Association of scopophobia with online learning fatigue among medical students in Brazil.

BACKGROUND: Scopophobia can be described in the medical field as the fear of being watched or stared at. Despite the relevance of scopophobia in remote learning scenarios, which have always existed and have been largely expanded during the pandemic in medical education, studies on this topic are exceedingly rare worldwide. Hence, to fill up this gap, a cross-sectional study of medical students was developed to assess the association of scopophobia with the prevalence of online learning fatigue. METHODS: A cross-sectional, quantitative, analytical study was carried out in Medical Schools of Brazil. To assess the risk of scopophobia, questions were developed, based on the literature on the topic. The Zoom Exhaustion & Fatigue Scale (ZEF) was used, and the questions have currently been validated for Brazilian Portuguese. Logistic regression models were also used to assess the relationship of scopophobia risk and ZEF scores. RESULTS: A total of 283 students from Brazil participated in the study. The median age was 23 years, and 64% of the participants were female. In total, 14.5% were considered to be at high risk for scopophobia. It was found that after adjusting for sex, income and number of residents in the household, scopophobia and the total zoom fatigue score remained associated. For the total score, each additional point on the scale increased the chance of scopophobia by 3%, and for the overall domain, 19% (p-values < 0.05). CONCLUSIONS: In conclusion, this study shows a relevant prevalence of students with scopophobia, which requires a differentiated approach on the part of teachers. The causes of scopophobia are often specific and have a psychological origin that goes beyond the usual pedagogical management. Therefore, motivation strategies are necessary in a general, as well as an individualized manner, aiming to favor the improvement of the online teaching and learning process.

Temporal Reduction in COVID-19-Associated Fatality Among Kidney Transplant Recipients: The Brazilian COVID-19 Registry Cohort Study.

Data from the general population suggest that fatality rates declined during the course of the pandemic. This analysis, using data extracted from the Brazilian Kidney Transplant COVID-19 Registry, seeks to determine fatality rates over time since the index case on March 3rd, 2020. Data from hospitalized patients with RT-PCR positive SARS-CoV-2 infection from March to August 2020 (35 sites, 878 patients) were compared using trend tests according to quartiles (Q1: <72 days; Q2: 72-104 days; Q3: 105-140 days; Q4: >140 days after the index case). The 28-day fatality decreased from 29.5% (Q1) to 18.8% (Q4) (pfor-trend = 0.004). In multivariable analysis, patients diagnosed in Q4 showed a 35% reduced risk of death. The trend of reducing fatality was associated with a lower number of comorbidities (20.7-10.6%, p for-trend = 0.002), younger age (55-53 years, pfor-trend = 0.062), and better baseline renal function (43.6-47.7 ml/min/1.73 m2, pfor-trend = 0.060), and were confirmed by multivariable analysis. The proportion of patients presenting dyspnea (pfor-trend = 0.001) and hypoxemia (pfor-trend < 0.001) at diagnosis, and requiring intensive care was also found reduced (pfor-trend = 0.038). Despite possible confounding variables and time-dependent sampling differences, we conclude that COVID-19-associated fatality decreased over time. Differences in demographics, clinical presentation, and treatment options might be involved.

Post Transplant Lymphoproliferative Disease Isolated to Kidney Allograft / Doença Linfo Proliferativa Pós-Transplante Isolada ao Enxerto Renal

ABSTRACT Post-transplantation lymphoproliferative disease (PTLD) comprises a heterogeneous group of hematolymphoid proliferations resulting from a monoclonal or polyclonal proliferation of lymphoid cells. The clinical presentation varies according to the affected sites. The gastrointestinal tract and the central nervous system are the most common, and constitutional symptoms are frequent. Isolated allograft involvement is rare. We report a case of polyclonal PTLD isolated in the kidney allograft in a patient who received an HLA-identical living donor seven years before. Noteworthy, this patient did not present constitutional symptoms, and his only clinical manifestation was graft dysfunction, expressed by an increase in serum creatinine and mild proteinuria. The diagnosis was performed through renal biopsy, which showed dense lymphoid interstitial infiltrate. The PTLD was polyclonal, unrelated to Epstein-Bar virus (EBV), and it was successfully treated with chemotherapy, reduced immunosuppression, and sirolimus.

