Enfoque médico social de la enfermedad renal crónica en Pediatría / Medical and social approach to chronic kidney disease in Paediatrics

RESUMEN Introducción: las malformaciones congénitas renales y de las vías urinarias constituyen un grupo heterogéneo de anomalías secundarias a un proceso anormal en el desarrollo embrionario del sistema renal. Objetivo: profundizar en los aspectos relacionados con el diagnóstico precoz de las malformaciones congénitas renales y de vías urinarias, como causa frecuente de la enfermedad renal crónica oculta en la edad pediátrica, desde una perspectiva integral y personalizada, sobre la base de un enfoque médico social. Métodos: se realizó una revisión sistemática sobre el tema en las bases de datos: EBSCO, SciELO, Scopus, PubMed, y en revistas de Nefrología pediátrica, de Pediatría, de Genética y de Teratología. Los artículos fueron publicados en idioma español o inglés. Se realizó un análisis de contenido directo para lograr la actualización teórica del tema con un enfoque médico social. Conclusiones: el desarrollo de la Nefrología pediátrica constituye una línea de trabajo del MINSAP. Sus principios son: la intersectorialidad, la prevención y la participación de especialidades afines (de manera que se alcancen resultados asistenciales, docentes e investigativos que determinen mayor calidad en el diagnóstico precoz de las malformaciones congénitas renales y de vías urinarias). Dicha afección es causa frecuente de la enfermedad renal crónica oculta en la edad pediátrica, desde una perspectiva integral y personalizada, sobre la base de un enfoque médico social.

ABSTRACT Introduction: congenital renal and urinary tract malformations constitute a heterogeneous group of anomalies secondary to an abnormal embryonic development of the renal system. Objective: to study in depth the aspects related to the early diagnosis of congenital renal and urinary tract malformations, as a frequent cause of occult chronic kidney disease in the paediatric age group, from an integral and personalized perspective, based on a medical and social approach. Methods: a systematic review on the subject was carried out in the following databases: EBSCO, SciELO, Scopus, PubMed, and in journals of Paediatric Nephrology, Paediatrics, Genetics and Teratology. The articles were published in Spanish or English languages. A direct content analysis was performed to achieve the theoretical update of the topic with a medical and social approach. Conclusions: the development of Paediatric Nephrology constitutes a line of work of MINSAP. Its principles are intersectoriality, prevention and participation of related specialities (in order to achieve care, teaching and research results that determine greater quality in the early diagnosis of congenital renal and urinary tract malformations). This condition is a frequent cause of occult chronic kidney disease in the paediatric age group, from an integral and personalized perspective, based on a medical and social approach.

Funcionabilidad y durabilidad de fístulas arterio-venosas para hemodiálisis en pacientes no diabéticos / Functionability and durability of arterio-venous fistulas for haemodialysis in non-diabetic patients

Introducción: Existe un incremento anual de pacientes con insuficiencia renal crónica tributarios a hemodiálisis. Para la realización de esta se requiere de la correcta inserción de accesos vasculares que sean duraderos y funcionales. Objetivo: Caracterizar la durabilidad y funcionabilidad de las fístulas arterio-venosas en pacientes no diabéticos con enfermedad renal crónica. Métodos: Se realizó un estudio ambispectivo en 60 pacientes no diabéticos, con enfermedad renal crónica, portadores de una fístula arterio-venosa interna autóloga. Se describieron las variables: edad, sexo, grado de la enfermedad, lugar de confección, durabilidad, funcionabilidad, intentos, superficialización, uso de prótesis de poli-tetra-fluoro-etileno y complicaciones. Resultados: La edad media de los pacientes fue de 55,7 ± 12,7 años y la mitad estuvo entre 40 y 59 años. Los del sexo masculino ocuparon el 71,7 por ciento. Las fístulas duraderas (66,7 por ciento) y las funcionales (71,7 por ciento) se mostraron como las de mayor aparición. Los pacientes con la enfermedad en grado 4 ocuparon el 51,7 por ciento. Las fístulas en zonas radio-cefálica (43,3 por ciento) y húmero-cefálica (45 por ciento) primaron. Solo el 71,7 por ciento tuvo un intento de cirugía. Únicamente en el 20 por ciento se realizó superficialización y cuatro pacientes (6,4 por ciento) recibieron prótesis de poli-tetra-fluoro-etileno. La trombosis representó la complicación más frecuente (25 por ciento). Conclusiones: La durabilidad y la funcionabilidad de las fístulas elaboradas se asociaron con factores como el grado de la enfermedad, el número de intentos, el uso de prótesis vasculares y las complicaciones(AU)

Introduction: There is an annual increase of patients with chronic renal impairment who need haemodialysis. The correct insertion of vascular accesses that are durable and functional is required to perform haemodialysis. Objective: Characterize the durability and functionability of arterio-venous fistulas in non-diabetic patients with chronic kidney disease. Methods: An ambispective study was conducted in 60 non-diabetic patients, with chronic kidney disease carrying an autologous internal arterio-venous fistula. The described variables were: age, sex, stage of the disease, place of manufacture, durability, workability, attempts, superficialization, use of polytetrafluoroethylene prostheses, and complications. Results: The average age of patients was 55.7 ± 12.7 years and half were between 40 and 59 years old. Males were 71.7 percent. Durable (66.7 percent) and functional (71.7 percent) fistulas were shown as the most common ones. Patients with a grade 4 disease represented the 51.7 percent. Fistulas in radio-cephalic zones (43.3 percent) and humerus-cephalic zone (45 percent) prevailed. Only 71.7 percent had an attempt of surgery. Only 20 percent had superficialization and four patients (6.4 percent) received polytetrafluoroethylene prostheses. Thrombosis was the most common complication (25 percent). Conclusions: The durability and functionability of the prepared fistulas were associated with factors such as the stage of the disease, the number of attempts, the use of vascular prostheses, and the complications(AU)

