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Kidney transplant recipients remain at high cardiovascular risk despite improved graft and patient survival. Physical inactivity, weight gain, and suboptimal dietary habits are common after transplantation and may contribute to this burden. The KT-LIFESTYLE trial is a pragmatic, multicentre, prospective, open-label randomized controlled study designed to evaluate whether a structured lifestyle intervention can reduce cardiovascular risk in kidney transplant recipients. Participants will be randomized 1:1 to individualized exercise prescription plus tailored dietary counselling or standard lifestyle advice. The intervention combines multidisciplinary assessment, individualized exercise programming, motivational interviewing, and nutritional counselling integrated into routine transplant follow-up. The primary endpoint is the change in 10-year cardiovascular risk, assessed by the Framingham score over 36 months. Secondary outcomes include renal function estimated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation estimated glomerular filtration rate, body composition, inflammatory markers, gut microbiota composition, health-related quality of life, adherence to physical activity and dietary counselling, hospital admissions, major adverse cardiovascular events, and all-cause mortality. KT-LIFESTYLE aims to provide evidence on the effectiveness and feasibility of a long-term lifestyle intervention after kidney transplantation. The study may also clarify the mechanisms through which lifestyle modification influences cardiovascular risk, inflammation, body composition, and gut microbiota in this population.Clinical trials registration number: NCT06806670.
Atrial fibrillation (AF) is frequent in dialysis patients and associates with a substantial increase in stroke, cardiovascular events, and mortality, yet the net clinical benefit of oral anticoagulation (OAC) in this setting remains uncertain. Dialysis patients were excluded from pivotal vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) trials, and observational data are conflicting. The PRO position argues that in carefully selected patients with very high thromboembolic risk and acceptable bleeding risk, thromboembolic prophylaxis-pharmacological with OAC or non-pharmacological with left atrial appendage closure (LAAC)-can reduce stroke and possibly mortality. This view is supported by several cohort studies suggesting lower ischemic events and improved survival when OAC is maintained, and international normalized ratio control is good, and by emerging data that LAAC may offer similar stroke protection with less bleeding and lower mortality than OAC or no prophylaxis. The CON position stresses that many large studies show no clear stroke reduction and consistently higher major bleeding with warfarin versus no OAC, that small randomized controlled trials of DOACs versus VKAs reveal very high absolute bleeding without clear efficacy gains, and that VKAs may aggravate vascular calcification. Both positions agree on the need for individualized, shared decision-making and for adequately powered randomized trials comparing OAC and LAAC with no specific therapy in dialysis AF.
Adults with cardiovascular-kidney-metabolic (CKM) syndrome, characterized by interactions among metabolic, chronic kidney disease (CKD) and cardiovascular disease, face a high symptomatic burden, mortality risk and costs. Dapagliflozin has demonstrated significant benefits in adults with type 2 diabetes (T2D), heart failure (HF) and CKD. This modelling study aimed to estimate the clinical events and associated healthcare costs of dapagliflozin in adults with CKM syndrome from the Spanish National Health System (NHS) perspective over 3 years. A cost-offset model compared clinical events and their associated costs of 100,000 adults with CKM syndrome treated with dapagliflozin added to standard of care (SoC) and SoC alone. Clinical event rates were derived from dapagliflozin trials (DECLARE-TIMI 58, DAPA-HF, DAPA-CKD and DELIVER), and costs from national databases and literature. Robustness was assessed through scenario and subgroup analyses. The carbon dioxide (CO2) footprint impact associated with hospitalization for heart failure (HF), urgent HF visits and end-stage renal disease was assessed in an exploratory analysis. Over 3 years, dapagliflozin added to SoC prevented 10,151 clinical events (2,822 cardiovascular; 5,519 renal; 1,810 deaths) and saved €159.11 million per 100,000 adults compared to SoC, mainly by preventing end-stage renal disease (69%; -€110.32 million). Considering drug acquisition cost, the net cost saving was €52.47 million per 100,000 adults, representing a €1.49 return for every euro invested in dapagliflozin. Scenario analyses were consistent with the base case. Subgroup analyses showed greater benefits in adults with multiple comorbidities, especially those with all three conditions. The CO2 footprint reduction was 2,176 tons of CO2 per 100,000 adults. Dapagliflozin in adults with CKM syndrome reduced the incidence of clinical events, generating cost savings and improving the sustainability of the Spanish NHS.
