Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment

Mycobacterium haemophilum is a slow-growing nontuberculous mycobacterium that can cause disease in both immunocompetent and immunocompromised patients. The most common clinical presentations of infection are the appearance of suppurative and ulcerated skin nodules. For the diagnosis, samples collected from suspected cases must be processed under the appropriate conditions, because M. haemophilum requires lower incubation temperatures and iron supplementation in order to grow in culture. In this case report, we describe the occurrence of skin lesions in a kidney transplant recipient, caused by M. haemophilum, associated with acupuncture treatment. The diagnosis was established by direct smear and culture of material aspirated from cutaneous lesions. Species identification was achieved by characterization of the growth requirements and by partial sequencing of the hsp65 gene. The patient was successfully treated with clarithromycin and ciprofloxacin for 12 months. Considering that the number of patients receiving acupuncture treatment is widely increasing, the implications of this potential complication should be recognized, particularly in immunosuppressed patients.

Conversion to sirolimus in kidney-pancreas and pancreas transplantation

Reports on the use of sirolimus (SRL) in pancreas transplantation are still limited. The aim of this study was to evaluate the outcome of SRL conversion in pancreas transplant patients. Among 247 patients undergoing simultaneous kidney-pancreas or solitary pancreas transplantation, 33 (13%) were converted to SRL. The reasons for conversion were calcineurin inhibitors (CNI) nephrotoxicity (n = 24; 73%), severe neurotoxicity owing to CNI (n = 1; 3%), severe and/or recurrent acute rejection episodes (n = 7; 21%), gastrointestinal (GI) side effects of mycophenolate mofetil (MMF; n = 5; 15%), and hyperglycemia (n = 4; 12%). Before conversion, all patients were maintained on a CNI, MMF, and low-dose steroids. They were gradually converted to SRL associated with either CNI or MMF withdrawal. Sixty-three percent (n = 15) of patients who were converted owing to CNI nephrotoxicity, showed stable or improved renal function. At 12 months after conversion, serum creatinine levels were significantly decreased in this group (2.2 +/- 0.5 vs 1.6 +/- 0.3 mg/dL; P = .001) and C-peptide values increased (2.9 +/- 1.1.1 vs 3.1 +/- 1.3 nmol/L; P = .018). The only patient with leucoencephalopathy showed improved neurologic status after SRL conversion. All patients converted to SRL because of GI side effects of MMF showed improvements, and none of those converted because of hyperglycemia experienced improvement. There were no episodes of acute rejection after conversion. We concluded that conversion to SRL in pancreas transplantation should be considered an important alternative strategy, particularly for CNI nephrotoxicity and neurotoxicity, and in cases of severe diarrhea due to MMF.

Proteinuria in Transplant Patients Associated With Sirolimus

Sirolimus (SRL) is a potent immunosuppressive drug used in organ transplantation for prophylaxis of acute allograft rejection. Conversion from calcineurin inhibitors to SRL has become an important alternative in patients with chronic allograft nephropathy. Recently, some reports have described the appearance of proteinuria after the use of SRL. The aim of the present study was to describe the incidence of proteinuria in transplant recipients receiving SRL in our transplant center. We studied 78 patients receiving SRL either de novo or after conversion. Eighteen transplant recipients (23.1%) developed proteinuria after SRL treatment. Proteinuria was diagnosed at 11.2 +/- 2.1 months after the initiation of SRL; in eight patients (44.4%) it occurred in the first 6 months. The mean value of proteinuria was 2.6 +/- 0.6 g/24 hours. In 5 patients (27.8%), proteinuria reached nephrotic levels, and in 13 patients (72.2%) was associated with edema. Renal allograft biopsies were performed before conversion to SRL, and a new biopsy, after the appearance of proteinuria. The light microscopy of biopsies performed after the onset of proteinuria showed no specific glomerular changes, except in 2 cases wherein the diagnosis was focal segmental glomerulosclerosis. Immunofluorescence was negative in all cases. In conclusion, in this study proteinuria was observed in 21.3% of patients receiving SRL therapy either as de novo protocol or after conversion to SRL. Proteinuria occurred early after the initiation of SRL therapy and in these cases, withdrawal of SRL was associated with reversion of proteinuria.

No induction versus anti-IL2R induction therapy in simultaneous kidney pancreas transplantation: a comparative analysis

The optimal immunosuppressive regimen for simultaneous kidney pancreas transplantation (SKPT) is still not established. We conducted a study to compare the safety and efficacy of no induction versus anti-IL-2 receptor induction protocols in SKPT recipients receiving the same maintenance regimen.

METHODS

Sixty-three SKPT recipients were divided into two groups: no induction group (n = 42) and anti-IL-2 receptor induction group (n = 21). All patients were maintained on tacrolimus, mycophenolate mofetil, and prednisone. Primary endpoints were 1-year acute rejection incidence and patient and graft survivals.

RESULTS

Demographic characteristics were similar between the groups. Acute rejection incidence at 1 year was equal in both groups (28.6%). Kidney and pancreas allograft survival in the no induction group were 78.6% and 76.2%, and in the anti-IL-2R induction group, 81% and 71.4%, respectively (P = NS). Patient survival was also similar: 83.3% in the no induction versus 85.7% in the anti-IL-2R induction group. Deaths due to sepsis were higher in the anti-IL-2R induction group, albeit not significantly.