Predictors associated with sickle cell nephropathy: a systematic review

SUMMARY INTRODUCTION: Sickle cell anemia affects more than 30 million people worldwide. Chronic kidney disease develops in 40% of individuals. The death rate of patients with sickle nephropathy is still high, with little known predictors related to its development. To answer the question "What predictors are associated with the onset of chronic kidney disease in patients with sickle cell anemia?", this article seeks to contribute to a better understanding of sickle nephropathy, making possible a new look at the sickle cell anemia and its kidney complications. METHODS: A systematic review was developed, using the PRISMA recommendation, for cohort studies on predictors related to the outcome of sickle nephropathy in patients with sickle cell anemia. RESULTS: Initially 321 studies were identified in Pubmed, of which six were selected to compose this systematic review. Lower hemoglobin levels, increased ages and albuminuria were the most pointed predictors associated with chronic kidney disease. CONCLUSION: The main predictors associated with the development of chronic kidney disease in individuals with sickle cell anemia were lower hemoglobin levels, increased ages, and albuminuria. New studies evaluating predictors for the development of chronic kidney disease in sickle cell anemia are needed to better understand its installation and prevent its progression.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala / Factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala / Fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala

ABSTRACT Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER's pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis. Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother's education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables. Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother's level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

RESUMEN Objetivo. Determinar los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala. Métodos. Se realizó una encuesta transversal. La población de estudio fue la totalidad de pacientes pediátricos con enfermedad renal crónica en fase 5 ingresados en la unidad de nefrología pediátrica de Fundanier (N = 156). Mediante el muestreo aleatorio simple se dispuso de un total de 100 participantes. La recopilación de datos consistió en un cuestionario que abordaba las características individuales y del hogar, el acceso y el uso de la atención de salud y el lugar de residencia al inicio de la enfermedad. La etiología de la enfermedad renal crónica se obtuvo a partir de los expedientes médicos y los datos secundarios se recopilaron a nivel municipal. Se calcularon las estadísticas descriptivas y se empleó el método de regresión logística para el análisis bifactorial y multifactorial. Resultados. La razón de posibilidades (OR) se aproximó a 1 en casi todas las variables. Dos excepciones destacables en lo relativo a las características domésticas fueron el nivel de escolaridad de la madre hasta la educación primaria (OR 2,2727) y el lugar de residencia en un entorno urbano en la aparición de los síntomas (OR 0,4035). Las excepciones con respecto a las características municipales fueron las zonas de agricultura intensiva a pequeña escala (OR 3,8923) y las zonas de agricultura intensiva a gran escala (OR 0,3338). Los valores P y los intervalos de confianza indican que la muestra no fue lo suficientemente amplia para recoger las asociaciones estadísticamente significativas entre variables. Conclusiones. Los resultados del estudio sugieren que los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala son las prácticas agrícolas intensivas en el municipio de residencia y el nivel de escolaridad de la madre. Las futuras investigaciones con niños podrían incluir el diseño de casos o los estudios poblacionales en comunidades agrícolas. Se recomiendan intervenciones de salud pública que incorporen el tamizaje de la función renal en niños.

RESUMO Objetivo. Identificar os fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Métodos. Foi realizado um estudo transversal em uma população que consistiu de todos os pacientes pediátricos com doença renal crônica ativa em estágio 5 atendidos na unidade de nefrologia pediátrica da Fundación para el Niño Enfermo Renal (FUNDANIER) (N = 156). O processo de amostragem aleatória simples determinou a obtenção de uma amostra com 100 participantes. Um questionário foi usado para a coleta de dados sobre as características pessoais e familiares dos participantes, acesso à assistência de saúde e utilização de serviços e local de residência ao início da doença. Informação sobre a etiologia da doença renal crônica foi obtida dos prontuários médicos. Também foram coletados dados secundários ao nível da localidade. Estatísticas descritivas foram estimadas e um modelo de regressão logística foi usado nas análises bivariada e multivariada. Resultados. As razões de chance (odds ratio, OR) de quase todas as variáveis se aproximaram de 1. As exceções nas variáveis relativas às características familiares foram escolaridade da mãe de nível fundamental (OR 2,2727) e residir em área urbana ao início dos sintomas (OR 0,4035). As exceções nas variáveis ao nível municipal foram áreas de agricultura intensiva em pequena escala (OR 3,8923) e em grande escala (OR 0,3338). Os valores de p e os intervalos de confiança indicam que o tamanho da amostra não foi grande o suficiente para detectar associações estatisticamente significativas entre as variáveis. Conclusões. O estudo demonstrou que práticas agrícolas intensivas na localidade de residência e nível de escolaridade da mãe são fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Outros estudos em crianças devem ser realizados como estudos de caso-controle ou estudos populacionais em comunidades agrícolas. Recomendam-se também intervenções de saúde pública com a avaliação preventiva da função renal em crianças.

