RESUMO
INTRODUCTION: Children with chronic kidney disease (CKD) and receiving peritoneal dialysis (PD) have disorders of mineral metabolism that impact their growth, survival and cardiovascular functions. New molecular markers offer a better understanding of the pathophysiology of this disease. OBJECTIVE: To characterize some components of mineral metabolism, with emphasis on FGF23/Klotho and cardiovascular functions (CV) of these patients. PATIENTS AND METHOD: Prospective observational cohort study. EXCLUSION CRITERIA: serum 25 (OH) vitamin D < 20 ng/ml, peritonitis within the last two months and active nephrotic syndrome. Calcemia, phosphemia, parathyroid hormone (PTH), 25 (OH) vitD3, 1.25 (OH) vitD3, FGF23 and Klotho in plasma were measured. FGF23 and Klotho were quantified in healthy children as a control group. Echocardiography was performed calculating the left ventricular mass index (LVMI). Descriptive statistics analysis, Pearson correlation coefficient for association among variables and multivariate analysis were conducted. RESULTS: 33 patients, 16 males, aged between 1.2 and 13.4 years were included. Age of onset for PD: 7.3 ± 5.0 years, time receiving PD: 13.5 ± 14.5 months. The plasma concentration of 25 (OH) vitD3 was 34.2 ± 6.3 pg/ml. Calcemia and phosphemia values were 9.8 ± 0.71 and 5.4 ± 1.0 mg/dl respectively. PTH was 333 ± 287 pg/ml. FGF23 in plasma was 225.7 ± 354.3 pg/ml and Klotho 131.6 ± 72 pg/ml, and in the controls ( n = 16 ), it was 11.9 ± 7.2 pg/ml and 320 ± 119 pg/ml, respectively. The residual and total dose of dialysis (KtV) was 1.6 ± 1.3 and 2.9 ± 1.6, respectively. FGF23 levels significantly correlated with calcium (p < 0.001, r = 0.85), and inversely with residual KtV, showing no relationship with phosphemia. Klotho level correlated negatively with residual KtV and also, it showed a negative association with chronological age and age at onset of PD. LVMI > 38 g/m² was confirmed in 20/28 patients. CONCLUSIONS: The values of FGF23, and PTH are elevated in children with CKD on PD. Klotho levels in CKD patients are lower than control children. A strong association of calcemia with FGF23 and PTH is reported. Residual renal function is inversely associated with FGF23 and Klotho. A high incidence of left ventricular hypertrophy was found evidencing a cardiovascular compromise in these patients.
Assuntos
Hipertrofia Ventricular Esquerda/epidemiologia , Minerais/metabolismo , Diálise Peritoneal/métodos , Insuficiência Renal Crônica/terapia , Adolescente , Idade de Início , Biomarcadores , Estudos de Casos e Controles , Criança , Pré-Escolar , Estudos de Coortes , Ecocardiografia , Feminino , Fator de Crescimento de Fibroblastos 23 , Fatores de Crescimento de Fibroblastos/sangue , Glucuronidase/sangue , Humanos , Hipertrofia Ventricular Esquerda/etiologia , Lactente , Proteínas Klotho , Masculino , Estudos Prospectivos , Insuficiência Renal Crônica/fisiopatologiaRESUMO
Introduction: Children with chronic kidney disease (CKD) and receiving peritoneal dialysis (PD) have disorders of mineral metabolism that impact their growth, survival and cardiovascular functions. New molecular markers offer a better understanding of the pathophysiology of this disease. Objective: To characterize some components of mineral metabolism, with emphasis on FGF23/Klotho and cardiovascular functions (CV) of these patients. Patients and Method: Prospective observational cohort study. Exclusion criteria: serum 25 (OH) vitamin D < 20 ng/ml, peritonitis within the last two months and active nephrotic syndrome. Calcemia, phosphemia, parathyroid hormone (PTH), 25 (OH) vitD3, 1.25 (OH) vitD3, FGF23 and Klotho in plasma were measured. FGF23 and Klotho were quantified in healthy children as a control group. Echocardiography was performed calculating the left ventricular mass index (LVMI). Descriptive statistics analysis, Pearson correlation coefficient for association among variables and multivariate analysis were conducted. Results: 33 patients, 16 males, aged between 1.2 and 13.4 years were included. Age of onset for PD: 7.3 +/- 5.0 years, time receiving PD: 13.5 +/- 14.5 months. The plasma concentration of 25 (OH) vitD3 was 34.2 +/- 6.3 pg/ml. Calcemia and phosphemia values were 9.8 ± 0.71 and 5.4 +/- 1.0 mg/dl respectively. PTH was 333 +/- 287 pg/ml. FGF23 in plasma was 225.7 +/- 354.3 pg/ml and Klotho 131.6 +/- 72 pg/ml, and in the controls ( n = 16 ), it was 11.9 +/- 7.2 pg/ml and 320 +/- 119 pg/ml, respectively. The residual and total dose of dialysis (KtV) was 1.6 +/- 1.3 and 2.9 +/- 1.6, respectively. FGF23 levels significantly correlated with calcium (p < 0.001, r = 0.85), and inversely with residual KtV, showing no relationship with phosphemia. Klotho level correlated negatively with residual KtV and also, it showed a negative association with chronological age and age at onset of PD. LVMI > 38 g/m² was confirmed in 20/28 patients...
