COVID-19 Computed tomography patterns in renal replacement therapy patients / Padrões de tomografia computadorizada da COVID-19 em pacientes em terapia renal substitutiva

ABSTRACT Introduction: Lung diseases are common in patients with end stage kidney disease (ESKD), making differential diagnosis with COVID-19 a challenge. This study describes pulmonary chest tomography (CT) findings in hospitalized ESKD patients on renal replacement therapy (RRT) with clinical suspicion of COVID-19. Methods: ESKD individuals referred to emergency department older than 18 years with clinical suspicion of COVID-19 were recruited. Epidemiological baseline clinical information was extracted from electronic health records. Pulmonary CT was classified as typical, indeterminate, atypical or negative. We then compared the CT findings of positive and negative COVID-19 patients. Results: We recruited 109 patients (62.3% COVID-19-positive) between March and December 2020, mean age 60 ± 12.5 years, 43% female. The most common etiology of ESKD was diabetes. Median time on dialysis was 36 months, interquartile range = 12-84. The most common pulmonary lesion on CT was ground glass opacities. Typical CT pattern was more common in COVID-19 patients (40 (61%) vs 0 (0%) in non-COVID-19 patients, p < 0.001). Sensitivity was 60.61% (40/66) and specificity was 100% (40/40). Positive predictive value and negative predictive value were 100% and 62.3%, respectively. Atypical CT pattern was more frequent in COVID-19-negative patients (9 (14%) vs 24 (56%) in COVID-19-positive, p < 0.001), while the indeterminate pattern was similar in both groups (13 (20%) vs 6 (14%), p = 0.606), and negative pattern was more common in COVID-19-negative patients (4 (6%) vs 12 (28%), p = 0.002). Conclusions: In hospitalized ESKD patients on RRT, atypical chest CT pattern cannot adequately rule out the diagnosis of COVID-19.

RESUMO Introdução: Doenças pulmonares são comuns em pacientes com doença renal em estágio terminal (DRET), dificultando o diagnóstico diferencial com COVID-19. Este estudo descreve achados de tomografia computadorizada de tórax (TC) em pacientes com DRET em terapia renal substitutiva (TRS) hospitalizados com suspeita de COVID-19. Métodos: Indivíduos maiores de 18 anos com DRET, encaminhados ao pronto-socorro com suspeita de COVID-19 foram incluídos. Dados clínicos e epidemiológicos foram extraídos de registros eletrônicos de saúde. A TC foi classificada como típica, indeterminada, atípica, negativa. Comparamos achados tomográficos de pacientes com COVID-19 positivos e negativos. Resultados: Recrutamos 109 pacientes (62,3% COVID-19-positivos) entre março e dezembro de 2020, idade média de 60 ± 12,5 anos, 43% mulheres. A etiologia mais comum da DRET foi diabetes. Tempo médio em diálise foi 36 meses, intervalo interquartil = 12-84. A lesão pulmonar mais comum foi opacidades em vidro fosco. O padrão típico de TC foi mais comum em pacientes com COVID-19 (40 (61%) vs. 0 (0%) em pacientes sem COVID-19, p < 0,001). Sensibilidade 60,61% (40/66), especificidade 100% (40/40). Valores preditivos positivos e negativos foram 100% e 62,3%, respectivamente. Padrão atípico de TC foi mais frequente em pacientes COVID-19-negativos (9 (14%) vs. 24 (56%) em COVID-19-positivos, p < 0,001), enquanto padrão indeterminado foi semelhante em ambos os grupos (13 (20%) vs. 6 (14%), p = 0,606), e padrão negativo foi mais comum em pacientes COVID-19-negativos (4 (6%) vs. 12 (28%), p = 0,002). Conclusões: Em pacientes com DRET em TRS hospitalizados, um padrão atípico de TC de tórax não pode excluir adequadamente o diagnóstico de COVID-19.

Association between chronic kidney disease stages and changes in ambulatory blood pressure monitoring parameters / Associação entre estágios da doença renal crônica e alterações dos parâmetros da monitorização ambulatorial da pressão arterial

Abstract Introduction: Blood pressure (BP) assessment affects the management of arterial hypertension (AH) in chronic kidney disease (CKD). CKD patients have specific patterns of BP behavior during ambulatory blood pressure monitoring (ABPM). Objectives: The aim of the current study was to evaluate the associations between progressive stages of CKD and changes in ABPM. Methodology: This is a cross-sectional study with 851 patients treated in outpatient clinics of a university hospital who underwent ABPM examination from January 2004 to February 2012 in order to assess the presence and control of AH. The outcomes considered were the ABPM parameters. The variable of interest was CKD staging. Confounding factors included age, sex, body mass index, smoking, cause of CKD, and use of antihypertensive drugs. Results: Systolic BP (SBP) was associated with CKD stages 3b and 5, irrespective of confounding variables. Pulse pressure was only associated with stage 5. The SBP coefficient of variation was progressively associated with stages 3a, 4 and 5, while the diastolic blood pressure (DBP) coefficient of variation showed no association. SBP reduction was associated with stages 2, 4 and 5, and the decline in DBP with stages 4 and 5. Other ABPM parameters showed no association with CKD stages after adjustments. Conclusion: Advanced stages of CKD were associated with lower nocturnal dipping and greater variability in blood pressure.

Resumo Introdução: A avaliação da pressão arterial (PA) tem impacto no manejo da hipertensão arterial (HA) na doença renal crônica (DRC). O portador de DRC apresenta padrão específico de comportamento da PA ao longo da monitorização ambulatorial da pressão arterial (MAPA). Objetivos: O objetivo do corrente estudo é avaliar as associações entre os estágios progressivos da DRC e alterações da MAPA. Metodologia: Trata-se de um estudo transversal com 851 pacientes atendidos nos ambulatórios de um hospital universitário que foram submetidos ao exame de MAPA no período de janeiro de 2004 a fevereiro de 2012 para avaliar a presença e o controle da HA. Os desfechos considerados foram os parâmetros de MAPA. A variável de interesse foi o estadiamento da DRC. Foram considerados como fatores de confusão idade, sexo, índice de massa corporal, tabagismo, causa da DRC e uso de anti-hipertensivos. Resultados: A PA sistólica (PAS) se associou aos estágios 3b e 5 da DRC, independentemente das variáveis de confusão. Pressão de pulso se associou apenas ao estágio 5. O coeficiente de variação da PAS se associou progressivamente aos estágios 3a, 4 e 5, enquanto o coeficiente de variação da pressão arterial diastólica (PAD) não demonstrou associação. O descenso da PAS obteve associação com estágios 2, 4 e 5, e o descenso da PAD, com os 4 e 5. Demais parâmetros da MAPA não obtiveram associação com os estágios da DRC após os ajustes. Conclusão: Estágios mais avançados da DRC associaram-se a menor descenso noturno e a maior variabilidade da pressão arterial.