Reflex anuria is a rare phenomenon characterized by the cessation of urine production from both kidneys, triggered by a painful stimulus or trauma to the urinary tract (kidney-ureter), in the absence of other explanatory events such as sepsis, shock or hypovolemia. A case of prolonged anuria and acute renal failure in a 21-year-old male with a history of lower back pain triggered by unilateral ureteral obstruction (stone) is presented. A contralateral renoureteral obstructive component has been ruled out. This led to the need for renal replacement therapy with hemodialysis and the placement of a double "J" ureteral stent. A few hours after treatment, recovery of urinary output and improvement in glomerular filtration rate were observed, making this one of the few cases reported with these characteristics. La anuria refleja es un fenómeno infrecuente y caracterizado por el cese en la producción de orina de ambos riñones, desencadenado por un estímulo que genere dolor o trauma en la vía urinaria (riñón-uréter), en ausencia de otros eventos que lo expliquen, como sepsis, shock o hipovolemia. Se presenta el caso de anuria prolongada e insuficiencia renal aguda en un varón de 21 años con antecedente de dolor lumbar desencadenado por una obstrucción ureteral (lito) unilateral, habiéndose descartado componente obstructivo renoureteral contralateral, que lo llevó al requerimiento sustitutivo renal mediante hemodiálisis además de colocación de catéter doble "J" ureteral. A las pocas horas del tratamiento realizado, se evidenció recuperación del débito urinario y mejoría del filtrado glomerular, siendo uno de los pocos casos reportados con estas características.
Creatinine increases during acute heart failure treatment may occur in the setting of hemoconcentration and decongestion, but the ranges of creatinine increase associated with lower risk, safety, or harm remain poorly defined. We studied 2043 consecutive hospitalizations for acute heart failure between 2014 and 2021. The main exposures were the maximum in-hospital increase in creatinine (ΔCr) and hemoglobin change (ΔHb). Models used restricted cubic splines for ΔCr, continuous ΔHb, and their interaction. Mortality and composite endpoints were analyzed with Cox models; first all-cause and heart failure rehospitalization were analyzed using Fine-Gray models. The primary ΔHb contrast was the observed interquartile range reporting contrast (+1.3 g/dL), rather than a subgroup cutoff. The median age was 77 [69-83] years and 57.6% of hospitalizations involved male patients. In the context of hemoconcentration, ΔCr ranges associated with lower risk were identified for mortality (0.10-0.18 mg/dL), first all-cause rehospitalization (0.06-0.25 mg/dL), first heart failure rehospitalization (0.00-0.32 mg/dL), and the composite of death or first all-cause rehospitalization (0.10-0.23 mg/dL). Harm thresholds were observed above 0.61, 0.98, and 0.91 mg/dL, respectively; no harm threshold was identified for heart failure rehospitalization. Among patients hospitalized with acute heart failure who achieved hemoconcentration, small creatinine increases were associated with lower risk, whereas larger increases were associated with a loss of benefit and, for some endpoints, harm. These findings support a continuous, context-dependent interpretation of worsening renal function during decongestive therapy.
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Mantle cell lymphoma (MCL) rarely causes glomerular disease. While immune complex-mediated and infiltrative lesions predominate, podocytopathies are exceptionally rare. We report a case of reversible focal segmental glomerulosclerosis (FSGS) occurring in the setting of blastoid-variant MCL, highlighting the paraneoplastic nature of the podocyte injury. A 69-year-old man presented with nephrotic syndrome and dialysis-dependent acute kidney injury (AKI). Kidney biopsy revealed FSGS. Subsequent diagnostic evaluation uncovered blastoid-variant MCL. Following lymphoma-directed chemotherapy, nephrotic syndrome resolved and renal function recovered, supporting a paraneoplastic mechanism of podocyte injury. This case underscores that MCL can induce a reversible paraneoplastic podocytopathy mimicking primary FSGS. Recognition of this entity is crucial to avoid unnecessary immunosuppression and to prompt early evaluation for underlying malignancy. Treating the neoplasm can result in renal recovery, emphasizing the functional connection between tumor activity and podocyte injury.
