Evaluation of Renal Impairment in Patients with Diabetic Kidney Disease by Integrated Chinese and Western Medicine / 中国结合医学杂志

OBJECTIVE@#To investigate the factors related to renal impairment in patients with diabetic kidney disease (DKD) from the perspective of integrated Chinese and Western medicine.@*METHODS@#Totally 492 patients with DKD in 8 Chinese hospitals from October 2017 to July 2019 were included. According to Kidney Disease Improving Global Outcomes (KDIGO) staging guidelines, patients were divided into a chronic kidney disease (CKD) 1-3 group and a CKD 4-5 group. Clinical data were collected, and logistic regression was used to analyze the factors related to different CKD stages in DKD patients.@*RESULTS@#Demographically, male was a factor related to increased CKD staging in patients with DKD (OR=3.100, P=0.002). In clinical characteristics, course of diabetes >60 months (OR=3.562, P=0.010), anemia (OR=4.176, P<0.001), hyperuricemia (OR=3.352, P<0.001), massive albuminuria (OR=4.058, P=0.002), atherosclerosis (OR=2.153, P=0.007) and blood deficiency syndrome (OR=1.945, P=0.020) were factors related to increased CKD staging in patients with DKD.@*CONCLUSIONS@#Male, course of diabetes >60 months, anemia, hyperuricemia, massive proteinuria, atherosclerosis, and blood deficiency syndrome might indicate more severe degree of renal function damage in patients with DKD. (Registration No. NCT03865914).

Calcificaciones pulmonares metastásicas, 3 casos clínicos / Metastatic pulmonary calcifications: three clinical cases

Las calcificaciones pulmonares metastásicas, hacen referencia a una enfermedad metabólica, caracterizada por depósitos de calcio en tejido pulmonar sano. La etiología es amplia e incluye enfermedades malignas y benignas, siendo la falla renal la causa más frecuente. Es una condición, que, a pesar de ser frecuente, suele ser subdiagnosticada, por presentar pocos o ningún síntoma. Presentamos tres casos clínicos asociados a enfermedad renal crónica, pre y post trasplante.

Metastatic pulmonary calcifications refer to a metabolic disease, characterized by calcium deposits in healthy lung tissue. The etiology is broad and includes malignant and benign diseases, the kidney failure being the most frequent cause. It is a condition, which, despite being frequent, is usually underdiagnosed, because it presents few or no symptoms. We present three clinical cases associated with pre- and post-transplant kidney disease.

Association between frailty and depression among hemodialysis patients: a cross-sectional study

ABSTRACT BACKGROUND: Frailty is consensually understood to be a clinical syndrome in which minimal stressors can lead to negative outcomes such as hospitalization, early institutionalization, falls, functional loss and death. Frailty is more prevalent among patients with chronic kidney disease (CKD), and those on dialysis are the frailest. Depression contributes towards putting patients with CKD into the frailty cycle. OBJECTIVE: To assess frailty and its relationship with depression among patients with CKD undergoing hemodialysis. DESIGN AND SETTING: Observational and quantitative cross-sectional study conducted in a renal therapy unit, located in the interior of the state of São Paulo, Brazil. METHODS: This investigation took place in 2019, among 80 patients. The following instruments were applied: a sociodemographic, economic and health condition characterization and the Subjective Frailty Assessment (SFA) and Patient Health Questionnaire-9 (PHQ-9). RESULTS: Among the patients, there was higher prevalence of females, individuals with a steady partner and retirees, and their mean age was 59.63 (± 15.14) years. There was high prevalence of physical frailty (73.8%) and depression (93.7%). Depression was associated with frailty, such that patients with depression were 9.8 times more likely to be frail than were patients without depression (odds ratio, OR = 9.80; 95% confidence interval, CI, 1.93-49.79). CONCLUSION: Based on the proposed objective and the results achieved, it can be concluded that depression was associated with the presence of frailty among patients with CKD on hemodialysis.

Recommendations for the diagnosis and management of Fabry disease in pediatric patients: a document from the Rare Diseases Committee of the Brazilian Society of Nephrology (Comdora-SBN) / Recomendações para o diagnóstico e manejo de pacientes pediátricos com doença de Fabry: documento do comitê de doenças raras da Sociedade Brasileira de Nefrologia (Comdora-SBN)

Fabry disease (FD) is a genetic disease, with X-chromosome linked inheritance, due to variants in the GLA gene that encodes the α-galactosidase A (α-GAL) enzyme. The purpose of the present study was to create a consensus aiming to standardize the recommendations regarding the renal involvement of FD with guidelines on the diagnosis, screening, and treatment of pediatric patients. This consensus is an initiative of the Rare Diseases Committee (Comdora) of the Brazilian Society of Nephrology (SBN). Randomized controlled clinical studies and studies with real-life data added to the authors' experience were considered for this review. The result of this consensus was to help manage patient and physician expectations regarding treatment outcomes. Thus, this consensus document recommends the investigation of the pediatric family members of an index case, as well as cases with suggestive clinical signs. From the diagnosis, assess all possible FD impairments and grade through scales. From an extensive review of the literature including pediatric protocols and particularly evaluating pediatric cases from general studies, it can be concluded that the benefits of early treatment are great, especially in terms of neuropathic pain and renal impairment parameters and outweigh the possible adverse effects that were mainly manifested by infusion reactions.

A doença de Fabry (DF) é uma doença genética, com herança ligada ao cromossomo X, devido a variantes no gene GLA que codifica a enzima α-galactosidase A (α-GAL). O propósito do presente estudo foi criar um consenso objetivando padronizar as recomendações em relação ao acometimento renal da DF com orientações sobre o diagnóstico, rastreamento, e tratamento de pacientes pediátricos. Esse consenso é uma iniciativa do Comitê de Doenças Raras (Comdora) da Sociedade Brasileira de Nefrologia (SBN). Foram considerados para esta revisão estudos clínicos controlados randomizados e estudos com dados de vida real somados à experiência dos autores. O resultado desse consenso foi auxiliar no gerenciamento das expectativas de pacientes e médicos quanto aos resultados do tratamento. Assim, este documento de consenso recomenda a investigação dos familiares pediátricos de um caso índice, assim como de casos com clínica sugestiva. A partir do diagnóstico, avaliar todos os possíveis acometimentos da DF e graduar através de escalas. A partir de uma revisão extensa da literatura incluindo protocolos pediátricos e avaliando particularmente os casos pediátricos de estudos gerais, pode-se concluir que os benefícios do tratamento precoce são grandes, principalmente quanto aos parâmetros de dor neuropática e do acometimento renal, e suplantam os possíveis adversos que foram sobretudo manifestados por reações infusionais.

