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.

Social determinants of health influencing the choice of dialysis modality in advanced chronic kidney disease: Need of an interdisciplinary approach.

INTRODUCTION: The influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the "non-medical" barriers that influence the choice of RRT in an advanced chronic kidney disease (ACKD) consultation in Spain. MATERIAL AND METHODS: Retrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel Scale) and instrumental activities of daily living (Lawton and Brody Scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged. RESULTS: A total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation (LDRT) and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7% vs. 22.5%) (p = 0.002), Spanish nationality (91% vs. 77.7%) (p < 0.001), to a lower language barrier (0.6% vs 10.5%) (p < 0.001), and to a higher score on the Barthel scale (97.4 vs 92.9) and on the Lawton and Brody scale (7 vs 6.1) (p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6% vs 35.2%; p = 0.006) and a higher proportion of Spaniards (94.7% vs 81%, p = 0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC. CONCLUSION: Despite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment.

Preoperative mapping and multidisciplinary team are the key to success of arteriovenous access for hemodialysis.

INTRODUCTION AND OBJECTIVES: Functional and durable vascular access is needed for adequate hemodialysis. Arteriovenous fistula is preferred over prosthetic grafts or central venous catheters, but it is associated with high rates of primary failure and maturation failure. Preoperative mapping of arm vessels with color Doppler ultrasound (CDU) has been shown to be helpful in achieving better short and long-term outcomes. Unfortunately, is more time-consuming than a physical examination and requires an experienced examiner and special equipment; some authors defend that CDU should not be part of the routine preoperative assessment. We reported our experience in preoperative vessel mapping using color Doppler ultrasound to purpose a vascular access to the surgical team, surveillance of vascular access, and evaluation of main outcomes (primary failure, maturation failure, and patency). METHODS: This is a single-center retrospective study that includes patients who attended a specific appointment for vascular access planning consultation between January 2019 and December 2021. A nephrologist performed the physical exam and vascular mapping and proposed to the vascular surgeon team a specific type and location of vascular access. Patients were followed until one month after the first hemodialysis through functioning vascular access. RESULTS: In this study, 167 patients were evaluated (114 incident patients - chronic kidney disease stage 4 or 5 - and 53 prevalent patients - under hemodialysis through central venous catheter). The vascular accesses proposed by nephrologist were radial-cephalic arteriovenous fistula in 70 patients (41.9%), brachio-cephalic arteriovenous fistula in 50 patients (29.9%), brachio-basilic arteriovenous fistula in 34 patients (20.4%), arteriovenous graft in 8 patients (4.8%) and central venous catheter in 2 patients (1.2%). Vascular access was constructed in 141 patients: distal arteriovenous fistula in 57 patients (40.4%), brachio-cephalic arteriovenous fistula in 54 patients (38.3%), brachio-basilic AVF in 27 patients (19.1%), and arteriovenous graft in 3 patients (2.1%). The created access corresponds to the proposed access in 129 patients (91.5%). Twenty-two (15.6%) primary failures were registered. Distal arteriovenous fistulas and diabetes mellitus were associated with a higher risk of primary failure (OR=3.929 (1.485-10.392), p=0.004; OR=3.867 (1.235-12.113), p=0.014, respectively). The incidence of maturation failure at eight weeks was 4.8%. The primary patency at 6, 12 and 24 months was 76.3%, 70.4% and 49.2%. Primary assisted patency was 84.8% at 6 and 12 months and 81.3% at 24 months. CONCLUSIONS: This study demonstrates that the study of the entire vascular territory performed with color Doppler ultrasound, within a multidisciplinary team of nephrologists and vascular surgeons, is associated with high rates of autologous access and very low rates of primary failure and maturation failure (almost unprecedented in the literature).

Pilot monitoring study in patients with diabetic kidney disease using NORA application.

