RESUMEN
BACKGROUND: In Peru, the incidence of primary focal segmental glomerulosclerosis (PFSGS) has considerably increased in the last decade and at the present; it is the first cause of primary glomerulonephritis in adults. Because of its prevalence and high probability to progress to end-stage renal disease (ESRD), we searched for factors with prognostic value for renal survival and proteinuria remission. SUBJECTS AND METHODS: Historical cohort of 44 patients. We studied clinical and histological characteristics at the time of renal biopsy and clinical condition and renal function at the end of follow-up. PRINCIPAL OUTCOMES: renal impairment (increase >or=50% of basal creatinine levels and/or ESRD), proteinuria remission (partial 0.3-3.49 g/day and complete < 0.3g/day). Kaplan-Meier's curves and Cox's Multivariate Regression were used. RESULTS: The 59% of patients were men. The 54.5% had renal failure, 53.5% nephrotic syndrome and 43.2% hypertension or high blood pressure (HBP) at renal biopsy. The frequency of histological variants was: not otherwise specified (NOS) 75%, cellular 13.6%, tip 6.8% and perihilar 4.5%. The 56.8% received steroids for 4.3 +/- 4.5 months and 32% of these patients were corticodependent. After a mean follow-up of 21.6 +/- 27.8 months, the renal function decreased in 18.2% of patients. The 37.8% and 32.4% of patients reached partial and complete proteinuria remission respectively. Treatment with steroids, antihypertensive therapy and IgM and C3 glomerular deposits were associated with a high renal survival. The treatment with steroids was the only factor that forecasted a high renal survival (hazard ratio or HR: 0.07, 0.01-0.9) and proteinuria remission (HR: 0.2, 0.04-0.9). In general, high blood pressure (HR: 6.2, 1.1-35.2), renal failure (HR: 2.9, 1.1-7.6), cellular variant and interstitial fibrosis (HR: 5.2, 1.02-26.7) were prognostic factors for not achieving proteinuria remission. CONCLUSIONS: In primary focal segmental glomerulosclerosis, treatment with steroids forecasted a high renal survival and proteinuria remission. Renal failure and interstitial fibrosis were prognostic factors for not achieving proteinuria remission.
Asunto(s)
Glomeruloesclerosis Focal y Segmentaria/complicaciones , Insuficiencia Renal/etiología , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Adulto JovenRESUMEN
AIM: We performed both a retrospective and prospective study to elucidate the types of glomerular diseases present in adults in Lima, Peru. MATERIAL AND METHODS: In the retrospective study, we analyzed 1,263 renal biopsies over a 10-year period (1985 -1995) that were processed at a central reference renal pathology laboratory in Lima. 101 cases were examined in the prospective study. RESULTS: The most common glomerular diseases observed were those due to systemic lupus erythematosus (30.2%), membranoproliferative glomerulonephritis (MPGN, 14.8%), and focal and segmental glomerulosclerosis (FSGS, 13.9%). Although mesangial-proliferative nephritis was observed in 9.5% of cases, IgA nephropathy was rare (0.9%). Examination of the year to year frequency showed that MPGN has tended to decrease in frequency with time whereas FSGS has been increasing. Although there is known to be a high frequency of infections in Peru, only 4.2% of the cases in the retrospective study were associated with infection. Furthermore, in the prospective study, only one case of hepatitis C and no cases of hepatitis B viral infection were detected, including in the 11 cases of MPGN observed. CONCLUSION: We conclude that the epidemiology of glomerular disease in Lima, Peru, is distinct from most areas of the world, but has similarities to certain regions in Africa, in that MPGN is common whereas IgA nephropathy appears to be rare. Further studies are necessary to elucidate the reasons why the patterns of glomerular disease are different from that observed in other parts of the world.
