Capacity for the management of kidney failure in the International Society of Nephrology Latin America region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA).

Successful management of chronic kidney disease (CKD) in Latin America (LA) continues to represent a challenge due to high disease burden and geographic disparities and difficulties in terms of capacity, accessibility, equity, and quality of kidney failure care. Although LA has experienced significant social and economic progress over the past decades, there are still important inequities in health care access. Through this third iteration of the International Society of Nephrology Global Kidney Health Atlas, the indicators regarding kidney failure care in LA are updated. Survey responses were received from 22 of 31 (71%) countries in LA representing 96.5% of its total population. Median CKD prevalence was 10.2% (interquartile range: 8.4%-12.3%), median CKD disability-adjusted life year was 753.4 days (interquartile range: 581.3-1072.5 days), and median CKD mortality was 5.5% (interquartile range: 3.2%-6.3%). Regarding dialysis modality, hemodialysis continued to be the most used therapy, whereas peritoneal dialysis reached a plateau and kidney transplantation increased steadily over the past 10 years. In 20 (91%) countries, >50% of people with kidney failure could access dialysis, and in only 2 (9%) countries, people who had access to dialysis could initiate dialysis with peritoneal dialysis. A mix of public and private systems collectively funded most aspects of kidney replacement therapy (dialysis and transplantation) with many people incurring up to 50% of out-of-pocket costs. Few LA countries had CKD/kidney replacement therapy registries, and almost no acute kidney injury registries were reported. There was large variability in the nature and extent of kidney failure care in LA mainly related to countries' funding structures and limited surveillance and management initiatives.

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.

Occupational risks associated with chronic kidney disease of non-traditional origin (CKDnt) in Brazil: it is time to dig deeper into a neglected problem.

In the past decades, an epidemic of chronic kidney disease (CKD) has been associated with environmental and occupational factors (heat stress from high workloads in hot temperatures and exposure to chemicals, such as pesticides and metals), which has been termed CKD of non-traditional origin (CKDnt). This descriptive review aims to present recent evidence about heat stress, pesticides, and metals as possible causes of CKDnt and provide an overview of the related Brazilian regulation, enforcement, and health surveillance strategies. Brazilian workers are commonly exposed to extreme heat conditions and other CKDnt risk factors, including increasing exposure to pesticides and metals. Furthermore, there is a lack of adequate regulation (and enforcement), public policies, and strategies to protect the kidney health of workers, considering the main risk factors. CKDnt is likely to be a significant cause of CKD in Brazil, since CKD's etiology is unknown in many patients and several conditions for its development are present in the country. Further epidemiological studies may be conducted to explore causal associations and estimate the impact of heat, pesticides, and metals on CKDnt in Brazil. Moreover, public policies should prioritize reducing workers´ exposure and promoting their health and safety.

Association between branched-chain amino acids and renal function in the ELSA-Brasil study.

BACKGROUND & AIMS: Epidemiologic studies show high circulating Branched-chain amino acids (BCAA) are associated with excess body weight, impaired fasting glucose, insulin resistance, high blood pressure, and dyslipidemia. There is scarce data on the association between renal function and circulating levels of BCAA. Therefore, we aim to study this association in a sample of the Brazilian Longitudinal Study of Adults (ELSA-Brasil) METHODS: We analyzed participants who had at the baseline BCAA: valine, isoleucine, and leucine measured through nuclear magnetic resonance. The outcomes evaluated were estimated glomerular function (eGFR - CKD-EPI without race) and 12h-albumin-creatinine ratio (ACR). In addition, we built unadjusted and adjusted multivariable linear regression models to investigate the association between the BCAA (total and individual) and eGFR and ACR. RESULTS: We studied 4912 participants (age 51.7(±9.0) years, 53.4% women, 59.5% White (59.5%), 32.7% hypertension, and 18.2% diabetes). The mean BCAA level was 429.15 ± 87.15. The mean eGFR was 84.95 ± 15 ml/min/1.73 m2, and the median ACR was 6.5 (1.8-4920) mg/g. Descriptive analyses comparing eGFR stratified <60 ml/min/1.73 m2 and ACR≥30 mg/g demonstrate that BCAA levels are higher in patients with eGFR<60 and ACR ≥30. Regarding eGFR, an inverse association was detected with BCAA levels when adjusted for demographic variables, and it is not maintained after adjustments for other confounders. Also, a positive association was found for ACR≥30 mg/g, and BCAA levels, and this association is not confirmed after adjustments. CONCLUSIONS: BCAA levels were inversely associated with eGFR and positively associated with ACR. Further studies are necessary to allow the comprehension of those associations.

