Jornal brasileiro de nefrologia : 'orgao oficial de Sociedades Brasileira e Latino-Americana de Nefrologia最新文献

Introduction: Hemodialysis patients are at high cardiovascular risk, with sudden death being one of the leading cause of mortality. Sleep disorders are highly prevalent in this population, and obstructive sleep apnea (OSA) has been associated with poorer blood pressure control and cardiovascular damage.

Objective: To investigate the association between an intermediate or high risk of OSA and the occurrence of major cardiovascular events in hemodialysis patients.

Methods: This prospective multicenter cohort study was conducted in three hemodialysis clinics between May 2022 and May 2024. A total of 165 patients aged 18 to 75 years who had been undergoing hemodialysis for at least 6 months were included. Clinical, labora-tory, and sleep-related variables, were assessed, including OSA risk (STOP-Bang), sleep quality (Pittsburgh Sleep Quality Index), chronotype (Morningness-Eveningness Questionnaire), and the occurrence of major adverse cardiovascular events (MACE+). Patients were followed for 22 to 24 months.

Results: Overall 64.8% of patients were classified as being at an intermediate or high risk for OSA. This group showed a higher prevalence of diabetes and obesity, poorer sleep quality, more cases of chronic restless legs syndrome, and lower dialysis adequacy. The incidence of major cardiovascular events was significantly higher among patients at risk of OSA (17.0% vs. 5.2%; p = 0.03), with an independent association observed between OSA and sudden death (OR 1.18, 95% CI 1.01-1.39; p = 0.03). Other sleep disorders were not associated with increased cardiovascular risk.

Conclusion: Hemodialysis patients had a high risk of OSA, which was independently associated with adverse cardiovascular outcomes.

Introduction: Chronic kidney disease (CKD) patients are at increased risk of fracture. Whether the type of renal osteodystrophy (ROD) contributes to fracture risk is not currently established since bone biopsies are not frequently performed in clinical practice. We aimed to evaluate the association of ROD subtypes, bone biomarkers, and fracture risk assessed with the FRAX® tool with the occurrence of fractures in predialysis CKD patients.

Methods: Retrospective study with patients followed between 2014-2023. Blood tests, including bone-related biomarkers (BRB), and bone biopsies were performed at the beginning of follow-up. Data from dual x-ray absorptiometry (DXA) scan and clinically evident fractures were obtained from medical registries. Radiographs of the thoracic/lumbar spine were evaluated to detect vertebral fractures, and the FRAX® index without bone mineral density (BMD) was calculated with the web-based tool.

Results: Median follow-up time was 7.5 ± 3 years and 9.3% of the patients had a bone fracture, with an incidence of 12/1000 patient-year. Patients who had a fracture had higher phosphorus levels (4.1 mg/dL vs 3.5 mg/dL, p = 0.047). Histomorphometric subtypes and BRB were not associated with incidence of fractures nor with fracture risk assessed by FRAX®. There was a tendency for lower bone volume in the group with fractures (p = 0.057). FRAX® (without BMD), regardless of the inclusion of CKD as secondary osteoporosis, showed an overall good diagnostic accuracy for predicting fractures in predialysis CKD.

Conclusion: ROD subtypes were not associated with incidence of fractures in these patients. The discriminative ability of FRAX in this population emphasizes its usefulness in CKD predialysis patients.

Introduction: Recurrent urinary tract infections (UTIs) significantly impact the quality of life due to symptoms, effects on sexual activity, persistent pain, and recurrent antibiotic use. This systematic review and meta-analysis aimed to evaluate the efficacy of D-mannose in preventing recurrent UTIs.

Methods: In May 2024, we systematically searched PubMed, EMBASE, and the Cochrane Library for randomized controlled trials (RCTs) comparing D-mannose treatment with no intervention or standard antibiotic therapy in patients at high risk for recurrent UTI. We applied a random-effects model to pool relative risks (RR) and 95% confidence intervals (CI).

Results: We included 6 RCTs comprising 1,167 participants, of whom 534 received D-mannose and 521 (97.6%) were women. D-mannose was not associated with a reduction in recurrent UTI compared with control (RR: 0.57, 95% CI 0.29 - 1.15; p < 0.01) or antibiotics (RR: 0.39, 95% CI 0.12 - 1.25; p < 0.01). Further analyses showed that D-mannose did not improve outcomes in a subgroup of postmenopausal women.

Conclusion: In this meta-analysis of RCTs, D-mannose did not reduce the incidence of recurrent UTIs compared with control or antibiotics in high-risk patients.

