Revista da Sociedade Brasileira de Medicina Tropical
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REFERÊNCIA
BINA, José Carlos et a . A field study of proteinuria in individuals infected with Schistosoma
mansoni. Revista da Sociedade Brasileira de Medicina Tropical, Uberaba, v. 18, n. 1, p. 7-10,
jan./mar. 1985. Disponível em:
<http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0037-86821985000100003&lng=en&nrm=iso>. Acesso em: 13 nov. 2017. doi:
http://dx.doi.org/10.1590/S0037-86821985000100003.
R evista da Sociedade B rasileira de M e dicina Tropical 18(1): 7-10, Jan-M ar, 1985
ARTIGOS
A FIELD STUDY OF PROTEINURIA IN INDIVIDUALS INFECTED WITH
SCHISTOSOMA M ANSONI
José Carlos B in a1, Zilton A. A nd rad e1, Reynaldo D ie tze
2
and A luízio Prata2
Proteinuria was detected in 2 4 .7 % o f 8 9 individuais with hepatosplenic schistosom iasis a n d in only 4.6% o f 86 subjects with m ild hepato-intestinal schistosom iasis, a li o f them living in com parable conditions in two endem ic areas in B ahia, B razil. F rom nine individuais who h adproteinuria o v e r3 0 mg/lOOml, eight had hepatosplenic schistosom iasis. These fin d in g s m a y be related to the presence o f schistosom al nephropathy a n d reveal the significance o f this condition in th e fie ld in endem ic areas o f schistosom iasis.
K ey words: Schistosom a m ansoni. Proteinuria. F ield study. Schistosomal nephropathy.
It has been documented that renal lesions appear to be associated with hepatosplenic schisto- somiasis mansoni in man1 2 3 There are many types of glomerular changes present but usually they are represented by chronic diffuse membrano-proliferative glomerulonephritis with lobular accentuation, and the nephrotic syndrome is the main form o f clinicai presentationó 15 16 Schistosomal antigens and several classes of immunoglobulins and complement have been detected in the glomerular lesions both in humans^H and in experimental animais"^ 7 12 14 Therefore, this feature o f hepatosplenic schistosomiasis is considered a good example o f immunocomplex disease produced by a parasitic infection. However, the clinicai significance o f renal involvement in subjects living in endemic areas, as opposed to hospitalized patients, has not been determined. The only previous attempt was that o f Lehman et a l1®.
The present study represehts an attem pt to investigate the significance o f proteinuria in infected people living in tw o endemic areas o f schistosom iasis in Bahia, Brazil.
M A T E R IA L A N D M E T H O D S
This study involved the quantitative estim ation of proteinuria and arterial blood pressure from 175 individuais living in Taquarendi and C aatinga do
Supported by C N P q , project P ID E V, process n? 3651/82. 1. C entro de Pesquisas G onçalo M oniz (F IO C R U Z /U F B a ),
Salvador - BA.
2. N úcleo de M edicina Tropical e N utrição, Universidade de Brasília, Brasília, Brasil.
R ecebido p ara publicação em 2 9 /8 /1 9 8 4 .
M oura, Bahia-Brazil, two highly endemic areas of schistosom iasis. T hese individuais were ali included in a longitudinal study and have been observed during several years. The majority have been treated, but re- infection seems to occur frequently. Ali the subjects were infected with S. m ansoni as determ ined by fecal exam ination perform ed by a quantitative method9. Following the criteria of P rata and B ina13 for the clinicai classification of schistosom iasis, subjects were divided into two groups: a) hepatointestinal group with 86 cases, and b) hepatosplenic group with 89 cases. Ali the patients with hepatosplenic schistosomiasis were included in the study. T hey showed an enlarged, sometimes nodular and hard liver, with prominent hypertrophy of the left lobe, and splenomegaly. A ctually, some o f them have had splenectom y in the past. F o r the purpose of the present study the hepato intestinal (mild, usually assym ptom atic infection) and hepatosplenic cases were paired whenever possible by age, sex and preferentially included those individuais from the same family or living in the same house. F or the determ ination of proteinuria, urine was collected in clean glass bottles, and tested imm ediately by Labstix (Am es C o.), at the time the patients were clinically re- examined. A li the individuais examined were perform- ing their usual work routine, only had mjld, vague com plaints, and a t clinicai exam ination did not seem to have any m ajor associated diseases. Results of proteinuria were quantitatively expressed as “ traces” , 30, 100, 300 and above 2,000m g per lOOml.
A rterial blood pressure was taken by the usual sphygm om anom eter method with the subject seated. Values above 140 x 90mmHg were considered as hypertension.
B in a JC , A n d ra d e Z A , D ie tz e R , Prata A. A Jle ld s tu d y o fproteinuria in individuais infected with Schistosom a mansoni. R evista da Sociedade B rasileira de M edicina T ropical 18: 7-10, Jan-M ar, 1985
R E S U L T S
Age and sex o f the individuais studied appear in Table 1. The youngest was 9 years old and the two groups considered are shown in Table 2. The total prevalence of proteinuria reaehed 14.8% , with 24.7% for hepatosplenic and 4.6% for the hepato-intestinal cases
( X l = 13.41 < 0.001), with no difference due to sex.
O fthe 26 individuais with proteinuria, 9 o f them could be considered to have striking proteinuria (above
3 0 m g /1 OOml), and only one o f the latter did not belong to the hepatosplenic group. The prevalence o f arterial hypertension was 22.2% (39 /1 7 5 ). Among the hypertensive subjects with proteinuria, 6.2% belonged to the hepato-intestinal group and 26.0% to the hepatosplenic group, as can observed in Table 3. Itc a n also be observed th at from the 39 subjects showing high blood pressure only 7 of them (17.9% ) presented proteinuria.