Regional Variation in Hemoglobin Distribution Among Individuals With CKD: the ISN International Network of CKD Cohorts.

Introduction: Despite recognized geographic and sex-based differences in hemoglobin in the general population, these factors are typically ignored in patients with chronic kidney disease (CKD) in whom a single therapeutic range for hemoglobin is recommended. We sought to compare the distribution of hemoglobin across international nondialysis CKD populations and evaluate predictors of hemoglobin. Methods: In this cross-sectional study, hemoglobin distribution was evaluated in each cohort overall and stratified by sex and estimated glomerular filtration rate (eGFR). Relationships between candidate predictors and hemoglobin were assessed from linear regression models in each cohort. Estimates were subsequently pooled in a random effects model. Results: A total of 58,613 participants from 21 adult cohorts (median eGFR range of 17-49 ml/min) and 3 pediatric cohorts (median eGFR range of 26-45 ml/min) were included with broad geographic representation. Hemoglobin values varied substantially among the cohorts, overall and within eGFR categories, with particularly low mean hemoglobin observed in women from Asian and African cohorts. Across the eGFR range, women had a lower hemoglobin compared to men, even at an eGFR of 15 ml/min (mean difference 5.3 g/l, 95% confidence interval [CI] 3.7-6.9). Lower eGFR, female sex, older age, lower body mass index, and diabetic kidney disease were all independent predictors of a lower hemoglobin value; however, this only explained a minority of variance (R2 7%-44% across cohorts). Conclusion: There are substantial regional differences in hemoglobin distribution among individuals with CKD, and the majority of variance is unexplained by demographics, eGFR, or comorbidities. These findings call for a renewed interest in improving our understanding of hemoglobin determinants in specific CKD populations.

Urgent-Start Peritoneal Dialysis: Brazilian Experience.

INTRODUCTION: Unplanned peritoneal dialysis (PD) is an important option for chronic kidney disease (CKD) patients requiring kidney replacement therapy urgently as it offers the convenience of home-based therapy. The objective of this study was to assess the Brazilian urgent-start PD program in three different dialysis centers where there is shortage of hemodialysis (HD) beds. METHODS: This prospective, multicentric cohort study included incident patients with stage 5 CKD and no permanent vascular access established who started urgent PD between July 2014 and July 2020 in three different hospitals. Urgent-start PD was defined as initiation of treatment up to 72 h after catheter placement. Patients were followed up from catheter insertion and assessed according to mechanical and infectious complications related to PD, patients, and technique survival. RESULTS: Over 6 years, 370 patients were included in all three study centers. Mean patient age was 57.8 ± 16.32 years. Diabetic kidney disease was the main underlying condition (35.1%) and uremia was the main cause for dialysis indication (81.1%). Concerning complications related to PD, 24.3% had mechanical complications, 27.3% had peritonitis, 28.01% had technique failure, and 17.8% died. On logistic regression, hospitalization (p = 0.003) and exit site infection (p = 0.002) were identified as predictors of peritonitis, while mechanical complications (p = 0.004) and peritonitis (p < 0.001) were identified as predictors of technique failure and switching to HD. Age (p < 0.001), hospitalization (p = 0.012), and bacteremia (p = 0.021) were observed to predict death. The number of patients on PD increased at least 140% in all three participating centers. CONCLUSION: PD is a feasible option for patients starting dialysis in an unplanned manner and may be a useful tool for reducing shortage of HD beds.

International practice patterns of dyslipidemia management in patients with chronic kidney disease under nephrology care: is it time to review guideline recommendations?

