Contributions to nephrology最新文献

Clinical Background: Chronic kidney disease (CKD) is a condition that causes important limitations to patients' lives. The limitations imposed as a result of the disease end up hampering the exercise of citizenship by individuals, including work and daily activities. Epidemiology: The prevalence of CKD in Brazil, India, Nigeria, Portugal, and South Africa is, respectively, 5.8-25.2, 13-17.2, 7.8-23.5, 6.1-20.7, and 6.4-17.3%, and is higher among the most disadvantaged populations. Challenges: The present study intends to make an intersection between health sciences, considering the reality faced by the patient with CKD, and the legal perspectives regarding the protective dimension of the right to healthcare and the access of these individuals to a better quality of life. Despite differences in size, population, and human development, there are some similarities among countries in the normative approach regarding the right to healthcare of patients with CKD. The study was developed based on an analysis carried out by legal scholars and specialists from Brazil, India, Portugal, South Africa, and Nigeria. Not only the texts of constitutions and laws were examined, but also how courts interpret and apply them. It was identified that the impact of kidney disease is also associated with human development issues. Adequate access to renal replacement therapy is not always found in the countries examined as well as to kidney transplants. It was observed that the constitutional protection of the right to healthcare is present in some constitutions such as those of Brazil, Portugal, and South Africa. Specific legislation that regulates access to medicines, dialysis, and kidney transplantation was analyzed. Financial aid and right to social assistance and social insurance benefits guaranteed by law are found only in some countries. However, for legal provisions to become effective, it is still necessary to overcome sociocultural and budgetary issues. Prevention and Treatment: Public policies directed to CKD patients, ensuring access to information, preventive measures, and treatment, should be elaborated to answer the increasing demand for renal replacement therapy, including dialysis and transplant.

Clinical Background: Neglected tropical diseases (NTDs), a major public health problem, frequently affect the kidneys. In this chapter, we discuss the NTDs which have been most studied in terms of renal involvement and present a summary of current knowledge regarding kidney disease in all NTDs, through a literature review. Epidemiology: There are more than 1 billion people in the world affected by NTDs. These infections can also be one of the etiologies of chronic kidney disease of unknown cause, which is another great public health problem in Latin America, and these diseases are most prevalent in young people, males, in their productive years, which increases its burden on the society. Challenges: Early detection of renal involvement is crucial to decrease the magnitude of the manifestations and hence allow more favorable outcomes, and for this purpose novel kidney injury biomarkers are a promising solution. Unfortunately, specific treatments for NTDs have not changed in the last decades, as novel drugs have not been investigated. Prevention and Treatment: Prevention includes vector control, blood bank tests, periodic serologic surveys, and health surveillance in general in order to decrease oral transmission and to maintain good hygiene conditions. Recently, many potential therapeutic targets have been evidenced in both clinical and experimental studies.

An estimated one-third of adults in developed countries and more than 80% of the population in many low- and middle-income countries use herbal and traditional medicines to promote health or for the treatment of common diseases. Herbal medicines can cause kidney damage as a result of intrinsic toxicity, adulteration, contamination, replacement, misidentification, mistaken labeling, and unfavorable herb-drug interactions. The kidneys, due to their high blood flow rate, large endothelial surface area, high metabolic activity, active uptake by tubular cells, medullary interstitial concentration, and low urine pH are particularly vulnerable to development of toxic injury in the form of different syndromes like acute kidney injury, nephrolithiasis, chronic interstitial fibrosis, or uroepithelial cancer. Herbal medicines can also cause crystalluria or hypertension and some could increase potassium blood levels in patients with kidney damage. It is of critical importance that health care organizations around the world regulate herbal and traditional remedies in order to reduce the risk of herb-toxic acute kidney injury or chronic kidney disease. The nephrologist must be aware of the potential nephrotoxicity from herbal medicine and supplements. A careful history and specific questioning about use of herbal medicines use is essential.