Introducción: Los niños portadores de Enfermedad renal crónica (ERC) en diálisis peritoneal (DP) presentan alteraciones del metabolismo mineral que afectan su crecimiento, estado cardiovascular y sobrevida. Nuevos marcadores moleculares representan una mejor comprensión de la fisiopatología de esta enfermedad. Objetivo: Caracterizar componentes del metabolismo mineral, con énfasis en FGF23/Klotho, y estado cardiovascular (CV) en este grupo de pacientes. Pacientes y Método: Estudio prospectivo observacional. Criterios de exclusión: niveles de 25 (OH) vitamina D < 20 ng/ml, peritonitis hasta 2 meses previos y síndrome nefrótico activo. Se midió calcemia, fosfemia, paratohormona (PTH), 25 (OH) vitD3, 1,25 (OH) vitD3, FGF23 y Klotho en plasma. Se cuantificó FGF23 y Klotho en niños sanos como grupo control. Se efectuó ecocardiografía, calculándose el índice de masa ventricular izquierda (IMVI). Se realizó análisis estadístico descriptivo, coeficiente de correlación de Pearson para asociación entre variables y análisis multivariado. Resultados: Se incluyeron 33 pacientes, 16 varones, edad 1,2 a 13,4 años. Edad de inicio de DP: 7,3 +/- 5,0 años, tiempo en DP: 13,5 +/- 14,5 meses. El nivel plasmático de 25 (OH) vitD3 fue 34,2 +/- 6,3 pg/ml. Los valores de calcemia y fosfemia fueron 9,8 +/- 0,71 y 5,4 +/- 1,0 mg/dl respectivamente. La PTH fue de 333 +/- 287 pg/ml. El FGF23 en plasma fue de 225,7 +/- 354,3 pg/ml y Klotho 131,6 +/- 72 pg/ml, y en los controles (n = 16) fue de 11,9 +/- 7,2 pg/ ml y 320 +/- 119 pg/ml, respectivamente. La dosis de diálisis (KtV) residual y total fue de 1,6 +/- 1,3 y 2,9 +/- 1.6, respectivamente. El nivel de FGF23 se correlacionó significativamente con la calcemia (p < 0,001, r = 0,85), e inversamente con el KtV residual, sin mostrar relación con la fosfemia. El nivel de Klotho...
Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Nefropatias/metabolismo , Nefropatias/terapia , Diálise Renal , Doença Crônica , Cálcio/sangue , Nefropatias/sangue , Fatores de Crescimento de Fibroblastos/metabolismo , Fósforo/sangue , Glucuronidase/metabolismo , Biomarcadores , Minerais/metabolismo , Hormônio Paratireóideo , Estudos ProspectivosRESUMO
Background: Hemolytic-uremic syndrome (HUS) is characterized by acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia. Aim: To describe the characteñstics ofpatients with the diagnosis ofHUS in Chile, and to identify the most reliable early predictors oímorbidity and moñality. Material and methods: The clinical records ofpatients with HUS aged less than 15 years, attended between January 1990 and December 2003 in 15 hospitals, were reviewed. Demographic, clinical, biochemical, hematological parameters, morbidity and mortality were analyzed. Results: A cohort of 587 patients aged 2 to 8 years, 48 percent males, was analyzed. Ninety two percent had diarrhea. At the moment of diagnosis, anuria was observed in 39 percent of the patients, hypertension in 45 percent and seizures in 17 percent. Forty two percent required renal replacement therapy (RRT) and perítoneal dialysis was used in the majoríty of cases (78 percent). The most frequently isolated etiological agentwas Escherichia coli. Mortality rate was 2.9 percent in the acute phase of the disease and there was a positive correlation between mortality and anuria, seizures, white blood cell count (WCC) >20.000/mm³ and requirements of renal replacement therapy (p <0.05). Twelve percent of patients evolved to chronic renal failure and the risk factors during the acute phase were the need for renal replacement therapy, anuria, WCC >20.000/mm³, seizures and hypertension. Conclusions: The present study emphasizes important clinical and epidemiological aspeets ofHUSin a Chilean pediatricpopulation.