BACKGROUND: In contrast to guidelines related to lipid therapy in other areas, 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend conducting a lipid profile upon diagnosis of chronic kidney disease (CKD) and treating all patients older than 50 years without defining a target for lipid levels. We evaluated multinational practice patterns for lipid management in patients with advanced CKD under nephrology care. METHODS: We analyzed lipid-lowering therapy (LLT), LDL- cholesterol (LDL-C) levels, and nephrologist-specified LDL-C goal upper limits in adult patients with eGFR < 60 ml/min from nephrology clinics in Brazil, France, Germany, and the United States (2014-2019). Models were adjusted for CKD stage, country, cardiovascular risk indicators, sex, and age. RESULTS: LLT treatment differed significantly by country, from 51% in Germany to 61% in the US and France (p = 0.002) for statin monotherapy. For ezetimibe with or without statins, the prevalence was 0.3% in Brazil to 9% in France (< 0.001). Compared with patients not taking lipid-lowering therapy, LDL-C was lower among treated patients (p < 0.0001) and differed significantly by country (p < 0.0001). At the patient level, the LDL-C levels and statin prescription did not vary significantly by CKD stage (p = 0.09 LDL-C and p = 0.24 statin use). Between 7-23% of untreated patients in each country had LDL-C ≥ 160 mg/dL. Only 7-17% of nephrologists believed that LDL-C should be < 70 mg/dL. CONCLUSION: There is substantial variation in practice patterns regarding LLT across countries but not across CKD stages. Treated patients appear to benefit from LDL-C lowering, yet a significant proportion of hyperlipidemia patients under nephrologist care are not receiving treatment.

Increase in peritoneal dialysis-related hospitalization rates after telemedicine implementation during the COVID-19 pandemic / Aumento de las tasas de hospitalización relacionadas con la diálisis peritoneal después de la implementación de telemedicina durante la pandemia de la COVID-19

Introduction and objectives: To minimize our peritoneal dialysis (PD) population exposure to coronavirus disease (COVID-19), in April 2020 we developed and implemented a telemedicine program. In this investigation, we aimed to compare the hospitalization rates and metabolic disorders in patients undergoing PD 6 months before and after the COVID-19 pandemic and telemedicine implementation. Materials and methods: This single-center retrospective analysis included all active prevalent patients undergoing PD from April 2020. Dialysis records were reviewed to obtain clinical, demographic, laboratory, appointment, and hospitalization data. We compared hospitalization rates (total, non-PD-related, and PD-related), hospitalization-associated factors, and metabolic disorders (hemoglobin, serum potassium, and serum phosphate) 6 months before and after the pandemic. Results: Our sample comprised 103 participants. During the pre-pandemic and post-pandemic periods, there were 13 and 27 hospital admissions, respectively. The total hospitalization incident rate ratio (IRR) was 2.48 (95% confidence interval [CI], 1.29–4.75). PD-related hospitalizations increased from 3 to 15 episodes (IRR=7.25 [95% CI, 2.11–24.78]). In the pre-pandemic period, the educational level was lower in participants hospitalised due to PD-related issues than in participants not hospitalised. In the post-pandemic period, only sex distribution differed between patients not hospitalised and those hospitalised due to non-PD-related issues. Only serum potassium levels changed significantly in the post-pandemic period (4.79±0.48 vs. 4.93±0.54mg/dL; P<0.01). (AU)

Introducción y objetivos: Para minimizar la exposición de nuestra población de diálisis peritoneal (DP) a la enfermedad por coronavirus (COVID-19), en abril del 2020 desarrollamos e implementamos un programa de telemedicina. En esta investigación, nuestro objetivo fue comparar las tasas de hospitalización y los trastornos metabólicos en pacientes sometidos a DP 6 meses antes y después de la pandemia de COVID-19 y la implementación de la telemedicina. Materiales y métodos: Este análisis retrospectivo de un solo centro incluyó a todos los pacientes prevalentes activos sometidos a DP desde abril del 2020. Se revisaron los registros de diálisis para obtener datos clínicos, demográficos, de laboratorio, de citas y de hospitalización. Comparamos las tasas de hospitalización (total, no relacionada con la DP y relacionada con la DP), los factores asociados a la hospitalización y los trastornos metabólicos (hemoglobina, potasio sérico y fosfato sérico) 6 meses antes y después de la pandemia. Resultados: Nuestra muestra fue compuesta por 103 participantes. Durante los períodos prepandémico y pospandémico, hubo 13 y 27 ingresos hospitalarios, respectivamente. La razón de la tasa de incidentes de hospitalización (TIR) total fue de 2,48 (intervalo de confianza [IC] del 95%, 1,29-4,75). Las hospitalizaciones relacionadas con la DP aumentaron de 3 a 15 episodios (TIR=7,25 [IC del 95%, 2,11-24,78]). En el período prepandémico, el nivel educativo fue más bajo en los participantes hospitalizados debido a problemas relacionados con la DP que en los participantes no hospitalizados. En el período posterior a la pandemia, solo la distribución por sexo difirió entre los pacientes no hospitalizados y los hospitalizados debido a problemas no relacionados con la DP. Solo los niveles de potasio sérico cambiaron significativamente en el período pospandémico (4.79±0.48 frente a 4.93±0.54 mg/dL; P<0.01). (AU)

