Monitoring and management of hyperglycemia in patients with advanced diabetic kidney disease

Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.     

A new biliary access technique for the long-term endoscopic management of intrahepatic stones

Intrahepatic stone disease poses a difficult postoperative management problem due to frequent stone recurrence. Most of the methods proposed for long-term access to the intrahepatic biliary tree require multiple sessions of additional, usually invasive, procedures. An alternative method for endoscopic long-term access to the intrahepatic ducts, represented by a side-to-side anastomosis between the isolated Roux-en-Y jejunal limb of the bilioenteric bypass and the duodenum (duodenojejunostomy), was used in eight patients with retained and/or recurrent stones after surgical treatment of intrahepatic stone disease. There were no short- or long-term complications or mortality associated with the duodenojejunostomy. Postoperative endoscopic access to the intrahepatic ducts was successfully achieved in five of six patients: one with stone recurrence, one with a left hepatic duct stricture and stone recurrence and one with known retained postoperative stones. In two patients, no stones were found at endoscopy. Side-to-side duodenojejunostomy may be useful in the long-term endoscopic management of recurrent intrahepatic biliary stone disease and should be indicated whenever a bilioenteric anastomosis is performed for the treatment of bilateral intrahepatic stone disease. Introduction     

A prospective study of visceral leishmaniasis in an endemic area of Brazil

The epidemiology, clinical patterns, and risk factors for visceral leishmaniasis were prospectively studied in an endemic area of Brazil. The prevalence of disease was 3.1% for children less than 15 years of age, and the annual incidence was 4.3 cases per 1,000 children. The number of children with disease fluctuated yearly and seasonally, and distribution of the disease varied within the endemic area. Risk factors included young age (median, three years) and malnutrition before the onset of disease. Intestinal parasitism, recent migration into the area, and house location within the area did not influence the progression of infection to disease. Serological testing indicated that 7.5% of children were infected with Leishmania each year and that the ratio of disease to infection was 1:18.5 for the whole area and 1:6.5 for the section with the highest prevalence of disease. Early diagnosis and therapy altered clinical patterns of the disease.     

Beta-blockade and exercise capacity in patients with mitral stenosis in sinus rhythm

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine whether beta-blocker treatment (atenolol) improves cardiopulmonary exercise performance and ventilatory response in patients with mitral stenosis in sinus rhythm. METHODS: A prospective study comparing the results of cardiopulmonary exercise tests (CPETs) was performed before and after atenolol therapy in 17 patients in NYHA classes I and II with mitral stenosis in sinus rhythm. Transthoracic echocardiography was performed pre-study, and left ventricular diameters, ejection fraction and mitral valve area monitored. CPETs (Naughton protocol) were performed by two different investigators before and after one-week atenolol therapy (50 mg/day). The second investigator was blinded to the result of the baseline test. O2 consumption, CO2 production, ventilatory parameters and respiratory exchange ratios were measured on line. RESULTS: Maximal O2 uptake (VO2max) did not differ significantly before and after beta-blockade (median 16.8 and 15.0 ml/kg/min, respectively. Median heart rate at rest (72 versus 55 beats/min; p = 0.0003) and during peak exercise (153 versus 105 beats/min; p = 0.0003), and anaerobic threshold (10 versus 8.9 ml/kg/min; p = 0.02) were lower with beta-blockade compared with the baseline state. Minute ventilation at maximum exercise (41 versus 40 l/min) and ventilatory equivalent for CO2 (34 versus 35) were unchanged with atenolol therapy, indicating no improvement in ventilatory performance. When patients were grouped into those in whom VO2max was improved with atenolol therapy (n = 7) and those in whom it was impaired (n = 10), there were no inter-group differences with respect to age, left ventricular function, severity of mitral stenosis, NYHA class and grade of beta-blockade reached. Four patients felt symptomatically worse during atenolol treatment (lower NYHA functional class). CONCLUSION: Beta-blockade does not improve exercise tolerance in patients with mitral stenosis in sinus rhythm. In addition, ventilatory performance does not change with treatment.     

Anomalous origin of the left pulmonary artery from the ascending aorta. Successful surgical correction in an infant with Fallot's tetralogy

We describe the case of a 40-day-old female patient with a history of breathlessness since birth who was referred to our hospital for surgical correction of common arterial trunk. The invasive investigation disclosed a Fallot cent s tetralogy anatomy associated with an anomalous origin of the left pulmonary artery from the ascending aorta. Immediately after diagnosis, the patient underwent a successful total surgical correction of the defect, including simultaneous anastomosis of the left pulmonary artery to the pulmonary trunk.     

Therapeutic biliary endoscopy in patients over 90 years of age

Endoscopic retrograde cholangiopancreatography (ERCP) is an established method to treat bile duct obstruction. Besides, ERCP is one of the most stricking parts of interventional endoscopy and takes advantage of its minimal invasive condition to be applied to a wide variety of patients. We present five patients over 90 years of age who underwent successfully and without complications six therapeutic ERCPs. Endoscopic biliary sphincterotomy, common bile duct stone extraction and plastic stent insertion all were performed uneventfully and solving the biliary obstruction. Therapeutic ERCP is a safe and effective modality to treat bile duct obstruction in patients over 90 years of age.