INTRODUCTION: Diabetic Kidney Disease (DKD) is the most common cause of end-stage chronic kidney disease (CKD), conditioning these patients to a worse renal prognosis and higher cardiovascular mortality and/or requirement for renal replacement therapy. The use of novel information and communication technologies (ICTs) focused on the field of health, may facilitates a better quality of life and disease control in these patients. Our objective is to evaluate the effect of monitoring DKD patients using NORA-app. MATERIAL AND METHODS: Prospective feasibility/validation study of NORA-app in patients with DKD stage G3bA3 or higher, followed in outpatient clinics of a tertiary care hospital. NORA-app is an application for smartphones designed to control risk factors, share educational medical information, communicate via chat with health professionals, increase treatment compliance (Morisky-Green), and collect patient reported outcomes such as anxiety and depression using HADs scale. Clinical-laboratory variables were collected at 3 months and compared to control patients who declined using NORA-app. RESULTS: From 01/01/2021 to 03/03/2022 the use of NORA-app was offered to 118 patients, 82 accepted and 36 declined (controls). After a mean follow-up period of 6,04 months and at the time of data extraction 71 (86.6%) NORA-app patients remain active users, 2 have completed the follow-up at one year and 9 are inactive (3 due to death and 6 due to non-locatable). There were no differences in baseline characteristics including Creatinine [2.1 (1.6-2.4) vs. 1.9 (1.5-2.5)] mg/dL and alb/creat [962 (475-1784) vs. 1036 (560-2183)] mg/gr between Nora and control patients respectively. The therapeutic compliance rate in the NORA-app group was 77%, improving at 90 days to 91%. Patients in the NORA-group showed significantly lower levels of alb/creat than controls (768(411-1971) mg/g Vs 2039 (974-3214) p = 0.047) at 90-day follow-up. CONCLUSIONS: In patients with DKD the use of NORA-app was maintained in the long-term, leading to high levels of treatment compliance, and achieving a better disease control. Our study suggests that the generalized use of ICTs may help in the personalized monitoring of these patients to delay the progression of kidney disease.

Chronic kidney disease, dialysis and climate change.

Chronic Kidney Disease is a serious public health problem and in clear relation to Climate Change and ecosystem maintenance. Renal health is particularly vulnerable to the impacts of climate change, and dialysis therapy (hemodialysis and PD) has a significant environmental footprint, conditioned by energy consumption and greenhouse gas production. In the last 50 years, people have changed ecosystems faster and more extensively than in any other period in human history. It is a consequence of ever-increasing demand for food, fresh water, fuel, industry, etc. and the result has been a substantial and largely irreversible loss of the diversity of life on Earth. Since 1979, human activities have caused the extinction of 60% of mammals, birds, fish and reptiles. There is an urgent need to adopt "Green Nephrology" measures by developing sustainable environmental solutions for the prevention and treatment of kidney diseases.

Renin–angiotensin–aldosterone system blockers effect in chronic kidney disease progression in hypertensive elderly patients without proteinuria: PROERCAN trial / Efecto de los bloqueantes del sistema renina-angiotensina-aldosterona en la progresión de enfermedad renal crónica en pacientes hipertensos añosos sin proteinuria: ensayo clínico Progresión de Enfermedad Renal Crónica en Ancianos

Introduction: Evidence about nefroprotective effect with RAAS blockers in elderly patients with chronic kidney disease (CKD) without proteinuria is lacking. The primary outcome of our study is to evaluate the impact of RAAS blockers in CKD progression in elderly patients without proteinuria. Materials and methods: Multicenter open-label, randomized controlled clinical trial including patients over 65 year-old with hypertension and CKD stages 3–4 without proteinuria. Patients were randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs and were followed up for three years. Primary outcome is estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcome measures include BP control, renal and cardiovascular events and mortality. Results: 88 patients were included with a mean age of 77.9±6.1 years and a follow up period of 3 years: 40 were randomized to RAAS group and 48 to standard treatment. Ethiology of CKD was: 53 vascular, 16 interstitial and 19 of unknown ethiology. In the RAAS group eGFR slope during follow up was −4.3±1.1ml/min, whereas in the standard treatment group an increase on eGFR was observed after 3 years (+4.6±0.4ml/min), p=0.024. We found no differences in blood pressure control, number of antihypertensive drugs, albuminuria, potassium serum levels, incidence of cardiovascular events nor mortality during the follow up period. Conclusions: In elderly patients without diabetes nor cardiopathy and with non proteinuric CKD the use of RAAS blockers does not show a reduction in CKD progression. The PROERCAN (PROgresión de Enfermedad Renal Crónica en ANcianos) trial (trial registration: NCT03195023). (AU)