CONCLUSION

The use of a no-induction protocol in SKPT is safe and effective immunosuppression that also reduces transplantation costs.

Influence of pancreas transplantation alone on native renal function

Pancreas transplantation alone (PTA) has become an accepted treatment of nonuremic diabetic patients, when the risks of secondary complications of diabetes mellitus are greater than those of the surgical procedure and the posttransplant immunosuppression. As a decrease in native renal function is expected, we followed this parameter among patients who underwent PTA. From January 1997 through January 2005, we performed 69 PTA in 66 patients. All patients showed glucose hyperlability with hypoglycemic unawareness, or two or more diabetic complications as well as creatinine clearance (CrCl) > or = 45 mL/min. Immunosuppression was based on tacrolimus, mycophenolate mofetil and prednisone. Twenty-four hour CrCl were performed after all successful PTA. We divided patients in two groups according to the pretransplant CrCl: group 1, CrCl < or = 70 mL/min (n = 20) and group 2, CrCl > 70 mL/min (n = 25). The data were analyzed using Student's t-test (P < or = .05 was considered significant). Twenty-one patients were excluded from the analysis because of death (n = 5) or graft loss (n = 8) during the first year or follow-up shorter than 1 year (n = 8). The mean value of CrCl decreased 28.8% (85.0 +/- 31 versus 60.5 +/- 36 mL/min; P < .001). There was also a 39.3% reduction among group 1 subjects (P = .003), including 10 who displayed CrCl < or = 30 mL/min. There was also a 24.4% reduction among group 2 (P = .008), but no patient developed end-stage renal disease. In conclusion, native renal function decreased significantly after PTA, but was well tolerated among patients with CrCl > 70 mL/min. Patients with CrCl < 70 mL/min show a significant risk of worsened renal function.

Enteric conversion after bladder drained pancreas transplantation experience of 14 cases

The method of exocrine diversion in pancreas allograft continues to be controversial due to the advantages versus disadvantages of bladder versus enteric techniques. Bladder drainage (BD) exposes the patient to urological and metabolic problems that may require conversion to enteric drainage (ED). The purpose of this study was to review our initial experience of conversion from BD to ED for patients who underwent pancreas transplantation originally with bladder diversion. Among 114 pancreas transplantation performed with BD, from January 1996 to April 2003, 60 were simultaneous pancreas-kidney transplantation (SPKT), 35 were pancreas transplantation alone (PA), and 19 were pancreas after kidney transplantations (PAK). Twenty-three (20.2%) cases were excluded due to early death of the patient or the graft, yielding an analyses of 91 patients. Enteric conversion (EC) was performed in 14 (15.4%) patients with a mean follow-up of 15.7 months (range, 3-51 months) after transplantation including 8 (8.8%) SPKT, 4 (4.4%) PAK, and 2 (2.2%) PA. No surgical morbidity or mortality was observed related to EC. All patients had complete resolution of the initial problem with preservation of pancreatic function. EC represents an easy, safe procedure with low morbidity and mortality rates, representing the option of choice for patients with persistent urological or metabolic disturbances.

Lamivudine therapy for hepatitis B in renal transplantation

Antiviral therapies are associated with an increased risk of acute rejection in transplant patients. The aim of the present study was to evaluate the efficacy and safety of lamivudine therapy for hepatitis B virus (HBV) infection in renal transplant patients. Six patients were included in this study. They received 150 mg/day of lamivudine during a follow-up period of 24 months. The laboratory tests monitored were HBV DNA, HBsAg, HBeAg, ALT, gamma-GT, serum creatinine and blood cyclosporine levels. The HBV DNA became undetectable in four patients as early as in the third month of treatment. After six months, the viral load was also negative in the other two patients, and remained so until 18 months of follow-up. The medication was well tolerated with no major side effects. Lamivudine was safe and effective in blocking HBV replication in renal transplant patients without any apparent increase in the risk of graft failure for the 24-month period of study.

Reciprocal influences between ambulatorial peritoneal dialysis and pulmonary function

The aim of this study was to verify if dialysis solution volumes used in patients on continuous ambulatory peritoneal dialysis (CAPD) interfere with pulmonary function and if the pulmonary volumes interfere with the lymphatic absorption of the peritoneal cavity. We submitted 10 CAPD patients with a mean age of 48 +/- 18 years and on CAPD for 35 +/- 27 months to the following evaluations: first, measurement of the lymphatic absorption from the peritoneal cavity; second, measurement of the hydrostatic intraperitoneal pressure; and third, expirometry with the peritoneal cavity full of dialysis solution and empty. There were no differences between the expirometry results obtained with the peritoneal cavity full and empty of dialysis solution, and the results were in accordance with the prediction for this population. The values did not correlate with the peritoneal lymphatic absorption of the peritoneal cavity. The cumulative lymphatic absorption of the peritoneal cavity after 4 h dialysis solution permanence was 197 +/- 93 ml, and the hydrostatic intraperitoneal pressure was 13.9 +/- 2.8 column centimeters of water. Neither of these correlated with pulmonary volumes. In conclusion, CAPD did not interfere with the pulmonary function, nor did the pulmonary function influence the lymphatic absorption of the peritoneal cavity of these patients.

