Serum bicarbonate levels and kidney outcomes in critically ill patients: a prospective cohort study.

BACKGROUND: The interplay between serum bicarbonate levels and kidney outcomes is not fully understood. We conducted a prospective cohort study in three intensive care units (ICUs) to evaluate the association of serum bicarbonate levels with acute kidney injury (AKI) and kidney function recovery in critically ill patients. METHODS: A prospective cohort study in three intensive care units (ICUs) was performed. The serum bicarbonate level in the first 24 h after ICU admission was categorized as low (< 22 mEq/L), normal (22-26 mEq/L), or high (> 26 mEq/L). Serum creatinine (SCr) levels according to the KDIGO AKI guideline were used for defining AKI within the first 7 days of ICU stay. At ICU admission, SCr ≥ 1.1 for women and ≥ 1.3 mg/dL for men were indicative of impaired kidney function. Mortality outcome was tracked up to 28 days, and kidney function recovery was assessed at hospital discharge. RESULTS: A total of 2732 patients (66 ± 19 years and 55% men) were analyzed, with 32% having impaired kidney function at ICU admission. Overall, 26% of patients had low bicarbonate levels, while 32% had high bicarbonate levels. Notably, patients with preserved kidney function showed a lower prevalence of low bicarbonate levels compared to those with impaired kidney function (20% vs. 39%, p < 0.001), while higher rates were observed for high bicarbonate (35% vs. 24%, p < 0.001). Compared with patients with normal serum bicarbonate levels, those with low bicarbonate were 81% more likely to develop AKI (OR = 1.81; 95% CI 1.10-2.99), whereas those with high bicarbonate were 44% less likely (OR = 0.56; 95% CI 0.32-0.98) in the adjusted model for confounders. Neither those with high nor low serum bicarbonate levels were associated with an increased risk of mortality (HR = 1.03; 95% CI 0.68-1.56 and 0.99; 95% CI 0.68-1.42, respectively). In subgroup analysis, regardless of the kidney function at ICU admission, serum bicarbonate levels were not associated with the development of AKI and all-cause mortality. Regarding kidney function recovery, higher non-recovery rates were found for those with low bicarbonate. CONCLUSION: In critically ill ICU patients, low bicarbonate levels were associated with the more likely development of AKI and subsequent non-recovery of kidney function, while high bicarbonate levels showed no such association. Therefore, low bicarbonate levels may be considered a risk factor for adverse kidney outcomes in critically ill patients.

Design and methodology of the SARCopenia trajectories and associations with adverse clinical outcomes in patients on HemoDialysis: the SARC-HD study.

BACKGROUND: Sarcopenia has been associated with adverse outcomes in patients with chronic kidney disease (CKD), particularly in those undergoing hemodialysis (HD). However, the trajectories across sarcopenia stages, their determinants, and associations with adverse clinical outcomes have yet to be comprehensively examined. METHODS: The SARC-HD is a multicenter, observational prospective cohort study designed to comprehensively investigate sarcopenia in patients on HD. Eligibility criteria include adult patients undergoing HD for ≥ 3 months. The primary objective is to investigate the trajectories of sarcopenia stages and their potential determinants. Secondary objectives include evaluating the association between sarcopenia and adverse clinical outcomes (i.e., falls, hospitalization, and mortality). Sarcopenia risk will be assessed by the SARC-F and SARC-CalF questionnaire. Sarcopenia traits (i.e., low muscle strength, low muscle mass, and low physical performance) will be defined according to the revised European Working Group on Sarcopenia in Older People and will be assessed at baseline and after 12 follow-up months. Patients will be followed-up at 3 monthly intervals for adverse clinical outcomes during 24 months. DISCUSSION: Collectively, we expect to provide relevant clinical findings for healthcare professionals from nephrology on the association between sarcopenia screening tools (i.e., SARC-F and SARC-CalF) with objective sarcopenia measurements, as well as to investigate predictors of trajectories across sarcopenia stages, and the impact of sarcopenia on adverse clinical outcomes. Hence, our ambition is that the data acquired from SARC-HD study will provide novel and valuable evidence to support an adequate screening and management of sarcopenia in patients on HD.

Intradialytic resistance training for short daily hemodialysis patients as part of the clinical routine: a quasi-experimental study.