Patiromer utilization in patients with advanced chronic kidney disease under nephrology care in Germany.

Background: Hyperkalemia (HK) is a frequent condition in patients with chronic kidney disease (CKD) that is associated with high morbidity and mortality. Patiromer has recently been introduced as a potassium binder. Data on patiromer use in patients with CKD in the real-world setting in Europe are lacking. We describe time to discontinuation and changes in serum potassium levels among German CKD stage 3-5 patients starting patiromer. Methods: Duration of patiromer use was estimated by Kaplan-Meier curve, starting at patiromer initiation and censoring for death, dialysis, transplant or loss to follow-up. Serum potassium levels and renin-angiotensin-aldosterone system inhibitor (RAASi) use are described at baseline and during follow-up, restricted to patients remaining on patiromer. Results: We identified 140 patiromer users within our analysis sample [81% CKD stage 4/5, 83% receiving RAASi, and median K+ 5.7 (5.4, 6.3) mmol/L]. Thirty percent of patiromer users had prior history of polystyrene sulfonate use. Overall, 95% of patiromer users stayed on treatment past 1 month, with 53% continuing for over a year. Mean serum potassium levels decreased after patiromer initiation and remained stable under treatment during follow-up (up to 180 days). Among these patients, 73%-82% used RAASis during the time periods before and after patiromer initiation, with no obvious trend indicating discontinuation. Conclusion: Real-world evidence of patiromer use in Germany shows that, in line with what has been observed in clinical trials, patients on patiromer have a reduction in serum potassium when used long-term. Moreover, most patients on patiromer do not discontinue treatment prior to 1 year after initiation.

Increase in peritoneal dialysis-related hospitalization rates after telemedicine implementation during the COVID-19 pandemic.

Introduction and objectives: To minimize our peritoneal dialysis (PD) population exposure to coronavirus disease (COVID-19), in April 2020 we developed and implemented a telemedicine program. In this investigation, we aimed to compare the hospitalization rates and metabolic disorders in patients undergoing PD 6 months before and after the COVID-19 pandemic and telemedicine implementation. Materials and methods: This single-center retrospective analysis included all active prevalent patients undergoing PD from April 2020. Dialysis records were reviewed to obtain clinical, demographic, laboratory, appointment, and hospitalization data. We compared hospitalization rates (total, non-PD-related, and PD-related), hospitalization-associated factors, and metabolic disorders (hemoglobin, serum potassium, and serum phosphate) 6 months before and after the pandemic. Results: Our sample comprised 103 participants. During the pre-pandemic and post-pandemic periods, there were 13 and 27 hospital admissions, respectively. The total hospitalization incident rate ratio (IRR) was 2.48 (95% confidence interval [CI], 1.29-4.75). PD-related hospitalizations increased from 3 to 15 episodes (IRR = 7.25 [95% CI, 2.11-24.78]). In the pre-pandemic period, the educational level was lower in participants hospitalised due to PD-related issues than in participants not hospitalised. In the post-pandemic period, only sex distribution differed between patients not hospitalised and those hospitalised due to non-PD-related issues. Only serum potassium levels changed significantly in the post-pandemic period (4.79 ± 0.48 vs. 4.93 ± 0.54 mg/dL; P < 0.01). Conclusion: This study showed a significant increase in hospitalization rates after the COVID-19 pandemic period and telemedicine implementation, mainly due to PD-related infectious causes. Strategies to improve distance monitoring assistance are needed for the PD population.