Baseline blood pressure and other variables influencing survival on haemodialysis of patients without overt cardiovascular disease

BACKGROUND

Age, diabetes and concomitant cardiovascular disease, recorded at the initiation of dialysis, allows the identification of patients with a high probability of early mortality. When all of these factors are taken into account the mortality rate of dialysis patients is still 3.5 times higher than for the general population. Information on the factors that increase the mortality of patients lacking the major cardiovascular risk factors is important because these are likely to be correctable, especially if detected early.

METHODS

We investigated prospectively the relevance of blood pressure and other variables recorded at the initiation of dialysis treatment on the survival of a group of 103 relatively young adult haemodialysis patients (mean age 44.3 years +/-13 SD), with a low prevalence of comorbidity and a median follow-up period of 79 months. Data were analysed by the Cox proportional regression model and survival curves were constructed by the Kaplan-Meier method.

RESULTS

Forty-four patients died, 20 (46%) of whom as a result of cardiovascular causes. Multivariate analysis showed that mortality was associated with age (P=0.0001), serum creatinine (P=0.005, negative association), left ventricular (LV) mass (P=0.003) and hypertension (P=0.03). Mortality was increased by 7% for each additional year of age, by 0.7% for each 1 g increase in LV mass, and was reduced by 23% for each additional mg/dl of serum creatinine. Hypertensive patients had a higher probability (x2.2) of dying compared with normotensive patients.

CONCLUSIONS

In addition to age and conditions of occult malnutrition, hypertension and LV hypertrophy, when present at the initiation of dialysis, play a major role in the mortality of low risk, relatively young dialysis patients. These potentially correctable factors should be actively sought and treated during the early stage of renal insufficiency to improve prognosis.

Pregnancy in women on chronic dialysis. A single-center experience with 17 cases

Successful pregnancy outcome is an uncommon occurrence in women requiring chronic dialytic treatment, and the most adequate dialysis therapy in the management of these pregnant patients has not been established. During the period 1988-1995, we studied the outcome of 17 pregnancies in dialyzed females, with an average age of 28.2 +/- 5.9 years (range: 18-38 years). Seven women had adequate urine volume (>800 ml/24 h). Five patients started dialysis after conception and the remaining 12 pregnancies were diagnosed after 6-72 months on dialysis. Fourteen women were maintained on hemodialysis (HD) and 3 on continuous ambulatory peritoneal dialysis (CAPD). The HD schedule was increased to 3 h 5-6 times weekly, and CAPD was increased to six 2-liter exchanges/day. Mean serum urea was 78.6 +/- 27.4 mg/dl (range 45-110); serum creatinine was 6.5 +/- 3.7 mg/dl (3.3-9.8 mg/dl); and hematocrit was 28.9 +/- 3.3 vol% (22-35 vol%). Anemia was partially controlled with rHuEpo in 8 patients. Significant problems were polyhydramnios in 7 cases (5 HD/2 CAPD), oligohydramnios in 1 (HD), gestational diabetes in 2 (CAPD), premature labor with spontaneous abortion at the 19th, 22nd and 28th weeks of gestation (2 HD/1 CAPD), hypertension in 8 (7 HD/1 CAPD), and sterile eosinophilic peritonitis in 1 case (CAPD). Mean gestational age at delivery in 14 successful pregnancies (12 HD/2 CAPD) was 32.3 +/- 2.6 weeks (27-36 weeks) and mean baby weight was 1,400.7 +/- 579.1 g (range 720-2,650 g). No congenital fetal abnormality was observed. Respiratory distress was observed in 6 infants, with 2 deaths (1 HD/1 CAPD) in the first week after delivery. In this study, successful pregnancies were reported in 70.6% of dialyzed women with uremia, with hemodialysis having a rate of fetal survival of 78.6% and CAPD with 33.3%.

Outcome of acute renal failure associated with cardiac surgery in infants

OBJECTIVE

To analyze the impact of acute renal failure (ARF) on the evolution of infants undergoing cardiac surgery.

METHODS

We assessed 15 infants undergoing cardiac surgery who developed (ARF). Their demographic, clinical and surgical data, and evolution were analyzed.

RESULTS

Their mean age was 4.4+/-4.0 months (8 days to 24 months). Twelve infants were males, and 4 patients already had ARF at surgery. The primary cause of ARF was immediate acute cardiac dysfunction in 10 infants, cardiac dysfunction associated with sepsis in 2 infants, and isolated sepsis in 3 infants. All children depended on mechanical ventilation during their postoperative period, 14 infants used vasoactive drugs, and 11 had an infectious process associated with ARF. Thirteen infants required dialytic treatment. Eleven infants developed oluguric ARF, and all had to undergo peritoneal dialysis; of the 4 patients with non-oliguric, 2 required dialysis, the main indication being hypervolemia. Of these 13 dialyzed infants, 4 died in the first 24 hours because of the severity of the underlying cardiac disease (mean urea level of 49+/-20 mg/dl). The mortality rate for the entire group was 60%, and it was higher among the patients with oliguria ARF (73% vs 25%, p<0. 001). The cause of death was acute cardiac dysfunction in 6 infants (early type-1 ARF) and sepsis in the 3 remaining infants (late type-2 ARF).