Obesity as a predictive factor for chronic kidney disease in adults: systematic review and meta-analysis

Chronic kidney disease (CKD) is one of the main chronic diseases affecting the world population due to its high prevalence and increasing morbidity. Similarly, obesity gained the interest of the scientific community as it directly or indirectly increases mortality from cardiovascular causes, and its prevalence characterizes a pandemic. The objective of this study was to investigate obesity measured by body mass index as a predictor for end-stage renal disease in the general adult population. A systematic review and meta-analysis was carried out by searching 10 databases for prospective or retrospective cohort studies, with no restrictions on the language of publication, including adults with obesity without previous renal disease and who evolved to CKD (diagnosed by estimated glomerular filtration rate below 60 mL&mac_middot;min-1&mac_middot;(1.73 m2)-1 over the follow-up period. The R software and Meta package were used for data analysis. After removing duplicates, 5431 studies were submitted to the steps of the systematic review, and 21 articles were included in the data analysis. In total, 3,504,303 patients, 521,216 with obesity, and an average follow-up time of 9.86 years were included. The relative risk of obese people for developing CKD in the random effects model was 1.81 (95%CI: 1.52-2.16). The evidence found in this meta-analysis confirmed that obese people are at higher risk of developing CKD that the non-obese population (1.81 times higher), with obesity being a priority risk factor in preventive actions.

Factores asociados a malformaciones congénitas renales y de vías urinarias / Factors associated to renal and urinary tract ´s congenital malformations

Introducción: Las malformaciones congénitas del riñón y del tracto urinario representan entre 20 y 30 por ciento de todas las malformaciones reconocidas en humanos. Objetivo: Identificar los antecedentes patológicos familiares y las enfermedades durante el embarazo asociados a la aparición de defectos congénitos renales. Métodos: Estudio descriptivo prospectivo transversal realizado en 672 niños nacidos entre julio de 2014 y junio de 2015 en Santa Clara, con ultrasonido prenatal normal. A todos los niños durante la consulta médica se les hizo examen físico detallado y previo consentimiento informado del familiar acompañante, se aplicó a estos una encuesta y se registraron variables epidemiológicas, antecedentes familiares de enfermedades renales, morbilidad de la madre durante el embarazo y se realizó un ultrasonido renal para identificar las alteraciones sonográficas sugerentes de algún tipo de anomalías del desarrollo renal. Resultados: En 40 (5,95 por ciento) pacientes se detectó alteración sonográfica. El 27,50 por ciento eran hijos de madres que presentaron alguna enfermedad durante el embarazo. La glucemia elevada afectó 10 por ciento de las madres de los niños con anomalías del desarrollo renal, seguida del bajo peso materno (7,5 por ciento). El hecho de presentar antecedente patológico familiar de enfermedad renal aportó un riesgo de 1,88 y en las de tipo obstructivo el riesgo fue de 5,08. Conclusiones: Las alteraciones sonográficas sugestivas de malformación congénita renal son más frecuentes en los lactantes cuyas madres presentaron concentraciones elevadas de glucosa y bajo peso durante el embarazo. Los niños con antecedentes familiares de malformación renal tienen mayor riesgo de presentar una anomalía del desarrollo renal(AU)

Introduction: Kidney and urinary tract´s malformations represent among 20 and 30 percent of all malformations known in humans. Objective: To identify during pregnancy family pathological history and diseases associated to the onset of renal congenital malformations. Methods: Prospective, descriptive, cross-sectional study carried out to 672 children with normal prenatal ultrasound whom were born from July, 2014 to June 2015 in Santa Clara province. All children during the medical consultation had a detailed physical examination and previous informed concent; it was applied also a survey and the epidemiologic variables, family history of renal diseases, morbility of the mother during pregnancy were recorded, and it was made a renal ultrasound to identify sonographic alterations suggesting any kind of anomaly in the renal development. Results: In 40 patients (5,95 percent), it was detected any sonographic alteration. 27,50 percent were children of mothers that presented any disease during pregnancy. High glycemia affected the 10 percent of mothers of children with anomalies in the renal development, followed by low maternal weight (7,5 percent). The fact of presenting a family pathological history of renal disease implied a risk of 1,88 percent and the risk was of 5,08 percent in the obstructive kind of diseases. Conlusions: Sonographic alterations suggesting renal congenital malformations are more frequent in newborns whose mothers had high concentrations of glycemia and low weight during pregnancy. Children with family history of renal malformations have higher risk of presenting an anomaly of the renal development(AU)

El riñón del niño prematuro: riesgos a largo plazo / The kidney of the premature child: long-term risks

Resumen: El recién nacido prematuro se enfrenta a las condiciones extrauterinas con sistemas aún inmaduros, tanto anatómica como fisiológicamente. El riñón termina de desarrollarse a finales del tercer trimes tre del embarazo, por lo que está especialmente expuesto a alterar su desarrollo normal en caso de nacer en forma prematura. Esta situación puede condicionar, entre otras consecuencias, una menor masa renal funcional y cambios microvasculares que representan un riesgo elevado de hipertensión arterial y daño renal crónico en el largo plazo. En el presente artículo se analiza la evidencia existente actual sobre estos riesgos en los prematuros y se ofrece un esquema de seguimiento de estos niños desde el punto de vista nefrológico.

Abstract: The premature newborn faces extrauterine conditions with some systems still immature, both ana tomically and physiologically. The kidney finishes developing at the end of the third trimester of pregnancy, so it is especially exposed to alter its normal development if preterm birth occurs. This si tuation may condition, among other consequences, a lower functional renal mass and microvascular changes comprising a high risk of chronic kidney disease in the long term and arterial hypertension. This article analyzes the current evidence on these risks in premature infants and offers a nephrology follow-up scheme of these children.

