Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension

A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis: Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications: Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

Assessment of physical activity by accelerometer and IPAQ-short version in patients with chronic kidney disease undergoing hemodialysis

To compare the short version of International Physical Activity Questionnaire (IPAQ) and the accelerometer measurement of physical activity (PA) in patients undergoing hemodialysis. Sample consisted of 40 patients (19 men) aged 45 ± 16 years. Patients reported their PA using the IPAQ during a face-to-face interview, and wore an Actigraph GT3-X accelerometer for 1 week to obtain minutes per day of light PA, moderate-to-vigorous PA (MVPA) and total PA as well as raw counts per day (vector magnitude). All PA-related variables were significantly correlated among instruments (r = 0.34-0.47) when analyzed as a group. However, when analyzed separately by gender, the relationships were present for women only (r = 0.46-0.62). IPAQ significantly underestimated light PA (IPAQ vs. accelerometer: 180.0 vs. 251.1 min/day, p = 0.019), but no differences were found between methods for MVPA and total PA. Modest correlations were found between self-reported PA time by IPAQ (short version) and accelerometer, but only in women. However, the IPAQ may underestimate light PA, which is the main form of PA in this population.

Cognitive impairment in chronic kidney disease

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Selenite and Selenate Effects on Mercury (Hg2+) Uptake and Distribution in Tilapia, Oreochromis niloticus L., Assessed by Chronic Bioassay

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Heat or cold chronic stress affects organ weights and Hsp70 levels in chicken embryos

This study was carried out with the objective of evaluating the effect of heat (38.8 degreesC) or cold (35.8 degreesC) stress on chicken embryo development and tissues Hsp70 levels, after the 13th day of incubation. Embryo weight (percent egg weight), organ weight (percent embryo weight) and Hsp70 levels (ng Hsp70 mug(-1) total protein) in different tissues (liver, breast muscle, heart, lungs, brain and kidney) were studied at the end of incubation. Cold stress induced a lower embryo weight and lower kidney and lungs weights, whereas heart and liver were lighter in heat-stressed embryos. An interaction between temperature and age was obtained only for Hsp70 levels in kidney and heart. Cold-stressed embryos showed higher Hsp70 levels in the brain, lungs and liver; a decrease in brain and breast muscle Hsp70 levels was seen from the 19th to 20th days in control embryos. Hsp70 levels increased with age in kidneys of control embryos and in heart of heat- and cold-stressed embryos. In conclusion, this study showed that chicken embryo organ weights are affected by incubation temperature, and that Hsp70 expression is tissue dependent (higher levels being seen in the brain) being cold-stress more effective in increasing Hsp70 levels in most studied tissues.

Enzyme Biomarkers of Renal Tubular Injury in Arterial Surgery Patients

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Postoperative renal function evaluation, through RIFLE criteria, of elderly patients who underwent femur fracture surgery under spinal anesthesia

Introduction. The postoperative acute renal failure (ARF) incidence in different kinds of surgery has rarely been studied. Age, cardiac dysfunction, previous renal dysfunction, intraoperative hypoperfusion, and use of nephrotoxic medications are mentioned as risk factors for ARF at the postoperative period. The postoperative ARF definition was based on the creatinine increase by the RIFLE classification (R = risk, I = injury, F = failure, L = loss, E = end stage), which corresponds to a 1.5 creatinine increase, two to three times, respectively, above the basal value. This study aimed to evaluate the postoperative ARF incidence in elderly patients who underwent femur fracture surgery under subarachnoid anesthesia and stratify it by the RIFLE criteria. Methods. Ninety patients older than 65 years under spinal anesthesia with fixed dosage of 15 mg of 0.5% isobaric bupivacaine associated with morphine 50 g were studied. Immediate postoperative creatinine was considered basal and compared with maximal creatinine evaluated at 24, 48, and 72 postoperative hours. Results. The mean age of the patients was 80.27 years. ARF incidence was 24.44% and stratified this way: R = 21.11% and I = 3.33%. Conclusions. In conclusion, the postoperative ARF incidence after femur fracture surgery in patients over 65 years was 24.44%. By analyzing the stratification based on the RIFLE classification, the incidence was categorized as Risk (R) = 21.11% and Injury (I) = 3.33%.

