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.
Chronic kidney disease (CKD) is a multifactorial clinical condition consisting of a complex set of manifestations that, in addition to renal involvement, involve multiple organ systems. Endocrine disorders are particularly common in patients with CKD and require proper management given their multisystemic effects. The main endocrine disorder found in patients with kidney disease is alterations in the calcium-phosphorus (PTH) axis, which is why nephrologists often focus exclusively on managing this condition, neglecting any other endocrine alterations observed in this patient group. Thyroid involvement appears worthy of attention both in terms of its numerical frequency and therapeutic implications. The aim of this review is to enable a proper assessment of thyroid disease in patients with kidney disease and to provide the tools for appropriate assessment and treatment.
Acute pancreatitis is a rare condition in pediatric patients, but there has been a considerable increase in cases and complications in recent years that, according to the literature, may reach up to 30% of cases. The present study aimed to determine whether the variables of sex, age group, etiology, nutritional status, lipase level, albumin level, and leukocyte count were associated with the development of early complications in pediatric patients diagnosed with acute pancreatitis. A retrospective study was carried out at the Hospital para el Niño Poblano, within the time frame of July 2014 and July 2024. The medical records of patients from 0 to 17 years 11 months of age, who met the diagnostic criteria for acute pancreatitis, were analyzed. JASP software was utilized for the statistical analysis, applying odds ratio (OR) to identify possible risk factors. A total of 143 patients were included, with a slight predominance of females (51%, n = 73). Of the local complications, pancreatic necrosis was documented in 16% (n = 23) and acute peripancreatic fluid collection in 12.6% (n = 18). The most frequent complications were cardiac (51.75%), renal (31.47%), pulmonary (18.18%), and metabolic (16.08%). Significant risk factors for the development of early complications in pediatric patients with acute pancreatitis were identified. These findings may support early assessment of disease severity and guide timely interventions.
Sleep-disordered breathing (SDB), comprising obstructive sleep apnea (OSA) and central sleep apnea (CSA), is highly prevalent in heart failure (HF) and is associated with adverse remodeling, arrhythmias, and worse clinical outcomes. However, despite improvements in physiological markers, treatment of SDB has not consistently translated into reductions in mortality or HF hospitalization. In OSA, continuous positive airway pressure (CPAP) improves symptoms, oxygenation, and selected physiological parameters, but evidence in HF is derived largely from small, short-term trials and reductions in hard clinical outcomes have not been demonstrated. Emerging data suggest that conventional metrics such as the apnea-hypopnea index incompletely capture cardiovascular risk and that physiological markers, including hypoxic burden and autonomic responses, may better identify high-risk phenotypes likely to benefit from treatment. Alternative therapies, including mandibular advancement devices, weight-loss strategies, hypoglossal nerve stimulation, and metabolic interventions, can improve OSA severity, although HF-specific outcome data remain limited. In CSA, which is often secondary to HF and reflects ventilatory-control instability, therapies such as CPAP and adaptive servo-ventilation have shown neutral or adverse long-term outcomes despite improvements in surrogate markers, suggesting that CSA may represent a marker of HF severity or a compensatory response rather than a straightforward therapeutic target. Emerging evidence also indicates that respiratory instability in HF extends beyond conventional nocturnal assessments. Collectively, these findings support phenotype-specific, precision-based approaches that integrate HF phenotype, physiological markers, and patient characteristics to optimize SDB management in HF.