Background and purpose: Hemodialysis patients have chronic systemic inflammation, musculoskeletal impairments, and body composition changes from several factors and exercise may attenuate. We evaluated the effects of an intradialytic resistance training program on body composition, physical function, and inflammatory markers in patients under short daily hemodialysis treatment. Materials and methods: A quasi-experimental study in clinical routine was conducted over eight months. Measures of physical function (handgrip strength, five-time sit-to-stand, timed-up and go, and gait speed), body composition (by bioelectrical impedance), and inflammatory markers (interleukin [IL]-1 beta, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-α) were assessed at baseline as well as at four and eight months past continued intervention. Patients underwent two intradialytic resistance training sessions per week supervised by exercise professionals. Results: A total of 18 patients (62 ± 14 years; 55.6% ≥ 60 years; 44% female) were included. Significant increases in body mass index and basal metabolic rate were found at four and eight months compared to baseline. For physical function, timed-up and go performance improved at four and eight months compared to baseline. The other body composition and physical function measures, as well as all inflammatory markers, did not significantly change over time. Conclusion: A supervised intradialytic resistance training program for patients on short daily hemodialysis treatment, as part of the clinical routine, may induce modest changes in body mass index, basal metabolic rate, and timed-up and go performance.

Implementing a resistance training programme for patients on short daily haemodialysis: A feasibility study.

BACKGROUND: Kidney failure patients receiving haemodialysis experience protein-energy wasting, muscle mass loss and physical function impairment. Intradialytic exercise interventions seem to modify these features, but they are often not implemented as a clinical routine. OBJECTIVE: To investigate the feasibility of implementing a supervised intradialytic resistance training programme as a clinical routine for patients receiving short daily haemodialysis. DESIGN: A prospective longitudinal study. PARTICIPANTS: Eighteen patients in a supervised intradialytic resistance training programme for 8 months. MEASUREMENTS: It consisted of a warm-up, lower- and upper-limb resistance exercises and a cool-down. Patients performed the resistance training during the first half of haemodialysis, twice a week, supervised by exercise physiologists and physiotherapists. The feasibility was assessed by the total and partial adherences, the reasons for refusing or for not exercising and the intradialytic complications. RESULTS: From a total of 953 potential exercise sessions, 759 were performed, with a 79.6% adherence rate. In the first 9 weeks, the adherence rate was 86.6% and the lowest rate was in the 19-27 weeks (73.5%). The main intradialytic complication during exercise sessions was hypotension (n = 31; 4.1%). The highest number of complications was reported during the first 9 weeks (n = 27; 9.1%). The main reasons for refusing or for not performing the intradialytic exercise sessions were clinical complications previous to exercise time (n = 63; 32.5%) and self-reported indisposition (n = 62; 32.0%). CONCLUSIONS: The intradialytic resistance training programme, supervised by exercise physiologists and physiotherapists, had very low complications, achieved a high long-term adherence rate and showed to be feasible as a clinical routine for patients receiving short daily haemodialysis.

Association of magnesium abnormalities at intensive care unit admission with kidney outcomes and mortality: a prospective cohort study.

BACKGROUND: Magnesium abnormalities have been associated with adverse kidney outcomes and mortality in critically ill patients, however, this association remains inconsistent. This study aimed to investigate the association of magnesium abnormalities at intensive care unit (ICU) admission with kidney outcomes (i.e., acute kidney injury (AKI) and kidney function recovery) and mortality risk in a large cohort of critically ill patients. METHODS: A prospective cohort study was conducted by collecting data from three ICUs in Brazil. The ICU admission serum magnesium level was used to define hypomagnesemia (< 1.60 mg/dL) and hypermagnesemia (> 2.40 mg/dL). The Kidney Disease Improving Global Outcomes AKI Guideline was used to define AKI based on serum creatinine levels. Kidney function recovery was defined as full recovery, partial recovery, and non-recovery at ICU discharge. Mortality was screened up to 28 days during ICU stay. RESULTS: A total of 7,042 patients was analyzed, hypomagnesemia was found in 18.4% (n = 1,299) and hypermagnesemia in 4.4% (n = 311). Patients with hypomagnesemia were 25% more likely to develop AKI after adjustment for confounding variables (OR = 1.25; 95% CI 1.08-1.46). No significant association was found for hypermagnesemia and AKI (OR = 1.18; 95% CI 0.89-1.57). Kidney function recovery was similar among groups but hypermagnesemia had lower non-recovery rates. Both hypomagnesemia and hypermagnesemia were associated with 65 and 52% higher mortality risk after adjustments for confounders, respectively (HR = 1.65; 95% CI 1.32-2.06 and 1.52; 95% CI 1.01-2.29). CONCLUSIONS: Hypomagnesemia, but not hypermagnesemia, at ICU admission was associated with AKI development. On the other hand, both hypomagnesemia and hypermagnesemia were associated with higher mortality risks.