Introduction: Chronic corticosteroid use, even at low doses, is associated with well-known adverse effects. However, steroid-free regimens after kidney transplantation (KT) have been linked to a higher incidence of acute rejection (AR), limiting their implementation to a few centers worldwide. In this study, we describe the pioneering experience of a Brazilian center that adopted a steroid-free immunosuppressive regimen in 2005 for patients at low to moderate immunological risk.

Methods: This single-center retrospective cohort study includes KT recipients who were submitted to steroid-free regimens between 2012 and 2019. The cohort was followed for three years in a real-world setting.

Results: A total of 562 patients were included, 71.4% male, with a median age of 48.1 years (IQR 35.5-58.6). Most (95.2%) received deceased donor allografts. All patients underwent induction therapy with antithymocyte globulin, and 82.2% received tacrolimus in combination with sirolimus or everolimus as maintenance therapy. After three years, 10.2% experienced treated AR episodes, with biopsy confirmation in 3.2%. Age (HR 0.946, 95% CI 0.923-0.969, p < 0.001) and HLA mismatches (HR 1.312, 95% CI 1.021-1.687, p = 0.034) were risk factors for rejection. Twenty-eight patients (5%) lost their grafts, and 5.7% died. Seventy-one patients (12.6%) required corticosteroid introduction over the years, with a median of 125.5 days (IQR 31.7-409) post-KT. The main reasons were perceived immunosuppressive regimen inefficacy (56.3%) and composition in a low-efficacy immunosuppressive regimen (18.6%).

Conclusion: Steroid-free immunosuppression was effective in low to moderate immunological risk KT recipients over a three-year follow-up period.

Introduction: Acute kidney injury (AKI) is a common complication following liver transplantation (LT). It is associated with factors such as perioperative hemodynamic instability, prolonged surgery, and use of nephrotoxic immunosuppressants, contributing to increased mortality, graft failure, and extended hospital stay.

Methods: A systematic search of the databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify observational studies with samples of at least 50 patients aged 18 years or older who underwent LT and analyzed AKI incidence post-procedure and assess long-term renal outcomes.

Results: A total of 30 studies with a total of 13,653 patients were included. The incidence of AKI post-LT was 46% (95% CI: 45%-47%), with significant variation across studies (24% to 84%) and high heterogeneity (I2 = 97%, p < 0.001). The pooled incidence of dialysis requirement post-LT was 10% (95% CI: 9%-11%), also highly variable across studies (2% to 36%) with high heterogeneity (I2 = 95%, p < 0.001). Common postoperative complications included prolonged mechanical ventilation, graft dysfunction, infections, and hypertension (HTN). Furthermore, the analysis highlighted significant AKI risk factors, such as HTN, diabetes, hyperlactatemia, hyperbilirubinemia, and prolonged hospitalization.

Conclusion: AKI and dialysis requirements are frequent complications following LT. Multiple risk factors, including HTN, diabetes, and prolonged hospitalization, are associated with an increased risk of AKI post-LT. The high incidence of AKI underscores the importance of early identification of at-risk patients and multidisciplinary approaches to improve outcomes.

Introduction: Podocytopathies are an important cause of nephrotic syndrome, and immunosuppression plays a pivotal role in disease management. The efficacy of biological agents such as rituximab (RTX), however, remains unclear, especially in adults. This study hypothesized that RTX is efficient and safe in the treatment of steroid-sensitive and steroid-resistant primary podocytopathies.

Method: A retrospective cohort study was conducted based on medical records before the first infusion of RTX (T0) and 1 to 3 months (T1) and 3 to 6 months after infusion (T2). Patients had biopsy-proven podocytopathies and received at least 500 mg of RTX. Individuals with secondary glomerular diseases were excluded.

Results: A total of 31 patients with a mean age at infusion of 32.9 years (SD 11.0) were included. At T2, remission was reached in 45.2%, with complete remission in 19.4%. Prior response to steroids was related to a better prognosis, with remission in up to 68.5% of these patients. Moreover, 20.0% of steroid-resistant patients reached adapted remission (≥ 35% proteinuria decrease + ≥ 20% serum albumin increase). Hypertension and previous use of calcineurin inhibitors were not predictors of clinical response. The most frequent adverse events were infection (12.9%) and rash (9.7%).

Discussion: In conclusion, our results suggest that RTX is a useful therapeutic option not only for steroid-sensitive podocytopathies, but also in selected steroid-resistant cases, determining a proteinuria decrease that can contribute positively to the clinical management of such glomerular diseases. RTX was generally efficient and well tolerated in this adult cohort.