Clinical characteristics of severe aortic stenosis patients combined with diabetes mellitus after transcatheter aortic valve replacement and short-term outcome / 中南大学学报(医学版)

OBJECTIVES@#Type 2 diabetes (T2DM) is a common comorbidity in patients with degenerative aortic stenosis (AS).As a key item of the American Society of Thoracic Surgeons (STS) score, it has a vital impact on the clinical prognosis of traditional thoracic surgery. T2DM has an adverse effect on the morbidity and mortality of cardiovascular diseases. At the same time, studies have shown that T2DM are associated with myocardial hypertrophy and remodeling, decreased left ventricular function, and worsening heart failure symptoms in the AS patients. Transcatheter aortic valve replacement (TAVR) as an interventional method to replace the aortic valve has better safety for middle and high risk patients in surgery, but the impact of T2DM on the clinical outcome of TAVR in AS patients is not clear.By analyzing the clinical and image characteristics of patients with AS and T2DM who received TAVR treatment, so as to explore the effect of T2DM on the perioperative complications and prognosis of TAVR.@*METHODS@#A total of 100 consecutive patients with severe AS, who underwent TAVR treatment and were followed up for more than 1 month, were selectedin the Second Xiangya Hospital of Central South University from January 2016 to December 2020.Among them, 5 patients who were treated with TAVR due to simple severe aortic regurgitation were not included, therefore a total of 95 patients with severe aortic stenosis were enrolled in this study.The age of the patients was (72.7±4.8) years old, and there were 58 males (61.1%), and the patients with moderate or above aortic regurgitation had 30 cases (31.6%). The patients were divided into a diabetic group and a non-diabetic group according to whether they were combined with T2DM.There was no statistical difference in age, gender, body mass index (BMI), STS score, and New York Heart Association (NYHA) cardiac function classification between the 2 groups (all P>0.05). The primary end point was defined as a composite event consisting of all-cause death and stroke one month after surgery, and the secondary end point was defined as TAVR-related complications immediately after surgery and one month after surgery.The preoperative clinical data, cardiac ultrasound data, CT data, postoperative medication and the incidence of each endpoint event were compared between the 2 groups.The predictive model of adverse events was constructed by single factor and multivariate logistic regression.@*RESULTS@#Compared with the non-diabetic group, the diabetic group had high blood pressure and chronic renal insufficiency.There was no significant difference in preoperative ultrasound echocardiography between the 2 groups. Preoperative CT evaluation found that the anatomical structure of the aortic root in the diabetic group was smaller than that in the non-diabetic group, and there was no significant difference in the incidence of bicuspid aortic valve between the 2 groups (all P<0.05). In terms of postoperative medication, the use of statins in the diabetes group was significantly higher than that in the non-diabetic group. In the diabetes group, 6 patients (37.5%) received insulin therapy, and 9 patients (56.3%) received oral medication alone.Univariate logistic regression analysis showed that the all-cause death and stroke compound events was increased in the diabetes group in 30 days after TAVR (OR=6.86; 95% CI: 2.14 to 21.79; P<0.01). Heart disease (OR=2.80; 95% CI: 0.99 to 7.88; P<0.05) and chronic renal insufficiency (OR=3.75; 95% CI: 1.24 to 11.34; P<0.05) were also risk factors for all-cause death and stroke compound events.In a multivariate analysis, after adjusting for age, gender, BMI, comorbidities, N-terminal pro-B type natriuretic peptide (NT-proBNP), total calcification score, ejection fraction, and degree of aortic regurgitation, T2DM was still a risk factor for all-cause death and stroke compound events in 30 days after TAVR (OR=12.68; 95% CI: 1.76 to 91.41; P<0.05).@*CONCLUSIONS@#T2DM is a risk factor for short-term poor prognosis in patients with symptomatic severe AS after TAVR treatment. T2DM should play an important role in the future construction of the TAVR surgical risk assessment system, but the conclusions still need to be further verified by long-term follow-up of large-scale clinical studies.

Hyperuricemia and chronic kidney disease: to treat or not to treat / Hiperuricemia e doença renal crônica: tratar ou não tratar

Abstract Hyperuricemia is common in chronic kidney disease (CKD) and may be present in 50% of patients presenting for dialysis. Hyperuricemia can be secondary to impaired glomerular filtration rate (GFR) that occurs in CKD. However, hyperuricemia can also precede the development of kidney disease and predict incident CKD. Experimental studies of hyperuricemic models have found that both soluble and crystalline uric acid can cause significant kidney damage, characterized by ischemia, tubulointerstitial fibrosis, and inflammation. However, most Mendelian randomization studies failed to demonstrate a causal relationship between uric acid and CKD, and clinical trials have had variable results. Here we suggest potential explanations for the negative clinical and genetic findings, including the role of crystalline uric acid, intracellular uric acid, and xanthine oxidase activity in uric acid-mediated kidney injury. We propose future clinical trials as well as an algorithm for treatment of hyperuricemia in patients with CKD.

