Search

Purpose This cross-sectional study aimed to evaluate BMD, bone microarchitecture and prevalent fractures in women with chronic hypoparathyroidism (HypoPT). Methods Twenty-seven women with HypoPT and 44 age-matched healthy women were included. Dual-energy x-rays absorptiometry (DXA) was used to evaluate areal BMD (aBMD) at the spine and hip as well as morphometric vertebral fractures (VFA). Microarchitecture and volumetric BMD (vBMD) were evaluated at distal radius and tibia using high resolution peripheral quantitative computed tomography (HR-pQCT). Biochemical parameters, including FGF23 (fibroblast growth factor 23), CTX (C- terminal telopeptide of type I collagen) and P1NP (procollagen type I N-terminal propeptide), were measured. Previous low-impact fractures were also assessed, and the 10-year fracture risk was estimated using the FRAX tool for Brazilian population. Results There was a low risk of fractures on FRAX tool in all patients, and only two had morphometric vertebral fractures: one patient presented severe VF (T5) and moderate VF (T6); another patient had moderate spinal deformity at T8. No patient had a history of previous clinical fractures. Compared to controls, HypoPT women had higher aBMD in the lumbar spine (p = 0.030), femoral neck and total hip (p

Introduction: Vascular calcification related to severe secondary hyperparathyroidism (SHPT) is an important cause of cardiovascular and bone complications, leading to high morbidity and mortality in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). The present study aimed to analyze whether ankle-brachial index (ABI), a non-invasive diagnostic tool, is able to predict cardiovascular outcomes in this population. Methods: We selected 88 adult patients on HD for at least 6 months, with serum iPTH>1,000pg/mL. We collected clinical data, biochemical and hormonal parameters, and ABI (sonar-Doppler). Calcification was assessed by lateral radiography of the abdomen and by simple vascular calcification score (SVCS). This cohort was monitored prospectively between 2012 and 2019 for cardiovascular outcomes (death, myocardial infarction (MI), stroke, and calciphylaxis) to estimate the accuracy of ABI in this setting. Results: The baseline values were: iPTH: 1770±689pg/mL, P: 5.8±1.2 mg/dL, corrected Ca: 9.7±0.8mg/dL, 25(OH)vit D: 25.1±10.9ng/mL. Sixty-five percent of patients had ABI>1.3 (ranging from 0.6 to 3.2); 66% had SVCS≥3, and 45% aortic calcification (Kauppila≥8). The prospective evaluation (51.6±24.0 months), provided the following cardiovascular outcomes: 11% of deaths, 17% of nonfatal MI, one stroke, and 3% of calciphylaxis. After adjustments, patients with ABI≥1.6 had 8.9-fold higher risk of cardiovascular events (p=0.035), and ABI≥1.8 had 12.2-fold higher risk of cardiovascular mortality (p=0.019). Conclusion: The presence of vascular calcifications and arterial stiffness was highly prevalent in our population. We suggest that ABI, a simple and cost-effective diagnostic tool, could be used at an outpatient basis to predict cardiovascular events in patients with severe SHPT undergoing HD. Resumo Introdução: A calcificação vascular relacionada ao hiperparatireoidismo secundário (HPTS) grave é uma causa importante de complicações cardiovasculares e ósseas, levando a alta morbidade e mortalidade em pacientes com doença renal crônica (DRC) em hemodiálise (HD). O presente estudo objetivou analisar se o índice tornozelo-braquial (ITB), uma ferramenta diagnóstica não invasiva, pode predizer desfechos cardiovasculares nesta população. Métodos: Selecionamos 88 adultos em HD há pelo menos 6 meses, com PTHi sérico>1.000pg/mL. Coletamos dados clínicos, parâmetros bioquímicos e hormonais, e ITB (sonar-Doppler). A calcificação foi avaliada por radiografia lateral do abdome e por escore de calcificação vascular simples (ECVS). Esta coorte foi monitorada prospectivamente entre 2012 e 2019 para desfechos cardiovasculares (óbito, infarto do miocárdio (IM), acidente vascular cerebral e calcifilaxia) para estimar a precisão do ITB neste cenário. Resultados: Os valores basais foram: PTHi: 1770±689pg/mL, P: 5,8±1,2 mg/dL, Ca corrigido: 9,7±0,8mg/dL, 25(OH)vit D: 25,1±10,9ng/Ml; 65% dos pacientes apresentaram ITB>1,3 (variando de 0,6 a 3,2); 66% tiveram ECVS≥3, e 45% calcificação da aorta (Kauppila≥8). A avaliação prospectiva (51,6±24,0 meses) forneceu os seguintes desfechos cardiovasculares: 11% de óbitos, 17% de IM não fatal, um AVC, 3% de calcifilaxia. Após ajustes, pacientes com ITB≥1,6 tiveram risco 8,9 vezes maior de eventos cardiovasculares (p=0,035), e ITB≥1,8 apresentaram risco 12,2 vezes maior de mortalidade cardiovascular (p=0,019). Conclusão: A presença de calcificações vasculares e rigidez arterial foi altamente prevalente em nossa população. Sugerimos o ITB, uma ferramenta diagnóstica simples e econômica, para ser usada em ambulatório para prever eventos cardiovasculares em pacientes com HPTS grave em HD.