Arginine vasopressin is primarily recognized as an osmoregulatory hormone; however, its contribution to vascular tone and blood pressure regulation under basal and hypertensive conditions remains debated. This study examined the effects of vasopressin deficiency induced by neurointermediate pituitary lobectomy in Wistar and spontaneously hypertensive rats, compared with sham-operated controls. Water intake, urine output, plasma vasopressin and oxytocin levels, blood pressure, and heart rate were evaluated over time. Neurointermediate pituitary lobectomy produced transient diabetes insipidus followed by the restoration of water balance, while plasma vasopressin and oxytocin levels remained markedly reduced at 3- and 90-days post-surgery (p < 0.0001 vs. Sham). This deficiency was associated with sustained hypotension in Wistar rats (~27 mmHg; p < 0.05) and normalized systolic blood pressure in spontaneously hypertensive rats (~50 mmHg; p < 0.001). Acute and chronic vasopressin and oxytocin deficiency causes transient diabetes insipidus, persistent hypotension in normotensive rats, and attenuated hypertension in spontaneously hypertensive rats with unchanged heart rate, demonstrating that vasopressin plays a key role in regulating both basal and hypertensive blood pressure.
Protein-energy wasting is common in critically ill patients with acute kidney injury. Renal replacement therapy (RRT) has negative effects on nutrient balance and can further deteriorate nutritional status. The prescribed dialysis modality is a determinant of micronutrient and amino acid losses, with continuous RRT (CRRT) leading to the greatest losses. It is essential to assess and monitor the nutritional status in any RRT modality, implementing conventional nutritional assessment tools (SGA) and technologies for monitoring hydration and body composition (BIA, US). Nutritional therapy should be initiated early via the enteral route, and if nutritional requirements cannot be achieved, parenteral nutrition can be implemented. Energy requirements range from 20-30 kcal/kg/day (quantifying nutritional/non-nutritional calories), and protein intake is 1.3-1.5 g/kg/day with conventional intermittent RRT, and 1.5-1.7 g/kg/day with prolonged intermittent and continuous RRT.
Incremental dialysis, applicable to both hemodialysis (HD) and peritoneal dialysis (PD), is an individualized approach. It consists of offering a dialysis dose adjusted to the patient's residual renal function (RRF) in order to achieve the same clinical outcomes observed with full doses, while improving quality of life and reducing exposure to the risks associated with the dialysis procedure. This Position Statement of the Brazilian Society of Nephrology (SBN) aims to present recommendations on eligibility criteria, prescription, monitoring, and safe implementation, as well as to report the clinical results already described with this approach. Eligibility includes a residual diuresis ≥ 500 mL/24h in HD or ≥ 100 mL/24h in PD and/or a urea clearance (Kru) ≥ 2.0 mL/min/1.73 m2, as well as clinical stability and adequate volume and metabolic control. Monitoring with regular reassessment of RRF is recommended. Indicators for dialysis dose intensification include hypervolemia, uremic symptoms, worsening of nutritional status, hyperkalemia, hyperphosphatemia, refractory metabolic acidosis, and laboratory findings of subdialysis. The implementation of incremental dialysis requires well-defined institutional protocols, systematic education of patients and families, a properly trained multidisciplinary team, and a shared decision-making process. Scientific evidence suggests that incremental dialysis is safe and effective, attenuating the loss of RRF, and can reduce hospitalizations, while maintaining or improving quality of life, without increasing mortality. Additionally, it may contribute to cost reduction and greater sustainability of the healthcare system, and should be considered an integral part of the contemporary therapeutic armamentarium. A diálise incremental, aplicável tanto à hemodiálise (HD) quanto à diálise peritoneal (DP), é uma abordagem individualizada que consiste em oferecer a dose de diálise ajustada à função renal residual (FRR) do paciente, de modo a alcançar os mesmos desfechos clínicos observados com doses plenas, porém, oferecendo melhor qualidade de vida e menor exposição aos riscos associados ao procedimento dialítico. Este Posicionamento da Sociedade Brasileira de Nefrologia (SBN) tem como objetivo apresentar recomendações sobre critérios de elegibilidade, prescrição, monitorização e implementação segura, bem como relatar os resultados clínicos já descritos com essa abordagem. A elegibilidade inclui uma diurese residual ≥ 500 mL/24h na HD ou ≥ 100 mL/24h na DP e/ou um clearance de ureia (Kru) ≥ 2,0 mL/min/1,73 m2, além de estabilidade clínica e controle volêmico e metabólico. Recomenda-se a monitorização com reavaliação regular da FRR. Os indicadores para intensificação da dose dialítica incluem hipervolemia, sintomas urêmicos, piora do estado nutricional, hiperpotassemia, hiperfosfatemia e acidose metabólica refratária, além de quadro laboratorial de subdiálise. A implementação da diálise incremental demanda protocolos institucionais bem definidos, educação sistemática de pacientes e familiares, uma equipe multiprofissional devidamente capacitada e um processo de decisão compartilhada. As evidências científicas sugerem que a diálise incremental é segura e efetiva, atenuando a perda da FRR, podendo reduzir hospitalizações, mantendo ou melhorando a qualidade de vida, sem aumentar a mortalidade. Adicionalmente, pode contribuir para a redução de custos e para a maior sustentabilidade do sistema de saúde, devendo ser considerada parte integrante do arsenal terapêutico contemporâneo.