RESUMO A doença linfoproliferativa pós-transplante (DLPT) é formada por um grupo heterogêneo de proliferações hematolinfóides resultantes da proliferação mono ou policlonal das células linfoides. O quadro clínico é variado e dependente dos sítios envolvidos, sendo o trato gastrintestinal e o sistema nervoso central os mais comuns, e sintomas constitucionais são frequentes. O envolvimento isolado do enxerto é raro. Relatamos aqui um caso de DLPT policlonal isolada do enxerto em um receptor de transplante renal com doador vivo HLA idêntico, ocorrido sete anos após o transplante. Digno de nota, o paciente não apresentou sintomas constitucionais e sua única manifestação clínica foi disfunção do enxerto, expressa através da elevação da creatinina e discreta proteinuria, sendo o diagnóstico realizado através de biópsia renal, que evidenciou infiltrado intersticial linfoide denso. Tratava-se de DLPT policlonal não relacionada ao vírus Epstein-Bar (EBV) e foi tratado com sucesso com quimioterapia, redução da imunossupressão e sirolimo.

High mortality among kidney transplant recipients diagnosed with coronavirus disease 2019: Results from the Brazilian multicenter cohort study.

BACKGROUND: Kidney transplant (KT) recipients are considered a high-risk group for unfavorable outcomes in the course of coronavirus disease 2019 (COVID-19). AIM: To describe the clinical aspects and outcomes of COVID-19 among KT recipients. METHODS: This multicenter cohort study enrolled 1,680 KT recipients diagnosed with COVID-19 between March and November 2020, from 35 Brazilian centers. The main outcome was the 90-day cumulative incidence of death, for the entire cohort and according to acute kidney injury (AKI) and renal replacement therapy (RRT) requirement. Fatality rates were analyzed according to hospitalization, intensive care unit (ICU) admission, and mechanical ventilation (MV) requirement. Multivariable analysis was performed by logistic regression for the probability of hospitalization and death. RESULTS: The median age of the recipients was 51.3 years, 60.4% were men and 11.4% were Afro-Brazilian. Comorbidities were reported in 1,489 (88.6%), and the interval between transplantation and infection was 5.9 years. The most frequent symptoms were cough (54%), myalgia (40%), dyspnea (37%), and diarrhea (31%), whereas the clinical signs were fever (61%) and hypoxemia (13%). Hospitalization was required in 65.1%, and immunosuppressive drugs adjustments were made in 74.4% of in-hospital patients. ICU admission was required in 34.6% and MV in 24.9%. In the multivariable modeling, the variables related with the probability of hospitalization were age, hypertension, previous cardiovascular disease, recent use of high dose of steroid, and fever, dyspnea, diarrhea, and nausea or vomiting as COVID-19 symptoms. On the other hand, the variables that reduced the probability of hospitalization were time of COVID-19 symptoms, and nasal congestion, headache, arthralgia and anosmia as COVID-19 symptoms. The overall 90-day cumulative incidence of death was 21.0%. The fatality rates were 31.6%, 58.2%, and 75.5% in those who were hospitalized, admitted to the ICU, and required MV, respectively. At the time of infection, 23.2% had AKI and 23.4% required RRT in the follow-up. The cumulative incidence of death was significantly higher among recipients with AKI (36.0% vs. 19.1%, P < 0.0001) and in those who required RRT (70.8% vs. 10.1%, P < 0.0001). The variables related with the probability of death within 90 days after COVID-19 were age, time after transplantation, presence of hypertension, previous cardiovascular disease, use of tacrolimus and mycophenolate, recent use of high dose of steroids, and dyspnea as COVID-19 symptom. On the other hand, the variables that reduced the risk of death were time of symptoms, and headache and anosmia as COVID-19 symptoms. CONCLUSION: The patients diagnosed with COVID-19 were long-term KT recipients and most of them had some comorbidities. One in every five patients died, and the rate of death was significantly higher in those with AKI, mainly when RRT was required.

Exploring the causes of the high incidence of delayed graft function after kidney transplantation in Brazil: a multicenter study.

This retrospective multicenter (n = 18) cohort study evaluated the incidence, risk factors, and the impact of delayed graft function (DGF) on 1-year kidney transplant (KT) outcomes. Of 3992 deceased donor KT performed in 2014-2015, the incidence of DGF was 54%, ranging from 29.9% to 87.7% among centers. Risk factors (lower-bound-95%CI OR upper-bound-95%CI ) were male gender (1.066 1.2491.463 ), diabetic kidney disease (1.053 1.2961.595 ), time on dialysis (1.005 1.0071.009 ), retransplantation (1.035 1.3971.885 ), preformed anti-HLA antibodies (1.011 1.3831.892 ), HLA mismatches (1.006 1.0661.130 ), donor age (1.011 1.0171.023 ), donor final serum creatinine (sCr) (1.239 1.3171.399 ), cold ischemia time (CIT) (1.031 1.0431.056 ), machine perfusion (0.401 0.5420.733 ), and induction therapy with rabbit antithymocyte globulin (rATG) (0.658 0.8000.973 ). Duration of DGF > 4 days was associated with inferior renal function and DGF > 14 days with the higher incidences of acute rejection, graft loss, and death. In conclusion, the incidence and duration of DGF were high and associated with inferior graft outcomes. While late referral and poor donor maintenance account for the high overall incidence of DGF, variability in donor and recipient selection, organ preservation method, and type of induction agent may account for the wide variation observed among transplant centers.