CONCLUSION

The mortality rate of ARF associated with cardiac surgery in infants was hight, being higher among children with oliguria; peritoneal dialysis was indicated due to clinically uncontrolled hypervolemia and not to the uremic hypercatabolic state.

[Causes and prognosis of acute renal failure in elderly patients]

The prolonged life span of populations is the obvious reason for an increasing proportion of elderly patients with acute renal failure (ARF). The role of age as a factor indicative of a poor prognosis is a matter of controversy.

OBJECTIVE

To evaluate this role we have analyzed the final outcome of elderly patients with ARF treated in our Nephrology Service.

MATERIAL AND METHODS

Among 361 ARF cases prospectively studied during a two-year period (January 1995 to December 1996), 130 (36%) occurred in patients over 70 years of age. Etiology, clinical course and prognosis were analyzed. The average age was 76.0 +/- 4.7 years, varying from 70 to 94 years; 84 patients (65%) were male, and surgical causes accounted for 51% of geriatric ARF.

RESULTS

The most frequent causes were: ischemic (volume depletion, arterial hypotension, and/or low cardiac output) in 48 patients (38%), sepsis in 40 (312%), nephrotoxic drugs in 46 (35%) and obstructive abnormalities in 10 (7.7%); in other 14 (11%) they were diagnosed more than a causal agent. Oliguria was present in 37. 2% (81 patients), and dialysis was needed in 50 patients (39%). The mortality in the population with age below 70 years was 43% and in the elderly patients was 53.8%; total mortality was similar in both groups of patients (p=0.085). Oliguria, need for dialysis, presence of surgical causes of ARF, and ARF acquired within the intensive care unit were associated with poor prognosis in elderly group.

CONCLUSION

We concluded that the percentile of elderly patients with ARF is elevated; they presented mortality about of 50%, and this is not superior to the observed in the youngest population; oliguria, dialysis need, ICU cares and surgery are factors of unfavorable prognostic in these patients.

Intraperitoneal pressure and hernias in children on peritoneal dialysis

Abdominal wall hernias have been increasingly recognized in patients on continuous ambulatory peritoneal dialysis (CAPD). They are also more frequent in children than in adults. The aim of this study was to determine the influence of intraperitoneal pressure (IPP) on the development of hernias in children on CAPD, and if there was a difference between IPP in children and adults. We studied 14 children aged 11.2 +/- 3.2 years, body weight 31.1 +/- 9.4 kg, who had undergone CAPD for 16.2 +/- 14.4 months. Also, 10 adults were studied, aged 48 +/- 18 years, body weight 62.4 +/- 13.9 kg, on the CAPD program for 35 +/- 27 months. The IPP was measured via a column of dialysate in the peritoneal dialysis line, immediately before the drainage of the peritoneal cavity. The pressure was measured with the patients in the supine position, at the level of the umbilical cicatrix with the zero point located on the mean axillary line. IPP was measured at inspiration and at expiration, and the mean of these two measurements was calculated. The children were divided in two groups: group 1 (n = 7) without hernias and group 2 (n = 7) with hernias (5 umbilical and 2 inguinal). The IPP of all children was 9.5 +/- 2.9 cm H2O. The IPP was 8.1 +/- 2.6 and 10.9 +/- 2.6 cm H2O in groups 1 and 2, respectively (P = 0.003). The instilled volume for test was similar in both groups. The IPP of the adults was 13.8 +/- 2.8 cm H2O, which was significantly greater than that of the children (P = 0.001). In conclusion, hernia is a common complication in children on CAPD and its prevalence is affected by IPP. Other associated factors may be the presence of anatomically weak sites in the abdominal wall of the children, since IPP is lower in children than in adults.

Effect of dialyser biocompatibility on recovery from acute renal failure after cadaver renal transplantation

BACKGROUND

It has been reported that patients with acute renal failure (ARF) requiring haemodialysis show an improved recovery of renal function when the dialysis treatment is performed using a biocompatible membrane rather than a bioincompatible membrane. However, most recent published human trials have not been able to confirm these findings.

METHOD

Over a 2-year period, we prospectively studied 53 patients with ARF after cadaver renal transplantation who required haemodialysis and randomized them into two treatment groups. One group underwent dialysis with a cuprophane membrane and the other group underwent haemodialysis with a more biocompatible membrane, polysulfone. All patients received an immunosuppressive regimen which included azathioprine, prednisone and cyclosporine.

RESULTS

There was no difference by patient characteristics or immunosuppressive regimen before acute tubular necrosis (ATN) recovery. In both groups the number of haemodialysis sessions required prior to the recovery of renal function (6.57+/-2.79 vs 6.05+/-2.40), the number of oliguric days (16.25+/-5.14 vs 14.40+/-4.67) and the number of hospital days (33.38+/-12.85 vs 30.10+/-11.00), were not statistically different. There was also no difference in long-term allograft outcome.

CONCLUSION

Our data demonstrate that the use of a more biocompatible membrane had no influence on the recovery from acute renal failure after renal transplantation.

