Recommendations Of The Brazilian Society Of Nephrology Regarding Pediatric Patients On Renal Replacement Therapy During The Covid-19 Pandemic.

INTRODUCTION: The impact of the new coronavirus (SARS-COV-2) and its worldwide clinical manifestations (COVID-19) imposed specific regional recommendations for populations in need of specialized care, such as children and adolescents with kidney diseases, particularly in renal replacement therapies (RRT). We present the recommendations of the Brazilian Society of Nephrology regarding the treatment of pediatric patients with kidney diseases during the COVID-19 pandemic. METHODS: Articles and documents from medical societies and government agencies on specific recommendations for children on RRT in relation to COVID-19 as well as those focused on epidemiological aspects of this condition in Brazil Were evaluated and analyzed. RESULTS: We present recommendations on outpatient care, transportation to dialysis centers, peritoneal dialysis, hemodialysis, and kidney transplantation in children and adolescents during the COVID-19 pandemic in Brazil. DISCUSSION: Despite initial observations of higher mortality rates in specific age groups (the elderly) and with comorbidities (obese, diabetics, and those with cardiovascular diseases), patients with chronic kidney disease (CKD) on RRT are particularly prone to develop COVID-19. Specific measures must be taken to reduce the risk of contracting SARS-CoV-2 and developing COVID-19, especially during transport to dialysis facilities, as well as on arrival and in contact with other patients.

Technical note and clinical instructions for Acute Kidney Injury (AKI) in patients with Covid-19: Brazilian Society of Nephrology and Brazilian Association of Intensive Care Medicine.

We produced this document to bring pertinent information to the practice of nephrology, as regards to the renal involvement with COVID-19, the management of acute kidney injury cases, and practical guidance on the provision of dialysis support.As information on COVID-19 evolves at a pace never before seen in medical science, these recommendations, although based on recent scientific evidence, refer to the present moment. The guidelines may be updated when published data and other relevant information become available.

Palliative Renal Care and the Covid-19 Pandemic.

INTRODUCTION: Palliative care is an approach aimed at relieving suffering, controlling symptoms and seeking to improve quality of life. It must be offered in conjunction with standard treatment for any disease that threatens the continuation of life, such as a Covid-19 infection. DISCUSSION: The bioethical principles and strategies used by palliative medicine can assist nephrologists in the care of patients with renal dysfunction, who face the difficulties of isolation at the beginning and follow-up of dialysis in outpatient treatment, and those who are at risk for a more serious disease progress. Some of them: - a Shared decision making, which enables the patient and family to participate as facilitators in the systematization of the team's reasoning, in addition to respecting the principle of autonomy; - Symptom Management: which should be a priority to ensure relief of suffering even in times of social isolation; - Communication skills: making it possible to alleviate suffering in announcing bad news or complex decisions through communication techniques;; - Bereavement assistance: which in acute situations such as the pandemic, causing unexpected losses, the importance of sympathy from healthcare professionals becomes even greater. CONCLUSION: The principles of palliative care are essential to face the challenges of a planet-wide crisis, which raises human suffering in all dimensions, and which requires the construction of strategies that can keep patients assisted, comfortable and with measures proportional to their clinical condition and preferences.

Technical note and clinical instructions for Acute Kidney Injury (AKI) in patients with Covid-19: Brazilian Society of Nephrology and Brazilian Association of Intensive Care Medicine / Nota técnica e orientações clínicas sobre a Injúria Renal Aguda (IRA) em pacientes com Covid-19: Sociedade Brasileira de Nefrologia e Associação de Medicina Intensiva Brasileira

ABSTRACT We produced this document to bring pertinent information to the practice of nephrology, as regards to the renal involvement with COVID-19, the management of acute kidney injury cases, and practical guidance on the provision of dialysis support.As information on COVID-19 evolves at a pace never before seen in medical science, these recommendations, although based on recent scientific evidence, refer to the present moment. The guidelines may be updated when published data and other relevant information become available.

