ado no uso por 6 meses de corticosteroides foi efetivo em reduzir a proteinúria durante os 12 meses de seguimento e foi bem tolerado pela maioria dos pacientes

Corticotherapy response in primary IgA nephropathy

INTRODUCTION: Some beneficial effects from long-term use of corticosteroids have been reported in patients with IgA nephropathy. OBJECTIVE: This retrospective study aimed to evaluate the outcome of proteinuria and renal function according to a protocol based on a 6-month course of steroid treatment. METHOD: Twelve patients were treated with 1 g/day intravenous methylprednisolone for 3 consecutive days at the beginning of months 1, 3, and 5 plus 0.5 mg/kg oral prednisone on alternate days for 6 months (treated group). The control group included 9 untreated patients. RESULTS: Proteinuria (median and 25th and 75th percentiles) at baseline in the treated group was 1861 mg/24h (1518; 2417 mg/24h) and was 703 mg/24h (245; 983) and 684 mg/24h (266; 1023) at the 6th (p < 0.05 vs. baseline) and 12th months (p < 0.05 vs. baseline), respectively. In the control group the proteinuria was 1900 mg/24h (1620; 3197) at baseline and was 2290 mg/24h (1500; 2975) and 1600 mg/24h (1180; 2395) at the 6th and 12th months, respectively (not significant vs. baseline). When compared with the control group, the treated group showed lower proteinuria (p < 0.05) during the follow-up and a higher number of patients in remission (p < 0.05) at the 6th and 12th months. Renal function did not change during the follow-up and the adverse effects were mild in most of the patients. CONCLUSION: The 6-month course of steroid treatment was effective in reducing proteinuria during the 12 months of the follow-up, and was well-tolerated by most of the patients