To describe and compare institutional patterns of vascular access device use, dwell time, and failure, and to explore their implications for nursing practice. Retrospective multicentre observational cohort study. Routinely collected nursing records of vascular access device insertion and removal were analysed from seven public hospitals over a one-year period. All devices inserted in hospitalised adults were included, with each device treated as an independent episode. Device failure was defined as removal due to any complication. Device use, dwell time, and failure were summarised by device type and institution. Time-to-event analyses were used to describe complication-free device survival. More than 200,000 vascular access device episodes were identified, of which ~85,000 had complete data for dwell time and removal reason. Short peripheral intravenous catheters accounted for the majority of devices and reportedly had the shortest dwell time and highest proportion of failure. Medium and long duration devices remained in situ for longer periods and had lower rates of failure, although their use varied substantially between hospitals. Marked inter-institutional variability was observed in device mix, reported dwell time, complications, and data completeness, with substantial missingness in key variables across hospitals. Substantial variability exists in vascular access device use, duration, and failure across hospitals. The use of short peripheral intravenous catheters dominates clinical practice despite early failure and limited alignment with expected treatment duration. These findings highlight opportunities to improve device selection and support more consistent, evidence-based nursing practice, but also underline the need to strengthen institutional data infrastructure and standardise vascular access documentation to enable reliable benchmarking and quality improvement. Optimising vascular access device selection according to anticipated treatment duration may reduce repeated insertions, improve patient comfort, and decrease nursing workload associated with device failure. What problem did the study address? ○ Inconsistent use, duration, and documentation of vascular access devices in routine hospital nursing practice. What were the main findings? ○ Short peripheral intravenous catheters were widely used and failed early, while longer-duration devices were used less frequently despite lower failure rates. Important gaps in data completeness were also identified across hospitals, particularly for dwell time and removal outcomes. Where and whom will the research have an impact? ○ The findings are relevant to nurses, nurse leaders, and healthcare organisations involved in vascular access decision-making and quality improvement. This study is reported in accordance with the STROBE guidelines for observational studies. No patient or public contribution.
To evaluate adherence to the recommendations of the EXTRIP (Extracorporeal Treatments In Poisoning) group for the indication of renal replacement therapy (RRT) in patients with lithium poisoning, determine factors associated with the use of this therapeutic method, and analyze its impact on clinical outcomes. Multicenter international observational study including all episodes of lithium poisoning treated from 2015 through 2022 in emergency departments (ED) and clinical toxicology units (CTU) of 23 tertiary referral centers in Spain, Ireland, and Switzerland. Events were retrospectively classified according to EXTRIP criteria as RRT recommended, suggested, or not recommended. Adherence to these recommendations and their association with clinical outcomes were analyzed using uni- and multivariate analyses. A total of 548 episodes of lithium poisoning were analyzed, of which 119 (21.7%) received RRT. According to EXTRIP criteria, RRT was recommended in 161 episodes (29.4%), suggested in 137 (25%), and not recommended in 250 (45.6%). Overall adherence to EXTRIP was 77.2%, and 69.6% when considering only strict indications. No significant differences were observed between adherent and non-adherent groups in the incidence of SILENT (Syndrome of Irreversible Lithium-Effectuated Neurotoxicity) at 60 days (7.1% vs 5.6%), need for critical care admission (16.8% vs 16.1%), or in-hospital mortality (3.3% vs 5.6%). Peak lithium concentration [3.45 (SD, 1.53) vs 2.05 (SD, 0.71) mEq/L; P < .001], decreased level of consciousness [49 (41.2%) vs 92 (21.4%); P < .001], and presence of atrioventricular block [6 (5.0%) vs 5 (1.2%); P = .008] were independent predictors for performing RRT. Adherence to EXTRIP recommendations was moderate to high but was not associated with improved clinical outcomes. These findings support an individualized approach based on clinical assessment when indicating RRT and suggest the need to refine EXTRIP criteria to improve applicability in real-world practice. Evaluar el grado de adherencia a las recomendaciones del grupo EXTRIP (Extracorporeal Treatments In Poisoning) para la indicación de terapia de reemplazo renal (TRR) en pacientes con intoxicación por litio, así como determinar los factores asociados al uso del citado método terapéutico y analizar su impacto en el desenlace clínico. Estudio observacional multicéntrico internacional que incluyó todos los episodios de intoxicación por litio atendidos entre 2015 y 2022 en los servicios de urgencias (SU) y unidades de toxicología clínica (UTC) de 23 hospitales de tercer nivel de España, Irlanda y Suiza. Los episodios se clasificaron retrospectivamente según los criterios EXTRIP en TRR recomendada, sugerida o no recomendada. Se analizó la adherencia a dichas recomendaciones y su asociación con los desenlaces