El riñón del niño prematuro: riesgos a largo plazo / The kidney of the premature child: long-term risks

Resumen: El recién nacido prematuro se enfrenta a las condiciones extrauterinas con sistemas aún inmaduros, tanto anatómica como fisiológicamente. El riñón termina de desarrollarse a finales del tercer trimes tre del embarazo, por lo que está especialmente expuesto a alterar su desarrollo normal en caso de nacer en forma prematura. Esta situación puede condicionar, entre otras consecuencias, una menor masa renal funcional y cambios microvasculares que representan un riesgo elevado de hipertensión arterial y daño renal crónico en el largo plazo. En el presente artículo se analiza la evidencia existente actual sobre estos riesgos en los prematuros y se ofrece un esquema de seguimiento de estos niños desde el punto de vista nefrológico.

Abstract: The premature newborn faces extrauterine conditions with some systems still immature, both ana tomically and physiologically. The kidney finishes developing at the end of the third trimester of pregnancy, so it is especially exposed to alter its normal development if preterm birth occurs. This si tuation may condition, among other consequences, a lower functional renal mass and microvascular changes comprising a high risk of chronic kidney disease in the long term and arterial hypertension. This article analyzes the current evidence on these risks in premature infants and offers a nephrology follow-up scheme of these children.

Evaluation of variables associated with the patency of arteriovenous fistulas for hemodialysis created by a nephrologist / Avaliação de variáveis associadas à permeabilidade de fístulas arteriovenosas criadas por um nefrologista para fins de hemodiálise

ABSTRACT Introduction: Arteriovenous fistula (AVF) is considered the gold standard vascular access for chronic hemodialysis, and its failure predicts higher morbidity and mortality rates. Objective: 1) To evaluate the success rate of AVF created by a nephrologist and 2) to identify clinical, laboratory, and demographic variables that influence AVF patency. Methods: A retrospective cohort study of 101 patients with chronic kidney disease for a total of 159 AVF created by a nephrologist between June 2010 and June 2013. Results: Of the AVFs created, 124 (78%) displayed immediate patency and 110 (62.9%) displayed late patency. Hemoglobin (10-12 g/dL) was the only variable related to late AVF patency (p = 0.05). An elevated blood pressure at time of surgery was associated with a lower number of procedures per patient (p = 0.001). Proximal AVF occurred more frequently in patients with dual access (p = 0.03). The AVF success rate was similar to those previously reported in the literature. Conclusion: Hemoglobin level in the recommended range has a favorable impact on late AVF patency and elevated blood pressure during surgery on the lower number of vascular accesses per patient. The high success rate indicates that it can be placed by trained nephrologists.

RESUMO Introdução: A fístula arteriovenosa (FAV) é considerada o acesso vascular padrão ouro para hemodiálise crônica, e sua falha prediz taxas mais altas de morbimortalidade. Objetivos: 1) Avaliar a taxa de sucesso da FAV criada por um nefrologista e 2) identificar variáveis clínicas, laboratoriais e demográficas que influenciam a patência da FAV. Métodos: Estudo de coorte retrospectivo de 101 pacientes com doença renal crônica, totalizando 159 FAVs criados por um nefrologista entre junho de 2010 e junho de 2013. Resultados: Das FAVs criadas, 124 (78%) apresentaram patência imediata e 110 (62,9%) apresentaram patência tardia. A hemoglobina (10-12 g/dL) foi a única variável relacionada à patência tardia da FAV (p = 0,05). A pressão arterial elevada no momento da cirurgia foi associada a um menor número de procedimentos por paciente (p = 0,001). A FAV proximal ocorreu com maior frequência em pacientes com dois acessos confeccionados (p = 0,03). A taxa de sucesso da FAV foi semelhante à relatada anteriormente na literatura. Conclusão: O nível de hemoglobina no intervalo recomendado tem um impacto favorável na perviedade tardia da FAV e pressão arterial elevada durante a cirurgia no menor número de acessos vasculares por paciente. A alta taxa de sucesso indica que ela pode ser feita por nefrologistas treinados.

