Renal Pathology in Portuguese HIV-Infected Patients

HIV-infected patients may be affected by a variety of renal disorders. Portugal has a high incidence of HIV2 infection and a low prevalence of HIV-infected patients under dialysis treatment. The aim of this study was to characterise the type of renal disease in Portuguese HIV-infected patients and to determine if HIV2 infection is associated to renal pathology. Only 60 of the 5158 HIV-infected patients followed in our hospital underwent renal biopsy. Clinical and laboratory data and the type of renal disease were reviewed. Male gender was predominant (76.7%), as was Caucasian race (78.3%). Mean age was 37.9±10.6 years. The majority had criteria for AIDS, 66% were on combined antiretroviral therapy and 18.3% were on dialysis. The predominant lesions were immunecomplex glomerulonephritis (n=19), tubulointerstitial nephropathy (n=12), focal segmental glomerulosclerosis(n=11), followed by HIVAN (n=8). Other patterns(amyloidosis, vasculitis, minimal change lesion) were observed. Only three patients were HIV2 infected, and presented diabetic nephropathy, acute tubular necrosis and tubulointerstitial nephritis. No correlations between clinical findings and renal pathology were found. In conclusion, renal disease in HIV patients has a broad spectrum, and renal biopsy remains the gold standard for establishing the diagnosis and guide treatment. Renal disease is not frequent in HIV2-infected patients, and, when present, is probably not directly associated with HIV infection.

Impact of Renal Dysfunction on Liver Transplantation: a Retrospective Study in 708 Orthotopic Liver Transplant Recipients

Renal dysfunction often complicates the course of orthotopic liver transplant recipients and is associated with increased morbid -mortality. The aims of this study were to determine the incidence of chronic renal disease and its impact on patient survival. Clinical data included age, gender and weight,aetiology of hepatic failure, presence of diabetes,hypertension, hepatitis B and C infection, renal dysfunction pretransplant and immunosuppression. Laboratory data included serum creatinine at days 1, 7, 21, month 6, 12 and yearly. The glomerular filtration rate was determined by Cockcroft-Gault equation. We studied retrospectively from September 1992 to March 2007 708 orthotopic liver transplant recipients. Mean age 44±12.6 years, 64% males, 17% diabetic, 18.8% hypertensive, 19.9% with hepatitis C and 3.8% hepatitis B. Renal dysfunction pretransplant was known in 21.6%. Mean follow-up was 3.6 years. Mean transplant survival 75% at 12 months. 154 patients died. Univariate and multivariate analyses were performed and a p<0.05 was considered significant. Acute kidney injury occurred in 33.2%. Chronic kidney disease stage 3 was observed in 34.3%,stage 4 in 6.2% and stage 5 in 5.1%. At the time of this study, 46.4% were on Cyclosporine A, 44.7% on tacrolimus and 8.9% on sirolimus. Using multivariate analysis, renal dysfunction was correlated with renal dysfunction pre -orthotopic liver transplant (p<0.001), acute kidney injury (p<0.001), haemodialysis development (p<0.001), and inversely correlated with the use of mycophenolate mophetil (p<0.001); mortality was positively correlated with renal dysfunction pretransplant (p=0.03),chronic kidney disease stage 4 (p=0.001), chronic kidney disease stage 5 (p<0.001) and inversely correlated with the use of tacrolimus (p=0.006). In conclusion orthotopic liver transplant recipients are disposed to renal complications that have a negative impact on survival of these patients.

De Novo Hypertension and Decline of Renal Function in a Young Woman with Systemic Lupus Erythematosus and Antiphospholipid Syndrome

Antiphospholipid syndrome nephropathy and lupus nephritis have similar clinical and laboratory manifestations and achieving the accuracy of diagnosis required for correct treatment frequently necessitates a kidney biopsy. We report the case of a 29-year-old woman referred to the nephrology service for de novo hypertension, decline of renal function and proteinuria. She had had systemic lupus erythematosus and antiphospholipid syndrome since the age of 21 and was taking oral anticoagulation. Two weeks later, after treatment of hypertension and achievement of adequate coagulation parameters, a percutaneous renal biopsy was performed. The biopsy revealed chronic lesions of focal cortical atrophy, arterial fibrous intimal hyperplasia and arterial thromboses, which are typical features of antiphospholipid syndrome nephropathy. We describe the clinical manifestations and histopathology of antiphospholipid syndrome nephropathy and review the literature on renal biopsy in patients receiving anticoagulation.