Recidiva del hiperparatiroidismo secundario a enfermedad renal crónica en diálisis luego de la paratiroidectomía / Recurrence of secondary hyper¬parathyroidism in dialysis patients after parathyroidectomy

La paratiroidectomía (PTX) es la terapia de elección en el hiperparatiroidismo secundario a enfermedad renal crónica (HPT-ERC) resistente al tratamiento médico. El objetivo del presente estudio fue evaluar el resultado de la PTX a largo plazo y sus factores predictores. Métodos: estudio unicéntrico retrospectivo observacional. Se incluyeron 92 pacientes con HPT-ERC en diálisis, en quienes se realizó la primera PTX en el Hospital Italiano de Buenos Aires entre 2006 y 2015 con seguimiento ≥ 6 meses. Se consideró persistencia del HPTERC con PTH > 300 pg/ml en el semestre posoperatorio, y recidiva con PTH > 500 pg/ml luego. Resultados: edad: 43,6±12,8 años, 50% mujeres, mediana 4,6 años de diálisis, PTH preoperatoria mediana 1639 pg/ml. A 39 se les realizó PTX subtotal (PTXS) y a 53 total con autoimplante (PTXT+AI). Se observó persistencia en 16 pacientes (17,4%). Presentaron recidiva 30 de 76 pacientes con adecuada respuesta inicial (39,5%; IC 95 28,5-50,5). La mediana de tiempo hasta la recidiva fue de 4,7 años (RIC 2,3-7,5). Los pacientes con recidiva presentaron mayor calcemia preoperatoria (mediana 9,9 vs. 9,3 mg/dl, p=0,035; OR ajustado 2,79) y menor elevación de fosfatasa alcalina en el posoperatorio (333 vs. 436 UI/l, p=0,031; OR ajustado 0,99). La recidiva se presentó más frecuentemente luego de la PTXT+AI (48,9%; OR ajustado 4,66), que en la PTXS (25,8%). Conclusiones: el tiempo en diálisis con inadecuado control metabólico constituye el principal factor para la recurrencia del HPT. Se postula que la mayor calcemia preoperatoria está relacionada con un HPT más severo y se asocia a recurrencia. Llamativamente, hallamos menores elevaciones de la fosfatasa alcalina durante el posoperatorio en pacientes con recurrencia. Hipotetizamos que esto pueda asociarse con menor mineralización en el posoperatorio e hiperfosfatemia sostenida, con consecuente estímulo paratiroideo. La menor recurrencia del HPT luego de la PTXS se vincula al sesgo generado en la selección del tipo de cirugía. (AU)

Parathyroidectomy is an effective therapy for refractory secondary hyperparathyroidism (sHPT). Continued dialysis represents risk for recurrent sHPT. The aim of this study was to estimate the proportion of recurrence and determine its predictors. Methods: We conducted a retrospective observational study of 92 adults in chronic dialysis, who underwent their first parathyroidectomy in this center between 2006 and 2015. We considered persistence of sHPT if PTH was > 300 pg/ml during the first postoperative semester, and recurrence if it was > 500 pg/ml afterwards. Results: Age 43.6+-12 y/o, 50% female, 4.6 years on dialysis, median preoperative PTH 1636 pg/ml (IQR 1226-2098). Subtotal parathyroidectomy (sPTX) was performed in 39, Total with autotransplantation (TA-PTX) in 53 patients. Persistence of sHPT occurred in 16 patients; relapse in 30 out of 76 with adequate initially response (39.5%; 95CI 28,5-50,5). Median time to recurrence: 4.7 y. Recurring patients had higher preoperative calcemia (9.9 vs 9.3 mg/dl; adj OR 2.79) and lower postoperative elevation of ALP (333 vs 436 UI/ml; adj OR 0.99). Recurrence presented more frequently in TA-PTX (48.9%; adj OR 4.66) than sPTX (25.8%). Conclusions: Time on dialysis with inadequate metabolic control remains the most important risk factor for sHPT recurrence. Higher preoperative levels of calcemia, related to sHPT severity, are associated with recurrence. Lower elevations of ALP during postoperative period in recurring patients are an interesting finding. We hypothesize that patients with less significant postoperative mineralization may have chronically higher levels of phosphatemia, stimulating parathyroid glands. Fewer recurrence in sPTX is associated to a bias in the procedure selection. (AU)

Nefropatía Mesoamericana / Mesoamerican Nephropathy

Resumen Desde la década de 1990, se comenzó a notar un incremento en la prevalencia de enfermedad renal crónica (ERC) a nivel de Centroamérica. Este incremento se ha presentado principalmente en trabajadores de campos agrícolas en esa región, quienes se encuentran sometidos a elevadas temperaturas, lo que condujo a su designación como nefropatía mesoamericana (MeN por sus siglas en inglés). Aunque su etiología no está esclarecida, se considera que existe un componente ocupacional y ambiental involucrado. El presente artículo, describe sus principales características, su posible etiología, diagnóstico y estrategias de prevención y tratamiento.

Abstract Since the 1990s, an increase in the prevalence of chronic kidney disease (CKD) in several countries in Central America began to be noticed. This increase has occurred mainly in agricultural workers within that region, who are subjected to high temperatures, which led to its designation as Mesoamerican Nephropathy (MeN). Although its etiology is not clarified, it is considered that there is an occupational and environmental component involved. In this article, its main characteristics are described, including what is known about its possible etiology, diagnosis and prevention and treatment strategies.

