Acute kidney injury (AKI) is a common problem highly associated with hospitalisation. AKI is the ... more Acute kidney injury (AKI) is a common problem highly associated with hospitalisation. AKI is the cause of harmful short-term consequences: longer hospital stays, greater disability after discharge, and greater risk of in-hospital mortality, as well as adverse long-term outcomes, such as progression to chronic kidney disease, development of cardiovascular disease, and increased risk of long-term mortality. The concept of AKI has changed since the introduction of the 'Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease' (RIFLE) classification. More recently, the 'Kidney Disease Improving Global Outcomes' (KDIGO) classification appears to have provided increased diagnostic sensitivity and outcome-prediction capability. Novel biomarkers and further research on the role of the immune system in AKI may help improve the diagnosis, severity, outcome evaluation, and treatment of the condition. In this review we describe the epidemiology, diagnosis, and prognosis of AKI, as well as possible future directions for its clinical management.
Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic in... more Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic inflammation and is the most common cause of new-onset glomerulonephritis in adults older than 50 years. Renal disease secondary to AAV can lead to chronic kidney disease (CKD) requiring renal replacement therapy in approximately 20–25% of patients. Relapses are infrequent in the population on dialysis, and treatment guidelines do not specify these patients. Reports regarding the clinical course, survival, or relapse rate after beginning dialysis are scarce. The authors present 3 cases of CKD patients on hemodialysis who presented with AAV relapse, successfully treated with rituximab, and provide a literature review on relapse treatment.
The optimal prophylaxis regimen for graft-versus-host disease (GVHD) in the setting of single-loc... more The optimal prophylaxis regimen for graft-versus-host disease (GVHD) in the setting of single-locus mismatched unrelated donor (MMUD) allogeneic hematopoietic stem cell transplantation (alloHSCT) is unclear. The use of high-dose post-transplant cyclophosphamide (PTCy) after haploidentical transplantation is effective at overcoming the negative impact of HLA disparity on survival. Limited information is available regarding the efficacy of this strategy in alloHSCT from MMUDs. Most of the published studies have used the triple immunosuppressant model of haploidentical transplant combining PTCy with calcineurin inhibitors and mycophenolate mofetil or methotrexate. In our study, we propose the use of a simpler GVHD prophylaxis protocol comprising PTCy in combination with tacrolimus for MMUD and matched unrelated donor (MUD) alloHSCT. We performed a retrospective analysis of 109 consecutive recipients of alloHSCT from unrelated donors (MMUD, n = 55; MUD, n = 54) in a single center. Graft source was primarily peripheral blood (98%). No differences were observed between the MMUD and MUD groups with respect to 100-day cumulative incidence of grade II to IV acute GVHD (aGVHD; 31% versus 32%, respectively, P = .9), grade III to IV aGVHD (9% versus 7%, P = .7), and moderate/severe chronic GVHD (cGVHD) at 2 years (18% versus 14%, P = .6). Both groups showed similar cumulative incidence of 1 year nonrelapse mortality (13% versus 9%; P = .5) and 3-year relapse rates (24% versus 25%, P = .7). Progression-free survival and overall survival at 3 years for MMUD and MUD were 56% and 57% (P = .9) and 64% and 65% (P = .6), respectively. The 3-year probability of survival free of moderate/severe cGVHD and relapse was 56% and 55%, respectively. GVHD prophylaxis with PTCy and tacrolimus achieves low rates of severe aGVHD and cGVHD, as well as good survival outcomes, in recipients of both MMUD and MUD peripheral blood alloHSCT. This strategy overcomes the negative impact of single-locus HLA disparity.
Background and Aims Glomerular diseases (GD) account for about 20% of chronic kidney disease caus... more Background and Aims Glomerular diseases (GD) account for about 20% of chronic kidney disease causes. They are a heterogeneous group of diseases and current treatment is still inadequate. Rituximab (RTX) is a chimeric antibody which binds specifically to the B-cell surface antigen CD20 and has been applied in the treatment of different GD. The authors present the single center experience of the use of RTX for the treatment of GD as well as a literature review. Method We performed a retrospective analysis of all patients with biopsy-proven GD treated with RTX as first or second-line therapy between January 2010 and March 2020. The protocol used was RTX 375 mg/m2 once a week for 4 weeks. Infusions were preceded by adequate premedication. Results Nineteen patients with biopsy-proven GD received RTX therapy. Seven patients had membranous nephropathy (MN) (36.8%), 4 patients had focal segmental glomerulosclerosis (FSGS), 4 patients had lupus nephritis (LN) and 4 patients had vasculitis (2...
Background and Aims Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisy... more Background and Aims Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. Method We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Service of Nephrology and Renal Transplantation of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) cu...