Mind the gap in kidney care: translating what we know into what we do / Atenção às lacunas no cuidado renal: traduzindo o que sabemos em ações

Abstract Historically, it takes an average of 17 years for new treatments to move from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. Now is the time to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions are diagnosed worldwide, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because it is often silent in the early stages. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from the patient to the clinician to the health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Resumo Historicamente, são necessários, em média, 17 anos para que novos tratamentos passem da evidência clínica para a prática diária. Considerando os tratamentos altamente eficazes disponíveis atualmente para prevenir ou retardar o início e a progressão da doença renal, esse período é demasiadamente longo. Agora é o momento de reduzir a lacuna entre o que sabemos e aquilo que fazemos. Existem diretrizes claras para a prevenção e o manejo dos fatores de risco comuns para doenças renais, como hipertensão e diabetes, mas apenas uma fração das pessoas com essas condições é diagnosticada mundialmente, e um número ainda menor recebe tratamento adequado. Da mesma forma, a grande maioria das pessoas que sofrem de doença renal não têm conhecimento de sua condição, pois ela costuma ser silenciosa nos estágios iniciais. Mesmo entre pacientes que foram diagnosticados, muitos não recebem tratamento adequado para a doença renal. Levando em consideração as graves consequências da progressão da doença renal, insuficiência renal ou óbito, é imperativo que os tratamentos sejam iniciados precocemente e de maneira adequada. As oportunidades para diagnosticar e tratar precocemente a doença renal devem ser maximizadas, começando no nível da atenção primária. Existem muitas barreiras sistemáticas, que vão desde o paciente até o médico, passando pelos sistemas de saúde e por fatores sociais. Para preservar e melhorar a saúde renal para todos em qualquer lugar, cada uma dessas barreiras deve ser reconhecida para que soluções sustentáveis sejam desenvolvidas e implementadas sem mais demora.

Bone aluminum accumulation in the current era / Acúmulo de alumínio no tecido ósseo na era atual

In the last few years, evidence from the Brazilian Registry of Bone Biopsy (REBRABO) has pointed out a high incidence of aluminum (Al) accumulation in the bones of patients with CKD under dialysis. This surprising finding does not appear to be merely a passive metal accumulation, as prospective data from REBRABO suggest that the presence of Al in bone may be independently associated with major adverse cardiovascular events. This information contrasts with the perception of epidemiologic control of this condition around the world. In this opinion paper, we discussed why the diagnosis of Al accumulation in bone is not reported in other parts of the world. We also discuss a range of possibilities to understand why bone Al accumulation still occurs, not as a classical syndrome with systemic signs of intoxication, as occurred it has in the past.

Nos últimos anos, evidências do Registro Brasileiro de Biópsia óssea (REBRABO) apontaram uma alta incidência de intoxicação por alumínio (Al) no tecido ósseo de pacientes com DRC em diálise. Essa surpreendente informação parece representar não apenas um acúmulo passivo deste metal, visto que dados prospectivos do REBRABO sugerem que a presença de Al no tecido ósseo pode estar independentemente relacionada a eventos cardiovasculares adversos maiores. Essas informações contrastam com a percepção mundial do controle epidemiológico dessa condição. Neste artigo de opinião, discutimos por que o diagnóstico de acúmulo ósseo de Al não é relatado em outras partes do mundo, e também discutimos uma gama de possibilidades para entender por que nós acreditamos que o acúmulo de Al no tecido ósseo ainda ocorre, não como se apresentava no passado, ou seja, como uma síndrome com sinais e sintomas sistêmicos de intoxicação.

Analysis of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios as inflammatory biomarkers in chronic kidney disease: impact of parathyroidectomy / Análise das relações neutrófilo/linfócito e plaqueta/linfócito como marcadores inflamatórios na doença renal crônica: impacto da paratireoidectomia

Abstract Introduction: Secondary hyperparathyroidism (SHPT) is one of the causes for inflammation in CKD. We assessed the impact of parathyroidectomy (PTX) on neutrophil-to-lymphocyte (N/L) and platelet-to-lymphocyte (P/L) ratios in SHPT patients. Methods: A total of 118 patients [hemodialysis (HD, n = 81), and transplant recipients (TX, n = 37)] undergoing PTX between 2015 and 2021 were analyzed. Results: There was a significant reduction in calcium and PTH levels in both groups, in addition to an increase in vitamin D. In the HD group, PTX did not alter N/L and P/L ratios. In the TX group, there was a reduction in N/L and P/L ratios followed by a significant increase in total lymphocyte count. Conclusion: N/L and P/L ratios are not reliable biomarkers of inflammation in SHPT patients undergoing PTX. Uremia, which induces a state of chronic inflammation in dialysis patients, and the use of immunosuppression in kidney transplant recipients are some of the confounding factors that prevent the use of this tool in clinical practice.

Resumo Introdução: O hiperparatireoidismo secundário (HPTS) é uma das causas de inflamação na DRC. Avaliamos o impacto da paratireoidectomia (PTX) nas relações neutrófilo/linfócito (N/L) e plaqueta/linfócito (P/L) em pacientes com HPTS. Métodos: Foram analisados 118 pacientes [hemodiálise (HD, n = 81) e transplantados (TX, n = 37)] submetidos à PTX entre 2015 e 2021. Resultados: Houve redução significativa de cálcio e PTH nos dois grupos, além de elevação de vitamina D. No grupo HD, a PTX não mudou as relações N/L e P/L. Já no grupo TX, houve redução nas relações N/L e P/L acompanhadas de elevação significativa do número de linfócitos totais. Conclusão: As relações N/L e P/L não são marcadores fidedignos de inflamação em pacientes com HPTS submetidos à PTX. A uremia, que induz um estado de inflamação crônica em pacientes dialíticos, e o uso de imunossupressão em pacientes transplantados renais são alguns dos fatores de confusão que impedem o uso dessa ferramenta na prática clínica.

The Role of Marein During Endothelial-Mesenchymal Transition in Diabetic Kidney Disease / Rol de la Mareína Durante la Transición Endotelial-Mesenquimatosa en la Enfermedad Renal Diabética

SUMMARY: Marein is a flavonoid compound that reduces blood glucose and lipids and has a protective effect in diabetes. However, the effect and mechanism(s) of marein on renal endothelial-mesenchymal transition in diabetic kidney disease (DKD) have not been elucidated. In this study, single-cell sequencing data on DKD were analyzed using a bioinformation method, and the data underwent reduced dimension clustering. It was found that endothelial cells could be divided into five subclusters. The developmental sequence of the subclusters was 0, 1, 4, 2, and 3, of which subcluster 3 had the most interstitial phenotype.The expression of mesenchymal marker protein:Vimentin(VIM), Fibronectin(FN1), and fibroblast growth factor receptor 1 (FGFR1) increased with the conversion of subclusters. In db/db mice aged 13-14 weeks, which develop DKD complications after 8-12 weeks of age, marein reduced blood levels of glucose, creatinine, and urea nitrogen, improved structural damage in kidney tissue, and reduced collagen deposition and the expression of FN1 and VIM. Marein also up-regulated autophagy marker:Light chain 3II/I(LC3II/I) and decreased FGFR1 expression in renal tissue. In an endothelial-mesenchymal transition model, a high glucose level induced a phenotypic change in human umbilical vein endothelial cells. Marein decreased endothelial cell migration, improved endothelial cell morphology, and decreased the expression of VIM and FN1. The use of the FGFR1 inhibitor, AZD4547, and autophagy inhibitor, 3-Methyladenine(3-MA), further demonstrated the inhibitory effect of marein on high glucose-induced endothelial-mesenchymal transition by reducing FGFR1 expression and up-regulating the autophagy marker protein, LC3II/I. In conclusion, this study suggests that marein has a protective effect on renal endothelial- mesenchymal transition in DKD, which may be mediated by inducing autophagy and down-regulating FGFR1 expression.