Introducción: Actualmente no existe suficiente evidencia sobre el efecto nefroprotector de los bloqueantes del sistema renina-angiotensina-aldosterona (BSRAA) en pacientes añosos con enfermedad renal crónica (ERC) sin proteinuria y sin cardiopatía. El objetivo es evaluar el efecto de los BSRAA en la progresión de la ERC en este grupo poblacional. Métodos: Se trata de un estudio prospectivo, aleatorizado, que compara la eficacia de los BSRAA vs. otros tratamientos antihipertensivos en la progresión renal en personas mayores de 65 años con ERC estadios 3 y 4 e índice albúmina/creatinina<30mg/g. Aleatorización 1:1 BSRAA o tratamiento antihipertensivo estándar. Se recogieron cifras tensionales y parámetros analíticos de un año previo a la aleatorización y durante el seguimiento. Resultados: Se incluyeron 88 pacientes seguidos durante tres años con edad media de 77,9±6,1 años. De estos, se aleatorizaron 40 al grupo BSRAA y 48 al estándar. La etiología de ERC fue: 53 vascular, 16 intersticial y 19 no filiada. En el primer grupo se observó una progresión de la ERC con una caída del filtrado glomerular estimado (FGe) de -4,3±1,1mL/min, mientras que en el grupo estándar un aumento del FGe durante el seguimiento de 4,6±0,4mL/min, p=0,024. No se apreciaron diferencias entre ambos en el control tensional, el número de antihipertensivos, la albuminuria, los niveles de potasio, la incidencia de eventos cardiovasculares ni la mortalidad durante el seguimiento. Conclusiones: En pacientes añosos no diabéticos con ERC no proteinúrica y sin cardiopatía el uso de BSRAA no añade beneficio en la progresión de la ERC. Ensayo clínico Progresión de Enfermedad Renal Crónica en Ancianos (PROERCAN) (NCT03195023). (AU)

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.

Contrast-induced encephalopathy in patients with advanced chronic kidney disease: What the nephrologist needs to know.

Contrast-induced encephalopathy is a neurological complication related to contrast used in endovascular procedures or computed tomography (CT). The main risk factors are arterial hypertension, diabetes mellitus, chronic kidney disease (CKD), hyperosmolar contrasts, the amount of infused contrast and its direct infusion in the posterior cerebral territory, or pathologies with blood-brain barrier damage. Symptomatology is non-specific and may present as altered level of consciousness, neurological focality or seizures. Diagnosis is done by exclusion after ischemic or hemorrhagic stroke has been ruled out; CT or MRI are useful for differentiation. Generally, it appears shortly after exposure and the symptoms lasts 48-72h with complete recovery, although cases with persistence of symptoms or longer duration have been described. Treatment consists of monitoring, supportive measures and kidney replacement therapy (KRT) with hemodialysis (HD) in patients in chronic KRT program. It is important for the nephrologist to be aware of this entity given the susceptibility of the patient on HD as well as its potential therapeutic role in these patients.

Definition and evolution of the concept of sarcopenia.

Sarcopenia and dynapenia are two terms associated with ageing that respectively define the loss of muscle mass and strength. In 2018, the European Working Group on Sarcopenia in Older People (EWGSOP) introduced the EWGSOP2 diagnostic algorithm for sarcopenia, which integrates both concepts. It consists of 4 sequential steps: screening for sarcopenia, examination of muscle strength, assessment of muscle mass and physical performance; depending on these last 3 aspects sarcopenia is categorised as probable, confirmed, and severe respectively. In the absence of validation of the EWGSOP2 algorithm in various clinical contexts, its use in haemodialysis poses several limitations: (a) low sensitivity of the screening, (b) the techniques that assess muscle mass are not very accessible, reliable, or safe in routine clinical care, (c) the sequential use of the magnitudes that assess dynapenia and muscle mass do not seem to adequately reflect the muscular pathology of the elderly person on dialysis. We reflect on the definition of sarcopenia and the use of more precise terms such as "myopenia" (replacing the classic concept of sarcopenia to designate loss of muscle mass), dynapenia and kratopenia. Prospective evaluation of EWGSOP2 and its comparison with alternatives (i.e. assessment of kratopenia and dynapenia only; steps 2 and 4) is proposed in terms of its applicability in clinical routine, resource consumption, identification of at-risk individuals and impact on events.

