Insuficiência renal aguda em pacientes com Síndrome Hellp

A síndrome HELLP ocorre em gestantes ou puérperas e é caracterizada pelo surgimento de hemólise, elevação de enzimas hepáticas e plaquetopenia. Desenvolve-se em aproximadamente 10% das gestantes com pré-eclampsia, sendo mais freqüente entre a 22a e 36a semanas de gestação. Insuficiência renal aguda é uma complicação freqüente e grave nessas pacientes. O objetivo deste estudo foi avaliar, em pacientes com síndrome HELLP, a prevalência de insuficiência renal aguda e estudar fatores a ela associados. Foram estudadas 49 gestantes com síndrome HELLP, internadas no Hospital de Clínicas de Porto Alegre no período de janeiro de 1990 a fevereiro de 2000. A elevação da creatinina sérica acima de de 1,5 mg/dl foi o critério utilizado para definir insuficiência renal aguda. As pacientes foram divididas em dois grupos: Grupo 1-pacientes que apresentaram insuficiência renal aguda e Grupo 2-pacientes que não apresentaram alteração da função renal. O Grupo 1 foi constituído de 23 pacientes (46,9%), dos quais 13 pacientes (26,6%) recuperaram gradualmente a função renal e 10 pacientes (20,4%) necessitaram de tratamento dialítico. Dos pacientes submetidos à diálise, três pacientes recuperaram função renal e 3 permanecem em hemodiálise crônica (6,1%) por danos renais irreversíveis. Ocorreram 6 óbitos (12,2%): 5 (10,2%) deles nas pacientes do grupo que desenvolveu insuficiência renal. Concluímos que a insuficiência renal aguda e crônica foi uma complicação freqüente e grave da síndrome HELLP nas gestantes estudadas. As pacientes submetidas à diálise apresentaram maior morbimortalidade e pior prognóstico. Essa situação pode levar à insuficiência renal terminal com necessidade de diálise crônica indefinidamente, com graves repercussões clínicas, econômicas e sociais.

Utilidade da ultra-sonografia e cintilografia da paratireóide no diagnóstico do hiperparatireoidismo secundário em pacientes com insuficiência renal crônica em hemodiálise

A osteodistrofia renal é uma complicação comum da insuficiência renal crônica. A biópsia óssea continua sendo o melhor método para o diagnóstico das doenças ósseas metabólicas. O objetivo deste estudo foi avaliar a utilidade da ultra-sonografia e da cintilografia com Tc-99m-sestamibi da paratireóide, como métodos diagnósticos não invasivos em pacientes com osteodistrofia renal em hemodiálise. Foram investigados 30 pacientes com insuficiência renal crônica, em tratamento com hemodiálise por no mínimo 6 meses, com sintomas e/ou com alterações bioquímicas sugestivas de doença óssea renal, sendo 19 mulheres e 11 homens, com média de idade de 43,9  9,17 anos. Quinze pacientes (50%) apresentaram diagnóstico de hiperparatireoidismo secundário, 5 (16,7%) de doença óssea mista, 3 (10%) de osteomalácia e 3 (10%) de doença óssea adinâmica. Glândulas aumentadas da paratireóide foram observadas em 12 (40%) pacientes na ultra-sonografia e em 15 (50%) na cintilografia com Tc-99m-sestamibi. O grupo de pacientes com glândulas aumentadas da paratireóide na ultra-sonografia, comparado com o grupo com glândulas não detectadas, apresentaram níveis séricos de PTHi aumentados (1536,6  881,8 x 811,7  705,5 pg/ml, p<0,05) e níveis séricos de albumina menores (3,690,24 x 4,030,44 g/dl, p<0,05). Todos os pacientes com níveis séricos de PTHi inferiores a 280 pg/ml apresentaram ecografias da paratireóide com resultados normais. Nove de 12 pacientes (83,3%), com ultra-sonografia com glândulas aumentadas da paratireóide, apresentavam níveis de PTHi superiores a 720 pg/ml. Ultra-sonografia mostrando glândulas aumentadas da paratireóide apresentou uma sensibilidade de 50%, uma especificidade de 66% e um valor preditivo positivo de 83% para o diagnóstico de doenças de alto remanejamento ósseo. Em relação aos resultados das cintilografias de paratireóide com Tc-99m-sestamibi, não houve diferenças nas médias dos níveis de PTHi entre os pacientes com ou sem glândulas aumentadas da paratireóide, assim como para os outros exames bioquímicos. Quando comparado aos níveis de PTHi, 2 pacientes apresentaram resultados positivos na cintilografia com PTHi inferior a 280 pg/ml e 8 (53,4%) acima de 720 pg/ml. Semelhante aos resultados das ultra-sonografias, a sensibilidade, a especificidade e o valor preditivo positivo da cintilografia para o diagnóstico das doenças de alto remodelamento ósseo foram baixos, 50%, 33% e 71%, respectivamente. Podemos concluir que a ultra-sonografia e a cintilografia com Tc-99m-sestamibi da paratireóide não foram bons métodos para o diagnóstico de doenças ósseas com alto remodelamento, no entanto, a ultra-sonografia da paratireóide foi superior a cintilografia com Tc-99m-sestamibi na detecção de glândulas aumentadas, sugerindo ser um marcador mais útil de gravidade em pacientes sintomáticos com hiperparatireoidismo secundário severo.