Selenium Nutritional Status and Glutathione Peroxidase Activity and Its Relationship with Hemodialysis Time in Individuals Living in a Brazilian Region with Selenium-Rich Soil.

Suboptimal selenium status may impair the antioxidant defense system in patients undergoing hemodialysis, compromising the selenoenzyme glutathione peroxidase activity. To evaluate the association between the duration of hemodialysis, nutritional selenium status, glutathione peroxidase activity (GPx), and thiobarbituric acid reactive substance (TBARS) levels in patients with chronic renal failure undergoing hemodialysis in a region of selenium-rich soils (Ceará, Northeast Brazil). The case-control study of 75 individuals aged 18 to 88 years was allocated between two groups: hemodialysis (n = 41) and control (n = 34). Plasma and erythrocytes selenium levels were determined by inductively coupled plasma optical emission spectrometry. The GPx activity and TBARS levels were also evaluated. In addition, the hemodialysis group was stratified according to the duration of treatment (≤ 59 months and ≥ 60 months). The Mann-Whitney test, Student's t test, and Pearson's or Spearman's correlation were applied according to the data distribution. Moreover, a quantile regression was performed. The significance level (p) was < 0.05. The hemodialysis group had lower selenium levels in their plasma and erythrocytes than the control group (p < 0.001). However, there was no difference in the GPx activity between the groups. Furthermore, an association between the hemodialysis group and selenium levels in plasma (coefficient - 16,343, p < 0.001) and erythrocytes (coefficient - 7839, p = 0.003) was observed by quantile regression, independent of age, sex, and body-mass index. In individuals who had undergone treatment for 60 months or more, GPx activity was lower (p = 0.026) and TBARS levels higher (p = 0.011) than in those who had undergone treatment for less than 60 months. The status of selenium was reduced in the hemodialysis group compared to the control group. The lower GPx activity and higher levels of TBARS in individuals who had undergone treatment for 60 months or more correlated with greater oxidative stress.

Registro Clínico Baseado em Problemas como instrumento para desenvolver competências em programa de residência médica / Problem-based clinical record as an instrument to develop competences in a medical residency program

Resumo: Introdução: As competências relevantes ao ensino médico atual são divididas em sete dimensões: cognitiva, técnica, contextual, integrativa, afetiva, relacional e hábitos da mente. No presente estudo, um instrumento de aprendizagem nomeado Registro Clínico Baseado em Problemas (RBP), composto por uma lista de problemas on-line dos pacientes com suas respectivas investigações e intervenções, foi desenvolvido e aplicado em um programa de residência médica em clínica médica. Objetivo: Este estudo teve como objetivo investigar a percepção dos médicos residentes e preceptores sobre a utilização do RBP no processo ensino-aprendizagem e no desenvolvimento de competências em suas várias dimensões. Método: Participaram do estudo 21 residentes e oito preceptores de uma enfermaria de clínica médica, distribuídos em três grupos focais, em que dialogaram sobre a utilização do RBP no serviço. Para a interpretação da fala dos participantes, utilizou-se a análise de conteúdo de Bardin. Resultados: Na percepção dos residentes, o RBP influenciou na organização do conhecimento e na motivação dentro da dimensão cognitiva. A dimensão integrativa foi a mais citada pelos participantes, visto que o RBP levou à reflexão e à estruturação do raciocínio por problemas, atuando positivamente na organização do conhecimento e na definição dos problemas mais relevantes. Na dimensão contextual, não houve consenso entre os residentes sobre o impacto na solicitação racional de exames, e os preceptores relacionaram a falta de impacto do RBP à falta de feedback. Na dimensão relacional, preceptores e residentes relataram que o RBP trabalhou a síntese e organização do pensamento. No discurso dos residentes, o RBP influenciou os hábitos da mente relacionados à capacidade do médico de autoavaliação e reflexão sobre sua prática. Conclusão: O RBP atuou como instrumento de aprendizagem, principalmente por estar associado a fatores psicopedagógicos relacionados à facilitação da aprendizagem. As dimensões de competências cognitiva, integrativa, contextual, relacional e hábitos da mente foram desenvolvidas pelo RBP. A visão dos residentes e preceptores sobre a relevância do RBP para a aprendizagem de competências foi divergente. As dimensões cognitiva, integrativa e hábitos da mente tiveram maior diferença entre os participantes. Para que o RBP gere um aprendizado mais eficaz, os preceptores precisam interagir mais com o instrumento e realizar regularmente o feedback com os residentes.