Competências de gestão para a função de Enfermeiro Gestor

O conceito de competências tem sido amplamente empregado nas práticas de Gestão de Recursos Humanos. Quando outras áreas, como a Enfermagem, concilia a prestação de cuidados com a própria gestão do seu capital humano, torna-se preponderante efetuar um cruzamento dos dois mundos. Este artigo pretende identificar as competências de gestão para a função de Enfermeiro Gestor, ou seja, para aqueles que exercem funções de gestão nas organizações, com base numa revisão de literatura. Foi possível identificar 189 competências, que se agruparam nas categorias: Gestão de recursos humanos, Competências interpessoais, Organização e planeamento, Competências técnicas de enfermagem, Comunicação, Preocupação pela qualidade, Conhecimento de políticas de saúde, Resiliência e motivação, Liderança, Competências técnicas de gestão, Resolução de problemas, Iniciativa, Pensamento crítico, Tecnologias de informação e Comunicação, Ética, Adaptação à mudança, Trabalho em equipa e Autonomia. Posteriormente, efetuou-se uma comparação das competências identificadas, com um estudo de referência publicado em 2010 pelo International Council of Nurses (ICN).

Análise da estrutura e da função da proteína morfogenética RodZ de Bacillus subtilis

Resumo: RodZ é um componente do sistema morfogenético das células bacterianas. É uma proteína transmembranar que localiza em bandas ao longo do eixo longitudinal da célula. Em Bacillus subtilis, RodZ consiste numa porção citoplasmática, RodZn, e em uma parte extra-citoplasmática, RodZc. RodZn contém um domínio em helixturn- helix (HTH), enquanto que RodZc pode ser dividido num domínio coiled-coil e num domínio terminal C, de função desconhecida. Um segmento transmembranar (TM) único separa RodZn de RodZc. A eliminação de rodZ causa alongamento do nucleóide e leva à produção de células polares nucleadas. Aqui, mostramos que RodZn é estruturado, estável e em hélice α. Descobrimos que as substituições Y32A e L33A na suposta hélice de reconhecimento (3) do motivo HTH, bem como as substituições Y49A e F53A, fora do motivo HTH (4), causam divisão assimétrica, mas apenas as últimas levam à deslocalização sub-celular de RodZ. Sugerimos que as hélices 3 e 4 são utilizadas para uma interacção proteína-proteína ou proteína- DNA essencial para divisão celular enquanto que 4 deve contactar um componente do citosqueleto, possivelmente MreB, uma vez que a correcta localização sub-celular de RodZ depende desta proteína. Em todos os mutantes as células polares são anucleadas, pelo que concluímos que o alongamento do nucleóide não é um prérequisito para divisão assimétrica. RodZc é largamente não estruturado mas com conteúdo de folha , sendo estabilizado pelo domínio coiled-coil. Mostramos uma relação homóloga entre RodZc e a bomba de transporte Na+/Ca2+ NCX1 e identificámos dois resíduos no domínio C, G265 e N275, essenciais para a manutenção da forma celular. Estes resíduos fazem parte de um motivo em gancho que pode actuar como um local de interacção com um ligando desconhecido. RodZn e RodZc são monoméricos em solução. Contudo, na membrana, RodZ interage consigo própria num sistema de dois híbridos (Split-Ubiquitin) em levedura, sugerindo que possa formar multímeros in vivo.-----------ABSTRACT: RodZ is a transmembrane component of the bacterial core morphogenic apparatus. RodZ localizes in bands long the longitudinal axis of the cell, and it is though to functionally link the cell wall to the actin cytoskeleton. In Bacillus subtilis, RodZ consists of a cytoplasmic moiety, RodZn, and an extracytoplasmic moiety, RodZc. RodZn contains a predicted helix-turn-helix domain, whereas RodZc is thought to contain a coiled-coil region and a terminal C domain of unknown function. A single transmembrane domain separates RodZn from RodZc. Deletion of rodZ causes elongation of the nucleoid and leads to the production of polar minicells containing DNA. Here, we have studied the structure and function of RodZn and RodZc. We show that RodZn is a stable, folded, -helical domain. We discovered that the Y32A and L33A substitutions within the presumptive recognition helix (3) of the HTH motif, as well as the Y49A and F53A substitutions outside of the HTH motif (in 4) cause asymmetric cell division. However, only the substitutions in 4 cause sub-celular delocalization of RodZ. We suggest that 3 and 4 are used for a protein-protein or protein-DNA interaction important for cell division, whereas 4 is likely to contact a cytoskeletal component, presumably MreB. The polar cells formed by all the mutants are anucleate. We conclude that nucleoid elongation is not a prerequisite for asymmetric division. RodZc appears to be a largely unstructured domain, with some -sheet content, and is stabilized by the coiled-coil region. We show a homology relationship between RodZc and the NCX1 Na+/Ca2+ transporter and we found two residues within the C domain, G265 and N275, that are important for cell shape determination. These residues are predicted to be essential determinants of a claw-like motif, which may act as a binding site for an unknown ligand. Both the isolated RodZn and RodZc proteins are monomeric in solution. However, because full-length RodZ interacts with itself in a split-ubiquitin yeast two-hybrid assay, we suggest that it may dimerize or form higher order multimers in vivo.