Prevalência da deleção 4977pb do DNA mitocondrial em pacientes com doença renal crônica em tratamento conservador ou submetidos a hemodiálise no sul do Brasil

Introdução. Danos no DNA mitocondrial (DNAmt) têm sido descritos em pacientes com doença renal crônica (DRC). Estes danos podem ser avaliados através da deleção 4977pb do DNAmt em diversos tecidos. Métodos. Identificamos a prevalência da deleção 4977pb do DNAmt através da técnica da reação em cadeia da polimerase (PCR) no sangue de pacientes com DRC em tratamento conservador (creatinina >2mg/dl) ou submetidos a hemodiálise. Resultados. A freqüência da ocorrência da deleção do DNAmt foi de 73.1% (38/52) nos pacientes com DRC submetidos a hemodiálise, 57.1% (27/42) nos pacientes com DRC em tratamento conservador e 27.8% (15/54) nos controles (P< 0.001). Não encontramos aumento da freqüência desta deleção em relação a idade dos pacientes com DRC (P= 0.54) ou ao tempo de diálise (P= 0.70). Conclusão. Danos no DNAmt podem ser induzidos pela DRC em especial nos pacientes submetidos a hemodiálise. Desta forma, a deleção 4977pb do DNAmt pode servir como um marcador de danos moleculares em pacientes com DRC.

Prevention of bacterial translocation using β-(1-3)-D-glucan in small bowel ischemia and reperfusion in rats

To investigate the role of β-(1-3)-D-glucan on 99mTc labelled Escherichia coli translocation and cytokines secretion in rats submitted to small bowel ischemia/reperfusion injury. Methods: Five groups (n=10 each) of Wistar rats were subjected to control(C), sham(S), group IR subjected to 45 min of bowel ischemia/60 min of reperfusion(I/R), and group I/R+glucan subjected to 45 min of bowel ischemia/60 min of reperfusion(I/R) and injected with 2mg/Kg intramuscular. Translocation of labelled bacteria to mesenteric lymph nodes, liver, spleen, lung and serum was determined using radioactivity/count and colony forming units/g(CFU/g). Serum TNFα, IL-1β, IL-6, IL-10 were measured by ELISA. Results: CFU/g and radioactivity/count were higher in I/R than in I/R+glucan rats. In C, S and S+glucan groups, bacteria and radioactivity/count were rarely detected. The I/R+glucan rats had enhancement of IL-10 and suppressed production of serum TNFα, IL-1β and, IL-6, compared to I/R untreated animals. Conclusion: The β-(1-3)-D-glucan modulated the production of pro-inflammatory and anti-inflammatory cytokines during bowel ischemia/reperfusion, and attenuated translocation of labelled bacteria

Translocation of 99mTc labelled bacteria after intestinal ischemia and reperfusion

Ischemia and reperfusion of the small intestine disrupts gut barrier, causes bacterial translocation and activates inflammatory responses. An experimental study was planned to evaluate if 99mTc labelled Escherichia coli translocates to mesenteric lymph nodes, liver, spleen, lung and serum of rats submitted to mesenteric ischemia/reperfusion. Additionally, it was observed if the time of reperfusion influences the level of translocation. METHODS: Forty male Wistar rats underwent 45 minutes of gut ischemia by occlusion of the superior mesenteric artery. The translocation of labelled bacteria to different organs and portal serum was determined in rats reperfused for 30 minutes, 24 hours, sham(S) and controls(C), using radioactivity count and colony forming units/g (CFU). RESULTS: All the organs from rats observed for 24 hours after reperfusion had higher levels of radioactivity and positive cultures (CFU) than did the organs of rats reperfused for 30 minutes, C and S, except in the spleen (p<0,01). CONCLUSION: The results of this study indicated that intestinal ischemia/reperfusion led to bacterial translocation, mostly after 24 hours of reperfusion