[Reversal of hepatorenal syndrome after liver transplantation. Considerations about 3 patients]

Hepatorenal syndrome was observed in 25% of the patients with end stage liver disease. In this situation they stayed longer time in intensive unit treatment, hemodialysis. This evolution was observed in 67% of them with this complication after surgery. In this report we describe three patients with hepatorenal syndrome reversible after liver transplant. We define the form of management of these patients after surgery, regard treatment with cyclosporine A, only 72 h after surgery, without administration of aminoglycosides and amphoterycin. This good evaluation also depends of absence of arterial hypotension or infection episodes during and after surgery. It also depends of the good conditions of the implanted liver.

[Clinical profile of aged patients with severe aortic stenosis]

PURPOSE

To evaluate clinical symptoms and echocardiographic findings in elderly patients with severe aortic stenosis and possible gender differences.

METHODS

We studied 54 patients, 24 (44.5%) males and 30 (55.5%) females aged 80.7 +/- 5.2 years with severe aortic stenosis. The following variables were analyzed: presence of clinical manifestations (dyspnea, angina, and syncope) and echocardiographic indices (left ventricular [LV] dimensions, ejection fraction [EF], and mass index).

RESULTS

Dyspnea was the most frequent symptom with overall prevalence of 44%. EF was lower than 50% in only 2 patients. There were no gender differences in the prevalence of any of the clinical manifestations. Male patients had higher LV volumes (p < 0.05) and lower EF (p = 0.03).

CONCLUSION

The data showing dyspnea as the most common clinical manifestation; EF > 50%; lower LV volumes and greater EF in female patients suggest that the adaptive mechanisms to this condition may be different between the two sexes.

Arterial blood pressure and left ventricular hypertrophy in haemodialysis patients

OBJECTIVE

To test the hypothesis that there is an association between arterial blood pressure and left ventricular hypertrophy and patterns of ventricular geometry, defined echocardiographically, in a group of stable haemodialysis patients with a low prevalence of extrarenal diseases.

DESIGN AND METHODS

Patients with end-stage renal failure treated by regular haemodialysis (aged 44.3 +/- 12.9 years, n = 103, among whom 52 men and 23 blacks, dialysis duration 49.8 +/- 35.3 months) were subjected to echocardiographic evaluation (M-mode, bidimensional and Doppler) on the day preceding dialysis. The average of all predialysis blood pressure determinations during the 3 months preceding the tests (34-38 determinations in each patient) were used as baseline data. Univariate and multivariate tests were used to assess the main variables associated with echocardiographically defined cardiac alterations and with patterns of ventricular geometry.

RESULTS

The systolic blood pressure was significantly associated with the left ventricular mass index and was significantly and independently correlated with left ventricular hypertrophy, posterior wall hypertrophy, left ventricle dilation and increased relative wall thickness. Other significant correlations were between the haematocrit level and left ventricular hypertrophy and between age and altered systolic and diastolic functions. Concentric ventricular hypertrophy was observed only in patients with a history of hypertension, whereas the prevalence of normal geometry was higher in patients without a history of hypertension.

CONCLUSION

The systolic blood pressure is an important factor influencing the occurrence of left ventricular hypertrophy in haemodialysis patients and also affects the left ventricle geometry in this population.

Blood pressure influences the occurrence of complex ventricular arrhythmia in hemodialysis patients

We investigated the relationship between blood pressure and the occurrence of complex ventricular arrhythmias (multiform, couplets, or runs) as assessed by 48-hour Holter monitoring in 74 stable long-term hemodialysis patients (44.5 +/- 12 years old; 54% men; 74% whites; dialysis duration, 51.3 +/- 36.1 months; systolic pressure, 146.6 +/- 19.3 mm Hg; diastolic pressure, 89.2 +/- 12.1 mm Hg; prevalence of arterial hypertension, 33.8%). Systolic and diastolic pressures represented the average of all predialysis determinations during the 3 months preceding the tests. Hemodialysis was performed midway through the Holter monitoring period. M-mode and bidimensional echocardiograms and myocardial perfusion tests were also obtained from all patients. Complex arrhythmias were observed in 37 individuals (50%). Univariate analysis showed that systolic pressure (P < .001), diastolic pressure (P < .05), age (P < .001), left ventricular posterior wall thickness (P < .01), left ventricular mass index (P < .05), and ischemic alterations on myocardial perfusion tests (P < .005) were significantly associated with complex arrhythmias. With the use of a multivariate model (stepwise logistic regression analysis) only systolic pressure (P < .01) and age (P < .05) were independently associated with complex arrhythmias. Sex; angina; dialysis duration; New York Heart Association functional class; use of digitalis; plasma levels of creatinine, sodium, potassium, calcium, and phosphate; hematocrit; left ventricular fractional shortening; left ventricular diastolic diameter; and ST segment deviation were not correlated with complex arrhythmias. The severity and frequency of complex arrhythmias were not influenced by hemodialysis. At follow-up (5 to 80 months) 5 patients had died of sudden death, 4 of whom were hypertensive and older than 45 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of echocardiographic changes associated with hemodialysis and renal transplantation