Diabetes Mellitus and Renal Disease: When to Perform a Renal Biopsy?

Background: Several studies suggest that nondiabetic renal disease (NDRD) is common in patients with diabetes mellitus. The aim of this analysis of renal biopsies in diabetic patients was (a) to assess the prevalence and type of NDRD and (b) to identify its clinical and laboratory predictors. Methods: This retrospective study analysed clinical and laboratory data and biopsy findings in diabetic patients observed by a single pathologist over the past 25 years. Based on biopsy findings, patients were categorised as (i) isolated diabetic nephropathy,(ii) isolated NDRD and (iii) NDRD superimposed on diabetic nephropathy. Results: Of the 236 patients studied, 60% were male and the mean age was 56.3 (±14.2) years. Of these, 91% had known diabetes mellitus at the time of biopsy (13% type 1 and 87% type 2). Isolated diabetic nephropathy was found in 125 (53%), isolated NDRD in 89 (38%) and NDRD superimposed on diabetic nephropathy in 22 (9%) patients. The main indication for biopsy in the three groups was nephrotic proteinuria. Patients with isolated NDRD and NDRD superimposed on diabetic nephropathy presented acute deterioration of renal function more frequently (p<0.001) and had more microhaematuria(p<0.001) as indications for renal biopsy. Focal segmental glomerulosclerosis and membranous nephropathy were the most frequent diagnoses in patients with NDRD. Patients with isolated diabetic nephropathy were younger (p=0.02), presented a longer duration of diabetes mellitus (p<0.001) and had more frequent retinopathy (p<0.001). The prevalence of microhaematuria was higher in patients with isolated or superimposed NDRD (p=0.01). Conclusion: The prevalence of NDRD (either isolated or superimposed on diabetes mellitus) is remarkably frequent in diabetic patients in whom nephrologists consider renal biopsy an appropriate measure. Predictors of NDRD were older age, shorter duration of diabetes mellitus, absence of retinopathy and presence of microhaematuria.

Leflunomide and Polyomavirus-Associated Nephropathy in Renal Transplant

Polyomavirus nephropathy is a major complication in renal transplantation, associated with renal allograft loss in 14 to 80% of cases. There is no established treatment, although improvement has been reported with a variety of approaches. The authors report two cases of polyomavirus infection in renal allograft recipients. In the first case, a stable patient presented with deterioration of renal function, worsening hypertension and weight gain following removal of ureteral stent placed routinely at the time of surgery. Ultrasound examination and radiology studies revealed hydronephrosis due to ureteral stenosis. A new ureteral stent was placed, but renal function did not improve. Urinary cytology revealed the presence of decoy cells and polyomavirus was detected in blood and urine by qualitative polymerase chain reaction. Renal biopsy findings were consistent with polyomavirus -associated nephropathy. In the second case, leucopaenia was detected in an asymptomatic patient 6 months after transplantation. Mycophenolate mophetil dosage was reduced but renal allograft function deteriorated, and a kidney biopsy revealed polyomavirus -associated nephropathy, also with SV40 positive cells. In both patients immunosuppression with tacrolimus was reduced, mycophenolate mophetil stopped and intravenous immune globulin plus ciprofloxacin started. As renal function continued to deteriorate, therapy with leflunomide (40 mg/day) was associated and maintained during 5 and 3 months respectively. In the first patient, renal function stabilised within one month of starting leflunomide and polymerase chain reaction was negative for polyomavirus after 5 months. A repeated allograft biopsy 6 months later showed no evidence of polyomavirus nephropathy. In the second patient, polyomavirus was undetectable in blood and urine by polymerase chain reaction after 3 months of leflunomide treatment, with no evidence of polyomavirus infection in a repeated biopsy 6 months after beginning treatment.