Prevention of bacterial translocation using β-(1-3)-D-glucan in small bowel ischemia and reperfusion in rats

To investigate the role of β-(1-3)-D-glucan on 99mTc labelled Escherichia coli translocation and cytokines secretion in rats submitted to small bowel ischemia/reperfusion injury. Methods: Five groups (n=10 each) of Wistar rats were subjected to control(C), sham(S), group IR subjected to 45 min of bowel ischemia/60 min of reperfusion(I/R), and group I/R+glucan subjected to 45 min of bowel ischemia/60 min of reperfusion(I/R) and injected with 2mg/Kg intramuscular. Translocation of labelled bacteria to mesenteric lymph nodes, liver, spleen, lung and serum was determined using radioactivity/count and colony forming units/g(CFU/g). Serum TNFα, IL-1β, IL-6, IL-10 were measured by ELISA. Results: CFU/g and radioactivity/count were higher in I/R than in I/R+glucan rats. In C, S and S+glucan groups, bacteria and radioactivity/count were rarely detected. The I/R+glucan rats had enhancement of IL-10 and suppressed production of serum TNFα, IL-1β and, IL-6, compared to I/R untreated animals. Conclusion: The β-(1-3)-D-glucan modulated the production of pro-inflammatory and anti-inflammatory cytokines during bowel ischemia/reperfusion, and attenuated translocation of labelled bacteria

Efeito do sildenafil na lesão renal por isquemia-reperfusão em ratos

A lesão renal causada pelo processo isquemia-reperfusão ocorre em várias intervenções cirúrgicas, como transplantes de rins, cirurgias vasculares renais e na nefrectomia parcial. Devido ao processo isquêmico, ocorre disfunção do órgão e morte celular. Com o objetivo de avaliar o efeito do sildenafil, em ratos, administrado previamente à isquemia renal e reperfusão, em avaliações cintilográficas e histopatológicas, foram utilizados vinte e quatro ratos Wistar, aleatoriamente distribuídos em dois grupos. Os animais receberam 0,1 ml IV 99mTecnécio-Etilenodicisteína, realizando-se a cintilografia renal inicial e, em seguida, foram submetidos à laparotomia, provocando-se isquemia no rim esquerdo, com oclusão da artéria renal, durante 1 hora, com posterior reperfusão. Os animais do grupo sildenafil receberam previamente 1mg/kg de sildenafil via oral, 60 minutos antes da isquemia. O grupo controle recebeu somente solução salina. Após a isquemia e reperfusão, metade dos animais de cada grupo foi avaliada com 24 horas e a outra metade, com sete dias, com nova cintilografia renal. Após eutanásia, com superdose de anestésico, os rins foram retirados e submetidos a exame histopatológico. Empregou-se avaliação estatística com o teste t de Student e com teste não-paramétrico de Mann-Whitney. Foi observado no rim esquerdo do grupo controle um déficit funcional nas imagens cintilográficas, após sete dias, comparativamente ao respectivo estudo cintilográfico inicial (p<0,05). Nos rins esquerdos dos animais do grupo controle (24 horas pós-isquemia), ocorreu um maior grau de necrose celular quando comparados ao grupo tratado com o sildenafil (p<0,05). A cintilografia e a histopatologia demonstraram que o sildenafil exerceu ação protetora dos rins, após episódio de isquemia-reperfusão renal normotérmica. Deve ressaltar-se o x caráter interdisciplinar desta tese, que contou com a participação ativa de profissionais das áreas de cirurgia, medicina nuclear, urologia, patologia e estatística

Renal and antibacterial effects induced by myotoxin I and II isolated from Bothrops jararacussu venom