Resumo A hiperuricemia é comum na doença renal crônica (DRC) e pode estar presente em até 50% dos pacientes que se apresentam para diálise. A hiperuricemia pode ser secundária ao comprometimento da taxa de filtração glomerular (TFG) que ocorre na DRC. No entanto, ela também pode preceder o desenvolvimento da doença renal e mesmo prever uma DRC incidente. Estudos experimentais de modelos hiperuricêmicos descobriram que tanto o ácido úrico solúvel quanto o cristalino podem causar danos renais significativos, caracterizados por isquemia, fibrose tubulointersticial e inflamação. Entretanto, a maioria dos estudos de randomização Mendeliana falhou em demonstrar uma relação causal entre o ácido úrico e a DRC, e os ensaios clínicos têm apresentado resultados variáveis. Aqui sugerimos explicações potenciais para os achados clínicos e genéticos negativos, incluindo o papel do ácido úrico cristalino, do ácido úrico intracelular e da atividade da xantina oxidase na lesão renal mediada por ácido úrico. Propomos ensaios clínicos futuros, bem como um algoritmo para o tratamento de hiperuricemia em pacientes com DRC.

Enfermedad renal crónica y pronóstico de pacientes con COVID-19 / Chronic kidney disease and prognosis of COVID-19 patients

Introducción: La COVID-19 ha desatado una emergencia en salud pública de carácter internacional, pues ha infescado y provocado muertes a millones de personas, desatando así una crisis humanitaria nunca antes vista. Las muertes por COVID-19 también se han asociado a la presencia de algunas enfermedades crónicas. Objetivo: Evaluar la asociación entre la enfermedad renal crónica y el peor pronóstico de pacientes con COVID-19. Métodos: Se realizó una búsqueda en las bases de datos PubMed, Scopus, EBSCO Host, Clinical Key, Hinari y Cochrane. Se consultaron artículos publicados hasta el 30 de abril de 2020. Se incluyeron artículos observacionales con información relevante respecto al desenlace de pacientes con COVID-19 y enfermedad renal crónica. Resultados: Fueron incluidos 13 artículos que resumen la información de 8207 pacientes, de los que 405 (4,9 por ciento) tenían enfermedad renal crónica. Se asoció la comorbilidad con un peor pronóstico en pacientes con COVID-19, con OR = 1,99 [IC 95 por ciento: 1,13-3,52; Z = 2,37; p = 0,02] y heterogeneidad I2 = 47 por ciento, (2 = 22,47 (p = 0,03). Al eliminar los estudios con mayor contribución a la heterogeneidad, se analizó información de 5924 pacientes y hubo una mayor asociación entre la enfermedad renal crónica y el peor pronóstico, con OR = 3,02 [IC 95 por ciento: 1,79-5,10; Z = 4,15; p < 0,0001] y heterogeneidad I2 = 0 por ciento, (2 = 3,78 (p = 0,88). Lo que se interpreta como que los pacientes con enfermedad renal crónica afectados con COVID-19 tienen una probabilidad tres veces mayor de presentar un peor pronóstico que la población general. Conclusiones: La enfermedad renal crónica empeora el pronóstico de los pacientes afectados con COVID-19(AU)

Introduction: COVID-19 has triggered a global public health emergency, for it has infected and caused the death of millions of people, thus unleashing an unprecedented humanitarian crisis. Deaths due to COVID-19 have also been associated to the presence of several chronic diseases. Objective: Evaluate the association between chronic kidney disease and the worst prognosis of COVID-19 patients. Methods: A search was conducted in the databases PubMed, Scopus, EBSCO Host, Clinical Key, Hinari and Cochrane for observational papers published before 30 April 2020 which contained relevant information about the outcome of patients with COVID-19 and chronic kidney disease. Results: A total 13 papers were included which summarize information about 8 207 patients, 405 (4.9 percent) of them with chronic kidney disease. Comorbidity was associated to a worse prognosis of COVID-19 patients, with OR = 1.99 [CI 95 percent: 1.13-3.52; Z = 2.37; p = 0.02] and heterogeneity I2 = 47 percent, (2 = 22.47 (p = 0.03). After deleting the studies with a greater contribution to heterogeneity, an analysis was conducted of the information about 5 924 patients, finding a greater association between chronic kidney disease and worst prognosis, with OR = 3.02 [CI 95 percent: 1.79-5.10; Z = 4.15; p < 0.0001] and heterogeneity I2 = 0 percent, (2 = 3.78 (p = 0.88). This implies that patients with chronic kidney disease affected by COVID-19 have three times as many chances of having a worse prognosis than the general population. Conclusions: Chronic kidney disease worsens the prognosis of COVID-19 patients(AU)

Interleukin-8 is increased in chronic kidney disease in children, but not related to cardiovascular disease / A Interleucina-8 é aumentada na doença renal crônica em crianças, mas não se relaciona a doença cardiovascular

Abstract Introduction: In this study, we aimed to detect the cytokine that is involved in the early stage of chronic kidney disease and associated with cardiovascular disease. Methods: We included 50 patients who were diagnosed with predialytic chronic kidney disease and 30 healthy pediatric patients in Ege University Medical Faculty Pediatric Clinic, İzmir/Turkey. Interleukin-8 (IL-8), interleukin-10 (IL-10), interleukin-13 (IL-13), and transforming grow factor-β1 (TGF-β1) levels (pg/mL) were measured by ELISA. Carotid-femoral pulse wave velocity (PWV), augmentation index (Aix), carotid intima media thickness (cIMT), and left ventricular mass index (LVMI) were evaluated as markers of cardiovascular disease. The presence of a cardiovascular disease marker was defined as an abnormality in any of the parameters (cIMT, PWV, Aix, and left ventricular mass index (SVKI)). The patient group was divided into two groups as with and without cardiovascular disease. Results: Mean Aix and PWV values were higher in CKD patients than controls (Aix: CKD 32.8±11.11%, healthy subjects: 6.74±6.58%, PWV CKD: 7.31±4.34m/s, healthy subjects: 3.42±3.01m/s, respectively; p=0.02, p=0.03). The serum IL-8 levels of CKD were significantly higher than of healthy subjects 568.48±487.35pg/mL, 33.67±47.47pg/mL, respectively (p<0.001). There was no statistically significant difference between IL-8, IL-10, IL-13, TGF-1, in CKD patients with and without cardiovascular disease (p> 0.05). Discussion: IL-8 is the sole cytokine that increases in pediatric patients with chronic kidney disease among other cytokines (IL-10, IL-13 and TGF-β1). However, we did not show that IL-8 is related to the presence of cardiovascular disease.