Estudio epidemiológico y demográfico de la consulta externa de Nefrología Pediátrica / Epidemiological and demographic study of the outpatient Pediatric Nephrology service

Antecedentes: a nivel mundial los datos epidemiológicos acerca de enfermedad renal en pacientes pediátricos son limitados, Honduras dispone de poca información actualizada. Objetivo: determinar la epidemiología y demografía de las atenciones en la consulta externa de Nefrología Pediátrica del Hospital Escuela Universitario, en Tegucigalpa, Honduras, en el período 2011-2015. Métodos: estudio descriptivo, retrospectivo. Universo conformado por 1 614 expedientes de pacientes atendidos en la consulta externa de Nefrología Pediátrica. Muestra de 1 141 expedientes, intervalo de confianza de 97 por ciento. Se realizó análisis univariado y bivariado de los datos con medidas de frecuencia y tendencia central utilizando el programa EPI-INFO 7.2 y Microsoft Office Excel 2013. Resultados: la prevalencia de las afecciones atendidas fueron: las infecciones del tracto urinario 516 (34,4 por ciento), seguido de 413 malformaciones nefrourológicas (26,5 por ciento) y 298 enfermedades glomerulares (19,9 por ciento). En cuanto al diagnóstico de infecciones del tracto urinario, se encontró que 49,8 por ciento se presentaron en menores de cinco años, y de estos, 67,1 por ciento pertenecían al sexo femenino. También, de estos pacientes, se encontró que 43 (8,3 por ciento) estaban asociados a alguna malformación congénita (las principales fueron defectos congénitos de la pelvis renal y malformaciones congénitas ureterales). Conclusiones: las infecciones del tracto urinario y las malformaciones nefrourológicas son las nefropatías más frecuentes en la consulta externa de Nefrología Pediátrica del principal hospital del país, y predominan en el sexo femenino. Las principales malformaciones nefrourológicas son las malformaciones congénitas y las hidronefrosis(AU)

Background: epidemiological data about renal disease in pediatric patients are limited worldwide. In Honduras updated information on this topic is scant. Objective: determine the epidemiology and demography of care at the outpatient Pediatric Nephrology service of the University Hospital in Tegucigalpa, Honduras in the period 2011-2015. Methods: a descriptive retrospective study was conducted of a universe of 1 614 records of patients cared for at the outpatient Pediatric Nephrology service. The study sample was composed of 1 141 records, and the confidence interval was 97 percent. Univariate and bivariate analysis of the data was based on frequency and central tendency measurements using the software EPI-INFO 7.2 and Microsoft Office Excel 2013. Results: the conditions cared for showed the following prevalence: urinary tract infection 516 (34.4 percent), followed by nephro-urological malformation 413 (26.5 percent) and glomerular disease 298 (19.9 percent). Of the total urinary tract infections diagnosed, 49.8 percent occurred in children under five years of age, 67.1 percent of whom were female. It was also found that 43 (8.3 percent) of these patients had some type of congenital malformation, mainly congenital defects of the renal pelvis and congenital ureteral malformations. Conclusions: urinary tract infections and nephro-urological malformations are the most frequent nephropathies at the outpatient Pediatric Nephrology service of the most important hospital in the country, with a predominance of the female sex. The main nephro-urological malformations were congenital malformations and hydronephrosis(AU)

Water balance in pediatric nephrology: construction of a Standard Operating Procedure / Balance hídrico en la nefrología pediátrica: construcción de un Procedimiento Operativo Estándar / Balanço hídrico na nefrologia pediátrica: construção de um Procedimento Operacional Padrão

ABSTRACT Objective: To construct a Standard Operating Procedure (SOP) about the water balance, to be used by the health team in the care of children hospitalized in a pediatric nephrology unit. Method: The study was carried out in two stages: integrative review of the literature for the development of SOP and validation by specialists. The search for literature occurred in the electronic databases PUBMED, SCOPUS, LILACS, BDENF. After the bibliographic survey the construction of the SOP was performed, which was evaluated by specialists. The analysis was performed by calculating the Content Validity Index (CVI). Results: nine studies were selected as results of the integrative review. The sample of specialists was composed of nine professionals. The study was evaluated in six items, five of which presented CVI = 1 and one obtained CVI = 0.77. Conclusion: the evaluation of specialists culminated in the validation of SOP, suggesting changes that were accepted and discussed with the literature.

RESUMEN Objetivo: construir un Procedimiento Operativo Estándar (POE) sobre el balance hídrico, para ser utilizado por el equipo de salud en el cuidado al niño internado en una unidad de nefrología pediátrica. Método: el estudio fue realizado en dos etapas: revisión integradora de la literatura para la elaboración del POE y validación por especialistas. La búsqueda de la literatura ocurrió en las bases de datos electrónicos: PUBMED, SCOPUS, LILACS, BDENF. Después del levantamiento bibliográfico se dio la construcción del POE que fue evaluado por especialistas. El análisis fue realizado por medio del cálculo del Índice de Validez de Contenido (CVI). Resultados: como resultados de la revisión integradora fueron seleccionados nueve estudios. La muestra de los especialistas fue compuesta por nueve profesionales. El estudio fue evaluado en seis ítems, de los cuales cinco presentaron CVI=1 y uno obtuvo CVI=0,77. Conclusión: la evaluación de los especialistas culminó en la validación del POE, siendo sugeridas alteraciones que fueron acatadas y discutidas con la literatura.