INTRODUCTION Factors associated with osteodystrophy in predialysis patients are poorly understood. In the present study, we attempted to evaluate the impact of body composition and hormonal regulatory factors on the bone microstructure in a group of men with chronic kidney disease (CKD) stages 3 and 4. MATERIALS AND METHODS 46 men, aged 50 - 75 years, with previously unrecognized CKD were evaluated by high-resolution peripheral quantitative computed tomography (HR-pQCT), and dual-energy X-ray absorptiometry (DXA). HR-pQCT parameters were correlated with estimated glomerular filtration rate (eGFR), age, body mass index (BMI), muscle mass index (MMI), and biochemistry. RESULTS As compared to patients in stage 3 CKD, those with stage 4 CKD showed lower serum 25-hydroxyvitamin D (25(OH)D) and bicarbonate levels, and higher serum fibroblast growth factor 23 (FGF-23) and parathyroid hormone (PTH) levels. They also exhibited lower total, trabecular, and cortical volumetric bone mineral density, lower trabecular bone volume/tissue volume, trabecular number, trabecular and cortical thickness, and increased heterogeneity of the trabecular network. In the whole cohort, cortical bone density and thickness were negatively associated with age, PTH, and FGF-23, and positively with BMI. Trabecular bone parameters were positively associated with MMI and 25(OH)D. After simultaneously adjusting for age and eGFR, BMI, and MMI remained significantly associated with bone microstructural variables. CONCLUSION HR-pQCT showed significant differences in bone microstructure in stage 4 vs. stage 3 CKD patients. Increased BMI, probably due to increased muscle mass, may favorably affect bone architecture in predialysis CKD patients. .

Patients with hereditary transthyroid (ATTR) amyloidosis usually present neurological (peripheral and autonomic) and cardiologic manifestations, but may also present renal manifestations due to glo...

Background Tubular dysfunction is prevalent among kidney transplant patients using calcineurin inhibitors, but our knowledge of the tubular effects of mTOR inhibitors is more limited. Methods 60 kidney transplant outpatients using either the calcineurin inhibitor tacrolimus or the mTOR inhibitor sirolimus were investigated for renal tubular dysfunction. Proximal tubule function was assessed by quantification of albumin and β2-microglobulin, tubular reabsorption of phosphate and fractional excretion of bicarbonate. Distal tubular function was evaluated by water deprivation test and by urinary acidification test using furosemide and fludrocortisone for pH, ammonium and titratable acidity measurements. Results The prevalence of distal renal tubular acidosis (dRTA) was 17% for both treatment groups. 70% of patients treated with sirolimus and 94% using tacrolimus presented with urine concentrating defect (p=0.04). Conclusion Distal RTA and urine concentrating defect were highly prevalent after kidney transplantation both in the sirolimus and tacrolimus treated patients. Acidification test was essential for the appropriate diagnosis of dRTA while dipstick urine specific gravity test was able to detect urine concentrating defect in this population.

