Estimated glomerular filtration rate in clinical practice: Consensus positioning of the Brazilian Society of Nephrology (SBN) and Brazilian Society of Clinical Pathology and Laboratory Medicine (SBPC/ML) / Estimativa da taxa de filtração glomerular na prática clínica: posicionamento consensual da Sociedade Brasileira de Nefrologia (SBN) e Sociedade Brasileira de Patologia Clínica e Medicina Laboratorial (SBPC/ML)

ABSTRACT Chronic kidney disease (CKD) represents one of today's main public health problems. Serum creatinine measurement and estimation of the glomerular filtration rate (GFR) are the main tools for evaluating renal function. There are several equations to estimate GFR, and CKD-EPI equation (Chronic Kidney Disease - Epidemiology) is the most recommended one. There are still some controversies regarding serum creatinine measurement and GFR estimation, since several factors can interfere in this process. An important recent change was the removal of the correction for race from the equations for estimating GFR, which overestimated kidney function, and consequently delayed the implementation of treatments such as dialysis and kidney transplantation. In this consensus document from the Brazilian Societies of Nephrology and Clinical Pathology and Laboratory Medicine, the main concepts related to the assessment of renal function are reviewed, as well as possible existing controversies and recommendations for estimating GFR in clinical practice.

RESUMO A doença renal crônica (DRC) representa um dos principais problemas de saúde pública da atualidade. A dosagem da creatinina sérica e a estimativa da taxa de filtração glomerular (TFG) são as principais ferramentas para avaliação da função renal. Para a estimativa da TFG, existem diversas equações, sendo a mais recomendada a CKD-EPI (Chronic Kidney Disease - Epidemiology). Existem ainda algumas controvérsias com relação à dosagem da creatinina sérica e da estimativa da TFG, uma vez que vários fatores podem interferir nesse processo. Uma importante mudança recente foi a retirada da correção por raça das equações para estimativa da TFG, que superestimavam a função renal, e consequentemente retardavam a implementação de tratamentos como diálise e transplante renal. Neste documento de consenso da Sociedade Brasileira de Nefrologia e Sociedade Brasileira de Patologia Clínica e Medicina Laboratorial são revisados os principais conceitos relacionados à avaliação da função renal, possíveis controvérsias existentes e recomendações para a estimativa da TFG na prática clínica.

The role of podocyte injury in the pathogenesis of Fabry disease nephropathy / O papel da injúria podocitária na patogênese da nefropatia da doença de Fabry

Abstract Renal involvement is one of the most severe morbidities of Fabry disease (FD), a multisystemic lysosomal storage disease with an X-linked inheritance pattern. It results from pathogenic variants in the GLA gene (Xq22.2), which encodes the production of alpha-galactosidase A (α-Gal), responsible for glycosphingolipid metabolism. Insufficient activity of this lysosomal enzyme generates deposits of unprocessed intermediate substrates, especially globotriaosylceramide (Gb3) and derivatives, triggering cellular injury and subsequently, multiple organ dysfunction, including chronic nephropathy. Kidney injury in FD is classically attributed to Gb3 deposits in renal cells, with podocytes being the main target of the pathological process, in which structural and functional alterations are established early and severely. This configures a typical hereditary metabolic podocytopathy, whose clinical manifestations are proteinuria and progressive renal failure. Although late clinical outcomes and morphological changes are well established in this nephropathy, the molecular mechanisms that trigger and accelerate podocyte injury have not yet been fully elucidated. Podocytes are highly specialized and differentiated cells that cover the outer surface of glomerular capillaries, playing a crucial role in preserving the structure and function of the glomerular filtration barrier. They are frequent targets of injury in many nephropathies. Furthermore, dysfunction and depletion of glomerular podocytes are essential events implicated in the pathogenesis of chronic kidney disease progression. We will review the biology of podocytes and their crucial role in regulating the glomerular filtration barrier, analyzing the main pathogenic pathways involved in podocyte injury, especially related to FD nephropathy.

Resumo O acometimento renal é uma das mais severas morbidades da doença de Fabry (DF), enfermidade multissistêmica de depósito lisossômico com padrão de herança ligada ao cromossomo X, decorrente de variantes patogênicas do gene GLA (Xq22.2), que codifica a produção de alfa-galactosidase A (α-Gal), responsável pelo metabolismo de glicoesfingolipídeos. A atividade insuficiente dessa enzima lisossômica gera depósitos de substratos intermediários não processados, especialmente do globotriaosilceramida (Gb3) e derivados, desencadeando injúria celular e, posteriormente, disfunção de múltiplos órgãos, incluindo a nefropatia crônica. A lesão renal na DF é classicamente atribuída aos depósitos de Gb3 nas células renais, sendo os podócitos o alvo principal do processo patológico, nos quais as alterações estruturais e funcionais são instaladas de forma precoce e severa, configurando uma podocitopatia metabólica hereditária típica, cujas manifestações clínicas são proteinúria e falência renal progressiva. Embora os desfechos clínicos tardios e as alterações morfológicas estejam bem estabelecidos nessa nefropatia, os mecanismos moleculares que deflagram e aceleram a injúria podocitária ainda não estão completamente elucidados. Podócitos são células altamente especializadas e diferenciadas que revestem a superfície externa dos capilares glomerulares, desempenhando papel essencial na preservação da estrutura e função da barreira de filtração glomerular, sendo alvos frequentes de injúria em muitas nefropatias. A disfunção e depleção dos podócitos glomerulares são, além disso, eventos cruciais implicados na patogênese da progressão da doença renal crônica. Revisaremos a biologia dos podócitos e seu papel na regulação da barreira de filtração glomerular, analisando as principais vias patogênicas envolvidas na lesão podocitária, especialmente relacionadas à nefropatia da DF.

