Estimated Glomerular Filtration Rate, Albuminuria, and Adverse Outcomes: An Individual-Participant Data Meta-Analysis.

Importance: Chronic kidney disease (low estimated glomerular filtration rate [eGFR] or albuminuria) affects approximately 14% of adults in the US. Objective: To evaluate associations of lower eGFR based on creatinine alone, lower eGFR based on creatinine combined with cystatin C, and more severe albuminuria with adverse kidney outcomes, cardiovascular outcomes, and other health outcomes. Design, Setting, and Participants: Individual-participant data meta-analysis of 27 503 140 individuals from 114 global cohorts (eGFR based on creatinine alone) and 720 736 individuals from 20 cohorts (eGFR based on creatinine and cystatin C) and 9 067 753 individuals from 114 cohorts (albuminuria) from 1980 to 2021. Exposures: The Chronic Kidney Disease Epidemiology Collaboration 2021 equations for eGFR based on creatinine alone and eGFR based on creatinine and cystatin C; and albuminuria estimated as urine albumin to creatinine ratio (UACR). Main Outcomes and Measures: The risk of kidney failure requiring replacement therapy, all-cause mortality, cardiovascular mortality, acute kidney injury, any hospitalization, coronary heart disease, stroke, heart failure, atrial fibrillation, and peripheral artery disease. The analyses were performed within each cohort and summarized with random-effects meta-analyses. Results: Within the population using eGFR based on creatinine alone (mean age, 54 years [SD, 17 years]; 51% were women; mean follow-up time, 4.8 years [SD, 3.3 years]), the mean eGFR was 90 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 11 mg/g (IQR, 8-16 mg/g). Within the population using eGFR based on creatinine and cystatin C (mean age, 59 years [SD, 12 years]; 53% were women; mean follow-up time, 10.8 years [SD, 4.1 years]), the mean eGFR was 88 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 9 mg/g (IQR, 6-18 mg/g). Lower eGFR (whether based on creatinine alone or based on creatinine and cystatin C) and higher UACR were each significantly associated with higher risk for each of the 10 adverse outcomes, including those in the mildest categories of chronic kidney disease. For example, among people with a UACR less than 10 mg/g, an eGFR of 45 to 59 mL/min/1.73 m2 based on creatinine alone was associated with significantly higher hospitalization rates compared with an eGFR of 90 to 104 mL/min/1.73 m2 (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.3]; 161 vs 79 events per 1000 person-years; excess absolute risk, 22 events per 1000 person-years [95% CI, 19-25 events per 1000 person-years]). Conclusions and Relevance: In this retrospective analysis of 114 cohorts, lower eGFR based on creatinine alone, lower eGFR based on creatinine and cystatin C, and more severe UACR were each associated with increased rates of 10 adverse outcomes, including adverse kidney outcomes, cardiovascular diseases, and hospitalizations.

Long-term follow-up of an IgA nephropathy cohort: outcomes and risk factors.

AIM: IgA nephropathy (IgAN), the most common glomerulopathy worldwide and in Uruguay, raised treatment controversies. The study aimed to analyze long-term IgAN outcomes and treatment. METHODS: A retrospective analysis of a Uruguayan IgAN cohort, enrolled between 1985 and 2009 and followed up until 2020, was performed. The Ethics Committee approved the study. The inclusion criteria were (a) biopsy-proven IgAN; (b) age ≥12 years; and (c) available clinical, histologic, and treatment data. The patients were divided into two groups, with immunosuppressive (IS) or without (NoIS) treatment. Outcomes (end-stage kidney disease/kidney replacement therapy [ESKD/KRT] or all-cause death) were obtained from mandatory national registries. RESULTS: The study population included 241 patients (64.7% men), median age 32 (19.5) years, baseline blood pressure <130/80 mmHg in 37%, and microhematuria in 67.5% of patients. Baseline proteinuria, glomerulosclerosis, and a higher crescent percentage were significantly more frequent in the IS group. Proteinuria improved in both groups. Renal survival at 20 years was 74.6% without difference between groups. In the overall population and in the NoIS group, bivariate Cox regression analysis showed that baseline proteinuria, endocapillary hypercellularity, tubule interstitial damage, and crescents were associated with a higher risk of ESKD/KRT or death, but in the IS group, proteinuria and endocapillary hypercellularity were not. In the multivariate Cox analysis, proteinuria in the NoIS group, crescents in the IS group and tubule interstitial damage in both groups were independent risk factors. CONCLUSION: The IS group had more severe risk factors than the NoIS group but attained a similar outcome.

Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes.

INTRODUCTION: The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. METHODS: A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. RESULTS: 14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000). CONCLUSION: Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

Mineral and bone disorder and longterm survival in a chronic kidney disease grade 3b-4cohort.

Mineral and bone disorder biomarkers 'normal ranges' are controversial. The aim of the study was to evaluate the association between serum calcium (Ca), phosphate (P), intact parathyroid hormone (iPTH), and 25(OH) vitamin D levels and mortality risk, in a chronic kidney disease (CKD) grade (G) 3b-4 cohort. The Uruguayan National Renal Healthcare Program (NRHP-UY) CKD patients' cohort, included between 1 October 2004 and 1 March 2020 and followed-up until 1 March 2021, was analyzed with the Ethics Committee approval. A total of 6473 patients were analyzed: 56% men, median age 73 (65-79) years, 55% on CKD G3b. At the end of the follow-up, 2459 (37.7%) patients had died (6.4/100 patient-year). There were iPTH data on 2013 patients (younger, with lower estimated glomerular filtration rate (eGFR) and lesser comorbidities). By bivariate Cox analysis the lowest death risk was observed with mean Ca between 9.01 and 10.25 mg/dl, P between 2.76 and 4.0 mg/dl, iPTH ≤ 105 pg/ml, and 25(OH) vitamin D >10 ng/ml. The multivariate Cox regression mortality risk adjusted to age, sex, CKD etiology, diabetes, smoking, cardiovascular comorbidity, blood pressure, proteinuria, eGFR, renin-angiotensin system blockers and vitamin D treatments, serum Ca, P, iPTH, and 25(OH) vitamin D (n = 964) showed that a higher mortality risk was associated with p > 4.00 mg/dl (HR 1.668, CI 95%: 1.201-2.317), iPTH >105 pg/ml (HR 1.386, CI 95%: 1.012-1.989), and 25(OH) vitamin D ≤ 10 ng/ml (HR 1.958, CI 95%: 1.238-3.098) and a lower mortality risk with 1,25(OH)2 vitamin D treatment (HR 0.639, CI 95%: 0.451-0.906). These data may contribute to the precise G3b-4 CKD-MBD biomarkers levels definition.

The Latin American Dialysis and Renal Transplantation Registry: report 2019.

BACKGROUND: Chronic kidney disease (CKD) in Latin America (LA) continues to represent a challenge due to the burden of disease it causes and the difficulty in accessing treatment. LA has a total population of 652 million people living in 20 countries that occupy an area of 19.2 million km2. The Latin American Dialysis and Renal Transplantation Registry (LADRTR), founded in 1991, has collected data and reports on patients receiving kidney replacement therapy (KRT) since 1993. This article summarizes the registry data for 2019. METHODS: Participating countries complete an annual survey collecting aggregated data on incident and prevalent patients on KRT in all modalities. The different treatment modalities considered were hemodialysis (HD), peritoneal dialysis (PD) and living functioning kidney graft (LFG). National gross domestic product per capita (GDP, expressed in US dollars) and life expectancy at birth (LEB) corresponding to the year 2019 were collected from the World Bank Data Bank. Prevalence and incidence were compared with previous years and were also correlated with GDP and LEB. RESULTS: On 31 December 2019 a total of 432 610 patients were in KRT in LA, corresponding to an overall unadjusted prevalence of 866 per million population (pmp). Regarding treatment modality, 66.7% of the prevalent patients were treated with HD and 9.3% with PD while 24% of the patients had an LFG. A total of 85 224 patients started KRT in LA, representing a total unadjusted incidence rate of 168 pmp. Diabetic nephropathy as a cause of CKD continues to be a relevant percentage (36%) and five countries reported CKD of nontraditional causes. The kidney transplant rate in the region was 22 pmp, varying from 1 to >60 pmp. The total prevalence of KRT correlated positively with GDP per capita (r 2 = 0.6, P < 0.01) and LEB (r 2 = 0.23, P < 0.05). The overall incidence rate also significantly correlated with GDP (r 2 = 0.307, P < 0.05). The overall unadjusted mortality rate was 13%. CONCLUSION: Accessibility to KRT is still limited in LA. It is necessary to continue the efforts made by each country and the Latin American Society of Nephrology and Hypertension to guarantee equal access to treatment.

Latin American registry of renal involvement in COVID-19 disease. The relevance of assessing proteinuria throughout the clinical course.