SARC-F and SARC-CalF are associated with sarcopenia traits in hemodialysis patients.

BACKGROUND: The SARC-F questionnaire assesses sarcopenia risk. The addition of a calf circumference measurement, known as SARC-CalF, has been recently proposed. We investigated possible associations of SARC-F and SARC-CalF with sarcopenia traits in patients undergoing hemodialysis. METHODS: Thirty patients (17 men; 57 ± 15 years) were enrolled. Sarcopenia risk was assessed by SARC-F (≥4) and SARC-CalF (≥11). Probable (low muscle strength or low skeletal muscle mass [SMM]) and confirmed (both) sarcopenia were diagnosed as recommended by the revised European Working Group on Sarcopenia in Older People. Muscle strength was assessed by handgrip strength (HGS) and five-time sit-to-stand test (STS-5), and physical performance was evaluated by gait speed. SMM was assessed by bioelectrical impedance. RESULTS: Sarcopenia risk by the SARC-F and SARC-CalF were found in 23% (n = 7) and 40% (n = 12) patients, respectively. The SARC-F and SARC-CalF were both associated with physical function, but not with SMM. Probable sarcopenia by HGS was associated with SARC-F and SARC-CalF. Moreover, both showed moderate Kappa agreement with slowness and probable sarcopenia by HGS and/or STS-5, but only SARC-CalF with probable sarcopenia by HGS. A larger sensitivity was found for SARC-CalF than SARC-F in detecting probable sarcopenia by HGS (70% vs 30%) and by HGS and/or STS-5 (63% vs 44%). CONCLUSION: SARC-F and SARC-CalF are associated with sarcopenia traits in patients undergoing hemodialysis. SARC-CalF seems to be more strongly associated with sarcopenia traits and present a higher sensitivity for probable sarcopenia than SARC-F, as it adds a direct measurement.

Physical activity is associated with nutritional biomarkers in hemodialysis patients: A cross-sectional study.

OBJECTIVE: To explore the association between physical activity levels and nutritional biomarkers in hemodialysis patients. METHODS: Eighty-six patients responded to the short version of the International Physical Activity Questionnaire to estimate the metabolic equivalent of tasks (MET) per week. A MET-min per week <600 was considered as sedentary. The nutritional biomarkers (i.e., albumin, globulin, and albumin/globulin ratio) were collected. RESULTS: Sixty-five patients (75.6%) were sedentary. Binary logistic regression showed that patients with low albumin levels had an 89% lower chance to be physically active (p = 0.037), but it was not significant in the adjusted analysis (p = 0.052). Albumin and albumin/globulin ratio levels were correlated with MET-min per week (r = 0.34 and 0.30; both p < 0.05). Additionally, lower median albumin and albumin/globulin ratio levels were found in the sedentary patients (p = 0.021 and p = 0.031), respectively. CONCLUSION: The physical activity levels were associated with albumin and albumin/globulin ratio, surrogates of nutritional status in hemodialysis patients. These nutritional biomarkers were lower in sedentary patients.

Epidemiological profile of acute kidney injury in critically ill patients admitted to intensive care units: A Prospective Brazilian Cohort / Perfil epidemiológico de injúria renal aguda em pacientes críticos admitidos em unidades de terapia intensiva: uma coorte brasileira prospectiva

Abstract Introduction Acute kidney injury (AKI) is a frequent syndrome affecting patients admitted to intensive care units (ICU), and it is associated with poor clinical outcomes. The aim of the present study was to understand the epidemiological profile of patients with AKI admitted to ICUs. Methods Prospective cohort study, carried out in three ICUs in the Federal District, Brazil. Between October/2017 and December/2018, 8,131 patients were included in the cohort. AKI was defined according to the KDIGO criteria. The main outcomes assessed were AKI development and mortality within 28 days of hospitalization. Results Of the 8,131 patients followed up, 1,728 developed AKI (21.3%). Of the 1,728 patients with AKI, 1,060 (61.3%) developed stage 1, while stages 2 and 3 represented 154 (8.9%) and 514 (29.7%), respectively. Of these, 459 (26.6%) underwent renal replacement therapy. The mortality was 25.7% for those with AKI, and 4.9% for those without AKI. Discussion Patients with AKI had higher mortality rates when compared to those without AKI. Likewise, among patients with AKI, higher disease stages were associated with higher death occurrences. AKI incidence (21.3%) and mortality (25.7%) in our study is in line with the largest meta-analysis ever conducted, in which incidence and mortality of 21.6 and 23.9% were observed, respectively. These findings confirm the importance of establishing the KDIGO guideline for the definition and management of AKI in Brazilian ICUs.