clínicos mediante análisis univariable y multivariable. Se analizaron 548 episodios, 119 (21,7%) recibieron TRR. Según los criterios EXTRIP, la TRR estaba recomendada en 161 episodios (29,4%), sugerida en 137 (25%) y no recomendada en 250 (45,6%). La adherencia global a EXTRIP fue del 77,2%, y del 69,6% al considerar únicamente las indicaciones estrictas. No se observaron diferencias significativas entre adherentes y no adherentes en la incidencia de síndrome de monotoxicidad irreversible por litio (SILENT) a los 60 días (7,1% vs. 5,6%), necesidad de ingreso en unidades de críticos (16,8% vs. 16,1%) ni mortalidad hospitalaria (3,3% vs. 5,6%). La concentración pico de litio [3,45 (DE 1,53) vs. 2,05 (DE 0,71) mEq/L, p < 0,001], la disminución del nivel de consciencia [49 (41,2%) vs. 92 (21,4%), p < 0,001] y la presencia de bloqueo auriculoventricular [6 (DE 5,0%) vs. 5 (DE 1,2%), p = 0,008], fueron predictores independientes para la realización de TRR. La adherencia a las recomendaciones de EXTRIP fue moderada-alta, pero no se relacionó con un mejor desenlace clínico. Estos hallazgos apoyan un enfoque individualizado basado en la valoración clínica para indicar la TRR y orientan a la necesidad de refinar los criterios EXTRIP para mejorar su aplicabilidad en la práctica real.
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.
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.
Anemia in chronic kidney disease (CKD) remains highly prevalent and is strongly associated with increased cardiovascular morbidity, mortality, and impaired quality of life. The Anemia Working Group of the Spanish Society of Nephrology reviews the KDIGO 2026 anemia guideline, structured into 4 chapters, integrating national epidemiological data and the regulatory framework of the Spanish National Health System to contextualize its implementation. The guideline introduces substantial updates, particularly in iron therapy strategies, the role of hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs), and the systematic assessment of treatment resistance. Iron deficiency is reclassified as 'systemic deficiency' or 'iron-restricted erythropoiesis', reinforcing a proactive intravenous iron approach in hemodialysis, supported by the PIVOTAL trial. Broader thresholds for initiating iron therapy in non-dialysis CKD are proposed, although uncertainties persist regarding upper ferritin and transferrin saturation limits. The guideline emphasizes individualized selection of the administration route and recommends withholding iron during systemic infections. Notably, treatment of marked iron deficiency without anemia is now considered. Erythropoiesis-stimulating agents remain first-line therapy once alternative causes are excluded and iron deficiency corrected. Hemoglobin targets remain < 11.5 g/dL, with individualized initiation between 8.5 and 10 g/dL depending on cardiovascular risk, symptoms, and transfusion needs, with slightly lower thresholds in dialysis (≥9-10 g/dL). The guideline stresses using the lowest effective erythropoiesis-stimulating agent or HIF-PHI dose, with adjustments every 4 weeks. HIF-PHIs, such as roxadustat, are reserved for non-dialysis CKD when erythropoiesis-stimulating agents are unsuitable, given potential risks and limited long-term data. Finally, Patient Blood Management strategies are promoted to reduce transfusions, particularly in kidney transplant candidates. This position statement underscores the importance of adapting international recommendations to Spanish clinical practice, prioritizing safety, individualized care, and shared decision-making.
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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.
Premature ovarian insufficiency (POI) is a major long-term adverse effect of cyclophosphamide (CYC) therapy in systemic lupus erythematosus (SLE). Reported prevalence varies due to differences in populations, protocols, and diagnostic criteria. Objective: To estimate the prevalence of POI in women with SLE exposed to CYC and explore sources of heterogeneity. MEDLINE, Embase, Web of Science, Scopus, and LILACS were searched from inception through October 2024. Twenty-one studies were included in the systematic review; 12 CYC-exposed cohorts contributed to the primary meta-analysis. Two reviewers independently extracted data and assessed study quality using the Joanna Briggs Institute checklist. The pooled prevalence of POI in SLE treated with CYC was 15% (95% CI 7-26%), with substantial heterogeneity (I2 = 85%; Cochran's Q = 73.98 p <0.0001; tau2 = 0.0353). In contrast, prevalence among unselected SLE populations was markedly lower, confirming the potential gonadotoxic effect of CYC. Temporal analysis showed reduced prevalence in studies published after 2005 (9%) compared with pre-2005 (29%), coinciding with adoption of Euro-Lupus low-dose protocols. Meta-regression identified age at exposure as a significant predictor (β = 0.21, 95% CI: 0.04-0.38, p = 0.017). Cumulative CYC dose was not independently associated with prevalence, likely reflecting the widespread adoption of lower-dose regimens after 2005. Methodological sensitivity analyses using logit transformation (20.0%, 95% CI 12.7-30.1) and GLMM (14.5%, 95% CI 7.1-27.2) were added to assess model robustness. Funnel-plot and the Egger's test indicated no evidence of publication bias (p = 0.91). Women with SLE treated with CYC show a substantial burden of POI, with an estimated prevalence of approximately 15%. These results underscore the need for standardized diagnostic criteria, fertility counseling, and individualized treatment decisions. https://www.crd.york.ac.uk/PROSPERO/view/, identifier CRD42025641213.
