Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 3 uppsatser.

Résumé de la thèse:Le syndrome néphrotique idiopathique (SNI) est la forme la plus fréquente de néphropathies glomérulaires et résulte d'altérations touchant les podocytes. La progression de la maladie est associée à une déplétion podocytaire et l'apparition de glomérulosclérose. Malgré de nombreuses études moléculaires et des avancées scientifiques indiscutables sur les formes génétiques, la pathogénie du SNI reste une énigme.Nous avons trouvé que la protéine c-mip est spécifiquement induite dans les podocytes des patients atteints de SNI.Nous avons montré que les souris transgéniques c-mip développent une protéinurie néphrotique qui n'est associée ni à des lésions inflammatoires glomérulaires ou interstitielles, ni à des dépôts de complexes immuns circulants ou de complément. Les études in vitro et in vivo ont démontré que c-mip se lie à Fyn et bloque la liaison de Fyn avec la néphrine et N WASP. Il en résulte une inhibition de la voie de signalisation de la néphrine et l'incapacité de N-WASP à recruter Nck, ce qui altère l'organisation du cytosquelette podocytaire et contribue au développement de la protéinurie masssive.D'autre part, nous avons montré que Wt1 se lie au promoteur de c-mip et bloque sa transactivation. Au cours du SNI acquis, les résultats obtenus in vitro et dans les souris transgéniques suggèrent que c-mip inhibe la transcription du gène de Wt1 médiée par NF-κB, interagit avec Wt1 via son domaine LRR et favorise la dégradation de Wt1 par le protéasome.Nous avons également trouvé que c-mip interfère avec l'activation de la voie NF-κB en destabilisant la sous-unité RelA, tandis que la sous-unité p50 est préservée. Les résultats in vitro et dans le modèle murin suggèrent que c-mip est dotée de propriétés pro-apoptotiques.Ces travaux montrent que la protéine c-mip joue un rôle crucial dans la physiopathologie du SNI et constitue une cible thérapeutique de choix. / SummaryPodocyte damages are the initiating event in the pathogenesis of idiopathic nephrotic syndrome (INS). Progression of podocyte disease is associated with cellular depletion and appearance of glomerulosclerosis. The molecular pathophysiology of this disease remains an enigma.We showed that c-mip (c-maf inducing protein) is up-regulated in podocytes during the active phase of INS.We generated c-mip transgenic mice overexpressing c-mip specifically in podocytes. These mice developed morphological and biochemical alterations similar to INS. We demonstrated that c-mip switches off podocyte proximal signaling by preventing the interaction between Fyn and nephrin, resulting in the inhibition of nephrin phosphorylation in vitro and in vivo. Moreover, we found that the in vivo interactions of Fyn with Nck and N WASP are inhibited, which may account for disorganization of the cytoskeleton and the effacement of foot processes.We showed that, under physiological conditions, Wt1 inhibits the transcriptional induction of c-mip. Conversely, we demonstrated that, under pathological conditions, c-mip inhibits NF κB mediated-Wt-1 transcription, interacts in vitro and in vivo with Wt1 via its LRR domain, and targets Wt1 to proteasome degradation.We also observed that the induction of c-mip in patients with INS is correlated with a downregulation of RelA in podocytes. We showed that c-mip alters NF-κB signaling by destabilizing the RelA protein, while p50 is preserved. Morever, the results established in stably transfected podocytes and in transgenic mice suggest that c-mip is a proapoptotic protein.Collectively, these data postulate that c-mip functions as a negative regulator and plays a central role in podocytes disorders during INS.

