Transitioning to peritoneal dialysis: it does not matter where you come from.

INTRODUCTION: Patients with end-stage renal disease (ESRD) frequently change renal replacement (RRT) therapy modality due to medical or social reasons. We aimed to evaluate the outcomes of patients under peritoneal dialysis (PD) according to the preceding RRT modality. METHODS: We conducted a retrospective observational single-center study in prevalent PD patients from January 1, 2010, to December 31, 2017, who were followed for 60 months or until they dropped out of PD. Patients were divided into three groups according to the preceding RRT: prior hemodialysis (HD), failed kidney transplant (KT), and PD-first. RESULTS: Among 152 patients, 115 were PD-first, 22 transitioned from HD, and 15 from a failing KT. There was a tendency for ultrafiltration failure to occur more in patients transitioning from HD (27.3% vs. 9.6% vs. 6.7%, p = 0.07). Residual renal function was better preserved in the group with no prior RRT (p < 0.001). A tendency towards a higher annual rate of peritonitis was observed in the prior KT group (0.70 peritonitis/year per patient vs. 0.10 vs. 0.21, p = 0.065). Thirteen patients (8.6%) had a major cardiovascular event, 5 of those had been transferred from a failing KT (p = 0.004). There were no differences between PD-first, prior KT, and prior HD in terms of death and technique survival (p = 0.195 and p = 0.917, respectively) and PD efficacy was adequate in all groups. CONCLUSIONS: PD is a suitable option for ESRD patients regardless of the previous RRT and should be offered to patients according to their clinical and social status and preferences.

Hypomagnesemia: a potential underlooked cause of persistent vitamin D deficiency in chronic kidney disease.

Magnesium and vitamin D play important roles in most cells of the body. These nutrients act in a coordinated fashion to maintain physiologic functions of various organs, and their abnormal balance could adversely affect these functions. Therefore, deficient states of both nutrients may lead to several chronic medical conditions and increased cardiovascular and all-cause mortality. Chronic kidney disease (CKD) patients have altered metabolism of both magnesium and vitamin D. Some studies indicate that magnesium could have a role in the synthesis and metabolism of vitamin D, and that magnesium supplementation substantially reversed the resistance to vitamin D treatment in some clinical situations. Recent observational studies also found that magnesium intake significantly interacted with vitamin D status and, particularly with the risk of cardiovascular mortality. It is therefore essential to ensure adequate levels of magnesium to obtain the optimal benefits of vitamin D supplementation in CKD patients. In this review, we discuss magnesium physiology, magnesium and vitamin D metabolism in CKD, potential metabolic interactions between magnesium and vitamin D and its clinical relevance, as well as the possible role of magnesium supplementation to assure adequate vitamin D levels.

Penile and digital calciphylaxis: A case report and literature review.

Calcific uremic arteriolopathy (CUA) represents a rare but severe disease with high morbimortality. The authors present the case of a 58-year-old male patient with chronic kidney disease due to obstructive uropathy, on hemodialysis (HD). He started HD due to uremic syndrome with a severe renal dysfunction, dysregulation of calcium and phosphate metabolism, and he presented with distal penile ischemia, which was treated with surgical debridement and hyperbaric oxygen therapy. Four months later, painful distal digital necrosis of both hands was observed. Extensive arterial calcification was observed on X-ray. A skin biopsy confirmed the presence of CUA. Sodium thiosulfate was administered for 3 months, HD was intensified, and hyperphosphatemia control was achieved, with progressive improvement of the lesions. This case illustrates an uncommon presentation of CUA in a patient on HD for a few months, non-diabetic and not anticoagulated, but with a severe dysregulation of calcium and phosphate metabolism.

Activated ZnCl2 biochar and humic acid as additives in monoammonium phosphate fertilizer: Physicochemical characterization and agronomic effectiveness.