Introducción y objetivos: Para minimizar la exposición de nuestra población de diálisis peritoneal (DP) a la enfermedad por coronavirus (COVID-19), en abril del 2020 desarrollamos e implementamos un programa de telemedicina. En esta investigación, nuestro objetivo fue comparar las tasas de hospitalización y los trastornos metabólicos en pacientes sometidos a DP 6 meses antes y después de la pandemia de COVID-19 y la implementación de la telemedicina. Materiales y métodos: Este análisis retrospectivo de un solo centro incluyó a todos los pacientes prevalentes activos sometidos a DP desde abril del 2020. Se revisaron los registros de diálisis para obtener datos clínicos, demográficos, de laboratorio, de citas y de hospitalización. Comparamos las tasas de hospitalización (total, no relacionada con la DP y relacionada con la DP), los factores asociados a la hospitalización y los trastornos metabólicos (hemoglobina, potasio sérico y fosfato sérico) 6 meses antes y después de la pandemia. Resultados: Nuestra muestra fue compuesta por 103 participantes. Durante los períodos prepandémico y pospandémico, hubo 13 y 27 ingresos hospitalarios, respectivamente. La razón de la tasa de incidentes de hospitalización (TIR) total fue de 2,48 (intervalo de confianza [IC] del 95%, 1,29-4,75). Las hospitalizaciones relacionadas con la DP aumentaron de 3 a 15 episodios (TIR = 7,25 [IC del 95%, 2,11-24,78]). En el período prepandémico, el nivel educativo fue más bajo en los participantes hospitalizados debido a problemas relacionados con la DP que en los participantes no hospitalizados. En el período posterior a la pandemia, solo la distribución por sexo difirió entre los pacientes no hospitalizados y los hospitalizados debido a problemas no relacionados con la DP. Solo los niveles de potasio sérico cambiaron significativamente en el período pospandémico (4.79 ± 0.48 frente a 4.93 ± 0.54 mg/dL; P < 0.01). Conclusión: Este estudio mostró un aumento significativo en las tasas de hospitalización después del período pandémico de COVID-19 y la implementación de la telemedicina, principalmente debido a causas infecciosas relacionadas con la DP. Se necesitan estrategias para mejorar la asistencia de monitoreo a distancia para la población con DP.

Increase in peritoneal dialysis-related hospitalization rates after telemedicine implementation during the COVID-19 pandemic.

INTRODUCTION AND OBJECTIVES: To minimize our peritoneal dialysis (PD) population exposure to coronavirus disease (COVID-19), in April 2020 we developed and implemented a telemedicine program. In this investigation, we aimed to compare the hospitalization rates and metabolic disorders in patients undergoing PD 6 months before and after the COVID-19 pandemic and telemedicine implementation. MATERIALS AND METHODS: This single-center retrospective analysis included all active prevalent patients undergoing PD from April 2020. Dialysis records were reviewed to obtain clinical, demographic, laboratory, appointment, and hospitalization data. We compared hospitalization rates (total, non-PD-related, and PD-related), hospitalization-associated factors, and metabolic disorders (hemoglobin, serum potassium, and serum phosphate) 6 months before and after the pandemic. RESULTS: Our sample comprised 103 participants. During the pre-pandemic and post-pandemic periods, there were 13 and 27 hospital admissions, respectively. The total hospitalization incident rate ratio (IRR) was 2.48 (95% confidence interval [CI], 1.29-4.75). PD-related hospitalizations increased from 3 to 15 episodes (IRR=7.25 [95% CI, 2.11-24.78]). In the pre-pandemic period, the educational level was lower in participants hospitalised due to PD-related issues than in participants not hospitalised. In the post-pandemic period, only sex distribution differed between patients not hospitalised and those hospitalised due to non-PD-related issues. Only serum potassium levels changed significantly in the post-pandemic period (4.79±0.48 vs. 4.93±0.54mg/dL; P<0.01). CONCLUSION: This study showed a significant increase in hospitalization rates after the COVID-19 pandemic period and telemedicine implementation, mainly due to PD-related infectious causes. Strategies to improve distance monitoring assistance are needed for the PD population.