Long-term hemodialysis has been reported to cause progression of left ventricular (LV) hypertrophy with a tendency toward asymmetric septal hypertrophy. Renal transplantation is believed to reverse some of these changes. The aim of this prospective study was to compare the effects of long-term hemodialysis and of successful renal transplantation on cardiac structure and function assessed by echocardiography. Fifty-three patients were submitted to two echocardiographic evaluations separated by a 30 +/- 8 month interval. At the first control, all patients were on hemodialysis; at the second, 36 patients remained on dialysis while 17 had been submitted to renal transplantation. Age (44 +/- 13 vs. 40 +/- 10 years), gender (male, 50% vs 53%), and duration of dialysis at the initiation of the study (43 +/- 34 vs. 47 +/- 32 months) were comparable in the 2 groups. The prevalence of LV hypertrophy were 83% (first control) and 69% (second control) in the dialysis group and 82% and 71% in the transplant group. Comparisons between the two periods within each group showed that hemodialysis was associated with a significant reduction of the E/A ratio (1.25 +/- 0.4 vs. 1.02 +/- 0.4, p < 0.001) and systolic (155 +/- 28 vs. 137 +/- 26 mm Hg, p < 0.001) and diastolic (94 +/- 21 vs. 84 +/- 16 mm Hg, p < 0.05) blood pressure, and no change in LV mass index (171 +/- 51 vs. 156 +/- 43 g/m2, NS). In the transplanted group, there were reductions in the E/A ratio (1.42 +/- 0.6 vs 1.10 +/- 0.4, p < 0.05) and in LV diastolic dimension (50 +/- 7 vs. 46 +/- 5 mm, p < 0.05), but not in systolic (155 +/- 27 vs. 152 +/- 31 mm Hg, NS) or diastolic (97 +/- 11 vs. 97 +/- 20 mm Hg, NS) blood pressure. The LV mass index also did not change significantly (157 +/- 51 vs. 133 +/- 31 g/m2, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty

Improvement in congestive heart failure and left ventricular function after dynamic cardiomyoplasty has been reported in patients with severe cardiomyopathies, but the long-term effects of this procedure remain unclear. In this investigation 31 patients undergoing cardiomyoplasty for treatment of idiopathic dilated cardiomyopathy were annually investigated with radionuclide scintigraphy, Doppler echocardiography, and right-sided heart catheterization. They were in New York Heart Association functional class III or IV before the operation. No hospital deaths occurred, but one patient with progressive heart failure required urgent heart transplantation 42 days after cardiomyoplasty. The other patients were followed up from 6 to 70 months (mean 25.6 months) and 12 patients died at late follow-up. Actuarial survivals were 86% at 1 year, 61.4% at 2 years, and 42.5% at 3 to 5 years of follow-up. Multivariate analysis of factors influencing outcome showed that long-term survival was significantly affected by preoperative functional class and pulmonary vascular resistance. Functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.7 in the surviving patients (p < 0.01). Furthermore, left ventricular ejection fraction improved from 19.8% +/- 3% to 23.9% +/- 7.2% (p < 0.01), and significant changes in stroke index, arterial pressure, pulmonary wedge pressure, and left ventricular stroke work index were also found at 6 months of follow-up. In the late postoperative period, the left ventricular ejection fraction tended to decrease and returned to preoperative levels at 5 years, whereas hemodynamic variables did not change significantly. Thus, despite the tendency of the left ventricular ejection fraction to decrease at late follow-up, the long-term course of these patients seems to be characterized by the maintenance of hemodynamic improvement. However, long-term survival after cardiomyoplasty is limited by the severity of the patient's condition before the operation.

[Transesophageal echocardiography in the study of vascular anastomosis in a patient with right lung transplantation]

A 46 years-old man was submitted to right orthotopic lung transplantation due to pulmonary emphysema. The transesophageal echocardiography was important in the evaluation of functional and morphological aspects of pulmonary vessels after this proceeding.

Beta-blocker infusion did not improve left ventricular diastolic function in myocardial infarction: a Doppler echocardiography and cardiac catheterization study

Left ventricular (LV) diastolic function changes after myocardial infarction. It has been suggested that beta blockers may improve diastolic function in hypertensive and heart failure patients. Doppler echocardiographic filling patterns and invasive hemodynamic indices have been used to analyze LV diastolic function. To determine the effect of beta blockers on LV diastolic function, we studied 32 patients with anterior wall myocardial infarction with a mean age of 53 years. Peak early and late flow velocities, peak early-to-late flow velocities ratio, pressure half time, diastolic filling period, isovolumic relaxation time, cardiac index, mean arterial pressure, wedge pressure, and systemic and pulmonary vascular resistance indices were obtained simultaneously before and after an intravenous infusion of 10 mg of atenolol. Cardiac index decreased from 4.27 +/- 0.97 to 3.19 +/- 0.91 l/min/m2 (p = 0.0001); mean arterial pressure decreased from 85 +/- 10 to 80 +/- 11 mmHg (p = 0.004); wedge pressure increased from 11 +/- 5 to 13 +/- 4 mmHg (p = 0.002); systemic vascular resistance index increased from 1586 +/- 409 to 1980 +/- 634 dyn.m2.s/cm5 (p = 0.0002); pulmonary vascular resistance index increased from 115 +/- 58 to 163 +/- 72 dyn.m2.s/cm5 (p = 0.0004); peak late flow velocity decreased from 64 +/- 15 to 49 +/- 14 cm/s (p = 0.0001); early-to-late ratio increased from 0.95 +/- 0.35 to 1.29 +/- 0.36 (p = 0.0001); diastolic filling period increased from 300 +/- 108 to 400 +/- 110 ms (p = 0.0001) and isovolumic relaxation time increased from 133 +/- 29 to 143 +/- 29 ms (p = 0.009). No significant changes were observed for peak early flow velocity and pressure half-time.(ABSTRACT TRUNCATED AT 250 WORDS)

