La oferta de médicos especialistas en Uruguay, 2020. El caso de la nefrología / Medical specialists supply in Uruguay in 2020. A study that focuses on nephrologists / Oferta de médicos especialistas no Uruguai, 2020. O caso da nefrologia

Resumen: Objetivo: estimar la oferta de nefrólogos en Uruguay en 2020. Método: Se plantea analizar las fuentes de información de acceso público como insumo para estimar la oferta de especialistas médicos en Uruguay, su completitud, fiabilidad y limitaciones. Resultados: en 2020, se identifican 178 médicos con desempeño profesional activo en el área de la nefrología en Uruguay. Es una especialidad con una pirámide feminizada (más del 70% son mujeres), y con más de la mitad de los médicos con edades por encima de los 49 años. Si se restringe el universo a los de 65 años o menos, el país cuenta con una oferta de 173 especialistas. Más allá de las limitaciones, es la mejor aproximación a la cantidad y estructura demográfica de la profesión en el país. Conclusiones: el estudio aporta una estimación sobre la oferta de recursos humanos en nefrología. El poder realizar este tipo de trabajo es un avance sustantivo para el Uruguay. La información y los sistemas de información se conciben como un insumo fundamental para el proceso de toma de decisión y gestión en salud. En tal sentido cobra relevancia la optimización del uso de los datos y la información disponible en cada momento, así como la identificación de los datos necesarios y no disponibles, de manera de promover su incorporación en próximas innovaciones de los sistemas de registros sistemáticos de datos.

Abstract: Objective: to estimate nephrologists´ supply in Uruguay in 2020. Method: an analysis of information sources of public access was performed to estimate medical specialists supply in Uruguay, as well as its completeness, reliability and limitations. Results: in 2020, 178 physicians were identified as active nephrology professionals in Uruguay. This area of specialization may be represented as a feminized pyramid, 70% of nephrologists are women and over 50% of them are over 49 years old. If you further restrict these specialists' universe to those who are 65 years old or younger, we find there are 173 medical specialists in Uruguay. Beyond limitations in the method, this is the most accurate survey in terms of the number of nephrologists in the country and the demographic structure of this medical specialization. Conclusions: the study provides an estimation on the human resources supply in nephrology. The ability to conduct this kind of study constitutes a significant progress in Uruguay. Information and information systems are seen as a key input to manage health issues and make decisions in the field of healthcare. As a matter of fact, optimization in the use of data and information available at any time, as well as identifying required data that are not available in order to promote its collection in future innovations of data recording systems is highly relevant.

Resumo: Objetivo: estimar a oferta de nefrologistas no Uruguai no ano de 2020. Método: propor a análise das futuras informações de acesso público como entrada para estimar a oferta de especialistas médicos no Uruguai, sua completitude, fiabilidade e limitações. Resultados: em 2020, foram identificados 178 médicos com desempenho profissional ativo na área da Nefrologia no Uruguai. É uma especialidade com uma pirâmide feminizada - mais de 70% são mulheres, e mais da metade dos médicos com mais de 49 anos. Se este universo for restringido a profissionais com 65 anos ou menos, o país conta com uma oferta de 173 especialistas. Mesmo considerando as limitações, esta é a melhor aproximação à quantidade e estrutura demográfica da profissão no país. Conclusões: o estudo aporta uma estimativa sobre a oferta de recursos humanos em nefrologia. A possibilidade de realizar este tipo de análise é um avanço importante para o Uruguai. A informação e os sistemas de informação são concebidos como um insumo fundamental para o processo de tomada de decisões e o processo de gestão em saúde. Sendo assim, a otimização do uso de dados e informações disponíveis em cada momento, bem como a identificação dos dados necessários e não disponíveis, para promover sua incorporação nas próximas inovações dos sistemas de registros sistemáticos de dados.

Evaluación de las necesidades de recursos humanos en salud: aplicación a la estimación de nefrólogos en Uruguay / Assessing the need for human resources in health: Nephrologist supply forecast in Uruguay / Avaliação das necessidades de recursos humanos em saúde: aplicação à estimativa de nefrologistas no Uruguai