The role of podocyte injury in the pathogenesis of Fabry disease nephropathy.

Renal involvement is one of the most severe morbidities of Fabry disease (FD), a multisystemic lysosomal storage disease with an X-linked inheritance pattern. It results from pathogenic variants in the GLA gene (Xq22.2), which encodes the production of alpha-galactosidase A (α-Gal), responsible for glycosphingolipid metabolism. Insufficient activity of this lysosomal enzyme generates deposits of unprocessed intermediate substrates, especially globotriaosylceramide (Gb3) and derivatives, triggering cellular injury and subsequently, multiple organ dysfunction, including chronic nephropathy. Kidney injury in FD is classically attributed to Gb3 deposits in renal cells, with podocytes being the main target of the pathological process, in which structural and functional alterations are established early and severely. This configures a typical hereditary metabolic podocytopathy, whose clinical manifestations are proteinuria and progressive renal failure. Although late clinical outcomes and morphological changes are well established in this nephropathy, the molecular mechanisms that trigger and accelerate podocyte injury have not yet been fully elucidated. Podocytes are highly specialized and differentiated cells that cover the outer surface of glomerular capillaries, playing a crucial role in preserving the structure and function of the glomerular filtration barrier. They are frequent targets of injury in many nephropathies. Furthermore, dysfunction and depletion of glomerular podocytes are essential events implicated in the pathogenesis of chronic kidney disease progression. We will review the biology of podocytes and their crucial role in regulating the glomerular filtration barrier, analyzing the main pathogenic pathways involved in podocyte injury, especially related to FD nephropathy.

Safety and feasibility of transcranial direct current stimulation in end-stage renal disease patients undergoing hemodialysis: an exploratory study.

INTRODUCTION: Patients with end-stage renal disease often face a challenging routine of hemodialysis, dietary restrictions, and multiple medications, which can affect their hemodynamic function. Home-based, safe, and nonpharmacological approaches such as transcranial direct current stimulation (tDCS) should be combined with conventional treatment. OBJECTIVE: To assess the safety and feasibility of tDCS on blood pressure and heart rate in patients with end-stage renal disease undergoing hemodialysis. METHOD: This is a parallel, randomized, sham-controlled trial. Patients undergoing hemodialysis for more than three months were included. The patients received ten non-consecutive 2mA tDCS sessions on the primary motor cortex . Each session lasted 20 minutes. At baseline and after each of the ten sessions, blood pressure and heart rate of the patients were measured hourly for four hours. RESULTS: Thirty patients were randomized to the active or sham group. The mean difference between the groups was calculated as the mean value of the sham group minus the mean value of the active group. Despite there were no statistical changes for all outcomes considering all 10 sessions, we found differences between groups for systolic -10.93 (-29.1;7.2), diastolic -3.63 (-12.4; 5.1), and mean blood pressure -6.0 (-16.3; 4.2) and hear rate 2.26 (-2.5; 7.1). No serious adverse events were found. The active group showed higher blood pressure values at all points, while heart rate was lower in the active group. CONCLUSION: tDCS is safe and feasible for patients with end-stage renal disease undergoing hemodialysis. Future studies should investigate whether tDCS could potentially induce a hypotensive protective effect during hemodialysis.

Understanding of the role of serum creatinine in a subset of the Brazilian population / Conhecimento de uma amostragem da população brasileira sobre a função da creatinina sérica

Abstract Introduction: Chronic kidney disease is usually asymptomatic, and its diagnosis depends on laboratory tests, with emphasis on serum creatinine and proteinuria. Objective: To assess knowledge on the role of serum creatinine as a biomarker of kidney function in a sample of the Brazilian population. Method: Cross-sectional observational study conducted in São Paulo (SP, Brazil), in which a random adult population was interviewed. Results: A total of 1138 subjects were interviewed, with a median age of 36 years old (27-52); 55.1% were female. Regarding the "creatinine" biomarker, 40.6% stated they had never performed such a test. When asked about their knowledge on the usefulness of this exam, only 19.6% knew its function. The other responses were "I don't know" (71.6%), evaluating heart function (0.9%) and liver function (7.8%). Of those who reported they had already taken a creatinine test, only 29.4% correctly identified the role of creatinine. When dividing the groups into "knows" and "does not know" the function of creatinine, a statistically significant difference (p < 0.05) was observed regarding level of education, female sex, being a healthcare student/worker, having ever measured creatinine, knowing someone with kidney disease and older age. In the multivariate analysis, the main variable related to knowing the creatinine role was having previously taken the test (OR 5.16; 95% CI 3.16-8.43, p < 0.001). Conclusion: There is a significant lack of knowledge about creatinine and its use in checkups. The results indicate that greater efforts are needed from healthcare professionals to raise awareness on the role of serum creatinine.

