artigo dE rEvisão rEviEw articlE RESUMO A vitamina K é lipossolúvel, principalmente, na coagulação sanguínea. Se apresenta sob as formas de filoquinona (K 1-predominante), dihidrofiloquinona (dK), menaquinona (K 2) e menadiona (K 3). Os fatores que interferem em sua absorção são: má absorção gastrintestinal, secreção biliar, ingestão insuficiente e uso de anticoagulantes, entre outros. As principais fontes de vitamina K são os vegetais e óleos, sendo esses os responsáveis pelo aumento da absorção da filoquinona. Os alimentos folhosos verde escuro, os preparados à base de óleo, oleaginosas e frutas como o kiwi, abacate, uva, ameixa e figo contêm teores significantes de vitamina K, enquanto que os cereais, grãos, pães e laticínios possuem teores discretos. A ingestão diária de aproximadamente 1µg por quilo de peso é considerada a mais segura, inclusive para a utilização de anticoagulantes orais, em que a concentração estável da vitamina proporciona a eficácia no tratamento. A droga anticoagulante oral geralmente utilizada é a varfarina, administrada como profilática e para tratamento de fenômenos tromboembólicos. Essa intervenção medicamentosa é monitorada pelo tempo de protrombina expresso pela razão normalizada internacional, tendo como objetivo estabelecer a faixa terapêutica entre 2 e 3, minimizando o risco de hemorragias. O efeito anticoagulante pode ser reduzido por fatores como ganho de peso, diarréia, vômito, idade menor que 40 anos e consumo excessivo de vitamina K na dieta alimentar.

The aim of this study was to analyze vitamin D levels and their association with bone mineral density and body composition in primary antiphospholipid syndrome. For this cross-sectional study 23 premenopausal women with primary antiphospholipid syndrome (Sapporo criteria) and 23 age- and race-matched healthy controls were enrolled. Demographic, anthropometric, clinical and laboratorial data were collected using clinical interview and chart review. Serum 25-hydroxyvitamin D levels, parathormone, calcium and 24-hour urinary calcium were evaluated in all subjects. Bone mineral density and body composition were studied by dual X-ray absorptiometry. The mean age of patients and controls was 33 years. Weight (75.61 [20.73] vs. 63.14 [7.34] kg, p = 0.009), body mass index (29.57 [7.17] vs. 25.35 [3.37] kg, p = 0.014) and caloric ingestion (2493 [1005.6] vs. 1990 [384.1] kcal/day, p = 0.03) were higher in PAPS than controls. All PAPS were under oral anticoagulant with INR within therapeutic range. Interestingly, biochemical bone parameters revealed lower levels of 25-hydroxyvitamin D [21.64 (11.26) vs. 28.59 (10.67) mg/dl, p = 0.039], serum calcium [9.04 (0.46) vs. 9.3 (0.46) mg/dl, p = 0.013] and 24-hour urinary calcium [106.55 (83.71) vs. 172.92 (119.05) mg/d, p = 0.027] in patients than in controls. Supporting these findings, parathormone levels were higher in primary antiphospholipid syndrome than in controls [64.82 (37.83) vs. 44.53 (19.62) pg/ml, p = 0.028]. The analysis of osteoporosis risk factors revealed that the two groups were comparable (p > 0.05). Lumbar spine, femoral neck, total femur and whole body bone mineral density were similar in both groups (p > 0.05). Higher fat mass [28.51 (12.93) vs. 20.01 (4.68) kg, p = 0.005] and higher percentage of fat [36.08 (7.37) vs. 31.23 (4.64)%, p = 0.010] were observed in PAPS in comparison with controls; although no difference was seen regarding lean mass. In summary, low vitamin D in primary antiphospholipid syndrome could be secondary to higher weight and fat mass herein observed most likely due to adipocyte sequestration. This weight gain may also justify the maintenance of bone mineral density even with altered biochemical bone parameters.

The authors reviewed the infl uence of nutritional factors on systemic lupus erythematosus (SLE) and discussed an alternative treatment option. The autoimmunity and infl ammatory process of SLE are related to the presence of dyslipidemia, obesity, systemic arterial hypertension, and metabolic syndrome, which should be properly considered to decrease cardiovascular risk. A diet with moderate protein and energy content, but rich in vitamins, minerals (especially antioxidants), and mono/ polyunsaturated fatty acids can promote a benefi cial protective effect against tissue damage and suppression of infl ammatory activity, in addition to helping the treatment of those comorbidities. Diet therapy is a promising approach and some recommendations may offer a better quality of life to patients with SLE.