Activated zinc biochar (ZnBC) and humic acid (HA) were used as coating agents in a soluble monoammonium phosphate (MAP) to modify phosphorus (P) use efficiency by altering adsorption/desorption kinetics between the granule region and the soil. The coated treatments MAPZnBC and MAPHA were compared with MAP through P diffusivity, kinetics, and agronomic evaluation. Eucalyptus sawdust was used as biomass for biochar synthesis, and a pre-pyrolysis treatment with zinc chloride (ZnCl2) was applied. The P diffusivity was evaluated in the fertosphere zone. Adsorption and desorption potential of the ZnBC compared with control biochar (BC) was evaluated separately. Desorption kinetics of P from soil was assessed after incubation with MAPZnBC and MAPHA. The shoot dry matter yield (SDM), P uptake, and P use efficiency (PUE) were evaluated with a pot experiment in a clay Oxisol sown with maize and soybeans as successive plant trials, under glasshouse conditions. Surface area values of 940 and 305 m2 g-1 combined with adsorption capacities of 106 and 53 mg P g-1 for ZnBC and BC, respectively, confirm the increased capacity of activated biochar to adsorb P. Both MAPZnBC and MAPHA decreased P diffusivity compared to MAP after 20 days of incubation. Moreover, MAPZnBC and MAPHA presented 20% and 34% more water-soluble phosphorus recovery. MAPZnBC expressed an increase in SDM while MAPHA highlighted P uptake and PUE compared with MAP. Both kinetic studies and agronomic evaluations showed that ZnBC and HA are suitable as coatings for phosphate fertilizers in terms of increasing P efficiency in the fertosphere on high P-fixing soils.

Knowledge, attitudes, and practice of dentists on Minimal Intervention Dentistry: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the knowledge, attitudes, and practice (KAP) of dentists on Minimal Intervention Dentistry (MID). DATA: Cross-sectional studies that analyzed KAP outcomes on MID principles were included. SOURCES: Eight databases (Cochrane, DOSS, Embase, LILACS, PsycINFO, PubMed, Scopus, and Web of Science) and the gray literature were searched on January 2022. STUDY SELECTION: Two independent reviewers selected the included studies, initially by screening titles and abstracts and, finally, by full-text reading. The methodological quality of studies was assessed by using the Joanna Briggs Institute Critical Assessment Checklist for Prevalence Studies. Proportion meta-analysis was conducted using a random effect model for data analysis. Cochran's Q test was used to assess the heterogeneity and the I² statistic for evaluation of true variation due to heterogeneity. RESULTS: Of 2079 studies initially identified, twelve were included in the systematic review. Twenty-four statements about MID were included in the meta-analysis, based on data from ten studies (n = 1728 participants). The pooled proportion of knowledge on MID was 75.66% (95%CI: 69.33 - 81.48; p < 0.01; I²: 97%; Tau2: 0.0456) and of attitudes and practice was 47.95% (95%CI: 38.55-57.43; p < 0.01; I²: 98%; Tau2: 0.0743). The higher prevalences rates were in the "knowledge" field, and the lowest was in "attitudes and practice". CONCLUSIONS: The findings suggest that the knowledge of dentists on MID topics is acceptable, and the attitudes and practices need improvements. The studies lacked uniformity in methods and there is still a need for more studies to elucidate the KAP of dentists worldwide. CLINICAL SIGNIFICANCE: Understanding the cognizance and the way oral healthcare professionals are treating dental caries is the first step to expanding the minimal intervention evidence into a dental practice. The final goal is to change the practice and make Minimal Intervention Dentistry the standard of care for dental caries worldwide. REGISTRATION: PROSPERO CRD42021257518.

Incremental Peritoneal Dialysis-Definition, Prescription, and Clinical Outcomes.

ABSTRACT: Incremental peritoneal dialysis (IPD) is a strategy of RRT that is based on the prescription of a lower dose rather than the standard full dose of peritoneal dialysis (PD). The clearance goals are achieved through the combination of residual kidney function (RKF) and peritoneal clearance. The dialysis prescription should be increased as the RKF declines. IPD has been associated with clinical, economic, and environmental advantages. We emphasize possible better quality of life, fewer mechanical symptoms, lower costs, slight adverse metabolic effects, and less plastic waste and water consumption. The potential benefits for RKF preservation and the lower risk of peritonitis have also been discussed. There are some concerns regarding this strategy, such as inadequate clearance of uremic toxins and/or severe electrolyte disturbances due to undetected loss of RKF, lower clearance of medium-sized molecules (such as ß-2-microglobulin) which mostly depends on the total PD dwell time, and patients' reluctance to dose adjustments. Current clinical evidence is based on moderate-quality to low-quality studies and suggests that the outcomes of IPD will be at least identical to those of full dose. This review aims to define IDP, discuss strategies for prescription, and review its advantages and disadvantages according to the current evidence.

