Preemptive kidney transplantation: why, when, and how?

Among renal replacement therapies, preemptive kidney transplantation (PKT) presents the best clinical, social, and economic results. However, it is still infrequently chosen as first therapy for patients with irreversible kidney failure. Initiatives in different parts of the world were developed to identify the reasons why PKT is still not widely used and to facilitate the access of patients with end-stage kidney disease to the advantages associated with it. This article addresses the main advantages and difficulties of PKT and discusses when it should be indicated and how to prepare potential recipients for PKT.

Acute kidney injury and electrolyte disorders in COVID-19.

Acute kidney injury (AKI) and electrolyte disorders are important complications of hospitalized coronavirus disease 2019 (COVID-19) patients. AKI is thought to occur due to multiple pathophysiological mechanisms, such as multiple organ dysfunction (mainly cardiac and respiratory), direct viral entry in the renal tubules, and cytokine release syndrome. AKI is present in approximately one in every ten hospitalized COVID-19 patients. The incidence rates of AKI increase in patients who are admitted to the intensive care unit (ICU), with levels higher than 50%. Additionally, renal replacement therapy (RRT) is used in 7% of all AKI cases, but in nearly 20% of patients admitted to an ICU. COVID-19 patients with AKI are considered moderate-to-severe cases and are managed with multiple interdisciplinary conducts. AKI acts as a risk factor for mortality in severe acute respiratory syndrome coronavirus 2 infection, especially when RRT is needed. Electrolyte disorders are also common manifestations in hospitalized COVID-19 patients, mainly hyponatremia, hypokalemia, and hypocalcemia. Hyponatremia occurs due to a combination of syndrome of inappropriate secretion of antidiuretic hormone and gastrointestinal fluid loss from vomiting and diarrhea. When it comes to hypokalemia, its mechanism is not fully understood but may derive from hyperaldosteronism due to renin angiotensin aldosterone system overstimulation and gastrointestinal fluid loss as well. The clinical features of hypokalemia in COVID-19 are similar to those in other conditions. Hypocalcemia is the most common electrolyte disorder in COVID-19 and seems to occur because of vitamin D deficiency and parathyroid imbalance. It is also highly associated with longer hospital and ICU stay.

COVID-19 in dialysis units: A comprehensive review.

The coronavirus disease 2019 (COVID-19) pandemic has been challenging for healthcare professionals worldwide. One of the populations affected by the pandemic are patients on renal replacement therapy, as kidney disease is an independent risk factor for severe COVID-19 and maintenance dialysis (a life-sustaining therapy) cannot be interrupted in the vast majority of cases. Over the past months, several authors and medical societies have published recommendations and guidelines on the management of this population. This article is a comprehensive review regarding the measures to prevent, contain and deal with a COVID-19 pandemic in the dialysis setting. We recapitulate the epidemiology and pathophysiology of COVID-19 in kidney dysfunction and present the main recommendations concerning the screening of healthcare personnel, dialysis patients and visitors as well as measures to improve the safety of the dialysis facilities' environments. In addition to preventive measures, this article briefly describes actions directed towards management of an outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a dialysis facility, the management of complications in dialysis patients with COVID-19 and overall data regarding the management of children with kidney disease.

Resistant hypertension: Prevalence and profile of patients followed in a university ambulatory.

BACKGROUND: Hypertension affects about 36 million Brazilians. It is estimated that 10%-20% of these have resistant hypertension. These patients are at an increased risk of early target organ damage, as well as cardiovascular and renal events. OBJECTIVE: To estimate the prevalence of resistant hypertension in a specialized outpatient clinic, to describe the sociodemographic and clinical characteristics of these patients, and to identify possible factors associated with resistant hypertension. METHODS: Data collection from medical records of hypertensive patients treated using oral antihypertensive drugs in optimized doses at a specialized university clinic from March 2014 to December 2014, after ethical approval statement. All patients were using appropriate antihypertensive drugs in optimized doses and assisted at a teaching-assistance clinic of internal medicine of the Bahiana School of Medicine and Public Health in Brazil. RESULTS: A total of 104 patients were enrolled and 31.7% (n = 33) had criteria for resistant hypertension. Of the total participants, 75.7% were female and 54.8% were black or brown. The average age was 61.7 years (SD ± 10.1). In the resistant hypertension group, 63.6% had diabetes, compared to 32.4% in the hypertension group. Among resistant hypertensive patients, 51.5% had dyslipidemia. Regarding drug treatment, 75.8% of the resistant hypertension group and 51.4% of the hypertension group used statins. Among patients with resistant hypertension, 90.9% used angiotensin II receptor blockers and 66.7%, dihydropyridine calcium channel blockers. In the resistant hypertension group, 75.8% used beta-blockers, against 25.4% in the hypertension group. CONCLUSION: The prevalence of hypertension was higher than that described in the global literature, which may be associated with the high percentage of black and brown ("pardos") patients in the population studied, and also because the study was performed in a specialized outpatient clinic.