Fabry disease: genetics, pathology, and treatment

SUMMARY Fabry disease (FD) is a recessive monogenic inheritance disease linked to chromosome X, secondary to mutations in the GLA gene. Its prevalence is estimated between 1:8,454 and 1:117,000 among males and is probably underdiagnosed. Mutations in the GLA gene lead to the progressive accumulation of globotriaosylceramide (Gb3). Gb3 accumulates in lysosomes of different types of cells of the heart, kidneys, skin, eyes, central nervous system, and gastrointestinal system, and may lead to different clinical scenarios. The onset of symptoms occurs during childhood, with acroparesthesia, heat intolerance, and gastrointestinal symptoms, such as nausea, vomiting, abdominal pain, and neuropathic pain. Subsequently, symptoms related to progressive impairment appear, such as angiokeratomas, cornea verticillata, left ventricular hypertrophy, myocardial fibrosis, proteinuria, and renal insufficiency. The latter being the main cause of death in FD. The gold standard for diagnosis is the genetic analysis in search of mutation, in addition to family history. In homozygous patients, the enzyme activity can also be used. Once the diagnosis is confirmed, the patient and their family should receive genetic counseling. The treatment, in turn, currently focuses mainly on replacing the enzyme that is absent or deficient by means of enzyme replacement therapy, with the purpose of avoiding or removing deposits of Gb3. Chaperones can also be used for the treatment of some cases. It is considered that the specific treatment should be initiated as soon as a diagnosis is obtained, which can change the prognosis of the disease.

Impact of Transcatheter Aortic Valve Implantation on Kidney Function / Impacto do Implante Percutâneo de Válvula Aórtica na Função Renal

Abstract Background: Chronic kidney disease (CKD) is frequently present in patients with aortic valve disease. Decreased kidney perfusion as a consequence of reduced cardiac output may contribute to renal dysfunction in this setting. Objective: Given the potential reversibility of kidney hypoperfusion after valve repair, this study aimed to analyze the impact of percutaneous transcatheter aortic valve implantation (TAVI) on kidney function. Methods: We performed a retrospective analysis of 233 consecutive patients who underwent TAVI in a single center between November 2008 and May 2016. We assessed three groups according to their baseline estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2): Group 1 with eGFR ≥ 60; Group 2 with 30 ≤ eGFR < 60; and Group 3 with eGFR < 30. We analyzed the eGFR one month and one year after TAVI in these three groups, using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula to calculate it. Results: Patients from Group 1 had a progressive decline in eGFR one year after the TAVI procedure (p < 0.001 vs. pre-TAVI). In Group 2 patients, the mean eGFR increased one month after TAVI and continued to grow after one year (p = 0.001 vs. pre-TAVI). The same occurred in Group 3, with the mean eGFR increasing from 24.4 ± 5.1 mL/min/1.73 m2 before TAVI to 38.4 ± 18.8 mL/min/1.73 m2 one year after TAVI (p = 0.012). Conclusions: For patients with moderate-to-severe CKD, kidney function improved one year after the TAVI procedure. This outcome is probably due to better kidney perfusion post-procedure. We believe that when evaluating patients that might need TAVI, this 'reversibility of CKD effect' should be considered.

Resumo Fundamento: Pacientes com doença valvar aórtica frequentemente apresentam doença renal crônica (DRC). Diminuição da perfusão renal como consequência da redução do débito cardíaco pode contribuir para a disfunção renal neste cenário. Objetivo: Dado o potencial de reversibilidade da hipoperfusão renal após o reparo valvar, este estudo teve o objetivo de analisar o impacto do implante percutâneo de válvula aórtica (TAVI - transcatheter aortic valve implantation) na função renal. Métodos: Foi realizada uma análise retrospectiva de 233 pacientes consecutivos submetidos ao TAVI em um único centro, entre novembro de 2008 e maio de 2016. Três grupos foram avaliados de acordo com a taxa de filtração glomerular estimada (TFGe) basal (mL/min/1,73 m2): Grupo 1 com TFGe ≥ 60; Grupo 2 com 30 ≤ TFGe < 60; e Grupo 3 com TFGe < 30. O TFGe foi analisado nestes três grupos um mês e um ano após o TAVI e calculado usando a fórmula do Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Resultados: Os pacientes do Grupo 1 tiveram um declínio progressivo da TFGe um ano após o procedimento TAVI (p < 0,001 vs. pré-TAVI). Nos pacientes do Grupo 2, a média da TFGe aumentou um mês depois do TAVI e continuou crescendo depois de um ano (p = 0,001 vs. pré-TAVI). O mesmo ocorreu no Grupo 3, com a média da TFGe subindo de 24,4 ± 5,1 mL/min/1,73 m2 antes do TAVI para 38,4 ± 18,8 mL/min/1,73 m2 um ano após o TAVI (p = 0,012). Conclusões: Em pacientes com DRC moderada a grave, a função renal melhorou um ano após o procedimento TAVI. Este resultado é provavelmente devido à melhora da perfusão renal pós-procedimento. Acredita-se que, ao avaliar pacientes que possam precisar de TAVI, este 'efeito de reversibilidade da DRC' deva ser considerado.

Early detection of chronic renal disease: coordinated work between primary and specialized care in an ambulatory renal network of Peru / Detecção precoce de doença renal crônica: trabalho coordenado entre atenção primária e especializada em uma rede peruana de atenção renal ambulatorial

Abstract Introduction: The aim of the study was to report the implementation of a functional network for the early diagnosis of chronic kidney disease (CKD) in patients with risk factors and the coordinated work between primary and specialized care in social security in Perú. Material and methods: A cross-sectional analysis of the data of patients evaluated in a health network in the city of Lima (2013 to 2016), older than 18 years, with risk factors for CKD, evaluated with serum creatinine and creatine albumin ratio in random urine (ACR). A multivariate logistic regression analysis was performed to evaluate the factors associated with the finding of CKD. Results: The implementation included training in renal health, installation of a digital database, organization of laboratories, and empowerment of primary care. We evaluated 42,746 patients of which 41.8% were men, with median age 69.2 years. The most frequent cause of detection was hypertension (HBP): 23,921 (55.9%). The prevalence of CKD was 12,132 (28.4%), the most frequent stage of CKD was 3a: 4735 (39.0%). Of the total, 6214 (14.5%) patients had microalbuminuria and 1335 (3.1%), macroalbuminuria. The risk of CKD increased 2.5 times (95% CI: 2.3-2.7) in patients with diabetes (DM) and HBP, in men (OR 1.2, 95% CI: 1.2-1.3) and as age increased (> 77 years: OR 2.7, 95% CI: 2.5-2.8). The identification of the disease in the primary care setting is 60% less likely than in specialized care. Conclusions: One of every four patients are diagnosed with CKD, and the simultaneous diagnosis of DM and HBP and old age are the most important factors.