Le syndrome néphrotique (SN) est causé par une altération glomérulaire, responsable d’une excrétion urinaire anormale de protéines plasmatiques, compliquée d’hypoalbuminémie. Le SN est toujours associé à une rétention rénale de Na + qui conduit à la génération d'ascite et / ou d'œdèmes. La pathogénie de la rétention de Na + et de la constitution d’œdèmes n’est pas entièrement élucidée. Dans notre étude, nous avons évalué le rôle possible des espèces réactives de l'oxygène (ROS) dans cette pathogénie. Notre étude dans le modèle de rat aminonucléoside puromycine (PAN) de SN fournit des éléments de preuve d'un rôle critique des ROS dans les troubles hydro-électrolytiques associés au SN. Dans le rein, l'endocytose de l'albumine anormalement filtrée dans le néphron distal induit un stress oxydatif qui est responsable de l’augmentation de la Na, K-ATPase. Dans le péritoine, le SN est associé à une augmentation marquée de la perméabilité à l'eau et à une diminution du coefficient de réflexion des protéines de la barrière péritonéale. Ces modifications, déclenchées par le stress oxydatif et l'activation subséquente de NF-kB, comptent pour environ deux tiers du volume de l'ascite. Enfin, nous avons confirmé que le stress oxydatif participe à la sécrétion de l'angiotensine-aldostérone et est nécessaire à l’apparition de l'hyperaldostéronémie observée chez les rats PAN-néphrotiques. / Nephrotic Syndrome (NS) is a nonspecific kidney disorder defined by abnormal urinary excretion of plasma proteins and hypoalbuminemia. NS is always associated with a renal retention of Na+ leading to the generation of ascites and/or edema. The pathogenesis of Na+ retention and edema is not fully elucidated. In our studies we evaluated the possible role of reactive oxygen species (ROS) in this pathogenesis. Our studies in the puromycin aminonucleoside (PAN) rat model of NS provided pieces of evidence for a critical role of ROS in the hydro-electrolytic disorders associated with NS. In the kidney, endocytosis of abnormally filtered albumin in the distal nephron induces an oxidative stress which is responsible for the up-regulation of Na,K-ATPase. In the peritoneum, NS is associated with a marked increase in water permeability and a decrease in the reflection coefficient to proteins of the peritoneal barrier. These changes, which are triggered by oxidative stress and subsequent activation of NF-kB, account for approximately two-third of the volume of ascites. Finally, we confirmed that oxidative stress participates in the angiotensin-stimulated secretion of aldosterone and is required for the hyperaldosteronemia observed in PAN-nephrotic rats.

Submitted by Jos? Henrique Henrique (jose.neves@ufvjm.edu.br) on 2018-09-04T14:47:20Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) adriana_suellen_santos.pdf: 1491836 bytes, checksum: 02ad34625981f94b921abb0390d2732b (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2018-10-05T19:49:42Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) adriana_suellen_santos.pdf: 1491836 bytes, checksum: 02ad34625981f94b921abb0390d2732b (MD5) / Made available in DSpace on 2018-10-05T19:49:42Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) adriana_suellen_santos.pdf: 1491836 bytes, checksum: 02ad34625981f94b921abb0390d2732b (MD5) Previous issue date: 2018 / Funda??o de Amparo ? Pesquisa do Estado de Minas Gerais (FAPEMIG) / A s?ndrome nefr?tica (SN) ? definida por protein?ria maci?a, edema, hipoalb uminemia e hiperlipidemia e desenvolve a partir da les?o dos glom?rulos, especialmente d os pod?citos. Pode ser um a altera??o prim?ria (idiop?tica), com o uma doen?a espec?fica para os rins, ou secund?ria a alguma doen?a sist?mica pr?via. Histologicamente, a s?ndrome nefr?tica idiop?tica ( SNI ) ? definida pela combina??o das manifesta??es cl?nicas associadas ?s anormalidades histol?gicas inespec?ficas do rim, incluindo glomerulo esclerose focal e segmentar (GESF). A SN pode ser estudada, em modelo animal, por m eio de inje??es locais de Cloridrato de doxorrubicina ( Adriamicina? ) na dose de 7,5mg/kg em que, inje??o intravenosa ?nica pode induz ir protein?ria grave, semelhante ? observada em humanos. Embora os mecanismos patog?nicos da SNI persistam obscuros, altera ??es das respostas imunol?gicas , como as respostas at?picas dos linf?citos T e a atua??o de citocinas e quimiocinas, parecem estar envolvidas no dano aos glom?rulos. Neste sentido, a finalidade do presente estudo foi avaliar a participa??o de citocinas e q uimiocinas, por meio da express?o de IL - 1, IL - 4, CXCL1, CCL3/MIP - 1 e CCL5/RANTES em amostras de tecido renal e de urina, nos mecanismos de ativa??o e migra??o leucocit?ria, bem como as altera??es bioqu?micas, histol?gicas e biom?tricas em ratos com SN indu zida pela doxorrubicina. O protocolo experimental foi devidamente registrado e aprovado pela comiss?o de ?tica no uso de animais, da Universidade Federal dos Vales do Jequitinhonha e Mucuri (CEUA - UFVJM) sob o protocolo N? 029/2014. Foram utilizados 25 rato s machos ( Wistar ) , peso m?dio de 350 gramas e idade m?dia de seis semanas . Os animais foram divididos em dois grupos: CON (n=5), que recebeu inje??o endovenosa de solu??o salina como grupo controle e DOXO (n=25), que recebeu inje??o endovenosa de doxorrubi cina. Os animais do grupo DOXO foram eutanasiados e avaliados nos tempos 7, 14, 21 e 28 dias ap?s a inje??o. Foram coletadas amostras urin?rias (24 hs) e amostras sangu?neas ( pun??o card?aca). Ap?s a coleta sangu?nea, os ?rg?os foram perfundidos com solu?? o salina, sendo coletados os rins direito e esquerdo, que foram pesados e devidamente acondicionados , para posteriores an?lises biom?tricas, histol?gicas e imunol?gicas. A contagem total de leuc?citos foi realizada em c?mara de Neubauer. A avalia??o das am ostras urin?rias e teciduais para a detec??o de citocinas e quimiocinas foi realizada por ELISA. A nimais do grupo DOXO desenvolveram protein?ria a partir do 7 ? dia ap?s a inje??o de doxorrubicina , a qual permaneceu durante todo o per?odo experimental. O bse rvou - se, ainda, hipercreatininemia, altera??es biom?tricas , histol?gicas e dos leucogramas neste mesmo grupo . De modo geral, os animais expressaram maior concentra??o de citocinas e quimiocinas no tecido renal do que na s amostras de urina, sugestivo de um processo de secre??o relacionad o ? produ??o tecidual local. Al?m disso, o s resultados obtidos n o presente estudo proporciona ra m uma contribui??o in?dita em rela??o ? participa??o da quimiocina CXCL1 na fisiopatogenia da SN. Sua express?o n a urina pode r? es tar r elacionada com a instala??o das rea??es oxidativas nas fases iniciais da doen?a, conforme j? demonstrado por nosso grupo, nest e modelo experimental . Podendo, ainda, sugerir a participa??o de leuc?citos polimorfonucleares (neutr?filos) na etiopatogenia da SN , em sua fase inicial . Contudo, outros estudos ser?o necess?rios a fim de correlacionar a express?o tecidual d a citocina CXCL1 ? presen?a de neutr?filos no tecido renal e, consequente, produ??o de radicais livres neste modelo experimental de nefropat ia induzida pela doxorrubicina. / Disserta??o (Mestrado) ? Programa de P?s-gradua??o em Ci?ncias Farmac?uticas, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2018. / Nephrotic syndrome (NS) is defined by massive proteinuria, edema, hypoalbuminemia and hyperlipidemia and develops from th e lesion of the glomeruli, especially the podocytes. It can be a primary (idiopathic) change, as a specific disease for the kidneys, or secondary to some previous systemic disease. Histologically, idiopathic nephrotic syndrome (NIS) is defined by the combi nation of clinical manifestations associated with nonspecific histological abnormalities of the kidney, including f ocal and segmental glomerulosclerosis (GESF). SN may be studied in animal models by means of local injections of doxorubicin hydrochloride (Adriamycin?) at a dose of 7.5 mg/kg , in which single intravenous injection may induce severe proteinuria similar to that seen in humans. Although the pathogenic mechanisms of NIS persist obscure, changes in immune responses, such as atypical T lymphocyte re sponses and cytokine and chemokine activity, appear to be involved in damage to the glomeruli. In this sense, the purpose of the present study was to evaluate the participation of cytokines and chemokines through the expression of IL - 1, IL - 4, CXCL1, CCL3/M IP - 1 and CCL5/RANTES in renal and urine tissue samples in the activation and migration mechanisms as well as the biochemical, histological and biometric alterations in doxorubicin - induced SN rats. The experimental protocol was duly registered and approved by the Ethics Committee on Animal Use, Federal University of the Jequitinhonha and Mucuri Valleys (CEUA - UFVJM) under protocol No. 029/2014. Twenty - five male rats (Wistar), mean weight of 350 grams and mean age of six weeks, were used. The animals were divi ded into two groups: CON (n = 5), who received intravenous injection of saline as a control group and DOXO (n = 25), who received intravenous injection of doxorubicin. Animals from the DOXO group were euthanized and evaluated at times 7, 14, 21 and 28 days after injection. Urinary samples (24 h) and blood samples (cardiac puncture) were collected. After the blood collection, the organs were perfused with saline, and the right and left kidneys were collected, which were weighed and properly conditioned, for later biometric, histological and immunological analyzes. Total leukocyte count was performed in the Neubauer chamber. The evaluation of the urinary and tissue samples for the detection of cytokines and chemokines was performed by ELISA. Animals from the D OXO group developed proteinuria from the 7th day after the injection of doxorubicin, which remained throughout the experimental period. Hypercreatininemia, biometric, histological and leukogram changes were also observed in this same group. In general, the animals expressed a higher concentration of cytokines and chemokines in the renal tissue than in the urine samples, suggestive of a secretory process related to the local tissue production. In addition, the results obtained in the present study provided a n unprecedented contribution to the participation of chemokine CXCL1 in the pathophysiology of NS. Its expression in urine may be related to the establishment of oxidative reactions in the early stages of the disease, as demonstrated by our group in this e xperimental model . It may suggest the participation of polymorphonuclear leukocytes (neutrophils) in the etiopathogenesis of NS in its initial phase. However, other studies will be necessary in order to correlate the tissue expression of cytokine CXCL1 wit h the presence of neutrophils in the renal tissue and, consequently, the production of free radicals in this experimental model of nephropathy induced by doxorubicin.

Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2012-07-30T18:14:04Z No. of bitstreams: 1 Maria Brandão Tavares Insufuciencia renal aguda em pacientes....pdf: 663822 bytes, checksum: 274b01e71441d9fca8554368ed006f32 (MD5) / Made available in DSpace on 2012-07-30T18:14:04Z (GMT). No. of bitstreams: 1 Maria Brandão Tavares Insufuciencia renal aguda em pacientes....pdf: 663822 bytes, checksum: 274b01e71441d9fca8554368ed006f32 (MD5) Previous issue date: 2011 / Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, Bahia, Brasil / A insuficiência renal aguda é comum em pacientes com síndrome nefrótica, podendo requerer terapia de substituição renal e ser irreversível. A insuficiência renal aguda nesses pacientes pode ser precipitada por processos infecciosos, hipovolemia, drogas nefrotóxicas; entretanto na maioria dos casos a etiologia não é identificada e a insuficiência renal aguda é considerada idiopática. A necrose tubular aguda foi associada à insuficiência renal aguda em adultos com lesão mínima. O objetivo deste estudo é avaliar a correlação entre a necrose tubular aguda definida histologicamente com insuficiência renal aguda em pacientes com doença glomerular. Biópsias renais de pacientes com glomerulopatia foram analisadas quanto à intensidade da necrose tubular aguda e esses dados correlacionados com os dados clínicos e presença de insuficiência renal aguda. A análise foi realizada em duas amostras e a intensidade de necrose tubular aguda graduada de duas formas: na primeira amostra a intensidade de necrose tubular aguda foi graduada em cinco níveis de intensidade; na segunda amostra foi feita uma estimativa em percentual da área da cortical acometida. A acurácia da análise semiquantitativa na primeira amostra foi avaliada por meio da correlação com análise morfométrica relativa ao número de túbulos com características necróticas por área de cortical (Spearman r=0,88, P<0,0001) e ao percentual de área da cortical com necrose tubular aguda (Spearman r=0,93, P<0,0001). A reprodutibilidade da análise intraobservador foi regular (kappa=0,53, P<0,0001). A primeira amostra constou de 149 casos com idade média de 21±16 anos. A síndrome nefrótica esteve presente em 104 (72%) pacientes e os principais diagnósticos foram: doenças do espectro Lesão Mínima – Glomeruesclerose Segmentar e Focal (45%). Necrose tubular aguda foi observada em 114 (77%) pacientes. insuficiência renal aguda foi diagnosticada em 43 (42%) pacientes. Houve correlação positiva entre a intensidade da necrose tubular aguda e a presença de insuficiência renal (gamma=0,70, P<0,0001). A segunda amostra foi composta por 80 pacientes com idade média 32 ± 18 anos. Síndrome nefrótica foi diagnosticada em 72 (90%) casos e os principais diagnósticos foram as doenças do espectro lesão mínima-Glomeruloesclerose segmentar e focal (54, 68%). Necrose tubular aguda foi observada em 60 (75%) pacientes e insuficiência renal aguda foi diagnosticada em 28 (35%) casos. A intensidade de necrose tubular aguda foi maior nos pacientes com (29,1 ± 27,7) que nos pacientes sem insuficiência renal aguda (5.4 ± 5.1, P<0,0001). A presença de necrose tubular aguda apresentou alta especificidade para diagnóstico de insuficiência renal aguda quando estimada em 10% da cortical representada (especificidade 96,1%, curva ROC [AUC=0,832, P<0,0001]). Não houve diferença entre os grupos com e sem insuficiência renal aguda em relação ao sexo, proteinúria, doença renal e albumina sérica, colesterol e triglicérides. A freqüência de hipertensão arterial sistêmica foi maior no grupo com insuficiência renal aguda com idade mais elevada (P=0,015). / Acute renal failure is common in patients with nephrotic syndrome and may require substitutive renal therapy and be irreversible. Acute renal failure in these patients may be precipitated by infection, hypovolemia and nephrotoxic drugs. However, in most cases the etiology of acute renal failure is not identified and the condition is considered idiopathic. Acute tubular necrosis was associated with acute renal failure in adults with minimal change disease. The aim of this study is to estimate the association between the histologically defined acute tubular necrosis with acute renal failure in patients with glomerular disease. Renal biopsies of patients with renal disease were analyzed for the intensity of acute tubular necrosis and these data correlated with the clinical data incouding presence of acute renal failure. The analysis was performed on two samples and the intensity of acute tubular necrosis was estimated in two ways: in the first sample the intensity of acute tubular necrosis was graded