La mareína es un compuesto flavonoide que reduce la glucosa y los lípidos en sangre y tiene un efecto protector en la diabetes. Sin embargo, no se han dilucidado el efecto y los mecanismos de la mareína sobre la transición endotelial- mesenquimatosa renal en la enfermedad renal diabética (ERD). En este estudio, los datos de secuenciación unicelular sobre DKD se analizaron utilizando un método de bioinformación y los datos se sometieron a una agrupación de dimensiones reducidas. Se descubrió que las células endoteliales podían dividirse en cinco subgrupos. La secuencia de desarrollo de los subgrupos fue 0, 1, 4, 2 y 3, de los cuales el subgrupo 3 tenía el fenotipo más intersticial. La expresión de la proteína marcadora mesenquimatosa: vimentina (VIM), fibronectina (FN1) y receptor del factor de crecimiento de fibroblastos. 1 (FGFR1) aumentó con la conversión de subgrupos. En ratones db/db de 13 a 14 semanas de edad, que desarrollan complicaciones de DKD después de las 8 a 12 semanas de edad, la mareína redujo los niveles sanguíneos de glucosa, creatinina y nitrógeno ureico, mejoró el daño estructural en el tejido renal y redujo la deposición y expresión de colágeno de FN1 y VIM. Marein también aumentó el marcador de autofagia: Cadena ligera 3II/I (LC3II/I) y disminuyó la expresión de FGFR1 en el tejido renal. En un modelo de transición endotelial-mesenquimal, un nivel alto de glucosa indujo un cambio fenotípico en las células endoteliales de la vena umbilical humana. Marein disminuyó la migración de células endoteliales, mejoró la morfología de las células endoteliales y disminuyó la expresión de VIM y FN1. El uso del inhibidor de FGFR1, AZD4547, y del inhibidor de la autofagia, 3-metiladenina (3-MA), demostró aún más el efecto inhibidor de la mareína en la transición endotelial-mesenquimal inducida por niveles altos de glucosa al reducir la expresión de FGFR1 y regular positivamente la proteína marcadora de autofagia. , LC3II/I. En conclusión, este estudio sugiere que la mareína tiene un efecto protector sobre la transición endotelial-mesenquimatosa renal en la ERC, que puede estar mediada por la inducción de autofagia y la regulación negativa de la expresión de FGFR1.

Caracterización de la situación problémica en un estudio psicosocial con pacientes con enfermedad renal crónica

Introducción: La enfermedad renal crónica es un problema de salud a nivel mundial, su manifestación más grave, la insuficiencia renal crónica, incide en el contexto cubano y determina el crecimiento de pacientes en hemodiálisis. El objetivo del texto es valorar los principales resultados del diagnóstico y caracterización de la situación problémica en un estudio de carácter psicosocial con pacientes con Insuficiencia Renal Crónica en la sala de Hemodiálisis del municipio Florida, de la provincia de Camagüey. Método: Es una investigación-acción participativa de corte experimental, que se desarrolla entre enero 2023 y diciembre del 2024 la cual constituye salida del proyecto de investigación Sistema de acciones psicosociales para el perfeccionamiento de la atención integral a los pacientes con enfermedades no transmisibles. El universo está constituido por 56 pacientes y la muestra por 22, que reciben tratamiento depurador y conservador, 22 familiares y 12 profesionales del servicio. El instrumento de investigación por excelencia fue la encuesta a participantes. Resultados: La edad de los pacientes no es definitiva de un grupo etario; predominan los hombres; se constata un elevado por ciento de pacientes con poca tolerancia a la adherencia al tratamiento e insuficiente desarrollo de las habilidades psicosociales y declaran la necesidad de poseer conocimientos para lograr estados de salud que conlleven a la sobrevida. Discusión: No existe coincidencia con lo constatado en la determinación de los grupos etarios de prevalencia para la enfermedad, pero los especialistas insisten en que la enfermedad no es privativa de un período de vida específico; reconocen la importancia del conocimiento de los factores de riesgo por el paciente para la prevención, promoción y educación en salud y resaltan la necesidad de la comunicación y la empatía entre el personal de salud y el paciente, para lograr resultados y estados emocionales favorables ante la enfermedad y el tratamiento.

Introduction: Chronic kidney disease is a global health problem. Its most serious manifestation, chronic kidney failure, affects the Cuban context and determines the growth of patients on hemodialysis. The objective of the text is to evaluate the main results of the diagnosis and characterization of the problematic situation in a psychosocial study with patients with Chronic Renal Failure in the Hemodialysis room of the Florida municipality, of the county of Camagüey. Method: It is an experimental participatory action research, which takes place between January 2023 and December 2024, which constitutes the output of the research project System of psychosocial actions for the improvement of comprehensive care for patients with non-communicable diseases. The universe is made up of 56 patients and the sample is made up of 22, who receive purifying and conservative treatment, 22 family members and 12 service professionals. The research instrument par excellence was the participant survey. Results: The age of the patients is not definitive of an age group; men predominate; A high percentage of patients are found to have low tolerance for adherence to treatment and insufficient development of psychosocial skills and declare the need to possess knowledge to achieve health states that lead to survival. Discussion: There is no coincidence with what was found in the determination of the prevalence age groups for the disease, but specialists insist that the disease is not exclusive to a specific period of life; recognize the importance of the patient's knowledge of risk factors for prevention, promotion and health education and highlight the need for communication and empathy between health personnel and the patient, to achieve favorable results and emotional states in the face of the disease and treatment.

Renal osteodystrophy and clinical outcomes: a prospective cohort study / Osteodistrofia renal e desfechos clínicos: um estudo de coorte prospectivo

Abstract Introduction: Renal osteodystrophy (ROD) refers to a group of bone morphological patterns that derive from distinct pathophysiological mechanisms. Whether the ROD subtypes influence long-term outcomes is unknown. Our objective was to explore the relationship between ROD and clinical outcomes. Methods: This study is a subanalysis of the Brazilian Registry of Bone Biopsies (REBRABO). Samples from individual patients were classified as having osteitis fibrosa (OF), mixed uremic osteodystrophy (MUO), adynamic bone disease (ABD), osteomalacia (OM), normal/minor alterations, and according to turnover/mineralization/volume (TMV) system. Patients were followed for 3.4 yrs. Clinical outcomes were: bone fractures, hospitalization, major adverse cardiovascular events (MACE), and death. Results: We enrolled 275 participants, of which 248 (90%) were on dialysis. At follow-up, 28 bone fractures, 97 hospitalizations, 44 MACE, and 70 deaths were recorded. ROD subtypes were not related to outcomes. Conclusion: The incidence of clinical outcomes did not differ between the types of ROD.

Resumo Introdução: Osteodistrofia renal (OR) refere-se a um grupo de padrões morfológicos ósseos que decorrem de mecanismos fisiopatológicos distintos. É desconhecido se os subtipos de OR influenciam desfechos em longo prazo. Nosso objetivo foi explorar as relações entre OR e desfechos. Métodos: Este estudo é uma subanálise do Registro Brasileiro de Biópsias Ósseas (REBRABO). As amostras de cada paciente foram classificadas em osteíte fibrosa (OF), osteodistrofia urêmica mista (MUO), doença óssea adinâmica (ABD), osteomalácia (OM), alterações normais/menores, e pelo sistema Remodelação / Mineralização / Volume (RMV). Os pacientes foram acompanhados por 3,4 anos. Os eventos clínicos foram: fraturas ósseas, hospitalizações, eventos cardiovasculares adversos maiores (MACE), e óbito. Resultados: Analisamos 275 indivíduos, 248 (90%) deles estavam em diálise. No acompanhamento, 28 fraturas ósseas, 97 hospitalizações, 44 MACE e 70 óbitos foram registrados. Os subtipos de OR não foram relacionados aos desfechos clínicos. Conclusão: A incidência de desfechos clínicos não diferiu entre os tipos de OR.