Introducción: mejorar la salud de la población, considerando acceso universal con equidad, requiere de un número de profesionales y una distribución de los mismos adecuada a los problemas de salud de las personas. Las metodologías rigurosas deberían incorporar la identificación de las necesidades en salud para poder cumplir con este principio. Objetivo: estimar estándares de necesidad de nefrólogos para la población de Uruguay en 2020. Método: se conformó un grupo de referentes en nefrología procedentes de la academia y/o Sociedad Científica, se recabaron antecedentes y fuentes de la especialidad vinculadas a los problemas de salud renal en la población. Se definieron un conjunto de supuestos y condiciones iniciales. Se estimó la necesidad de nefrólogos de Uruguay para el año 2020, total del país y por departamento, expresada en valores absolutos y en términos de tasas de profesionales respecto a la población. Se identificaron escenarios alternativos de necesidad a partir de modificaciones de las condiciones iniciales. Resultados: para todo el país la necesidad de nefrólogos se estima entre 139 y 192 profesionales, esto implica una tasa de necesidad en un rango de 39 a 54 por millón de habitantes. Conclusiones: el estudio es el primero en Uruguay en reportar estándares de necesidad de nefrólogos expresados en términos de tasas de especialistas por población en diferentes escenarios definidos a partir de criterios que han sido explicitados y fundamentados.

Introduction: improving the health of populations by means of favoring universal access with equity requires the appropriate number and right distribution of professionals, according to the different health problems people face. Rigorous methodologies should include identification of health requirements in order to comply with this principle. Objective: to estimate the demand for nephrologists in the Uruguayan population in 2020. Method: a group of reference nephrologists - scholars or members of the scientific society - was formed to forecast the demand for these specialists. To that end they reviewed historical data and sources of this field of knowledge that have some connection with kidney diseases in the studied population. Subsequently, a number of assumptions and initial conditions were defined to conduct the study. The demand for nephrologists in Uruguay by 2020 was estimated for the whole country and by department, and it was expressed in absolute values and professional-to-population ratio. Alternative requirement scenarios were identified based on modifications to the initial conditions. Results: the demand for nephrologists is between 139 and 192 professionals, which implies a 39 to 54 per 1 million inhabitants ratio. Conclusions: this is the first one of this kind of studies conducted in Uruguay to report standards for nephrologists requirement in specialists per one million inhabitants, for different scenarios defined based on criteria that have been made explicit and backed.

Introdução: melhorar a saúde da população, considerando o acesso universal com equidade, requer um número de profissionais com uma distribuição adequada aos problemas de saúde das pessoas. Para cumprir este princípio são necessárias metodologias rigorosas que incorporem a identificação das necessidades de saúde. Objetivo: estimar padrões de necessidade de nefrologistas para a população do Uruguai em 2020. Método: formou-se um grupo de referência em nefrologia da academia e/ou Sociedade Científica, que pesquisaram os antecedentes e as fontes da especialidade ligados a problemas de saúde renal na população. Um conjunto de premissas e condições iniciais foi definido. A necessidade de nefrologistas no Uruguai foi estimada para o ano de 2020, para o total do país e por departamento, expressa em valores absolutos e em termos de proporção de profissionais para a população. Cenários alternativos de necessidade foram identificados com base em modificações das condições iniciais. Resultados: para todo o país, a necessidade de nefrologistas está entre 139 e 192 profissionais, o que implica uma taxa de necessidade na faixa de 39 a 54 por milhão de habitantes. Conclusões: o estudo é o primeiro no Uruguai a relatar padrões de necessidade de nefrologistas expressos em termos de taxas de especialistas por população, em diferentes cenários definidos com base em critérios explicados e fundamentados.

Proyección de brecha de especialistas en nefrología en Uruguay 2020-2050: aplicación de un modelo de dinámica de sistemas

Objetivo Estimar el equilibrio/desequilibrio entre la oferta y la necesidad de nefrólogos en Uruguay para el año 2020 así como la tendencia hacia el 2050. Métodos Se desarrolló un modelo de simulación, aplicando la metodología de dinámica de sistemas con dos componentes: el de oferta y el de necesidad. Se definió 2020 como el año base y un horizonte de proyección hasta 2050. Se comparó la oferta y la necesidad en el periodo de proyección para establecer la brecha tanto en términos absolutos como relativos. Resultados La proyección de brecha para todos los escenarios considerados es de superávit en la mayor parte del periodo analizado. Conclusiones El trabajo aporta insumos respecto de aquellos parámetros sobre los que se puede incidir y que afectan a la oferta de especialistas. El valor de las proyecciones radica en su utilidad para identificar la situación actual y las tendencias futuras a las que deben responder los responsables de la formulación de políticas.

Objective To estimate the balance/imbalance between supply and demand of nefrologists in Uruguay for the year 2020, adding its tendency towards 2050. Methods A simulation model was developed, applying a two dynamic systems methodology with two components: that of supply and that of need. The base year was defined as 2020 with a projection horizon up to 2050. Supply and need were compared for the projection period to establish the gap, both in relative and absolute terms. Results The projection gap for all considered scenarios is that of surplus for most of the analyzed period. Conclusions This work offers input with respect of impactful parameters that affect healthcare specialists supply. The key value of the projections lies in its utility to identify the current situation and its future tendencies, to which those responsible for policy making have to respond.