Assuntos
Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Injúria Renal Aguda , Anuria/etiologia , Síndrome Hemolítico-Urêmica/complicações , Injúria Renal Aguda , Anuria/epidemiologia , Anuria/terapia , Serviços de Saúde da Criança/estatística & dados numéricos , Chile/epidemiologia , Seguimentos , Síndrome Hemolítico-Urêmica/mortalidade , Síndrome Hemolítico-Urêmica/terapia , Hospitalização , Modelos Logísticos , Prognóstico , Diálise Renal , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Hemolytic-uremic syndrome (HUS) is characterized by acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia. AIM: To describe the characteristics of patients with the diagnosis of HUS in Chile, and to identify the most reliable early predictors of morbidity and mortality. MATERIAL AND METHODS: The clinical records of patients with HUS aged less than 15 years, attended between January 1990 and December 2003 in 15 hospitals, were reviewed. Demographic, clinical, biochemical, hematological parameters, morbidity and mortality were analyzed. RESULTS: A cohort of 587 patients aged 2 to 8 years, 48% males, was analyzed. Ninety two percent had diarrhea. At the moment of diagnosis, anuria was observed in 39% of the patients, hypertension in 45% and seizures in 17%. Forty two percent required renal replacement therapy (RRT) and peritoneal dialysis was used in the majority of cases (78%). The most frequently isolated etiological agent was Escherichia coli. Mortality rate was 2.9% in the acute phase of the disease and there was a positive correlation between mortality and anuria, seizures, white blood cell count (WCC)>20.000/mm3 and requirements of renal replacement therapy (p<0.05). Twelve percent of patients evolved to chronic renal failure and the risk factors during the acute phase were the need for renal replacement therapy, anuria, WCC>20.000/mm3, seizures and hypertension. CONCLUSIONS: The present study emphasizes important clinical and epidemiological aspects of HUS in a Chilean pediatric population.
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Injúria Renal Aguda/etiologia , Anuria/etiologia , Síndrome Hemolítico-Urêmica/complicações , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Anuria/epidemiologia , Anuria/terapia , Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Chile/epidemiologia , Feminino , Seguimentos , Síndrome Hemolítico-Urêmica/mortalidade , Síndrome Hemolítico-Urêmica/terapia , Hospitalização , Humanos , Lactente , Modelos Logísticos , Masculino , Prognóstico , Diálise Renal , Estudos Retrospectivos , Fatores de RiscoRESUMO
Background: Cardiovascular risk, growth failure and the new immunosuppressive drugs, have encouraged steroid withdrawal or total avoidance with promising results in renal transplant (Tx) immunosuppression. Aim: To evaluate a new immunosuppressor protocol with early withdrawal of steroids in pediatric kidney transplant. Patients and methods: Prospective study in pediatric patients older than 1 year and low immunological risk. Group A (n =28): steroids in decreasing doses until day 7 post Tx, tacrolimus (FK) and micophenolate mofetil (MMF). Group B (n =28) control: steroids, cyclosporine and azathioprine or steroids, FK and MMF. In both groups the induction therapy included basiliximab. Anthropometric and biochemical variables (renal function, lipid profile, hematological, blood glucose and acid-base equilibrium), acute rejection and CMV infection, were evaluated. Mean values and variations for continuous variables were calculated at months 1, 6, 12 and 18. Results: Two children were withdrawn before month 2, one had an untreatable diarrhea and the second died due to Aspergillus septicemia. Mean values at months 1, 6, 12 and 18 for groups A and B: Creatinine clearence (ml/min): 85.4 vs 89; 79.9 vs 83; 89 vs 80; 79.8 vs 80.6 (p: ns); hematocrit ( percent): 28.8 vs 30.4; 31.7 vs 34.4; 34.4; 32.4 vs 34.8; 34.4 vs 35.5 (p: ns). Total cholesterol (mg/dl): 151 vs 206; 139 vs 174; 138 vs 186; 140 vs 180 (p <0.05). Mean delta height/age Z score at the first year: 0.5 vs 0.15; 0.7 vs 0.22; 0.97 vs 0.25 (p <0.05). Mean systolic blood pressure Z score: 0.9 vs 1.5; 0.5 vs 0.9; -0.3 vs 0.8; 0.1 vs 1.0 (p <0.05). The height/age Z score was significantly superior in patients without steroids. A normalization of growth patterns at month 18 was observed (< 0.05). Both groups presented a negative variation of creatinine clearance during the follow-up, but it was minor in the study group (p <0.05). Two acute rejections were found in each group, and no difference in CMV infections...