Activation and disease control of patients on chronic hemodialysis: An observational study.

BACKGROUND AND OBJECTIVE: Patient activation is a concept that refers to the willingness to manage one's health and medical care. To assess it, a patient activation measure (PAM) has been developed and validated. Several studies report low activation in patients with chronic diseases. However, information on activation in hemodialysis patients is scarce. The aim of the present study is to describe the activation level of patients on chronic treatment in an HD unit and its relationship with disease control parameters. MATERIALS AND METHODS: Cross-sectional observational study in patients with advanced chronic kidney disease on chronic HD treatment. Ninety-six patients were included. Activation was measured with the PAM-13 questionnaire. Its relationship with descriptive variables (age, sex, comorbidity, studies, habitat) and disease control variables (vascular access, blood flow, potassaemia, phosphataemia, interdialytic gain) was studied. For this purpose, Spearman's correlation test, multiple linear regression model and logistic model were used as statistical methods. RESULTS: The mean (SD) PAM-13 score was 63.19 (15.21). Activation was significantly associated with vascular access (P = 0.003), blood flow (P = 0.024), and interdialytic gain of patients (P = 0.008). CONCLUSIONS: Activation in patients on chronic hemodialysis treatment is low. Higher activation is related having an arteriovenous fistula, higher blood flow and lower interdialytic gain. Future studies are needed to confirm and apply our results.

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.

The urogenital microbiome in chronic kidney disease patients on peritoneal dialysis.

INTRODUCTION AND OBJECTIVES: Diabetes, dyslipidemia, older age, gender, urinary tract infections, and recent antibiotic intake have been associated with a decrease in the urobiome richness and other fluctuations in this microbiome. Gut and blood microbiome have been reported to be altered in patients with chronic kidney disease (CKD), and specifically in peritoneal dialysis (PD) patients. Still, there are currently no studies describing the urogenital microbiome in CKD-PD patients. In this study we characterized the urobiome profile in 46 PD patients and analyzed its clinical and inflammatory parameters. MATERIALS AND METHODS: Mid-stream urine, fecal and blood samples were collected from 46 patients undergoing PD at Centro Hospitalar Universitário de São João (CHUSJ) in Porto, Portugal. Exclusion criteria were age under 18 years old, inability to give informed consent, history of infection in the last three months, and antibiotic intake in the last three months. The microbiome communities were analyzed by amplification and sequencing of the V3-V4 region of the bacterial 16S rRNA gene. Correlations with the patients' clinical data and inflammatory profile were performed. RESULTS: CKD-PD patients presented a unique urobiome profile dominated by Bacillota, Actinomycetota and Pseudomonadota and characterized by a lower Shannon diversity than fecal and blood microbiome. The taxonomic profiles of urogenital samples were organized in multiple subtypes dominated by populations of Lactobacillus, Staphylococcus, Streptococcus, Gardnerella, Prevotella, Escherichia-Shigella, being similar to other non-PD-CKD patients. Gender, sCD14, residual diuresis and history of peritonitis were significantly associated to variations in the urobiome. Although not reaching statistical significance, diabetes and the time on PD also showed association with particular taxonomic groups. Depletion of Gardnerella, Staphylococcus, Corynebacterium, Lactobacillus or Dermabacter populations correlated with CKD-PD patients with history of diabetes, history of peritonitis and altered levels of sCD14. CONCLUSIONS: Our results highlight urogenital microbiome as a potential partner and/or marker in the overall health state of CKD-PD patients.