Salt-related practices and its association with 24-hour urinary sodium excretion in an Uruguayan population cohort / Prácticas relacionadas con la sal y su asociación con la excreción urinaria de sodio en 24 horas en una cohorte de población en Uruguay / Práticas relacionadas ao uso do sal e sua associação com a excreção de sódio na urina de 24 horas em uma coorte populacional uruguaia

Abstract Objectives. To evaluate the association between knowledge, attitudes, and behavior (KAB) towards sodium use and sodium intake measured by 24-hour urinary collection in an adult cohort from Uruguay (Genotype Phenotype and Environment of Hypertension Study, GEFA-HT-UY). Methods. In a cross-sectional study (n = 159), a single 24-hour urinary sample, participants' physical, biochemical and blood pressure measurements and questionnaire data were collected. The association between KAB and 24-hour urinary sodium excretion was assessed using general linear models. Results. Mean age of participants was 49.8±15.5 years, 67.9% were women, and mean 24-hour urinary sodium excretion was 3.6±1.7 g/day. Although 90.6% of participants exceeded the maximum recommended intake as indicated by urinary sodium excretion, more than half misperceived their actual intake, reporting consuming "the right amount." Almost three-quarters of the participants reported being concerned about the amount of sodium in their diet, but only 52.8% reported taking action to control it. Lack of procedural knowledge was observed. There was no association between KAB and sodium use and intake assessed by 24-hour urinary sodium excretion. Conclusions. The lack of association between KAB towards the use of sodium and intake measured by 24-hour urinary excretion reflects the need to support people with opportunities and motivations to reduce sodium consumption. Structural actions to promote an adequate food environment, such as the effective implementation of the front-of-package nutrition labeling in Uruguay, are positive steps.

RESUMEN Objetivos. Evaluar la relación entre conocimientos, actitudes y comportamientos en lo relativo a la ingesta de sodio medida por la recolección de orina de 24 horas en una cohorte de adultos en Uruguay (GEnotipo, Fenotipo y Ambiente de la HiperTensión Arterial en UruguaY, GEFA-HT-UY). Métodos. En un estudio transversal (n = 159), se obtuvo una muestra urinaria de 24 horas y los datos de un cuestionario y de las mediciones físicas, bioquímicas y de presión arterial de los participantes. Se evaluó la asociación entre conocimientos, actitudes y comportamientos y la excreción urinaria de sodio en 24 horas con modelos lineales generales. Resultados. La edad media de los participantes fue 49,8±15,5 años, 67,9% eran mujeres y la excreción urinaria media de sodio en 24 horas fue de 3,6±1,7 g/día. Aunque 90,6% de los participantes excedieron la ingesta máxima recomendada de acuerdo con la excreción urinaria de sodio, más de la mitad percibió su ingesta real incorrectamente al señalar que consumía "la cantidad correcta". Casi tres cuartas partes de los participantes manifestaron estar preocupados por la cantidad de sodio en su dieta, si bien solo 52,8% declaró haber tomado medidas para controlarla. Se observó una falta de conocimiento sobre los procedimientos. No se encontró una asociación entre conocimientos, actitudes y comportamientos y la ingesta de sodio evaluada mediante la excreción urinaria de sodio en 24 horas. Conclusiones. La falta de relación entre conocimientos, actitudes y comportamientos respecto del consumo de sodio y su ingesta medida por excreción urinaria en 24 horas refleja la necesidad de apoyar a las personas con oportunidades y motivaciones para reducir el consumo de sodio. Adoptar medidas estructurales que promuevan unas condiciones alimentarias adecuadas, como la aplicación efectiva del etiquetado nutricional frontal en Uruguay, constituye un paso en la dirección correcta.

RESUMO Objetivos. Avaliar a associação entre conhecimento, atitudes e comportamento (KAB, sigla do inglês Knowledge, Attitudes, Behavior) e o uso e ingestão de sódio, medida pela coleta de urina de 24 horas em uma coorte de adultos do Uruguai (Estudo do Genótipo, Fenótipo e Ambiente da Hipertensão, GEFA-HT-UY). Métodos. Em um estudo transversal (n = 159), foi coletada uma única amostra de urina de 24 horas dos participantes, medidas físicas, bioquímicas e de pressão arterial, e dados de questionários. A associação entre KAB e excreção urinária de sódio nas 24 horas foi avaliada por meio de modelos lineares gerais. Resultados. A idade média dos participantes foi de 49,8±15,5 anos; 67,9% eram mulheres e a excreção média de sódio na urina de 24 horas foi de 3,6±1,7 g/dia. Embora 90,6% dos participantes excedessem a ingestão máxima recomendada, conforme indicado pela excreção urinária de sódio, mais da metade dos participantes não tinha percepção da real ingestão de sódio, relatando consumir "a quantidade correta". Quase três quartos dos participantes relataram estar preocupados com a quantidade de sódio na dieta, mas apenas 52,8% relataram ter implementado medidas para controlá-la. Observou-se falta de conhecimento de procedimentos. Não houve associação entre KAB e o uso e a ingestão de sódio avaliada pela excreção de sódio na urina de 24 horas. Conclusões. A falta de associação entre KAB e o uso e a ingestão do sódio avaliada pela excreção urinária de 24 horas reflete a necessidade de oferecer apoio aos indivíduos por meio de oportunidades e motivações para reduzir o consumo de sódio. Ações estruturais para promover um ambiente alimentar adequado, como a implementação efetiva de advertências na rotulagem frontal dos alimentos no Uruguai, são passos positivos.