Resumo Introdução: O objetivo do presente estudo foi descrever a implementação de uma rede funcional para o diagnóstico precoce de doença renal crônica (DRC) em pacientes com fatores de risco e o coordenar os trabalhos entre atenção primária e especializada no sistema de seguridade social peruano. Material e métodos: Análise transversal dos dados de pacientes maiores de 18 anos com fatores de risco para DRC avaliados em uma rede de saúde na cidade de Lima (2013 a 2016) por meio de creatinina sérica e relação albumina/creatinina (RAC) em amostra aleatória de urina. Análise de regressão logística multivariada foi executada para avaliar os fatores associados à presença de DRC. Resultados: A implementação incluiu treinamento em saúde renal, instalação de um banco de dados digital, organização de laboratórios e empoderamento da atenção primária. Foram avaliados 42.746 pacientes, dos quais 41,8% eram homens, com idade mediana de 69,2 anos. A causa mais comum de detecção foi hipertensão, observada em 23.921 indivíduos (55,9%). A prevalência de DRC foi de 12.132 (28,4%), com estágio 3A sendo o mais frequente com 4735 casos (39,0%). Do total, 6214 (14,5%) pacientes apresentavam microalbuminúria e 1335 (3,1%) macroalbuminúria. O risco de DRC foi 2,5 vezes maior (IC 95%: 2,3-2,7) nos pacientes com diabetes e hipertensão, em homens (OR 1,2, IC 95%: 1,2-1,3) e idosos (> 77 anos: OR 2,7, IC 95%: 2,5-2,8). A identificação da doença no cenário da atenção primária é 60% menos provável do que na atenção especializada. Conclusões: Um em cada quatro pacientes é diagnosticado com DRC. Idade avançada e diagnóstico simultâneo de DM e hipertensão são os fatores mais relevantes.

Trastornos glomerulares en la práctica médica / Glomerulopathies in the medical practice

RESUMEN Las glomerulopatías agrupan varias nefropatías con lesiones fundamentalmente del corpúsculo renal y que se expresan principalmente por proteinuria, hematuria, edemas e hipertensión arterial. La presentación clínica varía en dependencia del tipo de enfermedad de que se trate. Constituye la causa más frecuente de enfermedad renal crónica en adultos jóvenes, por lo que su estudio resulta imprescindible sobre todo para el nivel primario de salud. El propósito fue actualizar consideraciones pertinentes sobre la conducta diagnóstica y terapéutica integral ante una glomerulopatía y valorar emisión de recomendaciones al respecto. Se realizó una búsqueda, análisis y síntesis de información a través de Bases de datos ScieLO Cuba, ScieLO regional, Pubmed, Cumed, Clinical Key en el período 2012-2017 con las palabras clave: síndrome nefrótico, glomerulonefritis, diagnóstico, terapéutica, atención integral. El abordaje en las glomerulopatías es integral, multidisciplinario e individualizado. En Cuba constituyen la cuarta causa de enfermedad renal crónica y predomina el síndrome nefrítico agudo postinfeccioso. El método clínico juega en ello un papel trascendental a la hora de reconocer y registrar sus aspectos clínicos, su etiología, su fisiopatología, y los exámenes complementarios que confirman su presencia o sus complicaciones, así como un tratamiento oportuno que garanticen el perfeccionamiento asistencial. El arma más poderosa ante el reto de los trastornos glomerulares es la visión integradora y con enfoque individual y social protagonizado por el médico ante este grupo de nefropatías en adultos.

ABSTRACT Glomerulopathies encompass a group of several renal disorders with lesions, mainly in the renal corpuscle, expressed in proteinuria, hematuria, edemas and arterial hypertension. Their clinical manifestations change in dependence of the kind of disease. They are the most frequent cause of chronic renal disease in young adults; therefore their study is very important above all in the health care primary level. The aim was updating pertinent considerations on the diagnostic behavior and comprehensive therapy in the case of glomerulopathy, and evaluating the emission of recommendations regarding to them. A search, analysis and synthesis of information was carried out in the databases ScieLO Cuba, ScieLO regional, Pubmed, Cumed, and Clinical Key in the period 2012-2017, using the key words nephrotic syndrome, glomerulonephritis, diagnosis, therapeutics, comprehensive care. The approach to glomerulopathies is comprehensive, multidisciplinary and individualized. They are the fourth cause of chronic renal disease; the acute post-infectious nephritic syndrome predominates. The clinical method plays a transcendental role at the moment of recognizing and registering their clinical characteristics, etiology and physiopathology, while complementary tests confirm their presence or complications, and therefore an opportune treatment guarantying the healthcare improvement. The most powerful weapon against the challenge of the glomerular disorders is the integrated vision with an individual and social approach led by the physician in the case of these nephropathies in adults.