RESUMO Este documento foi desenvolvido para trazer informações pertinentes à prática nefrológica em relação ao conhecimento sobre o acometimento renal da COVID-19, conduta frente aos casos de injúria renal aguda e orientações práticas sobre a provisão do suporte dialítico.Como as informações sobre a COVID-19 evoluem a uma velocidade jamais vista na ciência médica, as orientações apresentadas, embora baseadas em evidências científicas recentes, referem-se ao momento presente. Essas orientaços poderão ser atualizadas à medida que dados publicados e outras informações relevantes venham a ser disponibilizadas.

Palliative renal care and the covid-19 pandemic / Cuidado paliativo renal e a pandemia de Covid-19

ABSTRACT Introduction Palliative care is an approach aimed at relieving suffering, controlling symptoms and seeking to improve quality of life. It must be offered in conjunction with standard treatment for any disease that threatens the continuation of life, such as a Covid-19 infection. Discussion The bioethical principles and strategies used by palliative medicine can assist nephrologists in the care of patients with renal dysfunction, who face the difficulties of isolation at the beginning and follow-up of dialysis in outpatient treatment, and those who are at risk for a more serious disease progress. Some of them: - a Shared decision making, which enables the patient and family to participate as facilitators in the systematization of the team's reasoning, in addition to respecting the principle of autonomy; - Symptom Management: which should be a priority to ensure relief of suffering even in times of social isolation; - Communication skills: making it possible to alleviate suffering in announcing bad news or complex decisions through communication techniques;; - Bereavement assistance: which in acute situations such as the pandemic, causing unexpected losses, the importance of sympathy from healthcare professionals becomes even greater. Conclusion The principles of palliative care are essential to face the challenges of a planet-wide crisis, which raises human suffering in all dimensions, and which requires the construction of strategies that can keep patients assisted, comfortable and with measures proportional to their clinical condition and preferences.

RESUMO Introdução O cuidado paliativo é uma abordagem voltada para alívio do sofrimento, controle de sintomas e melhora da qualidade de vida. Deve ser oferecido em conjunto com o tratamento padrão de qualquer doença que ameace a continuidade da vida, como, por exemplo, a infecção pela Covid-19. Discussão Os princípios bioéticos e as estratégias utilizadas pela medicina paliativa podem auxiliar os nefrologistas no cuidado dos pacientes com disfunção renal, que, além de serem do grupo de risco para evolução mais grave da infecção por coronavírus, enfrentam as dificuldades do isolamento no seguimento do tratamento dialítico e ambulatorial. Essas ferramentas são: I) tomada de decisão compartilhada, que proporciona a participação do paciente e dos familiares como facilitadores na sistematização do raciocínio da equipe, além de respeitar o princípio da autonomia; II) manejo de sintomas, que deve ser prioridade para a garantia do alívio do sofrimento mesmo em momento de isolamento social; III) habilidades em comunicação, sendo possível amenizar dificuldades em anunciar más notícias ou decisões complexas através de técnicas de comunicação; IV) assistência ao luto, em que, em situações agudas como a pandemia, de perdas inesperadas, a importância do acolhimento dos profissionais de saúde torna-se ainda maior. Conclusão Os princípios dos cuidados paliativos são essenciais para enfrentar os desafios de uma crise humanitária, que causa sofrimento ao ser humano em todas as dimensões e exige a construção de estratégias que possam manter os pacientes assistidos, confortáveis e com medidas proporcionais à sua condição clínica e às suas preferências.

Recommendations of the brazilian society of nephrology regarding pediatric patients on renal replacement therapy during the covid-19 pandemic / Recomendações da sociedade brasileira de nefrologia para pacientes pediátricos em terapia de substituição renal durante a pandemia de covid-19