into five levels of intensity, in the second sample an estimate was made of the percentage of cortical area affected by acute tubular necrosis. The accuracy of the semiquantitative analysis in the first sample was evaluated by correlation with morphometric estimate of the number of necrotic tubules in a given cortical area (Spearman r = 0.88, P <0.0001) and the percentage of cortical area with acute tubular necrosis (Spearman r = 0.93, P <0.0001). The intraobserver reproducibility of the analysis was fair (kappa = 0.53, P <0.0001). The first sample consisted of 149 cases with mean age of 21 ± 16 years. Nephrotic syndrome was present in 104 (72%) and the main diagnoses were: disease spectrum Minimal Change - Focal and Segmental glomerulosclerosis (45%). Acute tubular necrosis was observed in 114 (77%) patients. Acute renal failure was diagnosed in 43 (42%) patients. There was a positive correlation between the intensity of tubular necrosis and acute renal failure (gamma = 0.70, P <0.0001). The second sample consisted of 80 patients with mean age of 32 ± 18 years. Nephrotic syndrome was diagnosed in 72 (90%) and the main diagnoses were diseases of the spectrum, Minimal Change-Focal and segmental glomerulosclerosis (54, 68%). Acute tubular necrosis was observed in 60 (75%) patients and acute renal failure was diagnosed in 28 (35%). The intensity of acute tubular necrosis was higher in patients with (29 ± 8) than in patients without acute renal failure (5 ± 5, P <0.0001). The presence of acute tubular necrosis showed high specificity for diagnosis of acute renal failure when 10% of represented cortical had necrotic tubules (96.1% specificity, ROC curve [AUC = 0.832, P <0.0001]). No difference between groups with or without acute renal failure was observed in relation to gender, proteinuria, kidney disease and serum albumin, cholesterol and triglycerides. The frequency of hypertension was higher in patients with acute renal failure with higher age (P = 0.015).

Orientador: Vera Maria Santoro Belangero / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-13T01:13:35Z (GMT). No. of bitstreams: 1 Oliveira_IzadeCastro_M.pdf: 676306 bytes, checksum: f6b42aa8aa8314e5682d47b1b1333c87 (MD5) Previous issue date: 2009 / Resumo: A síndrome nefrótica (SN) é definida pela perda maciça de proteína pela urina associada à hipoalbuminemia, edema e dislipidemia. O tratamento específico em crianças e adolescentes com síndrome nefrótica é realizado com medicações imunossupressoras. Sabe-se que a terapia prolongada de corticoesteróides ocasiona efeitos colaterais como: hipertensão arterial, alterações no crescimento e fácies cunshigóides (caracterizada por distribuição atípica de gordura corporal). Estudou-se retrospectivamente e transversalmente todos os pacientes com síndrome nefrótica córtico dependente (SNCD) e córtico resistente (SNCR), acompanhados no Ambulatório de Nefropediatria da FCM-Unicamp, com o objetivo de avaliar a evolução de parâmetros clínicos e laboratoriais. O estudo foi dividido em duas etapas: a primeira com o objetivo de avaliar a prevalência de síndrome metabólica em pacientes com SNCD e SNCR, a partir do prontuário foram obtidos: idade do início da SN, o tempo de tratamento, o total de doses de esteróides (mg/kg/dia), uso prévio de ciclosporina. Peso, estatura, circunferência da cintura, glicemia e isulinemia foram determinados no início do presente estudo. A SM foi definida utilizando quatro definições anteriormente publicadas sendo estas: Cook et al (2003), Weiss et al (2004), Silva et al (2005) e Jollife et al (2007), no qual foram estudados 21 pacientes, com idade média de 12,38±3,4 anos. A prevalência de síndrome metabólica variou de 14,2% a 23,8%, dependendo da definição utilizada, A freqüência de sobrepeso foi de 19,0% (4 / 21) e de obesidade foi de 23,5% (5 / 21). Na avaliação de fatores predisponentes para síndrome metabólica somente foram estatisticamente significativos os seguintes: uso prévio de ciclosporina (p=0,042) e síndrome nefrótica secundária à doença sistêmica (p=0,041). O segundo fetapa teve como objetivo avaliar o crescimento e a composição corporal em crianças e adolescentes com SNCD, no qual foram estudados crianças e adolescentes, em acompanhamento no ambulatório de Nefropediatria da FCM-Unicamp. A partir do prontuário foram obtidos: idade do início da SN, o tempo de tratamento, o total de doses de esteróides (mg/kg e mg/kg/d), peso e estatura da primeira visita, e os valores da albuminemia, proteinemia total, colesterol total, a cada seis meses em todo o tempo de seguimento. Determinou-se a dose total do uso de corticosteróide. As avaliações