Background: Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized pat... more Background: Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized patients. Major abdominal surgery has the second higher incidences of AKI, after cardiac surgery. AKI results from a complex interaction between hemodynamic, toxic and inflammatory factors. The pathogenesis of AKI following major abdominal surgery is distinct from cardiac and vascular surgery. The neutrophil, lymphocytes and platelets (N/LP) ratio has been demonstrated as an inflammatory marker and an independent predictor for AKI and mortality after cardiovascular surgery. The aim of this study was to evaluate the prognostic ability of the postoperative N/LP ratio after major abdominal surgery. Methods: We cross-examined data of a retrospective analysis of 450 patients who underwent elective or urgent major nonvascular abdominal surgery at the Department of Surgery II of Centro Hospitalar Lisboa Norte from January 2010 to February 2011. N/LP ratio was determined using maximal neutrophil counts and minimal lymphocyte and platelet counts in the first 12 h after surgery. AKI was considered when developed within 48 h after surgery. Results: One-hundred and one patients (22.4%) developed AKI. Patients with higher N/LP ratio had an increased risk of developing postoperative AKI (6.36 ± 7.34 vs 4.33 ± 3.36, p < 0.001; unadjusted OR 1.1 (95% CI 1.04-1.16), p = 0.001; adjusted OR 1.05 (95% CI 1.00-1.10), p = 0.048). Twenty-nine patients died (6.44%). AKI was an independent predictor of mortality (20.8 vs 2.3%, p < 0.0001; unadjusted OR 11.2, 95% CI 4. 8-26.2, p < 0.0001; adjusted OR 3.56, 95% CI 1.0 2-12.43, p = 0.046). In a multivariate analysis higher N/LP ratio was not associated with increased inhospital mortality. Conclusion: Postoperative N/LP ratio was independently associated with AKI after major abdominal surgery, although there was no association with in-hospital mortality.
This position paper from the American College of Physicians reaffirms ACP's opposition to the leg... more This position paper from the American College of Physicians reaffirms ACP's opposition to the legalization of physician-assisted suicide and affirms a professional responsibility to improve the care of dying patients. The paper is an update of ACP's 2001 paper.
Nefrologia : publicacion oficial de la Sociedad Espanola Nefrologia, Jan 2, 2018
Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs... more Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count <100×10cells/l or a >50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20×10cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150×10cells/l due to the intermittent use of heparin. Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be con...
The presence of human immunodeficiency virus (HIV)-related kidney disease is an important cause o... more The presence of human immunodeficiency virus (HIV)-related kidney disease is an important cause of mortality and morbidity. HIV infection induces renal injury by direct cytotoxicity or immune complex-mediated glomerulonephritis in patients with genetic susceptibility factors. In the last decades, with the development and diffusion of combination antiretroviral therapy, which has prolonged patient survival, there has been a shift in the spectrum of renal diseases in HIV-infected patients, with the decrease of glomerular diseases and increase in the role of nephrotoxicity and co-morbidities. This review provides a contemporary and critical review on the main renal syndromes occurring in HIV-infected patients.
Peritoneopleural shunt is an uncommon complication of peritoneal dialysis (PD) usually presenting... more Peritoneopleural shunt is an uncommon complication of peritoneal dialysis (PD) usually presenting early as a right pleural transudate. Peritoneopericardial shunt is an even rarer entity in PD, almost never occurring spontaneously. We present the case of a 37-year-old woman on PD for 24 months exhibiting a left pleural and pericardial effusion following pneumonia. Pleural fluid was initially compatible with an exudate with a high glucose concentration and later with a transudate. In order to clarify the suspicion of an ongoing shunt an abdominal scintigraphy was performed confirming the diagnosis of a peritoneopleuropericardial communication. This case underlines the importance of considering this unusual diagnosis in a patient on long-term PD. Its timely diagnosis is important to stop PD and start hemodialysis. .
cysteamine, there was a modification on the serum and urinary proteome of the patient with cystin... more cysteamine, there was a modification on the serum and urinary proteome of the patient with cystinosis, which became increasingly different from the proteome of the patient before beginning treatment with cysteamine and closer to the proteome of the healthy individual used as control (Figures 1 and 2). The changes on the proteomic profile after treatment with cysteamine are described. CONCLUSIONS: After beginning therapy with cysteamine, the proteomic profile of a patient with cystinosis became more similar to the profile of a healthy control. Identification of the proteins that change with therapy may provide insight into the pathophysiology of cystinosis and unravel new therapeutic targets.
Deafness, kidney disease and diabetes are not a usual association, neither is a family history of... more Deafness, kidney disease and diabetes are not a usual association, neither is a family history of these diseases. We present the case of a 47-year-old woman with non-nephrotic proteinuria, no haematuria, normal renal function, sensorineural hearing loss, recently diagnosed diabetes and maculopathy. There was a maternal family history of deafness, diabetes and renal disease. Renal biopsy revealed focal and segmental glomerulosclerosis (FSGS), leading to the pursuit of an m.3243A > G mitochondrial mutation and diagnosis of maternally inherited diabetes and deafness. The association of FSGS with mitochondrial diseases is not well known among nephrologists. Its timely diagnosis is important to avoid exposure to ineffective and unnecessary immunosuppression.