Resumo Introdução A injúria renal aguda (IRA) é uma síndrome frequente em pacientes admitidos em unidades de terapia intensiva (UTI) e está associada a negativos desfechos clínicos. O objetivo do presente estudo foi conhecer o perfil epidemiológico de pacientes com IRA admitidos em UTIs. Métodos Estudo de coorte prospectiva, realizado em três UTIs do Distrito Federal, Brasil. Entre o período de outubro/2017 e dezembro/2018, 8.131 pacientes foram incluídos na coorte. A IRA foi definida de acordo com o critério KDIGO. Os principais desfechos avaliados foram o desenvolvimento de IRA e mortalidade dentro de 28 dias de internação. Resultados Dos 8.131 pacientes acompanhados, 1.728 desenvolveram IRA (21,3%). Dos 1.728 pacientes com IRA, 1.060 (61,3%) desenvolveram o estágio 1, já os estágios 2 e 3 representaram 154 (8,9%) e 514 (29,7%), respectivamente. Destes, um total de 459 (26,6%) realizou terapia renal substitutiva. A mortalidade observada foi de 25,7% para aqueles com IRA e 4,9% para os não IRA. Discussão Os pacientes com IRA, comparados aos não IRA, apresentaram maior mortalidade. Da mesma forma, entre os pacientes com IRA, os estágios superiores estiveram associados à maior ocorrência de óbito. A incidência de IRA (21,3%) e mortalidade (25,7%) em nosso estudo está em consonância com a maior meta-análise já conduzida, na qual foram observadas incidência e mortalidade de 21,6 e 23,9%, respectivamente. Esses achados confirmam a importância de se estabelecer a diretriz KDIGO para definição e manejo da IRA em UTIs brasileiras.

Associação entre os sintomas depressivos e a gordura corporal em pacientes com doença renal crônica em hemodiálise / Association between depressive symptoms and body fat in chronic kidney patients in hemodialysis

| INTRODUÇÃO: O excesso de gordura corporal causa alterações metabólicas complexas que acentuam na patogênese e progressão da doença renal crônica (DRC). Além disto, os aspectos comportamentais negativos, como sintomas depressivos e o sedentarismo, são comuns e podem estar associados ao acúmulo de gordura corporal em pacientes que realizam tratamento em hemodiálise (HD). OBJETIVO: Verificar a associação entre os sintomas depressivos e a gordura corporal em pacientes com DRC em HD. MÉTODO: Trata-se de um estudo transversal de um centro clínico de HD em Brasília−DF. Trinta e nove pacientes foram incluídos (59,3±16,7; idade). A composição corporal foi avaliada por meio de bioimpedância tetrapolar. O inventário de depressão de Beck foi empregado para mensurar os sintomas depressivos. Para analisar a associação entre os sintomas depressivos e a gordura corporal foi adotado o teste de correlação de Spearman. RESULTADOS: Foi observado uma prevalência de depressão de 17,9%. Os sintomas depressivos foram positivamente correlacionados com a gordura corporal (r = 0,42; p = 0,008). CONCLUSÃO: Em nossos resultados, confirmamos que os sintomas depressivos estão associados à gordura corporal em pacientes com DRC em HD. Estes achados demonstram-se importantes para a prática clínica dos profissionais de saúde, sobretudo, nos aspectos dietéticos e psicológicos em pacientes com DRC, de forma que iniciativas de diagnóstico, prevenção e tratamentos sejam priorizadas com o objetivo de reduzir tais condições.