Peritubular Capillaries C4d Deposits in Renal Allograft Biopsies and Anti HLA I/II Alloantibodies Screening. Incidence and Clinical Importance

Aim: To characterise clinically the patients with C4d in peritubular capillaries deposits (C4dPTCD) and/or circulating anti-HLA class I/II alloantibodies. To determine the correlation between positive C4dPTCD and circulating anti-HLA class I/II alloantibodies during episodes of graft dysfunction. Subjects and Methods: C4d staining was performed in biopsies with available frozen tissue obtained between January 2004 and December 2006. The study was prospective from March 2005, when a serum sample was obtained at the time of biopsy to detect circulating anti-HLA class I/II alloantibodies. Results: We studied 109 biopsies in 86 cadaver renal transplant patients. Sixteen of these (14.7%) presented diffuse positive C4dPTCD. There was a 13.5% rate of +C4dPTCD incidence within the first six months of transplantation and 16% after six months (p>0.05). Half of the +C4dPTCD in the first six months was associated with acute humoral rejection. After six months, the majority of +C4dPTCD (n=7/8) was present in biopsies with evidence of interstitial fibrosis/tubular atrophy and/or transplant glomerulopathy. The C4dPTCD was more frequent in patients with positive anti-HCV antibodies(p<0.0001), a previous renal transplant (p=0.007), and with a panel reactivity antibody (PRA) ≥ 50%(p=0.0098). The anti-HCV+ patients had longer time on dialysis (p=0.0019) and higher PRA(p=0.005). Circulating anti-HLA I/II alloantibodies were screened in 46 serum samples. They were positive in 10.9% of samples, all obtained after six months post transplant. Circulating alloantibodies were absent in 92.5% of the C4d negative biopsies. Conclusion: We found an association between the presence of C4dPTCD and 2nd transplant recipients,higher PRA and the presence of anti-HCV antibodies. The presence of HCV antibodies is not a risk factor for C4dPTCD per se, but appears to reflect longer time on dialysis and presensitisation. In renal dysfunction a negative alloantibody screening is associated with a reduced risk of C4dPTCD (<10%).

C4d Detection in Renal Allograft Biopsies: Immunohistochemistry vs. Immunofluorescence

Introduction. Peritubular capillary complement 4d staining is one of the criteria for the diagnosis of antibody-mediated rejection, and research into this is essential to kidney allograft evaluation. The immunofluorescence technique applied to frozen sections is the present gold-standard method for complement 4d staining and is used routinely in our laboratory. The immunohistochemistry technique applied to paraffin-embedded tissue may be used when no frozen tissue is available. Material and Methods. The aim of this study is to evaluate the sensitivity and specificity of immunohistochemistry compared with immunofluorescence. We describe the advantages and disadvantages of the immunohistochemistry vs. the immunofluorescence technique. For this purpose complement 4d staining was performed retrospectively by the two methods in indication biopsies (n=143) and graded using the Banff 07 classification. Results. There was total classification agreement between methods in 87.4% (125/143) of cases. However, immunohistochemistry staining caused more difficulties in interpretation, due to nonspecific staining in tubular cells and surrounding interstitium. All cases negative by immunofluorescence were also negative by immunohistochemistry. The biopsies were classified as positive in 44.7% (64/143) of cases performed by immunofluorescence vs. 36.4% (52/143) performed by immunohistochemistry. Fewer biopsies were classified as positive diffuse in the immunohistochemistry group(25.1% vs. 31.4%) and more as positive focal (13.2% vs. 11.1%). More cases were classified as negative by immunohistochemistry (63.6% vs. 55.2%). Study by ROC curve showed immunohistochemistry has a specificity of 100% and a sensitivity of 81.2% in relation to immunofluorescence (AUC: 0.906; 95% confidence interval: 0.846-0.949; p=0.0001). Conclusions. The immunohistochemistry method presents an excellent specificity but lower sensitivity to C4d detection in allograft dysfunction. The evaluation is more difficult, requiring a more experienced observer than the immunofluorescence method. Based on these results, we conclude that the immunohistochemistry technique can safely be used when immunofluorescence is not available.