Introduction and Aims: Acute kidney injury is frequent among hospitalized patients and contribute... more Introduction and Aims: Acute kidney injury is frequent among hospitalized patients and contributes to adverse short-term and long-term consequences. The aim of this study was to evaluate the role of acute kidney injury after abdominal surgery on long-term outcomes. Methods: Retrospective cohort analysis of adult patients who underwent major abdominal surgery in Centro Hospitalar Lisboa Norte, Portugal, between January 2010 and February 2011 and were alive after hospital discharge. Patients were categorized according to the development of postoperative acute kidney injury, as defined by the Kidney Disease Improving Global Outcomes classification. Long-term renal outcomes (requirement for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and long-term mortality were evaluated. Continuous variables were analyzed using Student's t-test or Mann-Whitney U test. Categorical variables were analyzed using chi-square test. Univariate and multivariate analysis was used to determine predictors of renal outcome and mortality. Kaplan-Meier method and log-rank test were employed to analyze cumulative mortality. A p-value <0.05 was considered significant. Results: Three-hundred and ninety patients underwent major abdominal surgery, 72 (18.5%) of those developed postoperative acute renal injury: 57 at stage 1, 12 at stage 2 and 3 at stage 3; 2 of them received renal replacement therapy during hospitalization. Median follow-up was 38 months. Patients with acute kidney injury were more likely to be older, with higher comorbidity rate, and to undergo urgent or colorectal surgery. Acute renal injury was an independent risk factor for long-term adverse renal outcomes (adjusted hazard ratio 1.6, p-value=0.046) as well as long-term mortality (adjusted hazard ratio 1.4, p-value= 0.043). Conclusions: In survivors, postoperative acute kidney injury was associated with poor long-term renal function and mortality in patients undergoing major abdominal surgery.
Pulmonary-renal syndrome (PRS) is defined as pulmonary and renal failure, and is caused by immuno... more Pulmonary-renal syndrome (PRS) is defined as pulmonary and renal failure, and is caused by immunological and non-immunological diseases. Although the most frequent immunological causes for PRS are small vessel vasculitis and lupus, 1 other causes have to be considered. Here, we present the case of a 35-year-old, black, previously healthy woman referred from Cape Verde to our Department to investigate renal failure (creatinemia 2.5 mg/dL), hypertension, lower limbs edema, foamy urine, anemia (Hb 11.5 mg/dL), and bilateral arthralgias developing within the last 6 months. She had no family history of renal disease neither respiratory, neurologic or gastrointestinal symptoms nor alopecia, rash, oral ulcers, photosensitivity, hematuria or recent drug use. At admission, she was polypneic, hypertensive, aeodematous, oligoanuric, presented bilateral fine pulmonary crackles, and bilateral erythematous lesions in thighs. Laboratory revealed anemia (Hb 7.1 g/dL), leukocytosis with neutrophilia (16.670/mm3; 91.9%), elevated C-reactive protein (12.2 mg/dL), elevated erythrocyte sedimentation rate (70 mm 1st h), renal insufficiency (uremia 247 mg/dL, creatininemia 7.5 mg/dL), and of NT pro-BNP (>105 000 pg/mL). Blood gas test showed severe hypoxemia. Urinalysis showed haematuria (200/mm3) and proteinuria 300 mg/dL, without casts. Chest X-ray revealed bilateral diffuse opacities (Fig. 1), and chest CT suggested pulmonary hemorrhage. Ultrasonogram showed normal sized kidneys with increased echogenicity. She required mechanical ventilation and hemodialysis. Bronchofibroscopy revealed alveolar hemorrhage, and plasmapheresis was initiated. Complementary investigation showed nephrotic range proteinuria (4.7 g/24 h). Serum protein electrophoresis showed an alpha2 spike and hypogamaglobulinemia. Serum complement was normal and serology for lupus, vasculitis and cryoglobulinemia, as well as for human immunodeficiency virus, hepatitis B and C infections were negative. Echocardiogram revealed a type II diastolic dysfunction. A renal biopsy was performed and revealed nodular glomerulosclerosis. Immunofluorescence revealed linear staining for kappa light chains along the tubular basement membrane and also in the glomerulus, allowing the diagnosis of light chain deposits disease (LCDD) (Figs. 2 and 3). Serum immunofixation revealed a kappa light chain band, and urine immunofixation revealed Bence-Jones kappa. Bone marrow biopsy and
In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and... more In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and Endstage kidney disease) classification, was proposed in order to define and stratify the severity of acute kidney injury (AKI). This system relies on changes in the serum creatinine (SCr) or glomerular filtration rates and/or urine output, and it has been largely demonstrated that the RIFLE criteria allows the identification of a significant proportion of AKI patients hospitalized in numerous settings, enables monitoring of AKI severity, and is a good predictor of patient outcome. Three years later (March 2007), the Acute Kidney Injury Network (AKIN) classification, a modified version of the RIFLE, was released in order to increase the sensitivity and specificity of AKI diagnosis. Until now, the benefit of these modifications for clinical practice has not been clearly demonstrated. Here we provide a critical and comprehensive discussion of the two classifications for AKI, focusing on the main differences, advantages and limitations.
Mycophenolate mofetil (MMF) use in renal transplantation has allowed a significant decrease in ea... more Mycophenolate mofetil (MMF) use in renal transplantation has allowed a significant decrease in early acute rejection rates. We retrospectively evaluated the incidence of acute rejection episodes, renal function at the first year posttransplant, patient and graft survivals, cytomegalovirus (CMV) infection rate, influence of the degree of sensitization, and number of MHC antigen mismatches on graft survival in two groups of patients receiving either MMF or azathioprine. Group 1 included 149 patients receiving cyclosporine, MMF, and prednisolone; group 2 included 191 patients receiving cyclosporine, azathioprine, and prednisolone. The two groups did not differ in terms of age, sex, degree of sensitization (expressed as percentage of antibodies reactive to panel), MHC mismatch number, cold ischemia time, donor age, or anti-thymocyte globulin induction. In group 1 (MMF) there was a significant decrease in early acute rejection rate (19% vs 57%, P Ͻ .0001), longer graft survival at 10 years (92% vs 75%, P ϭ .006), and higher rate of CMV infection (22% vs 12%, P ϭ .004). Renal function at the first year posttransplant and patient survival during follow-up did not differ between the groups. The degree of sensitization influenced graft survival in group 2. The number of MHC mismatches did not influence graft survival in either group. With MMF, there was a significant reduction in early acute rejection rate, a significant increase in graft survival at 10-year follow-up, and diminished impact of the degree of sensitization on graft survival.