Effect of haematocrit on pump and kidney dysfunction after myocardial revascularization

Objective - Kidney dysfunction is a common complication after cardiac surgery. It occurs in 7 to 31% of the patients. The lowest haematocrit after cardiopulmonary bypass surgery (LHCT) has been identified as a risk factor for kidney dysfunction after cardiac surgery. The aim of this study is to determine whether different levels of haematocrit during cardiopulmonary bypass surgery are related to kidney dysfunction.Methods and results-A prospective study was conducted on consecutive adult patients undergoing myocardial revascularization. Preoperative renal function was assessed by baseline serum creatinine level (CrPre). Peak postoperative creatinine (CrPost) was defined as the highest daily in-hospital postoperative value. Peak fractional change in creatinine (% Delta Cr) was defined as the difference between the CrPre and CrePost represented as a percentage of the preoperative value. The LHTC was defined as the lowest recorded haematocrit prior to weaning from the initial pump run. A category variable was created for haematocrit based on the distribution of values. The category variable had the following cut-off points: less than 23%, 23.1 to 28% and greater than 28.1 %. Lowest haematocrit (26.62 +/- 4.15%), CPB (74.71 +/- 24.90 min), CrPre (1.23 +/- 0.37 mg/dl) and highest CrPost (1.52 +/- 0.47 mg/dl) data varied in near-normal fashion. Statistical significance has been observed in the < 23% lowest haematocrit group (CrIPOD and Cr5POD; P = 0.006) and the 23.1 28% lowest haematocrit level group (CrPre and Cr2POD; P = 0.047). CrPre and Cr5POD did not differ between groups (P > 0.05). The multiple linear regression model confirmed that the determinants for higher %Delta Cr were age, body surface area and preoperative serum creatinine level.Conclusion - The LHTC was not identified as a risk factor for kidney dysfunction after myocardial revascularization.

Myocardial dysfunction with increased ventricular compliance in volume overload hypertrophy

The aim this study was to evaluate systolic and diastolic function in volume overload induced myocardial hypertrophy in rats.Volume overload myocardial hypertrophy was induced in thirteen male Wistar rats by creating infrarenal arteriovenous fistula (AVF). The results were compared with a SHAM operated group (n = 11). Eight weeks after surgery, tail-cuff blood pressure was recorded, then rats were sacrificed for isolated heart studies using Langendorffs preparation.AVF rats presented increased left and right ventricular weights, compared to controls. The increased normalized ventricular volume (V0/LVW, 0.141 +/- 0.035 mL/g vs. 0.267 +/- 0.071 mL/g, P < 0.001) in the AVF group indicated chamber dilation. Myocardial hydroxyproline concentration remained unchanged. There was a significant decrease in +dP/dt (3318 +/- 352 mm Hg s(-1) vs. 2769 +/- 399 mm Hg s(-1); P=0,002), end-systolic pressure-volume relation (246 +/- 56 mm Hg mL(-1) vs. 114 +/- 63 mm Hg mL(-1);, P < 0,001), and -dP/dt (1746 +/- 240 min Hg s(-1) vs. 1361 +/- 217 mm Hg s(-1), P < 0.001) in the AVF group, which presented increased ventricular compliance (Delta V-25: SHAM=0.172 +/- 0.05 mL vs. AVF=0.321 +/- 0.072 mL, P < 0.001) with preserved myocardial passive stiffness (Strain(25): SHAM=13.5 +/- 3.0% vs. AVF=12.3 +/- 1.9%, P > 0.05).We conclude that volume-overload induced hypertrophy causes myocardial systolic and diastolic dysfunction with increased ventricular compliance. These haemodynamic features help to explain the long-term compensatory phase of chronic volume overload before transition to overt congestive heart failure. (c) 2006 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Vasculite necrosante na glomerulonefrite difusa aguda pós-infecciosa

Os autores relatam dois casos de glomerulonefrite difusa aguda pós-infecciosa com evolução clinicomorfológica incomum. As biópsias renais mostraram alterações características de glomerulonefrite difusa aguda associada à extensa necrose fibrinóide e infiltrado inflamatório leucocitário na parede de arteríolas e artérias interlobulares. Foram também observadas crescentes. Ambos os pacientes cursaram com insuficiência renal aguda severa, sendo que um dos pacientes recuperou a função renal e outro evoluiu para insuficiência renal crônica e óbito.

Influence of protein intake and muscle mass on survival in chronic dialysis patients

Introduction: Some studies suggest that high body mass index (BMI) confers survival advantage in dialysis patients, but BMI does not differentiate muscle from fat mass, and the survival advantage conferred by its increase seems to be limited to patients with high muscle mass. Thus, discriminating body components when evaluating nutritional status and survival is highly important. This study evaluated the influence of nutritional parameters on survival in patients on chronic dialysis. Subjects and methods: Anthropometry, bioimpedance, biochemistry, and dietary recall were used to investigate the influence of nutritional parameters on survival in 79 prevalent patients on chronic dialysis. Results: Protein intake <1.2 g/kg/day and creatinine <9.7 mg/dL were independent predictors of mortality in all patients. Regarding dialysis method, protein intake <1.2 g/kg/ day was predictive of mortality among hemodialysis patients, and percent standard mid-arm muscle circumference <80% was identified as a risk factor among peritoneal dialysis patients. Conclusion: Higher muscle mass, possibly favored by a higher protein intake, conferred survival advantage in dialysis patients.

Can Delivery Dialysis Dose Affect Survival of Acute Kidney Injury Patients?