Resumo Introdução: A doença renal crônica costuma ser assintomática e seu diagnóstico depende da realização de exames laboratoriais, com destaque para a creatinina sérica e pesquisa de proteinúria. Objetivo: Avaliar em uma amostra da população brasileira o conhecimento sobre o papel da creatinina sérica como marcador de função renal. Método: Estudo observacional transversal realizado na cidade de São Paulo (SP, Brasil), em que foi entrevistada uma população adulta aleatória. Resultados: Foram entrevistados 1138 indivíduos, com idade mediana de 36 anos (27-52); 55,1% do sexo feminino. Com relação ao marcador "creatinina", 40,6% afirmaram que nunca realizaram tal dosagem. Quando questionados quanto ao conhecimento sobre a utilidade desse exame, somente 19,6% sabiam a sua função. As outras respostas foram "não sei" (71,6%), avaliar o funcionamento do coração (0,9%) e fígado (7,8%). Dos que afirmaram já terem realizado o exame de creatinina, somente 29,4% acertaram a função da creatinina. Ao dividir os grupos em "sabe" e "não sabe" a função da creatinina, percebeu-se diferença estatisticamente significante (p < 0,05) em relação ao grau de escolaridade, sexo feminino, ser aluno/trabalhador da saúde, ter dosado creatinina alguma vez, conhecer alguém com doença renal e maior idade. Na análise multivariada, a principal variável relacionada com conhecer a função da creatinina foi ter realizado o exame anteriormente (OR 5,16; IC 95% 3,16-8,43, p < 0,001). Conclusão: Há grande desconhecimento sobre a creatinina e seu uso em check-ups. Os resultados indicam que é necessário maior esforço por parte dos profissionais de saúde para divulgar o papel da creatinina sérica.

Laboratory-based surveillance of chronic kidney disease in people with private health coverage in Brazil.

BACKGROUND: Although approximately 25% of Brazilians have private health coverage (PHC), studies on the surveillance of chronic kidney disease (CKD) in this population are scarce. The objective of this study was to estimate the prevalence of CKD in individuals under two PHC regimes in Brazil, who total 8,335,724 beneficiaries. METHODS: Outpatient serum creatinine and proteinuria results of individuals from all five regions of Brazil, ≥ 18 years of age, and performed between 10/01/2021 and 10/31/2022, were analyzed through the own laboratory network database. People with serum creatinine measurements were evaluated for the prevalence and staging of CKD, and those with simultaneous measurements of serum creatinine and proteinuria were evaluated for the risk category of the disease. CKD was classified according to current guidelines and was defined as a glomerular filtration rate (GFR) < 60 ml/min/1.73 m² estimated by the 2021 CKD-EPI equation. RESULTS: The number of adults with serum creatinine results was 1,508,766 (age 44.0 [IQR, 33.9-56.8] years, 62.3% female). The estimated prevalence of CKD was 3.8% (2.6%, 0.8%, 0.2% and 0.2% in CKD stages 3a, 3b, 4 and 5, respectively), and it was higher in males than females (4.0% vs. 3.7%, p < 0.001, respectively) and in older age groups (0.2% among 18-29-year-olds, 0.5% among 30-44-year-olds, 2.0% among 45-59-year-olds, 9.4% among 60-74-year-olds, and 32.4% among ≥ 75-year-olds, p < 0.001) Adults with simultaneous results of creatinine and proteinuria were 64,178 (age 57.0 [IQR, 44.8-67.3] years, 58.1% female). After adjusting for age and gender, 70.1% were in the low-risk category of CKD, 20.0% were in the moderate-risk category, 5.8% were in the high-risk category, and 4.1% were in the very high-risk category. CONCLUSION: The estimated prevalence of CKD was 3.8%, and approximately 10% of the participants were in the categories of high or very high-risk of the disease. While almost 20% of beneficiaries with PHC had serum creatinine data, fewer than 1% underwent tests for proteinuria. This study was one of the largest ever conducted in Brazil and the first one to use the 2021 CKD-EPI equation to estimate the prevalence of CKD.

Laboratory-based surveillance of chronic kidney disease in people with private health coverage in Brazil

BACKGROUND Although approximately 25% of Brazilians have private health coverage (PHC), studies on the surveillance of chronic kidney disease (CKD) in this population are scarce. The objective of this study was to estimate the prevalence of CKD in individuals under two PHC regimes in Brazil, who total 8,335,724 beneficiaries. METHODS Outpatient serum creatinine and proteinuria results of individuals from all five regions of Brazil, ≥18 years of age, and performed between 10/01/2021 and 10/31/2022, were analyzed through the own laboratory network database. People with serum creatinine measurements were evaluated for the prevalence and staging of CKD, and those with simultaneous measurements of serum creatinine and proteinuria were evaluated for the risk category of the disease. CKD was classified according to current guidelines and was defined as a glomerular filtration rate (GFR)<60 ml/min/1.73 m² estimated by the 2021 CKD-EPI equation. RESULTS The number of adults with serum creatinine results was 1,508,766 (age 44.0 [IQR, 33.9­56.8] years, 62.3% female). The estimated prevalence of CKD was 3.8% (2.6%, 0.8%, 0.2% and 0.2% in CKD stages 3a, 3b, 4 and 5, respectively), and it was higher in males than females (4.0% vs. 3.7%, p<0.001, respectively) and in older age groups (0.2% among 18-29-year-olds, 0.5% among 30-44-year-olds, 2.0% among 45-59-year-olds, 9.4% among 60-74-yearolds, and 32.4% among ≥75-year-olds, p<0.001) Adults with simultaneous results of creatinine and proteinuria were 64,178 (age 57.0 [IQR, 44.8­67.3] years, 58.1% female). After adjusting for age and gender, 70.1% were in the low-risk category of CKD, 20.0% were in the moderate-risk category, 5.8% were in the high-risk category, and 4.1% were in the very high-risk category. CONCLUSION The estimated prevalence of CKD was 3.8%, and approximately 10% of the participants were in the categories of high or very high-risk of the disease. While almost 20% of beneficiaries with PHC had serum creatinine data, fewer than 1% underwent tests for proteinuria. This study was one of the largest ever conducted in Brazil and the first one to use the 2021 CKD-EPI equation to estimate the prevalence of CKD.

