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

Renal failure is considered a life-limiting CONDITION that often requires Renal Replacement Therapy, such as dialysis or kidney transplantation. Dialysis can effectively relieve symptoms and prolong life, but its withdrawal results in severe complications and death. The decision to discontinue or refuse to dialysis must be made collaboratively by the patient, family, and healthcare team, considering the clinical condition, life expectancy, symptom burden, and individual preferences. This decision, involving clinical, bioethical, and legal aspects, is complex and requires a collective understanding of the process. Withdrawal to dialysis presents a challenge for nephrologists and the healthcare team due to the lack of clear guidelines, which can compromis the safety of the process and the patient's dignity. In this position statement, the Brazilian Society of Nephrology recommends a process for dialysis withdrawal or refusal, including identifying eligible patients, applying prognostic assessment tools, shared decision-making, advance care planning, and offering dialysis alternatives. The decision must be consensual, allowing adequate time for reflection, and healthcare services must provide comprehensive management of physical, psychological, social, and spiritual symptoms, as well as end-of-life care. Proper documentation in medical records is essential to ensure process transparency. Therefore, refusal or withdrawal to dialysis should be an informed decision that respects individual autonomy and balances clinical, bioethical, spiritual, and legal considerations.

Introduction: Acute kidney disease (AKD) is defined as functional and/or structural abnormalities of kidneys with health implications and a duration of ≤90 days. This study aimed to evaluate AKD as a more appropriate approach to these conditions for which we used a cohort of COVID-19 patients in whom kidney impairment is expressed by proteinuria and/or loss of function.

Methods: Observational, prospective, longitudinal, multinational cohort study conducted across five Latin American countries. Adult patients with diagnosis of COVID-19 were included. Upon hospital admission, urinalysis or urine strip test was performed. If protein was not detected, a follow-up search was conducted five days later. Patients were classified in four AKD categories: non-kidney disease, proteinuria only, acute kidney injury (AKI) only, and proteinuria and AKI.

Results: Three hundred and sixty patients were included. AKD was present in 273 (75.8%), of whom 142 (52.0%) had only proteinuria, 11 (4.1%) had AKI without proteinuria, and 120 (43.9%) had both proteinuria and AKI. Overall, proteinuria with or without AKI was present in 262 patients (72.8%). AKI with or without proteinuria occurred in 131 patients (36.4%). AKI was mainly severe, non-oliguric, and hospital-acquired. In-hospital mortality increased with the severity of AKD: non-kidney disease 9.5%, proteinuria only 22.8%, AKI only 56.7%, and proteinuria plus AKI 53.0% (p = 0.001).

Conclusions: Our data endorse a comprehensive approach based on the concept of AKD. This integrative approach, encompassing the structural and functional continuum of AKI, AKD, and CKD, enables timely interventions and the implementation of preventive and therapeutic strategies.

Introduction: Chronic Kidney Disease is associated, due to several factors linked to the disease, with a high rate of psychiatric disorders. With the COVID-19 pandemic, evidence suggests an increase in the already high prevalence of these disorders in chronic kidney patients. It is assumed that early diagnosis of psychiatric disorders can contribute to the development of treatment strategies, reducing the morbidity and mortality caused by the disorders.

Objective: To determine the prevalence of psychiatric disorders in hemodialysis patients, evaluating the association of COVID-19 and some variables with the occurrence of these disorders.

Methodology: Cross-sectional study carried out in a nephrology clinic in Bahia, in 2023. The sample consisted of 119 patients chosen by simple randomization. Patients were evaluated by the Mini International Neuropsychiatric Interview, an internationally validated interview.

Results: Sixty-two patients (52.1%) had at least one psychiatric disorder. The most common were Generalized Anxiety Disorder (GAD) (42%) and Major Depressive Episode (MDE) (18.5%). There was no association between COVID-19 diagnosis and any psychiatric disorder. Among the 58 patients who had COVID-19, men had a lower chance of developing some disorder (OR = 0.30; 95% CI [0.10-0.91]), as did patients with >5 years of treatment (OR = 0.17; 95% CI [0.05-0.61]).

Conclusions: The prevalence of psychiatric disorders is high. Among patients who had COVID-19, women had more psychiatric disorders, as well as, specifically, more GAD, and patients who had more than 5 years of treatment had a significantly lower chance of developing some psychiatric disorder.

Introduction: Cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CABG) often causes kidney dysfunction and increases morbidity and mortality.

Aims: To evaluate the effects of CPB on kidney structures of patients submitted to CABG using serum and urinary biomarkers.

Methods: This prospective study included patients who underwent CABG over a 14-month period. Data related to clinical, surgical, and laboratory were collected. The glomerular filtration rate was estimated using the CKD-EPI equation. The urinary biomarkers trialed were nephrin, KIM-1, MCP-1, Syndecan-1, and NGAL.