Microalbuminuria como marcador de daño renal en pacientes con hipertensión arterial / Microalbuminuria as a marker of kidney damage in patients with arterial hypertension

Introducción: La hipertensión arterial es un poderoso factor de riesgo de daño renal. La prevalencia es muy alta entre los pacientes con Enfermedad Renal Crónica. Objetivo: Determinar la presencia de Microalbuminuria y su valor como marcador de daño renal en pacientes con diagnóstico de Hipertensión arterial. Material y Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de 123 pacientes. Se determinó edad, sexo, cifras de colesterol, triglicéridos, creatinina y microalbuminuria y factores de riesgo vascular. Se utilizó la estadística descriptiva e inferencial. Resultados: El 40,7 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension de los pacientes pertenecen al grupo de más de 70 años con predominio del sexo masculino (65 por ciento), 62,6 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension presentaron microalbuminuria, 97,3 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension tenían factores de riesgo asociados con prevalencia aumentada del tabaquismo, dislipidemia, obesidad y enfermedades vasculares asociadas con RP>1. Predominó el grupo mayor de 70 años, del sexo masculino, con presencia de microalbuminuria. La presencia de más de tres factores de riesgo se asoció a la microalbuminuria. La presencia de microalbuminuria aumentó con los años de evolución de la enfermedad. Predominó el estadio 3 de la Enfermedad Renal Crónica en los pacientes con hipertensión arterial y microalbuminuria y se relacionó directamente con los años de evolución de la hipertensión arterial. Conclusiones: La determinación de la microalbuminuria en los pacientes con hipertensión arterial es un marcador de riesgo importante y sencillo para determinar el daño renal subclínico y está muy relacionado con el incremento de la edad del paciente, años de hipertensión y asociación con otros factores de riesgo vasculares(AU)

Introduction: Arterial hypertension is a powerful risk factor for kidney damage. The prevalence is very high among patients with chronic kidney disease. Objective: To determine the presence of microalbuminuria as a marker of kidney damage in patients with arterial hypertension admitted between September 2016 and September 2017. Material and Methods: A descriptive, longitudinal, prospective study was conducted in 123 patients. Age; sex; cholesterol, triglycerides, creatinine and microalbuminuria levels and vascular risk factors were determined. Descriptive and inferential statistics were used. Results: The 40.7 percent of patients belong to the group of patients of age more than 70 years, predominating the male sex (65 percent); 62.6 percent of them presented microalbuminuria and 97.3 percent had risk factors associated with an increased prevalence of smoking, dyslipidemia, obesity, and vascular diseases associated with RP> 1. The group of patients older than 70 years, male, and with presence of microalbuminuria predominated in the study. The presence of more than three risk factors was associated with microalbuminuria. The presence of microalbuminuria increased with the years of evolution of the disease. Stage 3 of chronic kidney disease predominated in patients with arterial hypertension and microalbuminuria and it was directly related to the years of evolution of arterial hypertension. Conclusions: The determination of microalbuminuria in patients with arterial hypertension is a simple and important risk marker to determine subclinical kidney damage and it is closely related to the increase in the age of the patient, the years of hypertension, and the association with other risk factors for vascular disease(AU)

Conservative management for patients with chronic kidney disease refusing dialysis / Tratamento conservador de paciente com doença renal crônica que renuncia à diálise

ABSTRACT Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.

RESUMO Estimativas sugerem que em torno de 20% a 30% dos óbitos de pacientes com doença renal crônica em estágio dialítico decorrem de renúncia à diálise, da interrupção do tratamento dialítico ou da incapacidade de oferecer tratamento dialítico em função das condições locais. O envelhecimento populacional, o aumento das comorbidades associadas à doença renal crônica e o nível socioeconômico do país contribuem para esse cenário. Em diversas ocasiões o nefrologista estará presente para intervir ativamente, mas em outras o médico generalista ou o médico de família estarão sós. O conhecimento das principais etiologias da doença renal crônica e das alterações metabólicas e dos sintomas associados à fase terminal da doença renal são condições importantes para a evolução do paciente sem sofrimento para uma boa morte. O objetivo desta revisão é familiarizar os membros da equipe multiprofissional para o reconhecimento e conduta quanto às alterações metabólicas e aos sintomas decorrentes da doença renal crônica tratada clinicamente sem suporte dialítico.

Epidemiological, clinical, and laboratory factors associated with chronic kidney disease in Mexican HIV-infected patients / Fatores epidemiológicos, clínicos e laboratoriais associados à doença renal crônica em pacientes mexicanos infectados pelo HIV

ABSTRACT Aim: To determine the prevalence of chronic kidney disease (CKD) and the epidemiological, clinical, and laboratory factors associated with CKD in Mexican HIV-infected patients. Methods: Cross-sectional study. We included 274 patients with HIV/AIDS. CKD was defined by the estimated glomerular filtration rate (eGFR < 60 mL/min/1.73 m2 assessed by CKD-EPI) and albuminuria criteria from KDIGO guidelines. Clinical, epidemiological, and laboratory characteristics were compared between patients with and without CKD. The factors associated with CKD were assessed by logistic regression analysis. Results: The mean age was 41±11 years, and 72.3% of the patients were men. The global prevalence of CKD was 11.7% (n = 32); 7.2% (n = 20) were defined by eGFR criterion; 7.6% (n = 21), by the albuminuria criterion; and 3.2% (n = 9), by both CKD criteria. The most frequently observed stages of CKD were KDIGO G3A1 stage with 4.7% (n = 13), KDIGO G1A2 stage with 3.6% (n = 10) and KDIGO G3A2 stage with 1.7% (n = 5). The factors associated with CKD were use of abacavir/lamivudine (OR 3.2; 95% CI 1.1-8.9; p = 0.03), a CD4 lymphocyte count < 400 cells/µL (OR 2.6; 95% 1.03-6.4, p = 0.04), age (OR 1.1; 95% CI 1.04-1.2, p = 0.001) and albuminuria (OR 19.98; 95% CI: 5.5-72.2; p < 0.001). Conclusions: CKD was a frequent complication in HIV-infected patients. These findings confirm the importance of screening and the early detection of CKD, as well as the importance of identifying and treating traditional and non-traditional risk factors associated with CKD.