Clinical Background: Nephrotoxic acute kidney injury or toxin-related acute kidney injury (ToxAKI) is a relevant and relatively common category of kidney damage. Exogenous toxins and venomous animals with epidemiologic variations across the world are some nephrotoxic agents. Epidemiology: The epidemiologic features of the toxic agent-related acute kidney injury are associated with different culture, biodiversity of the tropics, and economic status. It seems economic status is the major factor which defines the etiology of ToxAKI. In developing countries, the AKI is commonly associated with self-poisonings by pesticides and herbicides, while developed countries often notify poisonings due to antibiotics, nonsteroidal anti-inflammatory drugs, immunosuppressants (such as methotrexate), and iodinated contrast media. Moreover, envenoming due to snakes, spiders, and scorpions is more frequent in tropical regions. Challenge: Poisoned patients are more susceptible to renal impairment associated with renal replacement therapy and death. Prevention and Treatment: Preventing patient exposure and performing early diagnosis are crucial to beat the main causes of ToxAKI and further complications. Renal replacement therapy may be necessary to manage the patient, and it is associated with poor prognosis and death. According to each poisoning profile, specific measures are suggested. School-base interventions, early identification, treatment, and care of people with mental and substance use disorders, reducing access to chemical agents, making parents aware of the hazards of accidental poisoning in children, and maintaining fully functional poison control centers are vital actions too.

Clinical Background: Cancer therapeutics (for both solid and hematological malignancies) have evolved over the last two decades, from traditional chemotherapies to novel treatments. A better supportive care, older patients with comorbidities who receive multiple chemotherapeutic and pharmacological regimens, multiple CT scans with contrast agents, and new therapeutic options are also increasing the number of cancer patients who can develop acute kidney injury (AKI) or chronic kidney disease (CKD). Challenges: Targeted therapies and immunotherapies, which harness the body's own immune system to fight cancer cells have led to improved survival in cancer patients, yet all are associated with many organ toxicities. Renal toxicity is mainly represented by acute tubular-interstitial damage, glomerular lesions, thrombotic microangiopathy, tumor lysis, proteinuria, arterial hypertension, AKI, CKD, and secondary fluid/electrolyte disturbances. On the other hand, it is important to consider how the presence of CKD, AKI, and other renal disorders may affect treatment options for the oncologists and patient's outcome. All these features require a specialized approach. Prevention and Treatment: A new evolving field, namely Onconephrology, has emerged during the last few years, including the broad spectrum of renal disorders that can arise in patients with cancer. Nephrologists have become an indispensable part of the multidisciplinary cancer care teams, but a clear and updated knowledge of solid and hematological malignancies, always new anticancer therapies, and their relationships with kidney function is essential to ensure the highest quality of care. In this chapter, we summarize the principal aspects of this new field of Nephrology.

Clinical Background and Epidemiology: Nutrition and obesity are both important and common clinical issues in chronic kidney disease (CKD). Protein-energy wasting predicts adverse clinical outcomes in CKD. Obesity is associated with poor health outcomes. Nutrition management, specifically a protein-restricted diet, has been shown to ameliorate glomerular injury and progressive CKD by reducing glomerular hyperfiltration and hypertension. A protein-restricted diet has favorable metabolic and hemodynamic effects and effects on CKD-mineral bone disease that may favorably impact patients' outcomes. On the other hand, obesity may adversely affect kidney function both directly by placing an increased metabolic demand on the kidneys and indirectly through various humoral mechanisms mediated via adiponectin, leptin, and resistin that lead to hyperinsulinemia, insulin resistance, abnormal lipid metabolism, activation of renin-angiotensin aldosterone system, chronic inflammation, and oxidative stress, and could result in the development of obesity-related glomerulopathy. It is therefore important to raise more awareness of the two clinical issues and promote a healthy lifestyle with proper nutrition and exercise in CKD management. Challenges and Solutions: There are global shortage of dietitians and challenges in accessibility and availability of renal dietitians in many emerging countries as well as lack of reimbursement of dietitians' consultations. Many patients may not have the opportunity to be monitored and reviewed by dieticians on a regular basis. In addition, there are practical challenges in enforcing patients' adherence to a protein-restricted diet. Patients and nephrologists from developed countries maynot appreciate the need to adopt a protein restricted diets as dialysis is readily available. Furthermore, keto-analogues or nutrition supplements are not reimbursed in many parts of the world. Increased government advocacy, prioritization of renal nutrition care, and more trained renal dietitians are required in many parts of the world. More government resource allocation is required to increase renal dietitians' manpower in nephrology centers so to enable multidisciplinary nutrition management in CKD and end-stage kidney disease. On the other hand, prevention and treatment of obesity require lifestyle modifications including calorie restriction and adequate exercise, and they need to be maintained lifelong. Such changes may be difficult in modern societies with the "fast food culture" and increasing prevalence of sedentary lifestyles. Changes in lifestyle may become even more difficult as long-term complications such as diabetes and cardiovascular disease set in, which may further limit patients' mobility. To tackle the obesity epidemic, we need a global action plan to prevent and control non-communicable diseases. We need a concerted population-wide intervention by national governments, health policy planners, and professional organization