Abstract: Introduction: Competencies relevant to current medical education are classified into cognitive, technical, contextual, integrative, affective, relational, and habits of mind. In the present study, a learning instrument, called Problem-Based Clinical Record (RBP), composed of a list of patients' online problems with their respective investigations and interventions was developed and applied in a Medical Residency Program in internal medicine. Objectives: To investigate the perception of resident physicians and tutors on the use of RBP in the teaching-learning process and the development of skills in its various dimensions. Method: 21 residents and 8 preceptors of a Medical Clinic ward participated in the study, distributed into 3 focus groups, where they discussed the use of RBP in the service. The participants' oral accounts were interpreted using Bardin's content analysis. Results: In the residents' view, RBP influenced the organization of knowledge and motivation within the cognitive dimension. The integrative dimension was the most cited by the participants, since RBP led to reflection and the structuring of reasoning by problems, acting positively in the organization of knowledge and definition of relevant problems. In the contextual dimension, no consensus was found among residents regarding impact on the rational request for exams and the preceptors related to the lack of impact of RBP to the lack of feedback. In the relational dimension, preceptors and residents reported that RBP worked on the synthesis and organization of thought. The residents argued that RBP influenced habits of the mind, related to the physician's ability to self-assess and reflect on his practice. Conclusion: RBP acted as a learning tool, mainly because it is associated with psycho-pedagogical factors related to the facilitation of learning. The dimensions of cognitive, integrative, contextual, relational, and habits of the mind were developed by the RBP. The view of residents and tutors on the relevance of RBP for learning skills was divergent. The cognitive, integrative, and habits of the mind dimensions had a greater difference between the participants. For RBP to generate more effective learning, preceptors need to interact more with the instrument and regularly provide feedback to residents.

The Impact of Hypothermic Pulsatile Machine Perfusion Versus Static Cold Storage: A Donor-Matched Paired Analysis in a Scenario of High Incidence of Delayed Kidney Graft Function.

BACKGROUND The present study analyzed the impact of hypothermic pulsatile machine perfusion (MP) following a long period of static cold (SC) storage in the peculiar Brazilian scenario of high incidence of delayed graft function (DGF), despite good donor characteristics. MATERIAL AND METHODS A retrospective analysis, with a 1-year follow-up, of 206 recipients of donor-matched paired kidneys was performed. Of the 206 donor kidneys, 103 were maintained exclusively in static cold storage (SC group) and 103 were kept on machine perfusion after a period of SC preservation (MP group). All donors were brain dead. RESULTS Only 4.9% of the kidneys were from expanded-criteria donors. Static cold ischemia time (CIT) in the SC group was 20.8±4.1 hours vs. 15.8±6.2 hours in the MP group (P<0.001). Dynamic CIT in the MP group was 12.3±5.7 hours. MP significantly reduced DGF incidence (29.1% vs. 55.3%, P<0.001), and this effect was confirmed in multivariable analysis (OR, 1.115; 95% CI, 1.033-1.204, P=0.001). No differences were observed between the groups with regard to DGF duration, length of hospital stay, incidence of primary nonfunction and acute rejection, graft loss, death, or renal function. CONCLUSIONS In this Brazilian setting, MP following a long period of SC preservation was associated with reduced DGF incidence in comparison with SC storage without MP.

The impact of deceased donor maintenance on delayed kidney allograft function: A machine learning analysis.

BACKGROUND: This study evaluated the risk factors for delayed graft function (DGF) in a country where its incidence is high, detailing donor maintenance-related (DMR) variables and using machine learning (ML) methods beyond the traditional regression-based models. METHODS: A total of 443 brain dead deceased donor kidney transplants (KT) from two Brazilian centers were retrospectively analyzed and the following DMR were evaluated using predictive modeling: arterial blood gas pH, serum sodium, blood glucose, urine output, mean arterial pressure, vasopressors use, and reversed cardiac arrest. RESULTS: Most patients (95.7%) received kidneys from standard criteria donors. The incidence of DGF was 53%. In multivariable logistic regression analysis, DMR variables did not impact on DGF occurrence. In post-hoc analysis including only KT with cold ischemia time<21h (n = 220), urine output in 24h prior to recovery surgery (OR = 0.639, 95%CI 0.444-0.919) and serum sodium (OR = 1.030, 95%CI 1.052-1.379) were risk factors for DGF. Using elastic net regularized regression model and ML analysis (decision tree, neural network and support vector machine), urine output and other DMR variables emerged as DGF predictors: mean arterial pressure, ≥ 1 or high dose vasopressors and blood glucose. CONCLUSIONS: Some DMR variables were associated with DGF, suggesting a potential impact of variables reflecting poor clinical and hemodynamic status on the incidence of DGF.