Introduction: Patients on hemodialysis (HD) present high mortality from cardiovascular complications and high morbidity, including decreasing functional capacity and quality of life. Objective: To analyze clinical and laboratory responses of patients in HD to intradialytic cardiopulmonary rehabilitation on an outpatient basis. Methods: We evaluated 14 patients in a prospective study for 8 months using cardiopulmonary rehabilitation protocol (CRehab) consisted of intradialytic aerobic exercise with a cycle ergometer. We analyzed heart rate (HR), systolic (SBP) and diastolic blood pressure (DBP), peripheral oxygen saturation (SpO2) and modified Borg scale. We evaluated cardiac function by echocardiogram, functional capacity by six minutes walk test (6MWT), and quality of life by SF-36 survey, before and after CRehab. Biochemical data and KT/Vsp were collected form medical records. Results: During CRehab, the results of HR, SBP, DBP, SpO2 and Borg scale showed no significant changes. 6MWT test showed progressive increase in the distance covered (p < 0.001) as well as a reduction in the scale of Borg post-6MWT (p = 0.009). There was no significant change in any biochemical data or in KT/Vsp. There was increase in left ventricular ejection from 65.7 ± 10.2% to 73.6 ± 10.1% (p = 0.028) and in left ventricular diastolic diameter (p = 0.027). According to SF-36 survey, patients showed improvement in three areas: physical role functioning (p = 0.012), bodily pain (p = 0.007) and vitality (p = 0.009). Conclusion: The intradialytic CRehab applied in this population was safe and allowed objective improvement of functional capacity and exercise tolerance, subjective improvement in the perception of effort, significant increase in cardiac function and better quality of life in different domains.

Aging is associated with decreases in bone quality and in glomerular filtration. Consequently, osteoporosis and chronic kidney disease (CKD) are common comorbid conditions in the elderly, and often coexist. Biochemical abnormalities in the homeostasis of calcium and phosphorus begin early in CKD, leading to an increase in fracture risk and cardiovascular complications since early stages of the disease. The ability of DXA (dual energy X-ray absorptiometry) to diagnose osteoporosis and to predict fractures in this population remains unclear. The management of the disease is also controversial: calcium and vitamin D, although recommended, must be prescribed with caution, considering vascular calcification risk and the development of adynamic bone disease. Furthermore, safety and effectiveness of osteoporosis drugs are not established in patients with CKD. Thus, risks and benefits of antiosteoporosis treatment must be considered individually. O envelhecimento associa-se tanto ao declínio da qualidade óssea quanto da filtração glomerular. Consequentemente, osteoporose e doença renal crônica (DRC) são comorbidades frequentes em idosos, e muitas vezes coexistem. Anormalidades bioquímicas na homeostase do cálcio e do fósforo surgem precocemente na DRC, causando aumento do risco de fraturas e de complicações cardiovasculares desde fases precoces da doença. A capacidade da densitometria (DXA) em diagnosticar osteoporose e predizer fraturas nessa população é questionável. O manejo da doença é também controverso; cálcio e vitamina D são recomendados com cautela, devido ao risco de calcificações vasculares e de doença óssea adinâmica. Além disso, a segurança e a eficácia dos medicamentos para osteoporose ainda não estão estabelecidas em pacientes com DRC. Assim, riscos e benefícios do tratamento para osteoporose devem ser considerados individualmente nesses pacientes.

The relative lack of qualified teachers in the Amazon Region led to the adoption of Distance Education technologies in order to implement Nephrology classes in the fourth year of the medical course in Sao Lucas College (Faculdade de Sao Lucas), located in Porto Velho, Rondonia. In this paper, we describe the construction of the course on the Moodle platform, using a modular structure to discuss the main topics of Nephrology in online asynchronous forums based on illustrative clinical problems, and we also show the results of the classes, which has already been completed with 3 groups of medical students, and the evaluation of the methodology by the students and by the institution.

Primary Sjogren's syndrome (pSS) is an important cause of renal tubular dysfunction in adults, mainly due to acquired type 1 distal renal tubular acidosis (RTA 1) and concentration defects (CD). This cross-sectional study evaluated renal tubular function of patients with pSS, by detecting proximal tubular injury (through measurements of urinary β2 microglobulin and albumin), RTA 1 (through an acidification protocol using furosemide and fludrocortisone), and CD (through water deprivation test, WDT). A total of 25 patients with pSS were evaluated and despite a preserved renal function (eGFR 92.5 ± 26.3 mL/min/1.73 m(2)), 24% were diagnosed as RTA 1. On the other hand, CD was diagnosed in 28% of the patients who presented worse renal function (eGFR 68.6 ± 27.7 mL/min/1.73 m(2)). Increased β2 microglobulin was found in 16% of the patients, and all of them had impaired renal function (eGFR 39.5 ± 11.9 mL/min/1.73 m(2)). These data showed a high prevalence of tubular dysfunction, mainly RTA 1 and CD, in patients with pSS, and suggest that patients with this disorder should be evaluated by the acidification protocol used in this study and WDT for proper diagnosis. Proximal tubular injury was less common, and probably associated with worsening of renal function.