Risk factors associated with COVID-19 mortality in Mexico.

BACKGROUND: On December 31, 2019, one of the most serious pandemics in recent times made its appearance. Certain health conditions, such as obesity and diabetes mellitus, have been described to be related to COVID-19 unfavorable outcomes. OBJECTIVE: To identify factors associated with mortality in patients with COVID-19. MATERIAL AND METHODS: Retrospective cohort of 998,639 patients. Patient sociodemographic and clinical characteristics were analyzed, with survivors being compared with the deceased individuals. Cox proportional hazards model was used to identify variables predictive of COVID-19-associated mortality. RESULTS: Among the deceased patients, men accounted for 64.3%, and women, for 35.7%, with the difference being statistically significant. Subjects older than 80 years had a 13-fold higher risk of dying from COVID-19 (95% CI = 12,469, 13,586), while chronic kidney disease entailed a risk 1.5 times higher (95% CI = 1,341, 1,798), and diabetes mellitus involved a risk 1.25 times higher (95% CI = 1.238,1.276). CONCLUSIONS: Age, sex, diabetes mellitus and obesity were found to be predictors of COVID-19 mortality. Further research related to chronic obstructive pulmonary disease, cardiovascular diseases, smoking and pregnancy is suggested.

ANTECEDENTES: El 31 de diciembre de 2019, se inició una de las pandemias más graves de los últimos tiempos. Se ha descrito que ciertas condiciones de salud, como la obesidad y la diabetes mellitus, están relacionadas con desenlaces desfavorables por COVID-19. OBJETIVO: Identificar factores asociados a mortalidad en pacientes con COVID-19. MATERIAL Y MÉTODOS: Cohorte retrospectiva de 998 639 pacientes. Se analizaron las características sociodemográficas y clínicas de los pacientes, y se compararon supervivientes con fallecidos. Se utilizó el modelo de riesgos proporcionales de Cox para la identificación de variables predictivas de defunción por COVID-19. RESULTADOS: Entre los fallecidos, los hombres representaron 64.3 % y las mujeres 35.7 %, diferencia que resultó estadísticamente significativa. Las personas con más de 80 años presentaron un riesgo 13 veces mayor de morir por COVID-19 (IC 95 % = 12.469,13.586) y la enfermedad renal crónica, un riesgo de 1.5 (IC 95 % = 1.341, 1.798); la diabetes mellitus tuvo un riesgo de 1.25 (IC 95 % = 1.238,1.276). CONCLUSIONES: La edad, el sexo, la diabetes mellitus y la obesidad resultaron ser entidades predictivas de muerte por COVID-19. Se sugiere más investigación relacionada con enfermedad pulmonar obstructiva crónica, enfermedades cardiovasculares, tabaquismo y embarazo.

Esteatosis hepática metabólica y nefropatía diabética: una llamada a la acción / Targeting metabolic-associated fatty liver disease in diabetic kidney disease: A call to action

La incidencia y la prevalencia de hígado graso no alcohólico o enfermedad hepática metabólica (EHmet) está en aumento y es mayor en pacientes con diabetes mellitus tipo 2 (DM2). El riesgo cardiovascular y renal está claramente incrementado en estos pacientes, especialmente cuando se desarrolla nefropatía diabética. El eje cardio-reno-hepato-metabólico, conformado por la enfermedad cardiovascular (ECV), la enfermedad renal crónica (ERC), la EHmet y la DM2, tiene una base fisiopatogénica común. La relación clínica entre todos los componentes es inevitable y multidireccional, pudiendo la EHmet preceder al desarrollo de complicaciones cardiovasculares y renales, y también empeorar el pronóstico de las mismas una vez desarrolladas. En esta revisión enfatizamos la importancia de buscar y tratar la EHmet en pacientes con ERC y DM2 con el objetivo de identificar pacientes de mayor riesgo y de mejorar su pronóstico.(AU)