antropométricas (circunferência muscular do braço, dobra tricipital) foram determinadas quando os pacientes não tinham edema clínico. Estatística não paramétrica foi utilizada com significância de p <0,05. Dezoito pacientes, onze do sexo masculino, com idades de 12,22 ± 2,98 anos. Os z-escore de estatura/idade inicial e final foram significativamente diferentes (-0,69 ± 0,80 e -2,07 ± 1,61 (p = 0.003)). A média de perda de z-escore de estaura/idade foi de -1,37 ± 1, 55. Apenas quatro pacientes mantiveram seu crescimento dentro da normalidade. Neste grupo, os valores de proteinúria residual foi menor do que aqueles que tinham um déficit de crescimento. A circunferência muscular do braço foi significativamente pior neste último grupo. Concluiu-se que a alta prevalência de sobrepeso e obesidade pode estar relacionada com a elevada prevalência da SM. Além disso, o uso de ciclosporina e à presença do de doenças sistêmicas também são fatores predisponentes para o SM. O beneficio da corticoterapia na SNCD para obtenção da melhora da proteinúria e da hipoalbuminemia deve ser questionado em função dos seus efeitos colaterais irreversíveis sobre o crescimento e comprometimento da massa magra nesses pacientes, pois outros problemas como alterações de vitamina D e de insuficiência renal crônica pode ser minimizada durante o tratamento / Abstract: Nephrotic syndrome is characterized for massive proteinuria, edema and hyperlipidemia. The basis of treatment is immunosuppressive drugs meanly corticosteroids and cyclosporine. As the disease recurs, the treatment is prolonged and many collateral effects can be met. So arterial hypertension, growth failure and Cushing syndrome exogenous are common. Patients with cortico-depedent and cortico resistant were evaluated regardless to clinical and laboratorial aspects. The study was made in two fases: the first had as objective to evaluate the prevalence of metabolic syndrome (MS) in children and adolescents with steroid dependent (SDNS) and steroid resistant (SRNS) nephritic syndrome (NS). All children followed at the Pediatric Nephrology Unit, aged from five to eighteen with SDNS or SRNS. From the medical records were gotten: age of the start of NS, time of treatment, total doses of steroids (mg/kg/dial), previous use of cyclosporine. Weight, stature, waist circumference, glicemia and isulinemia were determined in the beginning of this study. The MS was defined using four previous published definitions by: Cook et al (2003); Weiss et al (2004); Silva et al (2005) e Jollife et al (2007). Twenty one patients, twelve male, media of age of 12.4±3.4 years old. The prevalence of MS varied from 14.28% (3/21) to 23.8% (5/21) according the MS definition. The frequency of overweight was 19.0% (4/21) and the obesity was 23.5% (5/21). In the assessment of predispose factors associated with MS only were statically significant the previous use of cyclosporine (p=0.042), the presence of NS due to systemic disease (p=0.041) and obesity (p=0.008). In the second part the objective was to evaluate the growth and body composition in children and adolescents with steroid-dependent nephrotic syndrome (SDNS). All children followed at the Pediatric Nephrology Unit, aged from five to eighteen with SDNS. From the medical records were gotten: age of the start of NS, time of treatment, total doses of steroids (mg/kg and mg/kg/d), weight and stature of the first visit and the values of albuminemia, total proteinemia, total cholesterol, every six months in all time of the follow-up. It was determined the total dosis of the use of corticosteroid. The anthropometric evaluations (arm muscle circumference, triceps skinfold) were determined when the patients had no clinical edema. Non parametric statistics was used with significance of p<0,05. Eighteen patients, eleven male, aged of 12,22±2,98 years old. Initial and final z score stature/age were significantly different (-0,69 ± 0,80 and -2,07 ± 1,61 (p=0,003). The media of loss of z score was -1,37±1,55. Only four patients keep their growth rate. In these group, the values of residual proteinuria was less than those one that had growth deficit. The arm muscle circunference was significantly worse in this last group. It was concluded that the high prevalence of overweight and obesity could be evolved in the high prevalence of MS. Besides that, the use of cyclosporine and the presence of system disease are also predispose factors to MS. For steroid dependent patients the use of steroids must be used with concerning the adverse effects upon growth since that is the most important cause of failure to thrive, because other problems like alterations of vitamin D and chronic renal failure can be minimized / Mestrado / Saude da Criança e do Adolescente / Mestre em Saude da Criança e do Adolescente