Clinical Background: Kidney transplantation (KT) is the best treatment for most patients with end-stage kidney disease (ESKD), providing better survival and quality of life and lower cost when compared to dialysis. Epidemiology: Despite robust evidence showing the superiority of KT over dialysis, a significant percentage of ESKD patients worldwide do not access this treatment. Challenges: Barriers resulting in inequalities and inequities in access to KT involves chronic kidney disease (CKD) diagnosis and management, including difficulties in accessing dialysis therapy before KT; suboptimal referral and enlistment to KT; and imbalance between supply and demand for organs. Low socioeconomic status has an important role in that scenario. Prevention and Treatment: Strategies to minimize disparities in access to KT involve public policies to ensure access to CKD diagnosis and treatment, health education, continuous training of health providers, infrastructure, and allocation policies.

Clinical Background: Poly- and perfluorinated compound (PFCS) pollution has been found to be the driver of different diseases, including glucose intolerance, hyperlipidemia, thyroid diseases, gestational diabetes mellitus and hypertension, testicular and genitourinary cancer, as well as impaired kidney function. This review focuses on the renal effects of PFCS, intending to clarify their occurrence and pathogenetic mechanisms. Epidemiology: Between October 31st, 2017, and March 31st, 2020, most frequently analyzed PFCS were perfluorooctane sulfonate, perfluorooctanoic acid, sodium perfluoro-1-hexanesulfonate, perfluoro-n-nonanoic acid, and perfluoro-n-decanoic acid. Unfortunately, the novel replacement compounds (e.g., perfluoroether carboxylic acid) are unregulated, and they are not under study. PFCS are linked with an impaired kidney function: the kidney is a target of PFCS because it is involved in their excretion. Inter- and intra-species variations exist and affect PFCS pharmacokinetics, leading to different risk profiles of adverse effects, even at similar exposures, and influencing the risk of renal damage in case of concomitant exposure to PFCS and some heavy metals. Challenges, Prevention and Treatment: In the last 20 years, much effort has been made to stop the PFCS production in Europe and USA. However, human exposure remains persistently high due to PFCS long half-life, the large-scale production in some countries and the unregulated novel compounds. This context makes further studies mandatory to understand the pathogenetic mechanisms of old and new PFCS and the effective strategies to remove PFCS from the human blood in the most affected areas of the world.

Clinical Background: Hydration status, which is influenced by environment and self-behavior is associated with kidney health and disease. Epidemiology: Lack of safe water, sanitation, and high temperatures are environmental issues that affect a significant part of the worldwide population. Occupational factors that discourage proper hydration, as well as low water intake in favorable environment conditions, are also highly prevalent. As a consequence, inadequate water intake can lead to several kidney problems ranging from uncomplicated urinary tract infections to kidney stones, acute kidney injury, and chronic disorders with high mortality rates. Challenges: Increasing water intake is an individual effort when self-behavior is the main reason for inadequate hydration status. When the environment is an obstacle, it might require complex changes in a concerted multidisciplinary effort from employers, health authorities, researchers, and governments. Prevention and Treatment: Strategies can be implemented at global, local, and individual levels. Global efforts include actions to decrease poverty and climate change consequences, while increasing access to safe water and sanitation. Local actions can improve working conditions and access to water and toilets to workers. At an individual level, self-monitoring through regular observation of thirst sensation, acute weight loss, urine frequency, and urine color are recommended tools to monitor hydration status.

Clinical Background: Automobile accidents constitute one of the main causes of morbidity and mortality worldwide. Kidney injury related to automobile accidents occurs through several mechanisms. Among the mechanisms are direct traumatic injury, rhabdomyolysis, acute renal failure, hypovolemic shock, and others. Kidney injuries after traffic accidents can have different forms of clinical presentation, which can include morphological and functional changes of the organ. Epidemiology: Annually, approximately 1.35 million individuals are fatal victims of motor vehicle accidents. Challenges: It is of the utmost importance to recognize and adequately manage kidney injuries secondary to automobile events, since their timely identification can prevent permanent damage to the organ and, at times, save lives. Prevention and Treatment: An approach with a focus on traffic safety is ideal for all users. The cornerstones of this approach are safe roads and road shoulders, adequate speeds, safe vehicles, and trained drivers. Kidney injury and death due to this condition can be prevented by effective and integrated traffic legislation. After the occurrence of traffic accidents, effective emergency care is vital. Thus, a series of urgent actions are essential to provide assistance to the injured individual. In patients who are victims of car accidents and develop acute kidney injury and rhabdomyolysis, a timely diagnosis is extremely important to be able to offer assistance to the patient still in the early stages.