Browsing by Author "Navarro, D"
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- Acute Kidney Injury in the Context of Inflammatory Bowel Disease - A Clinical CasePublication . Cristóvão Marques, J; Barata, R; Lemos Garcia, J; Navarro, D; Góis, M; Sousa, H; Cotovio, P; Ribeiro, F; Nolasco, FExtraintestinal manifestations of inflammatory bowel disease are common and extendable to all organs. Kidney and lower genitourinary system occurs in 4-23% of cases. This may be dependent on inflammatory bowel disease activity, secondary to metabolic disorders, drugs or others. We present a case of a 68-year-old man with ulcerative colitis for 22 years admitted in our department for acute nephritic syndrome. Urinary microscopy suggested glomerular injury. A kidney biopsy was performed and was compatible with acute interstitial nephritis and IgA nephropathy. Toxicity of mesalazine and glomerulonephritis secondary to ulcerative colitis were assumed. The patient suspended mesalazine and started prednisolone with clinical improvement. Our purpose is to sensitize the importance of having a prompt and thorough evaluation of acute kidney injury in patients with inflammatory bowel disease. We briefly review the broad spectrum of kidney manifestations in this population, focusing on mesalazine-induced nephrotoxicity.
- Atypical Adult-Onset Methylmalonic Acidemia and Homocystinuria Presenting as Hemolytic Uremic SyndromePublication . Navarro, D; Azevedo, A; Sequeira, S; Ferreira, AC; Carvalho, F; Fidalgo, T; Vilarinho, L; Santos, MC; Calado, J; Nolasco, FThrombotic microangiopathy (TMA) syndromes can be secondary to a multitude of different diseases. Most can be identified with a systematic approach and, when excluded, TMA is generally attributed to a dysregulation in the activity of the complement alternative pathways-atypical hemolytic uremic syndrome (aHUS). We present a challenging case of a 19-year-old woman who presented with thrombotic microangiopathy, which was found to be caused by methylmalonic acidemia and homocystinuria, a rare vitamin B12 metabolism deficiency. To our knowledge, this is the first time that an adult-onset methylmalonic acidemia and homocystinuria presents as TMA preceding CNS involvement.
- Bone Densitometry Versus Bone Histomorphometry in Renal Transplanted Patients: A Cross‐Sectional StudyPublication . Ferreira, AC; Mendes, M; Silva, C; Cotovio, P; Aires, I; Navarro, D; Caeiro, F; Salvador, R; Correia, B; Cabral, G; Nolasco, F; Ferreira, ABone loss leads to increase risk of fractures in renal transplantation. The aim of this study was to analyse the relationship between bone densitometry (DXA) findings, bone histomorphometry and bone-related molecules 1-year after renal transplantation. We performed a cross-sectional study of de novo renal transplanted patients that agreed to perform a bone biopsy and a DXA examination 1 year after transplantation. All patients underwent a laboratory evaluation, bone biopsy, DXA examination and cardiac CT 1 year after transplantation. 67 patients were included, 16 had a normal examination, and 18 patients were classified as having osteoporosis by DXA. Correlations between bone mineral density and T-scores of total femur and femoral neck were the ones that best correlated with bone volume assessed by a bone biopsy. The sensitivity of DXA for osteoporosis diagnosis was 47.0%, and the specificity was 81.2%. The positive predictive value was 50.0%, and the negative predictive value (NPV) was 80.0%. DXA parameters also correlated with klotho and sclerostin serum levels. In this population, a normal examination excluded the presence of osteoporosis, helping in identifying patients that would not benefit from therapy. Overall, densitometry in total femur and femoral neck correlated well with bone volume measured by bone biopsy.