Long-term cholecalciferol supplementation in hemodialysis patients: Effects on mineral metabolism, inflammation, and cardiac parameters.

BACKGROUND: Low levels of 25-hydroxyvitamin D [25(OH)D] are frequent in chronic kidney disease and are associated with adverse outcomes. The aim of this 5-year prospective study was to evaluate the effects of cholecalciferol supplementation on mineral metabolism, inflammation and cardiac parameters in hemodialysis (HD) patients. METHODS: The study included 97 patients. Cholecalciferol was given after HD according to 25(OH)D baseline levels measured twice (end of winter and of summer). The 25(OH)D levels, circulating bone metabolism, inflammation parameters, brain natriuretic peptide (BNP), pulse pressure (PP), and left ventricular mass index (LVMI) were evaluated before and after supplementation. RESULTS: There was a significant increase in 25(OH)D levels after supplementation (p < 0.001); however, serum calcium (p = 0.02), phosphorus (p = 0.018), and iPTH (p = 0.03) were decreased. Magnesium levels increased during the study (p = 0.03). A reduction in the number of patients under active vitamin D (p < 0.001) and in the dose and number of patients treated with darbepoetin (p = 0.02) was observed. Serum albumin increased (p < 0.001), and C-reactive protein decreased (p = 0.01). BNP (p < 0.001), PP (p = 0.007), and LVMI (p = 0.02) were significantly reduced after supplementation. CONCLUSIONS: Long-term cholecalciferol supplementation allowed correction of 25(OH)D deficiency, improved mineral metabolism with less use of active vitamin D, attenuated inflammation, reduced the dose of the erythropoiesis-stimulating agent, and improved cardiac dysfunction.

Incremental peritoneal dialysis: Is it better for preservation of residual kidney function and clinical outcomes?

INTRODUCTION: Incremental peritoneal dialysis (IPD) is based on the prescription of a dose lower than the standard (SPD). The combination of residual kidney function (RKF) and peritoneal clearance achieves clearance goals. The aim of this study is to compare the outcomes of IPD with SPD. MATERIALS AND METHODS: This was a single-center, retrospective study that included a cohort of prevalent peritoneal dialysis (PD) adults. Patients were assigned according to their first PD protocol in two groups - group A: IPD protocol (continuous ambulatory PD: less than 4 dwells daily, less than 2 L dwell volume, and/or treatment less than 7 days/week; automated PD: without a long dwell, less than 10 L daily delivered, and/or treatment for less than 7 days/week); group B: SPD protocol. RESULTS: 87 PD patients were included, 65.5% underwent IPD. The median follow-up time was 23 months (IQR 15 - 35). IPD had a higher glomerular filtration ratio (7 vs. 3.7, mL/min/1.73m2, p < 0.001) in the first 6 months, and after 24 months (4.8 vs. 1.9, mL/min/1.73m2, p = 0.002). IPD protocol was independently associated with GFR ≥ 5 mL/min/1.73m2 at 24 months (OR 13 per point, 95% CI 1.48 - 114.36, p = 0.021). IPD was also associated with a longer technique survival (log-rank test = 4.928, p = 0.026), lower hospital admissions per year (0.23 vs. 0.5, p = 0.001), and lower mortality (1.8% vs. 13.3%, p = 0.027). Cox regression demonstrated that IPD (HR 0.30; 95% CI 0.098 - 0.93); p = 0.036) was associated with a decrease in the risk of technique failure. CONCLUSION: The prescription of IPD seems to be beneficial, in terms of outcomes, for patients with substantial RKF.

Mal-positioning of a dialysis catheter: One lumen with arterial blood and the other with venous blood?

Partial anomalous pulmonary vein drainage is a rare congenital defect, where the pulmonary vein drains into a systemic vein instead of draining into the left atrium. We present a case of a 63-year-old woman on hemodialysis who was found to have a right pulmonary vein with anomalous drainage to the superior vena cava after mal-positioning of a dialysis catheter, which demonstrated unexpected blood results from the different lumina of the catheter. Multiple imaging techniques were used to deal with this rare clinical situation. This is the first case reporting a mal-positioning of a left-side internal jugular vein tunneled catheter into a right-side pulmonary vein.