Table 1 - A ge and sex o f 175 cases o f schistosom iasis presented in this study
Age (years) Sex case M ale control case F em ale control Np Total % < 20 6 9 6 8 29 (16,6) 20 - 29 6 13 5 6 30 (17,1) 30 - 39 10 8 11 12 41 (23,5) 40 - 49 5 9 14 6 34 (19,4) 50 - 59 5 8 17 1 31 (17,7) 60 or over 2 2 3 3 10 ( 5,7) Total 34 49 56 36 175 (100,0)
Table 2 - Prevalence o f proteinuria according to clinicai fo r m s o f schistosom iasis
Clinicai fo rm s
Np Proteinuria
Cases Positive (% ) N egative (% )
Hepato-intestinal Hepatosplenic 86 89 4 22 (4.6) (24.7) 82 67 (95.4) (75.3) Total 175 26 (14.8) 149 (85.2) Z 2 = 13.91 < 0 .0 0 1
The egg-load varied from 24 to 9,120 eggs be observed in Table 4. It can be noted th at ali peo-per gram of feces, and did not seem to correlate ple with proteinuria had less than 500 eggs per with the presence or degree o f proteinuria, as can gram o f feces.
Table 3 - Prevalence ofp ro tein u ria in cases o f schistosom iasis in relation to clinicai fo r m s a n d the presence o f arterial hypertension
H ypertension N o hypertension
Clinicai
---fo rm s no no
proteinuria proteinuria T otal proteinuria proteinuria Total Np (% ) NP (% ) Np (% ) Np (% ) NP (% ) Np (% )
H epato-intestinal 1 ( 6.2) 15 (93.8) 16 (100.0) 3 ( 4.3) 67 (95.7) 70 (100.0) Hepatosplenic 6 (26.0) 17 (74.0) 23 (100.0) 16 (24.3) 50 (75.7) 66 (100.0) Total 7 (17.9) 32 (82.1) 39 (100.0) 19 (13.9) 117 (86.1) 136 (100.0)
B in a J C , A n d ra d e Z A , D ie tz eR , P rata A. A fie ld study o f proteinuria in individuais infected with Schistosom a m ansoni Revista da Sociedade B rasileira de M edicina Tropical 18: 7-10, Jan-M ar, 1985
Table 4 -P r e v a le n c e o f proteinuria in relation to fe c a l egg-load in 175 subjects with schistosom iasis
Proteinuria
N.° eggs p e r gram o f feces
Total not done < 5 0 0 500 - 1000 > 1000 Present 2 24 0 0 26 A bsent 10 121 11 7 149 T otal 12 145 11 7 175 D IS C U S S IO N
Proteinuria, but not arterial hypertension, was found in the present study to be more prevalent in hepatosplenic than in mild or asym ptom atic schis tosom iasis. T hese fmdings are apparently in disa- greement with those of Lehm an et a l 1^ who found no correlation betw een proteinuria and splenomegaly in subjects infected with S. m an so n i and living in the field. H ow ever, they found an incidence o f 35.4% o f people with splenomegaly in their series. This is well above the usual 4-6% incidence o f hepatosplenic schistosom iasis observed in endemic areas o f Brazil^ and probably indicates th at not ali cases of splenome galy included in the study of Lehm an e t a l1(^ represented hepatosplenic schistosom iasis. This is an im portant point, because schistosom al glom erulopathy seems to be restricted to patients with hepatosplenic schisto som iasis1 5. A pparently portal hypertension and the consequent collateral circulation are criticai changes that serve to divert antigens, and/or immunocomplexes, generated in the portal system , from the Kupffer cell fllter to the kidneys1819.
T he prevalence o f proteinuria found in this field study am ongst hepatosplenic cases was 24.7% which is more impressive than the 15.0% o f renal disease present in patients with hepatosplenic schistosom iasis seen in our hospitais15 or the 12.0% incidence of chronic glomerulonephritis observed in autopsied
c a s e s ^ . O ur study is therefore in keeping with the concept o f schistosom al nephropathy and shows that renal involvem ent could be an im portant feature to be considered in hepatosplenic schistosom iasis in the endemic areas. Although proteinuria defined as “ traces” m ay not be significant, a clear cut difference of its prevalence was seen for the two groups. It represents values from 10 to 15mg per lOOml and can be considered as the upper physiological limits according to Souza e t a l17, who studied the elimination o f urinary protein in Brazilians. H ow ever w hen we consider expressive proteinuria (above 30m g/100m l) the dif
ference between hepatosplenic to hepato-intestinal schistosom iasis becomes striking, despite the small number of cases considered.
F rom ouro w n experience, arterial hypertension seems to be a frequent occurrence in people living in the interior o f the State o f Bahia, Brazil. Its causes and signficance needs investigation. It did not correlate, with hepatosplenic schistosom iasis in this present study, although one single blood pressure determina- tion is not an adequate m ethod to com pletely exclude this condition.
R E S U M O
Proteinúria f o i detectada em 2 4 ,7 % de 89 pacientes com a fo rm a hepatoesplênica da esquistos- som ose e em apenas 4,6% de 86 pacientes com a fo rm a hepatointestinal dessa parasitose. Todos os pacientes viviam em condições epidemiológicas se
m elhantes em d uas áreas endêm icas da Bahia, Brasil. D os nove indivíduos que tinham proteinúria acim a de 30m g/100m l, oito tinham a fo rm a hepa toesplênica da doença. E stes achados p o d em estar relacionados à presença de um a glom erulopatia esquistossom ótica e m ostra o significado desta con dição no cam po, em áreas endêm icas de esquistos- somose.
P alavras chaves: Schistosom a mansoni. Pro teinúria. E stu d o de campo. N efropatia esquistos som ótica.
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