The Latin American Society of Nephrology and Hypertension conducted a prospective cohort, multinational registry of Latin American patients with kidney impairment associated to COVID-19 infection with the objective to describe the characteristics of acute kidney disease under these circumstances. The study was carried out through open invitation in order to describe the characteristics of the disease in the region. Eight-hundred and seventy patients from 12 countries were included. Median age was 63 years (54-74), most of patients were male (68.4%) and with diverse comorbidities (87.2%). Acute kidney injury (AKI) was hospital-acquired in 64.7% and non-oliguric in 59.9%. Multiorgan dysfunction syndrome (MODS) due to COVID-19 and volume depletion were the main factors contributing to AKI (59.2% and 35.7% respectively). Kidney replacement therapy was started in 46.2%. Non-recovery of renal function was observed in 65.3%. 71.5% of patients were admitted to ICU and 72.2% underwent mechanical ventilation. Proteinuria at admission was present in 62.4% of patients and proteinuria during hospital-stay occurred in 37.5%. Those patients with proteinuria at admission had higher burden of comorbidities, higher baseline sCr, and MODS was severe. On the other hand, patients with de novo proteinuria had lower incidence of comorbidities and near normal sCr at admission, but showed adverse course of disease. COVID-19 MODS was the main cause of AKI in both groups. All-cause mortality of the general population was 57.4%, and it was associated to age, sepsis as cause of AKI, severity of condition at admission, oliguria, mechanical ventilation, non-recovery of renal function, in-hospital complications and hospital stay. In conclusion, our study contributes to a better knowledge of this condition and highlights the relevance of the detection of proteinuria throughout the clinical course.

Los riñones también hablan español / Kidneys also speak Spanish

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Recomendaciones sobre la vacunación contra SARS-CoV-2 / COVID-19 en pacientes con enfermedad renal y trasplante renal / Recommendations for the SARS-CoV-2 vaccination of patients with kidney disease and transplant recipients / Recomendações sobre vacinação contra SARS-CoV-2 / COVID-19 em pacientes com doença renal e transplante renal

Resumen: Este documento de recomendaciones tiene como objetivo orientar a médicos nefrólogos y no nefrólogos que asisten a pacientes con enfermedad renal crónica (ERC) en todas las etapas de la misma, en el proceso de vacunación contra el SARS-CoV-2. Como consecuencia de la situación epidemiológica y de los tiempos del proceso de elaboración de las vacunas disponibles, no se ha generado evidencia lo suficientemente potente, por lo que las recomendaciones no se acompañan del nivel de evidencia. Se fundamenta la necesidad de priorizar la vacunación en este grupo de pacientes en el mayor riesgo de adquirir la infección por SARS-CoV-2, desarrollar la enfermedad COVID-19 con mayor gravedad y presentar una mortalidad más elevada que la población general. Las recomendaciones se organizan por grupos de pacientes considerando pacientes con ERC no dialítica, diálisis y trasplante renal, y pacientes bajo tratamiento inmunosupresor.

Summary The objective of this document containing recommendations is to provide guidelines for nephrologists and non-nephrologists who assist patients with chronic kidney disease (CKD) at all stages of the disease on the vaccination process against SARS-CoV-2. As a consequence of the current epidemiological situation and the timing of the COVID-19 vaccine development -for available vaccines- there is no solid evidence, and thus, recommendations are not accompanied by the due medical proof. The need to prioritize vaccination in this group of patients is based on the increased risk of acquiring the SARS-CoV-2 infection, developing the COVID-19 disease with greater severity and presenting higher mortality rates than the general population. The recommendations are organized by groups of patients, considering patients with non-dialytic CKD, dialysis and kidney transplantation, and patients under immunosuppressive treatment.

Resumo: O objetivo deste documento de recomendações é orientar os nefrologistas e não nefrologistas que atendem pacientes com doença renal crônica (DRC) em todas as fases da doença, no processo de vacinação contra a SARS-CoV-2. Como consequência da situação epidemiológica e do momento do processo de produção das vacinas disponíveis, não foram geradas evidências suficientemente potentes, de modo que as recomendações não são acompanhadas de seu nível de evidência. A necessidade de priorizar a vacinação neste grupo de pacientes baseia-se no maior risco de adquirir a infecção pelo SARS-CoV-2, desenvolver a doença COVID-19 com maior gravidade e apresentar mortalidade superior à da população em geral. As recomendações são organizadas por grupos de pacientes, considerando pacientes com DRC não dialítica, em diálise, com transplante renal, e pacientes em tratamento imunossupressor.