Tobacco Use and the Kidney: A Review of Public Policies and Studies on Kidney Disease Progression.

Clinical Background: Cigarette smoking is one of the leading causes of preventable deaths, including cardiovascular diseases and cancer. However, the effects of tobacco use on chronic kidney disease (CKD) are less widespread. Epidemiology: Smoking tobacco is associated with proteinuria and attenuation of glomerular filtration rate in the general population of different ethnicities. Smoking also accelerates the progression of established CKD and aggravates proteinuria along the wide spectrum of causes determining kidney disease. Furthermore, smoking worsens the survival of kidney transplant recipients and shortens graft survival. Most of the effects of tobacco exposure are dose and time dependent and could be ameliorated with smoking cessation. Challenges: In the last decades, tobacco use policies and regulations were implemented around the world obtaining a global 6% reduction in smoking prevalence. However, the reduction was not proportionally equal in all the geographical areas around the world. The region of Americas experimented the most positive result in reducing smoking prevalence. Smoking trends in South East Asian and Eastern Mediterranean regions show minor decrease or increased rates. The World Health Organization projected reaching a global target prevalence of 15% by 2025. Prevention and Treatment: The results showing smoking cessation slows the progression of kidney disease in smokers should drive our effort to help our patients quit smoking. Smoking prevention at the population level, and particularly in those at risk of CKD or with established CKD should be part of health policies and regulations all around the world.

Recomendaciones sobre la vacunación contra SARS-CoV-2 / COVID-19 en pacientes con enfermedad renal y trasplante renal / Recommendations for the SARS-CoV-2 vaccination of patients with kidney disease and transplant recipients / Recomendações sobre vacinação contra SARS-CoV-2 / COVID-19 em pacientes com doença renal e transplante renal

Resumen: Este documento de recomendaciones tiene como objetivo orientar a médicos nefrólogos y no nefrólogos que asisten a pacientes con enfermedad renal crónica (ERC) en todas las etapas de la misma, en el proceso de vacunación contra el SARS-CoV-2. Como consecuencia de la situación epidemiológica y de los tiempos del proceso de elaboración de las vacunas disponibles, no se ha generado evidencia lo suficientemente potente, por lo que las recomendaciones no se acompañan del nivel de evidencia. Se fundamenta la necesidad de priorizar la vacunación en este grupo de pacientes en el mayor riesgo de adquirir la infección por SARS-CoV-2, desarrollar la enfermedad COVID-19 con mayor gravedad y presentar una mortalidad más elevada que la población general. Las recomendaciones se organizan por grupos de pacientes considerando pacientes con ERC no dialítica, diálisis y trasplante renal, y pacientes bajo tratamiento inmunosupresor.

Summary The objective of this document containing recommendations is to provide guidelines for nephrologists and non-nephrologists who assist patients with chronic kidney disease (CKD) at all stages of the disease on the vaccination process against SARS-CoV-2. As a consequence of the current epidemiological situation and the timing of the COVID-19 vaccine development -for available vaccines- there is no solid evidence, and thus, recommendations are not accompanied by the due medical proof. The need to prioritize vaccination in this group of patients is based on the increased risk of acquiring the SARS-CoV-2 infection, developing the COVID-19 disease with greater severity and presenting higher mortality rates than the general population. The recommendations are organized by groups of patients, considering patients with non-dialytic CKD, dialysis and kidney transplantation, and patients under immunosuppressive treatment.

Resumo: O objetivo deste documento de recomendações é orientar os nefrologistas e não nefrologistas que atendem pacientes com doença renal crônica (DRC) em todas as fases da doença, no processo de vacinação contra a SARS-CoV-2. Como consequência da situação epidemiológica e do momento do processo de produção das vacinas disponíveis, não foram geradas evidências suficientemente potentes, de modo que as recomendações não são acompanhadas de seu nível de evidência. A necessidade de priorizar a vacinação neste grupo de pacientes baseia-se no maior risco de adquirir a infecção pelo SARS-CoV-2, desenvolver a doença COVID-19 com maior gravidade e apresentar mortalidade superior à da população em geral. As recomendações são organizadas por grupos de pacientes, considerando pacientes com DRC não dialítica, em diálise, com transplante renal, e pacientes em tratamento imunossupressor.