INTRODUCTION: Excess body fat causes complex metabolic changes that enhance the pathogenesis and progression of chronic kidney disease (CKD). Furthermore, negative behavioral aspects such as depressive symptoms and a sedentary lifestyle are common and may be associated with the accumulation of body fat in patients undergoing hemodialysis (HD) treatment. OBJECTIVE: To verify the association between depressive symptoms and body fat in HD patients. METHODS: This is a cross-sectional study that enrolled thirty-nine patients (59,3 ± 16,7; age). The body composition was evaluated by bioimpedance tetrapolar. Beck's depression inventory was used to measure depressive symptoms. Anda, to analyze possible association between depressive symptoms and body fat, Spearman's correlation test was applied. RESULTS: A depression prevalence of 17.9% was observed. Depressive symptoms were positively correlated with body fat (r = 0.42; p = 0.008). CONCLUSION: Our results confirmed that depressive symptoms were associated with body fat in HD patients. These findings are important for the clinical practice of health professionals, especially in the dietary and psychological aspects; therefore, treatment initiatives for diagnosis, prevention are important to reduce these conditions.

Post-COVID-19 rehabilitation: a special look at chronic kidney disease patients.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can infect the kidney and the presence of chronic kidney disease (CKD) constitutes a higher risk of negative prognosis. SARS-CoV-2 main sequelae in CKD patients are an incomplete recovery of kidney function, muscle weakness and atrophy, breathiness, tiredness, pulmonary fibrosis, and initiation of kidney replacement therapy. The overall aim of this review is to provide a theoretical basis for early improvements of physical function health to all CKD stages by rehabilitation therapies. CONCLUSION: Chronic kidney disease patients infected with SARS-CoV-2 should be monitored by rehabilitation professionals as the cardiopulmonary, musculoskeletal, and cognitive systems might be deteriorated. Long-term consequences of SARS-CoV-2 are unknown and preventive rehabilitation may attenuate them.

Epidemiological profile of acute kidney injury in critically ill patients admitted to intensive care units: A Prospective Brazilian Cohort.

INTRODUCTION: Acute kidney injury (AKI) is a frequent syndrome affecting patients admitted to intensive care units (ICU), and it is associated with poor clinical outcomes. The aim of the present study was to understand the epidemiological profile of patients with AKI admitted to ICUs. METHODS: Prospective cohort study, carried out in three ICUs in the Federal District, Brazil. Between October/2017 and December/2018, 8,131 patients were included in the cohort. AKI was defined according to the KDIGO criteria. The main outcomes assessed were AKI development and mortality within 28 days of hospitalization. RESULTS: Of the 8,131 patients followed up, 1,728 developed AKI (21.3%). Of the 1,728 patients with AKI, 1,060 (61.3%) developed stage 1, while stages 2 and 3 represented 154 (8.9%) and 514 (29.7%), respectively. Of these, 459 (26.6%) underwent renal replacement therapy. The mortality was 25.7% for those with AKI, and 4.9% for those without AKI. DISCUSSION: Patients with AKI had higher mortality rates when compared to those without AKI. Likewise, among patients with AKI, higher disease stages were associated with higher death occurrences. AKI incidence (21.3%) and mortality (25.7%) in our study is in line with the largest meta-analysis ever conducted, in which incidence and mortality of 21.6 and 23.9% were observed, respectively. These findings confirm the importance of establishing the KDIGO guideline for the definition and management of AKI in Brazilian ICUs.

Intradialytic isometric handgrip exercise does not cause hemodynamic instability: A randomized, cross-over, pilot study.

Hemodialysis (HD) patients experience hemodynamic instability and intradialytic exercise seems to attenuate it. This study aimed to verify the acute hemodynamic response to different intradialytic handgrip exercise intensities in HD patients. In a randomized, cross-over, experimental pilot study, eight patients completed two experimental sessions and one control in random order: (a) regular HD; (b) low-intensity isometric handgrip exercise; and (c) moderate-intensity isometric handgrip exercise. BP and heart rate variability were recorded immediately before and every 15 minutes. Isometric handgrip exercise protocols, regardless of the intensity, did not lead to significant changes in hemodynamic stability, nor when compared to the control condition (P > .05). The systolic BP and double product significantly increased immediately after the moderate-intensity protocol (122.0 ± 15.9 vs 131.3 ± 19.8, P < .05; 9094.7 ± 1705.7 vs 9783.0 ± 1947.9, P < .05, respectively) but returned to the pre-exercise values 10 minutes later. We conclude that intradialytic isometric handgrip exercise does not induce hemodynamic instability at low and moderate intensities.