Severe Strongyloides stercoralis infection in kidney transplant recipients: a multicenter case-control study

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/Principal findings This was a retrospective, multicenter, case­control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5­965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05­18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2­7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001­1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46­2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83­35316.61). CONCLUSIONS/Significance Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment. (AU)

Infecção por parvovírus B19 em receptores de transplante renal: série de caso / Parvovirus B19 infection in kidney transplant recipients: a case series

Os receptores de transplante renal são mais suscetíveis a infecções, entre elas o parvovírus B19, que pode ser transmitido por via respiratória, adquirido por meio do enxerto ou por reativação de infecção latente. A anemia normocítica normocrômica, com diminuição dos reticulócitos e resistência ao tratamento com eritropoietina, é a principal forma de apresentação da infecção por parvovírus B19 em transplante renal. O diagnóstico requer alto índice de suspeição clínica e realização de testes diagnósticos selecionados. Tratamento com imunoglobulina e suspensão dos imunossupressores durante a infecção mostraram-se eficazes. Os autores relatam sua experiência com cinco casos de infecção por parvovírus B19 em receptores de transplante renal de um hospital universitário. Os aspectos clínicos, diagnósticos e terapêuticos são revistos.

Kidney transplant recipients are more susceptible to infections, including by parvovirus B19, spread through the respiratory tract, acquired through the graft or reactivation of latent infection. Normocytic normochromic anemia, with decreased reticulocytes and resistance to erythropoietin treatment, is the most common presentation of Parvovirus B19 infection in renal transplant. Diagnosis requires a higher clinical suspicion and the performance of selected diagnostic tests. Treatment with immunoglobulin and suspension of immunosuppressive therapy during the infection may be effective. The authors report five cases of PB19 infection in kidney transplant patients at a hospital. The clinical, diagnostic, and treatment features are reviewed.

Estratégia Adaptada de Feedback Voltado para Ambulatórios de Graduação / Feedback Strategy Adapted for University Undergraduated Student

RESUMO INTRODUÇÃO Feedback é uma informação provida pelo professor para melhorar o desempenho do estudante. Embora seja uma importante ferramenta de ensino e seja desejada pelos discentes, ainda é utilizada de maneira insuficiente. OBJETIVO Este estudo criou um manual para uso de feedback estruturado com base nos resultados de grupos focais que verificaram a percepção dos alunos do internato de Medicina sobre o tema. MÉTODOS Trinta e um alunos do internato de Medicina de uma instituição de ensino superior participaram de entrevistas de grupo focal sobre suas impressões relativas ao feedback. Os dados foram analisados pela Análise de Conteúdo de Bardin. RESULTADOS Os alunos compreendem o que é feedback e o vivenciam por meio das metodologias ativas de ensino. Reconhecem sua importância para o aprendizado, mas se queixam da baixa frequência desse instrumento. Sobre como gostariam de receber o feedback e as virtudes inerentes aos docentes e discentes para o sucesso do mesmo, notou-se o alinhamento de suas ideias com o que diz a literatura. CONCLUSÃO Os alunos conhecem feedback e o vivenciam na prática, reconhecendo sua importância para o aprendizado e sendo receptivos a ele. Desenvolveu-se um manual com estratégia de feedback estruturado voltado ao uso em ambulatórios didáticos na graduação em Medicina.

ABSTRACT INTRODUCTION Feedback is information provided by the teacher to improve student performance. Despite being an important teaching tool, and desired by the students, it is still not sufficiently used. OBJECTIVE This study created a manual for the use of feedback, structured based on the results of focus groups that explored the views of medical school interns on the subject. METHODS 31 medical interns of a Higher Education Institution took part in focus group interviews to gather their impressions on feedback. The data were analyzed using Bardin Content Analysis. RESULTS The students understand what feedback is, and experience it through active teaching methodologies. They recognize its importance for learning; however they complain that they do not receive feedback often enough. As to how they would like to receive feedback, and the virtues inherent to teachers and students for it success, it was found that the students' ideas are aligned with the literature. CONCLUSION Students know what feedback is, and experience it in practice; they recognize its importance for learning and are receptive to it. A manual was developed with a structured feedback strategy for use in university undergraduated students

Dengue in renal transplant recipients: Clinical course and impact on renal function.