May measurement month 2017: Latin America.

OBJECTIVES: To raise awareness of blood pressure, measured by number of countries involved, number of people screened, and number of people who have untreated or inadequately treated hypertension. METHODS: An opportunistic cross-sectional survey of volunteers aged at least 18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard May measurement month protocol. Eighteen countries in Latin America and the Caribbean participated in the campaign, providing us with a wide sample for characterization. RESULTS: During May measurement month 2017 in Latin America and the Caribbean, 105 246 individuals were screened. Participants who had cardiovascular disease, 2245 (2.3%) had a prior myocardial infarction, and 1711 (1.6%) a previous stroke, additionally 6760 (6.4%) individuals were diabetic, 7014 (6.7%) current smokers and 9262 (8.8%) reported alcohol intake once or more per week. Mean SBP was 122.7 mmHg and DBP was 75.6 mmHg. After imputation, 42 328 participants (40,4%) were found to be hypertensive. CONCLUSION: The high numbers of participants detected with hypertension and the relatively large proportion of participants on antihypertensive treatment but with uncontrolled hypertension reinforces the importance of this annual event in our continent, to raise awareness of the prevention of cardiovascular events.

Strain de la aurícula izquierda por speckle tracking: evaluación de su reproducibilidad global y segmentaria / Left atrium strain by speckle tracking: evaluation of its global and segmental reproducibility / Strain do atrio esquerdo por speckle tracking: avaliação da sua reprodutibilidade global e segmentar

Resumen: Objetivos: evaluar la reproducibilidad intra e interobservador en la medición del strain auricular izquierdo función reservorio mediante speckle tracking, usando un protocolo para su análisis global y segmentario. Métodos y resultados: se estableció un protocolo para la adquisición y medición del strain de la aurícula izquierda (SAI), para un análisis global y segmentario, utilizando un modelo tipo "ojo de buey". Se evaluó su reproducibilidad mediante el coeficiente de correlación intraclase (CCI) en 20 participantes de la cohorte GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY (GEFA-HT-UY). Se obtuvo una excelente reproducibilidad global intraobservador de 0,92 (IC: 0,81-0,97) y buena reproducibilidad interobservador de 0,82 (IC: 0,59-0,92). El análisis segmentario de SAI no fue reproducible. Los valores promedio de SAI fueron 31,0% (± 7,5) para la vista de 4 cámaras; 34,6% (± 9,9) para la vista de 2 cámaras, y 36,8% (± 13,9) para la vista de 3 cámaras. El valor global de SAI tomando las tres vistas fue de 34,1% (± 7,8) y de 32,8% (± 6,5) considerando las vistas de 4 y 2 cámaras. Conclusión: el protocolo de adquisición y análisis de SAI para la función de reservorio fue reproducible para su análisis global, no así para su análisis segmentario.

Summary: Objective: to evaluate intra and inter-observer reproducibility of speckle tracking left atrial strain reservoir function using a protocol for its global and segmental analysis. Methods: a protocol for acquisition and measurement of left atrial strain was created (bull's-eye type), for its global and segmental analysis. Reproducibility was assessed using intraclass correlation coefficient in twenty participants from the GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY cohort. For global assessment intra-observer reproducibility graded excellent (0.92 (IC: 0.81-0.97)) while inter-observer reached good reproducibility (0.82 (IC: 0.59-0.92)). Left atrial strain segmental analysis was not reproducible. Mean (±SD) left atrial strain was 31.0±7.5% for 4 chamber view, 34.6±9.9% for 2 chamber view and 36.8±13.9% for 3 chamber view. Global left atrial strain considering three views was 34.1±7.8%, and 32.8±6.5% considering 4 and 2 chamber views. Conclusion: left atrial strain acquisition and analysis protocol for reservoir function was reproducible for its global but not for its segmental analysis.