A composição corporal está associada com o risco de quedas e medo de cair em pacientes em hemodiálise / Body composition is associated with the risk of falls and fear of falling in hemodialysis patients

Pacientes com doença renal crônica (DRC) submetidos à hemodiálise (HD) apresentam alterações musculoesqueléticas e de composição corporal que podem levar à redução do equilíbrio, velocidade de caminhada e capacidade de realizar as atividades de vida diária, aumentando o risco de quedas. OBJETIVO: Investigar a associação da composição corporal com o risco de quedas e medo de cair em pacientes com DRC submetidos à HD. MATERIAIS E MÉTODOS: Estudo transversal com amostra de 40 pacientes em HD. Para o medo de cair e risco de quedas foram aplicados a Escala Internacional de Eficácia de Quedas e o QuickScreen Clinical Falls Risk Assessment. A amostra foi estratificada no percentil 50 para comparação da composição corporal de acordo com o risco de quedas e medo de cair. Para comparação entre os grupos, empregou-se o teste t de Student independente, e a correlação de Spearman para associar o risco de quedas e medo de cair com a composição corporal. O nível de significância adotado foi de p<0,05. RESULTADOS: Correlação moderada positiva entre a gordura corporal com o medo de cair (r=0,47) e risco de quedas (r=0,42) e correlação moderada negativa entre a massa magra com o medo de cair (r=- 0,51) e risco de quedas (r=-0,45). O grupo com maior risco de quedas apresentou maior gordura corporal (36,8±8,2 vs 30,9±6,9; p=0,043). O grupo com maior medo de cair obteve menor massa magra (41,6±9,2 vs 52,0±7,6; p=0,004). CONCLUSÃO: As variáveis de composição corporal associaram-se ao risco de quedas e ao medo de cair em pacientes com DRC submetidos à HD.

Pacientes com doença renal crônica (DRC) submetidos à hemodiálise (HD) apresentam alterações musculoesqueléticas e de composição corporal que podem levar à redução do equilíbrio, velocidade de caminhada e capacidade de realizar as atividades de vida diária, aumentando o risco de quedas. OBJETIVO: Investigar a associação da composição corporal com o risco de quedas e medo de cair em pacientes com DRC submetidos à HD. MATERIAIS E MÉTODOS: Estudo transversal com amostra de 40 pacientes em HD. Para o medo de cair e risco de quedas foram aplicados a Escala Internacional de Eficácia de Quedas e o QuickScreen Clinical Falls Risk Assessment. A amostra foi estratificada no percentil 50 para comparação da composição corporal de acordo com o risco de quedas e medo de cair. Para comparação entre os grupos, empregou-se o teste t de Student independente, e a correlação de Spearman para associar o risco de quedas e medo de cair com a composição corporal. O nível de significância adotado foi de p<0,05. RESULTADOS: Correlação moderada positiva entre a gordura corporal com o medo de cair (r=0,47) e risco de quedas (r=0,42) e correlação moderada negativa entre a massa magra com o medo de cair (r=- 0,51) e risco de quedas (r=-0,45). O grupo com maior risco de quedas apresentou maior gordura corporal (36,8±8,2 vs 30,9±6,9; p=0,043). O grupo com maior medo de cair obteve menor massa magra (41,6±9,2 vs 52,0±7,6; p=0,004). CONCLUSÃO: As variáveis de composição corporal associaram-se ao risco de quedas e ao medo de cair em pacientes com DRC submetidos à HD.

Do intravenous N-acetylcysteine and sodium bicarbonate prevent high osmolal contrast-induced acute kidney injury? A randomized controlled trial.