ABSTRACT Introduction The impact of the new coronavirus (SARS-COV-2) and its worldwide clinical manifestations (COVID-19) imposed specific regional recommendations for populations in need of specialized care, such as children and adolescents with kidney diseases, particularly in renal replacement therapies (RRT). We present the recommendations of the Brazilian Society of Nephrology regarding the treatment of pediatric patients with kidney diseases during the COVID-19 pandemic. Methods Articles and documents from medical societies and government agencies on specific recommendations for children on RRT in relation to COVID-19 as well as those focused on epidemiological aspects of this condition in Brazil Were evaluated and analyzed. Results We present recommendations on outpatient care, transportation to dialysis centers, peritoneal dialysis, hemodialysis, and kidney transplantation in children and adolescents during the COVID-19 pandemic in Brazil. Discussion Despite initial observations of higher mortality rates in specific age groups (the elderly) and with comorbidities (obese, diabetics, and those with cardiovascular diseases), patients with chronic kidney disease (CKD) on RRT are particularly prone to develop COVID-19. Specific measures must be taken to reduce the risk of contracting SARS-CoV-2 and developing COVID-19, especially during transport to dialysis facilities, as well as on arrival and in contact with other patients.

RESUMO Introdução O impacto do novo coronavírus (SARS-CoV-2) e as suas manifestações clínicas (Covid-19) em todo o mundo impôs recomendações regionais específicas a populações que necessitam de cuidados especializados, como crianças e adolescentes com doenças renais, particularmente em terapias de substituição renal (TRS). Apresentamos as recomendações da Sociedade Brasileira de Nefrologia em relação ao tratamento de pacientes pediátricos com doenças renais durante a pandemia Covid-19. Método Foram avaliados e analisados os artigos e documentos sobre recomendações específicas para Covid-19 de sociedades médicas e órgãos governamentais sobre crianças em TRS, bem como aqueles focados em aspectos epidemiológicos dessa condição no Brasil. Resultados Apresentamos as recomendações sobre atendimento ambulatorial, transporte para centros de diálise, diálise peritoneal, hemodiálise e transplante renal em crianças e adolescentes durante a pandemia de Covid-19 no Brasil. Discussão Apesar das observações iniciais de taxas de mortalidade mais altas em grupos etários específicos (idosos) e com comorbidades (obesos, diabéticos e aqueles com doenças cardiovasculares), pacientes com doença renal crônica (DRC) em TRS apresentam risco significativo de evoluir com Covid-19. Medidas específicas devem ser tomadas para reduzir o risco de contrair SARS-CoV-2 e desenvolver a Covid-19, principalmente durante o transporte para instalações de diálise, bem como na chegada e no contato com outros pacientes.

What is 'BEST' RRT practice?

Acute kidney injury (AKI) is a common complication among critical illnesses. In severe cases, renal replacement therapy (RRT) is required. It has been reported that hospital mortality of the patients who require RRT is more than 60%. Because of the high mortality, it is quite important to conduct RRT appropriately to improve outcome of patients with severe AKI. However, RRT is not a single homogeneous therapy but rather there are diverse modes of therapy and various ways of providing RRT that might affect its efficacy and safety. The Acute Dialysis Quality Initiative (ADQI) reviewed the available evidence and recommended that more research should be conducted on such technical aspects of RRT in order to determine if certain techniques are preferred for certain indications. As a response to the recommendation by ADQI, the BEST Kidney (Beginning and Ending Supportive Therapy for the Kidney) study was conducted. This study is a multicenter, multinational, prospective, epidemiological study with the aim of understanding multiple aspects of AKI at an international level. This study was conducted at 54 centers in 23 countries from September 2000 to December 2001. The study included more than 1,700 patients including 1,260 who were treated with RRT. Using the large database, several aspects related to RRT have been analyzed, including comparison of IRRT and continuous RRT (CRRT), timing of RRT initiation and discontinuation, and practice variations for CRRT around the world. This study found that RRT practice was quite varied around the world. RRT practice is not aligned with the best evidence and variations in practice may be responsible for significant morbidity. The BEST Kidney Study has generated several hypotheses related to RRT practice in the intensive care unit. Such hypotheses will need to be tested in future clinical trials and hopefully help reduce practice variations for patients with AKI requiring RRT.

[Anticoagulation in continuous renal replacement therapies (CRRT)]. / Anticoagulação em terapias contínuas de substituição renal.