- Cavernous Sinus Thrombosis in a Patient with Nephrotic SyndromePublication . Navarro, D; Ferreira, AC; Viana, H; Carvalho, F; Nolasco, F
- Cytomegalovirus Nephropathy in the Transplant PatientPublication . Ferreira, AC; Navarro, D
- Early Renal Protocol Biopsies: For Some But Not For All Renal Transplant Patients?Publication . Navarro, D; Ferreira, AC; Caeiro, F; Nolasco, F; Cotovio, P; Aires, I; Silva, C; Remédio, F; Ferreira, A; Viana, H; Carvalho, FSubclinical rejection following renal transplant is associated with worse outcomes, which can be prevented if recognized early. Protocol allograft biopsies have emerged as an option to identify and allow treatment of subclinical rejection, but optimal timing for their performance is not established. We retrospectively evaluated a cohort of 52 low immunological risk patients, who were submitted, from 2007 to 2010, to de novo renal transplant. We separated them into two groups depending on performing an early graft protocol biopsy before hospital discharge: Group A – 32 patients (61.5%) performed a protocol biopsy, and group B – 20 patients (38.5%) did not, the biopsy being considered not essential for various reasons. We analysed patients’ demographics, biopsy complications, graft function, rejection episodes, and patient and graft survival for a median follow-up time of 63.3 months (50.3-83.7). Group A and group B differed in gender (more female patients were biopsied), dialysis vintage (higher in group A), human leucocyte antigen mismatch (higher in group A), and induction protocol (more patients submitted to thymoglobulin than to basiliximab in group A). Protocol biopsy detected histological changes in four patients (12.5%) in group A (2 cellular and 2 borderline rejections), and all were treated accordingly. Moderate peri-graft hematoma was reported in two cases (3.9%). Despite the increased risk in group A, renal function at discharge was better than in group B (p < 0.05 for serum creatinine and eGFR). During follow-up, rejection episodes were similar in the two groups. By the end of follow-up (median 63.3 months), proteinuria and renal function were similar between the two groups. Using a multivariate regression model, and despite the initial differences, at the end of follow-up, patients submitted to early protocol biopsies had similar excellent prognosis as the very low-risk patients who were not biopsied. (p = 0.5). Following our results, we propose that timing of early protocol biopsy should be individualized according to the patient’s clinical and immunological risk.
- Henoch-Schönlein Purpura Associated with Pulmonary AdenocarcinomaPublication . Azevedo, A; Fernandes, V; Navarro, D; Ferreira, AC; Sousa, J; Viana, H; Carvalho, F; Nolasco, FIntroduction: The Henoch-Schönlein purpura (HSP) is an immunoglobulin A (IgA)-mediated smallvessel systemic vasculitis, rare in adults. The association with solid tumours has been described, especially with lung cancer. Case Report: We present the case of a 60-year-old Caucasian male, diagnosed with lung adenocarcinoma that underwent surgical resection without (neo)adjuvant theraphy. Two months latter he was admitted for abdominal pain, purpuric rash on his lower extremities and acute kidney injury, with serum creatinine (Scr) of 2 mg/dl. Urinalysis revealed haematuria and 24h proteinuria (P24h) of 1.5 g. The serum protein electrophoresis, complement components C3 and C4, circulating immune complexes, cryoglobulins, ANCA, ANA, anti-dsDNA and the remaining immunologic study as screening for viral infections (HCV, HBV and HIV) were negative. Renal ultrasound was normal and kidney biopsy revealed mild mesangial proliferation; 2 cellular glomerular crescents and 1 fibrinoid necrosis lesion; large amounts of red blood cell casts; lymphocytic infiltration in the intertubular interstitial capillaries; moderate arteriolar hyalinosis. Immunofluorescence demonstrated mesangial and parietal deposits of IgA. The diagnosis of HSP was assumed, and the patient started prednisolone 1 mg/kg/day. Ten months after diagnosis the patient’s baseline Scr is 1.4 mg/dl with P24h of 0.18g, without haematuria. Conclusion: Although this is a rare association and the exact mechanism behind the disease is yet unknown, physicians should be aware of it. The early recognition and treatment may prevent renal disease progression.