Incremento del riesgo hemorrágico en pacientes con fibrilación auricular y enfermedad renal crónica en hemodiálisis tratados con anticoagulantes. Serie de cuatro centros / Increased risk of bleeding in patients with atrial fibrillation and chronic kidney disease on hemodialysis treated with anticoagulants. A four center series

Resumen Objetivo: El objetivo de este estudio fue estimar si el uso de anticoagulantes se asociaba con una diferencia en la frecuencia de trombosis de cualquier sitio, hemorragia mayor y mortalidad en adultos con coexistencia de ambas patologías. Método: Se realizó un estudio de cohorte retrospectivo en cuatro centros de alta complejidad. Se incluyeron mayores de 18 años con ERC en hemodiálisis y FA no valvular, con indicación de anticoagulación (CHA2DS2VASc ≥ 2). El desenlace primario fue la ocurrencia de sangrado mayor, evento trombótico (accidente vascular cerebral, infarto agudo al miocardio o enfermedad tromboembólica venosa) o muerte. Se realizó ajuste por variables de confusión por regresión logística. Resultados: De los 158 pacientes incluidos, el 61% (n = 97) recibieron anticoagulante. El desenlace principal se encontró en el 84% de quienes recibieron anticoagulación y en el 70% de quienes no la recibieron (OR: 2.12, IC95%: 0.98-4.57; luego del ajuste OR: 2.13, IC95%: 1.04-4.36). De los desenlaces mayores se presentaron sangrado en el 52% vs. el 34% (OR: 2.03; IC95%: 1.05-3.93), trombosis en el 35% vs. el 34% (OR: 1.03; IC95%: 0.52-2.01) y muerte en el 46% vs. el 41% (OR: 1.25; IC95%: 0.65-2.38). Conclusiones: Los resultados de este estudio sugieren un incremento en el riesgo de sangrado en los pacientes con FA y ERC en hemodiálisis que reciben anticoagulación, sin disminución del riesgo de eventos trombóticos ni de muerte.

Abstract Objective: The aim of this study was to estimate whether the consumption of anticoagulants was associated with a difference in the frequency of thrombosis of any site, major bleeding and mortality, in adults with both diseases. Method: A retrospective cohort study was carried out in four high complexity centers. Patients older than 18 years with CKD on hemodialysis and non-valvular AF, with an indication for anticoagulation (CHA2DS2VASc ≥ 2), were included. The primary outcome was the occurrence of: major bleeding, thrombotic event (cerebrovascular accident, acute myocardial infarction or venous thromboembolic disease) or death. Adjustment for confounding variables was performed using logistic regression. Results: From 158 patients included, 61% (n = 97) received an anticoagulant. The main outcome was found in 84% of those who received anticoagulation and 70% of those who did not (OR: 2.12, 95%CI: 0.98-4.57; after the adjusted analysis OR: 2.13, 95%CI: 1.04-4.36). Separate outcomes were bleeding in 52% vs. 34% (OR: 2.03; 95%CI: 1.05-3.93), thrombosis in 35% vs. 34% (OR: 1.03; 95%CI: 0.52-2-01) and death in 46% vs. 41% (OR: 1.25; 95%CI: 0.65-2.38). Conclusions: The results of this study suggest an increased risk of bleeding in patients with AF and CKD on hemodialysis receiving anticoagulation, without a decrease in the risk of thrombotic events or all-cause mortality.

Calcifilaxis, factores de riesgo, tratamiento y evolución. Estudio retrospectivo de 39 pacientes / Calciphylaxis, risk factors, treatment and outcomes. Retrospective study of 39 patients

Resumen Introducción : La calcifilaxis es un trastorno vascular grave caracterizado por depósito de calcio en túnica me dia arteriolar, trombosis y necrosis cutánea. Se describió en pacientes con insuficiencia renal (CU), aunque puede producirse en su ausencia (CNU). Sus factores de riesgo están en estudio y su diagnóstico puede ser complejo. Su mortalidad se estimaba en 60-80%, aunque trabajos recientes indican que ha disminuido (40%). Métodos : Estudio retrospectivo entre el 1/1/2011 y el 31/12/2019. Se revisaron los antecedentes, las ca racterísticas clínicas, los hallazgos de laboratorio e histopatológicos, y la evolución de todos los pacientes con diagnóstico de calcifilaxis evaluados en el Hospital Italiano de Buenos Aires. Resultados : Se incluyeron 39 pacientes. El 61.5% (24) eran hombres y 38.5% (15) fueron casos de CNU. De éstos, 82% presentaba hipertensión arterial, 66% obesidad y 46% diabetes. El 49% recibía anticoagulantes dicumarínicos. Todos los pacientes con CNU y 75% con CU presentaron úlceras de fondo necrótico, localizadas con mayor frecuencia en las piernas. En 72% de los casos el diagnóstico histológico se efectuó con una toma de biopsia. En todos, el tratamiento fue multimodal y la mortalidad al año fue de 42%. Conclusión : Observamos una elevada proporción de pacientes con CNU, en relación con lo comunicado en la literatura, y la mitad recibía anticoagulantes di cumarínicos. El diagnóstico histológico se efectuó por biopsia en la mayor parte de los casos, para lo cual la toma quirúrgica de la muestra, la tinción con Von Kossa y la evaluación por un patólogo experto fueron claves.

Abstract Introduction : Calciphylaxis is a serious vascular dis order characterized by calcification of tunica media, in timal hyperplasia, thrombosis, and skin necrosis. It was described in patients with renal failure (UC), although it can occur in its absence (NUC). Its risk factors are under study and its diagnosis can be complex. Over a decade ago, its mortality was estimated at 60-80%. Recent stud ies indicate that it has decreased (40%). Methods : A retrospective study was carried out in the period between January 1, 2011 and December 31, 2019. The past medical record, clinical characteristics, labo ratory and histopathological findings, and evolution of all patients with calciphylaxis evaluated at the Hospital Italiano de Buenos Aires were reviewed. Results : Thirty-nine patients were included. Sixty-one percent were men and 39% were NUC cases. Eighty-two percent had arterial hypertension, 66% obesity and 46% diabetes. Of those, 49% received coumarin anticoagulants. All patients with NUC and 75% with UC presented ulcers with necrosis, located more frequently on the legs. In 72% of the cases the histological diagno sis was made with one biopsy. In all the treatment was multimodal and mortality at one year was 42%. Conclusion : We observed a high proportion of pa tients with NUC, in relation to what is reported in the literature, and that half received vitamin K antagonists. The histological diagnosis was made with one biopsy in most of the cases, as the surgical technique for taking the sample, the Von Kossa staining and the evaluation by an expert pathologist were the key of it.

Avaliação laboratorial do sangue e da saliva de pacientes com doença renal crônica e manifestações orais: uma revisão sistemática / Laboratory evaluation of blood and saliva of patients with chronic kidney disease and oral manifestations: a systematic review

A cavidade oral é afetada pelo caráter multissistêmico das consequências da Doença Renal Crônica (DRC) e estima-se que cerca de 90% destes pacientes têm sintomas orais. Alterações laboratoriais sanguíneas e salivares são frequentemente observadas e por isso, investigações sobre correlações clínico-laboratoriais são fundamentais para o manejo e tratamento dos pacientes. Neste estudo foi realizada uma revisão sistemática para identificar e avaliar as principais alterações laboratoriais no sangue e na saliva de pacientes portadores de DRC que apresentam manifestações orais. A busca bibliográfica incluiu artigos das bases de dados eletrônicas PubMed, Scopus, Biblioteca Virtual em Saúde, Web of Science, Embase e literatura cinzenta, incluindo estudos caso-controle, transversais e de coorte. A análise do risco de viés seguiu a abordagem QUADAS-2. PROSPERO CRD42022250533 é o registro dessa revisão. As principais alterações laboratoriais encontradas foram o aumento das concentrações sanguíneas e salivares de ureia, creatinina, fosfato e diminuição das concentrações de cálcio e da taxa de fluxo salivar. As concentrações dessas substâncias no sangue e na saliva e a TGF estavam diretamente correlacionadas. Foi observada existência da correlação entre o aparecimento das manifestações orais e as alterações laboratoriais, principalmente xerostomia, disgeusia e hálito urêmico. Em conclusão, a literatura tem revelado que as principais alterações laboratoriais encontradas são aquelas descritas comumente na rotina laboratorial, que as concentrações dessas substâncias no sangue e na saliva estão diretamente correlacionadas com a TFG, e existe correlação entre o aparecimento das manifestações orais e as alterações laboratoriais. Grandes oportunidades estão abertas para a investigação sobre de novos marcadores.