... Brain Natriuretic Peptide (BNP): A New Risk Marker in Hemodialysis Patients? Jorge, Sofia MD;... more ... Brain Natriuretic Peptide (BNP): A New Risk Marker in Hemodialysis Patients? Jorge, Sofia MD; Lopes, José António MD; Neves, Fernando MD; Gomes da Costa, António MD; Prata, M Martins MD, PhD. ... Egas Moniz, 1649-035, Lisboa, Portugal. ... C, van Kimmenade RR, Pinto YM. ...
A 45-year-old Caucasian male with a 16-year history of HIV-1 infection and a 5-year history of il... more A 45-year-old Caucasian male with a 16-year history of HIV-1 infection and a 5-year history of ileocecal non-Hodgkin lymphoma was admitted to the emergency room with fever, and abdominal pain and distension. In the previous month, he noticed abdominal pain. A CT scan and colonoscopy were performed and confirmed tumour relapse involving the distal ileum, caecum and right colon. At admission, the patient was dehydrated, hypotensive, tachycardic, tachypneic and febrile. He presented ascites and a petrous mass in the right lower abdominal quadrants. Oliguria was documented. Laboratory tests (Table 1) revealed anaemia, elevation of acute-phase reagents, renal dysfunction, hypernatraemia, metabolic acidosis and hypoxaemia. Elevation of creatine kinase and lactic dehydrogenase, and hyperphosphataemia, hypocalcaemia, hyperuricaemia and hyperkalaemia were also diagnosed. Abdominal plain did not reveal air-fluid levels, and abdominal CT scan showed ascites and a voluminous mass in the ileon, caecum and right colon. A paracentesis was performed and an exsudate with high cellularity (28.160/mm 3) with numerous blasts was drained. Fluid resuscitation was started and vasoactive support was needed. The patient required ventilatory support and was admitted to the Department of Intensive Medicine. Empirical antibiotherapy (meropenem) and rasburicase (0.2 mg/kg, single dose) were administered. There was refractory oliguria, and continuous venovenous haemodiafiltration was started. The abdomen remained distended, haemoglobin decreased by 2 g/dL and 2 units of erythrocyte concentrate were administered. Cultures were negative. Despite the central venous pressure of
Introduction Whether discernible advantages in terms of sensitivity and specificity exist with Ac... more Introduction Whether discernible advantages in terms of sensitivity and specificity exist with Acute Kidney Injury Network (AKIN) criteria versus Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease (RIFLE) criteria is currently unknown. We evaluated the incidence of acute kidney injury and compared the ability of the maximum RIFLE and of the maximum AKIN within intensive care unit hospitalization in predicting inhospital mortality of critically ill patients. Methods Patients admitted to the Department of Intensive Medicine of our hospital between January 2003 and December 2006 were retrospectively evaluated. Chronic kidney disease patients undergoing dialysis or renal transplant patients were excluded from the analysis. Results In total, 662 patients (mean age, 58.6 ± 19.2 years; 392 males) were evaluated. AKIN criteria allowed the identification of more patients as having acute kidney injury (50.4% versus 43.8%, P = 0.018) and classified more patients with Stage 1 (risk in RIFLE) (21.1% versus 14.7%, P = 0.003), but no differences were observed for Stage 2 (injury in RIFLE) (10.1% versus 11%, P = 0.655) and for Stage 3 (failure in RIFLE) (19.2% versus 18.1%, P = 0.672). Mortality was significantly higher for acute kidney injury defined by any of the RIFLE criteria (41.3% versus 11%, P < 0.0001; odds ratio = 2.78, 95% confidence interval = 1.74 to 4.45, P < 0.0001) or of the AKIN criteria (39.8% versus 8.5%, P < 0.0001; odds ratio = 3.59, 95% confidence interval = 2.14 to 6.01, P < 0.0001). The area under the receiver operator characteristic curve for inhospital mortality was 0.733 for RIFLE criteria (P < 0.0001) and was 0.750 for AKIN criteria (P < 0.0001). There were no statistical differences in mortality by the acute kidney injury definition/classification criteria (P = 0.72). Conclusions Although AKIN criteria could improve the sensitivity of the acute kidney injury diagnosis, it does not seem to improve on the ability of the RIFLE criteria in predicting inhospital mortality of critically ill patients. Key messages • The RIFLE criteria allowed the identification of 43.8% of ICU patients as having some degree of AKI. • The AKIN criteria could improve the sensitivity of the AKI diagnosis but do not improve on the ability of the RIFLE criteria in predicting inhospital mortality of ICU patients.