Resumo Introdução: Neste estudo, o objetivo foi detectar a citocina envolvida no estágio inicial da doença renal crônica e associada à doença cardiovascular. Métodos: Incluímos 50 pacientes diagnosticados com doença renal crônica pré-dialítica e 30 pacientes pediátricos saudáveis na Clínica Pediátrica da Faculdade de Medicina, Universidade de Ege, İzmir/Turquia. Níveis de interleucina-8 (IL-8), interleucina-10 (IL-10), interleucina-13 (IL-13), fator de transformação do crescimento -β1 (TGF-β1) (pg/mL) foram medidos por ELISA. Velocidade de onda de pulso carotídeo-femoral (VOP), índice de amplificação (AIx), espessura da camada íntima-média da carótida (cIMT), índice de massa do ventrículo esquerdo (IMVE) foram avaliados como marcadores de doença cardiovascular. A presença de marcador de doença cardiovascular foi definida como uma anormalidade em qualquer dos parâmetros (cIMT, VOP, AIx, índice de massa do ventrículo esquerdo (IMVE)). Os pacientes foram divididos em dois grupos como com e sem doença cardiovascular. Resultados: Valores médios de AIx e VOP foram maiores em pacientes com DRC que nos controles (AIx: DRC: 32,8±11,11%, indivíduos saudáveis: 6,74±6,58%, VOP: DRC: 7,31±4,34m/s, indivíduos saudáveis: 3,42±3,01m/s, respectivamente; p=0,02, p=0,03). Níveis séricos de IL-8 de DRC foram significativamente maiores que de indivíduos saudáveis 568,48±487,35pg/mL, 33,67±47,47pg/mL, respectivamente (p<0,001). Não houve diferença estatisticamente significativa entre IL-8, IL-10, IL-13, TGF-1, em pacientes com DRC com e sem doença cardiovascular (p> 0,05). Discussão: IL-8 é a única citocina que aumenta em pacientes pediátricos com doença renal crônica entre outras citocinas (IL-10, IL-13 e TGF-β1). Entretanto, IL-8 não se associou à presença de doença cardiovascular.

Daño renal en pacientes con COVID-19 / Kidney damage in COVID-19 patients

Introducción: La COVID-19 es una enfermedad relativamente nueva, que puede causar afecciones en diferentes órganos. El daño renal se asocia a la mortalidad, por lo que debe ser identificado precozmente. Objetivo: Describir el daño renal en pacientes de COVID-19. Métodos: Se realizó una revisión bibliográfica de materiales publicados durante el periodo comprendido entre el 20 de abril al 25 de agosto de 2020. Se consultaron las bases de datos PubMed, SciELO, Ebsco y Clinical Key, así como el motor de búsqueda Google Académico. Los métodos utilizados fueron análisis-síntesis, inducción-deducción e histórico-lógico. Análisis e integración de la información: Para realizar un diagnóstico precoz que permita modificar el pronóstico y la historia natural de la mortalidad, se realizan numerosas investigaciones en los pacientes portadores de la COVID-19. En la literatura científica se reportan artículos sobre la importancia de la detección del daño renal. Se ha identificado que, tanto el daño renal previo, como el desarrollo de este durante la COVID-19, desempeñan un rol importante en el aumento de la tasa de letalidad. Conclusiones: La Afección renal crónica es una agravante en pacientes que padecen COVID-19. La descripción de los mecanismos causantes de la lesión renal es fundamental para establecer el pronóstico de estos pacientes, sin embargo, luego de la revisión, se comprobó que aún es escasa la literatura científica que aborde la relación del daño renal durante la COVID-19(AU)

Introduction: COVID-19 is a relatively new disease that affects various organs. Associated as it is to mortality, kidney damage should be identified as early as possible. Objective: Conduct a bibliographic review aimed at describing kidney damage in COVID-19 patients. Methods: A bibliographic review was conducted of materials about the topic published from 20 April to 25 August 2020. The search was carried out in the databases PubMed, SciELO, Ebsco and Clinical Key, as well as the search engine Google Scholar. Analytic-synthetic, inductive-deductive and historical-logical methods were used. Data analysis and integration: In order to obtain an early diagnosis allowing to modify the prognosis and natural evolution of mortality, a large number of studies are performed on patients carrying COVID-19. Papers are found in the scientific literature which refer to the importance of detecting kidney damage. It has been found that kidney damage, either developing before or during the course of the disease, plays an important role in the increase in lethality. Conclusions: Kidney damage is common in COVID-19 patients. Describing the mechanisms causing the kidney injury is a fundamental pillar to establish the prognosis for these patients. The description of kidney damage during COVID-19 is still scarce in the scientific literature(AU)

Association between severe chronic kidney disease defined by cystatin-c and creatinine and clinical outcomes in an elderly population - an observational study / Associação entre doença renal crônica grave definida por cistatina-c e creatinina e desfechos clínicos em uma população idosa - um estudo observacional

ABSTRACT Introduction: Estimated glomerular filtration rate (eGFR) based on serum cystatin-C (sCys) seems as accurate as when based on serum creatinine (sCr), but sCys seems a better predictor of adverse outcomes. We aimed to study whether sCys could be a reliable tool for the prediction of adverse outcomes in elderly patients with severe chronic kidney disease (CKD). Methods: A group of 348 elderly patients with non-end-stage CKD (stages 1-4, according to eGFR-EPI sCr and/or sCys), referred to our consultation unit during 2016, was retrospectively studied and divided into four exclusive categories: CKD_stage4_neither (eGFR-sCr≥30mL/min; eGFR-sCys≥30mL/min), CKD_stage4_sCr_only (eGFR-sCr<30mL/min), CKD_stage4_sCys_only (eGFR-sCys<30mL/min) and CKD_stage4_combined (eGFRsCr<30mL/min; eGFR-sCys<30mL/min). Baseline characteristics, predictors of death, and clinical events (cardiovascular events and admissions for cardiovascular, acute kidney injury or infectious events) were explored until December 2018. Results: A 77±7.4 year-old cohort, with a modified Charlson Comorbidty Index (mCCI) of 3 (IQR:1-4), was followed-up during 29 (IQR: 26-33) months. There were no significant differences between the characteristics of the stage 4 groups. Survival analysis was stratified by follow-up at 12 months, and in the first year, survival curves of CKD_stage4_sCys_only and CKD_stage4_combined groups were significantly lower than the other groups (p=0.028). Adjusting for age, sex, and mCCI, CKD_stage4_sCys_only, conversely to CKD_stage4_sCr_only, had higher rates of clinical events (p<0.05) than CKD_stage4_neither group. Conclusion: In elderly patients with discordant CKD staging, sCys-based eGFR seems to be a better predictor of adverse outcomes than sCr-based eGFR. Patients with stage 4 CKD defined by sCr alone seem to behave similar to those with less severe CKD.