The oral cavity is affected by the multisystemic nature of the consequences of Chronic Kidney Disease (CKD) and it is estimated that around 90% of these patients present oral symptoms. Blood and salivary laboratory changes are frequently observed and, therefore, investigations of clinical-laboratory correlations are essential for the management and treatment of these patients. This study was carried out as a systematic review to identify and evaluate the main laboratory changes in the blood and saliva of patients with CKD who present oral manifestations. The bibliographic search included articles from the electronic databases PubMed, Scopus, Virtual Health Library, Web of Science, Embase and gray literature, including case-control, cross-sectional and cohort studies. The risk of bias analysis advanced the QUADAS-2 approach. PROSPERO CRD42022250533 is the record of this review. The main laboratory changes found were an increase in blood and salivary concentrations of urea, creatinine, phosphate and a decrease in calcium concentrations and salivary flow. The concentrations of substances in blood and saliva and TGF were directly correlated. The existence of the manifestation was observed between the appearance of oral manifestations and laboratory changes, mainly xerostomia, dysgeusia and uremic breath. In conclusion, the literature revealed that the main laboratory changes found are those commonly described in laboratory routine, that the concentrations of these problems in blood and saliva are directly correlated with GFR, and there is a manifestation between the appearance of oral manifestations and laboratory changes. . Great opportunities are open for the investigation of new markers.

Trastornos mentales en niños y adolescentes con enfermedad renal crónica: un primer estudio de detección realizado en Paraguay

Introducción: los niños y adolescentes con enfermedad renal crónica suelen enfrentar desafíos únicos que afectan significativamente su bienestar mental. Objetivo: este estudio tuvo como objetivo evaluar el estado de salud mental de niños y adolescentes con enfermedad renal crónica que reciben atención en el Departamento de Nefrología Pediátrica de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción. Metodología: este fue un estudio observacional descriptivo, prospectivo y transversal. Clasificamos a los participantes según factores sociodemográficos (edad, sexo, lugar de residencia, estado civil y educación de los padres, y ocupación parental) y variables clínicas (edad al diagnóstico de enfermedad renal crónica, patología subyacente, tipo de tratamiento). Las evaluaciones de salud mental utilizaron el Cuestionario Breve para el Cribado y Diagnóstico, adaptado de la Escala Infantil de Rutter. Los diagnósticos se clasificaron como no casos, casos probables sin complicaciones o casos definitivos complicados según la severidad de los síntomas. Resultados: nuestro estudio analizó a 28 jóvenes, predominantemente masculinos (57.1 %), con edades entre 2 y 17 años y una edad media de 12.3 años. Aproximadamente el 42.9 % provenía del campo, y la mitad tenía padres divorciados o separados. Clínicamente, el 42.9 % tenía enfermedad renal crónica en etapas I a III, el 17.9 % estaba en etapa IV, y el 39.3 % había recibido trasplantes de riñón. Las evaluaciones de salud mental mediante Cuestionario Breve para el Cribado y Diagnóstico revelaron que el 39.3 % no mostraba trastornos mentales probables, el 32.1 % eran casos probables sin complicaciones y el 28.6 % eran casos probables con complicaciones. La ansiedad con inhibición y los trastornos de conducta fueron los trastornos predominantes, afectando cada uno al 39.3% de los participantes. Conclusión: nuestra investigación subraya la significativa carga de trastornos de salud mental en un grupo de niños y adolescentes paraguayos con enfermedad renal crónica y la urgente necesidad de servicios de salud mental completos e integrados que estén específicamente diseñados para satisfacer las necesidades de esta población vulnerable.

Introduction: children and adolescents with chronic kidney disease often face unique challenges that significantly affect their mental well-being. Objective: this study aimed to assess the mental health status of children and adolescents with chronic kidney disease receiving care at the Departamento de Nefrología Pediátrica of the Facultad de Ciencias Médicas of the Universidad Nacional de Asunción. Methodology: this was a descriptive, prospective, cross-sectional observational study. We categorized participants based on sociodemographic factors (age, sex, residence, parents' marital status and education, and parental occupation) and clinical variables (age at chronic kidney disease diagnosis, underlying pathology, treatment type). Mental health assessments utilized the Brief Questionnaire for Screening and Diagnosis, adapted from Rutter's Child Scale. Diagnoses were classified as non-cases, probable uncomplicated cases, or definite complicated cases based on symptom severity. Results: our study analyzed 28 young individuals, predominantly male (57.1 %), aged between 2 and 17 years with a mean age of 12.3 years. Approximately 42.9 % hailed from the countryside, and half had parents who were divorced or separated. Clinically, 42.9 % had chronic kidney disease stages I to III, 17.9 % were at stage IV, and 39.3 % had received kidney transplants. Mental health assessments via Brief Questionnaire for Screening and Diagnosis revealed that 39.3 % did not show probable mental disorders, 32.1 % were probable cases without complications, and 28.6 % were probable cases with complications. Anxiety with inhibition and conduct disorders were the predominant disorders, each impacting 39.3 % of participants. Conclusion: our research underlines the significant burden of mental health disorders in a group of Paraguayan children and adolescents with chronic kidney disease and the pressing need for comprehensive, integrated mental health services that are specifically designed to meet the requirements of this vulnerable population.

Calidad de vida de los pacientes con Enfermedad Renal Crónica en tratamiento hemodialítico en el Hospital Nacional en el Departamento de Nefrología periodo 2022 - 2023

Introducción: los pacientes con enfermedad renal crónica con requerimiento de terapia sustitutiva renal (hemodiálisis) son frecuentes en el Paraguay, lo que afecta la calidad de vida de los que la padecen. Objetivo: conocer la calidad de vida de los pacientes con enfermedad renal crónica en tratamiento hemodialítico en el Departamento de Nefrología del Centro Médico Nacional-Hospital Nacional en el período 2022-2023. Metodología: observacional, descriptivo, de corte transversal realizado en el Departamento de Nefrología del Centro Médico Nacional-Hospital Nacional de Paraguay. Se incluyeron en el estudio 189 pacientes en que acudieron para tratamiento hemodialítico entre los años 2022-2023. La muestra fue censal. Para determinar la calidad de vida se utilizó el cuestionario Kidney Disease Quality of Life - 36 ítems. Los datos fueron analizados con el programa Epiinfo. Resultados: la edad media de los pacientes fue de 53 años, varones 58.2 %. El 98 % refirió la presencia de algún tipo de comorbilidad concomitante, las más frecuentes fueron diabetes Mellitus 43 % e hipertensión arterial 86 %. La media de meses en tratamiento hemodialítico fue de 20 meses. El cuestionario, Kidney Disease Quality of Life - 36 ítems, arrojó puntajes promedios menores a 50 en el componente mental (65.08) y en el componente físico (71.95) así como en la subescala carga de la enfermedad (55.55). Conclusión: la mayoría de los pacientes con enfermedad renal crónica con tratamiento hemodialítico en el Hospital Nacional evidencian una baja calidad de vida.