Urgent vs. planned peritoneal dialysis initiation: complications and outcomes in the first year of therapy / Diálise peritoneal de início urgente versus planejado: complicações e desfechos no primeiro ano de terapia

Abstract Introduction: Urgent-start peritoneal dialysis (US-PD) has been proposed as a safe modality of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients with an indication for emergency dialysis initiation. We aimed to compare the characteristics, 30-day complications, and clinical outcomes of US-PD and planned peritoneal dialysis (Plan-PD) patients over the first year of therapy. Methods: This was a single-center retrospective study that included incident adult patients followed for up to one year. US-PD was considered when incident patients started therapy within 7 days after Tenckhoff catheter implantation. Plan-PD group consisted of patients who started therapy after the breaking period (15 days). Mechanical and infectious complications were compared 30 days from PD initiation. Hospitalization and technique failure during the first 12 months on PD were assessed by Kaplan-Meier curves and the determinants were calculated by Cox regression models. Results: All patients starting PD between October/2016 and November/2019 who fulfilled the inclusion criteria were analyzed. We evaluated 137 patients (70 in the US-PD x 67 Plan-PD). The main complications in the first 30 days were catheter tip migration (7.5% Plan-PD x 4.3% US-PD - p= 0.49) and leakage (4.5% Plan-PD x 5.7% US-PD - p=0.74). Most catheters were placed using the Seldinger technique. The main cause of dropout was death in US-PD patients (15.7%) and transfer to HD in Plan-PD patients (13.4%). The occurrence of complications in the first 30 days was the only risk factor for dropout (OR = 2.9; 95% CI 1.1-7.5, p = 0.03). Hospitalization rates and technique survival were similar in both groups. Conclusion: The lack of significant differences in patients' outcomes between groups reinforces that PD is a safe and applicable dialysis method in patients who need immediate dialysis.

Resumo Introdução: A diálise peritoneal de início urgente (US-PD) foi proposta como modalidade segura de terapia renal substitutiva (TRS) para pacientes com doença renal em estágio 5 (DRC-5) com indicação de início de diálise de emergência. Buscamos comparar características, complicações em 30 dias e desfechos clínicos de pacientes em US-PD e diálise peritoneal planejada (DP-plan) no primeiro ano de terapia. Métodos: Estudo retrospectivo de centro único, que incluiu pacientes adultos incidentes em DP acompanhados por até um ano. Considerou-se US-PD quando os pacientes iniciaram terapia até 7 dias após implante do cateter Tenckhoff. O grupo DP-plan consistiu de pacientes iniciando terapia após período break-in (15 dias). Compararam-se complicações mecânicas e infecciosas 30 dias após o início da DP. Hospitalização e falha da técnica durante os primeiros 12 meses em terapia foram avaliados por curvas Kaplan-Meier e os seus determinantes foram analisados por modelos de regressão de Cox. Resultados: Analisaram-se todos os pacientes iniciando DP entre Outubro/2016-Novembro/2019 que preencheram os critérios de inclusão. Avaliamos 137 pacientes (70 US-PD x 67 DP-plan). As principais complicações nos primeiros 30 dias foram migração da ponta do cateter (7,5% DP-plan x 4,3% US-PD - p= 0,49) e extravasamento (4,5% DP-plan x 5,7% US-PD - p=0,74). A maioria dos cateteres foi implantada pela técnica de Seldinger. A principal causa de saída da terapia foi óbito em pacientes em US-PD (15,7%) e transferência para HD em pacientes em DP-plan (13,4%). A ocorrência de complicações nos primeiros 30 dias foi o único fator de risco para saída da terapia (OR = 2,9; IC 95% 1,1-7,5, p = 0,03). Taxas de hospitalização e sobrevida da técnica foram similares em ambos os grupos. Conclusão: A ausência de diferenças significativas nos desfechos dos pacientes entre os grupos reforça que DP é um método de diálise seguro e aplicável em pacientes que necessitam diálise imediata.

Impact of telemedicine on metabolic control and hospitalization of peritoneal dialysis patients during the COVID-19 pandemic: a national multicentric cohort study / Impacto da telemedicina no controle metabólico e hospitalização de pacientes em diálise peritoneal durante a pandemia de COVID-19: um estudo de coorte multicêntrico nacional