Abstract Congenital nephrotic syndrome of the Finnish type (NPHS1, CNF) is an autosomal recessive disease that affects 1:8000 newborns in Finland. NPHS1 is characterised by heavy proteinuria already in utero and typical signs of nephrotic syndrome (NS) are present at or soon after birth. Due to the evident absence of extrarenal symptoms, NPHS1 has been considered a model disease for NS. In this study, the NPHS1 locus on chromosome 19q13.1 was sequenced and analysed with computer programs to identify new genes in the region. Genes were further characterised and sequenced from NPHS1 patient samples, as well as from controls. Analysis of the data resulted in the identification of the affected gene with two mutations that were found to explain 94% of the Finnish NPHS1 cases. The NPHS1 gene was found to encode a novel single-pass transmembrane protein, termed nephrin, which belongs to the immunoglobulin superfamily of cell adhesion molecules. The NPHS1 gene was cloned and recombinant nephrin fragments were produced in prokaryotic and eukaryotic expression systems. These fragments were used to raise antibodies that were utilized to characterise the spatial and temporal expression of nephrin in kidney glomeruli. Nephrin was localised by electron microscopy (EM) in ladder-like structures of the early junctional complexes of developing columnar podocytes at the capillary stage. In mature glomeruli, nephrin was localised to the slit diaphragm (SD) between adjacent glomerular podocyte foot processes. In order to investigate the more general involvement of nephrin in proteinuric disease, its expression was studied in primary acquired NS by immunofluorescence microscopy. The level of nephrin expression was found to be significantly reduced in membranous glomerulonephritis, minimal change disease and in focal segmental glomerulosclerosis. The known effects of nephrin mutations, together with the structure predicted from its sequence and localisation of the protein to the SD, emphasizes its indispensable role in maintaining the integrity of the glomerular filtration barrier. The glomerular basement membrane has long been considered to possess the size-selective filtration property of the filtration barrier. However, the identification of nephrin in the SD, as well as its alterations in proteinuria, has led us to reconsider SD as the final decisive size-selective filter.

L'apparition d'une protéinurie néphrotique constitue un effet secondaire aux thérapies ciblées anti-angiogéniques utilisées en oncologie (anti-VEGF ligand et les inhibiteurs de récepteurs tyrosine kinase). Dans ces travaux, nous avons étudié 29 patients traités par ces thérapies. 8 d'entre eux ont développé des lésions glomérulaires minimes ou hyalinose segmentaire et focale (LGM/HSF) majoritairement suite au traitement par les inhibiteurs des récepteurs tyrosine kinases (RTKIs) et 13 présentaient principalement des lésions de microangiopathie thrombotique (MAT) après thérapie anti-VEGF ligand. Dans cette étude, nous avons mis en évidence que c-mip est un acteur majeur du développement de protéinurie néphrotique consécutive aux traitements par les RTKIs. En effet, le Sorafenib (RTKI) induit l’expression de c-mip en inhibant l’activité de RelA et ce mécanisme serait impliqué dans le déclenchement des lésions LGM/HSF. Le rôle de c-mip dans la physiopathologie des podocytopathies acquises nous a conduit à générer un modèle murin d'invalidation de c-mip, conditionnelle et spécifique du podocyte. Les souris déficientes pour c-mip ont été étudiées dans deux modèles expérimentaux de protéinurie, induits par le LPS et le Sorafenib, respectivement. Dans les deux modèles, la protéinurie était significativement atténuée chez les souris déficientes avec préservation de l'architecture glomérulaire en comparaison des souris témoins. Le sorafenib a entraîné chez les souris témoins des lésions glomérulaires caractérisées par des rétractions du floculus, des thrombi intraglomérulaires et des lésions podocytaires. Ces résultats suggèrent que le sorafenib constitue un nouveau modèle murin d'induction d'une glomérulopathie expérimentale et que l'invalidation de c-mip spécifiquement dans le podocyte confèrerait une résistance au développement de protéinurie et de lésions rénales, suggérant que c-mip serait une cible thérapeutique potentielle. / Nephrotic proteinuria constitutes a serious side effect of anti-angiogenic therapies commonly used in oncology (anti-VEGF