Revista de nefrología y terapéutica

Background: In this article, the author discusses critical appraisals of the major randomized controlled trials on the management of Atherosclerotic Renovascular Disease (ARVD). The article will also discuss the limitations of the published trials, while highlighting the crucial aspect of appropriate patient selection, the serious flaws noted, and the quality of the main studies. Also included are the six major randomized controlled trials that compared the difference between revascularization, either surgical or PTRA (Percutaneous Renal Angioplasty), with or without stent versus conservative management (medication).The author also discusses the recommended research for the management of atherosclerotic renovascular disease.

Methodology and search strategies to identify studies: A comprehensive search of PUBMED including Medical Subject Headings (MeSH) data base from 1990 to may 2012 and The Cochrane library was completed. Searching was only for relevant English papers related to the management of Atherosclerotic renovascular disease.. CASP questionnaire, Jadad scaling and (Oxford Centre for Evidence-based Medicine) levelling of evidence are used for the purpose of the critical appraisal.

Criteria for considering studies for this article: To be considered, clinical studies had to be randomized trials comparing intervention; balloon angioplasty or stenting or both or surgical revascularization versus medical treatment, or surgical versus balloon angioplasty with or without stenting in hypertensive patients who had atherosclerotic renal artery stenosis with a minimum of three months of follow up after treatment Only those studies included with adult patients (age >18 years) who had uncontrolled hypertension (diastolic blood pressure ≥ 95mmHg, treated or untreated) and moderate-to-severe (≥50%) unilateral or bilateral atherosclerotic renal artery stenosis. Studies which were not randomized or those related to fibromuscular dysplasia, meta-analysis, and diagnostic studies were excluded.

Objectives: Explaining a critical appraisal of six major randomized clinical trials which compared Revascularization (intervention) to medication (conservative treatment) which includes Angioplasty and Stenting for Renal Artery Lesions Trial (ASTRAL), Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function Trial (STAR), Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC), Essai Multicentrique Medicaments vs. Angioplastie trial (EMMA), Scottish and Newcastle Renal Artery Stenosis Collaborative Group trial (SNRASCG), and Prospective randomized trial of operative vs. interventional treatment for renal artery ostial occlusive disease (RAOOD) trials. We also highlighted some points about the ongoing CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial.

Conclusions: Correction of Astherosclerotic Renal Artery Stenosis (ARAS), either by surgical revascularization or percutaneous methods, including stenting, has not been shown to be beneficial in treating Atherosclerotic RAS over conservative treatment, although some of the studies showed blood pressure control benefit in intervention groups like EMMA, SNRASCG and post hoc analysis of DRASTIC studies. Consequently, it seems reasonable to consider interventional procedures to correct Renal artery stenosis in patients who do not respond to medical therapy or with poorly-controlled or resistant hypertension; recurrent flash pulmonary edema; dialysis dependent renal failure resulting from atherosclerotic renal artery stenosis; chronic kidney disease and bilateral renal artery stenosis; or Renal artery stenosis to a solitary functioning kidney and waiting for the next available research with less flaws and biases.

The prevalence of nephrolihiasis and chronic kidney disease has risen over the past three decades, we sought to determine if person with a history of kidney stones have lower renal function relative to non stone formers.

Methods: We conducted a case-control study utilizing 138 recurrent calcium kidney stone formers and 127 age and gender matched controls with no history of renal disease, all subjects were aged 30-55 years old, with no history of hypertension, diabetes mellitus, congestive heart failure and liver disease and also no urinary tract obstruction and medications can affect Glomerular Filtration Rate (GFR).

We estimated GFR by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EP I) equations and categorized using cut points suggested by Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines.

Results: Mean GFR in case group and control group was: 80.17(18.45) ml/min/1.73m2 and 83.80(15.75) ml/ min/1.73m2 respectively (P value: 0.09). Distribution of subjects among stone formers in stage I, II, III was 59(42.8%), 71(51.4%) and 8(5.8%) and in control group was 67(52.8%), 59(46.4%) and 1(0.8%) respectively, (p: 0.03). There was an inverse correlation between GFR and number of passed stone but there was no significant correlation between history of extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) and estimated GFR.

Conclusion: Recurrent calcium stone disease may be associated with nephron damage and an increased risk of chronic kidney disease.

Background: Membranous nephropathy (MN) is one of the most frequent causes of nephrotic syndrome in adults. The clinical course is variable, and its treatment is still a matter of controversies. The aim of this study was to establish when immunosuppressive (IMS) therapy should be indicated in our population with MN.

Methods: We evaluated retrospectively clinical and laboratorial data from 71 patients with primary MN, followed in the Glomerulopathy Section (UNIFESP), from 1976 to 2006.

Results: Ten of the 71 patients have not received any specific IMS treatment, while the remainders were submitted to several specific therapies. The final mean creatinine in the non-treated (2.0 ± 1.83 mg/dL) was higher than that of the treated group (1.66 ± 1.54 mg/dL) and there was a strong and significant difference between decreases of proteinuria levels in the group of treated patients when compared to the non treated group. The highest frequency of complete remission was observed in the treated patients (22.9% vs. 10% in non treated) and the highest index of non response in the non treated group (60% vs. 41% in treated), but these differences were not statistically significant. When we compared the patients who received oral corticosteroid, or intravenous (IV) methylprednisolone (MP) plus cyclophosphamide (Cyp), and non treated patients, we observed a favorable effect of the IMS treatment, especially of IV MP plus Cyp.

Conclusions: In a long term follow-up of MN patients IMS treatment was associated to better renal outcome, including more frequent remission, lower final proteinuria and serum creatinine.

A 19-year-old Caucasian male presented to Nephrology Clinic for evaluation of proteinuria. He denied any hearing or vision impairment. The patient reported significant family history for kidney problem in his father, paternal uncle, paternal aunts and his half brother who shared the same father. Physical examination revealed a blood pressure of 136/60 mmHg with no peripheral edema. Laboratory evaluation disclosed a serum creatinine of 0.7 mg/dl, 24-hour urine protein of 2.4 g and serum albumin of 3.7 g/dl. Urinalysis demonstrated dysmorphic red blood cells. A renal biopsy revealed the diagnosis of Alport syndrome. From his paternal family history, the disease was transmitted by autosomal dominant inheritance. The diagnosis of autosomal dominant Alport syndrome was made. He was prescribed lisinopril 5 mg per day. Referrals with Ophthalmology and Audiology were performed with showed no evidences of extrarenal involvement. At follow-up, 3 months later, patient continued to do well with serum creatinine of 0.7 mg/dl and urine protein-to-creatinine ratio of 1.75.

Alport syndrome is most commonly transmitted in an X-linked manner (80% of cases). Autosomal dominant transmission is rare and only accounts for 5% of affected patients. Extrarenal manifestations include hearing loss and ocular defects. Although the presence of these defects should prompt a search for Alport syndrome, patients with autosomal dominant Alport syndrome may present without these manifestations.