Introduction: patients with chronic kidney disease requiring renal replacement therapy (hemodialysis) are common in Paraguay, which affects the quality of life of those who suffer from it. Objective: to know the quality of life of patients with chronic kidney disease undergoing hemodialysis treatment in the Departmento de Nefrología of the Centro Médico Nacional-Hospital Nacional in the period 2022-2023. Methodology: observational, descriptive, cross-sectional carried out in the Nephrology Department of the Centro Médico Nacional-Hospital Nacional of Paraguay. 189 patients who came for hemodialysis treatment between 2022-2023 were included in the study. The sample was census. To determine quality of life, the Kidney Disease Quality of Life questionnaire - 36 items was used. The data were analyzed with the Epi Info program. Results: the average age of the patients was 53 years, 58.2 % men. 98 % reported the presence of some type of concomitant comorbidity, the most frequent being diabetes mellitus 43 % and arterial hypertension 86 %. The average number of months on hemodialysis treatment was 20 months. The questionnaire, Kidney Disease Quality of Life - 36 items, showed average scores less than 50 in the mental component (65.08) and in the physical component (71.95) as well as in the burden of the disease subscale (55.55). Conclusion: the majority of patients with chronic kidney disease with hemodialysis treatment at the National Hospital show a low quality of life.

Falta de adherencia al control médico en pacientes pediátricos con antecedente de glomerulonefritis infecciosa

Introducción: La glomerulonefritis pos infecciosa (GNPI) en la infancia es un factor de riesgo para el desarrollo de enfermedad renal crónica a largo plazo. La adherencia al control médico permite realizar la nefroprevención secundaria. Objetivo: evaluar la relación entre los factores de riesgo relacionados a la falta de adherencia al control médico de pacientes con GNPI en una cohorte pediátrica. Metodología: estudio descriptivo de asociación cruzada de cohorte retrospectiva de pacientes internados entre enero de 2000 a diciembre de 2018 en un hospital de referencia. Se analizó la relación entre: hacinamiento, colecho, escolaridad materna y paterna, número de hermanos, de convivientes y procedencia, con la falta de adherencia al control médico. Se utilizaron la prueba de chi cuadrado y regresión logística a un nivel de significancia de 0,05. Resultados: Se incluyeron 148 pacientes (103 niños y 45 niñas) entre 2 a 16 años (edad promedio: 8,5± 3,4 años). La falta de adherencia fue encontrada en 73 pacientes (49,3%) que se asoció a procedencia rural (p= 0,012, RR: 1,50, IC95%: 1,10-2,06), baja escolaridad materna (p= 0,046, IC95%: 1,54:1,14-2,08), baja escolaridad paterna (p= 0,02; RR: 1,483, IC95%: 1,09-2,01), >3 convivientes (p=0,007, RR: 1,630, IC95%: 1,21-2,19), colecho (p=0,026; RR: 1,52, IC95%: 1,02-2,27) y hacinamiento (p<0,0001; RR: 1,92, IC95%: 1,39-2,65). Por regresión logística, el hacinamiento (p=0,005; OR= 4,8) y procedencia rural (p=0,022; OR: 2,4) se mantuvieron asociados a la falta de adherencia. Discusión: El hacinamiento y la procedencia rural se asociaron en forma independiente con la pérdida de seguimiento. Se recomienda mayor intervención de la atención primaria de salud.

Introduction: Post-infectious glomerulonephritis (PIGN) in childhood is a risk factor for the development of long-term chronic kidney disease. Adherence to medical control allows secondary nephroprevention to be carried out. Objective: to evaluate the relationship between risk factors related to non-adherence to medical control of patients with IPGN in a pediatric cohort. Methods: descriptive study, with an analytical component of a retrospective cohort of patients hospitalized between January 2000 and December 2018 in a reference hospital. The relationship between: overcrowding, co-sleeping, maternal and paternal education, number of siblings, cohabitants and origin, with lack of adherence to medical control was analyzed. The chi-square test and logistic regression were used at a significance level of 0.05. Results: a total of 148 patients (103 boys y 45 girls) between 2 and 16 years old (mean age: 8.5± 3.4 years) were included. The lack of adherence was found in 73 patients (49.3%) that was associated with rural origin (p= 0.012, RR: 1.50, 95% CI: 1.10-2.06), low maternal education (p= 0.046, 95%CI: 1.54:1.14-2.08), low paternal education (p= 0.02; RR: 1.483, 95%CI: 1.09-2.01), >3 cohabitants (p=0.007, RR: 1.630, 95% CI: 1.21-2.19), co-sleeping (p=0.026; RR: 1.52, 95% CI: 1.02-2.27) and overcrowding (p<0.0001; RR: 1.92, 95% CI: 1.39-2.65). By logistic regression, overcrowding (p=0.005; OR= 4.8) and rural origin (p=0.022; OR: 2.4) remained associated with lack of adherence. Discussion: Overcrowding and rural origin were independently associated with loss to follow-up. Greater intervention by primary health care is recommended.

Accesibilidad, disponibilidad y asequibilidad de medicamentos para Niños con Enfermedad Renal Crónica en Guatemala / Access, availability and affordability of medications for children with Advanced Chronic Kidney Disease in Guatemala

El artículo tiene como objetivo analizar la disponibilidad, acceso y asequibilidad de los medicamentos para niños con Enfermedad Renal Crónica (ERC) en tratamiento con hemodiálisis (HD) en un país de bajos a medianos ingresos. Se llevó a cabo un estudio transversal para determinar los medicamentos más utilizados en una unidad de hemodiálisis pediátrica, incluyendo el nombre del medicamento, dosis, frecuencia, forma farmacéutica y vía de administración. Dos farmacias dentro del perímetro del hospital, una pública y una privada, fueron consultadas para determinar el costoy disponibilidad de medicamentos genéricos y de marca. De un total de 30 pacientes de la unidad de hemodiálisis, 22 expedientes fueron revisados. En general 94% de marca se encontraban disponibles en las farmacias consultadas en comparación a un 52% de los medicamentos genéricos. En farmacias públicas, 41% de medicamentos de marca y 29% de medicamentos genéricos se encontraban disponibles. El costo promedio para un mes de tratamiento con medicamentos de marca adquiridos en una farmacia privada era de $495.00 vs $299.00 en una farmacia pública. Para medicamentos genéricos, el costo promedio correspondía a $414.00 y $239.00 en farmacias privadas y públicas respectivamente. En promedio, los medicamentos de marca adquiridos en una farmacia privada requieren 41 días de trabajo en un mes a comparación de 25 días si se adquieren en una farmacia pública. Los medicamentos genéricos adquiridos en farmacias privadas corresponden a 34 días de trabajo vs 20 días en farmacias públicas. En general existió un acceso limitado a medicamentos genéricos y los medicamentos poseen un costo general más elevado a comparación de otros países lo que implica un posible impacto en la adherencia terapéutica y los padecimientos secundarios de la ERC en los pacientes pediátricos en Guatemala. Esta realidad se puede aplicar a otros países de bajos a medianos ingresos.