Treating autosomal dominant polycystic kidney disease (ADPKD) has always been a challenge because the disease is too complex for single-target drugs, which are often held back by side effects. This narrative review explores a different strategy: using plant-derived polyphenols to target multiple disease pathways at the same time. Looking at research from 2005 to 2026, we break down how key compounds like resveratrol, curcumin, naringenin, quercetin, and epigallocatechin-3-gallate (EGCG) actually work. Preclinical studies show these molecules can slow down cyst growth by tackling inflammation, rapid cell division, and tissue scarring all at once, while also resetting the skewed energy metabolism of cystic cells. Some mechanisms are strikingly specific, such as naringenin's direct interaction with polycystin-2 and quercetin's ability to clear senescent cells. Yet, the real-world hurdle is poor absorption; a recent clinical trial with standard curcumin fell short simply because the compound could not reach the kidneys in high enough concentrations. Moving forward, the field needs to focus on testing these compounds in realistic animal models, designing smart nanoformulations to improve bioavailability, and exploring combinations that could safely complement current therapies like tolvaptan.
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Since the publication of the previous consensus document on point-of-care lung ultrasound (PoCLUS) in 2012, new evidence has emerged. This consensus aims to update current recommendations by focusing on the clinical applications of PoCLUS as a standalone tool, while acknowledging that this focused approach represents a necessary preliminary step toward its effective integration with other organ-specific ultrasound examinations and complementary diagnostic modalities. A Delphi-based consensus process was conducted under the supervision of a Steering Committee (five voting members) and a Delphi Committee (two non-voting members). Experts were selected according to strict predefined criteria based on highly impactful scientific output and were assigned to specific domains. A structured literature review covering publications from 2012 to 2025 was performed. Statements were drafted, discussed through multiple online rounds, and iteratively refined. Anonymous voting was conducted for each statement using a predefined agreement threshold (80% full agreement); abstentions were excluded from percentage calculations. The process adhered to ACCORD recommendations. Twenty-one experts participated in the entire process. A total of 1775 new publications were reviewed, including 892 original studies, 62 meta-analyses, 38 guidelines, 162 original studies discussed in the first consensus. New statements were developed across multiple domains addressing ultrasound signs, technical aspects, monitoring strategies, and clinical applications of PoCLUS. Consensus was achieved for 83 statements following iterative discussion and voting rounds. This updated consensus provides evidence-based recommendations on the use of PoCLUS in clinical practice, defining its strengths and limitations as a standalone tool and identifying areas requiring further investigation.
Tuberculosis (TB) is a significant clinical and public health problem for patients with chronic kidney disease (CKD), particularly those requiring hemodialysis (HD). This population is particularly vulnerable due to the profound alteration of the immune response characteristic of CKD, which significantly increases the risk of reactivation of latent TB. The Mantoux test, for example, is not suitable for diagnosis due to the low sensitivity of these patients and the high rate of false positives due to vaccination. In contrast, IGRAs (interferon-gamma release assays) show superior sensitivity and specificity for diagnosing latent TB. Similarly, the high frequency of extrapulmonary manifestations of TB in dialysis patients must be taken into account, as this can lead to a delay in diagnosis and therefore favor nosocomial transmission. This is why it is essential to maintain a high level of clinical suspicion and make appropriate use of the available complementary tests in order to establish an early diagnosis and initiate targeted treatment to reduce morbidity and mortality. Regarding treatment in the general population, short, oral regimens are recommended for both drug-susceptible and drug-resistant TB in eligible individuals; however, there are no formal recommendations on the efficacy and/or safety of these regimens for the treatment of pulmonary tuberculosis in hemodialysis patients.
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