Abstract Introduction: The coronavirus-19 pandemic threatens the lives of all people, but results in higher mortality rates for patients with end-stage kidney disease (ESKD) including those on peritoneal dialysis (PD). Telemedicine was the main alternative to reduce exposure to the virus, but it was introduced in the Brazil without proper training. Objective: To investigate the impact of telemedicine on metabolic control, peritonitis rates, and hospitalization in PD patients during the pandemic. Methods: This was a retrospective multicenter cohort study. We included all adult patients on chronic PD from 9 clinics selected by convenience during the pandemic. The outcomes of interest were measured and compared between before and after switching to telemedicine using repeated measure analysis and multilevel Poisson regression. Results: The study included 747 patients with a mean age of 59.7±16.6 years, of whom 53.7% were male and 40.8% had diabetes. Biochemical parameters including hemoglobin, potassium, phosphate, calcium, and urea serum levels did not change significantly after transition to telemedicine. There was no association between telemedicine and peritonitis rates. In contrast, hospitalization rates increased significantly in the telemedicine period. The incidence rate ratio (IRR) for hospitalization in the telemedicine period was 1.54 (95%CI 1.10-2.17; p 0.012) and 1.57 (95%CI 1.12-2.21; p 0.009) in the mixed-effects Poisson regression before and after adjustment for the presence of confounders. Admissions for hypervolemia and infections not related to PD doubled after transition to telemedicine. Conclusion: The implementation of telemedicine without proper training may lead to an increase in adverse events in PD patients.

Resumo Introdução: A pandemia do coronavírus-19 ameaça a vida de todas as pessoas, mas resulta em uma alta taxa de mortalidade em pacientes com doença renal em estágio terminal (DRET), incluindo aqueles em diálise peritoneal (DP). A telemedicina foi a principal alternativa para reduzir a exposição ao vírus, mas foi introduzida no Brasil sem treinamento adequado. Objetivo: Investigar o impacto da telemedicina no controle metabólico, taxas de peritonite e hospitalização em pacientes em DP na pandemia. Métodos: Estudo de coorte multicêntrico retrospectivo. Incluímos todos os pacientes adultos em DP crônica de 9 clínicas selecionadas por conveniência durante a pandemia. Desfechos de interesse foram medidos e comparados entre antes e depois da mudança para telemedicina usando análise de medidas repetidas e regressão multinível de Poisson. Resultados: Incluiu-se 747 pacientes com idade média de 59,7±16,6 anos, sendo 53,7% homens e 40,8% diabéticos. Parâmetros bioquímicos, incluindo níveis séricos de hemoglobina, potássio, fosfato, cálcio e ureia não mudaram significativamente após transição para telemedicina. Não houve associação entre telemedicina e taxas de peritonite. Em contraste, taxas de hospitalização aumentaram significativamente no período de telemedicina. A razão de taxas de incidência (RTI) para internação no período de telemedicina foi 1,54 (IC95% 1,10-2,17; p 0,012) e 1,57 (IC95% 1,12-2,21; p 0,009) na regressão multinível de Poisson antes e após ajuste para presença de fatores de confusão. As internações por hipervolemia e infecções não relacionadas à DP dobraram após transição para telemedicina. Conclusão: A implementação da telemedicina sem treinamento adequado pode levar ao aumento de eventos adversos em pacientes em DP.

Distribution of kidney diseases in Joinville, Santa Catarina: analysis of a kidney biopsy data bank between 2008 and 2019 / Distribuição das nefropatias em Joinville, Santa Catarina: análise de um banco de dados de biópsia renal entre 2008 a 2019

Abstract Introduction: Studies based on kidney biopsies are important for the epidemiological understanding of nephropathies. Objective: To describe the main nephropathies diagnosed through renal biopsies, and compare them with regards to gender, time, healthcare insurance and age. Methods: A population-based retrospective study that reviewed all kidney disease diagnoses obtained by biopsy of a native kidney from pathology services between 2008 and 2019 in Joinville, Brazil. Results: Of 778 biopsies performed, 44.5% were primary nephropathies and 28.5% were secondary. The highest prevalence was focal segmental glomerulosclerosis (FSGS) [18.1%], followed by tubulointerstitial nephropathy (TIN) [15.9%] and IgA nephropathy (IgAN) [9.1%]. There was a growing increase in the prevalence of TIN among elderly and uninsured patients over the period. In the multivariate analysis, among the primary glomerulopathies, males had a higher risk for the occurrence of IgAN [OR=2.02; 95% CI 1.13-3.61; p=0.018], as well as being a protective factor for the occurrence of lupus glomerulonephritis (LGN) [OR=0.20, 95% CI 0.08-0.49; p<0.001]. Advancing age and dependence on a public healthcare decreased the likelihood of having a diagnosis of LGN [OR=0.91, 95% CI 0.88-0.94, p < 0.001 and OR=0.45, CI 95 % 0.21-0.96; p = 0.036, respectively]. Patients without private healthcare insurance were more likely to have TIN [OR=1.77, 95%CI 1.16-2.70; p = 0.008]. Conclusion: Sex, age and type of medical healthcare insurance may be related to the occurrence of some nephropathies. The increased risk of TIN in individuals without a private healthcare plan may be an indication of inequalities in health care.