Non-alcoholic fatty liver disease or metabolic-associated fatty liver disease (MAFLD) is a common condition with increasing prevalence and incidence, specially in patients with type 2 diabetes mellitus (DM2). Both cardiovascular and renal disease are clearly increased in these patients, particularly in those with diabetic nephropathy. In the liver–heart–kidney–metabolic axis, the common pathophysiological basis of MAFLD, cardiovascular disease (CVD), chronic kidney disease (CKD), and DM2 is the same. The clinical relationship between all of them is clear and is multidirectional: MAFLD may precede the development of cardiovascular and renal disease, and may also worsen the prognosis of these complications once developed. In this review we emphasize the importance of targeting MAFLD in diabetic kidney disease, with the goal of detecting high-risk patients in order to improve their prognosis.(AU)

Estrategias de prevención y tratamiento de la infección por SARS-CoV-2 (Severe Acute Respiratory Coronavirus 2) en pacientes con enfermedad renal crónica: revisión de la literatura / Strategies for prevention and treatment of SARS-CoV-2 infection in patients with chronic kidney disease: Literature review

La COVID-19 ha demostrado ser especialmente agresiva con los pacientes con enfermedad renal crónica (ERC). La menor tasa de respuesta inmunológica y la mayor facilidad para la progresión a formas graves de enfermedad ha propiciado este hecho, que se ha mantenido en la era posvacunal de la pandemia. Paradójicamente, la ERC ha sido excluida de la mayoría de los ensayos clínicos de las principales herramientas terapéuticas desarrolladas frente a SARS-CoV-2. Sin embargo, se ha ido reuniendo experiencia de uso de estos fármacos en distintos estadios de la ERC que avala su uso con garantías de eficacia y seguridad. El objetivo de esta revisión es reunir todas las indicaciones de tratamiento frente a la COVID-19 en los distintos estadios de la enfermedad adaptadas a la ERC en sus distintas fases, incluyendo el tratamiento sustitutivo renal.(AU)

COVID-19 has proven to be particularly aggressive in patients with chronic kidney disease (CKD). The lower immune response rate and the greater susceptibility to progress to severe forms of the disease have contributed to this phenomenon, which has persisted in the post-vaccination era of the pandemic. Paradoxically, CKD has been excluded from most clinical trials of the main therapeutic tools developed against SARS-CoV-2. However, experience in the use of these drugs has been accumulating in different stages of CKD, supporting their use with guarantees of efficacy and safety. The objective of this review is to gather all treatment indications for COVID-19 in the different phases of the disease, tailored to CKD in its various stages, including renal replacement therapy.(AU)

Efecto de los inhibidores del cotransportador sodio-glucosa tipo 2 sobre la anemia: posibles implicaciones clínicas / Effect of SGLT2 inhibitors on anemia and their possible clinical implications

Los inhibidores del cotransportador sodio-glucosa tipo 2 (iSGLT2) han demostrado su beneficio cardiovascular y renal en pacientes con diabetes mellitus tipo 2, insuficiencia cardiaca (IC) o enfermedad renal crónica (ERC). Desde los primeros estudios, con estos fármacos se objetivó un incremento inicial de los niveles de hemoglobina/hematocrito que se atribuyó a un aumento de la hemoconcentración asociados a su efecto diurético, aunque pronto se constató que aumentaban los niveles de eritropoyetina (EPO) y eritropoyesis, mejorando el metabolismo férrico. Los estudios de mediación objetivaron que el incremento de hemoglobina se asociaba estrechamente con los beneficios cardiorrenales de estas sustancias. En la presente revisión se discuten los mecanismos de mejora de la eritropoyesis y la implicación del aumento de hemoglobina sobre el beneficio pronóstico cardiorrenal de estos medicamentos.(AU)

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated cardiovascular and renal benefits in patients with type 2 diabetes mellitus, heart failure, or chronic kidney disease. Since the first studies with these drugs, an initial increase in hemoglobin/hematocrit levels was observed, which was attributed to an increase in hemoconcentration associated with its diuretic effect, although it was soon seen that these drugs increased erythropoietin levels and erythropoiesis, and improved iron metabolism. Mediation studies found that the increase in hemoglobin was strongly associated with the cardiorenal benefits of these drugs. In this review, we discuss the mechanisms for improving erythropoiesis and the implication of the increase in hemoglobin on the cardiorenal prognostic benefit of these drugs.(AU)