Pantoea in Peritoneal Dialysis: A Rare Cause of Peritonitis.

Peritonitis is the most common complication of peritoneal dialysis (PD) and an important cause of PD failure. There are numerous etiological agents, mostly bacteria. Pantoea spp is a rare cause of peritonitis. We describe three cases of Pantoea peritonitis in three PD patients. Previous reports have identified risk factors such as close contact with plants and animals. We review the typical clinical presentation and prognosis. It is fulcral to teach patients about the risks regarding proximity to plants and animals to prevent this type of infection.

Pregnancy in a woman undergoing peritoneal dialysis: Management and dialysis options.

Pregnancy in patients with end-stage renal disease on maintenance dialysis is uncommon, with annual incidences reported at 0.3 - 2.7%. Peritoneal dialysis usage in pregnancy has been less reported than hemodialysis, although outcomes are similar. Nowadays, there are insufficient data to establish a generalizable dialysis strategy in pregnant women with end-stage renal disease. As such, decisions should be individualized, depending on clinical factors, residual renal function, and, whenever possible, choice of the patient. We report the case of a 22-year-old patient receiving peritoneal dialysis who delivered a full-term, normal weight, healthy baby with increased dialysis dose achieved by supplementary hemodialysis during pregnancy, thus enabling peritoneal dialysis to be continued until the third trimester and minimizing hemodialysis requirements.

Biochar as composite of phosphate fertilizer: Characterization and agronomic effectiveness.

Organomineral phosphate fertilizers (OMP) may reduce phosphate release rate and its direct contact to the soil solid phase, increasing the effectiveness of phosphorus (P) fertilization. This study aimed to evaluate the effect of granulating biochar (BC) with triple superphosphate (TSP) in two forms (blend or coated) and three proportions (5, 15 and 25%, w/w) on the P release kinetics and plant growth. A successive plant trial using two soils of contrasting P buffering capacities and five P doses (0, 20, 40, 80 and 120 mg kg-1) was set to investigate the agronomic effectiveness of OMP that presented the slowest P release kinetic. The kinetic test showed that within the first 1.5 h, TSP, OMP blend and OMP coated fertilizers released 92, 82 and 36% of total P, respectively. Thereby, BC addition to TSP reduced the P release rate, mainly due to coating. The fertilizers coated with 15% and 25% BC (C15 and C25, respectively) presented the slowest P release rate. For the plant trial, C15 was chosen because it requires less BC when compared with C25 fertilizer. In the first crop, C15 provided more P to plants, especially in the soil with high P buffering capacity, which increased by 10% and 20% the P uptake and the P recovered by the plant when compared with TSP, respectively. In the sandy soil, fertilizers C15 and TSP showed the same performances regarding yield, P uptake and P recovery rate. At consecutive cultivation, regardless of the soil type, P sources (C15 and TSP) did not differ in yield, P uptake and P recovery. Therefore, biochar-based organomineral phosphate fertilizer can enhance P use efficiency in high P-fixing tropical soils, increasing P recovery and uptake when compared with TSP.

Subjective versus objective, polymer bur-based selective carious tissue removal: 1-year interim analysis of a randomized clinical trial.

We aimed to compare subjective (S) vs. objective (O) selective carious tissue removal using hand-excavation versus a self-limiting polymer bur, respectively. A community-based single-blind cluster-randomized controlled superiority trial was performed. This is a 1-year-interim analysis. 115 children (age 7-8 years) with ≥1 vital primary molar with a deep dentin lesion (>1/2 dentin depth) were included (60 S/55 O). The cluster was the child, with eligible molars being treated identically (91 S/86 O). Cavities were prepared and carious tissue on pulpo-proximal walls selectively removed using hand instruments (S), or a self-limiting polymer bur (Polybur P1, Komet). Cavities were restored using glass-hybrid material (Equia Forte, GC). Treatment times and children's satisfaction were recorded. Generalized-linear models (GLM) and multi-level Cox-regression analysis were applied. Initial treatment times were not significantly different between protocols (mean; 95%CI S: 433; 404-462 sec; O: 412; 382-441 sec; p = 0.378/GLM). There was no significant difference in patients' satisfaction (p = 0.164). No pulpal exposures occurred. 113 children were re-examined. Failures occurred in 22/84 O-molars (26.2%) and 26/90 S-molars (28.9%). Pulpal complications occurred in 5(6%) O and 2(2.2%) S molars, respectively. Risk of failure was not significantly associated with the removal protocol, age, sex, dental arch or tooth type (p > 0.05/Cox), but was nearly 5-times higher in multi-surface than single-surface restorations (HR: 4.60; 95% CI: 1.70-12.4). Within the limitations of this interim analysis, there was no significant difference in treatment time, satisfaction and risk of failure between O and S.