Assuntos
Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Imunossupressores/administração & dosagem , Transplante de Rim/imunologia , Ácido Micofenólico/análogos & derivados , Esteroides/administração & dosagem , Tacrolimo/administração & dosagem , Anticorpos Monoclonais/administração & dosagem , Creatinina/sangue , Quimioterapia Combinada , Seguimentos , Rejeição de Enxerto/prevenção & controle , Transplante de Rim/efeitos adversos , Ácido Micofenólico/administração & dosagem , Estudos Prospectivos , Proteínas Recombinantes de Fusão/administração & dosagemRESUMO
BACKGROUND: Cardiovascular risk, growth failure and the new immunosuppressive drugs, have encouraged steroid withdrawal or total avoidance with promising results in renal transplant (Tx) immunosuppression. AIM: To evaluate a new immunosuppressor protocol with early withdrawal of steroids in pediatric kidney transplant. PATIENTS AND METHODS: Prospective study in pediatric patients older than 1 year and low immunological risk. Group A (n =28): steroids in decreasing doses until day 7 post Tx, tacrolimus (FK) and mycophenolate mofetil (MMF). Group B (n =28) control: steroids, cyclosporine and azathioprine or steroids, FK and MMF. In both groups the induction therapy included basiliximab. Anthropometric and biochemical variables (renal function, lipid profile, hematological, blood glucose and acid-base equilibrium), acute rejection and CMV infection, were evaluated. Mean values and variations for continuous variables were calculated at months 1, 6, 12 and 18. RESULTS: Two children were withdrawn before month 2, one had an untreatable diarrhea and the second died due to Aspergillus septicemia. Mean values at months 1, 6, 12 and 18 for groups A and B: Creatinine clearance (ml/min): 85.4 vs 89; 79.9 vs 83; 89 vs 80; 79.8 vs 80.6 (p: ns); hematocrit (%): 28.8 vs 30.4; 31.7 vs 34.4; 34.4; 32.4 vs 34.8; 34.4 vs 35.5 (p: ns). Total cholesterol (mg/dl): 151 vs 206; 139 vs 174; 138 vs 186; 140 vs 180 (p <0.05). Mean delta height/age Z score at the first year: 0.5 vs 0.15; 0.7 vs 0.22; 0.97 vs 0.25 (p <0.05). Mean systolic blood pressure Z score: 0.9 vs 1.5; 0.5 vs 0.9; -0.3 vs 0.8; 0.1 vs 1.0 (p <0.05). The height/age Z score was significantly superior in patients without steroids. A normalization of growth patterns at month 18 was observed (< 0.05). Both groups presented a negative variation of creatinine clearance during the follow-up, but it was minor in the study group (p <0.05). Two acute rejections were found in each group, and no difference in CMV infections was observed. CONCLUSIONS: Early steroid withdrawal in pediatric renal transplant recipients was effective and safe and did not increase the risk of rejection.
Assuntos
Imunossupressores/administração & dosagem , Transplante de Rim/imunologia , Ácido Micofenólico/análogos & derivados , Esteroides/administração & dosagem , Tacrolimo/administração & dosagem , Adolescente , Adulto , Anticorpos Monoclonais/administração & dosagem , Basiliximab , Criança , Pré-Escolar , Creatinina/sangue , Quimioterapia Combinada , Feminino , Seguimentos , Rejeição de Enxerto/prevenção & controle , Humanos , Lactente , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Estudos Prospectivos , Proteínas Recombinantes de Fusão/administração & dosagemRESUMO
El modelo de la Cinética de Urea se ha usado rutinariamente para ajustar la terapia de hemodiálisis y diálisis peritoneal desde los estudios del Nacional Cooperative Dialysis Study (NCDS) a comienzos de la década del 70, derivando en lo que actualmente se conoce como la medición de la Dosis de Diálisis (Kt/V), la Depuración de Creatinina (CrCl), la Velocidad de Catabolismo Proteico (VCP), y elequivalente proteico de la Aparición de Nitrógeno Ureico (PNA), todos ellos parámetros que requieren una monitorización periódica de acuerdo a las recomendaciones DOQI (Dialysis Outcome Quality Initiative).