The urogenital microbiome in chronic kidney disease patients on peritoneal dialysis / El microbioma urogenital en pacientes con enfermedad renal crónica en diálisis peritoneal

Introduction and objectives: Diabetes, dyslipidemia, older age, gender, urinary tract infections, and recent antibiotic intake have been associated with a decrease in the urobiome richness and other fluctuations in this microbiome. Gut and blood microbiome have been reported to be altered in patients with chronic kidney disease (CKD), and specifically in peritoneal dialysis (PD) patients. Still, there are currently no studies describing the urogenital microbiome in CKD-PD patients. In this study we characterized the urobiome profile in 46 PD patients and analyzed its clinical and inflammatory parameters. Materials and methods: Mid-stream urine, fecal and blood samples were collected from 46 patients undergoing PD at Centro Hospitalar Universitário de São João (CHUSJ) in Porto, Portugal. Exclusion criteria were age under 18 years old, inability to give informed consent, history of infection in the last three months, and antibiotic intake in the last three months. The microbiome communities were analyzed by amplification and sequencing of the V3–V4 region of the bacterial 16S rRNA gene. Correlations with the patients’ clinical data and inflammatory profile were performed. Results: CKD-PD patients presented a unique urobiome profile dominated by Bacillota, Actinomycetota and Pseudomonadota and characterized by a lower Shannon diversity than fecal and blood microbiome. The taxonomic profiles of urogenital samples were organized in multiple subtypes dominated by populations of Lactobacillus, Staphylococcus, Streptococcus, Gardnerella, Prevotella, Escherichia-Shigella, being similar to other non-PD-CKD patients. Gender, sCD14, residual diuresis and history of peritonitis were significantly associated to variations in the urobiome. Although not reaching statistical significance, diabetes and the time on PD also showed association with particular taxonomic groups... (AU)

Introducción y objetivos: Diabetes, dislipemia, edad avanzada, género, infecciones del tracto urinario y toma reciente de antibióticos, entre otras, se han asociado a una disminución en la riqueza del urobioma y a otras fluctuaciones de dicho microbioma.Recientemente, se han descrito alteraciones en losmicrobiomas intestinal y en sangreen pacientes con enfermedad renal crónica (ERC) y, específicamente, en pacientes en diálisis peritoneal (DP).A pesar de ello, aún no existen estudios que describan el microbioma urogenital en pacientes en DP. En el presente trabajo, caracterizamos el urobioma en 46 pacientes en DP. Pacientes y métodos: Se recogieron muestras de orina (micción espontánea), heces y sangre de 46 pacientes en DP del Centro HospitalarUniversitário de São João en Oporto, Portugal. Los criterios de exclusión fueron edad menor a 18 años, incapacidad para entenderel consentimiento informado, e historia de infección y toma de antibióticos en los últimos 3 meses. Las comunidades microbiológicas fueron analizadas por amplificación y secuenciación de las regiones V3-V4 del 16S rRNA bacteriano. Se realizaron correlaciones con los datos clínicos y el perfil inflamatorio de los pacientes. Resultados: Los pacientes en DP presentaron un urobioma único dominado por Bacillota, Actinomycetota yPseudomonadota, y caracterizado por una menor diversidad de Shannon que los microbiomas en sangre e intestinal. Los perfiles taxonómicos de las muestras urogenitales se organizaron en múltiples subtipos dominados por poblaciones de Lactobacillus, Staphylococcus, Streptococcus, Gardnerella, Prevotella, Escherichia-Shigella, siendo similar al descrito para otros pacientes con ERC no en DP.Género, factor sCD14, diuresis residual yantecedentes de peritonitis se asociaron de forma significativa a cambios en el urobioma... (AU)

Vascular calcification in peritoneal dialysis patients and its association with bone-derived molecules and bone histomorphometry / Calcificación vascular en pacientes en diálisis peritoneal y su asociación con moléculas derivadas de hueso e histomorfometría ósea