Bone fracture risk factors in prevalent hemodialysis patients.

Bone fractures are an important cause of morbidity and mortality in hemodialysis (HD) patients. The aim of this study was to quantify the incidence of fractures in a cohort of prevalent HD patients and evaluate its relationship with possible risk factors. We performed a retrospective analysis of 341 patients, since they started HD (median of 51 months). Demographic, clinical, and biochemical parameters as well as vascular calcifications (VC) were evaluated. Fifty-seven episodes of fracture were identified with a median HD vintage of 47 months (incidence rate of 31 per 1000 person-years). Age (p < 0.001), female gender (p < 0.001), lower albumin (p = 0.02), and higher VC score (p < 0.001) were independently associated with increased risk of fracture, while active vitamin D therapy (p = 0.03) was associated with decreased risk. A significantly higher risk of incident fracture was also associated with higher values of bone-specific alkaline phosphatase (bALP) (p = 0.01) and intact parathyroid hormone (iPTH) levels either < 300 pg/mL (p = 0.02) or > 800 pg/mL (p < 0.001) compared with 300-800 pg/mL. In conclusion, bone fracture incidence in HD patients is high and its risk increases with age, female gender, lower serum albumin, and with the presence of more VC. Prevalent HD patients with low or high iPTH levels or increased bALP also had a higher fracture risk. Therapy with active vitamin D seems to have a protective role. Assessment of fracture risk and management in dialysis patients at greatest risk requires further study.

Sexual Dysfunction and Satisfaction in Kidney Transplant Patients.

INTRODUCTION: 10% of the world's population suffers from chronic kidney disease. Kidney transplants provide an improvement in the quality of life of those patients. Sexual dysfunction is common after kidney transplantation, and its etiology is presumed to be multifactorial. It has a negative impact on sexual satisfaction and health-related quality-of-life. The integration of a new organ into the body can imply an adjustment of body image, which may eventually have a negative influence on intimacy and sexual behaviors. AIM: To evaluate male sexual function, sexual satisfaction, and body image satisfaction among a convenience sample of patients who have had a kidney transplant. METHODS: This is a cross-sectional study that included 460 patients, from a single healthcare center, who had undergone a kidney transplant procedure >4 weeks ago. A total of 112 respondents (mean = 55.5 years, SD = 11.4) answered the questionnaires properly. MAIN OUTCOME MEASURES: All recruited patients answered a self-reported sociodemographic questionnaire, in addition to the International Index of Erectile function, the New Scale of Sexual Satisfaction, the Brief Symptom Inventory, and the Body Image Scale. RESULTS: A correlation was found between sexual function and sexual satisfaction (r = 0.598, P < .001, n = 112), as well as between body image satisfaction and sexual function (r = -0.193, P = .042, n = 112). The length of time after a kidney transplant (≤ or >36 months) was not associated with a difference in sexual functioning or sexual satisfaction. CLINICAL IMPLICATIONS: This study showed the obvious implications of sexual function on sexual satisfaction, which should alert healthcare professionals to the importance of identifying and managing sexual dysfunction in patients with chronic kidney disease, to optimize their global and sexual health satisfaction. STRENGTH & LIMITATIONS: This study identified a high prevalence of sexual dysfunction among kidney transplant recipients. This should reinforce the need for the medical community to evaluate the quality-of-life domains of patients with chronic disease. There is still a lack of information concerning any longitudinal evaluation of kidney transplant patients' sexual function and the effects that this surgery has on sexuality. CONCLUSIONS: This study corroborated the severe effects that kidney transplant patients often report regarding their sexuality. Among the patients who participated in the study, sexual function proved to be relevant in relation to sexual satisfaction. Mota RL, Fonseca R, Santos JC, et al. Sexual Dysfunction and Satisfaction in Kidney Transplant Patients. J Sex Med 2019;16:1018-1028.