RESUMO Objetivo: construir um Procedimento Operacional Padrão (POP) acerca do balanço hídrico, para ser utilizado pela equipe de saúde no cuidado à criança internada em uma unidade de nefrologia pediátrica. Método: o estudo foi realizado em duas etapas: revisão integrativa da literatura para elaboração do POP e validação por especialistas. A busca da literatura ocorreu nas bases de dados eletrônicas: PUBMED, SCOPUS, LILACS, BDENF. Após o levantamento bibliográfico deu-se a construção do POP que foi avaliado por especialistas. A análise foi realizada por meio do cálculo do Índice de Validade de Conteúdo (CVI). Resultados: como resultados da revisão integrativa foram selecionados nove estudos. A amostra dos especialistas foi composta por nove profissionais. O estudo foi avaliado em seis itens, os quais cinco apresentaram CVI=1 e um obteve CVI=0,77. Conclusão: a avaliação dos especialistas culminou na validação do POP, sendo sugeridas alterações que foram acatadas e discutidas com a literatura.

Interdisciplinariedade e trabalho em grupo em nefrologia / Interdisciplinary and group work in Nephrology

A constatação da alta prevalência, em pacientes com doenças renais, de sintomas psicopatológicos, da perda da sua qualidade de vida, além das perdas reais, e da falta de informação sobre sua doença e tratamento, aponta para a necessidade da atuação dos profissionais da saúde sobre esses pontos. Através da análise crítica da interdisciplinaridade, em contraponto à multidisciplinaridade, e do alcance que o trabalho grupal apresenta, é feita uma proposta de intervenção junto aos pacientes internados em uma enfermaria de Nefrologia. A intervenção proposta é um grupo interdisciplinar rotativo aberto que trabalhe as diferentes demandas trazidas por esses pacientes. Como exemplo, é apresentado o recorte de um dos grupos realizados onde os diferentes aspectos dessa intervenção são identificados e comentados.

The high prevalence of psychopathological symptoms among renal patients, the reduced quality of life that adds to their ensuing actual losses, and the lack of information on their illness and treatment, indicates that health professionals should act on these specific points. By means of a critical analysis of interdisciplinarity vis-à-vis multidisciplinarity and taking advantage of the reach of group work, we propose an intervention, consisting of an opened rotating interdisciplinary group, offered to patients admitted to a Nephrology ward, in order to deal with their different demands. As an example, excerpts from one group session are presented, and the various aspects of the intervention are identified and commented on.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

Acupuntura em Nefrologia: estado da arte / Acupuncture in nephrology: state of the art

A Medicina Tradicional Chinesa (MTC) apresenta conceitos diferenciados de fisiologia, propedêutica, etiopatogenia e tratamento e vem tornando-se cada vez mais uma abordagem terapêutica reconhecida em vários campos da medicina. Nesse contexto, a acupuntura constitui uma técnica de estimulação sensorial e periférica, que utiliza as propriedades integradas do sistema nervoso, para realizar sua função terapêutica. Atualmente, seus efeitos estão começando a ser entendidos pelos crescentes estudos na área da neuroanatomia e da neurofisiologia. Neste artigo, propusemo-nos a discutir resumidamente os conceitos e princípios que norteiam a MTC e revisar as evidências científicas da sua utilização em Nefrologia. Além disso, reportamos nossa experiência com o emprego da acupuntura e moxabustão na progressão da doença renal experimental. Este é um campo novo que se abre, sendo muito promissor como mais uma estratégia auxiliar no tratamento da insuficiência renal crônica.

Traditional Chinese Medicine (TCM) has different concepts of physiology, semiology, etiopathogenesis, and treatment, and it has been increasingly recognized as an effective therapeutic approach in several medical fields. Acupuncture is a sensorial and peripheral stimulation technique that uses the integrated properties of the nervous system to exert its therapeutic actions. The increased number of studies on neuroanatomy and neurophysiology has allowed us to begin understanding its effects. In this study, we propose a brief discussion on the concepts and principles that guide TCM, and review the scientific evidence of its use in Nephrology. We also report our experience with acupuncture and moxibustion on the progression of experimental renal disease. This is a new and promising ancillary therapeutic strategy in nephrology and it may be associated with conventional methods in the management of end-stage renal disease.