and tyrosine kinase receptorinhibitors, RTKI). In this work, we studied 29 patients treated by anti-angiogenic therapies. Eight of them developed minimal change nephrotic syndrome and focal and segmental glomerulosclerosis (MCNS/FSGS), mainly after RTKI treatment, and 13 underwent thrombotic microangiopathy lesions, mostly associated with anti-VEGF ligand therapy. C-mip overexpression was strongly related to the onset of nephrotic proteinuria after RTKI. Sorafenib (RTKI) induced c-mip expression by inhibiting RelA activity, ultimately leading to MCNS/FSGS. To confirm and clarify the pathophysiological role of c-mip in acquired podocytopathies, we generated a conditional, podocyte-specific c-mip knock-out mouse model. C-mip knockout mice were subjected to two experimental models of proteinuria, induced by LPS and Sorafenib, respectively. In each model, proteinuria was significantly decreased in cmip-invalidated mice, while glomerular architecture was preserved as compared to control mice. In the latter, Sorafenib led to glomerular tuft retractions, intraglomerular thrombi and podocyte lesions. This is suggested as the first experimental model of RTKI-induced glomerulopathy. Moreover, the podocyte specific knock out of c-mip confers resistance to proteinuria and renal injury, confirming c-mip as a potential therapeutic target in idiopathic nephrotic syndrome.

ABSTRACT: Hepatitis C virus (HCV) is associated with various glomerulopathies and nephrotic syndrome. However nephrotic syndrome following treatment is rare. Ledipasvir/sofosbuvir (L/S) has recently come into favor in treating HCV due to its relatively mild side effects compared to the more traditional interferon therapy. To the best of our knowledge, there are no reported cases of nephrotic syndrome following treatment with L/S. We present a case of nephrotic syndrome suspected secondary to L/S in a patient with chronic kidney disease. Increased vigilance when assessing therapeutic options in HCV patients with renal comorbidities can improve patient outcomes. A 63 year-old male patient presented to the hospital with shortness of breath, and a two-week history of bilateral lower extremity edema. Past medical history was significant for liver cirrhosis secondary to Hepatitis C genotype Ia, hepatocellular carcinoma status post liver transplantation 6 months prior to admission and Stage 3b chronic kidney disease with baseline creatinine (Cr) approximately 1.5 mg/dl. Medications included L/S for HCV and tacrolimus and prednisone for post-transplant treatment. Patient’s vitals were stable and physical exam was remarkable for facial swelling, mainly on the eyelids, decreased breath sounds bilaterally, distended abdomen with a fluid wave, and 2-3+ pitting edema up to the knees on lower extremities bilaterally. Laboratory work-up was remarkable for low albumin of 3.0 g/dl, and total protein of 5.6 g/ dl. Creatinine of 1.8 mg/dl was elevated from patient’s baseline. HCV viral load was undetectable and electrolytes, transaminases and the complete blood count were within normal limits. Subsequently, urine protein to creatinine ratio was measured because of generalized swelling and hypoproteinemia, which was found to be significantly high at 8.80, compared to 0.04 one year prior. 24-hour total urine protein was found to be 2065 mg/day. Renal ultrasonography showed no hydronephrosis and was otherwise unremarkable. Renal biopsy however, revealed changes suggestive of membranoproliferative glomerulonephritis (MPGN] most likely secondary to HCV. No immune complexes, lambda/kappa light chains, or cryogloblin were appreciated. Nephrotoxic agents such as diuretics and corticosteroids were held. Tacrolimus trough was appropriate to dose level and was continued along with L/S. As admission progressed the patient’s creatinine continued to get worse and rose up to 4.3 mg/dl with persistent proteinuria. With tacrolimus trough levels within normal limits and given L/S was the most recently initiated drug, L/S was thought to be the culprit and was thus held. The renal function began to improve gradually, and the patient was discharged in stable condition with close follow up. Follow up one month later found creatinine and renal function return to baseline and proteinuria resolved. Our case shows that Ledipasvir/sofosbuvir may possibly be related to nephrotic syndrome in HCV patients. Although further studies are needed to prove the causality our case seeks to raise clinical suspicion and increase vigilance when assessing therapeutic options in HCV patients with renal comorbidities such as chronic kidney disease.

No description available.