Estimated glomerular filtration rate in clinical practice: Consensus positioning of the Brazilian Society of Nephrology (SBN) and Brazilian Society of Clinical Pathology and Laboratory Medicine (SBPC/ML).

Chronic kidney disease (CKD) represents one of today's main public health problems. Serum creatinine measurement and estimation of the glomerular filtration rate (GFR) are the main tools for evaluating renal function. There are several equations to estimate GFR, and CKD-EPI equation (Chronic Kidney Disease - Epidemiology) is the most recommended one. There are still some controversies regarding serum creatinine measurement and GFR estimation, since several factors can interfere in this process. An important recent change was the removal of the correction for race from the equations for estimating GFR, which overestimated kidney function, and consequently delayed the implementation of treatments such as dialysis and kidney transplantation. In this consensus document from the Brazilian Societies of Nephrology and Clinical Pathology and Laboratory Medicine, the main concepts related to the assessment of renal function are reviewed, as well as possible existing controversies and recommendations for estimating GFR in clinical practice.

Understanding of the role of serum creatinine in a subset of the Brazilian population.

INTRODUCTION: Chronic kidney disease is usually asymptomatic, and its diagnosis depends on laboratory tests, with emphasis on serum creatinine and proteinuria. OBJECTIVE: To assess knowledge on the role of serum creatinine as a biomarker of kidney function in a sample of the Brazilian population. METHOD: Cross-sectional observational study conducted in São Paulo (SP, Brazil), in which a random adult population was interviewed. RESULTS: A total of 1138 subjects were interviewed, with a median age of 36 years old (27-52); 55.1% were female. Regarding the "creatinine" biomarker, 40.6% stated they had never performed such a test. When asked about their knowledge on the usefulness of this exam, only 19.6% knew its function. The other responses were "I don't know" (71.6%), evaluating heart function (0.9%) and liver function (7.8%). Of those who reported they had already taken a creatinine test, only 29.4% correctly identified the role of creatinine. When dividing the groups into "knows" and "does not know" the function of creatinine, a statistically significant difference (p < 0.05) was observed regarding level of education, female sex, being a healthcare student/worker, having ever measured creatinine, knowing someone with kidney disease and older age. In the multivariate analysis, the main variable related to knowing the creatinine role was having previously taken the test (OR 5.16; 95% CI 3.16-8.43, p < 0.001). CONCLUSION: There is a significant lack of knowledge about creatinine and its use in checkups. The results indicate that greater efforts are needed from healthcare professionals to raise awareness on the role of serum creatinine.

Safety and feasibility of transcranial direct current stimulation in end-stage renal disease patients undergoing hemodialysis: an exploratory study / Segurança e viabilidade da estimulação transcraniana por corrente contínua em pacientes com doença renal em estágio terminal submetidos à hemodiálise: um estudo exploratório

Abstract Introduction: Patients with end-stage renal disease often face a challenging routine of hemodialysis, dietary restrictions, and multiple medications, which can affect their hemodynamic function. Home-based, safe, and nonpharmacological approaches such as transcranial direct current stimulation (tDCS) should be combined with conventional treatment. Objective: To assess the safety and feasibility of tDCS on blood pressure and heart rate in patients with end-stage renal disease undergoing hemodialysis. Method: This is a parallel, randomized, sham-controlled trial. Patients undergoing hemodialysis for more than three months were included. The patients received ten non-consecutive 2mA tDCS sessions on the primary motor cortex . Each session lasted 20 minutes. At baseline and after each of the ten sessions, blood pressure and heart rate of the patients were measured hourly for four hours. Results: Thirty patients were randomized to the active or sham group. The mean difference between the groups was calculated as the mean value of the sham group minus the mean value of the active group. Despite there were no statistical changes for all outcomes considering all 10 sessions, we found differences between groups for systolic -10.93 (-29.1;7.2), diastolic -3.63 (-12.4; 5.1), and mean blood pressure -6.0 (-16.3; 4.2) and hear rate 2.26 (-2.5; 7.1). No serious adverse events were found. The active group showed higher blood pressure values at all points, while heart rate was lower in the active group. Conclusion: tDCS is safe and feasible for patients with end-stage renal disease undergoing hemodialysis. Future studies should investigate whether tDCS could potentially induce a hypotensive protective effect during hemodialysis.