The impact of functioning hemodialysis arteriovenous accesses on renal graft perfusion: Results of a pilot study.

INTRODUCTION: After a kidney transplant, it is unknown whether the maintenance of a functioning hemodialysis arteriovenous access could have deleterious effects on renal grafts. We hypothesize that maintaining an arteriovenous access can deviate a significant proportion of the cardiac output from the renal graft. The aim of this study was to investigate whether a temporary closure of the arteriovenous access could lead to an increase in graft perfusion. METHODS: We conducted a study in 17 kidney-transplanted patients with a functioning arteriovenous access. We evaluated, at baseline and 30 s after compression of the arteriovenous access (access flow occlusion), the hemodynamic parameters and the renal resistive index of the graft by Doppler ultrasound. RESULTS: After arteriovenous access occlusion 82.4% (n = 14) of the patients had a decrease in resistive index. All patients had a decrease in heart rate (67 vs 58 bpm, p < 0.001) and 14 (82.4%) had an increase in mean blood pressure (98.3 vs 101.7 mm Hg, p = 0.044). There was a significant decrease in the resistive index (ΔRI) after the access occlusion (0.68 vs 0.64, p = 0.030). We found a negative correlation in Qa (r2 = -0.55, p = 0.022) with the ΔRI, and Qa was an independent predictor of ΔRI in a model adjusted to pre-occlusion resistive index. CONCLUSION: Our results showed that temporary occlusion of an arteriovenous access causes a significant decline in renal graft resistive index and this decline is higher with the occlusion of accesses with higher Qa. These results suggest that the maintenance of arteriovenous accesses, mainly those with higher Qa, can decrease renal graft perfusion.

IGA nephropathy - Are intravenous steroid pulses more effective than oral steroids in relapse prevention? / Nefropatía por IgA. ¿Son los esteroides intravenosos más eficaces que los esteroides orales en la prevención de recaídas?

INTRODUCTION: It is recommended that IgA nephropathy (IgAN) is treated with steroids when the glomerular filtration rate (GFR) is > 50ml/min and proteinuria >1 g/day. Few studies have been performed comparing the two accepted steroid regimens (1g/day methylprednisolone pulses for 3 consecutive days at the beginning of months 1, 3 and 5, followed by 0.5 mg/kg prednisolone on alternate days vs. 1mg/kg/day oral prednisolone). The aim of this study was to compare these two steroid regimens in IgAN treatment. METHODS: We selected 39 patients with biopsy-proven IgAN treated with steroids. Mean age at diagnosis was 37.5 years, 23 males (59%), baseline proteinuria (Uprot) was 2.1 g/day and median serum creatinine (SCr) was 1.5 mg/dl. The mean follow-up period was 56 months. Twenty-five patients (64%) were treated with methylprednisolone pulses and 14 (36%) with oral steroids. RESULTS: Patients treated with steroid pulses presented lower relapse risk, defined as the reappearance of Uprot >1 g/day and an Uprot increase of more than 50% (incidence rate ratio of 0.18, 95% CI 0.02-0.5). The Kaplan-Meier analysis showed longer relapse-free period (p = 0.019). This result was confirmed in a multivariate analysis (p = 0.026). However, we did not find other differences between the two steroid regimens. CONCLUSIONS: In comparison to oral steroids, the intravenous pulse regimen was associated with a lower risk of relapse in IgAN, a known independent negative predictor of renal survival. No differences were found regarding the other renal outcomes