- Improvement of Mineral and Bone Disorders After Renal TransplantationPublication . Ferreira, AC; Mendes, M; Silva, C; Cotovio, P; Aires, I; Navarro, D; Caeiro, F; Ramos, R; Salvador, R; Correia, B; Cabral, G; Nolasco, F; Ferreira, ABackground: Posttransplant mineral and bone diseases are causes of fractures, and their association with cardiovascular events is being studied. Methods: We analyzed the evolution of biochemical, histological, and imaging parameters pre- and 1 y post-renal transplantation in 69 patients and correlated mineral and bone findings with coronary calcifications. At inclusion and after 12 mo, clinical data and echocardiographic findings were recorded, and laboratory evaluations, radiography of the pelvis and hands, and bone biopsy were performed. Noncontrast cardiac computed tomography was performed during the second evaluation. Results: Serum levels of fibroblast growth factor 23 and sclerostin decreased in all patients, parathyroid hormone levels decreased in 89.8% of patients, bone alkaline phosphatase levels decreased in 68.1% of patients, and alpha-Klotho levels increased in 65.2% of patients. More than half of the patients presented with renal osteodystrophy at both biopsies, but histological findings improved: a significant transition from high to normal or low turnover and no significant differences in volume, mineralization defect, or cortical porosity at the 2 evaluations. Alpha-Klotho, sclerostin, and bone alkaline phosphatase shifts affect bone changes. Neither echocardiographic findings nor vascular calcification scores differed between the 2 points. Both the pretransplant period (dialysis vintage, sclerostin, and low bone volume at baseline) and the maintenance of abnormalities in the posttransplant period (high turnover posttransplant) were the most reliable predictors of the severity of the coronary calcification percentile. Conclusions: Renal transplantation improved bone and mineral abnormalities. The pretransplant period determines the severity of calcification.
- Morphological Indexes: Can They Predict Lupus Nephritis Outcomes? A Retrospective StudyPublication . Navarro, D; Ferreira, AC; Viana, H; Carvalho, F; Nolasco, FINTRODUCTION: Lupus nephritis is a serious complication of systemic lupus erythematosus. Currently, therapy is guided by findings in the renal biopsy, following the International Society of Nephrology / Renal Pathology Society classification. Austin and Hill's histomorphological indexes are not routinely obtained. In this retrospective single-centre study, we aimed to analyze the importance and applicability of the different morphological indexes in predicting response to treatment and prognosis. MATERIAL AND METHODS: Patients with kidney biopsy demonstrating lupus nephritis from the 2010 - 2016 period were included. We analyzed their demographic data, comorbidities, clinical presentation and laboratorial evaluation at the time of renal biopsy. We evaluated the following outcomes: clinical remission, renal function and proteinuria at end of follow-up. Histologic analysis was performed using the International Society of Nephrology / Renal Pathology Society classification and the morphological indexes described by Austin (Activity and Chronicity) and Hill. Univariate and multivariate statistical analysis was performed using STATA software. RESULTS: We analyzed 46 biopsy-proven lupus nephritis cases, with a median follow-up of 31.9 (13.2 - 45.6) months. Based on biopsy findings, 35 patients were started on immunosuppressive therapy. We observed that Class IV patients had, at presentation, lower estimated glomerular filtration rate (67.3 vs 94.6 mL/min; p = 0.02), higher proteinuria (4.26 vs 2.37 g/24 hours; p = 0.02) and a non-significantly higher C3 consumption (58.9 vs 77.4 mg/dL; p = 0.06). We did not observe correlations between International Society of Nephrology / Renal Pathology Society classification and the outcomes at the end of follow-up. In contrast, both the Hill biopsy index and Austin's Chronicity index were correlated with renal function and proteinuria at the end of follow-up. Austin's Activity index correlated with the immunological findings (C3, C4 and anti-dsDNA) at presentation. DISCUSSION: Because clinical activity poorly correlates with histologic activity, histological findings are fundamental when assessing patients with suspected lupus nephritis. The most recent International Society of Nephrology / Renal Pathology Society report supports the European League Against Rheumatism guidelines, encouraging the adoption of histomorphological indexes when evaluating lupus nephritis. Our data, showing a correlation between the renal outcomes and the indexes described by Austin and Hill, supports this view. CONCLUSION: The histomorphological indexes in lupus nephritis are easily obtainable, can predict renal outcomes and may help in the management of such patients.
- Not the Usual SuspectPublication . Cardoso, F; Barata, R; Calado, J; Góis, M; Viana, H; Navarro, D; Mendes, M; Nolasco, F