Prospective cohort studies are important for understanding epidemiology, associations, and incidence of adverse outcomes of long-term conditions, including chronic kidney disease (CKD). Here, we draw on the combined expertise of the leaders of cohort studies within the ISN's International Network of CKD Cohorts (iNET-CKD) to provide insights into the design and conduct of prospective cohort studies in people with CKD. Formulating research questions that will remain relevant years after the cohort launch, when data will be available, is the first, and perhaps most challenging step of the study design. These questions will inform participant selection, sample size, duration of follow-up, outcome definitions, as well as frequency of encounters and data collection. Consideration should be given to the data elements to be collected, balancing burden with data value. At least 1 marker of glomerular filtration rate (GFR) (preferably both serum creatinine and cystatin C concentrations) and a measure of proteinuria (preferably urine albumin-to-creatinine ratio) are essential. Standard operating procedures should be developed for all assessments and for biosample collection and storage. Robust governance arrangements should be established to ensure effective management and sustainability of these complex projects, along with sufficient funding for the proposed study duration. Facilitating future collaboration with other cohort studies should be born in mind, to expand scientific output. This includes adoption of standard definitions and assessments, as well as making provisions for sharing of data and biosamples. A clear communication strategy that includes all stakeholders is essential to ensure maximum clinical impact.
Information about the clinical and epidemiological profile of children and adolescents undergoing chronic dialysis in Brazil is limited. To describe the clinical and epidemiological characteristics of the pediatric population undergoing chronic outpatient dialysis treatment in a capital city in Northeastern Brazil. This is a descriptive, observational, and retrospective study whose population consisted of all children and adolescents undergoing chronic outpatient dialysis treatment in São Luís, capital of the state of Maranhão, Brazil, in 2023. Thirty-two children and adolescents with chronic kidney disease (CKD) were undergoing dialysis treatment during this period, the majority (56.25%) being male. The mean age was 11.31 years (± 3.56). Regarding ethnicity, non-white individuals predominated (71.9%). The renal replacement therapy (RRT) modality was exclusively hemodialysis (HD), and the most commonly used vascular access at the end of the follow-up period was arteriovenous fistula (AVF) (56.2%). Regarding the underlying disease, 35% had an unknown etiology. There were nine transplants during the period, all from deceased donors. At that time, there was virtually universal access to erythropoiesis-stimulating agents and drugs for the prevention and treatment of bone mineral metabolic disorders. The high rate of unknown underlying disease and the exclusive use of HD as the RRT modality, rather than peritoneal dialysis, reflect diagnostic, therapeutic, and structural challenges. This scenario highlights the need for better planning of public policies aimed at managing pediatric CKD in the region. Informações acerca do perfil clínico e epidemiológico de crianças e adolescentes submetidos à diálise crônica no Brasil são escassas. Descrever as características clínicas e epidemiológicas da população pediátrica em tratamento dialítico crônico ambulatorial em uma capital do Nordeste do Brasil. Trata-se de um estudo descritivo, observacional e retrospectivo, cuja população foi composta por todas as crianças e adolescentes em tratamento dialítico crônico ambulatorial em São Luís, capital do estado do Maranhão – Brasil, no ano de 2023. Trinta e duas crianças e adolescentes portadores de doença renal crônica (DRC) estiveram em tratamento dialítico neste período, sendo a maioria (56,25%) do sexo masculino. A idade média foi de 11,31 anos (± 3,56). Quanto à etnia, predominavam os não brancos (71,9%). O tipo de terapia renal substitutiva (TRS) foi exclusivamente hemodiálise (HD), e o acesso vascular mais utilizado no final do período de seguimento foi a fístula arteriovenosa (56,2%). Acerca da doença de base, 35% não tiveram a etiologia identificada. Houve nove transplantes no período, todos com doador falecido, e, à época, havia acesso praticamente universal aos agentes estimuladores da eritropoiese e às drogas para prevenção e tratamento dos distúrbios do metabolismo mineral ósseo. A elevada taxa de desconhecimento da doença de base e a HD como método exclusivo de TRS, em detrimento da diálise peritoneal, refletem desafios diagnósticos, terapêuticos e estruturais, sublinhando a necessidade de melhor planejamento das políticas públicas voltadas ao manejo da DRC pediátrica na região.