Introduction: Data regarding vascular calcification (VC) in contemporary peritoneal dialysis (PD) patients is scarce. Bone–vascular axis has been demonstrated in hemodialysis (HD). However, studies showing the link between bone disease and VC in PD patients are lacking. The role of sclerostin, dickkopf-related protein 1 (DKK-1), receptor activator for nuclear factor kB ligand and osteoprotegerin (OPG) in VC in PD remains to clarify. Materials and methods: Bone biopsy was performed in 47 prevalent PD patients with histomorphometric analysis. Patients were submitted to pelvis and hands X-ray to evaluate VC using the Adragão score (AS). Relevant clinical and biochemical data was collected. Results: Thirteen patients (27.7%) had positive AS (AS≥1). Patients with VC were significantly older (58.9 vs. 50.4 years, p=0.011), had a lower dialysis dose (KT/V 2.0 vs. 2.4, p=0.025) and a higher glycosylated hemoglobin (7.2 vs. 5.4%, p=0.001). There was not any laboratorial parameter of mineral and bone disease used in clinical practice different between patients with or without VC. All diabetic patients had VC but only 8.1% of non-diabetic had VC (p<0.001). Patients with VC showed significantly higher erythrocyte sedimentation rate (ESR) (91.1 vs. 60.0mm/h, p=0.001), sclerostin (2250.0 vs. 1745.8pg/mL, p=0.035), DKK-1 (1451.6 vs. 1042.9pg/mL, p=0.041) and OPG levels (2904.9 vs. 1518.2pg/mL, p=0.002). On multivariate analysis, only ESR remained statistically significant (OR 1.07; 95% CI 1.01–1.14; p=0.022). Bone histomorphometric findings were not different in patients with VC. There was no correlation between bone formation rate and AS (r=−0.039; p=0.796). Conclusion: The presence of VC was not associated with bone turnover and volume evaluated by bone histomorphometry. Inflammation and diabetes seem to play a more relevant role in VC in PD. (AU)

Introducción Los datos sobre calcificación vascular (CV) en pacientes contemporáneos en diálisis peritoneal (DP) son escasos. En pacientes en hemodiálisis, se ha demostrado la existencia de una conexión entre hueso y sistema vascular; sin embargo, faltan estudios que muestren el vínculo entre la enfermedad ósea y la CV en pacientes en DP. Si la esclerostina, la proteína relacionada con Dickkopf 1 (DKK-1), el ligando del receptor activador para el factor nuclear κB (RANKL) y la osteoprotegerina (OPG) tienen un papel en la CV en pacientes en DP aún no está claro. Materiales y métodos Se realizó biopsia ósea en 47 pacientes prevalentes en DP y se analizó mediante histomorfometría. También se tomaron radiografías de pelvis y manos a los pacientes para evaluar la CV mediante el Índice de Adragão (IA). Además, se analizaron datos clínicos y bioquímicos relevantes. Resultados: Trece pacientes (27,7%) tuvieron IA positivo (IA ≥ 1). Los pacientes con CV eran significativamente mayores (58,9 vs 50,4 años, p=0,011) tenían menor dosis de diálisis (KT/V 2,0 vs 2,4, p=0,025) y niveles más elevados de hemoglobina glicosilada (7,2 vs 5,4%, p=0,001). No hubo ningún parámetro de laboratorio de enfermedad mineral y ósea utilizado en la práctica clínica diferente entre pacientes con o sin CV. Todos los pacientes diabéticos mostraron CV, sin embargo, solo el 8,1% de los no diabéticos tenían CV (p <0,001). Además, los pacientes con CV mostraron una velocidad de sedimentación globular más elevada (VSG) (91,1 vs. 60,0mm/h, p=0,001) y mayores concentraciones séricas de esclerostina (2.250,0 vs. 1.745,8 pg/ml, p=0,035), DKK-1 (1451,6 vs 1042,9 pg/ml, p=0,041) y OPG (2.904,9 vs. 1.518,2 pg/ml, p=0,002). En el análisis multivariante, solo la VSG fue estadísticamente significativa (OR 1,07; IC del 95%: 1,01-1,14; p=0,022)... (AU)