Hyperparathyroidism, vitamin D deficiency, increased fibroblast growth factor-23 (FGF-23), and metabolic acidosis promote bone fragility in chronic kidney disease (CKD). Although useful in predicting fracture risk in the general population, the role of dual-energy X-ray absorptiometry (DXA) in CKD remains uncertain. This cross-sectional study included 51 men aged 50-75 yr with moderate CKD. The stage 4 CKD patients had higher levels of parathyroid hormone (p

CONTEXT AND OBJECTIVE: Few studies have focused on bone disease in patients with chronic kidney disease under conservative treatment. The objective was to evaluate bone disease in patients with chronic kidney disease. DESIGN AND SETTING: Case series, at the Nephrology Division, Hospital Universitário Pedro Ernesto. METHODS: 131 patients with creatinine clearance from 10 to 60 ml/min/1.73 m² were followed up for at least one year. Serum creatinine, albumin, calcium, phosphorus, alkaline phosphatase, total CO2 (tCO2), intact parathyroid hormone (iPTH), and alkaline phosphatase were measured. Creatinine clearance was calculated from 24-hour urine creatinine measurements and protein ingestion estimates from urea assays. RESULTS: Patients presenting creatinine clearance < 30 ml/min/1.73 m² had higher iPTH values, but normal serum levels for calcium, phosphorus, alkaline phosphatase and tCO2. Patients presenting iPTH values of twice the normal upper limit (144 pg/ml) showed lower tCO2 values. Bone alkaline phosphatase was evaluated in 37 patients with creatinine clearance < 30 ml/min/1.73 m², showing correlation with alkaline phosphatase but not with parathyroid hormone. Bone biopsy on nine patients with creatinine clearance < 30 ml/min/1.73 m² and iPTH > 144 pg/ml showed osteitis fibrosa (4), mild lesion (4) and high turnover (1). CONCLUSION: The present data suggest the importance of early control for iPTH and metabolic acidosis, among patients under conservative management for chronic kidney disease, in order to prevent complications related to bone disease. CONTEXTO E OBJETIVO: A doença óssea em pacientes com doença renal crônica sob tratamento conservador tem sido pouco estudada. O objetivo do estudo foi avaliar a doença óssea em pacientes com doença renal crônica. TIPO DE ESTUDO E LOCAL: Estudo de casos, na Disciplina de Nefrologia, Hospital Universitário Pedro Ernesto. MÉTODOS: Foram avaliados por pelo menos um ano 131 pacientes com clearance de creatinina variando de 10 a 60 ml/min/1,73 m². No plasma, foram medidos creatinina, albumina, cálcio, fósforo, fosfatase alcalina, CO2 total (tCO2), hormônio paratiroidiano intacto (iPTH) e fosfatase alcalina. Da urina de 24 horas, foram avaliadas o clearance de creatinina e a ingestão protéica. RESULTADOS: Pacientes com clearance de creatinina < 30 ml/min/1,73 m² apresentaram maior nível de iPTH, apesar de valores normais para.cálcio, fósforo, fosfatase alcalina e tCO2. Pacientes com valores de iPTH duas vezes acima do valor superior da normalidade (144 pg/ml) apresentaram menor valor de tCO2. Fosfatase alcalina óssea foi avaliada em 37 pacientes com clearance de creatinina < 30 ml/min/1,73m², mostrando correlação com a fosfatase alcalina, mas não com o iPTH. Biópsia óssea em nove pacientes com clearance de creatinina < 30 ml/min/1,73m² e iPTH > 144 pg/ml mostrou osteíte fibrosa (4), lesão mínima (4) e alto remodelamento (1). CONCLUSÃO: Os resultados apontam para a importância de um controle precoce do iPTH e da acidose metabólica em pacientes sob tratamento conservador para doença renal crônica, no intuito de prevenir as complicações relacionadas com a doença óssea.