Acute kidney injury (AKI) is a common problem highly associated with hospitalisation. AKI is the ... more Acute kidney injury (AKI) is a common problem highly associated with hospitalisation. AKI is the cause of harmful short-term consequences: longer hospital stays, greater disability after discharge, and greater risk of in-hospital mortality, as well as adverse long-term outcomes, such as progression to chronic kidney disease, development of cardiovascular disease, and increased risk of long-term mortality. The concept of AKI has changed since the introduction of the 'Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease' (RIFLE) classification. More recently, the 'Kidney Disease Improving Global Outcomes' (KDIGO) classification appears to have provided increased diagnostic sensitivity and outcome-prediction capability. Novel biomarkers and further research on the role of the immune system in AKI may help improve the diagnosis, severity, outcome evaluation, and treatment of the condition. In this review we describe the epidemiology, diagnosis, and prognosis of AKI, as well as possible future directions for its clinical management.
Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic in... more Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic inflammation and is the most common cause of new-onset glomerulonephritis in adults older than 50 years. Renal disease secondary to AAV can lead to chronic kidney disease (CKD) requiring renal replacement therapy in approximately 20–25% of patients. Relapses are infrequent in the population on dialysis, and treatment guidelines do not specify these patients. Reports regarding the clinical course, survival, or relapse rate after beginning dialysis are scarce. The authors present 3 cases of CKD patients on hemodialysis who presented with AAV relapse, successfully treated with rituximab, and provide a literature review on relapse treatment.
The optimal prophylaxis regimen for graft-versus-host disease (GVHD) in the setting of single-loc... more The optimal prophylaxis regimen for graft-versus-host disease (GVHD) in the setting of single-locus mismatched unrelated donor (MMUD) allogeneic hematopoietic stem cell transplantation (alloHSCT) is unclear. The use of high-dose post-transplant cyclophosphamide (PTCy) after haploidentical transplantation is effective at overcoming the negative impact of HLA disparity on survival. Limited information is available regarding the efficacy of this strategy in alloHSCT from MMUDs. Most of the published studies have used the triple immunosuppressant model of haploidentical transplant combining PTCy with calcineurin inhibitors and mycophenolate mofetil or methotrexate. In our study, we propose the use of a simpler GVHD prophylaxis protocol comprising PTCy in combination with tacrolimus for MMUD and matched unrelated donor (MUD) alloHSCT. We performed a retrospective analysis of 109 consecutive recipients of alloHSCT from unrelated donors (MMUD, n = 55; MUD, n = 54) in a single center. Graft source was primarily peripheral blood (98%). No differences were observed between the MMUD and MUD groups with respect to 100-day cumulative incidence of grade II to IV acute GVHD (aGVHD; 31% versus 32%, respectively, P = .9), grade III to IV aGVHD (9% versus 7%, P = .7), and moderate/severe chronic GVHD (cGVHD) at 2 years (18% versus 14%, P = .6). Both groups showed similar cumulative incidence of 1 year nonrelapse mortality (13% versus 9%; P = .5) and 3-year relapse rates (24% versus 25%, P = .7). Progression-free survival and overall survival at 3 years for MMUD and MUD were 56% and 57% (P = .9) and 64% and 65% (P = .6), respectively. The 3-year probability of survival free of moderate/severe cGVHD and relapse was 56% and 55%, respectively. GVHD prophylaxis with PTCy and tacrolimus achieves low rates of severe aGVHD and cGVHD, as well as good survival outcomes, in recipients of both MMUD and MUD peripheral blood alloHSCT. This strategy overcomes the negative impact of single-locus HLA disparity.
Background and Aims Glomerular diseases (GD) account for about 20% of chronic kidney disease caus... more Background and Aims Glomerular diseases (GD) account for about 20% of chronic kidney disease causes. They are a heterogeneous group of diseases and current treatment is still inadequate. Rituximab (RTX) is a chimeric antibody which binds specifically to the B-cell surface antigen CD20 and has been applied in the treatment of different GD. The authors present the single center experience of the use of RTX for the treatment of GD as well as a literature review. Method We performed a retrospective analysis of all patients with biopsy-proven GD treated with RTX as first or second-line therapy between January 2010 and March 2020. The protocol used was RTX 375 mg/m2 once a week for 4 weeks. Infusions were preceded by adequate premedication. Results Nineteen patients with biopsy-proven GD received RTX therapy. Seven patients had membranous nephropathy (MN) (36.8%), 4 patients had focal segmental glomerulosclerosis (FSGS), 4 patients had lupus nephritis (LN) and 4 patients had vasculitis (2...
Background and Aims Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisy... more Background and Aims Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients. Method We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Service of Nephrology and Renal Transplantation of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) cu...