AIM: To present clinical characteristics from renal transplant recipients with dengue fever and its impact on graft function. METHODS: We retrospectively evaluated 11 renal transplant recipients (RTR) with dengue infection confirmed by laboratory test, between January 2007 and July 2012, transplanted in the Renal Transplant Center of Walter Cantídio University Hospital from Federal University of Ceará. RESULTS: Positive dengue serology (IgM) was found in all patients. The mean time between transplant and dengue infection was 43 mo. Fever was presented in all patients. Nine patients presented with classical dengue and two (18%) with dengue hemorrhagic fever. All cases had satisfactory evolution with complete recovery of the symptoms. The time for symptom resolution varied from 2 to 20 d, with an average of 9 d. An increase of creatinine after the infection was observed in three (27.2%) patients with no clinically impact on the kidney graft function. CONCLUSION: RTR with dengue infection seems to have a clinical presentation and evolution similar to those seen in the general population, with no long-term damage to patient and to the graft.

Comparative study between kidney transplantation with deceased donor expanded criteria and donor standard criteria in a single center in Brazil.

Introduction: Kidney transplants with expanded criteria donor have been associated with improved patient survival compared to those who remain on dialysis. Objective: To compare renal function and survival of the kidney graft of deceased donor with expanded criteria and standard criteria over a year in a single transplant center. Methods: 255 kidney transplant recipients with deceased donor were included in the study between the years 2011 to 2013 and they were separated into two groups according to the type of donor (expanded criteria donor - ECD - and standard criteria donor - SCD). Results: 231 deceased donor transplants (90.6%) were performed with standard criteria donor (SCD) and 24 (9.4%) with expanded criteria donor (ECD). There was no difference in the prevalence of delayed graft function - DGF - (62.9% vs. 70.8%; p = 0.44). Expanded criteria donor group had lower glomerular filtration rate (GFR) at the end of the 1st year (56.8 ± 26.9 vs. 76.9 ± 23.7; p = 0.001). Patient survival was significantly lower in the ECD group, but the graft survival was not different after death-censored analysis. Conclusion: The ECD group was associated with significantly lower levels of GFR during the first year of transplant and a lower patient survival at the 1st year when compared to the SCD.

Introdução: A aceitação dos rins com critério expandido de doação tem sido associada com melhor sobrevida do paciente em comparação àqueles que permanecem em terapia dialítica. Objetivo: Comparar a função renal e a sobrevida do enxerto renal de doador falecido critério expandido com os de doador falecido critério padrão ao longo de um ano em um único centro de transplantes. Métodos: Foram incluídos 255 receptores de transplante renal com doador falecido, realizados entre os anos de 2011 a 2013, sendo divididos em dois grupos segundo o tipo de doador (critério expandido - DCE - ou padrão -DCP). Resultados: Foram avaliados 231 receptores com doador critério ideal (90,6%) e 24 com doador critério expandido (9,4%). Não houve diferença na prevalência de função retardada do enxerto - DGF - (62,9% no DCP vs. 70,8% no DCE; p = 0,44) nos dois grupos. Os transplantes com DCE apresentaram uma taxa de filtração glomerular (TFG) significativamente inferior aos 12 meses (56,8 ± 26,9 vs. 76,9 ± 23,7; p = 0,001). A sobrevida dos pacientes em 1 ano foi significativamente inferior no grupo de DCE, mas não houve diferença na sobrevida dos enxertos após exclusão de perdas por óbito com rim funcionante. Conclusão: O grupo com DCE associou-se com níveis significativamente mais baixos de TFG ao longo do primeiro ano de transplante, bem como uma menor sobrevida dos pacientes em 1 ano, quando comparado ao grupo com doador padrão.

Comparative study between kidney transplantation with deceased donor expanded criteria and donor standard criteria in a single center in Brazil / Estudo comparativo entre transplantes renais com doador falecido critério expandido e critério padrão em um único centro no Brasil

Abstract Introduction: Kidney transplants with expanded criteria donor have been associated with improved patient survival compared to those who remain on dialysis. Objective: To compare renal function and survival of the kidney graft of deceased donor with expanded criteria and standard criteria over a year in a single transplant center. Methods: 255 kidney transplant recipients with deceased donor were included in the study between the years 2011 to 2013 and they were separated into two groups according to the type of donor (expanded criteria donor - ECD - and standard criteria donor - SCD). Results: 231 deceased donor transplants (90.6%) were performed with standard criteria donor (SCD) and 24 (9.4%) with expanded criteria donor (ECD). There was no difference in the prevalence of delayed graft function - DGF - (62.9% vs. 70.8%; p = 0.44). Expanded criteria donor group had lower glomerular filtration rate (GFR) at the end of the 1st year (56.8 ± 26.9 vs. 76.9 ± 23.7; p = 0.001). Patient survival was significantly lower in the ECD group, but the graft survival was not different after death-censored analysis. Conclusion: The ECD group was associated with significantly lower levels of GFR during the first year of transplant and a lower patient survival at the 1st year when compared to the SCD.