Determinants of the serial changes in measurements of renal allograft Doppler resistive index in the first postoperative month.

INTRODUCTION: The role of single Doppler-derived renal resistive index (RI) in renal allograft management is still a controversial issue, however detection of changes in serial duplex scanning has been reported as more valuable. This study aimed to test the hypothesis that early change in RI following transplantation may be related to factors associated with delayed graft function (DGF). MATERIAL AND METHODS: 113 patients were included, in whom two RI measurements were performed within 30 days post-transplant. According to an RI change (equal to or more than 10%) in the second measurement, patients were assigned to decrease (Group I), no change (Group II), or increase (Group III) group. RESULTS: 30 subjects had a decrease, 55 had no change, and 28 had an increase in the second RI measurement. The donors were younger in Group III in comparison to Group II. In comparison to Group I, Group III had a higher frequency of deceased donor, DGF, and presence of tubular necrosis and tubular vacuolization in peri-implantation biopsies. CONCLUSION: the increase of RI during the first weeks of the postoperative period seems to be associated with DGF and with tubular necrosis / tubular vacuolization in peri-implantation biopsies, likely related to ischemia reperfusion injury.

Emergent Arboviruses and Renal Transplantation: A Global Challenge.

In recent years, Zika, Chikungunya, Dengue, West Nile Fever, and Yellow Fever epidemics have generated some concerns. Besides difficulties related to vector control, there are challenges related to behavior of pathologies not yet fully understood. The transplanted population requires additional care due to immunosuppressive drugs. Furthermore, the potential risk of transmission during donation is another source of uncertainty and generates debate among nephrologists in transplant centers. Do the clinical outcomes and prognoses of these infections tend to be more aggressive in this population? Is there a risk of viral transmission via kidney donation? In this review article, we address these issues and discuss the relationship between arbovirus and renal transplantation.

Preemptive kidney transplantation: why, when, and how? / Transplante renal preemptivo: por que, quando e como?

ABSTRACT Among renal replacement therapies, preemptive kidney transplantation (PKT) presents the best clinical, social, and economic results. However, it is still infrequently chosen as first therapy for patients with irreversible kidney failure. Initiatives in different parts of the world were developed to identify the reasons why PKT is still not widely used and to facilitate the access of patients with end-stage kidney disease to the advantages associated with it. This article addresses the main advantages and difficulties of PKT and discusses when it should be indicated and how to prepare potential recipients for PKT.

Resumo Entre as terapias renais substitutivas, o transplante renal preemptivo (TRP) apresenta os melhores resultados clínicos, sociais e econômicos. No entanto, ainda é raramente escolhido como primeira terapia para pacientes com falência renal irreversível. Foram desenvolvidas iniciativas em diferentes partes do mundo para identificar as razões pelas quais o TRP ainda não é amplamente utilizado e para facilitar o acesso de pacientes com doença renal em estágio terminal às vantagens associadas ao mesmo. Este artigo aborda as principais vantagens e dificuldades do TRP e discute quando ele deve ser indicado e como preparar potenciais receptores para o TRP.

Renouncement of renal replacement therapy: withdrawal and refusal.

Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Determinants of the serial changes in measurements of renal allograft Doppler resistive index in the first postoperative month / Determinantes de alterações seriadas nas medidas do índice de resistividade de Doppler do aloenxerto renal no primeiro mês pós-operatório

Abstract Introduction: The role of single Doppler-derived renal resistive index (RI) in renal allograft management is still a controversial issue, however detection of changes in serial duplex scanning has been reported as more valuable. This study aimed to test the hypothesis that early change in RI following transplantation may be related to factors associated with delayed graft function (DGF). Material and methods: 113 patients were included, in whom two RI measurements were performed within 30 days post-transplant. According to an RI change (equal to or more than 10%) in the second measurement, patients were assigned to decrease (Group I), no change (Group II), or increase (Group III) group. Results: 30 subjects had a decrease, 55 had no change, and 28 had an increase in the second RI measurement. The donors were younger in Group III in comparison to Group II. In comparison to Group I, Group III had a higher frequency of deceased donor, DGF, and presence of tubular necrosis and tubular vacuolization in peri-implantation biopsies. Conclusion: the increase of RI during the first weeks of the postoperative period seems to be associated with DGF and with tubular necrosis / tubular vacuolization in peri-implantation biopsies, likely related to ischemia reperfusion injury.

Resumo Introdução: O papel do índice de resistividade renal (IR) derivado de varredura por Doppler no manejo de aloenxertos renais, em exame isolado, ainda é uma questão controversa; no entanto, em exames seriados, a detecção de alterações nas imagens duplex tem sido relatada como mais relevante. Material e métodos: 113 pacientes foram incluídos, nos quais duas medidas de IR foram realizadas dentro de 30 dias após o transplante. De acordo com uma alteração do IR (igual ou superior a 10%) na segunda medida, os pacientes foram classificados em redução (Grupo I), nenhuma alteração (Grupo II) ou aumento (Grupo III). Resultados: 30 indivíduos tiveram redução, 55 não tiveram alterações e 28 tiveram aumento na segunda medição do IR. Os doadores eram mais jovens no Grupo III em comparação ao Grupo II. Em comparação ao Grupo I, o Grupo III apresentou maior frequência de doador falecido, FTE, presença de necrose tubular e vacuolização tubular nas biópsias peri-implantares. Conclusão: o aumento do IR durante as primeiras semanas no período pós-operatório parece estar associado à FTE e à necrose tubular/vacuolização tubular nas biópsias peri-implantares, provavelmente relacionadas à lesão por isquemia-reperfusão.

Renouncement of renal replacement therapy: withdrawal and refusal / Renúncia à terapia renal substitutiva: descontinuação e sonegação

Abstract Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Resumo A renúncia à terapia renal substitutiva (TRS) é um dilema. Essa revisão aborda o conceito, magnitude, prognóstico, estratégias e condutas sobre o tema, em pacientes com doença renal crônica e com injúria renal aguda. Evidências indicam ser a recusa mais comum e de prognóstico mais incerto do que a suspensão da TRS. Quando a TRS não agrega sobrevida ou qualidade de vida, o tratamento conservador com cuidados paliativos pode ser uma alternativa. A evolução das diretrizes sobre a renúncia à TRS e a instituição de cuidados paliativos é revista, com ressalva à ausência de tais recomendações no Brasil. Em certos casos, a renúncia à TRS pode ter sustentação ética e legal no país, amparada pelo direito à morte digna. A maior expectativa de vida e pressões econômicas exigem maior discussão sobre indicações e uso sustentável da TRS, demandando maior conscientização e, possivelmente, a elaboração de diretrizes nacionais sobre o tema.

Experimentando a teoria na prática: reflexão a partir das vivências dos residentes em saúde da família na USF Antares / Experiencing the theory in practice: reflection from the experiences of residents in the family health at USF Antares

(...) Este trabalho busca analisar as atividades realizadas pela nossa equipe, alocada em Antares, através da produção de conhecimento a partir da experiência profissional. Utilizamos para tal fim os Diários Reflexivos, o Relatório de Identificação de Necessidades e Potencialidades da Unidade de Saúde da Família Antares, o Mapa Conceitual e dados resgatados através do Sistema de informação da Atenção Básica. A partir da experiência vivida em campo e das reflexões decorrentes desta prática, optamos por desenvolver projetos quem nos permitissem contribuir para a capacidade resolutiva das equipes e para a ampliação da clínica. Apesar da Estratégia de Saúde da família estar implantada há oito anos nesta Unidade de Saúde da família, há muito a caminhar para sua consolidação e ampliação das formas de cuidado.