This article aims to analyze the availability, access, and affordability of medications for children with advanced Chronic Kidney Disease (CKD) treated with hemodialysis (HD) in a low to middle income country (LMIC). A cross- sectional chart review was carried out to determine the most common medications used in an HD pediatric unit, including medication name, dose, frequency, dosage form, and route of administration. Two pharmacies within the hospital perimeter, one public and one private, were consulted to determine medication cost and availability for generic and brand-name equivalents. From 30 patients attending the HD unit, 22 records were reviewed. Overall, 94 % of brand name medications were available at pharmacies consulted, versus and 52% of generic medications. In public pharmacies, 41% of brand name, and 29% of generic medications were available. The average cost for a full month´s treatment for brand name drugs in the private pharmacy was 495.00 USD versus 299.00 USD in the public pharmacy. For generic drugs, the average cost was 414.00 USD, and 239.00 USD in private and public pharmacies respectively. On average, brand-name drugs in the private pharmacy cost 41 days' wages versus 25 in the public pharmacy. Generic drugs in the private pharmacy cost 34 days' wages versus 20 in the public pharmacy. Overall, there was limited access to generic medications, medications had an overall high cost compared to other countries both of which have the potential to impact treatment adherence and overall outcomes of CKD5 pediatric patients in Guatemala. This reality can be translated to other LMIC.

Calidad de vida y características clínicas de pacientes con trasplante renal con y sin rinosinusitis crónica / Quality of life and clinical characteristics of renal transplant patients with and without chronic rhinosinusitis

RESUMEN Introducción: El trasplante es el tratamiento de elección en pacientes con enfermedad renal crónica (ERC). Requiere inmunosupresión, que predispone al desarrollo de complicaciones; la rinosinusitis crónica (RSC) es una de las más importantes. Objetivo: Comparar las características de pacientes con ERC con y sin RSC en protocolo de trasplante en un hospital de concentración en Puebla, en México. Métodos: Estudio comparativo, transversal, retrospectivo, en pacientes de un hospital de tercer nivel de atención, con ERC y en protocolo de trasplante renal. Se aplicaron las escalas SNOT-22 y Lund-Mackay. Se utilizó estadística descriptiva y pruebas U de Mann-Whitney, exacta de Fisher y coeficiente de Phi; p<0.05, por lo que se consideró significativa. Resultados: Se reclutaron 360 pacientes: 49 presentaron RSC; prevalencia, 13.61 %; medias edad, 39.22 ±12.09 años y tiempo de evolución, 17.73 ±5.91 semanas. Presentaron poliposis nasosinusal 14.3 %; obstrucción nasal, 95.9 %; algia facial, 67.3%; rinorrea, 49 % e hiposmia/anosmia, 40.8 %. Factores de riesgo asociados: alergia a ácido acetilsalicílico (p=0.014) y atopia (p=0.000). Variantes anatómicas en pacientes con y sin RSC, respectivamente: Celdilla Agger-Nasi 95 % y 15.4 %; desviación septal, 50 % y 6.4 %; hipertrofia de cornetes, 50 % y 1.3 %; concha bullosa, 30 % y 4.2 % y cornete paradójico, 10 % y 1.6 %. La afectación de calidad de vida predominante en pacientes con y sin RSC fue moderada con un 53.1 % y leve, 97.1 % (p=0.000). Conclusión: La prevalencia de RSC fue 13.61 %; los factores de riesgo asociados, alergia al ácido acetilsalicílico y atopia y la variante anatómica predominante, Agger-nasal. La severidad tomográfica fue leve y la afectación de la calidad de vida, moderada.

ABSTRACT Introduction: Transplantation is the treatment of choice for patients with chronic kidney disease (CKD). It requires immunosuppression, which predisposes to the development of complications; chronic rhinosinusitis (CRS) is one of the most significant. Objetive: To compare the characteristics of patients with CKD and without CRS in a renal transplant protocol at a specialized hospital in Puebla, Mexico. Methods: A comparative, cross-sectional, retrospective study in patients with CKD and in renal transplant protocol at a third-level care hospital. The SNOT-22 and Lund-Mackay scales were applied. Descriptive statistics, Mann-Whitney U tests, Fisher's exact test, and Phi coefficient were used; p<0.05 was considered significant. Results: 360 patients were recruited: 49 presented with CRS; prevalence: 13.61%; mean age: 39.22 ± 12.09 years and duration of progression: 17.73 ± 5.91 weeks. Naso-sinusal polyposis was present in 14.3%; nasal obstruction in 95.9%; facial pain in 67.3%; rhinorrhea in 49% and hyposmia/anosmia in 40.8%. Associated risk factors: allergy to acetylsalicylic acid (p=0.014) and atopy (p=0.000). Anatomical variants in patients with and without CRS, respectively: Agger nasi cell 95% and 15.4%; septal deviation, 50% and 6.4%; turbinate hypertrophy, 50% and 1.3%; concha bullosa, 30% and 4.2%; and paradoxical turbinate, 10% and 1.6%. The predominant quality of life impact in patients with and without CRS was moderate at 53.1% and mild at 97.1% (p=0.000). Conclusion: The prevalence of CRS was 13.61%; the associated risk factors were allergy to acetylsalicylic acid and atopy, and the predominant anatomical variant was Agger nasi. The tomographic severity was mild, and the impact on quality of life was moderate.

Trimethylamine N-oxide and kidney diseases: what do we know? / N-óxido de trimetilamina e doenças renais: o que sabemos?

Abstract In the human gut, there is a metabolically active microbiome whose metabolic products reach various organs and are used in the physiological activities of the body. When dysbiosis of intestinal microbial homeostasis occurs, pathogenic metabolites may increase and one of them is trimethyl amine-N-oxide (TMAO). TMAO is thought to have a role in the pathogenesis of insulin resistance, diabetes, hyperlipidemia, atherosclerotic heart diseases, and cerebrovascular events. TMAO level is also associated with renal inflammation, fibrosis, acute kidney injury, diabetic kidney disease, and chronic kidney disease. In this review, the effect of TMAO on various kidney diseases is discussed.

Resumo No intestino humano, existe um microbioma metabolicamente ativo cujos produtos metabólicos alcançam diversos órgãos e são utilizados nas atividades fisiológicas do corpo. Quando ocorre disbiose da homeostase microbiana intestinal, os metabólitos patogênicos podem aumentar, e um deles é o N-óxido de trimetilamina (TMAO). Acredita-se que o TMAO tenha um papel na patogênese da resistência à insulina, diabetes, hiperlipidemia, doenças cardíacas ateroscleróticas e eventos cerebrovasculares. O nível de TMAO também está associado à inflamação renal, fibrose, lesão renal aguda, doença renal diabética e doença renal crônica. Nesta revisão, discute-se o efeito do TMAO em diversas doenças renais.

Assessment of atherosclerosis and endothelial dysfunction risk factors in patients with primary glomerulonephritis / Avaliação dos fatores de risco de aterosclerose e disfunção endotelial em pacientes com glomerulopatias primárias

Abstract Introduction: Glomerulonephritis are the third cause of chronic kidney disease (CKD) requiring dialysis in Brazil. Mineral and bone disorder (MBD) is one of the complications of CKD and is already present in the early stages. Assessment of carotid intima-media thickness (CIMT) and flow-mediated vasodilatation (FMV) are non-invasive ways of assessing cardiovascular risk. Hypothesis: Patients with primary glomerulonephritis (PG) have high prevalence of atherosclerosis and endothelial dysfunction, not fully explained by traditional risk factors, but probably influenced by the early onset of MBD. Objective: To evaluate the main markers of atherosclerosis in patients with PG. Method: Clinical, observational, cross-sectional and controlled study. Patients with PG were included and those under 18 years of age, pregnants, those with less than three months of follow-up and those with secondary glomerulonephritis were excluded. Those who, at the time of exams collection, had proteinuria higher than 6 grams/24 hours and using prednisone at doses higher than 0.2 mg/kg/day were also excluded. Results: 95 patients were included, 88 collected the exams, 1 was excluded and 23 did not undergo the ultrasound scan. Patients with PG had a higher mean CIMT compared to controls (0.66 versus 0.60), p = 0.003. After multivariate analysis, age and values for systolic blood pressure (SBP), FMV and GFR (p = 0.02); and FMV and serum uric acid (p = 0.048) remained statistically relevant. Discussion and conclusion: The higher cardiovascular risk in patients with PG was not explained by early MBD. Randomized and multicentric clinical studies are necessary to better assess this hypothesis.