Resumo Introdução: A aceitação dos rins com critério expandido de doação tem sido associada com melhor sobrevida do paciente em comparação àqueles que permanecem em terapia dialítica. Objetivo: Comparar a função renal e a sobrevida do enxerto renal de doador falecido critério expandido com os de doador falecido critério padrão ao longo de um ano em um único centro de transplantes. Métodos: Foram incluídos 255 receptores de transplante renal com doador falecido, realizados entre os anos de 2011 a 2013, sendo divididos em dois grupos segundo o tipo de doador (critério expandido - DCE - ou padrão -DCP). Resultados: Foram avaliados 231 receptores com doador critério ideal (90,6%) e 24 com doador critério expandido (9,4%). Não houve diferença na prevalência de função retardada do enxerto - DGF - (62,9% no DCP vs. 70,8% no DCE; p = 0,44) nos dois grupos. Os transplantes com DCE apresentaram uma taxa de filtração glomerular (TFG) significativamente inferior aos 12 meses (56,8 ± 26,9 vs. 76,9 ± 23,7; p = 0,001). A sobrevida dos pacientes em 1 ano foi significativamente inferior no grupo de DCE, mas não houve diferença na sobrevida dos enxertos após exclusão de perdas por óbito com rim funcionante. Conclusão: O grupo com DCE associou-se com níveis significativamente mais baixos de TFG ao longo do primeiro ano de transplante, bem como uma menor sobrevida dos pacientes em 1 ano, quando comparado ao grupo com doador padrão.

TINU syndrome: review of the literature and case report.

INTRODUCTION: Tubulointerstitial nephritis and uveitis syndrome (TINU Syndrome) is an uncommon clinical entity, and the majority of patients are adolescents and young women. The case reported refers to an elderly patient with ophthalmologic symptoms detected earlier than kidney manifestations, being probably the first case described in Brazil. CASE REPORT: Female patient, 60 years-old, sought medical attention for complaints of "red eye". Three months after the first episode of eye manifestation, the patient presented with systemic symptoms and renal dysfunction. Renal biopsy showed tubulointerstitial nephritis with signs of activity. DISCUSSION: The pathophysiology of TINU Syndrome remains poorly understood, probably involving both cellular and humoral immunity. This syndrome can be differentiated from systemic conditions associated with nephritis and uveitis, and prior exclusion of other diseases is necessary to confirm diagnosis, especially in the presence of ophthalmologic findings. CONCLUSION: The clinical suspicion and the knowledge of the management of the disease by nephrologists, internists and ophthalmologists is mandatory in the treatment of patients with TINU Syndrome.

Blood pressure measurement in hemodialysis: The importance of the measurement technique.

Systemic arterial hypertension contributes to the high cardiovascular morbidity in hemodialysis (HD) patients, but the accuracy of blood pressure (BP) measurement in this population has not been well studied. To evaluate the agreement between BP measurement using the routine measurement technique (usual method) and the technique recommended by the VII Joint (standard method). This cross-sectional study enrolled 124 patients in a single center who had undergone dialysis for more than three months and were 18 years of age or older. The BP was verified at the start of dialysis by the nursing team (usual method) and by the researchers (standard method). The agreement between the systolic and diastolic BP (SBP and DBP) measurements was tested by the Bland-Altman analysis. A difference in BP measurement higher than ±5 mm Hg was considered clinically significant. The studied group had a mean age of 53.2 years. The average difference between routine and standard BP measurement was -6 mm Hg for SBP (limits of agreement: -40.1-28 mm Hg; P <0.001) and -5.6 mm Hg for DBP (limits of agreement: -33.1-21.8 mm Hg; P <0.001). A clinically significant difference in BP measured by both methods was observed in 69.4% of the patients for SBP and in 61.3% for DBP. The disagreement between the results of different BP measurement methods in HD patients was significant and the BP was underestimated using the usual BP method. BP measurement standardization should be encouraged to avoid errors in diagnosis and therapy.

Síndrome TINU: revisão de literatura à propósito de um caso / TINU syndrome: review of the literature and case report

Resumo Introdução: A síndrome nefrite tubulointersticial e uveíte (síndrome TINU) é uma entidade clínica incomum e a maioria dos pacientes são adolescentes e mulheres jovens. O caso relatado a seguir refere-se a uma paciente idosa com manifestações oftalmológicas que antecederam às renais, sendo provavelmente o primeiro caso descrito no Brasil. Relato de Caso: Paciente feminina, 60 anos, procurou atendimento médico por queixa de "olhos vermelhos". Três meses após o primeiro episódio do quadro ocular, a paciente cursou com sintomas sistêmicos e disfunção renal. A biópsia renal evidenciou nefrite tubulointersticial com sinais de atividade. Discussão: A fisiopatologia da síndrome TINU permanece pouco entendida, provavelmente envolvendo a imunidade celular e humoral. Essa síndrome pode ser diferenciada de condições sistêmicas associadas à uveíte e à nefrite, sendo necessária a exclusão de outras doenças antes de se confirmar seu diagnóstico, especialmente na presença de achados oftalmológicos. Conclusão: A suspeição clínica e o conhecimento do manejo desta patologia por nefrologistas, internistas e oftalmologistas são mandatórios no tratamento do paciente com Síndrome TINU.