Background: Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized pat... more Background: Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized patients. Major abdominal surgery has the second higher incidences of AKI, after cardiac surgery. AKI results from a complex interaction between hemodynamic, toxic and inflammatory factors. The pathogenesis of AKI following major abdominal surgery is distinct from cardiac and vascular surgery. The neutrophil, lymphocytes and platelets (N/LP) ratio has been demonstrated as an inflammatory marker and an independent predictor for AKI and mortality after cardiovascular surgery. The aim of this study was to evaluate the prognostic ability of the postoperative N/LP ratio after major abdominal surgery. Methods: We cross-examined data of a retrospective analysis of 450 patients who underwent elective or urgent major nonvascular abdominal surgery at the Department of Surgery II of Centro Hospitalar Lisboa Norte from January 2010 to February 2011. N/LP ratio was determined using maximal neutrophil counts and minimal lymphocyte and platelet counts in the first 12 h after surgery. AKI was considered when developed within 48 h after surgery. Results: One-hundred and one patients (22.4%) developed AKI. Patients with higher N/LP ratio had an increased risk of developing postoperative AKI (6.36 ± 7.34 vs 4.33 ± 3.36, p < 0.001; unadjusted OR 1.1 (95% CI 1.04-1.16), p = 0.001; adjusted OR 1.05 (95% CI 1.00-1.10), p = 0.048). Twenty-nine patients died (6.44%). AKI was an independent predictor of mortality (20.8 vs 2.3%, p < 0.0001; unadjusted OR 11.2, 95% CI 4. 8-26.2, p < 0.0001; adjusted OR 3.56, 95% CI 1.0 2-12.43, p = 0.046). In a multivariate analysis higher N/LP ratio was not associated with increased inhospital mortality. Conclusion: Postoperative N/LP ratio was independently associated with AKI after major abdominal surgery, although there was no association with in-hospital mortality.
This position paper from the American College of Physicians reaffirms ACP's opposition to the leg... more This position paper from the American College of Physicians reaffirms ACP's opposition to the legalization of physician-assisted suicide and affirms a professional responsibility to improve the care of dying patients. The paper is an update of ACP's 2001 paper.
Nefrologia : publicacion oficial de la Sociedad Espanola Nefrologia, Jan 2, 2018
Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs... more Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count <100×10cells/l or a >50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20×10cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150×10cells/l due to the intermittent use of heparin. Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be con...
The presence of human immunodeficiency virus (HIV)-related kidney disease is an important cause o... more The presence of human immunodeficiency virus (HIV)-related kidney disease is an important cause of mortality and morbidity. HIV infection induces renal injury by direct cytotoxicity or immune complex-mediated glomerulonephritis in patients with genetic susceptibility factors. In the last decades, with the development and diffusion of combination antiretroviral therapy, which has prolonged patient survival, there has been a shift in the spectrum of renal diseases in HIV-infected patients, with the decrease of glomerular diseases and increase in the role of nephrotoxicity and co-morbidities. This review provides a contemporary and critical review on the main renal syndromes occurring in HIV-infected patients.
Peritoneopleural shunt is an uncommon complication of peritoneal dialysis (PD) usually presenting... more Peritoneopleural shunt is an uncommon complication of peritoneal dialysis (PD) usually presenting early as a right pleural transudate. Peritoneopericardial shunt is an even rarer entity in PD, almost never occurring spontaneously. We present the case of a 37-year-old woman on PD for 24 months exhibiting a left pleural and pericardial effusion following pneumonia. Pleural fluid was initially compatible with an exudate with a high glucose concentration and later with a transudate. In order to clarify the suspicion of an ongoing shunt an abdominal scintigraphy was performed confirming the diagnosis of a peritoneopleuropericardial communication. This case underlines the importance of considering this unusual diagnosis in a patient on long-term PD. Its timely diagnosis is important to stop PD and start hemodialysis. .
cysteamine, there was a modification on the serum and urinary proteome of the patient with cystin... more cysteamine, there was a modification on the serum and urinary proteome of the patient with cystinosis, which became increasingly different from the proteome of the patient before beginning treatment with cysteamine and closer to the proteome of the healthy individual used as control (Figures 1 and 2). The changes on the proteomic profile after treatment with cysteamine are described. CONCLUSIONS: After beginning therapy with cysteamine, the proteomic profile of a patient with cystinosis became more similar to the profile of a healthy control. Identification of the proteins that change with therapy may provide insight into the pathophysiology of cystinosis and unravel new therapeutic targets.
Deafness, kidney disease and diabetes are not a usual association, neither is a family history of... more Deafness, kidney disease and diabetes are not a usual association, neither is a family history of these diseases. We present the case of a 47-year-old woman with non-nephrotic proteinuria, no haematuria, normal renal function, sensorineural hearing loss, recently diagnosed diabetes and maculopathy. There was a maternal family history of deafness, diabetes and renal disease. Renal biopsy revealed focal and segmental glomerulosclerosis (FSGS), leading to the pursuit of an m.3243A > G mitochondrial mutation and diagnosis of maternally inherited diabetes and deafness. The association of FSGS with mitochondrial diseases is not well known among nephrologists. Its timely diagnosis is important to avoid exposure to ineffective and unnecessary immunosuppression.