Nephrotic syndrome associated with hepatointestinal schistosomiasis

Schistosomal nephropathy has long been related to the hepatosplenic form of schistosomiasis. In the last few years, 24 patients with hepatointestinal schistosomiasis and the nephrotic syndrome were studied. Aiming at evaluating a possible etiologic participation of schistosomiasis in the development of the nephropathy, this group was comparatively studied with a group of 37 patients with idiopathic nephrotic syndrome. Both groups had a different distribution of the histologic lesions. In the group with schistosomiasis there was a statistically significant prevalence of proliferative mesangial glomerulonephritis (33.3%), whereas in the control group there was prevalence of membranous glomerulonephritis (32.4%). On immunofluorescence, IgM was positive in 94.4% of the patients with schistosomiasis versus 55.0% in the control group (P < 0.01). In the group with schistosomiasis, 8 patients evidenced mesangial proliferative glomerulonephritis and 5, membranoproliferative glomerulonephritis. In both histological types immunofluorescence showed IgM and C3 granular deposits in the glomeruli. The data in this study suggests that mesangial proliferative and membranoproliferative glomerulonephritis, with glomerular granular IgM and C3 deposits, represent the renal lesions of the schistosomiasis associated nephropathy.

[Use of recombinant human erythropoietin in the treatment of anemia in hemodialyzed patients: a multicentric study]

Recombinant human erythropoietin (rHu-EPO) therapy was given to 25 patients undergoing long-term hemodialysis, for 12 weeks, in 5 Brazilian dialysis centers. The dose of rHu-EPO was given intravenously thrice weekly, initially at 50 Units/kg/dose. If the target hemoglobin concentration (10g/dL) was not achieved by four weeks the dose was increased to 75 and 100 Units/kg/dose. After 4 weeks hemoglobin concentration had achieved 10g/dL in only one patient, and, after 8 weeks, 10 patients (40% of all cases) had hemoglobin levels higher than the target concentration. After 12 weeks, the hemoglobin increased from 7.1 +/- 1.1 to 9.6 +/- 1.2 g/dL, the target hemoglobin concentration was achieved in 15 patients (60% of all cases). There was a significant (p < 0.05) increase in hematocrit (from 22 +/- 4 to 31 +/- 4 vol%), in body weight (from 55.03 +/- 12.24 to 56.16 +/- 12.86kg), and in serum phosphorus (from 5.85 +/- 2.02 to 6.82 +/- 2.34 mg/dL). There were no significant changes in blood pressure, serum levels of creatinine, of potassium, and of transferrin. Increase in blood pressure (in 3 patients), fever (in 2 patients), increase in the heparin dose needs (in 2 cases), and vascular access thrombosis (in 1 patient) were the most important adverse effects observed during rHu-EPO therapy. Thus, the anemia of chronic renal failure may be easily corrected with adequate amounts of recombinant human erythropoietin. Attention must be paid to some adverse effects during reversal of anemia.

Role of arterial hypertension in left ventricle hypertrophy in hemodialysis patients: an echocardiographic study

To assess the role of arterial hypertension in left ventricle (LV) hypertrophy among hemodialysis patients, echocardiographic evaluation was performed in 10 hypertensive and 13 normotensive hemodialysis subjects matched for age, sex, race, duration of dialysis treatment and degree of interdialytic volume expansion. We excluded from the latter group patients with previous hypertension since hypertensive heart disease may persist after adequate blood pressure control. We also studied 17 normal controls and 10 non-uremic patients with essential hypertension. Comparisons between the two uremic groups showed that the hypertensive patients had a higher mass index (222 +/- 74 x 108 +/- 26, p = 0.0001) and posterior wall thickness (12 +/- 2 x 9 +/- 2, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 5.8 +/- 1, p = 0.0001). There were no significant echocardiographic differences between normal controls and normotensive uremics. In contrast, compared to controls, hypertensive uremic patients showed an increased LV mass index (222 +/- 74 x 83 +/- 21, p = 0.0001) and posterior wall thickness (12 +/- 2 x 7 +/- 1, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 6.5 +/- 1.1, p = 0.001), characterizing concentric hypertrophy. They also had ventricular dilation with larger LV dimensions than in controls (53 +/- 5 x 47 +/- 4, p = 0.004). In patients with essential hypertension, the mass index (135 +/- 22), wall thickness (11 +/- 1) and LV radius/wall thickness ratio (4.3 +/- 0.7) significantly differed (p = 0.0001) from those in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Do mitral valve components have the same predictive value in percutaneous balloon mitral valvuloplasty? Doppler echocardiography study]

PURPOSE

To evaluate the predictive value of mitral valve components in percutaneous balloon mitral valvuloplasty (PBMV).