Resumo: Objetivo: avaliar a reprodutibilidade intra e interobservador do strain speckle tracking atrial esquerdo função de reservatório usando um protocolo para sua análise global e segmentar. Métodos: foi criado um protocolo de aquisição e mensuração de strain do atrio esquerdo, por sua análise global e segmentar (tipo olho de boi). A reprodutibilidade foi avaliada por meio do coeficiente de correlação intraclasse em vinte participantes da coorte GEnotipo, Fenotipo e Ambiente da Hiper-Tensiologia arterial em UruguaY. Para a avaliação global, a reprodutibilidade intra-observador foi excelente (0,92 (IC: 0,81-0,97)), enquanto o interobservador alcançou boa reprodutibilidade (0,82 (IC: 0,59-0,92)). A análise segmentar de strain do atrio esquerdo não foi reprodutível. A média (± SD) de strain do atrio esquerdo foi 31,0 ± 7,5% para 4 câmaras, 34,6 ± 9,9% para 2 câmaras e 36,8 ± 13,9% para 3 câmaras. A strain global, considerando três visualizações, foi de 34,1 ± 7,8% e 32,8 ± 6,5% considerando a visão de 4 e 2 câmaras. Conclusão: o protocolo de aquisição e análise de strain do atrio esquerdo para função de reservatório foi reproduzível para sua análise global, mas não para sua segmentação.

Central hemodynamics in relation to blood lead in young men prior to chronic occupational exposure.

Background: Aortic pulse wave velocity (aPWV) predicts cardiovascular complications, but the association of central arterial properties with blood lead level (BL) is poorly documented. We therefore assessed their association with BL in 150 young men prior to occupational lead exposure, using baseline data of the Study for Promotion of Health in Recycling Lead (NCT02243904). Methods: Study nurses administered validated questionnaires and performed clinical measurements. Venous blood samples were obtained after 8-12 h of fasting. The radial, carotid and femoral pulse waves were tonometrically recorded. We accounted for ethnicity, age, anthropometric characteristics, mean arterial pressure, heart rate, smoking and drinking, and total and high-density lipoprotein serum cholesterol, as appropriate. Results: Mean values were 4.14 µg/dL for BL, 27 years for age, 108/79/28 mm Hg for central systolic/diastolic/pulse pressure, 100/10% for the augmentation ratio/index, 1.63 for pressure amplification, 5.94 m/s for aPWV, 27/11 mm Hg for the forward/backward pulse pressure height, and 43% for the reflection index. Per 10-fold BL increase, central diastolic pressure and the augmentation ratio were respectively 5.37 mm Hg (95% confidence interval [CI], 1.00-9.75) and 1.57 (CI, 0.20-2.94) greater, whereas central pulse pressure and the forward pulse pressure height were 3.74 mm Hg (CI, 0.60-6.88) and 3.37 mm Hg (CI, 0.22-6.53) smaller (p ≤ .036 for all). The other hemodynamic measurements were unrelated to BL. The reflected pulse peak time was inversely correlated with diastolic pressure (r = -0.20; p ≤ .017). Conclusion: At the exposure levels observed in our current study, aPWV, the gold standard to assess arterial stiffness, was not associated with BL. Increased peripheral arterial resistance, as reflected by higher diastolic pressure, might bring reflection points closer to the heart, thereby moving the backward wave into systole and increasing the augmentation ratio in relation to BL.

Strain de la aurícula izquierda por speckle tracking: descripción de protocolo para su medición "paso a paso"

En base a la evidencia disponible y a la experiencia de trabajo en la cohorte del estudio GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY (GEFA-HT-UY) se describe un protocolo "paso a paso" para la adquisición y medición de strain de la aurícula izquierda, tanto de forma global como para un análisis segmentario tipo "ojo de buey", mediante ecocardiografía bidimensional con speckle tracking.

Summary: Based on the available evidence and work experience of the GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY (GEFA-HT-UY) cohort, a "step by step" protocol for the acquisition and measurement of the left atrial strain is described, both as a global and segmentary analysis ("bull's eye" like ) using two-dimensional speckle tracking echocardiography.

Baseado nos elementos disponíveis e a experiência de trabalhar na coorte do estudo GEnotipo, Fenotipo y Ambiente de la HiperTensión arterial en el UruguaY (GEFA-HT-UY) se descreve um protocolo de "passo a passo" para a aquisição e a medição do strain da aurícula esquerda, tanto em forma global como pra uma análise segmentar tipo "olho de boi", usando a ecocardiografia bidimensional com speckle tracking.

Desphospho-uncarboxylated matrix Gla protein is a novel circulating biomarker predicting deterioration of renal function in the general population.