EDITOR'S NOTE-About This Supplement

No abstract available.

Asian Leadership in Chronic Kidney Disease

Asian Pacific countries include those with the highest incidence of renal failure in the world, the richest and poorest economies and unparalleled diversity of economy, culture and geography. From this come many challenges, but also a strong basis for the introduction of strategies to combat renal diseases. With a rapidly developing scientific community, Asia needs to accept the challenge of becoming a global leader in nephrology in the near future.

Usefulness of ISN/RPS Classification of Lupus Nephritis

About 50-80% of patients with lupus suffer from lupus nephritis which is one of major causes of morbidity and mortality. Renal pathologists and nephrologists should evaluate the degree of histological damages to establish therapeutic plans for lupus nephritis. In order to standardize definitions, to emphasize clinically relevant lesions, and to improve interobserver reproducibility, the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification was proposed. Recently, several retrospective validation studies concerning the utility of the ISN/RPS classification, especially among class IV, were performed. In these reports, reproducibility is improved by the definition of diagnostic term, but the outcome related with classification, especially in class IV, is controversial. We performed retrospective analysis of 99 biopsy- proven subjects with lupus nephritis in our facility using the ISN/RPS classification. The class IV-G group tended to exhibit a worse renal outcome, but the difference compared with IV-S was not significant. In a Cox proportional hazards models, Independent histological predictors of poor renal outcome were extracapillary proliferation, glomerular sclerosis and fibrous crescents, while hyaline thrombi and fibrous adhesions were of favorable renal outcome. Both were similarly observed in IV-G and IV-S. The more qualitative categorization by the response to standard treatment may be needed to emphasize clinically relevant lesion related to renal outcome.

The Prevalence of Chronic Kidney Disease (CKD) and the Associated Factors to CKD in Urban Korea: A Population-based Cross-sectional Epidemiologic Study

Chronic kidney disease (CKD) is a worldwide problem. This study was designed to survey the prevalence and risk factors for CKD in Korea. The 2,356 subjects were selected in proportion to age, gender, and city. Subjects 35 yr of age or older were selected from 7 cities. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) Study equation, with albuminuria defined as a urine albumin to creatinine ratio of 30 mg/g or more. The overall prevalence of CKD was 13.7%. The prevalences of CKD according to stage were 2.0% stage 1, 6.7% stage 2, 4.8% stage 3, 0.2% stage 4, and 0.0% stage 5. The prevalences of microalbuminuria and macroalbuminuria were 8.6% and 1.6%, respectively. The prevalence of eGFR less than 60 mL/min/1.73 m2 was 5.0%. Age, body mass index (BMI), hypertension, diabetes mellitus, systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting blood glucose were independent factors related to the presence of CKD. In conclusions, Korea, in which the prevalence of CKD is increasing, should prepare a policy for early detection and appropriate treatment of CKD. The present data will be helpful in taking those actions.

Cardiac Autonomic Neuropathy as a Predictor of Deterioration of the Renal Function in Normoalbuminuric, Normotensive Patients with Type 2 Diabetes Mellitus

Our study was performed to determine whether cardiac autonomic neuropathy can predict deterioration of the renal function in normoalbuminuric, normotensive people with type 2 diabetes mellitus (DM). One hundred and fifty-six normoalbuminuric, normotensive people with type 2 DM were included in our retrospective longitudinal study. We categorized normal patterns, early patterns, and definite or severe patterns according to the results of the cardiac autonomic function test. Of 156 patients included, 54 had normal patterns, 75 had early patterns, 25 had definite or severe patterns, and 2 had atypical patterns. During a median follow-up of nine years, glomerular filtration rates (GFR) remained stable in the normal and early pattern groups (mean changes, 4.50% and 0.77%, respectively) but declined in those with definite or severe patterns (mean change, -10.28%; p=0.047). An abnormal heart response to the deep breathing test of the cardiac autonomic function tests was an independent predictor of GFR decline. Our data suggest that cardiac autonomic neuropathy, especially with a definite or severe pattern, might be associated with a subsequent deterioration in renal function in normoalbuminuric, normotensive people with type 2 DM.

Status of Initiating Pattern of Hemodialysis: A Multi-center Study

This study was to evaluate the status of initiating pattern of hemodialysis (HD). Five hundred-three patients in 8 University Hospitals were included. Presentation mode (planned vs. unplanned), and access type (central venous catheters [CVC] vs. permanent access) at initiation of HD were evaluated, and the influence of predialysis care on determining the mode of HD and access type was also assessed. Most patients started unplanned HD (81.9%) and the most common initial access type was CVC (86.3%). The main reason for unplanned HD and high rate of CVC use was patient-related factors such as refusal of permanent access creation and failure to attend scheduled clinic appointments. Predialysis care was performed in 57.9% of patients and only 24.1% of these patients started planned HD and 18.9% used permanent accesses initially. Only a minority of patients initiated planned HD with permanent accesses in spite of predialysis care. To overcome this, efforts to improve the quality of predialysis care are needed.