METHODS

53 patients undergoing PBMV were submitted to an echocardiographic analysis of mitral valve in order to note mobility, thickness, calcification of leaflets and subvalvar apparatus (SV). Mitral valve area (VA) before and after PBMV was obtained using continuous wave Doppler. Patients were divided in group 1 (VA enhance inferior to 50%) and 2 (VA enhance equal or superior to 50%) and subgroups A (VA post PBMV inferior to 1.5 sqcm) and B (VA post PBMV equal or superior to 1.5 sqcm). Correlations between the score of each component of mitral valve and the results were established.

RESULTS

Concerning to the total score, there was no significant difference between the groups and subgroups. Differences were significant when SV was analysed separately (p less than or equal to 0.001). VA average in patients with SV compromising grade 3 (1.28 +/- 0.26 sqcm) was inferior to those with grade 1 or 2 (p less than or equal to 0.001).

CONCLUSION

SV has a higher predictive value in the success of PBMV.

[Arterial hypertension in students of the great São Paulo area]

In 1,000 students from Great São Paulo First Degree Schools, from 6 to 18 years old, we studied: age, sex, race, weight, height, left arm circumference, blood pressure, pulse and family history of hypertension. Of these 550 were female and 450 male, with predominance of caucasians in both sexes (83.7%). The conclusions of this study were: until 9 years old the blood pressure was similar in both sexes. As the school girls grow up earlier, their blood pressure rose first, but after 16 years this fact changed: 126 +/- 3.5 x 76 +/- 2.8 in males and 115 +/- 2.0 x 74 +/- 1.9 in females. Students with a family history of hypertension had higher blood pressure than students without and the prevalence of systolic and diastolic hypertension was higher in the first group: 12.2 and 13.8 to 4.7 and 3.8% respectively. Diastolic blood pressure was dominant in only in males Negros. The prevalence of systolic and diastolic hypertension was 6.9% in these 1,000 students.

Left ventricular function changes after cardiomyoplasty in patients with dilated cardiomyopathy

Dynamic cardiomyoplasty has been reported in the treatment of severe myocardial failure. In this investigation significant improvement of left ventricular function with dynamic cardiomyoplasty was demonstrated in patients with dilated cardiomyopathy or Chagas' disease for more than 1 year of follow-up. Thirteen patients with advanced heart failure who were in New York Heart Association class III or IV were operated on. There were no operative deaths. Patients were followed up for a mean of 11.5 months, and two patients died during the late follow-up period. Five of nine patients observed long term are in New York Heart Association class I, three in class II, and one in class III. At 3 months of follow-up, Doppler echocardiography demonstrated that left ventricular segmental wall shortening increased from 11.4% +/- 2.3% to 16.4% +/- 3.9% (p less than 0.01), and left ventricular stroke volume from 23.9 +/- 5.7 to 34.4 +/- 10 ml (p less than 0.01). Radioisotopic left ventricular ejection fraction improved from 20.9% +/- 3.3% to 25.4% +/- 7.7% (p = 0.06), and its better increases occurred in patients with lesser left ventricular end-diastolic dimensions. Cardiac catheterization showed that left ventricular stroke work index increased from 14.6 +/- 3.8 to 23.7 +/- 6.7 gm.m/m2 (p less than 0.01), whereas pulmonary wedge pressure decreased from 24.8 +/- 3.7 to 17.2 +/- 5.8 mm Hg (p less than 0.01). At 6 and 12 months of follow-up, all the preceding values remained essentially unchanged. Thus cardiomyoplasty improves left ventricular function and may halt the steady evolution of severe cardiomyopathies.

[Doppler echocardiographic diagnosis of atherosclerotic aneurysm of the coronary artery]

A 74 year-old man with acute myocardial infarction submitted to thrombolytic therapy had the diagnosis of atherosclerotic aneurysm of the coronary artery attained with Doppler echocardiography. Subsequently diagnosis was confirmed by angiography and the atherosclerotic etiology identified in pathology.

[Continuous ambulatory peritoneal dialysis: efficient treatment for children with terminal uremia]

We have reviewed records of 12 children underwent CAPD between January 84 and May 88, ranging in age from 7 month to 16 years (mean age 8.9 +/- 4.9 years). CAPD treatment lasted from 3 to 24 months (average 10.3 months). Exchanges of dialysis fluid were performed by parents (8 cases) or children (3); mean volume was 41.7 +/- 8.7 ml/kg/exchange (range 32-58 ml/kg). During 132 patient months of treatment laboratory data showed a good metabolic control expect a tendency to hypoalbuminemia. There were 3 catheter changes. Complications were: peritonitis (15 episodes or one infection every 8.8 patient/treatment/months), hypertension (5 cases), hypervolemia (2), cuff extrusion (4), local exit site (5) and tunnel (2) infections and hernias (2). CAPD has been continued in 3 children; 6 other received renal transplantation, one was switched to hemodialysis and 2 died. This study has demonstrated that CAPD was an effective treatment for renal failure in children waiting renal transplant. Cuff extrusion and hypoalbuminemia were common complications in our children.

Right mammary-coronary anastomosis in a patient with situs inversus

We report a patient with situs inversus and ischemic heart disease who had myocardial revascularization with anastomosis of the right mammary artery to the anterior descending coronary artery.