RESUMO Introdução: A taxa estimada de filtração glomerular (TFGe) com base na cistatina-C sérica (Cis-C) parece ser tão precisa quanto aquela baseada na creatinina sérica (Cr), mas cis-C parece ser um melhor preditor de resultados adversos. Nosso objetivo foi avaliar se a cis-C poderia ser uma ferramenta confiável para a previsão de desfechos adversos em pacientes idosos com doença renal crônica grave (DRC). Métodos: Um grupo de 348 pacientes idosos com DRC em estágio não terminal (estágios 1-4, de acordo com TFGe-EPI Cr e/ou Cis-C), encaminhados para nossa unidade de consulta durante 2016, foi estudado retrospectivamente e dividido em quatro categorias exclusivas: DRC_estágio 4 nenhum (TFGe-Cr≥30mL/min; TFGe -Cis-C≥30mL/min), DRC_estágio 4_Cr apenas (TFGe-Cr <30mL/min), DRC_estágio 4 _Cis-C_apenas (TFGe-Cis-C <30 mL/min), DRC_estágio4_combinado (TFGe-Cis-C <30mL/min. TFGe-Cr <30mL/min). Características basais, preditores de óbito e eventos clínicos (eventos cardiovasculares e internações por doenças cardiovasculares, lesão renal aguda ou eventos infecciosos) foram explorados até dezembro de 2018. Resultados: Uma coorte de 77 ± 7,4 anos, com índice de comorbidade de Charlson modificado (mCCI) de 3 (IQR: 1-4), foi acompanhada durante 29 (IQR: 26-33) meses. Não houve diferenças significativas entre as características dos grupos no estágio 4. A análise de sobrevida foi estratificada pelo acompanhamento aos 12 meses, sendo que no primeiro ano, as curvas de sobrevida dos grupos DRC_estágio4_Cis-C_apenas e DRC_estágio4_ combinado foram significativamente inferiores quando comparadas com os restantes grupos (p = 0,028). Ajustando para idade, sexo e mCCI, DRC_estágio4_Cis-C_apenas, ao contrário do grupo DRC_estágio4_Cr_apenas, teve maiores taxas de eventos clínicos (p <0,05) do que o grupo DRC_estágio4_nenhum. Conclusão: Em pacientes idosos com estadiamento discordante da DRC, a TFGe baseada na Cis-C parece ser um melhor preditor de resultados adversos do que a TFGe baseada na Cr. Pacientes com DRC em estágio 4, definida apenas por Cr, parecem se comportar de forma semelhante àqueles com DRC menos grave.

Case reports of hypercalcemia and chronic renal disease due to cosmetic injections of polymethylmethacrylate (PMMA) / Relatos de casos de hipercalcemia e doença renal crônica devidas a injeções de polimetilmetacrilato (PMMA) por razões estéticas

Abstract Cosmetic injections of fillers are common plastic surgery procedures worldwide. Polymethylmethacrylate (PMMA) is a filler approved only for minimally invasive procedures in facial tissue and is among the most frequently used injectable substances for cosmetic purposes. Injection of a large volume of PMMA may lead to the development of severe hypercalcemia and chronic kidney damage in a probably underestimated frequency. In such cases, hypercalcemia develops due to a granulomatous foreign body reaction with extrarenal production of calcitriol. In the present report, we describe the cases of two patients who received injections of large volumes of PMMA and developed severe hypercalcemia and advanced chronic kidney disease. These reports highlight the importance of adhering to regulations regarding the use of PMMA and properly informing patients of the possibility of complications before undertaking such procedures.

Resumo Injeções de preenchimento de caráter estético são procedimentos comuns em cirurgia plástica em todo o mundo. O polimetilmetacrilato (PMMA) é um material de preenchimento aprovado apenas para procedimentos minimamente invasivos no tecido facial, e está entre as substâncias injetáveis mais frequentemente usadas para fins estéticos. A injeção de um grande volume de PMMA pode levar ao desenvolvimento de hipercalcemia grave e lesão renal crônica em uma frequência provavelmente subestimada. Nesses casos, a hipercalcemia se desenvolve devido a uma reação granulomatosa de corpo estranho, secundária à produção extrarenal de calcitriol. No presente artigo, descrevemos os casos de dois pacientes que receberam injeções de grandes volumes de PMMA e desenvolveram hipercalcemia grave e doença renal crônica avançada. Esses relatos destacam a importância de seguir as regulamentações sobre o uso do PMMA e informar adequadamente os pacientes sobre a possibilidade de complicações antes de realizar tais procedimentos.

High prevalence of biochemical disturbances of chronic kidney disease - mineral and bone disorders (CKD-MBD) in a nation-wide peritoneal dialysis cohort: are guideline goals too hard to achieve? / Alta Prevalência de Distúrbios Bioquímicos Minerais e Ósseos na Doença Renal Crônica em uma coorte de diálise peritoneal nacional: as metas das diretrizes são muito difíceis de alcançar?