INTRODUCCIÓN: Se recomienda el tratamiento de la nefropatía por IgA (NIgA) con esteroides cuando el índice de filtración glomerular (IFG)>50 ml/min y proteinuria >1 g/día. Pocos han sido los estudios realizados comparando los 2 esquemas de esteroides aceptados (1g/día de metilprednisolona en pulsos durante 3 días consecutivos en el principio de los meses 1, 3 y 5 seguido de 0,5 mg/kg en días alternos de prednisolona vs. 1mg/kg/día de prednisolona oral). El objetivo de este estudio fue comparar estos 2 esquemas de esteroides en el tratamiento de la NIgA. MÉTODOS: Fueron seleccionados 39 pacientes con NIgA demostrada por biopsia y tratados con esteroides. La edad media al diagnóstico fue de 37,5 años, 23 varones (59%), proteinuria basal (Uprot) 2,1g/día y la creatinina sérica mediana (SCR) 1,5mg/dl. El periodo medio de seguimiento fue de 56 meses. Veinticinco de los pacientes (64%) fueron tratados con pulsos de metilprednisolona y 14 (36%) con esteroides orales. RESULTADOS: Los pacientes tratados con pulsos de esteroides presentan menor riesgo de recaída, definido como la reaparición de una Uprot>1g/día y aumento de más del 50% de la Uprot (razón de tasa de incidencia: 0,18; IC 95%: 0,02-0,5) y el Kaplan-Meier mostró período más largo libre de recaída (p = 0,019). Este resultado se confirmó en un análisis multivariante (p = 0,026). Sin embargo, no se encontraron otras diferencias entre los esquemas de esteroides. CONCLUSIONES: En comparación con los esteroides orales, el esquema en pulsos intravenosos se relacionó con un menor riesgo de recaída en la NIgA, un conocido predictor negativo independiente de la supervivencia renal. No se encontraron diferencias en cuanto a los otros outcomes renales

Recuperação da função ventricular após ressincronização cardíaca em criança com cardiomiopatia induzida pelo marcapasso / Ventricular function recovery after cardiac resynchronization in child with pacing-induced cardiomyopathy

A cardiomiopatia induzida pelo marcapasso é uma cardiomiopatia que ocorre em pacientes expostos a estimulação ventricular direita, sendo definida pela piora da função sistólica do ventrículo esquerdo na ausência de outras etiologias possíveis, com ou sem evidência de insuficiência cardíaca. Sua incidência varia de 9% a 26%, dependendo da população estudada e do período de acompanhamento. Relata-se o caso de uma criança submetida a implante de marcapasso ventricular por bloqueio atrioventricular total, que evoluiu com disfunção ventricular grave e insuficiência cardíaca 14 meses após o implante. Após realização de terapia de ressincronização cardíaca, a criança evoluiu com melhora clínica e remodelamento reverso do ventrículo esquerdo

Pacing-induced cardiomyopathy is observed in patients exposed to right ventricular pacing and is defined as worsening of left ventricular systolic function in the absence of alternative causes, with or without clinical evidence of heart failure. Incidence ranges from 9% to 26%, depending on the study population and the length of follow-up. This is a case report of a child with univentricular pacemaker for total atrioventricular block that evolved into severe ventricular dysfunction and heart failure after implant. Cardiac resynchronization was performed and the child evolved with clinical improvement and reverse left ventricular remodeling

Are high flow arteriovenous accesses associated with worse haemodialysis?

INTRODUCTION: An arteriovenous (AV) access flow (Qa) of 400 mL/min is usually sufficient for an effective hemodialysis (HD), but some accesses continue developing and become high flow accesses (HFA). Some authors postulated that an HFA might shift a significant portion of dialyzed blood from the cardiac output, which could decrease HD efficiency and lead to volume overload. OBJECTIVE: The aim of our study was to evaluate if HFA is associated with reduced HD efficiency and/or volume overload in prevalent HD patients. METHODS: We performed a 1-year retrospective study and assessed HD efficiency by the percentage of sessions in which the Kt/V > 1.4 and volume overload by bioimpedance spectroscopy. RESULTS: The study included 304 prevalent HD patients with a mean age of 67.5 years; 62.5% were males, 36.2% were diabetics, with a median HD vintage of 48 months. Sixteen percent of the patients had a HFA (defined as Qa > 2 L/min). In multivariate analysis, patients with HFA presented higher risk of volume overload (OR = 2.67, 95%CI = 1.06-6.71) and severe volume overload (OR = 4.06, 95%CI = 1.01-16.39) and attained dry weight less frequently (OR = 0.37, 95%CI = 0.14-0.94). However, HFA was not associated with lower Kt/V. CONCLUSION: Our results suggest that patients with HFA have higher risk of volume overload. However, contrarily to what has been postulated, HFA was not associated with less efficient dialysis, measured by Kt/V. Randomized controlled trials are needed to clarify these questions.