Resumo Introdução: Glomerulopatias são a terceira causa de doença renal crônica (DRC) com necessidade de diálise no Brasil. Distúrbio mineral e ósseo (DMO) é uma das complicações da DRC e está presente já nos estágios iniciais. A avaliação da espessura médio-intimal de carótidas (EMIC) e da vasodilatação fluxo-mediada (VFM) são maneiras não invasivas de avaliação do risco cardiovascular. Hipótese: Pacientes com glomerulopatias primárias (GP) apresentam alta prevalência de aterosclerose e disfunção endotelial, não explicada totalmente pelos fatores de risco tradicionais, mas provavelmente influenciada pela instalação precoce do DMO. Objetivo: Avaliar os principais marcadores de aterosclerose em pacientes com GP. Método: Estudo clínico, observacional, transversal e controlado. Foram incluídos portadores de GP e excluídos menores de 18 anos, gestantes, menos de três meses de seguimento e os com glomerulopatia secundária. Também foram excluídos aqueles que, no momento da coleta, apresentavam proteinúria maior que 6 gramas/24 horas e uso de prednisona em doses superiores a 0,2 mg/kg/dia. Resultados: 95 pacientes foram incluídos, 88 colheram os exames, 1 foi excluído e 23 não realizaram a ultrassonografia. Os pacientes com GP apresentaram maior EMIC média em relação ao controle (0,66 versus 0,60), p = 0,003. Após análise multivariada, mantiveram relevância estatística a idade e os valores de pressão arterial sistólica (PAS), VFM e TFG (p = 0,02) e VFM e ácido úrico sérico (p = 0,048). Discussão e conclusão: Pacientes com GP apresentaram maior risco cardiovascular, entretanto esse risco não foi explicitado pelo DMO precoce. Estudos clínicos randomizados e multicêntricos são necessários para melhor determinação dessa hipótese.

Diseño de una escala predictiva de mortalidad en pacientes con enfermedad renal crónica

Introducción: La predicción de mortalidad en pacientes con enfermedad renal crónica, mediante escalas o índices pronósticos presenta limitaciones reales. Objetivo: Diseñar una escala predictiva de mortalidad en pacientes con enfermedad renal crónica. Métodos: Se realizó un estudio observacional, analítico, longitudinal prospectivo en 169 pacientes con enfermedad renal crónica desde el 1 de enero de 2022 al 31 de diciembre de 2022. La investigación se desarrolló en 2 etapas: durante los primeros 6 meses del año se analizaron las variables de estudio para el diseño de la escala predictiva. En los próximos 6 meses, los pacientes fueron seguidos para identificar la ocurrencia o no de la variable dependiente mortalidad. Se determinó la capacidad discriminatoria de la escala predictiva y se evaluaron curvas de supervivencia. Resultados: Las variables que conformaron la escala predictiva fueron edad > 65 años, enfermedad cardiovascular, albúmina 390 mmol/L. El poder discriminatorio para predecir mortalidad fue bueno, índice C: 0,856 (IC 95 %: 0,783-0,929; p< 0,001). Los pacientes con valores menores a 4 puntos presentaron media de supervivencia de 149,438 ± 7,296 días. En cambio, los que tenían valores superiores presentaron media de supervivencia de 93,128 ± 8,545 días. Conclusiones: La escala predictiva contribuyó a la estratificación del riesgo de mortalidad de los pacientes. Las variables incluidas son de fácil determinación e interpretación por lo que es un modelo útil en la toma de decisiones médicas en el ámbito clínico actual.

Introduction: The prediction of mortality in patients with chronic kidney disease using scales or prognostic indices has real limitations. Objective: Design a mortality predictive scale in patients with chronic kidney disease. Methods: A prospective observational, analytical, longitudinal study was carried out in 169 patients with chronic kidney disease from January 1, 2022 to December 31, 2022. The research was developed in 2 stages: during the first 6 months of the year, the variables were analyzed for the design of the predictive scale. In the next 6 months, patients were followed to identify the occurrence or not of the dependent variable mortality. The discriminatory capacity of the predictive scale was determined and survival curves were evaluated. Results: The variables that made up the predictive tool were age > 65 years, cardiovascular disease, albumin 390 mmol/L. The discriminatory power to predict mortality was good, C index: 0.856 (95% CI: 0.783-0.929; p< 0.001). Patients with values less than 4 points had a mean survival of 149.438 ± 7.296 days. In contrast, those with higher values presented a mean survival of 93.128 ± 8.545 days. Conclusions: The scale contributed to the stratification of the mortality risk of the patients. The variables included are easy to determine and interpret, making it a useful model for medical decision making in the current clinical setting.

Cryptococcus laurentii fungemia in a patient with chronic kidney disease on hemodialysis / Fungemia por cryptococcus laurentii em paciente com doença renal crônica em hemodiálise

Introduction: Chronic Kidney Disease (CKD) is a relevant comorbidity from clinical and public health perspectives. Infections are an important cause of death in those patients. Although rare, fungal infections are increasing in incidence. Case report: a 45-year-old female patient with CKD due to systemic lupus erythematosus (SLE) was admitted to a tertiary hospital due to a bloodstream infection (BSI) caused by Cryptococcus laurentii. She received treatment with anidulafungin with good initial response but presented clinical and laboratory worsening after a few days, and the treatment was switched to amphotericin B. The hemodialysis access was changed. Chest tomography, echocardiogram, eye fundus examination, and cerebrospinal fluid study did not show changes. After 32 days of amphotericin B, the patient presented clinical improvement and was discharged to take oral fluconazole for three (3) months. Conclusion: BSI due to Cryptococcus laurentii is rare in patients on chronic hemodialysis with a high potential for complications. Physicians should have clinical suspicion for those infrequent infections infractions, and culture evaluation should always be performed. The diagnosis is still a challenge, as well as the therapeutic regimen.

Introdução: a doença renal crônica (DRC) é uma comorbidade relevante do ponto de vista clínico e de saúde pública. As infecções configuram importante causa de morte nesses pacientes. Embora raras, as infecções por fungos têm incidência crescente. Relato de caso: uma paciente do sexo feminino, 45 anos, com DRC por lúpus eritematoso sistêmico (LES) foi internada em hospital terciário devido à infecção de corrente sanguínea (ICS) por Cryptococcus laurentii. Recebeu tratamento com anidulafungina com boa resposta inicial, porém, devido à piora clínica e laboratorial, o tratamento foi modificado para anfotericina B, assim como foi realizada a troca do acesso para hemodiálise. A tomografia de tórax, o ecocardiograma, o exame de fundo de olho e o estudo do líquido cefalorraquidiano não evidenciaram alterações. Após 32 dias de anfotericina B, a paciente apresentou melhora clínica e recebeu alta hospitalar com fluconazol via oral por 3 meses. Conclusão: a ICS por Cryptococcus Laurentii é rara nos pacientes em hemodiálise crônica, porém com alto potencial de complicações. Há a necessidade de suspeição clínica e avaliação por culturas, sendo o diagnóstico ainda um desafio, bem como o esquema terapêutico.