Hemodiafiltración en línea como terapia de reemplazo renal crónica. Primera experiencia nacional en el Hospital Universitario / Online haemodiafiltration therapy to treat chronic kidney disease. First national experience in the university hospital / Hemodiafiltração on line como terapia de substituição da função renal crônica. Primeira experiência nacional no hospital universitário

Resumen: La enfermedad renal crónica tiene una prevalencia estimada de 6,5% a 8% en los adultos mayores de 18 años en Uruguay. A pesar de los esfuerzos por realizar un diagnóstico temprano y retrasar su progresión un porcentaje de pacientes requiere terapia de reemplazo renal (TRR) mediante diálisis, con una tasa de incidencia anual de 166 pacientes/millón de población. A pesar de las mejoras en el cuidado nefrológico y en las técnicas de hemodiálisis, la mortalidad anual de los pacientes en esta técnica es elevada en nuestro país (16,5%) y en todo el mundo. Con el objetivo de mejorar estos aspectos se han ensayado técnicas dialíticas que asocian la convección como estrategia para depurar moléculas de mayor tamaño que habitualmente no se depuran en la hemodiálisis convencional. La hemodiafiltración en línea (HDF-OL) es una técnica convectiva. Cuando se utiliza como TRR crónica se asocia a una reducción de la mortalidad de 30%-35% comparada con la hemodiálisis convencional. En el año 2014 se instrumentó esta técnica en el Hospital de Clínicas, siendo el centro pionero en el país en contar con ella como TRR crónico. El proceso de implementación implicó cambios de la infraestructura (monitores de diálisis, centro de tratamiento del agua), formación de recursos humanos, cambios en el funcionamiento y controles microbiológicos programados. El control de calidad sistemático y los diferentes estudios realizados en este período de cinco años han mostrado que es una técnica segura, capaz de remover solutos de tamaño medio y de disminuir los requerimientos de eritropoyetina. No se encuentra aún financiada por el sistema de salud, lo que puede constituir una barrera en su difusión a nivel nacional. En el presente trabajo se revisan las características fundamentales de la hemodiafiltración, su beneficio comparado con la hemodiálisis convencional, y el proceso de implementación de la técnica junto con algunos resultados iniciales en el Hospital de Clínicas.

Summary: Chronic kidney disease has an estimated prevalence of 6.5% to 8% in adults older than 18 years old in Uruguay. Despite efforts to make an early diagnosis and delay its progression, a percentage of patients require renal replacement therapy (RRT) with dialysis, the annual incidence rate being 166 patients per million population. Regardless of improvements in nephrology care and hemodialysis techniques, annual mortality ratex for this technique is high in our country (16.5%) and around the world. In order to improve these aspects, different dialysis techniques associating convection as a strategy to purify larger molecules that are rarely purified in conventional hemodialysis have been tried out. Online haemodiafiltration (OL-HDF) is a convective technique. When used as a chronic RRT it is associated to a 30-35% reduction in mortality compared to conventional hemodialysis. In 2014 this technique was introduced in the University Hospital, being it the first center that offered it as chronic renal replacement therapy. The implementation process implied changes in infrastructure (dialysis computer screens, water treatment center), the training of human resources, changes in the operation system and programmed microbiological controls. A systematic quality control and the different studies conducted in this 5-year period have proved it is a safe technique that removes average size solutes and reduces the erythropoietin requirements. This technique is still not funded by the health system, what may result in an obstacle for it to be applied nationally. This study reviews the main features of haemodiafiltration, its benefits when compared to conventional hemodialysis and the process needed to implement the technique, along with initial results in the University Hospital.