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Humanos , Cinética , Farmacocinética , Soluções para Hemodiálise/análise , Diálise PeritonealRESUMO
Stunting is common among pediatric patients on peritoneal dialysis. Aim: To stablish the best profile for urea kinetic variables associated to growth inchildren on chronic peritoneal dialysis (PD). Patients and Methods: Twenty patients, aged 1 month to 14 years, 13 males, were followed for 6-12 months, with monthly measurements of weight/age and height/age Z score; plasma creatinine, BUN, protein and albumin and urine and dialysate urea nitrogen, creatinine, protein and albumin. Minimum total Kt/V was 2.1. Dialysis dose (Kt/V), Protein Equivalent of Urea Nitrogen Appearence (PNA), Protein Catabolic Rate (PCR) and Nitrogen Balance (NB) were calculated. To identify the variable(s) associated to growth, the Tree Classification Model (CART) Enterprise Miner 8.1 was applied. Results: Mean total/residual Kt/V: 3.4±1.3/1.69±1.27; Daily Protein Intake (DPI) was 3.25±1.27 g/kg/day. nPNA, PCR and NB were 1.37±0.44, 0.84±0.33 and 1.86±1.25 g/kg/day, respectively. Mean heigth/age Z score was -2.3±1.19. Eleven patients showed a positive height/age delta Z (mean 0.55±0.38) and nine showed a negative growth (mean -0.50±0.42). The main variable explaining the positive growth was a Nitrogen Balance between 0.54 and 2.37 g/kg/ day, mean 1.55±0.21 (p <0.001). The second associated variable to growth was a residual Kt/V between 0.43 and 4.6 (2.02±0.49) (p <0.05). Kt/V and nPNA showed a significant correlation, but no correlation could be found between Kt/V and NB. Conclusions: Nitrogen Balance was the main variable associated to growth in pediatric PD, with values between 0.53 to 2.38 g/kg/day. The second variable was a residual Kt/V between 0.43 and 4.6. Therapy should be reassessed with NB values less than 0.54 or above 2.37 g/kg/day....
Assuntos
Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Fenômenos Fisiológicos da Nutrição Infantil , Crescimento , Soluções para Hemodiálise/administração & dosagem , Diálise Peritoneal/métodos , Fenômenos Fisiológicos da Nutrição do Adolescente , Ingestão de Energia , Seguimentos , Falência Renal Crônica/terapia , Nitrogênio/urina , Estado Nutricional , Estudos ProspectivosRESUMO
Introducción: El Síndrome Hemolítico Urémico (SHU) se caracteriza por falla renal aguda, anemia hemolítica microangiopática y trombocitopenia; es la causa más frecuente de insuficiencia renal aguda en la infancia. Objetivo: a) Describir las características actuales del cuadro inicial de SHU en nuestro medio y comparar con lo descrito anteriormente; b) Describir la evolución a 1 año plazo y evaluar posibles factores pronósticos de función renal. Sujetos y Métodos: Se estudiaron variables demográficas, presentación clínica, exámenes bioquímicos y hematológicos, en 374 pacientes con SHU diagnosticados entre Enero 1990 a Diciempe 2002 en 9 hospitales de la Región Metropolitana; se evaluó además función renal al año de seguimiento en una muestra de 213 pacientes y se identificaron factores pronósticos de insuficiencia renal crónica y mortalidad utilizando el análisis de regresión logística. Resultados: Se analizaron 374 pacientes, 50,5 por ciento mujeres, 65,5 por ciento de la Región Metropolitana, edad promedio 1,5 ± 1,4 años (0,2 a 8); 91 por ciento presentó diarrea, 31 por ciento ocurrió en verano, al ingreso 57 por ciento presentó anuria, 43,3 por ciento hipertensión arterial y convulsiones 23 por ciento. Al alta 28 por ciento persistía hipertenso. Las terapias de sustitución renal utilizadas fueron: diálisis peritoneal (50 por ciento), hemodiafiltración (6 por ciento) y hemodiálisis (3 por ciento); recibió plasmaféresis 1 por ciento. Se aisló agente etiológico en 17 por ciento, siendo en 69 por ciento E. coli enterohemorrágica. La mortalidad fue de 2,7 por ciento, siendo la causa principal la falla orgánica múltiple. En el seguimiento al año: 80 por ciento mantuvo función renal normal, 14 por ciento presento deterioro de la función renal, 6 por ciento proteinuria y 4 por ciento hipertensión. Se encontró significativo como factor pronóstico de daño renal: hipertensión arterial (p < 0,0001), necesidad de peritoneodiálisis y hemodiálisis (p: 0,001, p: 0,0015 respectivamente), anuria (p: 0,005) y convulsiones (p: 0,01). Se correlacionó con mortalidad en la etapa aguda: convulsiones, requerimiento de hemodiafiltración y plasmaféresis, (p < 0,0001, p: 0,0001 y p < 0,0001 respectivamente).