Background: Recent studies showing an inverse association between estimated glomerular filtration rate (eGFR), a microvascular trait, and inactive desphospho-uncarboxylated matrix Gla protein (dp-ucMGP) support the hypothesis that after vitamin K-dependent activation, matrix Gla protein (MGP) is renoprotective, but these were limited by their cross-sectional design. Methods: In 1009 randomly recruited Flemish (50.6% women), we assessed the association between eGFR and plasma dp-ucMGP, using multivariable-adjusted analyses. Results: From baseline to follow-up 8.9 years later (median), dp-ucMGP increased by 23.0% whereas eGFR decreased by 4.05 mL/min/1.73 m2 (P < 0.001). In 938 participants with baseline eGFR ≥60 mL/min/1.73 m2, the incidence of eGFR <60 mL/min/1.73 m2 at follow-up was 8.0% versus 4.1% in the top versus the bottom halve of baseline dp-ucMGP. For a 5-fold higher plasma dp-ucMGP at baseline, eGFR at follow-up decreased by 3.15 mL/min/1.73 m2 [95% confidence interval (CI) 1.26-5.05; P = 0.001]. The hazard ratio expressing the risk of progression to eGFR <60 mL/min/1.73 m2 was 3.49 (95% CI 1.45-8.40; P = 0.005). The hazard ratio relating the presence of microalbuminuria at follow-up to baseline dp-ucMGP was 4.70 (95% CI 1.57-14.1; P = 0.006). Conclusions: In conclusion, circulating inactive dp-ucMGP, a biomarker of poor vitamin K status, predicts renal dysfunction. Possible underlying mechanisms include protection by activated MGP against calcification and inhibition of the bone morphogenetic protein-signalling pathway.

37. Strain auricular izquierdo por speckle tracking: protocolo para su estudio y creación de modelo para análisis segmentario

Antecedentes: el strain auricular izquierdo reservorio (SAIR) nos da información adicional respecto a la función auricular izquierda y presiones de llenado del VI. También predice eventos adversos (IC, FA). No existen publicaciones que protocolicen el método, y la evidencia disponible es dispar por diferencias en su metodología. Luego de una extensa revisión bibliográfica y en base a la experiencia de nuestro grupo de trabajo proponemos un protocolo para su estudio. Objetivo: protocolizar la medición del SAIR con Speckle Tracking. Familiarizar al ecocardiografista con esta nueva técnica. Material y método: se realizó una extensa revisión bibliográfica. Se adquirieron imágenes de ETT de pacientes de la cohorte poblacional GEFA-HT-Uy. Se realizó posproceso de las imágenes en Echopac mediante Q Analysis, utilizando Speckle Tracking. Durante un año se desarrolló la técnica realizando múltiples mediciones de Strain auricular reservorio por dos investigadores clínicos, con avanzado nivel técnico en ecocardiografía (nivel 3). Se realizaron tres medidas por paciente, normatizando la medición en base a ensayo y error. Se creó un modelo de análisis segmentario de aurícula izquierda (tipo "bull eye"). Posteriormente se confeccionó un protocolo detallado para el estudio del SAIR gatillado por onda R, el cual proponemos presentar en el Congreso Uruguayo de Cardiología. Resultados: se adquirieron imágenes de 52 pacientes, 28 mujeres. Se realizaron 156 medidas de Strain auricular, tres por paciente. Se elaboró un protocolo que estandariza la medida, gatillada por onda R. En base a este protocolo hemos estudiado la reproducibilidad de la medición del SAIR, ensayo que se presenta en forma separada. Conclusiones: se desarrolló un modelo inédito de análisis segmentario de la aurícula izquierda. Se estandariza medición del SAIR mediante Speckle Tracking. Esto permite desarrollar líneas de investigación en función auricular con este método innovador.

Nitro-Arachidonic Acid Prevents Angiotensin II-Induced Mitochondrial Dysfunction in a Cell Line of Kidney Proximal Tubular Cells.

Nitro-arachidonic acid (NO2-AA) is a cell signaling nitroalkene that exerts anti-inflammatory activities during macrophage activation. While angiotensin II (ANG II) produces an increase in reactive oxygen species (ROS) production and mitochondrial dysfunction in renal tubular cells, little is known regarding the potential protective effects of NO2-AA in ANG II-mediated kidney injury. As such, this study examines the impact of NO2-AA on ANG II-induced mitochondrial dysfunction in an immortalized renal proximal tubule cell line (HK-2 cells). Treatment of HK-2 cells with ANG II increases the production of superoxide (O2●-), nitric oxide (●NO), inducible nitric oxide synthase (NOS2) expression, peroxynitrite (ONOO-) and mitochondrial dysfunction. Using high-resolution respirometry, it was observed that the presence of NO2-AA prevented ANG II-mediated mitochondrial dysfunction. Attempting to address mechanism, we treated isolated rat kidney mitochondria with ONOO-, a key mediator of ANG II-induced mitochondrial damage, in the presence or absence of NO2-AA. Whereas the activity of succinate dehydrogenase (SDH) and ATP synthase (ATPase) were diminished upon exposure to ONOO-, they were restored by pre-incubating the mitochondria with NO2-AA. Moreover, NO2-AA prevents oxidation and nitration of mitochondrial proteins. Combined, these data demonstrate that ANG II-mediated oxidative damage and mitochondrial dysfunction is abrogated by NO2-AA, identifying this compound as a promising pharmacological tool to prevent ANG II-induced renal disease.