BACKGROUND: N-acetylcysteine (NAC) or sodium bicarbonate (NaHCO3), singly or combined, inconsistently prevent patients exposed to radiographic contrast media from developing contrast-induced acute kidney injury (CI-AKI). OBJECTIVE: We asked whether intravenous isotonic saline and either NaHCO3 in 5% dextrose or else a high dose of NAC in 5% dextrose prevent CI-AKI in outpatients exposed to high-osmolal iodinated contrast medium more than does saline alone. METHODS: This completed prospective, parallel, superiority, open-label, controlled, computer-randomized, single-center, Brazilian trial (NCT01612013) hydrated 500 adult outpatients (214 at high risk of developing CI-AKI) exposed to ioxitalamate during elective coronary angiography and ventriculography. From 1 hour before through 6 hours after exposure, 126 patients (group 1) received a high dose of NAC and saline, 125 (group 2) received NaHCO3 and saline, 124 (group 3) received both treatments, and 125 (group 4) received only saline. RESULTS: Groups were similar with respect to age, gender, weight, pre-existing renal dysfunction, hypertension, medication, and baseline serum creatinine and serum cystatin C, but diabetes mellitus was significantly less prevalent in group 1. CI-AKI incidence 72 hours after exposure to contrast medium was 51.4% (257/500), measured as serum creatinine > (baseline+0.3 mg/dL) and/or serum cystatin C > (1.1 · baseline), and 7.6% (38/500), measured as both serum creatinine and serum cystatin C > (baseline+0.3 mg/dL) or > (1.25 · baseline). CI-AKI incidence measured less sensitively was similar among groups. Measured more sensitively, incidence in group 1 was significantly (p<0.05) lower than in groups 2 and 3 but not group 4; adjustment for confounding by infused volume equalized incidence in groups 1 and 3. CONCLUSION: We found no evidence that intravenous isotonic saline and either NaHCO3 or else a high dose of NAC prevent CI-AKI in outpatients exposed to high osmolal iodinated contrast medium more than does saline alone. TRIAL REGISTRATION: ClinicalTrials.gov NCT01612013.

Vitamin D and Kidney disease: what we know and what we do not know / Vitamina D e doença renal: o que nós sabemos e o que nós não sabemos

Vitamin D deficiency is common in the chronic kidney disease (CKD) population. CKD has been recognized as a significant public health problem and CKD patients are at increased risk of total and cardiovascular morbidity and mortality. There are increasing epidemiological data suggesting that vitamin D deficiency may play a role in overall morbidity and mortality associated with CKD. The vitamin D hormonal system is classically implicated in the regulation of calcium homeostasis and bone metabolism but there is ample evidence to support the claim that extra renal conversion of 25(OH)D to 1.25(OH)2 has significant biological roles beyond those traditionally ascribed to vitamin D. Based on the current state of evidence this review intends to give an update on novel biological and clinical insights with relevance to the steroid hormone vitamin D specifically in patients with kidney disease.

A deficiência de vitamina D é um achado comum em pacientes com doença renal crônica (DRC). A DRC é reconhecida como um problema de saúde pública importante, com elevado risco de morbimortalidade total e cardiovascular. Inúmeras publicações epidemiológicas sugerem que a morbimortalidade nesses pacientes pode estar associada à deficiência de vitamina D. O sistema hormonal da vitamina D é classicamente implicado na regulação do metabolismo ósseo e da homeostase do cálcio; entretanto, há uma grande evidência de que a conversão de 25(OH)D para 1.25(OH)2 tem um papel biológico significante além daquele tradicionalmente descrito. Baseada em atual evidência, esta revisão pretende ressaltar os aspectos clínicos e biológicos relevantes no sistema hormonal da vitamina D especificamente em pacientes com doença renal.

Improving outcomes in patients with lupus and end-stage renal disease.

The development of lupus-related end-stage renal disease (ESRD) confers the highest mortality rates among individuals with lupus. Lupus-related ESRD is also associated with higher morbidity and mortality rates compared with non-lupus ESRD. We review the evidence that persistent lupus activity, hypercoagulability, and continuing immunosuppression may contribute to unfavorable outcomes in dialysis and renal transplantation among lupus patients. Robust epidemiologic studies are needed to develop individualized evidence-based approaches to treating lupus-related ESRD. In the meantime, managing lupus-related ESRD presents a significant challenge for clinicians and requires a team approach involving nephrologists and rheumatologists. Goals of therapy after developing ESRD should include continuing monitoring of lupus activity, minimizing corticosteroid exposure, and choosing the most appropriate renal replacement therapy based on patient's risk profile and quality-of-life considerations.

Vitamin D and kidney disease: what we know and what we do not know.

Vitamin D deficiency is common in the chronic kidney disease (CKD) population. CKD has been recognized as a significant public health problem and CKD patients are at increased risk of total and cardiovascular morbidity and mortality. There are increasing epidemiological data suggesting that vitamin D deficiency may play a role in overall morbidity and mortality associated with CKD. The vitamin D hormonal system is classically implicated in the regulation of calcium homeostasis and bone metabolism but there is ample evidence to support the claim that extra renal conversion of 25(OH)D to 1.25(OH)2 has significant biological roles beyond those traditionally ascribed to vitamin D. Based on the current state of evidence this review intends to give an update on novel biological and clinical insights with relevance to the steroid hormone vitamin D specifically in patients with kidney disease.