Resumo Introdução: Pacientes com doença renal em estágio terminal (DRET) geralmente enfrentam uma rotina desafiadora de hemodiálise, restrições alimentares e diversos medicamentos, podendo afetar sua função hemodinâmica. Abordagens domiciliares, seguras e não farmacológicas, como a estimulação transcraniana por corrente contínua (ETCC), devem ser combinadas com tratamento convencional. Objetivo: Avaliar segurança e viabilidade da ETCC na pressão arterial e frequência cardíaca em pacientes com DRET em hemodiálise. Método: Estudo paralelo, randomizado, controlado por placebo. Foram incluídos pacientes em hemodiálise por mais de três meses. Os pacientes receberam dez sessões não consecutivas de ETCC de 2mA no córtex motor primário. Cada sessão durou 20 minutos. No início do estudo e após cada uma das dez sessões, a pressão arterial e frequência cardíaca dos pacientes foram medidas a cada hora durante quatro horas. Resultados: Trinta pacientes foram randomizados para grupo ativo ou sham. A diferença média entre grupos foi calculada como valor médio do grupo sham menos valor médio do grupo ativo. Apesar de não haver alterações estatísticas para todos os desfechos considerando as 10 sessões, encontramos diferenças entre os grupos para pressão arterial sistólica -10,93 (-29,1; 7,2), diastólica -3,63 (-12,4; 5,1) e média -6,0 (-16,3; 4,2) e frequência cardíaca 2,26 (-2,5; 7,1). Não encontramos eventos adversos graves. O grupo ativo apresentou valores maiores de pressão arterial em todos os pontos, enquanto a frequência cardíaca foi menor no grupo ativo. Conclusão: ETCC é segura e viável para pacientes com DRET submetidos à hemodiálise. Estudos futuros devem investigar se a ETCC pode potencialmente induzir um efeito hipotensor protetor durante a hemodiálise.

A Cross-sectional study on the prevalence and risk stratification of chronic kidney disease in cardiological patients in São Paulo, Brazil

ABSTRACT: Chronic kidney disease (CKD) provides a worse prognosis for patients with heart disease. In Latin America, studies that analyzed the prevalence and risk stratification of CKD in this population are scarce. We aimed to evaluate CKD prevalence and risk categories in patients of a public referral cardiology hospital in São Paulo, Brazil. This was a cross-sectional study based on a laboratory database. Outpatient serum creatinine and proteinuria results performed between 1 January 2021 and 31 December 2021 were analyzed. CKD was defined by estimated glomerular filtration rate (eGFR) 30 mg/g. A total of 36,651 adults were identified with serum creatinine levels (median age 72.4 [IQR, 51.0­73.6] years, 51% male). Among them, 51.9% had UACR dosage (71.5% with UACR < 30 mg/g, 22.6%, between 30­300 mg/g, and 5.9% with UACR > 300 mg/g). The prevalence of CKD was 30.9% (15.3% stage 3a, 10.2% stage 3b, 3.6% stage 4, and 1.7% stage 5), and the distribution of patients in the risk categories of the disease was: 52.0% with low-risk, 23.5%, moderate risk, 13.0%, high risk, and 11.2%, very high. In an outpatient setting, the prevalence of CKD in cardiological patients was almost three times (31%) that of the general population; about half of the individuals evaluated (48%) were not screened for an important risk marker (proteinuria), and approximately a quarter of these patients (24%) were in the high or very high CKD risk categories.

Prevalence and risk stratification of chronic kidney disease in a tertiary cardiology hospital: a cross-sectional study

INTRODUCTION: Chronic kidney disease (CKD) is common, preventable and silent in its early stages. Therefore, early detection of this condition in the population at risk, through laboratory tests, is essential. OBJECTIVES: To estimate the CKD prevalence and perform its risk stratification in a tertiary health service specialized in cardiology. METHODS: The study was cross-sectional and based on laboratory records of patients from a public hospital specialized in cardiology. The evaluated tests were serum creatinine and urinary albumin/creatinine ratio (ACR, random sample) performed on an outpatient basis between 01/01/2021 and 12/31/2021. Duplicate exams and patients under 18 years of age were excluded. The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI creatinine equation. CKD was defined by eGFR 300mg/g). According to the CKD risk map, individuals with simultaneous creatinine and ACR measurements were stratified into low, moderate, high or very high risk. RESULTS: The sample consisted of 36,651 patients in whom the same number of serum creatinine results and 19,031 ACR results were evaluated (median patients'age 72.5 [51.0-73.6] years, 51.3% male). The prevalence of CKD was 30.9% and patients with stages 3a, 3b, 4 and 5 corresponded to 15.3%, 10.2%, 3.6% and 1.7%, respectively. CKD was more frequent in older age groups: 18- 29 years (2.5%), 30-44 years (8.4%), 45-59 years (25.5%), 60-74 years (30 .7%) and ≥75 years (56.8%) (p<0.001). Patients with albuminuria categories A1, A2 and A3 were 71.5%, 22.6% and 5.9%, respectively. ACR ≥30mg/g was not associated with age: 18-29 years (23.3%), 30-44 years (23.4%), 45-69 years (26.0%), 60-74 years (28 .5%) and ≥75 years (36.9%) (p=0.671). Patients with simultaneous measurements of serum creatinine and ACR were 19,031 and their distribution in the CKD risk categories was: low (52.0%), moderate (23.8%), high (13.1%) and very high risk (11.2%). CONCLUSIONS: The results showed that CKD is present in about 30% of the patients assisted in the cardiology institute evaluated. In up to half of the patients, the risk of major outcomes such as hospitalization, need for renal replacement therapy, and death was moderate, high, or very high.