RESUMO Objetivo: Determinar a prevalência de doença renal crônica (DRC) e os fatores epidemiológicos, clínicos e laboratoriais associados à DRC em pacientes mexicanos infectados pelo HIV. Métodos: Estudo transversal. Incluímos 274 pacientes com HIV/AIDS. A DRC foi definida pela taxa de filtração glomerular estimada (TFGe < 60 mL/min/1,73 m2, avaliada pelo CKD-EPI) e pelos critérios de albuminúria das diretrizes do KDIGO. As características clínicas, epidemiológicas e laboratoriais foram comparadas entre pacientes com e sem DRC. Os fatores associados à DRC foram avaliados por análise de regressão logística. Resultados: A média da idade foi de 41 ± 11 anos e 72,3% dos pacientes eram homens. A prevalência global de DRC foi de 11,7% (n = 32); 7,2% (n = 20) foram definidos pelo critério TFGe; 7,6% (n = 21), pelo critério da albuminúria; e 3,2% (n = 9), pelos dois critérios para DRC. Os estágios mais frequentemente observados da DRC foram o estágio KDIGO G3A1 com 4,7% (n = 13); estágio KDIGO G1A2 com 3,6% (n = 10) e estágio KDIGO G3A2 com 1,7% (n = 5). Os fatores associados à DRC foram o uso de abacavir/lamivudina (OR 3,2; IC95% 1,1-8,9; p = 0,03), contagem de linfócitos CD4 < 400 células/µL (OR 2,6; 95% 1,03-6,4, p = 0,04), idade (OR 1,1; IC95% 1,04-1,2, p = 0,001) e albuminúria (OR 19,98; IC95%: 5,5-72,2; p < 0,001). Conclusões: A DRC foi uma complicação frequente em pacientes infectados pelo HIV. Esses achados confirmam a importância do rastreamento e da detecção precoce da DRC, bem como a importância de identificar e tratar os fatores de risco tradicionais e não tradicionais associados à DRC.

2019 World Kidney Day Editorial - burden, access, and disparities in kidney disease / Editorial do Dia Mundial do Rim 2019 - impacto, acesso e disparidades na doença renal

Abstract Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Resumo A doença renal é um problema de saúde pública global, afetando mais de 750 milhões de pessoas em todo o mundo. O ônus da doença renal varia substancialmente em todo o mundo, assim como sua detecção e tratamento. Em muitos contextos, as taxas de doença renal e a provisão de seus cuidados são definidas por fatores socioeconômicos, culturais e políticos que levam a disparidades significativas. O Dia Mundial do Rim 2019 oferece uma oportunidade para aumentar a conscientização sobre doenças renais e destacar as disparidades em seu impacto e estado atual da capacidade global de prevenção e tratamento. Aqui, destacamos que muitos países ainda carecem de acesso a diagnósticos básicos, uma força de trabalho treinada em nefrologia, acesso universal à atenção primária à saúde e terapias de substituição renal. Apontamos para a necessidade de fortalecer a infra-estrutura básica para serviços de cuidados renais para detecção e tratamento precoce de lesão renal aguda e doença renal crônica em todos os países e defender abordagens mais pragmáticas para o fornecimento de terapias de substituição renal. Alcançar a cobertura universal de saúde em todo o mundo até 2030 é um dos Objetivos de Desenvolvimento Sustentável da Organização Mundial da Saúde. Embora a cobertura universal de saúde não inclua todos os elementos do tratamento renal em todos os países, entender o que é viável e importante para um país ou região com foco na redução do impacto e das consequências da doença renal seria um passo importante para alcançar a equidade na saúde renal.

APOL1 risk variants and kidney disease: what we know so far / Variantes de risco APOL1 e doença renal: o que sabemos até agora

ABSTRACT There are striking differences in chronic kidney disease between Caucasians and African descendants. It was widely accepted that this occurred due to socioeconomic factors, but recent studies show that apolipoprotein L-1 (APOL1) gene variants are strongly associated with focal segmental glomerulosclerosis, HIV-associated nephropathy, hypertensive nephrosclerosis, and lupus nephritis in the African American population. These variants made their way to South America trough intercontinental slave traffic and conferred an evolutionary advantage to the carries by protecting against forms of trypanosomiasis, but at the expense of an increased risk of kidney disease. The effect of the variants does not seem to be related to their serum concentration, but rather to local action on the podocytes. Risk variants are also important in renal transplantation, since grafts from donors with risk variants present worse survival.

RESUMO Existem importantes diferenças na doença renal crônica entre caucasianos e afrodescendentes. Foi amplamente aceito que isso ocorreu devido a fatores socioeconômicos, mas estudos recentes mostraram que as variantes gênicas da apolipoproteína L-1 (APOL1) estão fortemente associadas à glomeruloesclerose segmentar e focal, nefropatia associada ao HIV, nefroesclerose hipertensiva e nefrite lúpica na população afrodescendente. Essas variantes chegaram à América do Sul através do tráfico intercontinental de escravos, e proporcionaram uma vantagem evolutiva aos portadores, protegendo contra formas de tripanossomíase, mas à custa de um maior risco de doença renal. O efeito das variantes não parece estar relacionado à sua concentração sérica, mas sim à sua ação local sobre os podócitos. Variantes de risco também são importantes no transplante renal, já que enxertos de doadores com variantes de risco apresentam pior sobrevida.