Resumo: No Uruguai a doença renal crônica tem uma prevalência estimada de 6.5 a 8% nos adultos maiores de 18 anos. Apesar dos esforços para realizar um diagnóstico precoce e retardar sua progressão uma porcentagem de pacientes requer terapia de substituição da função renal (TSFR) mediante diálise, com uma taxa de incidência anual de 166 pacientes/milhão de habitantes. Independentemente das melhorias na atenção nefrológica e nas técnicas de hemodiálise, a mortalidade anual dos pacientes em tratamento com esta técnica é elevada no Uruguai (16.5%) e no mundo todo. Buscando melhorar esses aspectos foram ensaiadas varias técnicas dialíticas que associam a convecção como estratégia para depurar moléculas de maior tamanho que habitualmente não são depuradas na hemodiálise convencional. A hemodiafiltração on line (HDF-OL) é uma técnica convectiva. Quando é utilizada como TSFR crônica está associada a uma redução da mortalidade de 30-35% comparada com a hemodiálise convencional. Esta técnica foi instrumentada em 2014 no Hospital de Clínicas, sendo este o centro pioneiro no Uruguai em utilizá-la como TSFR crônico. O processo de implementação impôs mudanças na infraestrutura (monitores de diálise, centro de tratamento da água), formação de Recursos Humanos e mudanças no funcionamento e controles microbiológicos programados. O controle de qualidade sistemático e os diferentes estudos realizados neste período de 5 anos mostraram que é uma técnica segura, capaz de remover solutos de tamanho médio e de reduzir os requerimentos de eritropoietina. A atual falta de financiamento pelo sistema de saúde pode ser uma barreira para sua difusão no país. Neste trabalho faz-se uma revisão das características fundamentais da hemodiafiltração, seu beneficio comparado com a hemodiálise convencional, o processo de implementação da técnica e alguns resultados iniciais do Hospital de Clínicas.

Substitution of Oral for Intravenous Cyclophosphamide in Membranous Nephropathy.

Background: Optimal immunosuppressive treatment for membranous nephropathy is still a matter of controversy. Current recommendations include oral cyclophosphamide combined with steroids (modified Ponticelli regimen) as first-line treatment in patients who are high risk. However, concerns about the cumulative toxicity of oral cyclophosphamide persist. In the last 30 years, a protocol based on low-dose intravenous cyclophosphamide plus steroids has been used to treat membranous nephropathy in Uruguay. We aimed to assess the efficacy of this regimen to induce clinical remission in patients with membranous nephropathy. Methods: In this retrospective, observational cohort study, we analyzed the outcome of 55 patients with membranous nephropathy treated between 1990 and 2017 with a 6-month course of alternating steroids (months 1, 3, and 5) plus intravenous cyclophosphamide (single dose of 15 mg/kg on the first day of months 2, 4, and 6). Results: At 24 months, 39 (71%) patients achieved clinical response with complete remission observed in 23 patients (42%) and partial remission in 16 (29%). Median time to achieve partial and complete remission was 5.9 and 11.5 months, respectively. Absence of response was observed in 16 patients (29%), five of whom started chronic RRT after a median follow-up of 3.5 years. Clinical relapse occurred in nine of 33 (27%) patients at a median of 34 months after treatment discontinuation. Conclusions: Replacement of oral cyclophosphamide with a single intravenous pulse on months 2, 4, and 6 of the modified Ponticelli regimen can be an effective and safe alternative for treatment of membranous nephropathy. Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_09_24_KID0002802020.mp3.

EPILAT-IRA Study: A contribution to the understanding of the epidemiology of acute kidney injury in Latin America.

INTRODUCTION: Epidemiology of acute kidney injury (AKI) is highly dependent on patient characteristics, context and geography. Considering the limited information in Latin America and the Caribbean, we performed a study with the aim to contribute to improve its better understanding. METHODS: Observational, prospective, longitudinal, multinational cohort study addressed to determine risk factors, clinical profile, process of care and outcomes of AKI in the region. Patients meeting KDIGO AKI definition were included over a 9-month period and designated community or hospital-acquired. De-identified clinical and lab data were entered in a specifically designed on-line platform. Co-variables potentially linked to AKI onset, in-hospital and 90-days mortality, were recorded and correlated using a multiple logistic regression model. RESULTS: Fifty-seven physicians from 15 countries provided data on 905 patients, most with acceptable basic needs coverage. Median age 64 (50-74) yrs; most of them were male (61%) and mestizos (42%). Comorbidities were present in 77%. AKI was community-acquired in 62%. Dehydration, shock and nephrotoxic drugs were the commonest causes. During their process of care, 77% of patients were assessed by nephrologists. Kidney replacement therapy (KRT) was performed in 29% of cases. In-hospital mortality was 26.5% and independently associated to older age, chronic liver disease, hypotension, shock, cardiac disturbances, hospital-acquired sepsis, KRT and mechanical ventilation. At 90-days follow up partial or complete renal recovery was 81% and mortality 24%. CONCLUSIONS: AKI was mainly community-acquired, in patients with comorbidities and linked to fluid loss and nephrotoxic drugs. Mortality was high and long-term follow up poor. Notwithstanding, the study shows partially the situation in the participant countries rather than the actual epidemiology of AKI in Latin America and Caribbean, a pending and needed task.