The first appointment with a nephrologist: Brazilian patients' demographic and kidney function characteristics. A retrospective study

ABSTRACT BACKGROUND: The number of nephrologists has risen slowly, compared with the prevalence of chronic kidney disease (CKD) in Brazil. Data on patients referred to nephrology outpatient clinics remains scarce. OBJECTIVE: To determine the demographic and kidney function characteristics of patients at their first appointment with a nephrologist. DESIGN AND SETTING: Retrospective study conducted at three nephrology outpatient clinics (public and private services), in São Paulo, Brazil. METHODS: From December 2019 to February 2020, we collected patient data regarding demographics, kidney function parameters and comorbidities. We then analyzed data on 394 patients who met a nephrologist for their first appointment. RESULTS: The main comorbidities were hypertension (63.7%), diabetes (33.5%) and nephrolithiasis (22.3%). Regarding CKD stages, 24.1%, 9.1%, 13.7%, 15.2%, 15.2% and 2.3% of the patients were in stages 1, 2, 3a, 3b, 4 and 5, respectively. Proteinuria was absent or mild, moderate and high in 17.3%, 15.2% and 11.7%, respectively; and 16.2% had not undergone previous investigation of serum creatinine or proteinuria (55.8%). For 17.5%, referral to a nephrologist occurred late. Patients in public services were older than those in private services (59 years versus 51 years, respectively; P = 0.001), more frequently hypertensive (69.7% versus 57.5%; P = 0.01) and reached a nephrologist later (22.4% versus 12.4%; P = 0.009). CONCLUSION: Referrals to a nephrologist were not being made using any guidelines for CKD risk and many cases could have been managed within primary care. Late referral to a nephrologist happened in one-fifth of the cases and more frequently in the public service.

Supply/need ratio of medical appointments and diagnostic tests and monitoring of chronic kidney disease in the Unified Health System: descriptive study, São Paulo, Brazil, 2019 / Relación oferta/necesidad de consultas médicas y pruebas diagnósticas y seguimiento de la enfermedad renal crónica en el Sistema Único de Salud: estudio descriptivo, São Paulo, Brasil, 2019 / Razão oferta/necessidade de consultas médicas e exames de diagnóstico e acompanhamento da doença renal crônica no Sistema Único de Saúde: estudo descritivo, estado de São Paulo, 2019

Objective: To determine the supply/need ratio of procedures related to the diagnosis and care of chronic kidney disease in the SUS in the State of São Paulo, Brazil, in 2019. Methods: Descriptive study using data from SUS outpatient and hospital information systems. The number of medical consultations and diagnostic and follow-up tests for kidney disease carried out was compared with the estimates of need recommended by ministerial guidelines. Results: The exclusive SUS users were 28,791,244 and the number of individuals with hypertension and/or diabetes, 5,176,188. The number of procedures performed and the relationship between this number and the population's need was 389,414 consultations with a nephrologist (85%), 11,540,371 serum creatinine measurements (223%), 705,709 proteinuria measurements (14%), 438,123 renal ultrasounds (190%) and 1,045 kidney biopsies (36%). Conclusion: In the care of chronic kidney disease in the SUS, there is simultaneously a lack of supply, waste, and deficient tracking of important procedures.

Objetivo: Determinar la relación oferta/necesidad de procedimientos relacionados con el diagnóstico y atención de la enfermedad renal crónica en el SUS del Estado de São Paulo, Brasil, en 2019. Métodos: Estudio descriptivo utilizando datos de los sistemas de información ambulatoria y hospitalaria del SUS. Se comparó el número de consultas médicas y pruebas de diagnóstico y seguimiento de la enfermedad renal realizados con las estimaciones de necesidad recomendadas por directrices ministeriales. Resultados: Los usuarios exclusivos del SUS fueron 28.791.244 y el hipertensos y/o diabéticos, 5.176.188. El número de procedimientos realizados y la relación entre este número y la necesidad de población fue: 389.414 consultas con nefrólogo (85%), 11.540.371 determinaciones de creatinina sérica (223%), 705.709 determinaciones de proteinuria (14%), 438.123 ecografías renales (190%) y 1.045 renales biopsias (36%). Conclusión: En la atención de enfermedad renal en SUS, existe simultáneamente falta de suministro, desperdicio y seguimiento deficiente de los procedimientos importantes.

Objetivo: Determinar a razão oferta/necessidade de procedimentos relacionados com o diagnóstico e assistência à doença renal crônica no Sistema Único de Saúde (SUS), no estado de São Paulo, Brasil, 2019. Métodos: Estudo descritivo, utilizando dados dos sistemas de informações ambulatoriais e hospitalares do SUS. O número de consultas médicas e exames diagnósticos e acompanhamento da doença renal, realizados no período, foi comparado com as estimativas de necessidade, obtidas por diretrizes ministeriais. Resultados: Usuários exclusivos do SUS foram 28.791.244, e indivíduos com hipertensão e/ou diabetes mellitus, 5.176.188. O número de procedimentos realizados e a razão entre esse número e a necessidade da população foi de 389.414 consultas com nefrologista (85%), 11.540.371 dosagens de creatinina sérica (223%), 705.709 dosagens de proteinúria (14%), 438.123 ultrassonografias renais (190%) e 1.045 biópsias renais (36%). Conclusão: Na assistência à doença renal crônica no SUS, existe, simultaneamente, falta de oferta, desperdício e rastreamento deficiente de procedimentos importantes.