Abstract Introduction: Tubulointerstitial nephritis and uveitis syndrome (TINU Syndrome) is an uncommon clinical entity, and the majority of patients are adolescents and young women. The case reported refers to an elderly patient with ophthalmologic symptoms detected earlier than kidney manifestations, being probably the first case described in Brazil. Case Report: Female patient, 60 years-old, sought medical attention for complaints of "red eye". Three months after the first episode of eye manifestation, the patient presented with systemic symptoms and renal dysfunction. Renal biopsy showed tubulointerstitial nephritis with signs of activity. Discussion: The pathophysiology of TINU Syndrome remains poorly understood, probably involving both cellular and humoral immunity. This syndrome can be differentiated from systemic conditions associated with nephritis and uveitis, and prior exclusion of other diseases is necessary to confirm diagnosis, especially in the presence of ophthalmologic findings. Conclusion: The clinical suspicion and the knowledge of the management of the disease by nephrologists, internists and ophthalmologists is mandatory in the treatment of patients with TINU Syndrome.

Metabolic acidosis and its association with nutritional status in hemodialysis.

INTRODUCTION: Metabolic acidosis is a common problem in dialysis patients and plays an important role in the pathogenesis of protein-energy malnutrition in these patients. OBJECTIVES: To assess the prevalence of metabolic acidosis in hemodialysis and search their association with nutritional status. METHODS: A cross-sectional study was performed in hemodialysis patients at a single center. Nutritional status was assessed by anthropometric, biochemical and multifrequency bioelectrical impedance analysis. Metabolic acidosis was defined as serum bicarbonate (BIC) < 22 mEq/L and patients were divided into 3 groups according to BIC (< 15.15 to 21.9 and ≥ 22). The association between BIC and continuous variables was investigated using the Kruskal Wallis test. The linear correlation between BIC and the variables of the study was also tested. RESULTS: We studied 95 patients, 59% male, mean age 52.3 years. The prevalence of metabolic acidosis was 94.7%. BMI, interdialytic weight gain and PTH were significantly different among the 3 groups of BIC. The BIC was negatively correlated with urea, phosphorus and interdialytic weight gain. There was no significant correlation with albumin, phase angle and lean body mass index. CONCLUSION: The prevalence of metabolic acidosis was high in this population, and a lower BIC correlated with higher levels of urea, PTH, phosphorus, interdialytic weight gain and lower BMI. The evaluation of acid-basic status should be routinely implemented in dialysis patients by considering the negative effects of acidosis on the nutritional status, inflammation and bone disease.

Proteinúria after kidney transplantation - prevalence and risk factors.

INTRODUCTION: Proteinuria after kidney transplantation (Tx) has variable incidence and is associated with cardiovascular risk and graft survival. OBJECTIVE: To evaluate the prevalence of proteinuria after kidney Tx and its associated factors. METHODS: The prevalence of PTN was evaluated according to definition ≥ 500 mg/24 hours. Patients were divided into 3 groups: group A, < 500 mg, B, 500-1000 mg and C, > 1000 mg. We tested the association between PTN and: age/gender of the donor and recipient, type of donor, delayed graft function, acute rejection, hypertension and creatinine. The variables with a p value < 0.20 in the bivariate analysis were included in a multivariate logistic regression analysis. RESULTS: 173 recipients were evaluated, mean age 39 years, 57.2% male and 60.7% deceased donor. The prevalence of PTN after kidney Tx was 24.3%. The distribution of patients according to PTN was 75.7% for group A, 15.6% for group B and 8.7% for group C. The following factors were associated with higher risk of PTN: male recipients, living donor and hypertension. Creatinine at month 12 moths post-Tx was higher among patients with proteinuria. 60% of patients with PTN ≥ 500 mg/24 hours were treated with ACEI/ARB. CONCLUSION: The prevalence of PTN after kidney Tx varied between 24.3%, according to the definition used. The male gender of the recipient, living donor and hypertension were associated with the occurrence of PTN after kidney Tx. Blockade of the renin-angiotensin system must be prescribed to more patients.