Intensity of dialysis dose in acute kidney injury (AKI) might benefit critically ill patients. The aim of this study was to evaluate the effect of intermittent hemodialysis (IHD) dose on mortality in patients with AKI. Methods: Prospective observational study was performed on AKI patients treated with IHD. The delivered dialysis dose per session was calculated based on single-pool Kt/V urea. Patients were allocated in two groups according to the weekly delivered median Kt/V: higher intensity dialysis dose (HID: Kt/V higher than median) and lower intensity dialysis dose (LID: Kt/V lower than median). Thereafter, AKI patients were divided according to the presence or absence of sepsis and urine output. Clinical and lab characteristics and survival of AKI patients were compared. Results: A total of 121 AKI patients were evaluated. Forty-two patients did not present with sepsis and 45 did not present with oliguria. Mortality rate after 30 days was lower in the HID group without sepsis (14.3% x 47.6%; p = 0.045) and without oliguria (31.8% x 69.5%; p = 0.025). Survival curves also showed that the HID group had higher survival rate when compared with the LID group in non-septic and non-oliguric patients (p = 0.007 and p = 0.003, respectively). Conclusion: Higher dialysis doses can be associated with better survival of less seriously ill AKI patients.

High volume peritoneal dialysis vs daily hemodialysis: A randomized, controlled trial in patients with acute kidney injury

There is no consensus in the literature on the best renal replacement therapy (RRT) in acute kidney injury (AKI), with both hemodialysis (HD) and peritoneal dialysis (PD) being used as AKI therapy. However, there are concerns about the inadequacy of PD as well as about the intermittency of HD complicated by hemodynamic instability. Recently, continuous replacement renal therapy (CRRT) have become the most commonly used dialysis method for AKI around the world. A prospective randomized controlled trial was performed to compare the effect of high volume peritoneal dialysis (HVPD) with daily hemodialysis (DHD) on AKI patient survival. A total of 120 patients with acute tubular necrosis (ATN) were assigned to HVPD or DHD in a tertiary-care university hospital. The primary end points were hospital survival rate and renal function recovery, with metabolic control as the secondary end point. Sixty patients were treated with HVPD and 60 with DHD. The HVPD and DHD groups were similar for age ( 64.2 +/- 19.8 and 62.5 +/- 21.2 years), gender ( male: 72 and 66%), sepsis ( 42 and 47%), hemodynamic instability ( 61 and 63%), severity of AKI ( Acute Tubular Necrosis-Index Specific Score (ATN-ISS): 0.68 +/- 0.2 and 0.66 +/- 0.2), Acute Physiology, Age, and Chronic Health Evaluation Score (APACHE II) (26.9 +/- 8.9 and 24.1 +/- 8.2), pre-dialysis BUN (116.4 +/- 33.6 and 112.6 +/- 36.8mg per 100 ml), and creatinine ( 5.8 +/- 1.9 and 5.9 +/- 1.4 mg per 100 ml). Weekly delivered Kt/V was 3.6 +/- 0.6 in HVPD and 4.7 +/- 0.6 in DHD ( P<0.01). Metabolic control, mortality rate ( 58 and 53%), and renal function recovery ( 28 and 26%) were similar in both groups, whereas HVPD was associated with a significantly shorter time to the recovery of renal function. In conclusion, HVPD and DHD can be considered as alternative forms of RRT in AKI.

Advances in Peritoneal Dialysis in Acute Kidney Injury

Peritoneal dialysis (PD) is a simple, safe, cheap, and efficient renal replacement therapy method. It can correct metabolic disorders and fluid overload in acute kidney injury (AKI) patients both in and out of the intensive care unit. Use of PD in AKI is enhanced by placement of a Tenckhoff catheter, which can be safely accomplished at the bedside. Some PD modalities, such as high-volume PD and continuous-flow PD, can provide dialysis doses and efficiency comparable to extracorporeal blood purification methods. PD is particularly suitable for neonates, children, and patients with refractory heart failure or who are otherwise hemodynamically unstable. PD should be considered in situations where systemic anticoagulation and/or vascular access are problematic. PD is limited by a lower efficiency that may produce inadequate renal replacement in larger and/or severely hypercatabolic patients. Fluid removal can be unpredictable, there is a risk of infection, and possible issues with mechanical ventilation. In this article, we discuss the use of PD in AKI, with emphasis on recent advances. Copyright (c) 2012 S. Karger AG, Basel

When is dialysis indicated in acute kidney injury?

The indications for dialysis in patients with acute kidney injury (AKI), as well as the dose and timing of initiation, remain uncertain. Recent data have suggested that early initiation of renal replacement therapy (RRT) may be associated with decreased mortality but not with the recovery of kidney function. A blood urea nitrogen (BUN) level of 75 mg/dL is a useful indicator for dialysis in asymptomatic patients, but one that is based on studies with limitations. Different parameters, including absolute and relative indicators, are needed. Currently, nephrologists should consider the trajectory of disease, and the clinical condition and prognosis of the patient are more important than numerical values in the decision to initiate dialysis.