Continuous renal replacement therapies (CRRT) are commonly used in the majority of critically ill patients who need dialysis. Treatment success depends on an efficient anticoagulation protocol devised to maintain the dialysis circuit unclotted, with minimal complications such as bleeding due to excessive anticoagulation. Several features can contribute to dialysis circuit thrombosis, such as the speed of pump blood flow, dialysis catheter, type of dialyzer membrane and also, the type of technique prescribed. Unfractioned heparin (UFH) is the anticoagulant most used in CRRT. Recently, low-molecular weight heparins (LMWH) have been shown to be safe and effective drugs for this purpose. In critically ill patients, who frequently have contraindications to systemic anticoagulation, regional anticoagulation with trisodium citrate is an increasingly accepted method due to its safety and efficiency if applied under strict metabolic control. Regional anticoagulation with UFH/protamin now has limited use because of side effects related to protamin. If the patient has contraindication to systemic anticoagulation or if regional anticoagulation with citrate is not available, continuous flushing of circuit dialysis with saline is the only applicable alternative. In patients with contraindication to heparinization, new drugs not yet available in Brazil, such as prostaglandins, recombinant hirudin, argatroban and nafamostat can be used.

Anticoagulação em terapias contínuas de substituição renal / Anticoagulation in continuous renal replacement therapies (CRRT)

As terapias contínuas de substituição renal (TSRC) são comumente usadas na maioria de pacientes criticamente enfermos com indicação de diálise. O sucesso das TSRC depende de um protocolo de anticoagulação eficiente para manter permeável o circuito de diálise, minimizando complicações como sangramento por anticoagulação excessiva ou a necessidade da troca do sistema por coagulação do mesmo, por anticoagulação insuficiente. Vários fatores podem contribuir para a trombose do circuito de diálise, como a velocidade do fluxo de sangue através do circuito, o cateter de diálise, o tipo de membrana utilizada no filtro dialisador e, também, o tipo de terapia prescrita. A heparina não fracionada (HNF) é o anticoagulante mais utilizado para as diferentes técnicas de diálise e, mais recentemente, as heparinas de baixo peso molecular (HBPM) têm se mostrado seguras e efetivas para TRSC. Em pacientes criticamente enfermos que freqüentemente têm contra-indicação para anticoagulação sistêmica, existe a alternativa da anticoagulção regional com citrato trissódico, método eficiente e seguro, se aplicado com controle metabólico estrito. A anticoagulação regional com HNF/protamina tem seu uso limitado, atualmente, por apresentar muitas complicações decorrentes de efeitos adversos da protamina. Na impossibilidade do paciente ser anticoagulado, ou se a anticoagulação regional com citrato não for disponível, a lavagem freqüente do circuito de diálise com solução salina é a única alternativa aplicável. Novas drogas ainda não disponíveis no Brasil, como prostaglandinas, hirudina recombinante, argatroban e nafamostat podem ser utilizadas em pacientes com contra-indicação para heparinização.

Continuous renal replacement therapies (CRRT) are commonly used in the majority of critically ill patients who need dialysis. Treatment success depends on an efficient anticoagulation protocol devised to maintain the dialysis circuit unclotted, with minimal complications such as bleeding due to excessive anticoagulation. Several features can contribute to dialysis circuit thrombosis, such as the speed of pump blood flow, dialysis catheter, type of dialyzer membrane and also, the type of technique prescribed. Unfractioned heparin (UFH) is the anticoagulant most used in CRRT. Recently, low-molecular weight heparins (LMWH) have been shown to be safe and effective drugs for this purpose. In critically ill patients, who frequently have contraindications to systemic anticoagulation, regional anticoagulation with trisodium citrate is an increasingly accepted method due to its safety and efficiency if applied under strict metabolic control. Regional anticoagulation with UFH/protamin now has limited use because of side effects related to protamin. If the patient has contraindication to systemic anticoagulation or if regional anticoagulation with citrate is not available, continuous flushing of circuit dialysis with saline is the only applicable alternative. In patients with contraindication to heparinization, new drugs not yet available in Brazil, such as prostaglandins, recombinant hirudin, argatroban and nafamostat can be used.