Bothrops jararacussu myotoxin I (BthTx-I; Lys 49) and II (BthTX-II; Asp 49) were purified by ion-exchange chromatography and reverse phase HPLC. In this work we used the isolated perfused rat kidney method to evaluate the renal effects of B. jararacussu myotoxins I (Lys49 PLA(2)) and II (Asp49 PLA(2)) and their possible blockage by indomethacin. BthTX-1 (5 mu g/ml) and BthTX-II (5 mu g/ml) increased perfusion pressure (PP; ct(120) = 110.28+/-3.70 mmHg; BthTX I = 171.28+/-6.30* mmHg; BthTX II = 175.50+/-7.20* mmHg), renal vascular resistance (RVR; ct(120) = 5.49+/-0.54 mmHg/ml.g(-1) min(-1); BthTX I = 8.62+/-0.37* mmHg/ml g(-1) min(-1); BthTX II=8.9+/-0.36* mmHg/ml g(-1) min(-1)), urinary flow (UF; ct(120)= 0.14+/-0.01 ml g(-1) min(-1); BthTX I=0.32+/-0.05* ml g(-1) min(-1); BthTX II=0.37+/-0.01* ml g(-1) min(-1)) and glomerular filtration rate (GFR; ct(120)=0.72+/-0.10 ml g(-1) min(-1); BthTX I=0.85+/-0.13* ml g(-1) min(-1); BthTX II=1.22+/-0.28* ml g(-1) min(-1)). In contrast decreased the percent of sodium tubular transport (%TNa+; ct(120)=79,76+/-0.56; BthTX I=62.23+/-4.12*; BthTX II=70.96+/-2.93*) and percent of potassium tubular transport (%TK+;ct(120)=66.80+/-3.69; BthTX I=55.76+/-5.57*; BthTX II=50.86+/-6.16*). Indomethacin antagonized the vascular, glomerular and tubular effects promoted by BthTX I and it's partially blocked the effects of BthTX II. In this work also evaluated the antibacterial effects of BthTx-I and BthTx-II against Xanthomonas axonopodis. pv. passiflorae (Gram-negative bacteria) and we observed that both PLA2 showed antibacterial activity. Also we observed that proteins Also we observed that proteins chemically modified with 4-bromophenacyl bromide (rho-BPB) decrease significantly the antibacterial effect of both PLA(2). In conclusion, BthTx I and BthTX II caused renal alteration and presented activity antimicrobial. The indomethacin was able to antagonize totally the renal effects induced by BthTx I and partially the effects promoted by BthTx II, suggesting involvement of inflammatory mediators in the renal effects caused by myotoxins. In the other hand, other effects could be independently of the enzymatic activity of the BthTX II and the C-terminal domain could be involved in both effects promoted for PLA(2). (C) 2005 Elsevier Ltd. All rights reserved.

Renal effects and vascular reactivity induced by Tityus serrulatus venom

Tityus serrulatus, popularly known as yellow scorpion, is one of the most studied scorpion species in South America and its venom has supplied some highly active molecules. The effects of T. serrulatus venom upon the renal physiology in human showed increased renal parameters, urea and creatinine. However, in perfused rat kidney the effects were not tested until now. Isolated kidneys from Wistar rats, weighing 240-280 g, were perfused with Krebs-Henseleit solution containing 6% (g weight) of previously dialysed bovine serum albumin. The effects of T. serrulatus venom were studied on the perfusion pressure (PP), renal vascular resistance (RVR), urinary flow (UF), glomerular filtration rate (GFR), sodium tubular transport (%TNa+), potassium tubular transport (%TK+) and chloride tubular transport (%TCl-). Tityus serrulatus venom (TsV; 10 mu g/mL) was added to the system 30 min after the beginning of each experiment (n = 6). This 30 min period was used as an internal control. The mesenteric bed was perfused with Krebs solution kept warm at 37 T by a constant flow (4 mL/min), while the variable perfusion pressure was measured by means of a pressure transducer. The direct vascular effects of TsV (10 mu g/mL/min; n=6), infused at a constant rate (0.1 mL/min), were examined and compared to the infusion of the vehicle alone at the same rate. TsV increased PP (PP30'= 127.8 +/- 0.69 vs PP60' = 154.2 +/- 14 mmHg*, *p < 0.05) and RVR (RVR30' = 6.29 +/- 0.25 vs RVR60' = 8.03 +/- 0.82 mmHg/mL g(-1) min(-1)*, *p < 0.05), decreased GFR (GFR(30') =0.58 +/- 0.02 vs GFR(60') = 0.46 +/- 0.01 mL g(-1) min(-1)*, *p < 0.05) and UF (UF30' = 0.135 +/- 0.001 vs UF60' = 0.114 +/- 0.003 mL g(-1)min(-1)*, *p < 0.05). Tubular transport was not affected during the whole experimental period (120 min). on the other hand, the infusion of TsV (10 mu g/mL/min) increased the basal perfusion pressure of isolated arteriolar mesenteric bed (basal pressure: 74.17 +/- 3.42 vs TsV 151.8 +/- 17.82 mmHg*, *p < 0.05). TsV affects renal haemodynamics probably by a direct vasoconstrictor action leading to decreased renal flow. (c) 2005 Elsevier Ltd. All rights reserved.