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Glomerulonefritis Membranoproliferativa/epidemiología , Glomeruloesclerosis Focal y Segmentaria/epidemiología , Nefritis Lúpica/epidemiología , Adulto , Biopsia , Femenino , Humanos , Riñón/patología , Masculino , Perú/epidemiología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: We assessed whether immunohistologic markers for glomerular or tubulointerstitial injury might provide better correlations with ongoing renal function and disease activity as compared with the WHO classification or the NIH activity and chronicity indices in lupus nephritis. METHODS: Thirty-three patients with clinically defined systemic lupus underwent renal biopsy over a 1-year period at Hospital Loayza in Lima, Peru. Biopsy specimens were evaluated for macrophages, proliferating cells, alpha-actin expression, and type IV collagen deposition in both glomeruli and the tubulointerstitium and the results compared with the current WHO and NIH classifications in relation to the clinical presentation. RESULTS: Patients with WHO class IV lupus nephritis were more likely to have lower serum complements, greater proteinuria and hematuria, and worse renal function. An elevated NIH activity index correlated with microhematuria, proteinuria, and impaired renal function, whereas an elevated chronicity index correlated with renal function, hypertension, and microhematuria, but not with proteinuria. The presence of glomerular macrophages correlated with both glomerular alpha-actin expression and type IV collagen deposition, but did not correlate with renal function or proteinuria. In contrast, interstitial macrophages correlated not only with interstitial collagen deposition and myofibroblast accumulation, but also correlated with both renal function and the presence of nephrotic syndrome. CONCLUSIONS: Both the WHO classification and the NIH activity/chronicity indices correlate with clinical manifestations of lupus nephritis. While glomerular macrophage accumulation correlates with mesangial cell activation (alpha-actin expression) and collagen deposition, and interstitial macrophage accumulation correlates with interstitial fibroblast activation and collagen deposition, only interstitial macrophages correlate with renal function. Of particular interest will be future studies to determine whether these markers correlate with the prognosis.
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Nefritis Lúpica/patología , Actinas/metabolismo , Adolescente , Adulto , División Celular , Colágeno/metabolismo , Creatinina/sangre , Femenino , Hematuria/fisiopatología , Humanos , Inmunohistoquímica , Glomérulos Renales/metabolismo , Glomérulos Renales/patología , Túbulos Renales/metabolismo , Túbulos Renales/patología , Nefritis Lúpica/clasificación , Nefritis Lúpica/fisiopatología , Macrófagos/patología , Masculino , Persona de Mediana Edad , Perú , Antígeno Nuclear de Célula en Proliferación/metabolismo , Proteinuria/fisiopatologíaRESUMEN
In orthostatic hypotensive patients renin is reported to increase in response to head-up tilt unless the lesion involves postganglionic sympathetic efferent nerves. The authors examined responses of plasma renin activity (PRA) to acute blood pressure reduction in 4 patients with orthostatic hypotension. When the coexistence of normal plasma norepinephrine (PNE) and normal or high-normal pressor response to alpha stimulant is considered to be a sign of preserved function of postganglionic fibers, 2 of the patients had sympathetic lesions mainly confined to central and/or preganglionic fibers. They were diagnosed as having multiple system atrophy (MSA). The other 2 were diagnosed as having idiopathic orthostatic hypotension with possible postganglionic lesions. Although 1 MSA patient showed an increase in PRA from 2.0 to 4.7 ng/mL/hr in response to the tilt, the other MSA patient showed no PRA response to the tilt. The head-up tilt did not provoke an apparent PRA response in patients with idiopathic orthostatic hypotension. The authors infused sodium nitroprusside (SNP) in the 3 patients whose PRA did not respond to the head-up tilt. The infusion decreased blood pressure by 40 mmHg or more, but PRA responses were inappropriately small or suppressed. In all cases, PNE did not respond at all to the head-up tilt and to the infusion of SNP. These findings suggest that possible preservation of postganglionic fibers does not necessarily indicate an intact responsiveness of PRA. The PRA profiling may not be an accurate predictor for the site of the fiber degeneration in orthostatic hypotension.
Asunto(s)
Hipotensión Ortostática/sangre , Renina/sangre , Anciano , Presión Sanguínea/efectos de los fármacos , Femenino , Humanos , Hipotensión Ortostática/fisiopatología , Masculino , Persona de Mediana Edad , Nitroprusiato/farmacología , PosturaRESUMEN
Presentamos la casuístic de Tumores Carcinoide de un período de 13 años en un hospital. La frecuencia fue de 1.54 casos por año; el 65 por ciento de ellos fue en varones, el grupo etareo más agectado correspondió al comprendido entre los 61-70 años, siendo la mediana los 48 años. Se observó que en el sexo masculino fue más frecuente en los mayores de 40 años, mientras que en el femenino lo fueron en lmenores de esa edad. Las localizaciones primarias más frecuentes fueron: bronquio (25 por ciento);estómago (20 por ciento),apéndice(15 por ciento) y recto(15 por ciento). Los primarios digestivos correspondieron al 50 por ciento de casos, los extradigestivos al 40 por ciento y desconocido en el 10 por ciento. sobre el tipo histológico: en los digestivos fue más frecuente el E, y en los estradigestivos el B. Las manifestaciones clínicas más frecuentes fueron dolor (47 por ciento) y fiebre (26.3 por ciento). El Síndrome Carcinoide se presentó en 3 casos: dos de ellos sin metástasis hepáticas. Nuestra serie se asemeja más a la descrita en la literatura japonesa