Introduction and Aims: Acute kidney injury is frequent among hospitalized patients and contribute... more Introduction and Aims: Acute kidney injury is frequent among hospitalized patients and contributes to adverse short-term and long-term consequences. The aim of this study was to evaluate the role of acute kidney injury after abdominal surgery on long-term outcomes. Methods: Retrospective cohort analysis of adult patients who underwent major abdominal surgery in Centro Hospitalar Lisboa Norte, Portugal, between January 2010 and February 2011 and were alive after hospital discharge. Patients were categorized according to the development of postoperative acute kidney injury, as defined by the Kidney Disease Improving Global Outcomes classification. Long-term renal outcomes (requirement for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and long-term mortality were evaluated. Continuous variables were analyzed using Student's t-test or Mann-Whitney U test. Categorical variables were analyzed using chi-square test. Univariate and multivariate analysis was used to determine predictors of renal outcome and mortality. Kaplan-Meier method and log-rank test were employed to analyze cumulative mortality. A p-value <0.05 was considered significant. Results: Three-hundred and ninety patients underwent major abdominal surgery, 72 (18.5%) of those developed postoperative acute renal injury: 57 at stage 1, 12 at stage 2 and 3 at stage 3; 2 of them received renal replacement therapy during hospitalization. Median follow-up was 38 months. Patients with acute kidney injury were more likely to be older, with higher comorbidity rate, and to undergo urgent or colorectal surgery. Acute renal injury was an independent risk factor for long-term adverse renal outcomes (adjusted hazard ratio 1.6, p-value=0.046) as well as long-term mortality (adjusted hazard ratio 1.4, p-value= 0.043). Conclusions: In survivors, postoperative acute kidney injury was associated with poor long-term renal function and mortality in patients undergoing major abdominal surgery.
Pulmonary-renal syndrome (PRS) is defined as pulmonary and renal failure, and is caused by immuno... more Pulmonary-renal syndrome (PRS) is defined as pulmonary and renal failure, and is caused by immunological and non-immunological diseases. Although the most frequent immunological causes for PRS are small vessel vasculitis and lupus, 1 other causes have to be considered. Here, we present the case of a 35-year-old, black, previously healthy woman referred from Cape Verde to our Department to investigate renal failure (creatinemia 2.5 mg/dL), hypertension, lower limbs edema, foamy urine, anemia (Hb 11.5 mg/dL), and bilateral arthralgias developing within the last 6 months. She had no family history of renal disease neither respiratory, neurologic or gastrointestinal symptoms nor alopecia, rash, oral ulcers, photosensitivity, hematuria or recent drug use. At admission, she was polypneic, hypertensive, aeodematous, oligoanuric, presented bilateral fine pulmonary crackles, and bilateral erythematous lesions in thighs. Laboratory revealed anemia (Hb 7.1 g/dL), leukocytosis with neutrophilia (16.670/mm3; 91.9%), elevated C-reactive protein (12.2 mg/dL), elevated erythrocyte sedimentation rate (70 mm 1st h), renal insufficiency (uremia 247 mg/dL, creatininemia 7.5 mg/dL), and of NT pro-BNP (>105 000 pg/mL). Blood gas test showed severe hypoxemia. Urinalysis showed haematuria (200/mm3) and proteinuria 300 mg/dL, without casts. Chest X-ray revealed bilateral diffuse opacities (Fig. 1), and chest CT suggested pulmonary hemorrhage. Ultrasonogram showed normal sized kidneys with increased echogenicity. She required mechanical ventilation and hemodialysis. Bronchofibroscopy revealed alveolar hemorrhage, and plasmapheresis was initiated. Complementary investigation showed nephrotic range proteinuria (4.7 g/24 h). Serum protein electrophoresis showed an alpha2 spike and hypogamaglobulinemia. Serum complement was normal and serology for lupus, vasculitis and cryoglobulinemia, as well as for human immunodeficiency virus, hepatitis B and C infections were negative. Echocardiogram revealed a type II diastolic dysfunction. A renal biopsy was performed and revealed nodular glomerulosclerosis. Immunofluorescence revealed linear staining for kappa light chains along the tubular basement membrane and also in the glomerulus, allowing the diagnosis of light chain deposits disease (LCDD) (Figs. 2 and 3). Serum immunofixation revealed a kappa light chain band, and urine immunofixation revealed Bence-Jones kappa. Bone marrow biopsy and
In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and... more In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and Endstage kidney disease) classification, was proposed in order to define and stratify the severity of acute kidney injury (AKI). This system relies on changes in the serum creatinine (SCr) or glomerular filtration rates and/or urine output, and it has been largely demonstrated that the RIFLE criteria allows the identification of a significant proportion of AKI patients hospitalized in numerous settings, enables monitoring of AKI severity, and is a good predictor of patient outcome. Three years later (March 2007), the Acute Kidney Injury Network (AKIN) classification, a modified version of the RIFLE, was released in order to increase the sensitivity and specificity of AKI diagnosis. Until now, the benefit of these modifications for clinical practice has not been clearly demonstrated. Here we provide a critical and comprehensive discussion of the two classifications for AKI, focusing on the main differences, advantages and limitations.