Estimation of Glomerular Filtration Rate Based on Serum Cystatin C versus Creatinine in a Uruguayan Population.

Background. Estimation of glomerular filtration rate (eGFR) from biomarkers has evolved and multiple equations are available to estimate renal function at bedside. Methods. In a random sample of 119 Uruguayans (54.5% women; 56.2 years (mean)), we used Bland and Altman's method and Cohen's kappa statistic to assess concordance on a continuous or categorical (eGFR < 60 versus ≥60 mL/min/1.73 m(2)) scale between eGFRcys (reference) and eGFR derived from serum creatinine according to the Modification of Diet in Renal Disease (eGFRmdrd) or the Chronic Kidney Disease Epidemiology Collaboration equations (eGFRepi) or from both serum cystatin C and creatinine (eGFRmix). Results. In all participants, eGFRmdrd, eGFRepi, and eGFRmix were, respectively, 9.7, 11.5, and 5.6 mL/min/1.73 m(2) higher (P < 0.0001) than eGFRcys. The prevalence of eGFR <60 mL/min/1.73 m(2) was the highest for eGFRcys (21.8%), intermediate for eGFRmix (11.8%), and the lowest for eGFRmdrd (5.9%) and eGFRepi (3.4%). Using eGFRcys as reference, we found only fair agreement with the equations based on creatinine (Cohen's kappa statistic 0.15 to 0.23). Conclusion. Using different equations we reached clinically significant differences in the estimation of renal function. eGFRcys provides lower estimates, resulting in higher prevalence of eGFR <60 mL/min/1.73 m(2).

Rabdomiólisis por hipopotasemia severa: Report of six cases / Severe hypokalemic rhabdomyolysis

Rhabdomyolysis results from acute necrosis of skeletal muscle fibers and consequent leakage of muscle constituents into the circulation. It ranges from an asymptomatic state to a severe condition associated with extreme elevations in creatine kinase and acute renal failure. Reported etiologies of rhabdomyolysis include alcohol abuse, drugs, muscle trauma and muscle overexertion. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, toxins and endocrine disorders. Hypokalemia is a rare cause of rhabdomyolysis. We report six patients aged 31 to 57 years (three women) with a severe hypokalemic rhabdomyolysis, secondary to chronic diarrhea in two patients, treatment with loop diuretics in one and Gitelman syndrome in three. Rhabdomyolysis may be underdiagnosed in the context of hypokalemia, because the neuromuscular symptoms can be attributed solely to the electrolyte disorder.

Risk stratification by 24-hour ambulatory blood pressure and estimated glomerular filtration rate in 5322 subjects from 11 populations.

No previous study addressed whether in the general population estimated glomerular filtration rate (eGFR [Chronic Kidney Disease Epidemiology Collaboration formula]) adds to the prediction of cardiovascular outcome over and beyond ambulatory blood pressure. We recorded health outcomes in 5322 subjects (median age, 51.8 years; 43.1% women) randomly recruited from 11 populations, who had baseline measurements of 24-hour ambulatory blood pressure (ABP(24)) and eGFR. We computed hazard ratios using multivariable-adjusted Cox regression. Median follow-up was 9.3 years. In fully adjusted models, which included both ABP(24) and eGFR, ABP(24) predicted (P≤0.008) both total (513 deaths) and cardiovascular (206) mortality; eGFR only predicted cardiovascular mortality (P=0.012). Furthermore, ABP(24) predicted (P≤0.0056) fatal combined with nonfatal events as a result of all cardiovascular causes (555 events), cardiac disease (335 events), or stroke (218 events), whereas eGFR only predicted the composite cardiovascular end point and stroke (P≤0.035). The interaction terms between ABP(24) and eGFR were all nonsignificant (P≥0.082). For cardiovascular mortality, the composite cardiovascular end point, and stroke, ABP(24) added 0.35%, 1.17%, and 1.00% to the risk already explained by cohort, sex, age, body mass index, smoking and drinking, previous cardiovascular disease, diabetes mellitus, and antihypertensive drug treatment. Adding eGFR explained an additional 0.13%, 0.09%, and 0.14%, respectively. Sensitivity analyses stratified for ethnicity, sex, and the presence of hypertension or chronic kidney disease (eGFR <60 mL/min per 1.73 m(2)) were confirmatory. In conclusion, in the general population, eGFR predicts fewer end points than ABP(24). Relative to ABP(24), eGFR is as an additive, not a multiplicative, risk factor and refines risk stratification 2- to 14-fold less.