A Rare Obstetric Outcome in Uterus Didelphys with Obstructed Hemivagina and Ipsilateral Renal Agenesis

Background: The unique clinical syndrome of uterus didelphys, obstructed hemivagina, and ipsilateral renal anomaly is very rare and can be quite difficult to recognize because of the enormous heterogeneity in its clinical presentation. There are few long-term reports of the reproductive performance of women with this syndrome following treatment, or about the location of subsequent pregnancies. Case: A case in which two spontaneous pregnancies occurred alternatively in both hemiuteri: one despite a previous ipsilateral large hematometra and hematocolpos and the other, 8 years after, simultaneously with contralateral hematometra and hematocolpos(because of vaginal restenosis), is reported. Drainage of hematocolpos was performed at 14 weeks of pregnancy with immediate pain relief. Results: Pregnancy proceeded without complications. Eight month after delivery, a vaginoplasty was performed by excising the longitudinal vaginal septum, and marsupializing the vaginal cuff. Conclusions: This case highlights the importance of a correct and early diagnosis of developmental anomalies of the urogenital tract, as well as how a conservative approach in a Mullerian anomaly with unilateral obstruction led to two successful pregnancies occurring alternatively in the unaffected and in the previously blocked side. This is additional information supporting that every effort should be made to preserve the obstructed uterus.

Implicações da certificação pela NP 4427:2004 na função recursos humanos

Este estudo tem como principal objetivo compreender as mudanças na função recursos humanos após a certificação do sistema de gestão de recursos humanos de uma empresa no âmbito da Norma Portuguesa 4427:2004 – “Sistemas de gestão de recursos humanos – requisitos”. Neste sentido, foi realizada uma abordagem teórica à evolução da função recursos humanos, apresentada a NP 4427:2004 e a contextualização teórica e normativa das práticas de gestão de recursos humanos desenvolvidas nesse âmbito. De forma a dar resposta à questão de pesquisa foi utilizada uma metodologia qualitativa, com recurso ao estudo de caso único numa empresa portuguesa certificada no âmbito da NP 4427:2004. No processo de recolha de dados recorremos à análise documental e à realização de entrevistas aos treze colaboradores vinculados à empresa desde data anterior à certificação. Os resultados sugerem mudanças ao nível da atuação da gestão de recursos humanos na empresa que, com a implementação e certificação pela NP 4427:2004, se tornou mais estratégica e dinamizadora de práticas de recursos humanos sistematizadas e preocupadas com o desenvolvimento das pessoas. Depois de apresentados e discutidos os resultados, o estudo apresenta também sugestões de pesquisa futura sobre o tema da NP 4427:2004 e contributos práticos da investigação para a empresa objeto de estudo.

Função Sexual após Braquiterapia Prostática de Baixa Taxa de Dose

A braquiterapia prostática de baixa taxa de dose é considerada uma opção terapêutica adequada para o carcinoma da próstata. É habitualmente, apresentada como a melhor forma de preservar a função eréctil de entre os diversos tratamentos de carcinoma da próstata. Contudo, estudos recentes demonstram que, também a braquiterapia prostática pode, no longo prazo, provocar algum grau de disfunção eréctil (DE). As taxas de DE nas diversas séries publicadas, são muito variáveis. Os resultados da influência da dose de radiação, isoladamente (D90) ou quando incidindo sobre o feixe neurovascular ou o bulbo são contraditórios. O tipo de isótopo utilizado não tem qualquer influência sobre a DE. No entanto factores como a idade, a função eréctil pré-tratamento, a diabetes, a utilização de radioterapia externa adjuvante e/ou hormonoterapia neoadjuvante podem condicionar os resultados obtidos. Otratamento da disfunção eréctil deve ser efectuado com inibidores da fosfodiesterase, obtendo-se boas taxas de resposta. Podem surgir outras alterações da função sexual, nomeadamente, hematospermia, dor durante o orgasmo e alteração da intensidade do orgasmo.

Review of genitourinary tuberculosis with focus on end-stage renal disease

Tuberculosis (TB) is a current public health problem, remaining the most common worldwide cause of mortality from infectious disease. Recent studies indicate that genitourinary TB is the third most common form of extra-pulmonary disease. The diagnosis of renal TB can be hypothesized in a non-specific bacterial cystitis associated with a therapeutic failure or a urinalysis with a persistent leukocyturia in the absence of bacteriuria. We report on the case of a 33-year-old man who presented on admission end stage renal disease (ESRD) secondary to renal TB and a past history of pulmonary TB with important radiologic findings. The diagnosis was based on clinical findings despite all cultures being negative. Empiric treatment with tuberculostatic drugs was started and the patient became stable. He was discharged with no symptom, but without renal function recovery. He is on maintenance hemodialysis three times a week. TB is an important cause of kidney disease and can lead to irreversible renal function loss.