Razão oferta/necessidade de consultas médicas, exames de diagnóstico e acompanhamento da doença renal crônica no Sistema Único de Saúde: estudo descritivo, estado de São Paulo, 2019 / Relación oferta/necesidad de consultas médicas, pruebas diagnósticas y seguimiento de la enfermedad renal crónica en el Sistema Único de Salud: estudio descriptivo, São Paulo, Brasil, 2019 / Supply/demand ratio for medical consultations, diagnostic tests and chronic kidney disease monitoring in the Brazilian National Health System: a descriptive study, state of São Paulo, Brazil, 2019

Objetivo: Determinar a razão oferta/necessidade de procedimentos relacionados com o diagnóstico e assistência à doença renal crônica no Sistema Único de Saúde (SUS), no estado de São Paulo, Brasil, 2019. Métodos: Estudo descritivo, utilizando dados dos sistemas de informações ambulatoriais e hospitalares do SUS. Os números de consultas médicas e exames diagnósticos e de acompanhamento da doença renal realizados no período foram comparados com as estimativas de necessidade obtidas por diretrizes ministeriais. Resultados: Usuários exclusivos do SUS eram 28.791.244, e indivíduos com hipertensão e/ou diabetes mellitus, 5.176.188. O número de procedimentos realizados e a razão entre esse número e a necessidade da população foram de 389.414 consultas com nefrologista (85%); 11.540.371 dosagens de creatinina sérica (223%); 705.709 dosagens de proteinúria (14%); 438.123 ultrassonografias renais (190%); e 1.045 biópsias renais (36%). Conclusão: Na assistência à doença renal crônica no SUS existem, simultaneamente, falta de oferta, desperdício e rastreamento deficiente de procedimentos importantes.

Objetivo: Determinar la relación oferta/necesidad de procedimientos relacionados con el diagnóstico y atención de la enfermedad renal crónica en Sistema Único de Salud (SUS) del Estado de São Paulo, Brasil, en 2019. Métodos: Estudio descriptivo utilizando datos de los sistemas de información ambulatoria y hospitalaria del SUS. Se comparó el número de consultas médicas, pruebas de diagnóstico y seguimiento de la enfermedad renal realizados con las estimaciones de necesidad recomendadas por directrices ministeriales. Resultados: Los usuarios exclusivos de SUS fueron 28.791.244 e hipertensos y/o diabéticos, 5.176.188. El número de procedimientos realizados y la relación entre este número y la necesidad de la población fueran de 389.414 consultas con nefrólogo (85%); 11.540.371 determinaciones de creatinina sérica (223%); 705.709 determinaciones de proteinuria (14%); 438.123 ecografías renales (190%); y 1.045 biopsias renales (36%). Conclusión: En la atención de enfermedad renal en SUS existe, simultáneamente, falta de oferta, desperdicio y seguimiento deficiente de procedimientos importantes.

Objective: To determine the supply/demand ratio for procedures related to diagnosis and treatment for chronic kidney disease in the Brazilian National Health System (SUS), in the state of São Paulo, Brazil, 2019. Methods: This was a descriptive study, using data from the SUS outpatient and hospital information systems. The numbers of medical consultations, diagnostic and chronic kidney disease monitoring tests, performed in the period, were compared with the demand estimation, obtained through ministerial guidelines. Results: Exclusive SUS users were 28,791,244, and individuals with arterial hypertension and/or diabetes mellitus, 5,176,188. The number of procedures performed and the ratio between this number and the needs of the population were 389,414 consultations with nephrologists (85%); 11,540,371 serum creatinine tests (223%); 705,709 proteinuria tests (14%); 438,123 kidney ultrasounds (190%); and 1,045 kidney biopsies (36%). Conclusion: In the chronic kidney disease care in the SUS it could be seen simultaneous existence of lack of supply, waste and inadequate screening of important procedures.

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil / Qualidade de atenção primária em doença renal crônica em um serviço público de um município do Estado de São Paulo, Brasil / Calidad de los cuidados de salud en la atención primaria relacionados con la enfermedad crónica de riñón en un servicio público en una ciudad del Estado de São Paulo, Brasil

Abstract: Complications of chronic kidney disease (CKD) can be avoided when promptly diagnosed and treated. The objective was to describe quality indicators of CKD detection and health care in the primary care public service of a city in the State of São Paulo, Brazil. This retrospective study analyzed charts of patients who attended primary care in the public service between November 2019 and February 2020. We selected 10 health quality indicators based on their scientific relevance and availability from the medical records that could express how CKD was identified and managed in primary health care. We estimated the adequate percentage of health indicators with data from 1,066 individuals who had ≥ one risk factor for CKD: hypertension, diabetes, or > 60 years old. Among patients, 79.4% had information on serum creatinine, whereas 58.8% were investigated for proteinuria. Blood pressure data were found in 98.9% of the records. The percentage of patients with blood pressure < 140x90mmHg, glycosylated hemoglobin < 6.5% and LDL-cholesterol < 100mg/dL was 79.2%, 49.2%, and 33.3%, respectively. Renin-angiotensin system blockers were prescribed to 82.8% of the patients with hypertension and CKD. Serum potassium was measured in 35.7% for those who were using renin-angiotensin system blockers. Among those people with CKD, 16.7% had CKD assigned in the medical records as a diagnose. Among those participants at higher risk for CKD, the referral rate to a nephrologist was 31.6%. This study confirmed some missed quality indicators of CKD in primary healthcare. Our results may help administrators develop public policies that improve health care for individuals at high risk for CKD. Long-term follow-up of the health indicators we proposed here will be useful to assess the impact of policy intervention.