Abstract Introduction: Chronic kidney disease - mineral and bone disorders (CKD-MBD) are common in dialysis patients. Definition of targets for calcium (Ca), phosphorus (P), parathormone (iPTH), and alkaline phosphatase (ALP) and their treatment recommendations, are provided by international guidelines. There are few studies analyzing CKD-MBD in peritoneal dialysis (PD) patients and the impact of guidelines on mineral metabolism control. The aim of our study was to describe the prevalence of biomarkers for CKD-MBD in a large cohort of PD patients in Brazil. Methods: Data from the nation-wide prospective observational cohort BRAZPD II was used. Incident patients were followed between December 2004 and January 2011. According to KDOQI recommendations, reference ranges for total Ca were 8.4 to 9.5 mg/dL, for P, 3.5 to 5.5 mg/dL, for iPTH, 150-300 pg/mL, and for ALP, 120 U/L. Results: Mean age was 59.8 ± 16 years, 48% were male, and 43% had diabetes. In the beginning, Ca was 8.9 ± 0.9 mg/dL, and 48.3% were on the KODQI target. After 1 year, Ca increased to 9.1 ± 0.9 mg/dL and 50.4% were in the KDOQI preferred range. P at baseline was 5.2 ± 1.6 mg/dL, with 52.8% on target, declining to 4.9 ± 1.5 mg/dL after one year, when 54.7% were on target. Median iPTH at baseline was 238 (P25% 110 - P75% 426 pg/mL) and it remained stable throughout the first year; patients within target ranged from 26 to 28.5%. At the end of the study, 80% was in 3.5 meq/L Ca dialysate concentration, 66.9% of patients was taking any phosphate binder, and 25% was taking activated vitamin D. Conclusions: We observed a significant prevalence of biochemical disorders related to CKD-MBD in this dialysis population.

Resumo Introdução: Os distúrbios minerais e ósseos da doença renal crônica (DMO-DRC) são comuns em pacientes em diálise. A definição de metas para cálcio (Ca), fósforo (P), paratormônio (PTHi) e fosfatase alcalina (FA) e suas recomendações de tratamento são fornecidas por diretrizes internacionais. Há poucos estudos analisando o DMO-DRC em pacientes em diálise peritoneal (DP) e o impacto das diretrizes no controle do metabolismo mineral. O objetivo do nosso estudo foi descrever a prevalência de alterações nos marcadores para DMO-DRC em uma grande coorte de pacientes em DP no Brasil. Métodos: Foram utilizados dados da coorte observacional prospectiva nacional BRAZPD II. Pacientes incidentes foram acompanhados entre Dezembro de 2004 e Janeiro de 2011. De acordo com as recomendações do KDOQI, os intervalos de referência para Ca total foram de 8,4 a 9,5 mg/dL, para P, 3,5 a 5,5 mg/dL, para PTHi, 150-300 pg/mL, e para FA, 120 U/L. Resultados: A idade média foi de 59,8 ± 16 anos, 48% eram homens e 43% tinham diabetes. No início, o Ca era de 8,9 ± 0,9 mg/dL, e 48,3% estavam na meta do KODQI. Após 1 ano, o Ca aumentou para 9,1 ± 0,9 mg/dL e 50,4% estavam na faixa preferida do KDOQI. P basal era 5,2 ± 1,6 mg/dL, com 52,8% na meta, diminuindo para 4,9 ± 1,5 mg/dL após um ano, quando 54,7% estavam na meta. O PTHi basal mediano foi de 238 (P25% 110 - P75% 426 pg/mL) e permaneceu estável durante o primeiro ano; os pacientes dentro da meta variaram de 26 a 28,5%. No final do estudo, 80% estavam na concentração de 3,5 meq/L de Ca dialisato, 66,9% dos pacientes estavam tomando qualquer quelante de fosfato, e 25% estavam tomando vitamina D ativada. Conclusões: Observamos uma prevalência significativa de distúrbios bioquímicos relacionados ao DMO-DRC nesta população em diálise.

Cardiovascular Risk Factors in Patients with Chronic Kidney Disease Under Conservative Treatment

Abstract Background Cardiovascular disease (CVD) is commonly associated with chronic kidney disease (CKD). These diseases have a significant impact on life expectancy. Individuals with CKD are more likely to die from CVD than to progress to end-stage kidney disease. Objective To assess cardiovascular risk factors of patients with CKD under conservative treatment. Methods This was an observational, cross-sectional study. Socioeconomic, anthropometric, biochemical, and physical inactivity data were assessed, and 10-year risk for CVD were estimated using the Framingham Score in patients with CKD under conservative treatment. For statistical analysis, the Student's t-test and Pearson's chi-square test were performed. Results A total of 172 individuals were evaluated, 57% of whom were male, with an average age of 68.85 ± 11.41 years. The prevalence of hypertension and diabetes were 87.2% and 53.5%, respectively; 62.2% were physically inactive; 9.9% of men were smokers and 12.8% consumed alcohol. According to BMI, 82.4% of adults <60 years old and 60.6% of those older than 60 years were overweight. High waist circumference and a high waist-hip ratio were highly prevalent in females (91.9% and 83.8%, respectively) and males (64.3% and 39.8%, respectively); 92.4% had a high body fat percentage and 73.3% high uric acid levels. According to the Framingham score, 57% have a medium or high risk of developing CVD in 10 years. Conclusion There was a high prevalence of cardiovascular risk factors in the population studied. The assessment of cardiovascular risk factors in patients with CKD makes it possible to guide the conduct of health professionals to prevent mortality from cardiovascular causes. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

The association between Hba1c and arterial stiffness among non-diabetic patients with chronic kidney disease / Associação entre Hba1c e rigidez arterial entre pacientes sem diabetes com doença renal crônica