Minimal Proteinuria One Year after Transplant is a Risk Factor for Graft Survival in Kidney Transplantation

It is generally accepted that one-year post-transplant proteinuria over 0.5 gm per day has a negative impact on renal graft survival. In this study, the effects of minimal proteinuria less than 0.5 g/day were analyzed in 272 renal recipients who had survived for one year with a functioning graft. Recipients were classified by one-year posttransplant proteinuria: no proteinuria group ( or =0.5 g/day). Recipients were followed up for 87.1+/-21 months after transplantation and 38 (13.9%) lost their graft during follow-up. Fifteen percent of patients had minimal proteinuria and 7.8% had overt proteinuria. Five-year graft survival in the minimal proteinuria group was 83.0%, and that in the overt proteinuria group was 70%, in contrast to 97.1% in the no proteinuria group (p=0.01 for trend). In a multivariate analysis, the minimal proteinuria group (relative risk [RR], 4.90; 95% confidence interval [CI], 2.09-11.46) and the overt proteinuria group (RR, 8.75; 95% CI, 3.29-23.29) had higher risks of graft failure than the no proteinuria group. Even minimal proteinuria at one year after transplantation was strongly associated with poor graft outcome. Therefore, it appears logical to consider a low level of proteinuria as a risk factor for graft survival in renal recipients.

Clinical Significance of Monitoring Circulating CD4+CD25+ Regulatory T Cells in Kidney Transplantation during the Early Posttransplant Period

The CD4+CD25+ T regulatory cells (Tregs) play an important role in immune tolerance in experimental transplantation but the clinical significance of circulating Tregs in the peripheral blood is undetermined. In 50 kidney transplant (KT) recipients, 29 healthy controls and 32 liver transplant (LT) recipients, the frequency of Tregs was measured with flow cytometry before and after transplantation. In the KT recipients, IL-10 secretion was measured with an enzyme-linked immunospot (ELISPOT) assay. The median frequency of circulating Tregs before KT was similar to that in healthy controls but significantly lower than that in LT patients before transplantation. The frequency of Tregs was significantly decreased in patients with subclinical acute rejection compared with those without subclinical acute rejection. Calcineurin inhibitors (CNIs) and anti-CD25 antibody decreased the frequency of Tregs but mTOR inhibitor did not. The frequency of donor-specific IL-10 secreting cells did not correlate with the number of Tregs. The frequency of circulating Tregs in KT recipients is strongly affected by CNIs and anti-CD25 antibody, and a low frequency of Tregs is associated with subclinical acute rejection during the early posttransplant period.

Historia clínica automatizada de enfermos renales dialiticodependientes y su aplicación / Automated medical record of dialysis-dependent renal patients and its application

En el Departamento de Hemodiálisis del Hospital General Dr. Juan Bruno Zayas Alfonso en Santiago de Cuba, son atendidos 160 pacientes con afecciones renales crónicas, que reciben tratamiento dialítico. Con vista a registrar y conservar toda la información al respecto se aplicó un programa informático (gestor de base de datos): EMALEX (historia clínica automatizada de enfermos renales crónicos en diálisis) desde mayo hasta agosto del 2007, que fue perfeccionado a partir de determinadas opiniones del Consejo Científico Nacional de Nefrología. Este programa permite almacenar, organizar y preservar toda la evolución del paciente, desde la inclusión en el proceso de diálisis hasta su exclusión. Posee un sistema de ayuda al médico y proporciona al usuario una herramienta útil, de fácil manipulación y confiable en los resultados, entre otras importantes ventajas.

One hundred and sixty patients with chronic renal disorders that receive dialysis treatment are assisted in the Hemodialysis Department of Dr. Juan Bruno Zayas Alfonso General Hospital in Santiago de Cuba. With the purpose of registering and preserving all the information in this respect a computer program was applied (database agent): EMALEX (automated medical records of chronic renal patients assisted by dialysis) from May to August, 2007, which was improved taking into account certain opinions of the National Scientific Council of Nephrology. This program allows to store, organize and preserve the patient's clinical course, from the admission in the dialysis process to his discharge. It has a help system for the doctor and it provides the user an useful tool, of easy manipulation and reliable in the results, among other important advantages.