Raising Awareness of Acute Kidney Injury: A Latin American Experience.

INTRODUCTION: Raising awareness of acute kidney injury (AKI) is an essential strategy for minimizing the burden of this lethal syndrome. The AKI Commission of the Latin American Society of Nephrology and Hypertension conducted an educational program based on networked learning. METHODS: Two online courses with similar methodologies were developed, 1 course for nephrologists and the other for primary care physicians (PCP). The courses were developed as a distance education, asynchronous online modality with multiple educational strategies: written lessons, videos, e-rounds, and clinical simulation. Knowledge gain was explored through a 10-question test before and after course completion. RESULTS: The course for nephrologists had 779 participants from 21 countries; 52% were male, and 46% were <35 years of age. Mean qualification increased from 5.87 to 8.01 (36% gain of knowledge). The course for PCPs had 2011 participants, 81% of whom were physicians. The time from graduation was <5 years in 52%. In both courses, clinical simulation was considered the best part and lack of time the main limitation for learning. Because 48% of the nephrologist course attendees were interested in AKI activities, a Latin American AKI Network site (RedIRA) composed of a brief review, a clinical forum, a self-assessment, and a bibliography on AKI was launched on a monthly basis in November 2016. To date there are 335 users from 18 countries. CONCLUSIONS: Distance education techniques were effective for learning about AKI and are a potential tool for the development of a sustainable structure for communication, exchange, and integration of physicians involved in the care of patients with AKI.

Phylogeography of screaming hairy armadillo Chaetophractus vellerosus: Successive disjunctions and extinctions due to cyclical climatic changes in southern South America.

Little is known about phylogeography of armadillo species native to southern South America. In this study we describe the phylogeography of the screaming hairy armadillo Chaetophractus vellerosus, discuss previous hypothesis about the origin of its disjunct distribution and propose an alternative one, based on novel information on genetic variability. Variation of partial sequences of mitochondrial DNA Control Region (CR) from 73 individuals from 23 localities were analyzed to carry out a phylogeographic analysis using neutrality tests, mismatch distribution, median-joining (MJ) network and paleontological records. We found 17 polymorphic sites resulting in 15 haplotypes. Two new geographic records that expand known distribution of the species are presented; one of them links the distributions of recently synonimized species C. nationi and C. vellerosus. Screaming hairy armadillo phylogeographic pattern can be addressed as category V of Avise: common widespread linages plus closely related lineages confined to one or a few nearby locales each. The older linages are distributed in the north-central area of the species distribution range in Argentina (i.e. ancestral area of distribution). C. vellerosus seems to be a low vagility species that expanded, and probably is expanding, its distribution range while presents signs of genetic structuring in central areas. To explain the disjunct distribution, a hypothesis of extinction of the species in intermediate areas due to quaternary climatic shift to more humid conditions was proposed. We offer an alternative explanation: long distance colonization, based on null genetic variability, paleontological record and evidence of alternance of cold/arid and temperate/humid climatic periods during the last million years in southern South America.

Acute kidney injury after cardiac surgery is associated with mid-term but not long-term mortality: A cohort-based study.

Acute kidney injury (AKI) in cardiac surgery is associated with complications, early and late mortality and increased health care expenditures. The overall dynamic comorbidity-adjusted contributions of an episode of AKI on mortality during long-term follow-up have not been fully explored. A longitudinal cohort of 7075 adult patients admitted for cardiac surgery were enrolled in the study. Follow-up data were obtained through telephonic survey after 1, 5, 10, and 15 years or from the National Mortality Registry. All-cause mortality was assessed at five time intervals: I) 30 days after surgery to 1 year; II) 1 to 3 years; III) 3 to 5 years; IV) 5 to 10 years; and V) 10 to 15 years. For the adjustment of mortality for comorbidity and pre-, intra- and postoperative variables, Cox proportional hazard regression models were conducted within each period. The overall incidence of AKI was 36.1%. AKI was an independent predictor of death only during the first five years after surgery (30 days to 1 year: HR 1.834, 95% CI 1.459 to 2.306; 1 to 3 years: HR 1.285, 95% CI 1.023 to 1.610; and 3 to five years: HR 1.330, 95% CI 1.123 to 1.750). Only age, diabetes mellitus and CHF were associated with increased risk of death over the entire follow-up period. Our study demonstrates a transient association of AKI with long-term mortality that progressively decreases and vanishes five years after surgery. The knowledge of this dynamic is crucial to understanding this complex association, planning health care and allocating resources.