Resumo: As complicações da doença renal crônica (DRC) podem ser evitadas quando a doença é diagnosticada e tratada oportunamente. O estudo teve como objetivo descrever a qualidade dos indicadores da detecção e assistência para a DRC no sistema púbico de saúde em um município do Estado de São Paulo, Brasil. O estudo retrospectivo analisou prontuários de pacientes que utilizaram serviços de atenção primária no sistema público entre novembro de 2019 e fevereiro de 2020. Selecionamos dez indicadores de qualidade com base na relevância científica e disponibilidade, a partir dos prontuários médicos. Calculamos o percentual de adequação com dados de 1.066 indivíduos que apresentavam ≥ 1 fatores de risco para DRC: hipertensão, diabetes ou idade > 60 anos. No total, 79,4% dos pacientes apresentavam informação sobre creatinina sérica, e 58,8% foram investigados para proteinúria. Dados de pressão arterial foram encontrados em 98,9% dos prontuários. As proporções de pacientes com pressão arterial < 140x90mmHg, hemoglobina glicada < 6,5% e LDL < 100mg/dL foram 79,2%, 49,2% e 33,3%, respectivamente. Os antagonistas do sistema renina-angiotensina foram prescritos em 82,8% dos pacientes com hipertensão e DRC. O potássio sérico foi medido em 35,7% dos pacientes em uso de antagonistas do sistema renina-angiotensina. Entre os indivíduos com DRC, 16,7% tinham esse diagnóstico registrado no prontuário médico. Entre os participantes com risco mais elevado de DRC, 31,6% foram encaminhados para um nefrologista. O estudo confirmou a falta de alguns indicadores de qualidade para DRC na assistência primária. Os resultados podem ajudar gestores a desenvolverem políticas públicas que melhorem a assistência para indivíduos com risco maior de DRC. O seguimento a longo prazo dos indicadores de saúde propostos aqui será útil para avaliar o impacto dessa política de intervenção.

Resumen: Las complicaciones de la enfermedad crónica de riñón (ECR) se pueden evitar cuando esta enfermedad se diagnostica con prontitud y se trata. El objetivo fue describir indicadores de calidad en la detección de ECR, así como la asistencia en el servicio público de una ciudad, en el Estado de São Paulo, Brasil. Este estudio retrospectivo analizó fichas de pacientes que acudían a atención primaria en el servicio público, entre noviembre 2019 y febrero 2020. Seleccionamos 10 indicadores de calidad en salud, basados en relevancia científica y disponibilidad de registros médicos. Calculamos el porcentaje de adecuación de ellos con datos de 1.066 personas que tenían ≥ 1 factor de riesgo ECR: hipertensión, diabetes, o > 60 años. Un 79,4% de los pacientes tenían información sobre la creatinina sérica, y se investigó a un 58,8% en el caso de la proteinuria. Los datos de presión sanguínea se encontraron en un 98,9% de los registros. El porcentaje de pacientes con presión sanguínea < 140x90mmHg, hemoglobina glicada < 6,5% y LDL < 100mg/dL fue 79,2%, 49,2%, y 33,3%, respectivamente. Se prescribieron bloqueadores del sistema renina-angiotensina a un 82,8% de los pacientes con hipertensión y ECR. Se midió el potasio sérico en un 35,7% de aquellos quienes estaban usando bloqueadores del sistema renina-angiotensina. Entre aquellas personas con ECR, 16,7% había ECR asignado en los registros médicos como diagnosis. Entre aquellos participantes en riesgo mayor por ECR, la tasa de derivación a un nefrólogo fue 31,6%. Este estudio confirmó algunos indicadores de calidad olvidados de ECR en los cuidados de salud en la atención primaria. Nuestros resultados quizás podrían ayudar a los gestores a desarrollar políticas públicas que mejoraran el cuidado de salud para las personas con alto riesgo de ECR. El seguimiento a largo plazo de los indicadores de salud que propusimos aquí será útil para evaluar el impacto de la política de intervención.

Inflammation and kidney involvement in human viral diseases caused by SARS-CoV-2, HIV, HCV and HBV

Inflammation is closely related to renal diseases. This is particularly true for renal diseases caused by infections as in viral diseases. In this review, we highlight the inflammatory mechanisms that underlie kidney dysfunction in SARS-CoV-2, human immunodeficiency (HIV), hepatitis C (HCV), and hepatitis B (HBV) infections. The pathophysiology of renal involvement in COVID-19 is complex, but kidney damage is frequent, and the prognosis is worse when it happens. Virus-like particles were demonstrated mostly in renal tubular epithelial cells and podocytes, which suggest that SARS-CoV-2 directly affects the kidneys. SARS-CoV-2 uses the angiotensin-converting enzyme 2 receptor, which is found in endothelial cells, to infect the human host cells. Critical patients with SARS-CoV-2-associated acute kidney injury (AKI) show an increase in inflammatory cytokines (IL-1β, IL-8, IFN-γ, TNF-α), known as cytokine storm that favors renal dysfunction by causing intrarenal inflammation, increased vascular permeability, volume depletion, thromboembolic events in microvasculature and persistent local inflammation. Besides AKI, SARS-CoV-2 can also cause glomerular disease, as other viral infections such as in HIV, HBV and HCV. HIV-infected patients present chronic inflammation that can lead to a number of renal diseases. Proinflammatory cytokines and TNF-induced apoptosis are some of the underlying mechanisms that may explain the virus-induced renal diseases that are here reviewed.(AU)