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ResumoObjetivo: Avaliar a eficácia da intervenção nutricional na redução do excesso de peso (EP), em pacientes com síndrome do anticorpo antifosfolípide (SAF). Métodos: Incluídos 40 pacientes, acima de 18 anos, com diagnóstico de SAF primária ou secundária, acompanhados no Serviço de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP) e recrutados no período de outubro de 2005 a fevereiro de 2006. Foram coletados dados demográficos e realizados a revisão de prontuários, a mensuração de peso e da altura, o cálculo do índice de massa corpórea (IMC) atual e a adequação da dieta pelo IMC ideal. Foi realizada avaliação na primeira consulta e após intervalo mínimo de dois meses. Resultados: A média de idade dos pacientes foi de 41 anos, sendo 93% de mulheres. Os pacientes com SAF primária perfaziam 25%, com média de dois anos da doença. A trombose venosa ocorreu em 63%, arterial em 48% e manifestações obstétricas em 27%. Na primeira consulta, 68% apresentavam EP, 27% eram eutróficos e 5% estavam com baixo peso (BP). Após três meses de intervenção, os eutróficos mantiveram o peso e os de BP tornaram-se eutróficos, segundo o IMC. Interessantemente, entre os pacientes com EP (n = 27), 82% emagreceram, 14% engordaram e 4% se mantiveram. Especificamente, 11 pacientes apresentaram 1% a 3% de perda ponderal de peso, oito perderam de 4% a 7%, dois reduziram 8% a 9% e um reduziu 13,6% com o acompanhamento nutricional. Conclusão: Foi demonstrado no presente estudo que a intervenção nutricional conseguiu atingir metas para redução de peso, possibilitando diminuição no risco trombótico num curto período, sendo, portanto, uma modalidade terapêutica inicial e de eleição para corrigir o EP em pacientes com SAF.Palavras-chave: síndrome do anticorpo antifosfolípide, obesidade, trombose, síndrome metabólica, sobrepeso, excesso de peso. AbstRActObjective: To evaluate the efficacy of the nutricional intervention in the loss of the weight excess (WE), in patients with the antiphospholipid antibody syndrome (APS). Methods: Forty patients older than 18 years-old were included, with a diagnosis of either primary or secondary APS, followed at the the Rheumatology Outpatient Clinic from HCFM-USP and were recruited between october/2005 and february/06. Demographic data and patient records were reviewed. Body weight, height and current Body Mass Index (BMI) were recorded as well as diet adjustment according to ideal BMI. Patients were subjected to a first medical and nutritional evaluation and subsequently at least 2 months after baseline. Results: The mean age was 41 years old and 93% of the patients were female. The patients with primary APS were 25%, the mean disease duration was 2 years. Venous thrombosis occurred in 63%, arterial in 48% and obstetric events in 27%. In the first consultation 68% presented WE, 27% were euthrophic and 5% were of low weight (LW). After three months of intervention, the eutrophics maintained body weight while those with LW became eutrophic. Among the patients wit...

To describe the case of a patient with celiac disease who achieved a complete response to a gluten-free diet. A 28-year-old woman presented with diarrhea, oral ulcers, and refractory uveitis of 2.5-years duration. She was treated with prednisone, mydriatic drops, and infliximab with no response. She was referred to our hospital at which point her previous diagnosis of uveitis was confirmed; she was also diagnosed with right-sided sacro-iliitis. The patient did not have arthritis or any skin conditions. Three tests for fecal parasites and a fecal leukocyte were negative. Endoscopy revealed atrophic appearance of the duodenal mucosa. Biopsy showed atrophy of the duodenal villi with intra-epithelial lymphocytes, hyperplasia of the crypts, and chronic inflammatory infiltrate. The search for antiendomysial antibody was >1/1,280. The patient was started on a gluten-free diet and after 3 months demonstrated significant improvement of gastrointestinal symptoms and uveitis, as well as a reduction of antiendomysial antibodies (1/80). After 6 months, there was complete remission of gastrointestinal symptoms and total control of uveitis. The antiendomysial antibody was negative at that time. Clinical uveitis as a manifestation of celiac disease has been described in only two cases in the literature. This case study is the third to demonstrate that uveitis is a clinical symptom that can be addressed in patients with celiac disease.

There are several issues regarding diet in patients with antiphospholipid syndrome. This article focuses on main factors such as vitamin K ingestion and its relationship with anticoagulants and healthy diet for obesity, dyslipidemia, hypertension, diabetes mellitus that are important risk factors for hypercoagulability. Last, diet rich in calcium is also important since these patients are under anticoagulants and heparins that are related to osteoporosis/osteopenia. The medical follow-up in combination with nutrition counseling was carried out for guiding patients to acquire healthy habits in order to improve their quality of life and gain control of the comorbidities.

A síndrome do anticorpo antifosfolípide (SAF) é uma doença autoimune caracterizada pela presença do anticorpo antifosfolípide (aPL) associada à trombose e/ou morbidade gestacional. O tratamento da síndrome, na presença de um evento trombótico, consiste na anticoagulação com antagonista de vitamina K (varfarina), sendo seu monitoramento necessário para que se evitem complicações como sangramento e novos eventos trombóticos. A checagem das interações medicamentosas e dietéticas minimiza os riscos do tratamento. O controle dos fatores de risco por meio de hábitos saudáveis é meta importante no tratamento, a fim de obter melhora na qualidade de vida bem como aumento de sobrevida do paciente. Unitermos: Dicas para pacientes. Dieta na síndrome do anticorpo antifosfolípide. Hábitos de vida. Interações. Varfarina.