Mycophenolate mofetil (MMF) use in renal transplantation has allowed a significant decrease in ea... more Mycophenolate mofetil (MMF) use in renal transplantation has allowed a significant decrease in early acute rejection rates. We retrospectively evaluated the incidence of acute rejection episodes, renal function at the first year posttransplant, patient and graft survivals, cytomegalovirus (CMV) infection rate, influence of the degree of sensitization, and number of MHC antigen mismatches on graft survival in two groups of patients receiving either MMF or azathioprine. Group 1 included 149 patients receiving cyclosporine, MMF, and prednisolone; group 2 included 191 patients receiving cyclosporine, azathioprine, and prednisolone. The two groups did not differ in terms of age, sex, degree of sensitization (expressed as percentage of antibodies reactive to panel), MHC mismatch number, cold ischemia time, donor age, or anti-thymocyte globulin induction. In group 1 (MMF) there was a significant decrease in early acute rejection rate (19% vs 57%, P Ͻ .0001), longer graft survival at 10 years (92% vs 75%, P ϭ .006), and higher rate of CMV infection (22% vs 12%, P ϭ .004). Renal function at the first year posttransplant and patient survival during follow-up did not differ between the groups. The degree of sensitization influenced graft survival in group 2. The number of MHC mismatches did not influence graft survival in either group. With MMF, there was a significant reduction in early acute rejection rate, a significant increase in graft survival at 10-year follow-up, and diminished impact of the degree of sensitization on graft survival.
... Brain Natriuretic Peptide (BNP): A New Risk Marker in Hemodialysis Patients? Jorge, Sofia MD;... more ... Brain Natriuretic Peptide (BNP): A New Risk Marker in Hemodialysis Patients? Jorge, Sofia MD; Lopes, José António MD; Neves, Fernando MD; Gomes da Costa, António MD; Prata, M Martins MD, PhD. ... Egas Moniz, 1649-035, Lisboa, Portugal. ... C, van Kimmenade RR, Pinto YM. ...
A 45-year-old Caucasian male with a 16-year history of HIV-1 infection and a 5-year history of il... more A 45-year-old Caucasian male with a 16-year history of HIV-1 infection and a 5-year history of ileocecal non-Hodgkin lymphoma was admitted to the emergency room with fever, and abdominal pain and distension. In the previous month, he noticed abdominal pain. A CT scan and colonoscopy were performed and confirmed tumour relapse involving the distal ileum, caecum and right colon. At admission, the patient was dehydrated, hypotensive, tachycardic, tachypneic and febrile. He presented ascites and a petrous mass in the right lower abdominal quadrants. Oliguria was documented. Laboratory tests (Table 1) revealed anaemia, elevation of acute-phase reagents, renal dysfunction, hypernatraemia, metabolic acidosis and hypoxaemia. Elevation of creatine kinase and lactic dehydrogenase, and hyperphosphataemia, hypocalcaemia, hyperuricaemia and hyperkalaemia were also diagnosed. Abdominal plain did not reveal air-fluid levels, and abdominal CT scan showed ascites and a voluminous mass in the ileon, caecum and right colon. A paracentesis was performed and an exsudate with high cellularity (28.160/mm 3) with numerous blasts was drained. Fluid resuscitation was started and vasoactive support was needed. The patient required ventilatory support and was admitted to the Department of Intensive Medicine. Empirical antibiotherapy (meropenem) and rasburicase (0.2 mg/kg, single dose) were administered. There was refractory oliguria, and continuous venovenous haemodiafiltration was started. The abdomen remained distended, haemoglobin decreased by 2 g/dL and 2 units of erythrocyte concentrate were administered. Cultures were negative. Despite the central venous pressure of
Introduction Whether discernible advantages in terms of sensitivity and specificity exist with Ac... more Introduction Whether discernible advantages in terms of sensitivity and specificity exist with Acute Kidney Injury Network (AKIN) criteria versus Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease (RIFLE) criteria is currently unknown. We evaluated the incidence of acute kidney injury and compared the ability of the maximum RIFLE and of the maximum AKIN within intensive care unit hospitalization in predicting inhospital mortality of critically ill patients. Methods Patients admitted to the Department of Intensive Medicine of our hospital between January 2003 and December 2006 were retrospectively evaluated. Chronic kidney disease patients undergoing dialysis or renal transplant patients were excluded from the analysis. Results In total, 662 patients (mean age, 58.6 ± 19.2 years; 392 males) were evaluated. AKIN criteria allowed the identification of more patients as having acute kidney injury (50.4% versus 43.8%, P = 0.018) and classified more patients with Stage 1 (risk in RIFLE) (21.1% versus 14.7%, P = 0.003), but no differences were observed for Stage 2 (injury in RIFLE) (10.1% versus 11%, P = 0.655) and for Stage 3 (failure in RIFLE) (19.2% versus 18.1%, P = 0.672). Mortality was significantly higher for acute kidney injury defined by any of the RIFLE criteria (41.3% versus 11%, P < 0.0001; odds ratio = 2.78, 95% confidence interval = 1.74 to 4.45, P < 0.0001) or of the AKIN criteria (39.8% versus 8.5%, P < 0.0001; odds ratio = 3.59, 95% confidence interval = 2.14 to 6.01, P < 0.0001). The area under the receiver operator characteristic curve for inhospital mortality was 0.733 for RIFLE criteria (P < 0.0001) and was 0.750 for AKIN criteria (P < 0.0001). There were no statistical differences in mortality by the acute kidney injury definition/classification criteria (P = 0.72). Conclusions Although AKIN criteria could improve the sensitivity of the acute kidney injury diagnosis, it does not seem to improve on the ability of the RIFLE criteria in predicting inhospital mortality of critically ill patients. Key messages • The RIFLE criteria allowed the identification of 43.8% of ICU patients as having some degree of AKI. • The AKIN criteria could improve the sensitivity of the AKI diagnosis but do not improve on the ability of the RIFLE criteria in predicting inhospital mortality of ICU patients.
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