Resumo Introdução: Estudos com base em biópsias renais são importantes para o entendimento epidemiológico das nefropatias. Objetivo: Descrever as principais nefropatias diagnosticadas por meio de biópsias renais e comparar com relação ao gênero, período, plano de saúde e à idade. Métodos: Estudo retrospectivo de base populacional que revisou todos os diagnósticos de doenças renais obtidos por biópsia de rim nativo de serviços de patologias entre 2008 a 2019, em Joinville, Brasil. Resultados: Do total de 778 biópsias realizadas, 44,5% eram nefropatias primárias e 28,5%, secundárias. A maior prevalência foi de glomeruloesclerose segmentar e focal (GESF) [18,1%], seguida por nefropatia tubulointersticial (NTI) [15,9%] e nefropatia IgA (NIgA) [9,1%]. Houve crescente aumento da prevalência de NTI nos pacientes idosos e sem plano de saúde ao longo do período. Na análise multivariada, entre as glomerulopatias primárias, o sexo masculino apresentou maior risco para ocorrência de NIgA [OR=2,02, IC 95% 1,13-3,61; p=0,018], bem como foi um fator de proteção para ocorrência de glomerulonefrite lúpica (GNL) [OR=0,20, IC 95% 0,08-0,49; p < 0,001]. O avançar da idade e a dependência de plano público de saúde diminuíram a chance para o diagnóstico de GNL [OR=0,91, IC 95% 0,88-0,94, p < 0,001 e OR=0,45, IC 95% 0,21-0,96; p = 0,036, respectivamente]. Pacientes sem plano privado de saúde apresentaram mais chance de NTI [OR=1,77, IC 95%1,16-2,70; p = 0,008]. Conclusão: Sexo, idade e tipo de assistência médica podem estar relacionados à ocorrência de algumas nefropatias. O maior risco de NTI em indivíduos sem plano de saúde privado pode ser um indicativo de desigualdades no cuidado à saúde.

Urgent vs. planned peritoneal dialysis initiation: complications and outcomes in the first year of therapy.

INTRODUCTION: Urgent-start peritoneal dialysis (US-PD) has been proposed as a safe modality of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients with an indication for emergency dialysis initiation. We aimed to compare the characteristics, 30-day complications, and clinical outcomes of US-PD and planned peritoneal dialysis (Plan-PD) patients over the first year of therapy. METHODS: This was a single-center retrospective study that included incident adult patients followed for up to one year. US-PD was considered when incident patients started therapy within 7 days after Tenckhoff catheter implantation. Plan-PD group consisted of patients who started therapy after the breaking period (15 days). Mechanical and infectious complications were compared 30 days from PD initiation. Hospitalization and technique failure during the first 12 months on PD were assessed by Kaplan-Meier curves and the determinants were calculated by Cox regression models. RESULTS: All patients starting PD between October/2016 and November/2019 who fulfilled the inclusion criteria were analyzed. We evaluated 137 patients (70 in the US-PD x 67 Plan-PD). The main complications in the first 30 days were catheter tip migration (7.5% Plan-PD x 4.3% US-PD - p= 0.49) and leakage (4.5% Plan-PD x 5.7% US-PD - p=0.74). Most catheters were placed using the Seldinger technique. The main cause of dropout was death in US-PD patients (15.7%) and transfer to HD in Plan-PD patients (13.4%). The occurrence of complications in the first 30 days was the only risk factor for dropout (OR = 2.9; 95% CI 1.1-7.5, p = 0.03). Hospitalization rates and technique survival were similar in both groups. CONCLUSION: The lack of significant differences in patients' outcomes between groups reinforces that PD is a safe and applicable dialysis method in patients who need immediate dialysis.