Blood pressure (BP) exhibits specific characteristics in elderly patients. We evaluated the association between positional BP changes during orthostatism and the presence of hypertension-mediated organ damage (HMOD) in functionally preserved elderly hypertensive patients. This was a multicenter, cross-sectional study of 156 hypertensive patients with a mean age of 75 ± 5.8 years (49% women). Central and peripheral office and 24-h BP were measured using an oscillometric device. Orthostatic BP changes were recorded according to the conventional definition of orthostatic hypotension (OH) and also as a continuous variable obtained by subtracting values (supine BP - orthostatic BP). Treating BP as a continuous variable, patients were divided into two groups based on orthostatic BP changes, below or above the median of the distribution. HMOD was assessed as renal (reduced glomerular filtration rate and/or increased albuminuria), cardiac [left ventricular hypertrophy (LVH)], and arterial (increased aortic pulse wave velocity). OH was present in 33 patients (21%), whereas orthostatic BP change showed a wide distribution. A total of 145 patients (92.9%) presented HMOD (48% kidney disease, 47% LVH, and 81% arterial stiffness). All patients with OH showed HMOD involvement and significantly higher values of all systolic BP estimates. Although OH and HMOD were not significantly associated, analysis of orthostatic BP changes showed greater renal damage in the group with a BP reduction above the median compared with those with a reduction below it, after adjustment for age, office BP, and alpha-blocker treatment (p < 0.05). Orthostatic BP reduction is associated with renal damage in functionally preserved elderly hypertensive patients.
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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.
Kidney involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) remains a major determinant of adverse patient outcomes. Several histological and clinicopathological scoring systems have been proposed to predict kidney prognosis and guide treatment decisions. This retrospective cohort study evaluated patients with kidney biopsy-proven AAV, diagnosed between January 2013 and December 2023. The primary endpoint was progression to end-stage kidney disease (ESKD). Cox regression analysis was used to evaluate clinical and histological predictors of ESKD. Kaplan-Meier analysis, Harrell's C-statistics, and Cramér's V were used to assess the performance and concordance of Berden classification, Mayo Clinic Chronicity Score (MCCS), Renal Risk Score (RRS), and Improved ANCA Kidney Risk Score (AKRiS). Of 53 included patients, 22.6% progressed to ESKD. Interstitial fibrosis and tubular atrophy ≥25% was the strongest histological predictor of ESKD, and MCCS (HR 1.574 [95% CI 1.123-2.206]), RRS (HR 1.405 [95% CI 1.110-1.777]) and AKRiS (HR 1.254 [95% CI 1.090-1.442]) proved to be independent predictors of ESKD. AKRiS showed the highest discriminative performance (C-statistic 0.871 [95% CI 0.781-0.989]) and differentiated kidney survival across all risk categories. Cross-comparison revealed significant concordance among low and high-risk groups of MCCS, RRS, and AKRiS. In a contemporary cohort of AAV, MCCS and AKRiS demonstrated the strongest predictive performance for ESKD. The combined use of histological and clinicopathological scores may improve risk stratification and support more personalized treatment decisions, particularly in patients with intermediate risk.
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.
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