The role of indomethacin and tezosentan on renal effects induced by Bothrops moojeni Lys49 myotoxin I

Renal changes determined by Lys49 myotoxin I (BmTx I), isolated from Bothrops moojeni are well known. The scope of the present study was to investigate the possible mechanisms involved in the production of these effects by using indomethacin (10 mu g/mL), a non-selective inhibitor of cyclooxygenase, and tezosentan (10 mu g/mL), an endothelin antagonist. By means of the method of mesenteric vascular bed, it has been observed that B. moojeni myotoxin (5 mu g/mL) affects neither basal perfusion pressure nor phenylephrine-preconstricted vessels. This fact suggests that the increase in renal perfusion pressure and in renal vascular resistance did not occur by a direct effect on renal vasculature. Isolated kidneys from Wistar rats, weighing 240-280 g, were perfused with Krebs-Henseleit solution. The infusion of BmTx-I increased perfusion pressure, renal vascular resistance, urinary flow and glomerular filtration rate. Sodium, potassium and chloride tubular transport was reduced after addition of BmTx-I. Indomethacin blocked the effects induced by BmTx-I on perfusion pressure and renal vascular resistance, however, it did not revert the effect on urinary flow and sodium, potassium and chloride tubular transport. The alterations of glomerular filtration rate were inhibited only at 90 min of perfusion. The partial blockade exerted by indomethacin treatment showed that prostaglandins could have been important mediators of BmTx-I renal effects, but the participation of other substances cannot be excluded.The blockage of all renal alterations observed after tezosentan treatment support the hypothesis that endothelin is the major substance involved in the renal pathophysiologic alterations promoted by the Lys49 PLA(2) myotoxin I, isolated from B. moojeni. In conclusion, the rather intense renal effects promoted by B. moojeni myotoxin-I were probably caused by the release of renal endothelin, interfering with the renal parameters studied. (c) 2006 Elsevier Ltd. All rights reserved.

Avaliação clínica e microbiológica das condições de saúde oral dos receptores de transplante renal do Hospital Universitário Onofre Lopes, Natal RN

Introduction: The chronic immunosuppression promotes the development of changes in the oral cavity of the kidney transplant recipients (KTR), however with the exception of gingival overgrowth, little is known regarding the prevalence of oral lesions in this population. Objective: To evaluate the prevalence of clinical and microbiological conditions of the oral cavity of the recipients of kidney transplantation and the associated factors. Methods: This was a cross-sectional study which examined 96 clinical KTR and experimental where collected saliva stimulated them to identify Candida sp. Data collection consisted of evaluation stomatologic, socio-demographic, clinical aspects of transplantation, condition of oral hygiene and dental caries, yonder to questions about knowledge of oral alteration after transplantation. Results: Of the total, 66.7% of KTR had some type of oral manifestation. The most common was saburral tongue, followed by gingival overgrowth, with both oral manifestations related to gender and concomitant use of cyclosporine and nifedipine (p <0.05). Tacrolimus showed a protective effect for gingival overgrowth (OR = 0.13). The oral hygiene was associated with saburral tongue(p = 0.03) and severity of gingival overgrowth (p = 0.0001). Oral candidiasis was diagnosed in 17.7% of patients and Candida albicans was isolated most frequently in the saliva of RTR with a colonization of 58.3%. The average DMF-T increased with age. The method of oral hygiene was most used brush and toothpaste to 61.5%. Changes in the oral cavity was seen in 54.2% of KTR, citing as the main growth and gingival ulcers. Instructions for oral hygiene after transplantation were neglected for 61.5% of RTR. Dry mouth and halitosis were reported in 30.2% and 36.5% respectively. Conclusions: More the half of the KTR had at least one injury of the mouth, the immunosuppressive drugs and oral hygiene are associated with these alterations. Prospective cohort studies are needed to elucidate the relationship between oral manifestations and levels of drug and risk of oral manifestations occur over time. The kidney transplant recipients showed to be aware of oral alterations occurred after transplantation and uninformed about the oral hygiene instructions. With regard to hygiene, the incidence of caries was considered high, conditions of risk were identified and improvements in primary attention should be encouraged and reflected in the monitoring of renal transplant