Abstract Background Cardiovascular events are seen more frequently after the age of 60 and they are a significant cause of morbidity and mortality. Arterial stiffness is a property that can be expressed by pulse wave velocity and this value is assumed to be a predictor of cardiovascular events. Patients with chronic kidney disease and dysregulated blood sugar have increased atherosclerosis and arterial stiffness, but the relationship between physiological levels of Hba1c and arterial stiffness is less clear in chronic kidney disease patients without diabetes mellitus. Objectives Here, we aimed to investigate the degree of arterial stiffness among non-diabetic, non-dialysis dependent chronic kidney disease patients with physiological HbA1c levels. Methods We enrolled 51 patients who were followed up at Ege University Hospital Nephrology Department between February and June 2015. Non-diabetic, non-dialysis dependent chronic kidney disease patients were included in the study. Blood pressure and pulse wave velocity were measured with an applanation tonometry device (Sphygmocor Vx Software Atcor Medical, Australia). Correlations between pulse wave velocity and the aforementioned parameters were investigated (see below). Results We detected a significant correlation between pulse wave velocity and systolic blood pressure (p=0.0001) and Hba1c (p=0.044) separately. There was an inverse correlation with creatinine clearance (p=0.04). We also detected a significant correlation with serum phosphorus level (p=0.0077) and furosemide use (p=0.014). No correlations were found among the other parameters. Conclusions Arterial stiffness is an important predictor of cardiovascular events and measuring it is an inexpensive method for estimating morbidity and mortality. Our study supports the importance of measuring arterial stiffness and of controlling blood glucose levels, even at physiological Hba1c values, especially for chronic kidney disease patients.

Resumo Contexto Os eventos cardiovasculares são mais frequentes em pessoas com mais de 60 anos, e sugere-se que sejam causas significativas de morbidade e mortalidade. A rigidez arterial é expressa pela velocidade da onda de pulso, e presume-se que esse valor seja um preditor de eventos cardiovasculares. Os pacientes com doença renal crônica e desregulação do açúcar no sangue têm aterosclerose e rigidez arterial aumentadas. No entanto, a relação entre os níveis fisiológicos de Hba1c e a rigidez arterial entre pacientes com doença renal crônica sem diabetes melito é menos clara. Objetivos Buscamos investigar o grau de rigidez entre os pacientes sem diabetes e portadores de doença renal crônica sem dependência de diálise com níveis fisiológicos de HbA1c. Métodos Incluímos 51 pacientes, sem diabetes e com doença renal crônica sem dependência de diálise, que estavam em acompanhamento no Departamento de Nefrologia do Ege University Hospital entre fevereiro e junho de 2015. A pressão sanguínea e a velocidade da onda do pulso foram medidas com um dispositivo de tonometria de aplanação (Sphygmocor Vx Software Atcor Medical, Austrália). A correlação entre a velocidade da onda de pulso e os parâmetros mencionados anteriormente foi investigada. Resultados Detectamos correlação significativa entre a velocidade da onda de pulso e a pressão arterial sistólica (p = 0,0001) e Hba1c (p = 0,044) separadamente. Foi constatada correlação inversa com a depuração de creatinina (p = 0,04). Também detectamos correlação significativa com o nível de fósforo sérico (p = 0,0077) e o uso de furosemida (p = 0,014). Não foi encontrada correlação entre outros parâmetros. Conclusões A rigidez arterial é um preditor importante de eventos cardiovasculares, e a sua medição é um método de baixo custo para estimar a morbidade e mortalidade. Nosso estudo corrobora a importância da medição da rigidez arterial e do controle dos níveis de glicemia sanguínea mesmo em valores de Hba1c fisiológicos, principalmente para pacientes portadores de doença renal crônica.

Técnica de remodelamento com uso de stents em T e molas para tratamento de aneurisma renal complexo / Remodeling technique using T-stenting and coils to treat complex renal aneurysm

Resumo O aneurisma da artéria renal é uma condição rara, que vem sendo cada vez mais diagnosticada devido ao uso mais amplo da angiotomografia. Descrevemos um caso de aneurisma da artéria renal tipo II complexo em uma paciente com hipertensão arterial sistêmica e doença renal crônica não dialítica. O tratamento estabelecido foi o reparo endovascular através da combinação da técnica de remodelamento com stents em T e molas, para a preservação dos ramos arteriais renais. Foram obtidos resultados arteriográficos satisfatórios e boa evolução clínica.

Abstract Renal artery aneurysm is a rare condition that is being diagnosed with increasing frequency because of wider use of angiotomography. We describe a case of complex type II renal artery aneurysm in a patient with systemic arterial hypertension and non-dialysis chronic kidney disease. The treatment performed was endovascular repair using the remodeling technique with T-stenting and coils to preserve the renal arterial branches, obtaining satisfactory arteriographic results and good clinical outcomes.

Fatores associados à síndrome cardiorrenal em pacientes com insuficiência cardíaca descompensada / Factores asociados al síndrome cardiorrenal en pacientes con insuficiencia cardíaca descompensada / Factors associated with cardiorenal syndrome in patients with decompensated heart failure

Resumo Objetivo: Identificar a prevalência da síndrome cardiorrenal (SCR) em pacientes com insuficiência cardíaca (IC) crônica descompensada e sua associação com os dados sociodemográficos, clínicos, achados admissionais, mortalidade e tempo de hospitalização. Método: Estudo transversal, com abordagem quantitativa. A amostra foi constituída por 379 prontuários de pacientes adultos com o diagnóstico médico de IC crônica descompensada, admitidos em hospital público no estado de São Paulo, ao longo de 2015. A coleta de dados ocorreu em 2016. A disfunção renal foi considerada em pacientes com diagnóstico prévio de doença renal crônica (DRC) pela taxa de filtração glomerular (TFG) < 89 mL/min/1.73 m2. Testes com valor de p menor ou igual a 0,05 foram estatisticamente significativos. Resultados: A prevalência da SCR foi de 54,1%, sendo 24,8% do tipo 1 e 29,3% do tipo 2. Os principais fatores associados à SCR foram: maior média de idade, mulheres, IC de etiologia isquêmica, menor fração de ejeção, portadores de diabetes mellitus, doença arterial coronariana, uso de estimuladores cardíacos artificiais, hipotireoidismo e doença de Chagas, bem como o perfil hemodinâmico de descompensação da IC nos tipos C e L. Destacam-se, ainda, inapetência, sonolência, estertores na ausculta respiratória, alteração na perfusão tissular, redução do débito urinário, com aumento dos níveis séricos de potássio, ureia e creatinina na avaliação clínica inicial. Os pacientes com disfunção renal apresentaram maior mortalidade, sem diferença significativa quanto ao tempo de hospitalização. Conclusão: Houve alta prevalência da SCR em pacientes com IC crônica descompensada, associada à maior mortalidade e diversos indicadores clínicos.