Results: Out of 30 patients enrolled, 22 were assessed. The mean age was 65 years and most were male. During CABG, the On-pump group had increased urinary nephrin (p = 0.007) and urinary (p = 0.036) and serum NGAL (p = 0.030) levels compared to the Off-pump group. Moreover, intraoperatively, in the On-Pump clusters, the urinary NGAL was correlated with the decrease of glomerular filtration rate in the first 48 hours after CABG (Rho = - 0.838, p = 0.009). There was no statistical difference in clinical and surgical aspects between groups according to use of CBP during CABG.

Conclusion: CBP procedure used during CABG was associated with relevant effects on kidney structure, such as podocyte and tubular injury. Urinary NGAL was able to predict an impairment of glomerular filtration 48 hours after CABG.

This narrative review aims to present the current information on cardiovascular diseases, focusing on hypertension (HT) and associated comorbidities in Latin American and Caribbean (LAC) countries, and compare successful global studies on the subject. LAC countries have unique characteristics, including high socioeconomic inequality and unequal access to health and urban infrastructure. At the same time, urbanization and economic growth have contributed to the proliferation of unhealthy lifestyles. HT is the primary risk factor for cardiovascular morbidity and mortality, affecting between 20 and 40% of the population in this region. It is of utmost importance to address the alarmingly low rates of awareness, treatment, and control of HT. This is further compounded by the rising prevalence of patients with metabolic disorders. Obesity and HT are two pivotal drivers of the cardio-renal disease continuum because patients with uncontrolled cardiovascular risk in mid-life are likely to be at increased risk of clinical cardiovascular and chronic kidney disease in old age. A series of recommended actions include developing population-wide prevention and control programs, implementing opportunistic screening, and using out-of-office blood pressure measurements. It is imperative that primary care and treatment adherence are reinforced. Moreover, accessibility and optimal distribution of efficacious, cost-effective antihypertensive medications are of paramount importance. Insights from high-income countries should be effectively conveyed to LAC countries, respecting the particularities of the regions involved.

Introduction: IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis, with a variable clinical course. This study aimed to evaluate real-world kidney outcomes in children with IgAN and compare these with predictions from the International IgAN Prediction Tool for children (IIgAN-PT).

Methods: A single-center, longitudinal retrospective study was conducted on pediatric patients diagnosed with IgAN from 2010 to 2022. Data on clinical, laboratory, and histological parameters were analyzed. The IIgAN-PT score was calculated for each patient at biopsy and one year after biopsy. The primary outcome was a composite endpoint of ≥30% eGFR decrease or progression to end stage kidney disease (ESKD).

Results: Among 23 patients (57% male, median age at biopsy 13.8 years), MEST-C scores showed M1 in 87%, E1 in 22%, S1 in 39%, T1/2 in 13%, and C1 in 26%. During a median 3.1-year follow-up, 26% reached the primary outcome, while the median predicted risk based on IIgAN-PT was 6.5%. Additionally, 57% experienced eGFR decline (annual median decline of 5.6 mL/min/1.73 m2). Application of the updated IIgAN-PT one-year post-biopsy (n = 13) resulted in a median predicted risk of 1.79%, while 23% met the primary outcome.

Conclusion: The observed eGFR decline or progression to ESKD was higher than predicted, highlighting the need for early diagnosis, monitoring, and treatment. Small-scale studies like ours underscore the importance of early intervention and may inform the design of larger studies to improve the predictive ability of the IIgAN-PT tool in diverse clinical settings.

The concept of cardiovascular-kidney-metabolic health is based on the idea of a multifaceted interaction among several cardiovascular, renal, and meta-bolic factors. Alterations in this complex interaction have a significant impact on morbidity and mortality. The ramifications of poor cardiovascular-kidney-metabolic health are far-reaching, with a notable clinical impact. A considerable proportion of the population is affected by precarious cardiovascular, renal, and metabolic health, and indivi-duals with adverse social determinants of health endure an even greater burden. To this end, it is essential to develop an approach that incorporates metabolic staging and prioritizes lifelong prevention. Equally imperative is integrating the social determinants of health into care models for Cardiovascular-kidney-metabolic syndrome, facilitating patient-centered interdisciplinary care. The American Heart Association (AHA) provides guidelines on the definition, staging, paradigms, and holistic approaches to the management of patients with this syndrome. Furthermore, it offers a comprehensive framework for effectively and equitably improving the cardiovascular, kidney, and metabolic health of the population.

C3 glomerulopathy represents a heterogeneous group of glomerulopathies characterized by hyperactivity of the alternative complement pathway. Although the pathophysiology is incompletely understood, an association between this disease and monoclonal gammopathies is increasingly recognized, especially in older individuals. There is still some uncertainty regarding the best treatment for patients with monoclonal gammopathy-associated C3 glomerulopathy. However, recent evidence suggests that myeloma-targeted therapies are associated with improved renal outcomes compared with conservative or conventional immunosuppressive therapies. This case report describes the clinical course and long-term follow-up of a patient with monoclonal gammopathy-associated C3 glomerulonephritis treated with myeloma-targeted therapy.