Resumen Objetivo: Identificar la prevalencia del síndrome cardiorrenal (SCR) en pacientes con insuficiencia cardíaca (IC) crónica descompensada y su relación con los datos sociodemográficos, clínicos y descubiertos en la admisión, la mortalidad y el tiempo de hospitalización. Métodos: Estudio transversal, con enfoque cuantitativo. La muestra estuvo compuesta por 379 historias clínicas de pacientes adultos con diagnóstico médico de IC crónica descompensada, ingresados en hospital público en el estado de São Paulo, durante 2015. La recolección de datos se realizó en 2016. La disfunción renal fue considerada en pacientes con diagnóstico previo de enfermedad renal crónica (ERC) por el índice de filtración glomerular (IFG) < 89 mL/min/1.73 m2. Pruebas con un valor de p menor o igual a 0,05 fueron estadísticamente significativos. Resultados: La prevalencia del SCR fue del 54,1 %, del cual el 24,8 % fue de tipo 1 y el 29,3 % de tipo 2. Los principales factores asociados al SCR fueron: mayor promedio de edad, mujeres, IC de etiología isquémica, menor fracción de eyección, portadores de diabetes mellitus, enfermedad arterial coronaria, uso de estimuladores cardíacos artificiales, hipotiroidismo y enfermedad de Chagas, así como también el perfil hemodinámico de descompensación de la IC en el tipo C y L. Además, se destacan la inapetencia, somnolencia, estertores en la auscultación pulmonar, alteración en la perfusión tisular, reducción del flujo urinario, con aumento del nivel en sangre de potasio, urea y creatinina en la evaluación clínica inicial. Los pacientes con disfunción renal presentaron mayor mortalidad, sin diferencia significativa con relación al tiempo de hospitalización. Conclusión: Se observó una alta prevalencia del SCR en pacientes con IC crónica descompensada, relacionada con una mayor mortalidad y diversos indicadores clínicos.

Abstract Objective: to identify cardiorenal syndrome (CRS) prevalence in patients with decompensated chronic heart failure (HF) and its association with sociodemographic and clinical data, admission findings, mortality and length of hospital stay. Methods: a cross-sectional study with a quantitative approach. The sample consisted of 379 medical records of adult patients with a medical diagnosis of decompensated chronic HF admitted to a public hospital in the state of São Paulo, throughout 2015. Data collection occurred in 2016. Kidney failure was considered in patients with a previous diagnosis of chronic kidney disease (CKD) by glomerular filtration rate (GFR) <89 mL/min/1.73 m2. Tests with a p value less than or equal to 0.05 were statistically significant. Results: CRS prevalence was 54.1%, with 24.8% being type 1 and 29.3% being type 2. The main factors associated with CRS were: higher mean age; women; HF of ischemic etiology; lower ejection fraction; people with diabetes mellitus; coronary artery disease; artificial cardiac stimulator use; hypothyroidism and Chagas disease; hemodynamic profile of HF decompensation in types C and L. Also noteworthy are inappetence, drowsiness, rales on respiratory auscultation, alteration in tissue perfusion, decreased urine output, with increased serum levels of potassium, urea and creatinine in the initial clinical assessment. Patients with kidney failure had higher mortality, with no significant difference in length of hospital stay. Conclusion: There was a high prevalence of CRS in patients with decompensated chronic HF, associated with higher mortality and several clinical indicators.

Depressão em pacientes com doença renal crônica em hemodiálise e transplante renal / Depression in patients with chronic renal disease on hemodialysis and renal transplantation

O desenvolvimento de pesquisas, diante da relevância do tema, propicia suporte teórico, favorecendo a atuação da assistência multidisciplinar, no intuito de fortalecer o vínculo terapêutico, a relação com a família e o cuidado de modo integral. O objetivo deste estudo foi revisar os principais aspectos clínicos da depres- são entre pacientes com doença renal crônica em hemodiálise e transplantados renais com base nas evidências científicas atuais. O aumento da expectativa de vida acarreta a elevação da inci- dência das doenças crônicas não transmissíveis ­ dentre elas a doença renal crônica ­, que são vistas como fatores que afetam o paciente, tanto no âmbito físico como no psicológico, gerando a associação de doenças crônicas com distúrbios psicoafetivos. Estudos prévios mostram que a depressão é três a cinco vezes mais prevalente no estágio avançado da doença renal crôni- ca do que na população em geral. A prevalência de depressão nos pacientes em hemodiálise está em torno de 20% a 40%, re- presentado uma questão de saúde pública. Apesar de sua alta prevalência, a depressão é subdiagnosticada e subtratada, pois os profissionais de saúde assemelham os sintomas depressivos com os das doenças crônicas, focalizando apenas nos aspectos físicos da enfermidade. É essencial que os profissionais da saúde estejam qualificados para reconhecer as manifestações iniciais para o diagnóstico correto da depressão, posto que esse distúrbio possui ligação direta com o sucesso terapêutico.

The development of research, given the relevance of the theme, provides theoretical support favoring the performance of multi- disciplinary care, to strengthen the therapeutic bond, the rela- tionship with the family, and care in an integral way. The objective of this study was to review the main clinical aspects of depression among patients with chronic kidney disease on hemodialysis and with kidney transplantation based on current scientific evidence. The increase in life expectancy leads to an increase in the inciden- ce of noncommunicable chronic diseases, among them chronic kidney disease, which are seen as factors that affect the patient both physically and psychologically, leading to the association of chronic diseases with psycho-affective disorders. Previous studies show that depression is five to three times more prevalent in the advanced stage of chronic kidney disease than in the general po- pulation. The prevalence of depression in hemodialysis patients is around 20% to 40%, representing a public health issue. Despite its high prevalence, depression is underdiagnosed and undertrea- ted, because health professionals relate depressive symptoms to those of chronic diseases, focusing only on the physical aspects of the disease. It is essential that health care professionals are qualified to recognize the initial manifestations for the correct diagnosis of depression, since this disorder has a direct connec- tion with therapeutic success.